The rip-off

Have you or any of your loved ones experienced our health care system lately?

If so, how was that experience for you?

Were you pleased with your care? Were you able to access the system easily? Did it treat you with dignity, respect, and competence? Did you feel well after your engagement with the system? And were you satisfied afterward that you got what you paid for?

Or did you feel like the system failed you? That it addressed your acute illness but not your overall health? That it moved you around like a cog in a vast machine? That it never met your unique need? And ransacked your pocketbook in the process?

According to a study by Fidelity Investments, a married couple in their 60s in the U.S. will need an average of $245,000 to cover medical expenses before they die. That figure doesn’t even include over-the-counter drugs, long-term care, and most dental care.

My wife fell and hurt her hand some time ago while playing tennis. We went to an urgent care center close by. The nurse practitioner on duty spoke to her for not more than a minute or two and never examined her hand. She did order an X-ray, which fortunately showed no fracture. The total bill for this visit? Over $1600. The contracted insurance rate knocked the cost down to a little over $600.

Mind you, this was a simple health matter. In our experience as front-line community physicians we’ve found that as the illness gets more complex, it only gets worse. Perhaps you’ve experienced the same.

Does it seem to you, as it does to us, that our health care system is at a critical crossroads?

I’ve discovered his weakness

We love Superman. Not the newer Superman films, but the Christopher Reeve Superman.

There’s a scene in Reeve’s Superman II in which the villain General Zod is fighting Superman high above the streets of Metropolis. Zod sees Superman saving the citizens from his mayhem. Before this point, Zod doesn’t know what Superman is really about. Now he thinks he gets it:

This “super-man” is nothing of the kind; I’ve discovered his weakness…He cares. He actually cares for these Earth people.

Many doctors we know actually care for their patients. But the changes in medicine being touted as the “new health care” are eviscerating our power. And we don’t feel so super anymore.

To understand why, it might help to outline the trajectory of health care so far.

Health 1.0

With the Scientific Revolution, we set off the human body and mind from the natural world and the divine. This move led to modern medicine as we’ve known it.

“Health 1.0” has dramatically increased our lifespan. But it’s essentially run health care as a cottage industry without evidence-based guidelines, quality measures, or standardization. You mess with my physician autonomy and my patient’s autonomy at your peril. And volume trumps value.

So we’ve done excessive tests and procedures and practiced wasteful, unreliable medicine.

We’ve realized that Health 1.0 has shortchanged the quality of our health care.

And nearly bankrupted us.

Health 2.0

“Health 2.0” seeks to upgrade health care into a 21st –century industry. We no longer see health care as a fragmented, piecemeal jumble of individual patient-doctor interactions. It can actually be an integrated system for delivering standardized medicine across different systems. Communal guidelines have priority over my physician autonomy. And I’m rewarded for the value of the health care I provide, not the volume of health care I deliver.

In Health 2.0 evidence-based medicine comes fully online, and adoption of the electronic health record is central to its cause. Silicon Valley promises to track, data-mine, and algorithmically diagnose anything and everything that can be measured. From health IT emerges the “e-patient,” who uses electronic information systems to assume an equal partnership with the doctor.

Sounds great, doesn’t it? And in many ways it is. There can be no going back to a health care system that was evidence-ignorant, volume-based, and cost-unconscious.

But we argue that Health 2.0 isn’t playing the highest game to be played in health care.

Perhaps the biggest reason for this is that doctors have become disengaged from a health care system that’s not honoring the sanctity and uniqueness of the patient-doctor relationship. A relationship that can’t be pigeonholed into the generic flatland of quality measures and performance metrics.

And in not getting this crucial relationship right, Health 2.0 misses the mark.

Physician Danielle Ofri writes about an encounter with a patient in her forties who asked about getting a mammogram. Dr. Ofri knew evidence for this screening test in this age group has been quite conflicting. But a memo from her department administrator was urging her to order the test. Why? Because regulatory agencies were using mammograms as a “performance indicator” to grade her hospital’s quality of care.

Dr. Ofri spent extra time explaining the controversy regarding the test. The patient decided to have the mammogram. But if she hadn’t, Dr. Ofri’s performance indicator would have been penalized.

So who’s offering the higher level of care? The doctor who shepherds her patient through the messy imperfections inherent in much of medical decision-making? Or the doctor who plays to the metric?

In the midst of this fundamental void embedded in Health 2.0, many doctors are just checking themselves and their practices out of the story. They’re selling out to big hospitals and health care systems.

Or they’re simply hanging it up.

When you have the keystone of our health care system, the doctor, checking out — you’ve got a problem. It seems “Big Medicine” isn’t fulfilling us. For all its merits, we feel impotent in Health 2.0’s shadow.

