Opening Pandora’s Box: Exposing Health Care Challenges Requires Tough Conversations

By Richard Watson, MD, Co-Founder, Motient
Twitter: @Motient_io

When I was in medical school, I painted houses for work. While my friends seemed to have medically related jobs, I was out on a ladder with a brush in hand, under the scorching heat of Kansas City. The money was good, and I had a wife and two small children to support.

It was good work, but it did have its interesting twists. We’d get a request to paint, and we’d go out to the address, measure, count the windows, look at the trim, and make a bid. One coat, two coats, scraping, pressure washing, repairing all the rough spots, all factors that influence the final dollar. We always added a fudge factor, trying to guess where the issues and labor would go.

Without a doubt, we would be painting the house and come across some issue that needed a repair period, so we would try to remove enough of the problem so that the owner could make a decision about how far they were willing to go to repair. Sometimes they just wanted to “caulk it and paint it,” meaning, ‘we don’t care what’s under there, just cover it up.’ Others would want to open it up and see just how extensive the problem would be. This process is known as “Pandora’s Box.” Some houses, of some vintages, are just massive maintenance money pits. And the more you open, the more you find. It can be a never-ending project!

When Your System Need More Than a Patch Job

There’s a lot of discussion around health care post-pandemic. The system is limping out of this current phase, but everyone seems resigned that these ebbs and flows are the new reality. Our company works in the area of helping facilities understand the movement of patients between facilities and helping in that process.

We’ve come to see how our cobbled-together reimbursement system is not prepared to deal with the changing healthcare landscape. Our per capita healthcare spending has ballooned to almost $13,000, about twice that of the next country. For that big-ticket, we have more hospitalizations for preventable disease, a higher suicide rate, and lower life expectancy. The difficulty in discussing any change in this environment makes the process seem fruitless. The bureaucratic nightmare that is our reimbursement system and our approach to providing private insurance is so complex, that there is no appetite to do any major repair. Instead, just “caulk and paint it”.

How to Open Pandora’s Box — and Transform It

Understandably, if the layers were uncovered, the Pandora’s Box would be unleashed. But make no mistake, to move the needle on this issue isn’t about antibiotic choices or readmission rates, it requires wholesale elimination of current segments of the non-direct patient care expense line. Hardly something bureaucratic systems with a heavy capitalist overlay are in the mood for.

Value-based care seemed to offer some solutions. It just seems that if you don’t change the rules, the bottom line looks the same regardless of who spends the money. Personally, I think this will take a greenfield effort. Go to where the change is happening and use that as an opportunity.

  1. We as a country have to embrace health. We can’t make the choices we are making individually without having to be financially responsible for those choices. Our unhealthy population that continually doesn’t bear the burden of those choices is crippling the entire system. We constantly are given examples of other countries with seemingly better healthcare systems only to realize that their population embraces health in a much a different way, than we currently do in the United States. These philosophical changes don’t come easy and most often it is necessary to start early in order to see a real difference.
  2. Paying for and delivering healthcare will need to look a lot different in the next 20 years. The tsunami that is the coming healthcare expense line cannot be supported under any reasonable financial basis. Connecting people and resources with the continuum of care model, utilizing targeted interventions, and careful allocation of diagnostic tools and treatments will be imperative. It is hard to believe that introducing new layers of technology to the system will actually make the system more financially sustainable. It seems that every layer of technology just adds a layer of opportunity for those in the business of paying for health care. Resource matching will be necessary at every level.
  3. Novel models need to be embraced. The Rural Emergency Hospital is just now being explored. A novel payment method tied to a very specific set of services in the discrete locale might have some chance. But it will only have the chance to be effective if the bureaucracy is not there. The system must be willing to let go of the encumbrances that are dragging it down. The increasing costs of electronic health records, quality metrics, and numerous layers of middle managers and marketing people end up hurting patients and patient care. It’s not hard to argue that in spite of all of the technological changes over the last 20 years, we have done little to advance true patient care and outcomes.

There’s no doubt that we are at a crossroads. The choices that are made in response to the struggle we have come through will be solidified for the foreseeable future. The will and the perseverance to get to the real issues, not just the quick patch and paint, will truly transform health care.

This article was originally published on the Motient blog and is republished here with permission.