How To Understand U.S. Healthcare? Follow The Money | Dr. Jonathan Burroughs | TEDxWolfeboro

what went wrong with the United States healthcare so we spend twice as much as everyone else in the industrialized world and we don't even live as long as 36 other countries in the industrialized world what happened what I'd like to do is share with you the problem and then hopefully the solution so what's the problem the first issue is perverse incentives so have you ever thought to yourself why do surgeons make so much and doctors that take care of your children or take care of your cognitive issues make so little well it turns out that the answer is in a little game I call follow the money you see whenever I don't understand what's going on in the United States I play follow the money and then what seems irrational and strange to me suddenly becomes rational and clear so it turns out that Medicare through the Medicare Payment Advisory Commission sets the rates for doctors and hospitals get paid for everything they do Congress oversees Medicare and of course we know PAC dollars political action committees pay for politicians to get elected now if your are Siemens or General Electric or Hewlett Packard what do you want in exchange for your millions of dollars that you spend getting politicians elected well of course you want to return on investment on the stuff that you sell so the idea is for Medicare to reimburse doctors and hospitals at a sufficiently high rate that they'll want to do more of your stuff whatever that stuff is so we have a reimbursement system that's based on return on investment for stockholders and investors and has almost nothing to do with human health now I will tell you in other countries of the of the world people get paid for keeping people healthy but that's not how fee-for-service works in the United States we get paid in the United States for doing procedures and tests that are a benefit to suppliers and by the way end of life is a one trillion dollar business did you know that 40% of Americans died in hospitals every year and 20% died intensive care units and the sad thing is these people are going to die anyway in every other country of the world people die at home with the families they love in comfortable peaceful surroundings but in the United States we've created a huge 1 trillion dollar industry on taking care of people in the last six months of their life many of my colleagues complain that when they have a quality initiative and they be able to cut complication rate or death rate the the chief financial officer complains that you've now cut my revenue because now the people are leaving the hospital sooner or not getting a sick or not getting as many complications we're not making as much money you see the problem is we get paid for sickness and not for health we get paid for procedures and tests and not for people keeping people healthy and that's a serious problem the next issue is non-value-added variation both clinical and administrative my colleague Atul Gawande a physician in Boston wrote a wonderful article in 2004 called the bell curve and he demonstrated that with children and adults with cystic fibrosis your life expectancy will be as much as 25 to 30 years different based on where you go to get your care and which doctor takes care of you that's a huge amount of variation in terms of spending doctors spend as much as a thousand percent difference taking care of the same patient with the same diagnosis based on their own particular clinical patterns and administrators spend up to 30 40 50 % differently managing labor and supply chain you see in the 20th century we created in health care what's called a cottage industry that basically means that every doctor treats the patient the way they want to not necessarily according to evidence and administrators in health care have done the same thing they've run their hospitals the way they wanted to and didn't have to follow any scientifically sound basis or use analytics or use shooter's to help guide them in their management so we have way too much variation in fact clinical and administrative variation is now the third greatest cause of death in the United States and our healthcare system behind cancer and heart disease so what we have to do in this century is somehow eliminate the non-value-added variation that has caused so much harm to so many people and finally the third major problem with our healthcare system is our government is going bankrupt from healthcare and Social Security so how did we ever get to 65 is the eligibility age of Medicare well it turns out it all started back in 1875 when kaiser von vilhelm and Otto von Bismarck created the first social security system in Western Europe you see at that time Otto von Bismarck wanted to create an entitlement program for the elderly and he asked his actuarial he said find me the age at which only 3% of Germans are still alive and the age they came up with was 70 well because of politics they had to negotiate down down to 65 but 60 years later when Franklin Roosevelt started the first Social Security system in the United States he used Otto von Bismarck Stata and 30 years after that when Lyndon Johnson and Wilbur Mills created hicfa the precursor to our now Medicare and Medicaid they used the same data so as it turns out eighty percent of Americans lived to the age of 65 and at the age of 65 they have a 20 year life expectancy more for women less for men that means we've created a Ponzi scheme that means we've created a system whereby 20 percent of Americans support eighty percent of Americans for 25 percent of our lives and that's not what entitlement programs were set up to do they were meant to be a safety net for people with healthcare issues at the end of their life not in the middle or the middle end of their life it was never meant to be for a quarter of their entire lives so somehow we have to fix the entitlement programs now a simple solution would be for healthy people who can afford it they can be given the option of not collecting Social Security and Medicare until they're older in exchange for better benefits I would personally defer my Medicare till I was 80 if I knew that when I got to 80 I could get my supplemental covered get my pharmaceuticals covered and get my long-term care covered that would me give me a sense of great security and I would be happy to forego the Medicare for the next 15 years but Congress and our political system is not quite ready to take that on so what's the solution what do we have to do to make health care workable in the United States and make it the health care system that we deserve well the first thing is we have to digitize health care how many of you remember the days when in order to make a deposit or withdrawal in a bank you had to take a bank book during banking hours go to a bank and see a banker and of course we used to laugh about bankers hours because they were between 9:00 a.m. and 3:30 p.m. Monday through Friday because they had to spend the last hour and a half counting their money and I remember taking that little bank book in and getting it stamped and being able to either withdraw money or put money in and deposit well that sounds crazy today in 24 hour ATMs when any day of the week any time of day any country were in we can deposit withdraw money at our on demand well health care has to go there to see right now to get my medical record I have to go to a hospital sometimes I get into a portal but the portal doesn't have most of my information so I have to go to AB Hospital sign a release during hospital hours when the medical records department