COVID19: assessing our healthcare system

Healthcare has received a lot of discussion over the past decade or two in US political debate.   At the center of this debate is a general recognition of the great benefits that our healthcare offers and now we need to make efforts to be sure that these benefits reach everyone who need them.

While there is recognition that more development is needed, the healthcare system is presented as being offering highly effective treatments for the full range of human ailments.   There is some debate about which country has the best practices in different areas, but even if our offerings are inferior to other countries, ours are still good enough that we should offer them to whoever needs them.

This debate has led to two relatively unchallenged claims.   One is that each person is entitled to medical attention to any and all of their individual complaints.    The other is that this medical attention is actually valuable for the complaints.

The focus for policy making is on the issues of building capacity to accommodate the total population with needs and making those offerings affordable.

We are taking for granted that the utilization of healthcare services is justified by the verification of qualifying symptoms.   If the symptoms are verified, then the patient is entitled to any and all relevant healthcare.

Although the Affordable Care Act of 2010 was comprehensive in nature, most of the debate I recall concerned treating chronic illnesses or acute conditions such as heart attacks or strokes.   The medical systems handle these conditions at a continuous rate every month, making it possible to maintain specialties and specialized facilities for different conditions.   Those specialized resources are always well utilized and sustainable as far as funding permits.   The goal of ACA is to manage those costs and to finance the system so that every one who needs the specialty will get access independent of the patient’s ability to pay or the patient’s prior history including pre-existing conditions, or accumulated expenses of past treatments.

I also recall some discussions about verifying the effectiveness of the treatments using incentives or penalties based on the outcomes of the treatment.    The supported treatments also needed to be based on evidence of both the treatment and the eligibility of the patients.

My reflections on the ACA is just from an outsider general-population point of view, with a bias toward preferring the health insurance market that preceded the ACA — I accepted the limitations of pre-existing conditions, annual limits, and life-time limits because I could plan my life around it.   In exchange for removing those limits, I have to pay far more in premiums making unaffordable my previous practice of taking lengthy periods of time off from work.

With that bias in mind, I have some reservations about the current health care approach.

Prior to ACA, I had an insurance that I treated as catastrophic insurance.   My insurance was just a comprehensive plan with a high deductible.   There were other plans available called catastrophic plans that had extremely high deductibles.   I did not have those plans, but I treated the ones I had as a catastrophic plan.   I avoided seeking medical care unless I absolutely needed it, and often paid up front without filing a claim even though it would have counted against the deductible.   My general attitude was that medical insurance was there for emergencies or surprises, not for general health maintenance.

From the start of the ACA, I felt pressured into seeking regular doctor’s visits and annual checkups.   I am still not convinced this is beneficial, but I accept it.   More generally, there is an implicit contract concerning my body that is similar to a vehicle lease terms: I’m obligated to take it in regularly for routine maintenance or checkups.

In exaggerated terms, I am leasing my body for my personal pursuits, but I do not own my body.   If something comes up that doesn’t seem right, or if I injury myself, I need to take the body in to get looked at.   When I do take the body in, I need to allow the medical system do whatever it recommends.  Even when given the option of getting second opinions, at the end I need to choose one of the recommendations.   The option to ignore medical recommendation comes with a living will or a do not resuscitate declaration that forfeits the medical care options.

This is very different from the catastrophic insurance approach to medical care.   For catastrophic insurance, I avoid medical care that I can not immediately pay for unless there is a very unusual event.   Catastrophic care provides that initial care for a short while and likely would not maintain the care needed if the consequences require chronic care.    With current policies, I am encouraged to seek out medical assistance for all complaints and at least check in once in a while if I have no complaints.

Early on, I wrote that although ACA covered epidemic type diseases, it did not appear to be well suited for it.   A big part of the problem I saw was in the premiums.   The premiums are priced to cover the expected costs of serving the entire population in the same plan.   With a large enough population, the insurer could reasonably predict the next year’s costs based on the likely conditions the populations will need treated.   These predictions are largely for the conditions like heart attacks, cancer, strokes, organ failures, etc. that are not contagious.   They also include conditions that are mildly contagious so as to have a predictable annual rate of occurance.

The insurance premiums cannot predict a once in a lifetime epidemic that will quickly spread to a large number of covered people.

The problem with the modern insurance approach is that it trains people to seek medical attention.   In the past, if we felt sick, we’d at first just treat ourselves unless it got seriously bad.   Now, we feel entitled to immediately check in with our doctors for any condition that becomes even a slight inconvenience.

I think the COVID19 situation exposes the problem with this approach.   Now that people understand the possibility of this particular disease, they are quick to check any symptoms with their doctors.   A lot of this early symptoms would qualify for getting tested and many of these will end up with positive testing.   The positive testing will lead to followups so that a further deterioration would result in a hospital admission into an area with other COVID19 positive patients who may have worse strains.   From there, the patient may quickly move to an invasive ventilator with its low survival rate.

The multiple problems I see are

  1. People are too eager to seek medical care when home care might have sufficed.
  2. Evidence-based practices available to the hospital (at least initially) will be based on past diseases that resemble the current one, and these practices may not be appropriate for this disease.
  3. Once admitted into the medical system, the patient remains until the case is closed by either a full recovery or death.   There can be no voluntary return to home care.
  4. If during the ongoing epidemic the hospitals begin to notice that the evidence-based treatments are not working or counter productive, they need to take extreme professional risks to try something different.
  5. If during the ongoing treatment, the patient notices that the treatments are not working, they are not at liberty to object.

