ACA 101: Hammers. Nails and An Employer’s Search for Objective Advice


In ancient Athens, the philosopher Diogenes wandered the daylight markets holding a lantern, looking for what he termed, “an honest man.” It seems since the dawn of the consumer economy that customers and buyers have traded most heavily on a single currency – trust. Three millennia later, our financial system still hinges on the basic premise that the game is not rigged and any trusted intermediary is defined by a practitioner who puts his client’s interests ahead of his own.

Anyone responsible for procurement of healthcare may feel like a modern-day Diogenes as they wander an increasingly complex market in search of transparent partners and aligned interests. The art of managing medical costs will continue to be a zero-sum game where higher profit margins are achieved at the expense of uninformed purchasers. It’s often in the shadowed areas of rules-based regulation and in between the fine print of complex financial arrangements that higher profits are made. Are employers too disengaged and outmatched to manage their healthcare expenditures? Are the myriad intermediaries that serve as their sentinels, administrators and care managers benefiting or getting hurt by our current system’s lack of transparency and its deficit of information?

Who’s to Blame for the Failure to Rein In Healthcare Costs?

In his recent column “Yes, Employers Are To Blame for Our High Medical Prices,” Princeton political economist Uwe Reinhardt controversially lays partial blame for the healthcare cost crisis at the feet of employers. Reinhardt suggests that some employers have been passive, uninformed and in some cases, unable to muster the internal energy to get their own leadership teams to commit time to becoming more informed purchasers of health services. Where corporate procurement might realize aggressive discounts from vendors, healthcare has remained outsourced to insurers who have been largely unsuccessful in controlling rising costs and conflicts of interest.

Poor procurement arises out of a failure to act properly – to be informed, to be prepared and to ask the right questions. Some critics of our broken system complain that employers are simply getting poor advice from consultants, agents and brokers who often move at the speed of disruption-averse clients. Some point to government for public-to-private cost-shifting, poorly conceived legislation, and poor regulatory oversight over an industry that has witnessed the rapid consolidation of hospitals and insurers into an oligopoly of control that is difficult to deconstruct.

As the next phases of reform plays out across public and commercial markets, unintended consequences, odd alliances and new conflicts of interest will arise out of the ground fog of purchasing choices. Employers without a firm grasp of the key elements of healthcare cost-management are likely to fall prey to flavor-of-the-month stop gap solutions or Trojan Horse cost-shifting schemes that may control employer costs but will do little to ameliorate underlying negative trends.

Will Self-Centered Fear Reveal the Worst of the Industry?

Healthcare industry stakeholders are scrambling to remain relevant as the locomotive of Obamacare leaves the station. Players once considered essential stewards and stations along the tracks to controlling healthcare costs are worried that they may soon be bypassed. Disintermediation is weighing heavily on anyone who sits in between those that deliver care and those who consume it. The national vision seems clear: universally affordable health coverage leading to lower costs for both the private and public sectors. And while we are at it, let’s toss in a free flat-screen TV.

Employers are naturally cynical to the legislative complexities of the ACA and are having a tough time trying to figure out how to use the momentum of health care reform to make changes that will insulate them from future cost increases. But, it’s hard to know which direction to go – especially when opinions diverge around the likelihood that market-based reforms can lead to sustained low single-digit medical trend. It’s getting hard to know whose opinion to believe, and worse yet, what is motivating their point of view.

The anxiety around disintermediation is causing many stakeholders to explore how to move up and down the services value chain in an effort to carve out a permanent role as a participant in the new age of healthcare delivery. In doing so, many firms are discovering inherent channel conflicts and developing facilities that may cannibalize their own existing business models to survive the digital transformation of an analog industry.

If we believe that any 2.0 version of a solution should be better, faster and cheaper, we should be excited about the changes that lay ahead. The challenge for employers will be to see through to the institutional incentives that are causing many players to pivot into new business models – consultants selling products, hospitals selling insurance, insurance companies becoming providers, and employees being asked to become consumers. Just how muddy is the water getting? Consider the following positions.


