With Obamacare firmly in the crosshairs of Republican lawmakers, the debate around U.S. healthcare is at a fever pitch. While there is no shortage of opinions on the best route forward, the timeliness of the debate also gives us an interesting chance to dive into some of the numbers around healthcare – namely how people even get coverage in the first place.
How Americans Get Healthcare
The following infographic shows a breakdown of how Americans get healthcare coverage, based on information from Census Bureau’s surveys. It shows the proportion of Americans getting coverage from employers, Medicaid, Medicare, non-group policies, and other public sources. The graphic also includes the 9% of the population that is uninsured, as well.
Employer-Based: Includes those covered by employer-sponsored coverage either through their own job or as a dependent in the same household.
Medicaid: Includes those covered by Medicaid, the Children’s Health Insurance Program (CHIP), and those who have both Medicaid and another type of coverage, such as dual eligibles who are also covered by Medicare.
Medicare: Includes those covered by Medicare, Medicare Advantage, and those who have Medicare and another type of non-Medicaid coverage where Medicare is the primary payer. Excludes those with Medicare Part A coverage only and those covered by Medicare and Medicaid (dual eligibles).
Other Public: Includes those covered under the military or Veterans Administration.
Non-Group: Includes individuals and families that purchased or are covered as a dependent by non-group insurance.
Uninsured: Includes those without health insurance and those who have coverage under the Indian Health Service only.
Why the Debate is Paramount
If you ask some people what is going on with U.S. healthcare, they will tell you that things are going “sideways” – that costs are going up, but care is not improving anywhere near the same pace.
It’s fair to say that care has been going sideways in the U.S. for some time, and the stakes couldn’t be higher. So, what needs to be done to fix the problem?
Healthcare is claiming an ever-increasing share of national wealth. In recent years, healthcare expenditure in Organization for European Cooperation and Development (OECD) countries has been rising at a rate one to two percentage points faster than GDP. If this trend were to continue, healthcare would represent more than 25 percent of France’s GDP—and more than 35 percent of the US’s—by 2050. Clearly, action is needed to bring costs under control.
Moreover, medical errors and other safety lapses persist even in the strongest health systems and are often caused by inconsistencies in care and lack of adherence to good practices. Outcomes vary enormously across healthcare systems and among the care providers within them. For instance, maternal mortality is four per 100,000 births in Italy, but more than three times higher in the US, at 14. Postoperative pulmonary embolisms and thrombosis affect 865 of every 100,000 patients leaving a hospital in France, but just 107 in Belgium, a difference of 706 percent. Regular albumin screening to prevent complications is provided annually for 88 percent of diabetics in the Netherlands, but for fewer than 30 percent of those in France.
Medical errors are the third-most-common cause of death in the US after cancer and heart disease, accounting for more than 250,000 deaths every year. Addressing these issues and the variations in care practices and quality that cause them is another priority for all countries.
As payment and care delivery models shift from episodic, fee-for-service care toward population health and value-based reimbursement, health care leaders are focused more than ever on patient engagement as a key to driving down costs and improving outcomes. And yet, as so many of us know who have attempted to manage our own care or tend to sick family members, the health care system rarely feels like it’s been set up to help us succeed.
What’s needed is a fundamental redesign of the patient’s role — from that of a passive recipient of care to an active participant charged with defined responsibilities, equipped to dispatch them, and accountable for the results. In other words, we need to view the patient’s role as a job and then design that job in such a way as to drive the best health outcomes possible.
The most profound reforms of a public health service may come from initiatives that operate in the shadows with little financial resources because they attract less attention from vested interests. Reform projects that operate away from scrutiny can develop resourcing space that allows for rapid change with little negotiations and minimal coordination cost.
Public health reform initiatives which attract little attention can achieve bigger results because they are relatively shielded from too much interference. Change can come despite, and perhaps even because of, a lack of resources. Usually, organizational change entails a shift in resource control, and this prompts resistance by people who feel this can undermine their resource-derived authority.
Patient advocates and others who have studied the U.S. health care system have catalogued the degree of unpaid, and unsupported, work patients take on in service of their own care. The average, low-risk patient must follow up on referrals to specialists, fill and manage medications, and comply with physical therapy and other regimes. With legacy, pre-internet software systems still the norm in most hospital environments, patients also become unpaid couriers, shuttling critical health data from one provider to the next.
