Why is Healthcare So Hard to Fix?

(A Recipe for Disaster)

I recently watched the newest Marvel Blockbuster — Captain America: The Winter Soldier. Aside from the spectacular CGI, unrelenting action and comedic dialogue, one part of the story resounded with me. Hydra, the secret organization plotting world domination. Taken from Greek legend, the Hydra was a monstrous creature with nine heads, the center one immortal. As each head was cleaved, two emerged in its place. While the story of the Hydra is a myth, our current healthcare system has embodied the multifarious nature of the beast. Attempt to standardize practice and insurers poke holes in reimbursement plans. Bring health records into the electronic space, interoperability thwarts sharing patient information between health systems. Specialize physician roles away from Primary Care and watch Obesity and Type II Diabetes rates skyrocket. These are just a few critical issues that plague health care in the United States, and as one issue is closer to being solved it seems as if two more are burgeoning in its place.

Let’s backtrack to 1980. Our nation had 50 million fewer people, obesity rates halved today’s count and healthcare was almost entirely off the grid. What causes led to a two-fold increase in our nation’s healthcare GDP over the next 35 years to it’s current 18% peak? There are numerous factors at play, too many to list, so I’ll give you my top three: 1)Replacement of granular cane sugar with high fructose corn syrup (HFCS)— leading the surge for our Obesity epidemic 2) Non-standardization of care, administration, or documentation 3) An aging population that costs more to care for.

In 1977 the United States was hit with multiple sugar tariffs and quotas, ramping up the price of sugar cane importation — leading producers to seek cheaper options. Around the same time buzz around HFCS was mounting. With government regulations subsidizing corn, costs remained modest and production of HFCS, derived from milling and refining corn, was the obvious alternative. America’s food and beverage industry slurped up the sugary goodness as did the rest of the nation. “What’s the big deal?” one may ask… “Americans drank sugar loaded sodas before the switch to HFCS, what’s really changed?” From the lens of the general consumer — nothing. A bottle of Coca-Cola still has its unparalleled flavors and sweetness packed with a hit of caffeine. The beverage even has a small portion of sodium, leaving you thirst receptors itching for more. The differentiator of course is the use of HFCS as a sweetener, which now over 40% of commercially sold beverages use in America. Coke and other sodas have become as dangerous to our health as many other hazardous drugs when consumed in excess.

Unlike glucose, fructose cannot be metabolized effectively to fuel our body and unless burned off through exercise, will be converted to fat. Insulin beta-receptors which are responsible for taking up excess blood glucose for storage do not have the same transporters for fructose. Thus, excess fructose in the bloodstream will lead to all the manifestations of metabolic syndrome: Type II Diabetes, Atherosclerosis, Hypertension, Dyslipidemia and Obesity. Furthermore, fructose interferes with our satiety system, not suppressing Ghrelin, a hormone released when we feel full. Marry hunger insensitivity with sugary coated vasculature, that’s one nuptial doomed to last. As Dr. Robert Lustig put it “Fructose is a chronic hepatotoxic, it’s ‘alcohol without the buzz,’ but FDA can’t and won’t regulate it.” The increase in HFCS consumption eerily overlapping our Obesity epidemic in the past 35 years is no mistake. It’s an addiction. The # 1 problem facing our healthcare system in my book is reflected by the rise of lifestyle related diseases, such as Obesity, which can only be countered by a shift to prevention based care. We must stop trying to put out the fires and start preventing them from igniting in the first place.

The importance of preventive medicine cannot be overstated, however, acute and long term care will always be necessary — thus defining standardized and best practice is critical to limit unnecessary services and waste in the delivery of care. Currently there’s over $765 billion dollars of waste in our U.S. healthcare system.

