Quora Question: Is Healthcare in the U.S. Failing?

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Supporters of the Affordable Care Act celebrate after the Supreme Court up held the law in the 6-3 vote at the Supreme Court in Washington June 25, 2015. People who bought subsidized health insurance through the federal exchange expressed relief about the King v. Burwell ruling. Joshua Roberts/Reuters

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Answer from Michael Critelli, former member of Institute of Medicine Roundtable on Science & Value-Based Care:

What are the differences in the healthcare systems that account for the poorer outcomes in the U.S? Before answering this question, I would caution you to study how outcomes are measured. For example, some countries measure life expectancy differently than others, and have different reporting on outcomes of healthcare procedures.

There is a great deal of research that supports the proposition that healthcare only accounts for 10 to 20 percent of health outcomes. The remainder results from economic, social and community issues such as whether we have affordable housing, communities that are safe from violence, walkable communities, good and safe work environments, access to healthy food and beverages, and community layouts that encourage physical activity. Our physicians are very good, perhaps better than others, but they start with sicker patients. In other words, our healthcare system starts with tougher challenges than do many others.

That being said, there are several structural problems with our healthcare system:

  • We over-reward specialists and under-reward primary care physicians. Other countries have systems that cause patients to get more coordinated care led by primary care physicians. We allow too many patients to wander around the healthcare physicians consulting with multiple specialists, which means that, in many cases, the care a physician delivers is done inappropriately because he or she does not have all the relevant information.
  • We rely too heavily on expensive diagnostic imaging tests and under-reward primary care physicians and specialists who try to get to the root causes of a healthcare problem. We structure our system to cause healthcare providers to default to redundant and, sometimes, harmful testing and surgical procedures.
  • We devote too many resources to people who are at the end of their lives, trying to keep them alive a few days or weeks longer, instead of intervening earlier and helping them be healthy. We have a “sick care” system, not a healthcare system.
  • Government over-regulates the details of healthcare processes, and under-regulates results. Doctors are micro-managed, and each claim has an expensive processing system. We should move to accountable care, in which providers are rewarded for delivering high quality care at lower cost, not trying to scrutinize every single healthcare event.

Ultimately, we get what we pay for: a system in which many people make money doing the wrong things. The people benefiting from our existing system are not the patients or the doctors who achieve good results, but all the intermediaries, both private and government, who have turned our system into a profit and political favor-dispensing machine, as opposed to a healthcare machine.

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