Nearly 30% of patients physically carry x-rays, test results, and other critical health data from one provider’s office to the next. And 55% say their medical history is missing or incomplete when they visit their doctor.
For patients who suffer from chronic or complex conditions, the burden of treatment must be shouldered alongside the burden of illness. The self-management of a chronic illness demands, on average, two hours of patient work each day — work that is often poorly supported, stressful, and frustrating in nature. Rather than having patients as passive recipients of care, they must be active producers of their care, in partnership and coordination with physicians and clinical staff.
We need to acknowledge and account for all the patient work that now goes unrecognized and unsupported. This means grappling with the complexity of tasks patients take on as they seek care across an ever-expanding number of settings — work that varies widely depending on acuity level, disease state, demographics, insurance type, socioeconomic conditions, and so on.
For years, hospitals and medical groups, looking to move the needle on patient satisfaction, have focused largely on managing and optimizing isolated episodes of care. Surveys focus on patient satisfaction with individual encounters within a single institution. But the way we access and experience care has changed. Where we used to have a lifelong relationship with a family doctor, we now switch doctors frequently due to scheduling issues, changes in insurance coverage, and other factors. We’re also more likely to seek care outside the walls of health systems or the boundaries of specific networks — whether it be through urgent care visits, virtual consults, or alternative therapies. And we know that much of what affects our health, for better or worse, happens between visits.
As we shift toward population health, with provider reimbursements tied directly to improved outcomes, we need to move from managing episodes of care to managing the entire patient journey across the full ecosystem of care. The patient journey becomes the operational backdrop against which patients, physicians, and other staff and caregivers must play their respective parts.
If the patient is to have a job in the care-delivery process, we must apply the same principles of intentional work design to their jobs as we do to those of physicians and clinical staff. Only 20% of doctors report high levels of engagement in their jobs. Those who are highly engaged, however, point to a few key drivers: trust in leadership and the system, open communication and feedback, and an operationally effective work environment that allows them to deliver high-quality patient care. It’s not a stretch to suggest that patients would be engaged and motivated by the same drivers.
The roles and responsibilities of patients currently are almost never clearly defined or fully supported. Patients routinely take on frustrating tasks, such as the transfer of vital information from one provider to another, that technology should be designed to handle. They struggle to get access to the information they need to tend to their own care, and get little feedback or satisfaction from seeing their actions move the needle on results. For patients to be satisfied with care, motivated to play their part, attentive to required screenings, and compliant with care, they need the support of a system designed to help them do their jobs effectively.
Saying that the patient has a job to do does not in any way suggest that patients must shoulder the burden of their responsibilities unsupported. Technology is the key enabler of patients’ success, providing the information, visibility, and feedback they need to do their jobs.
The goal should be to understand all the key points of engagement that are needed in order to support the patient before, during, and between visits. Naturally, the patient journey and points of engagement look very different for a healthy 28-year-old than they do for a 55-year-old smoker with diabetes and hypertension. But both have jobs to do that can only be done effectively with the support of surrounding technology.
For example, data aggregated from a multitude of sources — from electronic health records to insurance data — can be used to paint a complete picture of the patient. Smart scheduling systems and patient portals help patients access care on demand. Reminders via text and other modes help the patient arrive on time and prepared. Open data exchange allows personal health information to travel from one provider or encounter to the next so the patient isn’t playing courier.
For high-risk patients, wearable devices and care management apps help them stay compliant and connected to care teams 24/7. Technology can’t do patients’ job for them. They still need to embrace behavior change and take accountability for their own care. But it can make their job easier to do, more likely to be effective, and more satisfying and rewarding.
It’s widely accepted that we will never realize the goals of health care’s Triple Aim — reducing costs, improving the health of populations, and improving the patient experience — without putting patients at the center of their care. To do this effectively, however, health care leaders must do more than retool old mission statements or retrain physicians and frontline staff. They will need to reorient their thinking to acknowledge the critical job of the patient, design it thoughtfully into new operational frameworks, and invest in the networked technology required to support it all. Only when patients, physicians, and staff are all working together, fully engaged and enabled to do what each does best, will we achieve the clinical and financial outcomes we are all aiming for.