Early on in the COVID19 epidemic, I was bothered by the obsession over the rare and expensive invasive ventilation equipment.    My suspicions were that the medical staff were over-eagerly installing these ventilators or that patients were led to believe that their best hopes were to get on these sooner rather than later.   The mere hype about the ventilators and their necessity for this condition may have lead to patients demanding they get it out of as sense of entitlement guaranteed by their insurance.   When the time came for the medical staff to offer this treatment, I expect many patients would not hesitate and consider the risks even when those are explained.   The ventilators were covered by insurance so of course they should go on them.

There may be evidence now that the ventilator use may have been a cause of many of the early deaths.   The high initial death rates (and the recent lowering of death rates) may be due to changes in medical practices rather than changes in the virus itself.   The epidemic fears at first may have turned out to be the result of medical practices making the virus more lethal then it otherwise would have been.    We won’t learn if that is true for many months or even years, but I wouldn’t be surprised if it were found to be true eventually.   It seems very miraculous for a natural virus to appear at this level of global population density and be this devastating without ever having appeared before.

A summary of the above is that the ACA type insurance discourages people from self-treating a cold-like symptom that are indistinguishable from early symptoms of the epidemic.   This leads to a cascade of events that pushes them into an improperly prepared medical system that eventually increases their chances of dying for the first many months that it takes to get the approved practices updated to better match the optimal treatments for this particular virus.

I don’t trust that the bureaucratic approach of managed health care is appropriate for handling epidemics even when I do trust it being appropriate for other more commonly occurring conditions.    I really think there needs to be a completely different health system for handling epidemics, and this system focuses on optimizing treatments instead of shutting down economies and seeking some miracle vaccine.

There is another area of suspicion I have about the managed health care approach such as what underlies the ACA.   That concerns the focus on the primary mission of managing those routinely occuring conditions.

Recently, we have heard of directions to record as COVID19 death every death where a patient tests positive for COVID19 or where the patient was suspected of having COVID19.    A large proportion of the deaths occur among the elderly and those with pre-existing conditions.

I understand that this is standard practice.   The recent infection probably increased the stress beyond the body’s weakened ability to deal with it.   If the patient did not get this disease, they likely would have lived much longer because their prior conditions were reasonably well managed.

I think it is also standard practice because attributing the death to COVID19 helps protect the evidence being collected about the effectiveness of the treatments for the pre-existing conditions.

  • Elderly people recently getting a good checkup with assurance that they will live for many years to come, then get COVID19 and die.   Attributing their death to COVID19 preserves the accuracy of the checkup results
  • People with conditions being well-managed with modern medicine.  Attributing their death to COVID19 preserves the efficacy of the treatment they were getting.
  • People going into hospice with life expectancy of many weeks die sooner when they get COVID19, attributing the death to COVID19 preserves the promise of the additional weeks.
  • People getting hospital treatment for COVID19 and die because the practices failed to save them, attributing the death to COVID19 preserves the reputation of the evidence-based care.
  • People getting hospital treatment for some other conditions unrelated to COVID19 but then later tested positive for the disease.   Attributing their death to COVID19 helps to avoid biasing the data about the effectiveness of the treatment of their initial condition

A key principle in managed health care is the data collection that verifies the approved evidence based treatments for the routinely treated conditions.   Epidemics are incompatible with that data collection.

To keep the data collection unbiased as possible from the anomalous epidemic conditions, there must be a bias to attribute deaths to the virus.   This approach simply provides a way to keep these deaths from contaminating the the data collections for the treatments that the patients normally would have received.

This data collection practice to benefit the continuous improvement of treatments for the preexisting conditions has the accidental side effect of inflating the death numbers for the epidemic.

Epidemics are rare and generally brief compared the other conditions that the medical system treats.   As a result, deaths during the epidemic are data outliers that need to be removed from the evidence collection of those other treatments.   The attribution of death to the epidemic is a convenient way to dispose of outlier data points.

The basic working of managed health care systems is that they are not well equipped for epidemics.   Epidemics are very inconvenient to the normal working of this system.

In other words, the modern medical system cannot tolerate epidemics.  This might explain the historically unprecedented government actions of isolating the healthy, shutting down economies, and cutting corners to get a vaccine as quickly as possible.    It is as if the existing medical system is closing its eyes and screaming “Just make it disappear”.

Maybe the modern medical system is overly specialized for handling the manageable chronic conditions or resolving acute conditions unrelated to infectious diseases.

A very different medical system is required for handling epidemics.   Such a system needs to be more flexible to quickly adapt to observations by the practicing doctors, freeing them up from having to wait for the settled science.   It would also be more honest about attributing the deaths to the epidemic and thus provide better confidence about the case fatality rates.    A medical system for infectious disease would recognize that these diseases are recoverable and once recovered the patient can go on without further medical observation.   The priority is on optimizing treatments for both their effectiveness and their minimizing the expenditures of limited resources.

Unlike our current medical system, a medical system specialized for infectious diseases can adapt to a steady stream of new cases and even improve the outcomes from better practices.   Such a system would limit isolation to quarantines of the sick and not demand isolating the healthy, not require shutting down economies.   Such a system would be prioritize its focus on improving treatment instead of a frantic and potentially fruitless pursuit of a vaccine.   Certainly, such a system would welcome an effective vaccine, but it does not depend on it.

We once had a medical system that can competently manage epidemics.   We discarded it to make room for the managed-condition healthcare system we have now.   Our system has proved that it cannot tolerate an epidemic, something that history tells us is a fact of nature.   As a result, when an epidemic appears, we have to stop everything until a vaccine can make it go away.

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