Health 3.0

It’s high time to present a viable alternative. A health care system with greater depth than Health 2.0. One that doesn’t regress back to a paternalistic medicine of the past, where power was exclusively in the hands of the physician. Or careen forward to a faceless medicine where power is being transferred to administrators, algorithms, and inhumane EMRs.

In “Health 3.0,” technology won’t be a tool for meaningless abuse. Everything that can be automated will be. But the patient’s visit to a Health 3.0 clinic will feel anything but automated. He’ll feel like he’s entered a sacred space for healing, where everyone from the receptionist to the billing staff is invested in his being well.

As doctors in Health 3.0, we’ll present ourselves as what John Mackey, cofounder of Whole Foods Market, calls servant-leaders. We’ve renewed our calling to the practice of medicine: not to an insular, antiquated practice of yesteryear, or to one that caters to the lower common denominators of health. No, we’re in service to something bigger and deeper. This gives us great power.

We ground this power in the time-tested patient-doctor relationship. We listen to the patient with full awareness and presence. We’re actively building the trust so critical to this relationship. This trust allows both the patient and us to be appropriately accountable to each other. We’ll have the patient bear the responsibility to help herself to health. And she’ll have us bear the responsibility to guide her.

The relationship isn’t so much equal and symmetric as it is a full embodiment of what both of us can bring to the table. The e-patient is expected to take an active role in the management of his health. And he gets to decide what fits best with his own unique needs and treatment philosophy.

But unlike in Health 2.0, we are “e-doctors.” We feel empowered to enlist our unique knowledge, experience, authority, and autonomy in teaching the patient how to manage his health. And we’ll seamlessly blend our autonomy with communal guidelines.

In this more enlightened health care system, we practice evidence-informed medicine. Not evidence-ignored medicine or evidence-enslaved medicine.

We won’t order a bunch of unnecessary, costly tests and procedures that aren’t evidence-based. We’ll recommend medications where necessary, in accordance with well-designed trials. But we’ll also examine the patient’s diet, stressors (environmental, community), and unique purpose. Because we know these things matter to her well-being. Through both experience and intuition.

We welcome metrics. But metrics aren’t just meant to standardize doctors to shifty, population-based guidelines. As said in the past by The Wall Street Journal:

the illusion that science can provide some objective answer that applies to everyone…is a special danger.

More sophisticated metrics can measure and validate what’s real in health care. Not just what’s true. But what’s beautiful, and good. So we can fairly judge what’s working uniquely for the patient. And ourselves be fairly judged on the results.

Let’s say our patient is sick enough to need hospitalization. Imagine him being admitted to a hospital where all the principles of Health 3.0 are fully online. Where doctors and nurses practice acute care medicine and “root care medicine” side by side. Where his care is carefully coordinated among his health care team, instead of multiple specialists parading into his room with little clue as to what each other is doing.

And where administrators actually view the hospital as a cost center, not a profit center. Their entrepreneurial goal isn’t to play the dubious game of keeping hospital beds filled with patients just sick enough to utilize a smorgasbord of high-dollar services, while getting them out before the length of stay eats into profits. They don’t engage in a medical arms race with other hospitals to see who can market the biggest, baddest equipment in town — especially when evidence supporting the equipment is questionable. They don’t lobby Washington cronies incessantly to prop up their mercantilist medical complexes. They’re not interested in doctor-employees churning out health care dollars, in a mad effort to grab a bigger piece of a finite health care pie.

No, these administrators actually seek to grow the whole pie. They’re invested in a deeper, more integrated health care system that will be profitable to all stakeholders — doctors and other health care professionals, patients, families, nurses, researchers, employers, employees, lawyers, lawmakers, taxpayers, and the administrators themselves.

And as one of the key stakeholders, we physicians will be tapping into the spirit of the entrepreneur. We’re value creators, not wealth stealers. And we’re creating something more transformative than, say, some clinic in Walmart where we’re just a commodity in the business of medicine.

We’re transforming the patient’s relationship to illness and wellness. But the beauty is, it’s a two-way exchange. In the process of helping her, we ourselves are transformed. Because what we’ve done together is to bring out in each other our unique selves: the irreducibly personal essences of who we are, from which our unique gifts flow.

We’ve invoked our patient’s unique self to uplift her to renewed health. And she’s invoked our unique selves to rejuvenate our calling to the practice of medicine.

In this relationship of connection and trust, health care itself is transformed.

We care

General Zod didn’t get it. He didn’t discover Superman’s weakness. He discovered his strength.

We care. And we need a system that renews our care, rather than beating it into submission.

Health 1.0 is over.

Health 2.0 isn’t good, beautiful, or true enough.

Let’s play a much bigger game. Let’s create a unique symphony of servant-leaders, who call one another to our unique selves so that together we reclaim our health, power, and well-being.

Health 3.0.