Harnessing the full potential of digital innovations in healthcare could have a profound impact on the quality and financial sustainability of health systems. It would also involve profound changes for care providers and healthcare professionals. To shift mind-sets, healthcare authorities will require a clear and compelling vision and ambitious action. But the benefits for both quality and economics will be well worth it.
Right now, the majority of health care is paid for by fee for service. Doctors are paid each time they order a service, such as medical tests, surgery, or medications. The danger is that this can lead to too many tests, too many procedures, too many medications. And since everything in medicine has risks and benefits, we know that doing too much can actually harm patients. Too many prescriptions can lead to harmful side effects or unanticipated interactions among drugs. Doing unnecessary screening tests lead to false positives, images or lab results that indicate there might be a problem, when there really isn’t a problem. This then leads to more and often invasive tests, which carry their own risks. The current system rewards doctors for providing more care and more services, with little regard for whether those services provide any value.
Most physicians are very concerned about antibiotic prescribing and think it’s a bad thing, but when you look at their electronic records, you see they’re doing it fairly often!
Antibiotic resistant illnesses, sometimes called superbugs, are on the rise — affecting 2 million Americans, with as many as 23,000 dying from them each year. And nearly half of the antibiotics prescribed outside the hospital aren’t appropriate or medically necessary.
A lot of people just go to their doctor and say I can’t miss work, I can’t miss school — may I have an antibiotic? Not realizing antibiotics aren’t risk free. They hand them out like M&Ms in a candy jar. We just want doctors to be really mindful when they prescribe.
Many of the problems we face in medicine are doctors’ doing. Physicians are people, too. Not all their decisions are driven by their understanding of disease — they also respond to social cues and the behavior of their peers in making decisions.
Many patients are harmed. Colonoscopies, which are used to detect colon cancer, are one example. They can be effective as a screening tool for people in their 50s and 60s. But as you get older, the lining of the colon thins. So the benefits begin to be outweighed by the risks that the colonoscopy could damage your intestines. A perforated colon requires surgery, and can result in sepsis or even death, while a small cancerous polyp might never kill an elderly person.
Mammograms can also be effective in catching breast cancer early. But they can result in false positives, biopsies, even surgery that does more harm than good. Another example is total hip or knee replacements. For the right patients, replacements can make people active again, which is terrific. But for some people, the risks of infection and other complications may outweigh any benefits. The problem is that the current fee-for-service model encourages even well-intentioned doctors to do procedures that may do more harm than good.
The profession is beginning to recognize this. For example, the American Board of Internal Medicine (ABIM) has developed an initiative called Choosing Wisely with a list of procedures and tests that are over-utilized given lack of evidence that they benefit patients. Examples include routine imaging for low back pain and use of antibiotics for upper respiratory infections.
Now there is a new approach called Accountable Care Organizations, or ACOs. The idea is simple. Instead of rewarding doctors and hospitals for the volume of services they provide, the system rewards them for keeping patients healthy—keeping them out of the hospital, for example, and for preventing illnesses and complications. ACOs are accountable both for the cost and quality of care for patients.
Hospitals or doctor groups that decide to become ACOs must agree to meet quality measurements. With all patients, the strategy is to engage them, to give them the most complete information, to support them in their treatment plan, and to prevent unnecessary hospitalizations or readmissions. It is called shared decision-making. In the case of cancer, patients should be given information about all the treatment options—chemotherapy, radiation, surgery, or watchful waiting—and then decide, in collaboration with their doctors, what’s best for them.
How do you fit that long-delayed appointment with your doctor into your jam-packed schedule? Telemedicine is your answer. Telemedicine technologies can connect you and your doctor in cyberspace. Telemedicine redefines modern health care. With the aid of wearable health monitors, computers, and video, doctors are able to evaluate, diagnose, and treat you—all without your physical presence in their office.
