Reforming the Heathcare “Debate”: Function Junction

Alright, well, we discussed . . ok, I dictated. . . the problems with the healthcare system and no one seemed to complain; so, I will go on to step 2, Solutions. . .

Nope!!!  Not yet.  (Didn’t I say I was going to suck all the life out of this debate?)  While we know at a high level what is probably bothering everyone about the Healthcare System, we don’t really have enough of an understanding of the System to actually start thinking about how to fix it.  To go back to our broken car analogy, we’ve determined its problems (fuel efficiency is not what it is supposed to be; its acceleration is lacking; and its performance is continually degrading.), but we did this by comparing it to other similar vehicles.  We can’t rationally decide how to fix it (or if we should just replace it), because we haven’t really looked under the hood to see what kind of engine it has.

Part of the reason we need a better understanding of the system is due to the nature of the brain.  I keep using the car example, because cars are easier to think about than a massive transactional system.  Cars are physical objects, and the human brain does really well with physical objects.  All the way back in the womb, each one of us started unconsciously building a library of physical laws in our brains.  Through our earliest years, we subconsciously and consciously conducted science experiments to refine this library (learning to roll, repeated interactions with toys, dropping spoons).  So now, if you read “car” you probably (and immediately) think of a four-wheeled platform with a gas pedal, a brake pedal, a steering wheel and an engine (again, “engine” and all those other components trigger their own images).  However, if you read “Social Security System” I will bet that you don’t quite get such an image.  You might think of your Social Security Card or Number; you might think of income taxes or some personal view of the politics involving that System; but you don’t actually think of an image which brings all of those parts together (not as concrete of an image as you do with “car” or “engine”).  This failure isn’t because such an image doesn’t exist, or that the system is really that complex, but because our brains don’t have such a well established and detailed library of transactional systems and the natural laws which make them work.   (Think of the first time you really understood what a government was--not just the names of the founding fathers or state capitals.  At that age you could already imagine a basic car (and could probably draw one—talent dependent).) 

This limitation is important, because we have to understand that a transactional system like Healthcare can—and I say should—be treated like a physical thing.  I say “should” because dealing with these concrete terms gives us major advantages over some philosophical concept, which is all we will really have otherwise.   Once we define it in somewhat concrete terms, then we have a better chance of coming up with more reasonable and quantifiable solutions.  The more measurable the definition the more likely we can be certain of the solution.  We have to first accept the idea that the System actually does have definition like a car though it may be difficult for us to picture.  One way to get that picture is to think about its most general functions.  For example, a car has several obvious functions:

- It can move itself forwards or backwards.
- It can stop its motion.
- It can be turned while moving forwards or backwards.
- It allows one person, the driver, who rides on it to direct and coordinate these functions.
- It moves based on an energy supply that it carries with it.
- It has the capacity to carry more than the driver.

You’ll notice that this could fit the definition of a car, a moped, a motorcycle, or a bicycle-built-for-two (if you consider the people to also be energy supplies).  “Car” is one solution to this set of functions.  If we got more specific about these functions --“It can move forwards at 55 mph”—it can narrow down that list to “car.”  Because of the challenge of picturing the Healthcare System, we should stay at this less detailed level of description.  The Healthcare System will take a bit more work to think up, but it’s the only way to get a realistic and useful set of possible solutions. 

Let’s start this by mastering the obvious.  The Healthcare System revolves around human health.  Sure, this sounds pretty clear, but it’s a philosophical rabbit hole.  What is “health”?  How do we measure “health”?  We’re going to have to follow the white rabbit to get to the answer (a la Alice in Wonderland or Matrix—I’m sure Matrix fans would prefer “take the red pill” however, the white rabbit reference is valid, check it!).  The first stop in the hole is that sign that says “Health is the state of being healthy”, which doesn’t seem to tell us much of anything unless you go deeper and is pretty much the dictionary definition.  Where else should we go for this definition, the highly technical journals or the ads for Abrocker or Vitameatavegamin?  I think the more reasonable path is actually to think about our own experiences with being healthy. 

First, we’ve drawn the boundary of our Healthcare System such that it leaves out food production.  This implies that we can’t actually talk about healthy diets, at least in this part of the discussion.  This sort of limits us to thinking about what could possibly send us past the boundary we’ve defined.  If you’re a male between 18 and 40, you probably aren’t going to be familiar with this term, but the standard point-of-entry into the system is called your “annual check-up.”  This exam is the standard point of entry into the healthcare system.  It normally involves the following, according to WebMD:

-Blood Pressure
-Heart Exam
-Lung Exam
-Head and Neck Exam
-Abdominal Exam
-Neurological Exam
-Dermatological Exam
-Extremities Exam
-“Sex Specific Exams”
-Lab Tests: Blood Count, Chemistry Panel, Urinalysis

