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Author: Vickie Williams

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Why “House” is the True American Health Care Hero, And What To Do About It

After reading their article “The U.S. Health Care System:   A Product of American History and Values,” it struck me that David W. Johnson and Nancy Kane described exactly why the devious, unethical, but brilliant physician “House” would be the perfect depiction of a health care hero to  many Americans.  Johnson and Kane explain how the  American health care non-system is a product of the value Americans place on self-reliance.  This has created an individualistic culture and a view that health care is an individual, rather than a collective responsibility.  Couple this with the American preference for markets rather than governments to solve problems, and you get the fragmentation we have now.

In America, physicians are recognized and rewarded for being “the best” (i.e., the most specialized, or the most “brilliant”) rather for collaborating to achieve the best  outcomes.   Couple this with a health care finance and delivery system that is the product of years of crisis management, rather than any cohesive  forward-thinking planning.  You put all of these things together, and you get – - – House.

The irony of this is that the actor who plays House on the series, Hugh Laurie, is British.  The British health care system was established shortly after World War II with an eye towards ongoing health management of an entire population.  A system like Britain’s would not reward or idolize House for his anti-social, egocentric behavior; it would reward him for good patient outcomes (which would make for boring TV, but good medicine).  If  House spent less time performing his egocentric, lone-ranger-like antics and more time coordinating  patient care with his far-more-dedicated-than-him team of doctors, his (and the team’s) rewards would be much greater.

This is not to say that there are no egotistic, self-important health care providers in countries with centralized health care systems.  Nevertheless, if the incentives don’t reward that kind of behavior, and the society does not place high value on individualism above outcomes, at least it wouldn’t be encouraged.    As Johnson and Kane conclude, the current recession, coupled with increased globalization,  have given us a unique opportunity to redefine our core values and align our health care system with those values.  We can use models from other countries, but maintain a uniquely American perspective, reflecting the best of American creativity.  Economist Richard Florida, in his recent book “The Great Reset,” posits that times of great economic upheaval are also opportunities for innovation.  This is as true in health care as it is true in technology or any other field.  If we want world-class health care for all, we cannot remain prisoners of the accidents of history that shaped our current health care system.

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Integrated Delivery Systems as a Panacea

In “Curing Fragmentation with Integrated Delivery Systems,” Alain Enthoven, the father of “managed competition,” extols his creation as a cure for what ails America’s fragmented health system.  Indeed, many of Enthoven’s proposals for reducing fragmentation in our health care system, such as regional health insurance exchanges, were incorporated into the Patient Protection and Affordable Care Act (“PPACA”), the health care reform bill signed into law on March 23, 2010.

Although a proliferation of integrated delivery systems competing with each other for business may be a step in the right direction, it will do little or nothing to cut down on the enourmous amount of health care resources spent on compliance with ever-expanding numbers of billing rules.  Even Professor Enthoven acknowledges that a single-payer system could solve many of the same problems as his integrated delivery system proposal, but he believes that Americans do not have the political will to accept such a system.  Professor Enthoven also fails to consider that even less-radical changes to our health care system, such as adopting a system of encrypted medical records that a patient carries with her, like the French “carte vitale,” would greatly cut down on or eliminate poor medical outcomes that are attributable to fragmentation in the system.

A well-managed single-payer system could  satisfy the American appetite for market competition, and achieve more than the integrated delivery systems proposed by Professor Enthoven.  Competition could still take place at the insurer level, much like in Germany, or it could take place amongst providers, such as in Japan (whose system author T.R. Reid cleverly describes as “Bismarck on Rice” in his recent book The Healing of America (Penguin Press 2009)).

Professor Enthoven’s example of the “epitome of integrated delivery system[s]” is Kaiser Permanente (for which Enthoven is also a consultant, according to his Stanford University on-line biography).  His vision is for the American people to have a choice of many Kaiser Permanente-like organizations.  This presumes that people want choices when it comes to picking a health plan, a presumption shared by PPACA.  I believe that is incorrect.  What people want is choice of providers.  Nobody loves their payers; they love their doctors.  They want to make sure they don’t receive numerous bills for every little service they receive, but they don’t really care about who pays those bills.  Only the ultimate integrated delivery system, a single-payer one with a compensation system based on outcomes, not services, will achieve this.

It is true that many of the single-payer systems in use around the world are underfunded and under inflationary pressure.  A single-payer system in the United States would be no exception.  Despite our current economic woes, we remain the richest country in the world.  As Dr. Marcia Angell, former editor-in-chief of the New England Journal of Medicine stated in the 2000 PBS documentary “Healthcare Crisis:  Who’s at Risk?,” the amount of our GDP that we spend on health care is not really important.  What is important is that we get good outcomes and the customer satisfaction that we are paying for.  Managed competition and “integrated delivery systems” although a step in the right direction, will not solve our problems in the long run.