These technologies offer convenience and huge potential cost savings, but they are not without controversy. Some doctors are concerned about the safety of prescribing drugs without examining the patient in person. Can they really assess what the patient needs over a video link? They also worry that telemedicine could depersonalize your health care. In addition, some medical problems will always demand a physical exam.
Still, some aspects of telemedicine are likely in your future, if they aren’t already. Here’s what you need to know about this form of health care, and how to use it for your advantage.
Telemedicine provides opportunities to keep people healthy and outside of hospitals. For example, in certain regions and medical practices in the US:
You can send a digital image of a suspicious rash, along with your medical history, to a dermatologist, who will review it, diagnose, and prescribe medication to treat it.
You can check-in with your doctor after surgery for follow-up care in your own home.
If you have diabetes, you can monitor your blood sugar levels at home and upload the readings to your doctor’s computer, saving yourself a time-consuming visit. Irregular blood sugar levels would generate an alert to the doctor’s staff to call you in for immediate intervention to prevent complications. If you have hypertension, you can wear a monitor that tracks your blood pressure daily and transmits your results to your medical record, allowing your doctor to track your progress.
United Healthcare, announced that it has established a partnership with Doctor On Demand, along with two other telemedicine companies. United Healthcare says that 20 million of its insured patients are able to use their smartphones to consult with doctors.
Here are some of the key pros and cons to help you decide. Among the pros:
- Convenience. Need a quick consultation with your doctor? Telemedicine can save you travel time and the hassle of sitting in a waiting room with other sick people.
- Increased rural access. There’s a shortage of doctors in many rural areas of the US. Telemedicine has a unique capacity to increase medical service to rural patients.
- Cost and efficiency. Doctors often charge less for a telemedicine consultation than they do for an in-person visit. A telemedicine consult might cost $40 to $70, compared for $130 to $180 for an office visit. In addition, telemedicine allows doctors to efficiently and closely monitor patients with chronic conditions such as diabetes and high blood pressure.
- Second opinions. Telemedicine allows a far-away specialist to evaluate your MRI, X-ray, or other scans and tests. This will help patients who want a second opinion, as well as doctors who want to consult with experts on complicated cases.
Despite this wide range of potential benefits, telemedicine still has its share of downsides:
- Inadequate assessment. When consulting your doctor online you don’t get a physical examination. Certain non-verbal cues might still slip through the cracks. Your doctor must rely on your own descriptive abilities instead of his or her own expert touch. At worst, this could lead to an improper diagnosis.
- A depersonalized experience. Telemedicine may be more impersonal than a face-to-face visit with your doctor. A good doctor-patient relationship is characterized by trust and intimacy. Patients often bring up issues during a doctor’s visit that go beyond their immediate health problem.
- Electronic defaults. Technology is only as reliable as the electrical current that keeps it running. If your Internet connection is disrupted, your session will stop instantly. Technical problems could complicate your online consultation or remote monitoring.
Healthcare companies are developing new digital technologies to give consumers more control over the care they receive. That could upend the industry’s move toward greater consolidation and scale.
In the not-distant future, financially accountable, tech-enabled consumers may avail themselves of a range of discrete digital health services from a variety of providers. As a result, they would be able to create their own health-management ecosystems, acting as stewards of their care and controlling not just where they access it but also how and from whom, as well as the price they pay. The impact of these changes—the friction created between large, fully integrated healthcare systems that prioritize efficiency and scale, and newer, more distributed digital upstarts emphasizing speed and the consumer experience—could put up for grabs $270 billion of the incumbents’ current revenues and an additional $13 billion to $24 billion in new ones.
Admittedly, several significant barriers must be overcome before that shift in the sector’s dynamics can fully take root. At present, the effectiveness of many digital and mobile technologies remains to be proved. In fact, the IT platforms needed to aggregate data and to integrate the consumer experience across care venues and new modalities (e-visits, for example) remain to be built. Other hurdles include concerns about information security and about who should underwrite the cost of adopting these solutions at scale, as well as the potential need for US Food and Drug Administration (FDA) approval of some devices. But even the modest adoption of the new technologies could have enormous implications for providers and health insurers alike.