Depending on what they find here you may go further into the system or stay out.  Notice that most of these tests aren’t actually looking to tell how well you are, they are actually trying to find something wrong with you: signs of disease, cancer, disorders and other anomalies.  Consider what can’t get caught in a doctor’s office, which might send us to the ER—none of those things would make you say “I am so incredibly healthy!”  “Healthy” for the System seems more about what takes us away from some “normal” physical state than what could make us better than normal.  If we think about what brings us into the system, we first have to think that it is about identifying problems with our health and then trying to find some resolution to those problems.  Finding some resolution is kind of a target and not necessarily a “shall do” because there might not be resolutions to some particular problems.  For this reason, let’s state our first requirement as:

The Healthcare System should detect health related problems of individuals and restore those individuals to as full health as possible with all available knowledge and technology.

I think this requirement is rather complete, but it really only talks to one aspect of the system.  The other major component of the healthcare system is the business end, literally.  Let’s not get into the solution side of this (federal program vs. individual funding) but talk to more of the obvious.  More specifically, let’s talk about all the people in the system that should to get paid (leaving out how they get paid).  Obviously, everyone in the system who provides a service should get paid.  However, let’s get a little more specific.  Everyone who participates in the function we previously described should get paid towards their contribution to that diagnosis and restoration.  We can look at this as something more concrete, like a construction contractor.  The contractor gets paid for doing to the work and that money gets split up according to the job: some goes to the guys who did the work (usually at a predefined rate agreed to before the job started and normally based on hours), some towards the rental or purchase of certain tools, some goes towards materials used on the job, some goes towards future growth of the firm, etc.  The workers come in different price ranges dependent on their availability and any special skills they possess—the rarer, the higher the bill.  Why should we consider the pay scheme to repair a house, a car or a refrigerator to be any different than that of a person?  Yes, there are more specialties and equipment involved, but no matter how you combine them, they don’t really change this fundamental structure.  Does hospitalization really change the structure of a Hotel payment structure combined with a repair facility payment scheme?  The requirement for payment seems to be this:

The Healthcare System should pay those involved in the actions relative to providing goods and services as the real cost of labor and material allowing normal growth (as with any other business).

There is another side to this requirement, pricing.  Not only should people be compensated for their actions, but they should also fairly reflect the pricing of their goods and services.  I love to use pricegrabber.com because I can quickly compare the prices of things I’m interested in buying at a bunch of stores to find the best price for those items.  It also gives ratings for those stores so you also know the likelihood of a good delivery, and how they handle any issues with the thing you bought.  Pricegrabber is really only making the job of comparative shopping easier, but it is something we do (or should do) with any purchase.  Comparative shopping is simply the market at work.  The ability to compare prices and goods between different stores keeps those prices in check.  The more competition that exists for particular products, the closer to the real price of the good or service one is likely to get.  This pricing competition works for contractors and mechanics as it does for product retailers.  Why shouldn’t it also be the basis of Healthcare pricing?  The only unusual case which the users of the Healthcare System must deal with is the Emergency Room.  One doesn’t normally have the time to compare prices for ER services which may cause price gouging.  However, we can make one general requirement that covers both of these:

The Healthcare System shall provide a means provide fair pricing for services and products rendered.

The three preceding requirements are pretty cut and dry for a normal business (provide a service, pay people for providing that service, price your service reasonably), but we have one requirement that is far outside the norm for a typical business—access.  Normally, businesses only provide access based on the ability of the customer to pay for that service.  For instance, a mechanic is not going to do a job for free; they might not even diagnose the problem for free, but for Healthcare, we must mandate access to everyone.  Let’s actually keep this requirement as vague as it sounds:

The Healthcare System shall provide full access to all available knowledge and technology to all potential users.

If we accept this as a “must have,” then we can consider all of the options towards meeting that requirement in the next phase.  This requirement also does not exclude people who can pay or pay part of their care and will lead towards some novel solutions when we consider these requirements together.  It also seems to make us start thinking about those who might abuse this access.  What if people pretend they can’t pay when they can?  Who actually will pay?  When you think of large organizations, you can probably conceive of a million ways that system can be cheated.  For our problem, I believe we should consider this cheater problem beyond just this requirement.  It’s too vague to say “make sure people don’t cheat,” but something should be included about cheater prevention.  Let me propose (again, I really mean “dictate”) the following requirement:

The Healthcare System shall have a means to regulate each functional requirement such that it automatically prevents abuse.

This requirement essentially means that for every idea we come up with for a requirement there should also be an idea for how to keep that concept from being abused. 

So, that’s it, and by “it” I mean this part of “it” not actually all of “it.”  Next time I’ll actually talk about potential solutions, and by the pace of the Healthcare “debate” I’m pretty sure I’ll have time to get into it.