Escaping the broken health care escape room – GWC Mag

Escape rooms have become very popular. Entering a room of seemingly unconnected clues with a group of family members or coworkers creates a sense of fear and excitement that ultimately leads, if successful, to a great sense of accomplishment and relief. The entire experience is designed to enhance trust among team members and inspire confidence in working together to solve difficult problems. When it comes to improving the health care system, there is no shortage of collaborators, innovators, and policy leaders. Despite this, there does not appear to be a solution that works for everyone, and that is perhaps why the topic is never discussed by the current candidates running for office. It’s as if the escape room had a clue that was mistakenly left out or that the group trapped did not possess the right skill sets individually or were incapable of working together. If we are going to reform the system, we have to ask first if it is meant to be changed.

Many physicians believe the system is broken. Others, including myself, have begun to realize it is performing precisely as designed. By creating a coverage system guaranteed by the government but managed by a private third party, you exclude the need for accountability and transparency. Insurers can set whatever price they want for the premium for the service and can also determine what is covered. By increasing both the cost of care and the cost of paying for care, they have created a positive feedback loop that drives profits in seeming perpetuity. The only threat is out pricing the market, but when employers can no longer afford higher premiums, they just increase the deductibles or tax subsidy. Plenty of people complain, but to date, few can opt out. In other words, there is no escaping.

However, the system does not exist solely to generate revenue for health insurers. Its purpose is to deliver medical care to keep people in good health so they can work, take care of their children, and fulfill the basic requirements of being a productive member of a community. Paying premiums is supposed to guarantee access to essentially prepaid services. However, nearly 70 percent of the amount collected goes to management, leaving the rest to pay for physicians, hospitals, and prescriptions. It’s no wonder even the busiest and wealthiest health systems run at a constant deficit. Many others fall victim to mergers and acquisitions, leveraging patients for capital to buy time, that is, until the note comes due.

The solutions proposed by government policymakers and industry experts are aimed at controlling spending by shrinking the clinical side of the equation while leaving the insurance component intact. This has led to restrictions in the form of prior authorizations, capitation, and outright denials of care. Insurers have now outsourced these services to offshore call centers and AI algorithms designed not to pay out claims that adversely impact the balance sheet. Every attempt to improve efficiency has only created more obstacles, more data requirements, more data breaches, and more opportunities to add management fees. Once again a system designed intentionally to benefit the payor.

And who are the payors? Insurers work through employers to offer benefits at the highest premium with the lowest utilization and that require deductibles, restrictions, and co-insurances. A recent report showed how the burden of health insurance disproportionality affects the lower-wage worker: “Families with workplace health insurance may have missed out on $125,000 in earnings over the past three decades as a result of rising premiums eating into their pay, according to a new JAMA Network Open study.” It’s not just about employers limiting the number of full-time employees to avoid paying benefits; it’s that health insurance premiums have outpaced salaries and continue to do so with no end in sight. The only way to force change is to limit the role of employer-based insurance and replace it with a more flexible and transparent marketplace.

Just as technology has transformed how and where we work, it has also changed the way we deliver medical care. Patients have access to a large amount of information and consequently know more about their choices and what they have to pay out of pocket. What they don’t know is what the actual total cost of care is. That is kept intentionally opaque, presumably so premiums can be determined independent of price, relying instead on risk. But what if an employee could choose how to spend their premium? What if they kept some to cover the unexpected but banked the rest in the form of a health savings account, building individual health equity? These are simple solutions that can work as long as the price is transparent and there are laws that prevent third parties, including the government, from spending a patient’s health care dollars without permission.

We cannot remain in the escape room any longer. The system is rigged to fail, and as we witness the demise of yet another hospital system owned and gutted by private equity, we have to ask if the Affordable Care Act, in fact, did not what was intended but what it was designed to do, namely convert health care from a service industry to a commodity. The prices will rise only until the money runs out or until people are unable or unwilling to pay. We have a choice as a nation of voters, and if health care is a consumer product, we ought to have better protections in place. Perhaps it’s time to press the panic button, open the door, and demand a refund.

Paula Muto is a vascular surgeon.