According to our research and analysis, technologies that make it possible to deliver primary care less expensively could save $175 billion to $220 billion a year if they came into widespread use. Although consumers are likely to be the primary beneficiaries of the savings, incumbents will probably capture some of the money. Increased automation and self-service could lower their overall administrative costs by an additional $24 billion to $48 billion annually through productivity gains.
Although some of the new technologies will replace more expensive services, others (personal diagnostic devices, for example) will create new classes of offerings. Furthermore, healthcare-utilization levels may rise once primary care becomes cheaper and more accessible. Combined, these factors could generate $13 billion to $24 billion in new revenues for incumbents and technology companies.
To better understand the path to this reordered landscape and its implications for participants in the sector, we interviewed technology innovators, investors, healthcare providers, and insurers. We also surveyed thousands of US consumers. Our research revealed five key findings, three of which we outline here:
Consumers are starting to replace traditional healthcare services with digital ones. Although utilization trails awareness, inroads are being made, particularly among younger Americans. Millennials, for example, are twice as likely as Baby Boomers (and three times as likely as people born before 1945) to use email or text messages to communicate with physicians.
Investment in digital and mobile health and in related technologies is robust and growing. The strongest growth has occurred among direct-to-consumer technologies that require little or no involvement by physicians (for example, wearable fitness trackers and scheduling applications) and among intermediated technologies (more complex ones, such as remote diagnostic equipment, that require a doctor’s prescription). Investors appear equally interested in both, but for different reasons: direct-to-consumer technologies for their ability to achieve scale quickly and intermediated ones for their greater cost-reduction potential.
New technologies address consumer dissatisfaction with the current healthcare system. These technologies fall into six categories, all of which could alter the economics of the healthcare system:
- self-service tools that make it easier to schedule appointments, renew prescriptions, and pay bills
- “quantified self” and wellness tools that assess a patient’s health status, monitor adherence to treatment, or enable coaching, as well as devices that can be worn, ingested, or embedded in the human body
- clinical-transparency tools that help patients use healthcare services more appropriatelyby enabling them to make more informed decisions
- financial-transparency tools that help consumers to compare prices and benefits from different health plans and providers
- virtual-access tools that enable consumers to consult with doctors online, to be monitored remotely, or to receive certain types of care at home
- IT platforms that aggregate data from different tools and enable them to work together, as well as technologies that help consumers receive information through multiple channels
While it remains unclear who will pay for the new technologies, most of the stakeholders we interviewed believe that employers, providers, and insurers will assume this responsibility.
The more engaged consumers enabled by new digital health technologies could shift the sector’s dynamics in three ways:
- The basis for competitive advantage changes. The geographic scope of competition, historically concentrated in metropolitan areas, could broaden, especially once digital access points, such as self-service tools, become more prevalent and price- and quality-transparency tools alert consumers to higher-value alternatives.
- Consumers become clinical-data integrators. Increasingly, consumers could own and manage their clinical data, which would allow them to decide for themselves who should gain access to that information (and when) in clinical, transactional, and administrative settings.
- The roles of providers and insurers evolve. Providers, especially physicians, could find themselves spending less time gathering information about their patients and more time helping them make sense of the information already gathered. Insurers may become trusted advisers, helping consumers to understand how best to manage their financial accountability and risk preferences. They’ll have competition for this role, though. Retirement and wealth advisers, for example, could include health-risk assessments and estimates of health costs in the advice they give clients.
Notwithstanding the barriers, incumbents should be prepared to make bold changes to their business and operational models to compete in a digital healthcare landscape. Their approach to the coming transformation should be comprehensive and integrated, not a series of random, disconnected initiatives. The transformation process will require frequent trade-offs between physical and digital assets, and all bets on new technologies will probably have to be reviewed every three to six months.
Incumbents shouldn’t rely on price as the sole point of competitive difference. Those that prevail will be defined by how well they know their customers—and by how customers behave in a given scenario. Physically active consumers, for example, may be price seekers when they shop for primary-care services but completely indifferent to price when they look for orthopedic surgeons.
The full impact of engaged, tech-enabled healthcare consumers may not be felt for five to ten years, but now is the time for providers and insurers to start preparing for the new reality. If they don’t, they might find it too late to remain in the game. In other sectors, many companies that didn’t prepare for the impact of digital and mobile technologies eventually lost out to more nimble new entrants.
