February 9, 2016

Healthcare is Broken but Fixable

Our healthcare system is broken, but fixable, as I learned from meeting with George Halvorson, an exceptionally visionary healthcare leader.

He wrote an incredibly insightful book entitled Don’t Let Healthcare Bankrupt America (2013). It contained many profound insights. Those which stuck with me were:

Instead of empowering healthcare providers to do the right things, we reward them handsomely for continuing to do the wrong things, and we penalize them for continuously improving and innovating;

  • The prices for healthcare services bear no relationship to one another, to the cost of delivering care, or to the quality of care. In fact, the higher price institutions often deliver far poorer quality care than the lower price ones.
  • We get less access to primary, specialist, and hospital care than Europe and we wait longer for appointments;
  • More care usually means worse care, contrary to what most Americans believe; and
  • The biggest health improvement step we can take is actually quite easy to do: increase the walking we do.

We pay for the wrong healthcare.

Health plans and Medicare/Medicaid pay doctors only if they file claims with standardized and approved diagnostic and treatment billing codes.

As Halvorson notes, we pay for treatment included in coded billing systems and withhold payment for anything absent from them. Process improvement techniques that save lives, reduce care costs, and improve health, but require significant investments, when not covered by billing codes, are not reimbursable.

The rigid billing code system we use disempowers doctors and patients, and stifles innovation, quality improvement, and patient empowerment.

He proposes that we pay fixed amounts for assigned populations based on meeting robust quality standards (this is called “accountable care”) and fixed amounts for an entire episode of care. I agree.

Healthcare pricing is completely lacking any anchor in cost, quality, geography or patient benefit. It is completely arbitrary, except that the uninsured pay a lot more.

Price comparison data demonstrates that there are huge disparities within and between communities for identical clinical, pharmaceutical and diagnostic laboratory transactions. For the same medical office, hundreds of separate health plans cover the patient population, each with different pricing for comparable medical treatments.

These price differences are unrelated to cost, quality of care, location, or value to the patient. Halvorson also points out that there is a huge disparity among prices for a clinical treatment, drug, or diagnostic test in the United States versus anywhere else in the world.

Thus, we pay more and get less than if we were in another country. We need standardized pricing, which simplifies billing and administrative processes for providers and health plans.

We get poorer access to healthcare than people in most other developed countries.

Halvorson convincingly demolishes the misconception that we get better access to healthcare because we spend so much more. In fact, we create so much inefficiency in care delivery that we get less productivity from each healthcare provider than just about any other developed country.

US doctors and nurses are of comparable quality and they do the medical parts of their job at a comparable level of speed and skill.

However, because of the ridiculous administrative burden placed on US practitioners by Medicare and the commercial insurance system to support claims, audits, and government regulations, we add 1-2 hours of non-value-added work to every private practitioner’s day. Outside the U.S., there is a much lower practitioner administrative burden.

More care is often worse care.

This is probably the most counterintuitive insight one gets from George Halvorson. When Americans get as much healthcare as possible, they pay more and often experience worse outcomes.


In America, doctors average 7-10 minutes with each patient. Writing a prescription, often the easiest thing to do, is often worse for the patient than doing nothing:

When many overweight patients complain of severe back pain, doctors prescribe pain medication, which can lead to painkiller addiction and eventually to alcohol abuse.

  • Drugs have negative side effects. 30% of all people who take powerful antibiotics experience diarrhea. People taking drugs for mental health conditions see their weight increase. Years ago, a young homeless man at a social service agency I support ballooned from 160 to 400 pounds in two years because he was taking anti-psychotic drugs, which then led to Type 2 diabetes and hypertension.
  • Antibiotic-resistant bacteria result from excessive prescribing of powerful antibiotics, combined with incomplete or improper medication adherence.
  • Individuals on multiple medications sometimes find that one medication may make another completely ineffective.


Many surgeries have negative outcomes. For example, prostate cancer surgery often has no more beneficial effect than less intensive treatments, but it messes up many critical bodily functions.

For certain conditions, such as back, knee, and hip problems, physical therapy is a far better choice than surgery, since it enables the patient to be more self-reliant.

Exposure to diagnostic imaging tests

Clinical research indicates that children under 12 who have too many radiation-emitting diagnostic imaging tests experience higher brain cancer incidence. Parents unintentionally expose their children to excessive radiation because they want to manage sports-induced concussions.

Chemotherapy and other aggressive end-of-life treatments

Too many hospitals and cancer treatment centers and media stories describe individuals who “fight a brave battle” against cancer. The implication is that getting aggressive treatment always prolongs life and constitutes being “brave” and “fighting” the cancer, as opposed to “giving up.”

The tragedy of this misconception is twofold:

Many people survive longer by selecting palliative care alternatives. Atul Gawande of the Harvard Medical School pointed this out in August, 2010, article. Aggressive care often shortens life.


  • The quality of life for someone electing palliative care is often far better. They are alert, able to work and to engage in recreational activity with their loved ones and friends, and most importantly, able to plan the way they want to wind up their affairs.


I loved this part of Halvorson’s book. I walk over 10,000 steps every day, and try to get over 20,000 a day on the weekends. The exact number of steps is less important than the focus on remaining physically active.

Dr. James Levine of the Mayo Clinic has said that prolonged sitting (4 or more hours per day) is “the new smoking.” Walking around periodically is valuable for musculo-skeletal function.

Halvorson de-emphasizes harder-to-do strenuous exercise in favor of easy-to-do walking. We can walk inside our apartment or home, at work, while we are shopping, or reading.

Four great inventions of the last 30 years have liberated us to walk while on the phone or even while reading: cordless or mobile phones, speaker phone features on mobile phones, mute buttons on phones (gives us more freedom to walk in a noisier area) and Kindle software (which enables us to walk while reading.)

Walking is liberating and empowering.

The big message in George Halvorson’s book and other works.

George Halvorson delivers a strong message of empowerment: of patients, healthcare providers, and, most important of all, American society. His messages on how to improve healthcare save money, deliver better care at lower cost to more people, and, most important of all, liberate human, financial and other resources to solve many other societal problems.