The practice of great medicine has become much simpler. Health care is the barrier.


We pay more than any other country for health care, yet we have suffered the biggest drop in life expectancy since World War II. Something went wrong. In an era of record inflation and rising taxes, isn’t it time to ask ourselves where the money is going, what exactly we are paying, and why?

Surprisingly, nearly half of the federal budget goes to health care one way or another. Either directly through Medicare and the ACA or indirectly by paying federal employee health benefits. Health care is the biggest line item for any organization after payroll, and government is no different. When you look more closely at healthcare spending, only 27% goes to individual patient care. The rest is devoted to the management of this care.

This means that a third of our tax money goes to insurers, agencies and benefit managers who are responsible for setting the price of everything from pharmaceuticals to surgical procedures. This requires volumes of data collection which ultimately calculates risk and allocates resources. If that sounds like rationing, it is, and we are paying the price.

But in the age of technology, when a patient can be given a cancer pill rather than being admitted for intravenous drips or going home immediately after joint replacement surgery, medical care has become much more efficient and less expensive. Bernie Sanders has a heart attack, is treated, sent home the next day and is back on the campaign trail a week later. The price of his heart stent is one thing, but the cost of recovering him is nil because the system in place to help him recover is no longer needed. It is the family’s responsibility to take time off work or find resources to support themselves. These costs are not taken into account and are not compensated.

We talk about the social determinants of health, but what we really mean is that when we move care out of the controlled environment of a hospital, we have to be prepared for uneven outcomes. If a patient lives alone on a sixth floor with no elevator or in an assisted living facility with 24-hour services, these results will be different. But we are spending little or none of the money spent on health care to address it. Instead, we are funding an elaborate complaints and denial system to manage the cost and quality of care within a structured, data-driven system that has so far failed badly on both counts. .

The truth is that practicing excellent medicine just got a whole lot easier; health care is the barrier.

So what to do? If we only need 27% of the cake for medical care, why not take the remaining two-thirds and reuse it? What if we gave it back to the patients? Provide federally funded health savings credits to patients who stay healthy or pay out of pocket to see their doctor. Medicare patients could be eligible to receive 100% coverage for the big stuff if they choose to pay for the small encounters out of pocket. And those below the poverty line could have health vouchers, much like a food stamp, which guarantees access with choice. Cashback and participation only require transparent pricing.

A hybrid model means fewer complaints, fewer rejections and better service. It also means fewer opportunities to share or breach data. More and more often, it is cheaper and faster to pay out of pocket than to wait for insurance approval each time you need care. Stories occur daily of people expecting their insurance to cover their medical bills only to find that if they had paid out of pocket it would have cost a lot less than the surprise bill in their inbox.

Patients have had the right to informed consent for nearly 40 years. During this time, medical information has become universally available. We no longer practice a paternalistic model of care, where the doctor knows what is best for you, so why are we asking an insurer? We work with our patients in a more collaborative approach. Not only do patients pay for their care, but they also bear more of the burden of recovery. Our system is not designed for this. So why do we keep asking permission to receive the care we’ve already paid for? In the age of informed consent and price transparency, managed care has no place. It’s time to redirect that money to better serve those responsible for improving outcomes: patients. Let’s start asking lawmakers for a new plan, if we don’t do it soon, the health care budget will swallow us whole, and there will be nothing left to pay for our medical care.

Paula Muto is a vascular surgeon.

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