Five Principles for the Future of Healthcare
Bert R. Mandelbaum, MD, DHL (Hon)
May 03, 2017
The failure of the US Congress to repeal and replace the Affordable Care
Act (ACA) in March illustrated an important problem in the way that politicians
are thinking about healthcare. Politics should not determine how we care
for people in need. Rather than trying to accommodate our healthcare system
to a political ideology—whether it is capitalism, socialism, or
libertarianism—we should start with what the patient needs and build
from there.
The patient is not in the center of the maze we call the ACA. The patient
is off to one side and the physician is off to the other side. Despite
their protests about expensive risk pools in the ACA exchanges, the five
biggest US health insurers have done well since the act was implemented.
Collectively, their annual profits went up 17%, from $12.8 billion in
2013 to $14.6 billion in 2016.[1-9]That $1.8 billion profit was lifted from the pockets of patients and providers.
Table. Change in Top 5 Health Insurers' Profits Under the ACA, in Billions
of Dollars
Insurers
|
2013
|
2016
|
% Change
|
UnitedHealth
|
$5.67[1]
|
$7.29[2]
|
39
|
Anthem
|
$2.49[3]
|
$2.47[3]
|
-1
|
Aetna
|
$1.91[4]
|
$2.30[5]
|
23
|
Cigna
|
$1.48[6]
|
$1.90[7]
|
36
|
Humana
|
$1.23[8]
|
$0.61[9]
|
-127
|
TOTALS
|
$12.79
|
$14.58
|
17
|
What did the consumer get? Higher premiums. If you put the patient first—not
lobby groups, not payers, not the president—then we will do what
we need to do.
Everyone is going to be sick or injured sometime. We must do whatever we
can to keep healthy people healthy and take care of those who are not.
Rather than focusing on being for or against Donald Trump's healthcare
plan, let us focus on the health of the American people.
Mandelbaum's Five Principles
Here are the principles I believe we should use to shape our healthcare system:
1. Empower patients. Patients should be the masters of their fates. To help them, we must coordinate
the messages they are getting about their health. Instead of a mix of
messages from the American Heart/Cancer/Diabetes/etc Association, the
Academy of Nutrition and Dietetics, the Centers for Disease Control and
Prevention, the Department of Agriculture, and so on, let us create a
single portal with clear, evidence-based information.
Diabetes, heart disease, sarcopenia, and cardiac disease are causing so
many of the problems we see in our patients. We can empower patients to
lead healthy lives, taking advantage of technology such as biosensors
that connect to smartphones and activity monitors that measure how much
you walk, helping them focus on performance and prevention.
2. Expand access. Right now we are talking about whether people with preexisting conditions
should be able to buy health insurance, and how long kids should be able
to stay on their parents' health insurance plans. Let's keep it
simple: Everyone should be able to buy health insurance. Period.
3. Centralization. The market for healthcare coverage should not stop at state borders. In
Maryland, the Shock Trauma Center at the University of Maryland, a single
integrated trauma hospital, cares for people in Maryland, New Jersey,
parts of Pennsylvania, and beyond, and they do it much better than anyone
else. Everywhere else, gunshot victims may be treated in one place, car
accident victims in another, and so on. The University of Maryland is
the model for ultimate specialization in regional Centers of Excellence.
Similarly, if you could sell insurance over state borders, instead of insuring
1 million people in each state you could insure 100 million people across
states. That would increase the risk pool, attract more insurers, and
bring down the cost.
4. Stop cherry-picking. Some health plans want to skim the healthiest patients from the risk pool.
That may work very well as a business model, but it leaves holes in the
healthcare safety net. The government should provide subsidies to insurers
so that they can afford to take care of the very sickest people.
5. Optimize technology. We are already using technology to create a dense cloud of metrics about
our patients. There are smartphone apps that show how effectively you
have managed your blood pressure. We can look at a disease process with
thousands and millions of data points that we have never been able to
look at before. Artificial intelligence can help physicians manage and
assemble such data for research and diagnosis. Let's make that predictable,
personalized, participatory, and preventive.
Once we completely untangle the genome, there will be things that some
people need and others do not, and vice versa. We are already advising
certain patients about what they should eat and what drugs they should
take based on their genes. And we are learning how to modulate the immune
system to better fight diseases as well. There is going to be even more
precision in the future.
The use of robots has revolutionized prostatectomy, making it less invasive
and with less nerve injury and bleeding. The doctor sits 8-10 feet behind
the operating table, driving the robot to do the dissection. In orthopedics,
we have MAKOplasty, in which robots help perform partial knee replacements
using CT in a manner similar to navigating by GPS technology, and the
computer does not allow the orthopedist to put a partial knee replacement
in the wrong place! We also now have robots that can help a person walk,
remind a person to take medicine, and make sure they take the correct dose.
Four-dimensional endoscopy is coming to orthopedic surgery. In this technology,
temporal information is added to special information, allowing us to be
much more refined and efficient. With 4K video imaging, which displays
four times the number of pixels in full high definition, neurosurgeons
can now go through the nose and into the brain to find tumors and remove
them. Virtual and augmented reality can help train new surgeons through
simulations. Three-dimensional printing will improve the accuracy and
precision of medical implants and other devices, and will help us to better
visualize joints and organs.
Employing these five principles would get us a lot farther along toward
the healthcare we need than would politics. That is where we will end
up if we focus on what Hippocrates said over 2400 years ago: "The
regimen I adopt shall be for the benefit of my patients according to my
ability and judgment, and not for their hurt or for wrong."[10]
Let's make that guidance from the past central to our future.
References
-
United Health Group. United Health Group reports 2013 results.
http://www.unitedhealthgroup.com/~/media/UHG/PDF/2013/UNH-Q4-2013-Release.ashx?la=en Accessed April 25, 2017.
-
United Health Group. United Health Group reports 2016 results.
http://www.unitedhealthgroup.com/~/media/4F32B92CA7D74B509F37B32D0B649845.ashx Accessed April 25, 2017.
-
Anthem. Anthem annual income statement.
https://amigobulls.com/stocks/ANTM/income-statement/annual?f=pg Accessed April 25, 2017.
-
Aetna. Aetna reports fourth-quarter and full-year 2013 results.
https://news.aetna.com/news-releases/aetna-reports-fourth-quarter-and-full-year-2013-results/ Accessed April 25, 2017.
-
Aetna. Aetna reports fourth-quarter and full-year 2016 results.
https://news.aetna.com/news-releases/aetna-reports-fourth-quarter-and-full-year-2016-results/ Accessed April 25, 2017.
-
Cigna. Cigna reports strong full year 2013 results, expects growth in 2014.
https://www.cigna.com/newsroom/news-releases/2014/cigna-reports-strong-full-year-2013-results-expects-growth-in-2014 Accessed April 25, 2017.
-
Cigna. Cigna reports 2016 results, expects attractive earnings growth in 2017.
https://www.cigna.com/newsroom/news-releases/2017/cigna-reports-2016-results-expects-attractive-earnings-growth-in-2017 Accessed April 25, 2017.
-
Humana. Humana 2013 annual report.
http://phx.corporate-ir.net/phoenix.zhtml?c=92913&p=irol-reportsannual Accessed April 25, 2017.
-
Humana. Humana 2016 annual report.
http://phx.corporate-ir.net/phoenix.zhtml?c=92913&p=irol-reportsannual Accessed April 25, 2017.
- Kaba R, Sooriakumaran P. The evolution of the doctor-patient relationship.
Int J Surg. 2007;5:57-65.