A Tangled Mess of Incompatible Motivations

The healthcare debate in the U.S. has been THE hot topic of the summer of 2009. My Twitter posts have been hammering on that particular drum like a shaggy Muppet. It's time to step back and logically examine the motivations of four of the current players in the upside-down craziness we call our for-profit healthcare system in this country, if for no other reason than to figure out why they act as they do. The four players are care providers (doctors and hospitals), insurance companies, pharmaceutical companies and the patients, and each wants something slightly different from the healthcare system. It is these different desires that are at odds with each other, and that opposition is contributing to the declining quality of healthcare in our country.

In a for-profit system, three of the four players compete for the attentions of the fourth and most important player, the patient. The patient is the ultimate source of profit for those three players, though not always in the most direct manner. The patient's motivations are easy enough to decipher, because we all share them. No matter if you are rich or poor, male or female, no matter what race or creed, religion or sexual preference, you access the healthcare system for one reason only: you want to be healthy. That's it, you want to be healthy. Unfortunately, the for-profit system has added a qualifier to that desire. Everyone wants to be healthy, and will do everything within their means in order to achieve that health. The for-profit system restricts that health based on the financial means of the patient. Everyone wants to be healthy, but no one wants to go bankrupt doing it. After all, if your cancer is cured but you lose your home and can't afford to feed yourself, the cure is akin to burning the grass to mow your lawn. Yes, your grass is indeed controlled, but it looks like the aftermath of Hiroshima and smells like gasoline. People want their health so they can enjoy their life as it is, not so they can move into a van down by the river. I'm sure most patients could care less who treats them so long as the end result is health without financial ruin.

The other three players have entirely different motivations, and it becomes most apparent when you consider what type of patient these players desire the most. Care providers, such as hospitals and doctors, are paid based on the services they render, whether that be an MRI, 20 minutes in consultation with a patient, an X-Ray, a surgery, or a hospital stay. Their most profitable patient is likely someone who is just sick enough to need plenty of care but not terminally ill. This ideal patient is also someone with the financial means to pay every time services are rendered, whether they pay directly or through an insurance provider. Healthy patients are no good to them because they don't need that many services. Poor people can't pay, so in addition to the costs of providing care and the time they take away from patients who can pay, poor people cost more because the provider often has to pay for collection agencies to extract as much money as they can from the non-paying clients.

Pharmaceutical companies want patients that are very similar to a hospital's ideal patient. As long as you're just sick enough to need constant medication but not sick enough that the medication is only delaying the inevitable, you are manna from heaven if you have the means to pay. In addition, if you need help for a condition that doesn't threaten your life like impotence, you are even better. No one NEEDS Viagra - it could go away tomorrow and the patients who use it wouldn't die. These drugs are very similar in my mind to things like alcohol or tobacco without the deadly side effects. Get the patient hooked on the euphoric feeling the drug provides, and they will keep coming back so long as they can pay. But people who can't pay for even the basics of care without significant hardship? Like care providers, pharma doesn't want them either.

Insurance companies, however, want a completely different type of patient. Their ideal patient isn't a patient at all, it's a healthy customer with the financial means to pay premiums. Premiums are revenue, revenue leads to profit. But the minute a patient needs to use the insurance product, they are a drain on the insurance company's revenue. Paying claims is a loss. The most profitable patient is the one that never uses the service.

With that in mind, it becomes obvious that providers and pharma are at odds with the insurance companies. Hospitals and pharma need patients that use their services, but insurance companies need patients who do not need those services. When those services are used by patients, it is in the best interests of the insurance companies that the prices for each service are as low as possible, while the care provider and the pharmaceutical companies want to charge as much as the market will allow. The patient wants to be healed with minimal financial loss and minimal interference.

How do you reconcile such conflicting desires? As a matter of policy, which desire should the government pay most attention to when discussing reforms? Is it the care providers, who want patients to use as many of their services as possible? Is it the pharmas, who want patients to use as many drugs as possible? Is it the insurance companies, who generate huge profits from not providing their services? Or is it the patient, the people part of the whole "We the people" form of government?

Government policy must put the needs of the whole community first in a system founded on the principles in the U.S. Constitution. All four of the players in this drama have financial motivations as a component of their desires. Is it more important for hospitals to make a profit than for insurance companies? Since hospitals provide the care that saves patients' lives, I would lean towards the hospitals. Should pharmaceutical companies be more important than hospitals? They are likely to be co-equal if not slightly less important than the hospital itself. In all this, insurance companies are the least important - after all, their function is that of a facilitator of payment. While their function can certainly ease the burden of the sick, are we any better off for having a third party extract a fee for shuffling paperwork instead of dealing with direct payment for services rendered?

But what should become readily apparent in all of this is that none of these entities exist, none of their profits are possible without the patient. If no one gets sick, the providers do not get paid. If no one needs to pay for treatment, insurance companies have no function. If all the patients die off, no one gets paid. The source of all the profit in the system is ultimately the patient. And since every single last one of us will be a patient at some point in our life, the patient IS the most important element in the entire healthcare system. Government policy must absolutely center on the patient, and the patient's desire for health without financial hardship must absolutely take precedence over any other desire.

There may well be room for profit in a patient-centric system. We can argue over the amount of that profit, or the recipient, as there are valid arguments to be made on all sides. But those arguments must never, ever forget that without caring for the patient, there can be no profit.

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