A comment from a nurse on one of my posts said, “We have a health repair system, we need a health maintenance system.” The more I think about it, the more sense that statement makes.
Most of you own an automobile and you understand how to keep it running. I have a Honda CRV with over 200,000 miles on it that we use to run around town. I take it to the shop every 5000 miles for an oil change and an inspection. We have done the recommended maintenance procedures regularly. I asked the mechanic how long the car should last. He said that he sees cars all the time with over 300,000 miles on them. The car is still in good shape mechanically. We all understand that cars need oil changes, the right oil level, a radiator full of water, antifreeze, the proper tire pressure, etc. Most of us do those things, and the need for repairs is low. Our CRV has never needed a major repair. The car dealer provides you with an owner’s manual that tells you what you need to do.
Car dealers go to great lengths to make it easy to maintain your car and avoid expensive repairs. You can make an appointment online. They send an appointment reminder. They have a comfortable waiting room. They offer a shuttle to take you back to your home or work. There are maintenance companies that focus on convenience. You can get a ten minute oil change and “Jiffy Lube has over 2,000 service centers coast-to-coast with a nationwide database that keeps your service records on file so you can get a quick, consistent and quality experience every time.” Anywhere you are in the country, if you need service, Jiffy Lube can see your maintenance history. In contrast, your health maintenance records are often unavailable if you need care outside of the system you use.
Our healthcare system is arranged around more expensive repairs rather than maintenance. In fact, large hospital systems actively undermine effective maintenance programs. In one community, the physicians in the community created a program to treat arterial disease and prevent heart attacks and strokes more effectively. They were very successful. Within two years, there were fewer heart attacks and the program was saving millions of dollars in costs. They approached the big hospital system to partner with them to make the program more effective. The hospital bought it instead. As soon as they had control, the hospital dismantled the health maintenance system so that their beds and cath labs would be full. Once again, more people were having heart attacks and they needed cath labs and hospital beds.
These big hospital systems made sense, but it is another good idea that did not pan out. The great idea was that very large hospital systems would produce economies of scale. That happens in other businesses, but it has not happened in this case. In fact, when the hospital buys practices to control admissions, expensive test volumes, and specialty referrals, increased costs are built into the payment schedule. "When small doctors’ practices join large hospitals, their patients pay an average of $75 more every year for outpatient services like check-ups, even though the number of appointments stays the same.” That is just for Medicare and that is just for visits. Big hospital systems control most of the other infrastructure of medicine: lab tests, x rays, nuclear medicine tests, and operating rooms. That revenue is usually not available to independent primary care groups. The result is independent primary care is gone. Primary care doctors can make more by working for the hospital and there very few primary care doctors in our area that are independent.
And that is the problem. Primary care practice in the hospital is structured to feed the beast—to keep the beds full, the x ray machines running, and the specialists busy. It is to repair people who have broken down late in the disease process. Independent advanced primary care, customer-owned primary care, or value-based primary care are the only effective paths to a health maintenance system. Primary care has been diverted from its primary role of health maintenance to feeding the human health repair system. As with your car, repairs are much more expensive than maintenance. Sure, we can do a heart transplant, but it is better to treat the blood pressure so that the heart does not break down.
There is more bad news. These large healthcare systems are supposed to be not-for-profit, but don’t be fooled for a minute. Major health system CEOs are becoming wealthier while you are losing ground. In the 82 largest health systems in the country, 90% of the CEOs made more than a million dollars a year. Many made more. One made $21 million a year. They get paid to get bigger, to beat their competition, and to create a black bottom line. “These large nonprofits (were) organized as charities under IRS Section 501(c)3 with the mission of delivering affordable healthcare to their communities.” They don’t do that. As described above, they fight affordable care and dismantle affordable healthcare systems that are a threat to their bottom line.
It has really gotten out of hand. A recent proposed hospital merger in Michigan would have created the larges employer in the state and a healthcare monopoly in many areas. The current administration recognizes “hospital mergers can be harmful to patients and encourages the Justice Department and Federal Trade Commission (FTC) to review and revise their merger guidelines to ensure patients are not harmed by such mergers."
“Hospitals are a really important part of the American economy. Not just in terms of health and well-being, but in terms of dollars and cents. The largest chunk of America's healthcare spending goes to hospitals. And the hospital sector is one of the largest sectors in the overall American economy, accounting for about 6 percent of America's GDP. Hospitals do a lot of good things. They save lives. They create good jobs. But because of growing monopolization of them, Zack Cooper, an economist at Yale School of Public Health, worries that they're becoming like a "Dracula" that "sucks some of the vibrancy out of a lot of towns across the country."
In addition to decades of mergers and acquisitions with hospitals gobbling up other hospitals, hospitals have also been increasingly buying up physician practices. Economists refer to this as "vertical integration." Think steel manufacturers buying the railroad lines. Like with mergers and acquisitions, Cooper says, many of these deals have not received adequate scrutiny from federal regulators.
The research clearly shows, Cooper says, that growing monopolization has raised prices for patients. Less competition means hospitals can charge higher prices and get away with it. They can pay lower wages and get away with it. And they can provide worse care and get away with it. "We want firms to compete and be incentivized to raise their quality to attract more consumers, and the more that hospitals merge, the less sharp those incentives become," Cooper says. "We have evidence that death rates are literally higher in markets where hospitals face less competition."
As you can clearly see, large hospital systems are a barrier to the outpatient healthcare maintenance operations that are required to improve health and lower costs. Even if you have heart artery disease already, a focus on maintenance makes it ten times as likely you will still be alive in ten years compared with our current repair system—the care that most people receive.
Healthcare dominated by large hospital systems will never improve health and reduce costs.
Excellent piece, I had no idea the “nonprofits” were scams. I’m 100% with you on maintenance. Wish more people would get on board with that.
Agreed. I'm on the maintenance plan.