LETTERS FROM THE GLOBAL PROVINCE
Healthcare: Answering the Wrong Questions, Global Province Letter, 7 June 2017
Our Life as a Consigliere. We have spent 50 years advising chief executives, owners of companies, a few politicians, a couple of college presidents, and managing directors of a bevy of charities and do-good organizations. The problem is not to find answers. Time in and time out, these are bright fellows who simply know more about what they are doing than anybody else, including us. But invariably they are asking the wrong questions, seeking answers to trivial problems, neglecting the real crisis underfoot.
There's a substantial literature, witty to boot, about getting the question right, proving that most of us are so imprisoned, by the box we find ourselves in, that we simply have no idea what is outside our walls, or soaring overhead. In short, it says we tend to ask the wrong questions, so we tend to get utterly worthless answers. This simple insight may help you understand why the nation is suffering from depression, inertia, economic stagnation, and a whole crop of snake oil salesmen posing as leaders. Many have uttered versions of this truism:
1. "It's not that they can't see the solution. They can't see the problem." - G.K. Chesterton
2. "There are no right answers to wrong questions." - Ursula K. Le Guin
3. "We thought that we had the answers, it was the questions we had wrong." - Bono
4. "Ask the right questions if you're going to find the right answers." - Vanessa Redgrave
5. "Asking the right questions takes as much skill as giving the right answers." - Robert Half
6. "What people think of as the moment of discovery is really the discovery of the question." - Jonas Salk
7. "What we observe is not nature itself, but nature exposed to our method of questioning." - Werner Heisenberg
8. "The uncreative mind can spot wrong answers, but it takes a very creative mind to spot wrong questions." - Antony Jay
9. "In school, we're rewarded for having the answer, not for asking a good question." - Richard Saul Wurman
10. "In all affairs, it's a healthy thing now and then to hang a question mark on the things you have long taken for granted." - Bertrand Russell 11. "Computers are useless. They can only give you answers." - Pablo Picasso
12. "Judge a man by his questions rather than his answers." - Voltaire
13. "We hear only those questions for which we are in a position to find answers." - Friedrich Nietszche
14. "My greatest strength as a consultant is to be ignorant and ask a few questions." - Peter Drucker
15. "He who asks a question is a fool for five minutes; he who does not ask a question remains a fool forever." - Chinese proverb
Healthcare. So, too, with healthcare. We've got it wrong. As best we know, we pay aplenty for the most complex healthcare in the world. That is, we spend the most per capita, but our health is not improving, and, in fact, is arguably getting worse. On the national stage, we argue about how to get the costs of healthcare down, but spend virtually no time or thought on improving our health and health treatment. We are dying expensively and worse we are dying a little sooner. As reported in the Atlantic:
American life expectancy fell by one-tenth of a year since 2014, from 78.9 to 78.8, according to a report released last week by the National Center for Health Statistics. As The Washington Post reported, the last time the life expectancy went down instead of up was in 1993, during the throes of the AIDS epidemic. Meanwhile, the number of years people are expected to live at 65 remained unchanged, suggesting people are falling ill and dying young.
The overall death rate rose by 1.2 percent in 2015, the first time since 1999. The death rates went up for white men and women and for black men, but did not change significantly for Hispanics or black women.
A Big Dose of Reality. AIn other words, we are fiddling while Rome burns. To do anything about health, healthcare, and its costs, we must take some tough medicine and face up to some hard truths. To wit:
1. The nation is growing older fast, with a bigger chunk of the population over 60. The oldies suffer from chronic diseases, which physicians don't really know how to treat, so medical authorities wrestle with diabetes, and Parkinson's, Alzheimer's, several types of cancer, and so on with very limited success. These are really public health problems, best addressed by diet, exercise and other measures much earlier in life that help avert the disease condition altogether. Instead, we spend countless dollars trying to round up the cows after they are out of the barn.
2. A goodly part of our health dilemma arises from the fact that unhealthy conditions are deeply entrenched in society and have nothing to do with the doctor-patient relationship. Preservatives in our food, a plethora of hidden electrical and sonic waves, water that is infested with chemicals and other foreign ingredients, work practices that lead to massive stress, inertia resulting in obesity and impaired hearts , depression, and so on—these are just a few examples of killers built into our life. Physicians to some extent are really just moving the deck chairs in trying to extend lives in a meaningful way. One can run or walk five miles every day to help the body along, but it does not avail much if we are gulping fumes, tainted foods, and bizarre drinks and pills (the side effects of high drug usage promoted by the drug companies are rather underestimated) all the while.
3. Warren Buffet preaches that the big healthcare issue is its high cost, not health taxes. True enough. But the brilliant economist William Baumol provides a lesson that Buffett probably has missed. Getting health care costs down is like rolling rocks uphill. It is an insanely labor intensive sector where labor ratios (costs) keep swelling as you add bodies. The wicked truth of the professional services sector is that productivity does not rise as you achieve scale, but actually goes down. It is hard as it can be to take bodies out of health. We should instead pay attention to taking out bodies in other sectors that are providing worthless services, such as the vastly overstaffed financial sector. We have more banks and countless other financial services than we need, which dream up useless unneeded products in order to expand and survive. Healthcare costs in reality have to expand disproportionately, no matter how prudent we are, says Baumol.
