Healthcare in the United States and Around the World

A Little Bit of History

As we begin our discussion about healthcare in the United States, let’s recall the early health history of our country and take a look at how far we’ve come. In the mid-1800’s/ early1900’s we had a lot of very contagious diseases and infections that we didn't know how to control or treat. So, they would get out of control and reach epidemic proportions, and that's what we were concerned with treating. We were basically just taking care of those who were ill.

As we learned more about the science behind the cause of these illnesses, we were able to find ways to control them. As we progressed through the 1900’s there were many developments that helped improve healthcare and decrease the high death rate due to epidemics and outbreaks. One of the areas that you might be interested in going into and that has really made a difference in controlling the spread of diseases is epidemiology. Epidemiology is the study of tracking and studying how a disease is being spread, where it's being spread, and where it originated. With that kind of data, we can try to figure out how to limit the impact and spread of the disease. We saw this in action with the Ebola outbreak. There were teams of epidemiologists tracking the victims, the carriers, trying to identify sources and contain the exposure. They worked alongside other healthcare providers to contain the outbreak. There were teams of epidemiologists tracking the victims, the carriers, trying to identify sources and contain the exposure. They worked alongside other healthcare providers to contain the outbreak and were able to prevent a more widespread epidemic.

Progress in Healthcare

When we look at science and technological improvements over the last century, there's so much we know and can do now that we didn't know and couldn't do before. For example, it wasn’t until the 1990’s that ultrasounds started to become common for pregnant women to check on the health of a fetus. This is a 4-D ultrasound of a baby about thirty weeks in utero. Technology now allows us to take an in-depth look at the heart structure, the formation of the brain, and spinal cord. We have genetic tests we can do on babies ten weeks after conception to look for specific chromosomal abnormalities. This concept is amazing and the ability to have that kind of information has improved the way we can deliver healthcare and practice medicine. We’ve also had the establishment of health departments whose services promote the health of the public, and many public health initiatives whose aim is disease prevention. There are a lot of jobs in this area (I’ll give you a hint as to why, it has a lot to do with the current healthcare reform act). The Hill-Burton act, in the 1960s, led to the establishment of regulated hospital systems across the country, which are now flushed with technology and specialized staff that are able to provide much higher levels of care for individuals, with better outcomes compared to a century ago. We now know the importance of hygiene. It’s taught on many levels from school to the home. This advancement has led to improvements of the public's health and healthcare. In addition, there's been a lot of public education surrounding nutrition. So, now we know what to do to keep ourselves healthy and there is a lot of disease prevention associated with nutrition. We have gone from using basic apprenticeships to train doctors to establishing medical schools that have advanced training for physicians. This knowledge base that physicians have today compared to what they had even twenty-five years ago is huge in comparison and we have ways to deliver that care and knowledge to individuals. All of these improvements that we've talked about have really changed the focus of the way we provide healthcare.

Chronic Diseases

Chronic diseases are diseases that occur over a long period of time. Heart disease, for example, can be due to a genetic issue or a defect, but in many cases, it has to do with diet. High cholesterol can lead to the establishment of plaques within your arteries that make it difficult for you to efficiently transport blood and oxygen throughout the body. Someone with heart disease ends up having problems with different tissues in addition to the heart or circulatory issue. This is not like an infectious disease that's relatively brief because people get it, get really sick and die because we don’t have a cure. Chronic diseases, like heart disease, build up over time. The individual will have side effects, and treat those effects for years and years in some cases and then ultimately may end up with surgery, transplants or potentially a debilitating effect like a stroke or heart attack. These may cause further tissue damage and leads to additional care needs. Other chronic (and unfortunately these days common) illnesses that you will recognize include diabetes, cancer, hypertension and dementia. It’s important to recognize that these are much more expensive, lengthy treatments and will have a different focus when we talk about insurance, healthcare and factors influencing healthcare reform.

Emerging Diseases

We also see more emerging diseases. By emerging diseases, we mean those new illnesses that pop up, for example the Zika virus that's being spread by mosquitoes. It’s too early to tell with today’s technology if we may be able to control it and eradicate it, although it could turn into something more (it certainly would have 100 years ago!). Another example is MRSA (Methicillin-Resistant Staphylococcus Aureus), which is a bacterium that we used to be able to treat, but it has evolved to become resistant to previous drugs. It's an emerging disease because we have a novel mechanism that it’s using to escape the drugs that we have. There are a few other drugs that were backups to methicillin that aren't working either on some strains of staph aureus. HIV had been a focus for quite a while. Due to science and research, there are lot of improvement in the care and longevity of HIV patients. SARS, H1N1, and the Ebola virus have arisen in your lifetime, and in the past ten years have become diseases that needed research and resources put towards them.

