In "Catastrophic Care: How American Health Care Killed My Father – And How We Can Fix It," author David Goldhill channels his incredulousness over how the healthcare system operates into an open challenge to society and the healthcare industry to examine why the healthcare system is the way it is and how it can be changed. He talked to Healthcare Finance News about his book.
Q: What do you think is most important takeaway for readers?
[See also: Reading List: Beau Keyte and Jim Luckman]
A: That much of the conventional wisdom on which our current system is based is outdated. The presumption that all health care must be funded by insurance, that consumers cannot perform their normal role, that insurers and governments can do a better job of driving quality and value, and that improvement in quality must mean increase in cost has been undermined by changes in health care, in technology and in the general economy. Certainly, some of our need for health care is urgent, major and unexpected and that calls for insurance and other elements of the unusual healthcare economy. But the largest share – and the fastest growing part – is about preventive care, routine ailments and the long-term management of conditions or even mere markers that suggest risk. Most care is now obtained after a considered decision by patient in consultation with a doctor. All of this gives us the freedom to make health care – our largest industry – function more normally like other industries.
Q: In your opinion, can the healthcare system be remodeled so that it benefits patients and keeps healthcare businesses profitable? Why/why not, and if it can be, how?
A: We need to realign industrial incentives with patient/consumer needs. Because the nature of care has changed, much of the demand in the industry can be bought more normally directly by consumers and through health savings. This means reducing the role of insurance – and reducing the complexity, administrative cost and economic distortions associated with health insurance. So for more healthcare services, the patient, not an intermediary, becomes the real customer. And by doing so, we completely restructure providers' incentives – realigning their economic goals to match consumer needs. We force them to chase consumers – to compete for business – on the basis of value, quality, service and safety.
Q: Many books and articles for the general public, like yours, have been and continue to be written about the dismal state of our healthcare system and industry reform. There may be a brief uproar but then it quickly fades away. If there is no buy-in from the public, can reform really happen?
[See also: Reading List: Fredric Tobis, 'The Healthcare Crisis: The Urgent Need for Physician Leadership']
A: That's absolutely right. There can be no meaningful reform without popular re-thinking about health care. But intuitively, most people already know something is fundamentally wrong. For an industry that employs so much advanced diagnostic and treatment technology, the face that most providers present to patients is of administrative confusion, lack of transparency, mind-numbing complexity, frequent errors and unimaginable cost. In the 21st century, we see such poor customer service in nothing else. When I make public appearances, I find little disagreement with the idea that healthcare providers lack a consumer focus, and a growing awareness that maybe making health care so special has merely given the industry a pass. So yes it will take time. But 315 million of us have at least one story of healthcare dysfunction.
Q: You write in the book that it will take many decades to untangle our healthcare system. What happens in the meantime?
A: A lot is changing already because of the growth of high-deductible insurance. Traditional healthcare experts think these matter because consumers will make better choices, but I suspect what's really important is that as the numbers of patients directly paying for their care reaches critical mass, providers will change their approach. I've had a high-deductible plan for years, and have a number of providers who cater to those paying out of pocket. It's a different experience. We can't construct a perfect system ever, much less overnight. But reform at the margins can have oversize effects today.
Q: Is there something about your book that I haven't asked you that you would like to add that you think is important for readers to know?
A: Many analysts of health care seem to revel in the system's complexity, but in some ways the problem is a simple one – industry incentives that aren't aligned with ours. No one can get rich in health care by offering better quality, higher efficiency, lower prices, more attentive customer service or even greater safety. In fact, any of those obvious improvements usually reduce profitability. And until that changes – until the incentives allow providers to make more money for achieving society's goals – we're not going to make much progress.