is open signed the forms so I can get a portal where I can get part of my medical information and if I go to two hospitals I have to go to two portals or go to to hospitals during hospital hours to get my medical records well that's obviously a crazy way to deliver healthcare services so we need to digitize healthcare so that we can get our information anytime we want wherever we want whenever we want because it should belong to us and not to a hospital so we have to digitize all of healthcare also if we want to access information about our health we should be able to go on to a cloud-based system that we can download our health information and get health care advice 24 hours a day seven days a week so digitalization is one of the ways in which we can make health care better number two standardization remember the Atul Gawande he demonstrated there was a doctor at the University of Minnesota that if you saw that doctor in you at cystic fibrosis your average life expectancy would be thirty years longer than almost everywhere else so when there's an evidence-based best practice we have to require physicians and administrators to utilize that best practice it shouldn't be up to the individual physician any longer how to take care of each and every patient if there is evidence that there's a better way to do it and the same thing is true for health care experts and administrators if there's a better way to manage labor costs or supply chain costs or to manage the cost of running a hospital or healthcare system and there's a better way to do it and there better tools to do it we should require our healthcare leaders to use those tools we want to narrow variation as much as possible so the difference between the best care and the worst care is actually very small and that's because everyone is following evidence-based practice so in the 21st century we have to eliminate what's called non-value-added variation that harms people or it causes them to die prematurely number three we have to commoditize care now commoditization or the race to the bottom means that healthcare is way too expensive we have to lower its costs and quickly you may not know this but health care is the number one cause of personal bankruptcy among working Americans with health care insurance in fact if you want to render a family insolvent bankrupt the easiest thing to do is give them a case of cancer or hepatitis C the out-of-pocket expenses can be as much as 50 to $100,000 a year the average American family has enough savings to last for 3 months if you were to cut off their paycheck and throw some chemotherapy at people or radiation to people at three and four times the cost of that same treatment overseas is to literally put the security the economic security of the average American family in jeopardy and we have to stop doing that so what's one solution well I got to use that solution not so long ago when I had a nasty dermatitis of my wrist and it was four o'clock in the morning on a Sunday and I had to see a client I had to see a client the next day and I was saying where can I go and what I did is I took out my phone I took out my iPhone and I pushed on an app and I looked at the phone and I looked at the doctors and I had 36 doctors to choose from and I chose a board certified internist and I had to wait a full two minutes for that doctor to come on the phone and she took a history and did a physical she looked at my ears my eyes my mouth my heart my lungs and I was astonished at how good the examination was because I was a practicing clinician and actually the view of my ears and the sounds of my heart and lungs were better than I ever had with a stethoscope or an otoscope when I used to look through people's ears and she looked at the rash and she says it looks like a dermatitis and I says that's what I think it is and she said what's been helpful to you in the past and I told her and she said well I notice on the GPS system there's a Walgreens right across the street from the hotel would you like me to phone it in and have them deliver it to your hotel room I said that would be terrific so 20 minutes later a young man came with my medication I paid for the medication went back to bed the entire interaction took a little over 24 minutes and it cost $59 that's an example of a smart way to get routine care today you shouldn't have to go to a doctor's office sit in a waiting room be with a nurse for 30 minutes only to have five minutes with a doctor pay a higher fee than what I paid and basically spend half your day getting care that is really routine so we have to figure out ways creative ways to make health care much less expensive without sacrificing quality and by the way I believe in giving people a choice about that if someone wants to pay extra to see their doctor that's absolutely fine or pay a little bit extra to see a nurse practitioner that's fine and if they want to go to retail clinics that's fine and if they want to use their iPhone or smartphone that's fine too so what we need is to give people options different cost options which to get healthcare systems and then finally the last solution is globalization you see we don't know it but we're actually in competition where the rest of the world and let me explain there's a company in Boston called patients Beyond Borders and it's the largest medical tourists travel agency in the United States and what they do is they find lower-cost options for Americans who cannot afford healthcare in the United States to go abroad and get treated for instance you can fly to Germany and get chemotherapy for 90% less than you can in the United States and it can mean the difference between having cancer and getting treated and not going bankrupt and having cancer and getting a treated and going bankrupt so medical tourism is now the fastest growing industry in the United States it's now 2 million Americans go overseas every year for health care and it's a hundred and twenty five million dollar business that's set to double every two years and now large companies are sending their employees to health care systems that are willing to guarantee quality and cost at a significant savings for instance Mass General in Boston does business with Riyadh Saudi Arabia Virginia Mason in Seattle Washington does business with Tokyo Tokyo does the business with Beijing China and people fly from Beijing China to Tokyo and from Tokyo they go to Seattle Washington why to get guaranteed care with guaranteed quality at a fraction of the cost so we have to understand we're in competition with the world and we have to create a health care system that is cost-effective that is standardized that is commoditized and is digitized so I'd like to leave you with the final quote general Tsin Seki the former Joint Chiefs of Staff and also former head of the VA hospital system once famously said if you don't like change you're gonna like your relevance even less and it's critically important for our healthcare system to understand that we're not a cottage industry anymore we have tools like analytics and data that can help us to practice evidence-based medicine we can eliminate variation we can make health care less expensive we can compete on the global stage and we can digitize health care so everybody can get the health care they need anytime anyplace anywhere they want and then we can have the health care system that we all deserve thank you

Channel: TEDx Talks

Views: 82,876

Keywords: TEDxTalks, English, Health, Disease, Ideas, Illness, Medicine, Public health, Social Change

Id: mTXVcwVVjoQ

Length: 16min 56sec (1016 seconds)

Published: Mon Jun 11 2018