Acute Diseases

Historically, the emphasis by insurance companies in the US has been on the short-term treatments. In other words, taking care of individuals who get very sick, acutely sick. This has been one of the problems in the US healthcare system. There are socio-economic disparities in terms of who's getting the treatment that they need, who's getting preventative treatment and who's ending up sicker because they didn't have access to preventative treatment. You might imagine if you were wealthy then you might go to the doctor if you had a cough or felt a little funny. If you didn't have the money to go the doctor and your insurance wasn't going to help you much, then you just wouldn't go. An untreated cough and cold could progress into a more severe illness and eventually may end up as bronchitis or worse, pneumonia where the person ends up in the hospital. Whereas, if the person had had early preventative care maybe there would have been earlier treatment for that minor cough or cold and it would not have gotten worse. With regard to insurance and coverage it has been recognized that if we focus on prevention and care of chronic illnesses over a longer period of time where you're maintaining that patient’s health then its more efficient in the long run. It's much cheaper to provide for someone in smaller amounts over a period of time versus ending up in the hospital with huge medical bills and much worse prognoses in some cases. This is a big change in focus for insurance companies and as we will discuss a big difference between the US and other countries in terms of care.

Technology

The technology that we've talked about - the MRIs, Cat Scans, screenings, ultrasounds - is all expensive. It’s expensive to develop, it's expensive to upkeep, it's expensive to stay on top of the technology and make sure that you have the latest and greatest. The US is a world leader in this area.

Baby Boomers

Then there is the baby boomer population that is aging into the system, remember them? They have specific foci on their health, specifically those that go along with getting older. Disorders like Alzheimer’s, orthopedic issues, if there's a weight issue, there may be diabetes or heart disease. Also, generally as you get older you tend to get sicker, that goes for pretty much everybody, therefore, we are starting to see a much larger group of people in this country with greater healthcare needs. That baby boomer population is going to cost money.

Reimbursement

Another factor in the cost of healthcare is the method of reimbursement for providers. I have to say here that although healthcare providers are the easiest targets to blame for costs, they are not the largest factor! However, there are ways to minimize costs and maximize quality related to provider care. Let’s remember that historically when some providers were paid for services under some methods of reimbursement, they may have been paid per procedure. They wouldn't be paid by whether or not those procedures are helping you to get better or maintaining your health. Hopefully you see that basing reimbursement on procedures ethically has issues and may drive costs in ways that may incentivize unnecessary testing. Stated simply, in this type of model the more tests a provider does, the more money they may make. We like to think our providers are ethical. I'm sure everyone listening who's going into healthcare will be, however, it's tempting. There are systems setup that play on that kind of reimbursement scenario. This system does not minimize healthcare related costs and is addressed by the latest healthcare reform bill.

Prescription Development

Prescription drug development and marketing is also expensive. One prescription drug cost million upon millions of dollars to research and develop and years of clinical trials to gain FDA approval. Sometimes at the end of all that they end up with a drug that doesn't actually get approved or ends up in clinical trials that aren't successful so it, which adds to the overall cost. While we know the drugs themselves are costly there is a lot that goes into that price.

Administration

As I mentioned, we see more chronic diseases now than ever before and more hospitalizations as a result. A large proportion of healthcare costs goes to administration. That's another area that healthcare reform is really trying to focus on - decreasing administrative cost and putting more money into care versus inflationary administrative costs. Along those same lines historically we've had a system that wasn't streamlined. For example, let’s say you went to your primary care provider; afterward you might also follow up with a specialist. Your primary care provider might not get all of your information to the specialist that they need to go forward with treatment, so tests can be rerun and services billed again. A lack of communication between different healthcare providers can increase costs due to duplication of services or miscommunication of information. The idea is that streamlining of technology and communication in healthcare will lead to less repetitive testing and visits to doctors or specialists, and a decrease in the number of procedures that individuals really don’t need.