Getting off the Dime. We have been asking financial questions, not health questions, though we are dealing with wellness. How, we ask, does every American get covered? And how, we ask, do we chop the cost of healthcare, or at least arrest its upward spiral? We are not asking how we radically raise the quality of healthcare. We are not asking what imaginative things we have to do since healthcare is an intrinsically expensive service, inflated by hungry insurance companies, out of control pharmaceuticals, and technology playboys.
To get somewhere, we need to take chunks of healthcare out of the existing healthcare system. As posed above, strong public health measures and enforcement are vital to virtually eliminate environmental and societal hazards that guarantee a lot of illness. That is, society will have to be redesigned to simply make sure a lot of bad health never happens.
But, too, we need to encourage developments that might upset the healthcare applecart, things that may well provide cures instead of palliatives and band aids. We will mention a couple here.
Fecal Transplants One area of current study that is quite promising, but still very experimental, is fecal transplants. As defined by Wikipedia,"Fecal microbiota transplant (FMT), also known as a stool transplany, is the process of transplantation of fecal bacteria from a healthy individual into a recipient. FMT involves restoration of the colonic microflora by introducing healthy bacterial flora through infusion of stool, e.g. by enema, orogastric tube or by mouth in the form of a capsule containing freeze-dried material, obtained from a healthy donor." The treatment has shown to be reasonably effective for sundry intestinal conditions, particularly for Crohn's disease, for which there is no known cure. There is the thought that it may impact neurological conditions such as Parkinson's, and various renowned clinics around the country are looking at such applications. This treatment is interesting in that it builds on our understanding of the importance of the biome in our general health, but also seems to support the idea that there is a clear connection between the brain and its afflictions and the gut. It is most interesting that it is a process that can be sustained outside the hospital. Those who want to alter healthcare costs must devise treatments that virtually take place outside the healthcare system .
Optogenetics. Another breathtaking field of medical investigation that may turn medicine on its head is optogenetics. It, too, is already being used to treat the untreatable, being applied to cases of severe depression, and examined in Switzerland as a way to reverse blindness. It permits us to look at cells in process, most importantly in the case of the brain, where it is now understood that neurological afflictions are not so much the result of chemical imbalance, as previously thought, but due rather to an overall breakdown of neural circuitry. Broadly this technology permits scientists to really look in detail at the very complex systems that make up the body. The promise here is that treatments can become more precise and targetted for a host of conditions, displacing the crude and rather expensive methods of the past. For a look at the work of one leader in this field, see "Lighting the Brain."
Don't Reform. Replace. We've been inclined to say we can get our arms around healthcare by patching insurance, medical process, pharmaceuticals, etc. Chances are, that just won't work. We need to take healthcare out of the hospital and, often, outside the healthcare system. As treatment of chronic problems becomes even more predominant with the aging of our population and the spread of long-term disease even in our younger generations, the healthcare system becomes irrelevant. The challenge is to fix conditions in advanced society that generate so many health problems. Certain diseases—from diabetes to depression—do not respond that well to the healthcare system anyway, and are better treated by new institutions that foster self directed medical care. In other words, healthcare is too expensive and too important to simply be left to the medical industry, but must become an obligation of every sector of society.
Then too, we must give our attention to big developments that can revolutionize the nature of healthcare, because they do much more about health than the pills and band aid approach doctoring offers. Immunization, for instance, was one of the great developments of the 20th century, even putting a few diseases to rest, such that we no longer needed to treat them.
P.S. Low productivity in the hugely growing service sector of the economy in some measure explains the overall static nature of the U.S. economy, including slow revenue growth, lagging wages, and other signs of dysfunction. Basumol deserves a whole lot of attention for his comprehension of the dynamics of services.
P.P.S. Baumol predicted that frantic attempts at high security growing out of 9/11 and terrorist disturbances would be a drag on risk taking, innovation, and economic growth. Simple to say, he was right.
P.P.P.S. Should you want further evidence of how unhealthy developed nations are, study the isolated places where people live quite a bit longer. Mostly, they are out of the way places. See "The Secret of Long Life."
P.P.P.P.S. We like to think of The Anatomy of Melancholy, Robert Burton's 1621 tome of melancholia, as the first great Western medical textbook. It ranges all over the place, trying to come to terms with everything under the sun that affects and afflicts the human body and spirit. Like modern medical texts, it is full of distractions that don't much help a practitioner with everyday human problems. It is a bit literary, too, and like modern textbooks gives space over to pronouncements that are only grounded in tradition, not science. In other words, it resembles modern medicine and healthcare, which is a hodgepodge of the good and the bad and is not good at distinguishing between the relevant and the cul de sacs. Today we know, for instance, that the singular focus on cholesterol, which dominated our thinking about heart ailments just a few short years ago, was crazy; now we look at more factors. This bias stalled important research on a host of cardiac issues. Similarly, Alzheimer's research today is too focused on plaque. All too often, good medicine is no medicine.
P.P.P.P.P.S. The focus on costs, and not health quality, have led to some unethical, even shady, practices at certain healthcare institutions around the country. Doctors at some hospitals have complained to us about this kind of care that has been instituted by the business people at the institutions involved. We are aware, for instance, of hospitals where outpatients are lucky if they see a doctor. Instead they are palmed off on nurses and other personnel who offer counsel and more, ostensibly under a doctor's supervision. We recently called a hospital in Seattle where a physician is offering a pain reduction program, but it is entirely under the supervision of an incompetent nurse and it trumpets self directed care.
P.P.P.P.P.P.S. Often it makes no difference if we ask the right question. Politicians and pundits typically give us canned speeches, no matter what we say or ask, responses that have absolutely nothing to do with our questions.
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