Five Principles for the Future of Healthcare

Bert R. Mandelbaum, MD, DHL (Hon)

May 03, 2017

The failure of the US Congress to repeal and replace the Affordable Care Act (ACA) in March illustrated an important problem in the way that politicians are thinking about healthcare. Politics should not determine how we care for people in need. Rather than trying to accommodate our healthcare system to a political ideology—whether it is capitalism, socialism, or libertarianism—we should start with what the patient needs and build from there.

The patient is not in the center of the maze we call the ACA. The patient is off to one side and the physician is off to the other side. Despite their protests about expensive risk pools in the ACA exchanges, the five biggest US health insurers have done well since the act was implemented. Collectively, their annual profits went up 17%, from $12.8 billion in 2013 to $14.6 billion in 2016.^[1-9]That $1.8 billion profit was lifted from the pockets of patients and providers.

Table. Change in Top 5 Health Insurers' Profits Under the ACA, in Billions of Dollars

What did the consumer get? Higher premiums. If you put the patient first—not lobby groups, not payers, not the president—then we will do what we need to do.

Everyone is going to be sick or injured sometime. We must do whatever we can to keep healthy people healthy and take care of those who are not. Rather than focusing on being for or against Donald Trump's healthcare plan, let us focus on the health of the American people.

Mandelbaum's Five Principles

Here are the principles I believe we should use to shape our healthcare system:

1. Empower patients. Patients should be the masters of their fates. To help them, we must coordinate the messages they are getting about their health. Instead of a mix of messages from the American Heart/Cancer/Diabetes/etc Association, the Academy of Nutrition and Dietetics, the Centers for Disease Control and Prevention, the Department of Agriculture, and so on, let us create a single portal with clear, evidence-based information.

2. Expand access. Right now we are talking about whether people with preexisting conditions should be able to buy health insurance, and how long kids should be able to stay on their parents' health insurance plans. Let's keep it simple: Everyone should be able to buy health insurance. Period.

3. Centralization. The market for healthcare coverage should not stop at state borders. In Maryland, the Shock Trauma Center at the University of Maryland, a single integrated trauma hospital, cares for people in Maryland, New Jersey, parts of Pennsylvania, and beyond, and they do it much better than anyone else. Everywhere else, gunshot victims may be treated in one place, car accident victims in another, and so on. The University of Maryland is the model for ultimate specialization in regional Centers of Excellence.

Similarly, if you could sell insurance over state borders, instead of insuring 1 million people in each state you could insure 100 million people across states. That would increase the risk pool, attract more insurers, and bring down the cost.

4. Stop cherry-picking. Some health plans want to skim the healthiest patients from the risk pool. That may work very well as a business model, but it leaves holes in the healthcare safety net. The government should provide subsidies to insurers so that they can afford to take care of the very sickest people.

5. Optimize technology. We are already using technology to create a dense cloud of metrics about our patients. There are smartphone apps that show how effectively you have managed your blood pressure. We can look at a disease process with thousands and millions of data points that we have never been able to look at before. Artificial intelligence can help physicians manage and assemble such data for research and diagnosis. Let's make that predictable, personalized, participatory, and preventive.

Once we completely untangle the genome, there will be things that some people need and others do not, and vice versa. We are already advising certain patients about what they should eat and what drugs they should take based on their genes. And we are learning how to modulate the immune system to better fight diseases as well. There is going to be even more precision in the future.

The use of robots has revolutionized prostatectomy, making it less invasive and with less nerve injury and bleeding. The doctor sits 8-10 feet behind the operating table, driving the robot to do the dissection. In orthopedics, we have MAKOplasty, in which robots help perform partial knee replacements using CT in a manner similar to navigating by GPS technology, and the computer does not allow the orthopedist to put a partial knee replacement in the wrong place! We also now have robots that can help a person walk, remind a person to take medicine, and make sure they take the correct dose.

Four-dimensional endoscopy is coming to orthopedic surgery. In this technology, temporal information is added to special information, allowing us to be much more refined and efficient. With 4K video imaging, which displays four times the number of pixels in full high definition, neurosurgeons can now go through the nose and into the brain to find tumors and remove them. Virtual and augmented reality can help train new surgeons through simulations. Three-dimensional printing will improve the accuracy and precision of medical implants and other devices, and will help us to better visualize joints and organs.

Employing these five principles would get us a lot farther along toward the healthcare we need than would politics. That is where we will end up if we focus on what Hippocrates said over 2400 years ago: "The regimen I adopt shall be for the benefit of my patients according to my ability and judgment, and not for their hurt or for wrong."^[10]

Let's make that guidance from the past central to our future.

References

1. United Health Group. United Health Group reports 2013 results. http://www.unitedhealthgroup.com/~/media/UHG/PDF/2013/UNH-Q4-2013-Release.ashx?la=en Accessed April 25, 2017.
2. United Health Group. United Health Group reports 2016 results. http://www.unitedhealthgroup.com/~/media/4F32B92CA7D74B509F37B32D0B649845.ashx Accessed April 25, 2017.
3. Anthem. Anthem annual income statement. https://amigobulls.com/stocks/ANTM/income-statement/annual?f=pg Accessed April 25, 2017.
4. Aetna. Aetna reports fourth-quarter and full-year 2013 results. https://news.aetna.com/news-releases/aetna-reports-fourth-quarter-and-full-year-2013-results/ Accessed April 25, 2017.
5. Aetna. Aetna reports fourth-quarter and full-year 2016 results. https://news.aetna.com/news-releases/aetna-reports-fourth-quarter-and-full-year-2016-results/ Accessed April 25, 2017.
6. Cigna. Cigna reports strong full year 2013 results, expects growth in 2014. https://www.cigna.com/newsroom/news-releases/2014/cigna-reports-strong-full-year-2013-results-expects-growth-in-2014 Accessed April 25, 2017.
7. Cigna. Cigna reports 2016 results, expects attractive earnings growth in 2017. https://www.cigna.com/newsroom/news-releases/2017/cigna-reports-2016-results-expects-attractive-earnings-growth-in-2017 Accessed April 25, 2017.
8. Humana. Humana 2013 annual report. http://phx.corporate-ir.net/phoenix.zhtml?c=92913&p=irol-reportsannual Accessed April 25, 2017.
9. Humana. Humana 2016 annual report. http://phx.corporate-ir.net/phoenix.zhtml?c=92913&p=irol-reportsannual Accessed April 25, 2017.
10. Kaba R, Sooriakumaran P. The evolution of the doctor-patient relationship. Int J Surg. 2007;5:57-65.