Having an optimistic outlook on life, a general expectation that good things will happen, helps people live longer. People who are optimistic have a significantly reduced risk of dying from several major causes of death — including cancer, heart disease, stroke, respiratory disease, and infection.
While most medical and public health efforts today focus on reducing risk factors for diseases, evidence has been mounting that enhancing psychological resilience may also make a difference. We should make efforts to boost optimism, which has been shown to be associated with healthier behaviors and healthier ways of coping with life challenges.
Optimism can be altered with relatively uncomplicated and low-cost interventions — even something as simple as having people write down and think about the best possible outcomes for various areas of their lives, such as careers or friendships. Encouraging use of these interventions could be an innovative way to enhance health in the future.
Greece has the most corrupt public health system on planet Earth! Greek doctors in public hospitals demand bribes for all operations! No bribe means a lot of trouble, such as infinite delays, curved queueing, bad operations, and wrong medicines! Health insurance means nothing to Greek public doctors! The government encourages doctor bribes and long queues! To see a public doctor, you have to wait six months! Even though Greeks paid for state health insurance, the government of Greece wants to make their experience in public hospitals so miserable in order for them to go to private doctors and private hospitals, which are not covered by the state health insurance! This way, the Greek government saves a lot of money.
Greece’s hospitals welcome back corrupt doctors ousted for demanding huge bribes from patients. The legal remedy allowing the reinstatement of corrupt doctors emanates from a notorious Katrougalos law named after the relevant labor minister. Among others, the law stipulates that public employees suspended for serious on-the-job infractions can re-appeal their cases. Based on the Katrougalos law’s procedures, suspended doctors can have their case returned to the pseudo-disciplinary boards of their respective hospitals in order for their case be reviewed anew by amiable corrupt colleagues.
A culture of bribes in Greek hospitals is extremely disgusting. Nurses are very glad to help doctors lie, abuse, and rob patients at pain point under duress. Nobody cares, nobody gives a damn. Administrators are in cahoots with the corrupt doctors. The whole staff is a big mafia protecting corrupt doctors. Medical errors and other safety lapses have a lot to do with the flow of bribes.
We cannot believe that the administrations of hospitals are not aware of the huge corruption of their doctors, and we cannot believe the Greek Ministry of Health is not aware of what’s happening at hospitals. We do not know how the flow of medical bribes works, where it originates and where it ends. The European Union must investigate the flow of bribes, because no Greek organization is willing to do it.
Widespread grafts and bribes by Depuy, a subsidiary of Johnson & Johnson, through a network of offshore companies, went to Greek doctors in two hundred public hospitals who received bribes amounting to thirty billion euros. The charges include passive and active bribery, fraud, embezzling public money, and laundering.
The investigations revealed that medical equipment imported into Greece by Depuy were overpriced by up to 35%, with 20% going to doctors for their pseudo-preference to the products and 15% to cover expenses to maintain the network of accountants and lawyers who had set up and were operating the 15 off-shore consultant services companies through which the money was funneled to the end recipients.
Greek authorities are investigating the Swiss pharmaceutical giant Novartis over bribery and price inflation. These involve illegal earnings of a dozen billion euros. A Novartis executive had walked out onto a high terrace of the Hilton Hotel in Athens and threatened to jump off. He has been summoned to give evidence in the case. Police negotiators were able to prevent the suicide at the last minute.
Novartis paid huge bribes to many Greek officials, politicians, and doctors in public hospitals. Whistleblowers have passed documents to the judicial authorities which indicate that five thousand people in Greece were targeted, and were given bribes. People who didn’t go along with it were subjected to workplace harassment. Company employees felt like warriors with high sales targets that absolutely had to be achieved, even though the pharmaceutical market kept shrinking because of the economic crisis.
Many people had been putting their hand deep in the honeypot. Novartis was selling medicines and services to state clinics at inflated prices, and this poses the question of whether a lack of transparency in the procurement system may have led to this cost trap. State hospitals are forced to pay too much for medicines. The state prosecutor is currently examining files and bank transactions of doctors suspected of receiving money from Novartis. The investigators want to use these to trace the flow of money.