Two Myths: that the system of health care is failing26 November 2015
Longer ago than I care to remember, I started a book called Managing the Myths of Health Care. This week I finished a draft of it suitable to submit for publication. So here, and for the next two weeks, are some excerpts from the book. This one is about two of the major myths.
Myth #1: that health care is a system. Calling something a system does not make it a system where it matters, namely in the consolidated delivery of its services, on the ground. In health care, mostly we have a collection of disease cures, or at least treatments, often the more acute the better. Overall, we favor cure over care, acute diseases over chronic ones, and the treatment of diseases in particular over the prevention of them and the promotion of health in general.
It is certainty important to treat people who are ill, but it is also politically advantageous: they are an aggressive lobby, in the hospitals and governments, to spend as much as necessary to get them well. The many more people who will be getting these diseases, but don’t know it yet, hardly lobby at all in comparison. (That would take a systems perspective.). So we spend the lion’s share of our money treating diseases, whereas more on preventing them would actually increase our longevity!1
Myth #2: this so-called system is failing. If there is one general area of agreement in health care, it is that this “system” is failing, all over the world. Users and providers alike complain bitterly about their services.
At a party in Montreal a few years ago, I got into a conversation with a young radiologist who went on and on about how bad health care was in Quebec. “You did your residency in the United States,” I finally intervened: “How about that?” She threw her hands in the air: “Don’t get me started on the American system!” Some time later I was in Italy, with some people working in the field who were likewise putting down their health care. So how does Italy compare with other countries, I asked. Oh, they replied, in the latest ranking by the World Health Organization (2000), Italy ranked second best in the world. I guess second best is not good?
Quite the opposite. In most places in the developed world, the treatment of disease is succeeding―albeit expensively. And where health care does not focus, in preventing illness in the first place, there have still been improvements, for example in the promotion of better eating and more exercise. It is just that here the pace of improvement has been much slower, and the resources expended for this are shamefully low (this in the face of a perpetual battle with so many forces that promote poor eating and sedentary living).
On some of the broadest measures of health, such as life expectancy and infant mortality, performance in most countries has been steadily improving. For example, a World Health Report found that Chilean women in 1998 could expect to live to age 79 on average, 46 years longer than their predecessors of 1910. Indeed, they could even expect to live 25 years longer than women in 1910 whose countries had the 1998 Chilean level of income.2 The report concluded that access “to new knowledge, drugs, and vaccines appears to have been substantially more important” than improvements in food intake and sanitation. Health care has its problems, to be sure, but it has been making remarkable progress—where it cares.
Imagine that you have chest pains and are offered the following choice. (1) Health care circa 1960: Your GP comes to your house, gets you straight into a hospital with attention from many sympathetic doctors and nurses, who eventually send you home to rest and hope for the best. Or (2) Health care now: No doctor will come to your house. You get yourself to an overcrowded emergency room, eventually to get to cardiac surgery, where a stent is installed—with perhaps no personal attention at all—so that you can be sent home the next day, in rather good shape.
The problem: We don’t want to pay for this success. Let me repeat: In most places in the developed world, the treatment of disease is succeeding―albeit expensively. We just don’t want to pay for it. And herein lies the great problem in health care today: this field is suffering from success more than failure.
Medicine has been practically brilliant at developing expensive new treatments, and pharmaceutical companies have been particularly clever at getting away with pricing their innovations obscenely.3 Who among us is prepared to forego one of these needed to save our life?
Of course, as the costs of treatments go up, so too must the expenditures to cover them, whether in the form of taxes, insurance premiums, or personal payments. If we want more, we have to pay more. But in this age of consumptive greed, we want to pay less―or at least not that much more.
For the most part in the field of health care, we are not buying services so much as the possibility of needing services (i.e., insurance). Why, then, should I pay for you, who is sick, while I am healthy, and probably invincible at that? In other words, while the ill act as a concerted force for spending more individually, the healthy act as a general lobby for spending less collectively.
This is not a happy combination: it makes the field of health care sick. It encourages us to intervene in all kinds of dysfunctional ways, not directly and clinically, but indirectly and administratively. And that often drives clinicians literally to distraction. To cite two common examples, we reorganize them relentlessly and measure their behaviors obsessively.
Next week I wish to discuss a number of these popular ways not to fix health care, and the week after that, to propose a different way to think about dealing with this problem.
© Henry Mintzberg 2015
1 How much, for example, do we spend on researching the causes of breast cancer, compared with developing treatments for it? One physician/researcher in the field gave me her estimate of that figure: 1%. So the next time you make a donation, bear in mind that a penny for prevention can be worth a pound for cure.
2 World health Organization (1999) The World Health Report 1999: Making a Difference
3 See my article “Patent Nonsense” in the Canadian Medical Association Journal http://www.cmaj.ca/content/175/4/374.full.pdf+html