In hospitals and clinics throughout the country, providers attempt to deliver optimal care to their patients, but at what cost? Non-standardized care can range from providers using different methods of care for the same procedure, nurses using non-health literate verbiage, even lack of communication between our EHRs. The latter has become a hot topic of late, as interoperability has created a barrier for providers to share patient information across platforms. To begin reducing waste and delivering optimal care we must start trimming the fat. Using one medical supply company instead of three, teaching nurses current health literacy standards in attempt to lower readmission rates upon discharge, adopting innovative strategies and lean methodologies for administrative operations, optimizing EHRs for information sharing… the list goes on. The ACO model has put an expiration date on independent and small-practice medical groups who simply can’t cough up the cash to stay afloat. Agile project management and innovative solutions by healthcare giants will determine our ability to reduce waste.

An exciting example is ThedaCare, an Appleton, WI based health system, which has shifted their focus towards creating value for their patients through lean methodologies. From revamping administrative operations to manage projects via a Kanban Canvas to partnering with The Ohio State University’s Fisher College of Business to create a Center for Lean Healthcare Research… ThedaCare is constantly evaluating areas of their business with room for improvement and the ability to reduce waste.

The third group weighing in on healthcare’s dramatic GDP surge is the elderly population. Our population has outlasted all previous generations in terms of life expectancy, via natural and unnatural methods. We have evolved into more intelligent and efficient creatures, preventing disease or treating it appropriately before causing any severe ailments. Illnesses which harrowed our species not long ago have been either eradicated or vaccinated and replaced by lifestyle diseases, such as poor nutritional decisions and exercise habits. Our medical research, innovations and technology have allowed us to age healthfully but when necessary also actively play a role in extending our lives — for the better or worse. Where do we draw the line? For this article’s purpose let’s define the elderly population as anyone age 65+ (it tends to vary across literature). The elderly cost 3–5 times more to care for than those < 65 y/o.

Furthermore, the last year of life costs ~1/3 of total medical costs for that patient. So the question we must continually ask ourselves is: are these end-of-live services and treatments necessary? The problem is the answer is not cut and dry, and gray areas emerge as the end of life nears. Starting the conversation about end-of-life treatment options with family members and providers can ease the burden of all parties involved. It will also help the physician execute the proper treatments as indicated by one’s Medical Advance Directive, a document everyone over 18 should have. By honoring patient’s wishes and delivering care that is necessary for the specific diagnosis and wanted by the patient— health systems can cut costs and support patient’s and families through difficult times. As Dr. Atul Gawande recently published, sometimes it’s all about giving the patient “The Best Possible Day” and letting them live out their remaining time peacefully.

My “Best Possible Day” Recipe

Prep Time: 15 min
Cook Time: 15 min
Serves: 4

Ingredients

1. 1.5 lbs. fresh tomatillos — husked, rinsed and halved
2. 1 large garlic clove
3. 1 large jalapeño — halved lengthwise, stemmed and seeded
4. 1/4 cup chopped cilantro
5. 2 tbs. vegetable oil (or corn oil)
6. 1 tsp. ground cumin
7. 1/2 tsp. coriander
8. 1/2 tsp. salt & freshly ground pepper
9. 1 lb. shredded cooked chicken
10. 1 cup pepper jack cheese
11. 1/2 cup queso fresco
12. 1 scallion diced
13. 1/4 cup sour cream
14. 6-ounce bag corn tortilla chips

Directions

1. Preheat the oven to 450°. In a blender or food processor, puree the tomatillos, garlic, jalapeño and cilantro until smooth. In a large saucepan, heat the oil until shimmering. Add the cumin and coriander and cook over high heat until fragrant, 30 seconds. Add the tomatillo puree, bring to a boil and cook until the sauce loses its bright green color, 3 minutes. Season with salt and pepper.
2. In a medium bowl, toss the chicken with 1/2 cup of the pepper Jack, the queso fresco , scallion and half of the tomatillo sauce; season with salt and pepper. In another bowl, toss the tortilla chips with the remaining sauce.
3. Spread half of the chips in an 8–by–11–inch baking dish; top with chicken and cover with the remaining tortilla chips. Don’t pack the chips down. Dollop the sour cream over the chips and sprinkle with the remaining 1/2 cup of pepper Jack. Bake for 15 minutes, or until the cheese is browned. Serve at once.