Decoding health care: How we pay for it and how we can improve it

Part one: Why bother?

Health care in the United States is hopelessly broken.

Or is it? Typically that introductory sentence is followed by a laundry list of all the things that are wrong with no attention to what is right. And often that opinion is offered by someone with an axe to grind, more often than not a politician. I am not about to defend the shortcomings which we can concede require attention. But many of the criticisms are not particularly thoughtful or analytical and focus on dog whistles. And what makes this particularly maddening is that most Americans do not really understand how the system works, and so cannot form an educated opinion on the topic of the day. Instead they echo the sentiment of whatever talking head is of their political persuasion. And as we learned the hard way during Covid, introducing politics of either flavor is not a good way to foster dialogue and progress in health care.

So I humbly offer to share my views as an insider about what people should know about how this complex system works. Of course these are my perspectives and my opinions. But I do have some bona fides. I went to a top notch medical school, Washington University in St. Louis, and did my internal medicine and hematology-oncology training at another top notch program, the Hospital of the University of Pennsylvania. I was on the University of Oklahoma medical school faculty for seven years, then went into private practice in upstate New York. While in practice, I pursued a career path as a physician executive with US Oncology, the largest private practice oncology network in the US. After 15 years, I left practice to become national medical director, Oncology Solutions, at Aetna. I subsequently have worked at a health care start up and as a health care consultant, working mostly with the pharmaceutical and diagnostic industries. I have worked for just about every segment of the health care universe except the government although I have had many opportunities to work with them (and these have been positive for the most part). I have seen it all: the good, the bad and the ugly. And I would like to start a discussion about some of the things I have seen, and start talking about ways we can make things better. By the way, if you want a flavor for the types of things I have done, Google me.

Probably a good way to start is to defend my view that most people do not really understand how health care “works”. The best data involves surveys of consumer understanding of health insurance. These surveys ask people to define premium, deductible, copay, etc. Some of the best information comes from the Kaiser Family Foundation and the Robert Wood Johnson Foundation. These surveys of a “representative population” ask people to define terms they are likely to encounter whenever they pay a medical bill. And it should come as no surprise that “normal people” are often unable to do so. In fact, about half struggle with the terms premium, deductible and copay. Recent surveys have asked the same questions to Black and Hispanic groups and the results are even more concerning. The answers track with socioeconomic status, age, and education across all groups, ie richer, older and more educated score higher.

Now like all surveys you need to ask yourself if the “representative population” is really representative of the population as a whole. And how you ask the question can elicit wildly different answers. These are acknowledged shortcomings of this study methodology (facts we seem to regularly forget when the popular press talks about health care). But these results are believable. Anyone (including me) who has received an EOB (explanation of benefits) from an insurance company that explains how and why a medical bill was paid has experienced some degree of befuddlement. Importantly, less literacy translates to bad decisions about health care, like the decision to avoid care altogether. Now take the discussion to the next level. How much do people know when we start talking about health care delivery and payment on a more global level? Instead of talking about co-pay, we talk about pharmacy and medical benefit design. As far as I know, there is little or no data about literacy at this level. In my experience, this type of literacy is lacking, even among folks who work in the health care industry.

Why does this matter? Let’s use your relationship with your car as an analogy. You probably know how to pump gas and put air in the tires. But do you know how to fix a flat or change your oil? And how about judging whether the issue is your alternator or your battery? Or whether all Americans should give up their gas guzzlers and be required to transition to electronic vehicles? That is in essence what Bernie Sanders wants you to do with your healthcare (and probably with your car, too). By the way, I chose Bernie Sanders because if you search “health care system is broken” his name comes up several times. Now this is truly an apolitical column. But the truth is that most Americans really do not have the fundamental knowledge base that will allow them to participate in an informed fashion. They get their information from the television (especially cable news), or social media or occasionally the newspaper. I believe that this topic is much too important to delegate to these sources.

So my goal is to discuss a variety of topics that are key to understanding health care delivery and payment, rather than debating the premise that health care in the US is hopelessly broken. Since I am an oncologist and have focused on cancer care my entire career, I will address these issues in the cancer population. Since almost everyone has a personal experience with cancer I hope this feels right. I would like to engage everybody, including folks who are regular working people who would just as soon avoid all interactions with the medical system, as well as my colleagues who wake up every day to work in some way in the health care industry.

I am certain not everybody will agree with me, but I do not mind. Once we can agree about what is going on and what is at stake maybe we can have a civil exchange about the best way to make health care better. Ultimately, we should be able to make decisions for ourselves rather than buy a new car based on what a politician tells us to do.