As inpatient admissions continue to decline and larger healthcare systems find themselves burdened with brick-and-mortar overhead and high unit costs, there is pressure to continue to pivot into integrated health delivery and higher volumes of ambulatory and outpatient services. So far, so good.

With healthcare reform, these same hospitals are being encouraged to form risk-bearing Accountable Care Organizations (ACO) to help manage population health of retirees and share in the subsequent savings that could be achieved by focusing on value instead of volume. It seems an easy jump to turn an ACO into a commercial venture offering employers the ability to contract directly with the large hospital system as their medical home – essentially becoming an HMO, bearing risk for the health of its members. Incentives change from treating illness to keeping people healthy. The big problem is most of the hospital systems putting their toe in the water of these risk arrangements are also the most expensive hospitals in any PPO network.

Will these hospitals be able to achieve competitive unit cost and low year-on-year trend increases, or will they simply reduce some cost by disintermediating insurers but continue to charge higher costs for services? Once risk shifts to integrated healthcare delivery systems, expect more liability arising out of alleged conflicts of interest and rationing of care.


Many argue that insurers, not unlike banks, have become highly risk averse and are rapidly moving toward a new role as health service and technology infrastructure providers. Most insurers have failed to become trusted consumer brands. Much of this distrust is arguably deserved given their historic insensitivities to customer service and business practices that left purchasers unable to decipher the complex and seemingly arbitrary calculus of pricing and claims payment policies. Most small and mid-sized employer renewals have become frustrating annual rites of passage.

Truth be told, most fully insured employers are beginning to understand that healthcare is like a Las Vegas casino – if you play long enough, the House always wins. The deck is further stacked against business as employers are often scared away from more efficient financing methods like self-insurance to fully insured, bundled programs where all health services are provided through a single insurer including RX, behavioral health, chiropractic and radiology. Bundling affords insurers ample pricing mobility to move required margins across a range of services to achieve their profit targets. While there is nothing illegal with these business practices, it does give rise to healthy cynicism regarding the industry’s commitment to achieve affordable care over personal profit. As one healthcare executive commented, “Look, our job is to hide the Easter eggs and your job (as an advisor) is to find them.”

Public managed care stocks are enjoying 52-week highs as Wall Street clearly sees no signs of near-term pricing pressure. Optically, the new insurer business model, which is now expanding into Medicaid and Medicare, gives the appearance that insurance firms are operating at lower margins while their health service subsidiaries report record growth and profit. It’s hard to trust a vendor who is both serving clients as claim payer and providing services through a subsidiary for undisclosed transfer pricing. This practice will give rise to conflicts of interest as payers pivot into providing care.


Large consulting firms have long-since laid claim to the high ground of objective employer advocacy. As retiree medical and RX costs began to balloon in the late 2000’s, consulting firms saw value in carving out elements of these costs from insurers — creating owned and managed facilities to purchase drugs and offer defined contribution retiree exchanges. A rush of mergers and consolidations introduced additional services to traditional Human Resource and Employee Benefits consultants offering outsourced administration and defined contribution exchanges for active employees. The success of these first-generation facilities led to higher margin annualized revenue streams and a pressure to expand proprietary product solutions into a culture that had historically been agnostic to solutions and vendors.

As employers express interest in exchanges and alternative delivery models, consulting firms see an opportunity to leverage their trusted relationships to steer clients to owned and operated facilities. While clearly believing their owned solutions offer a better mousetrap, the fee for service consulting community is now confronted with a business model conundrum. Do we create products and proprietary facilities to meet the profitable and growing demand for administration and service platforms? If so, will our own consultants consent to steering our customers to our own facilities?

To add additional pressure, Wall Street has rewarded public consulting firms and defined contribution/benefits administration companies with generous valuation uplifts – increases in market cap well ahead of actual enrollment, creating internal pressure to promote exchange participation to deliver on analyst expectations. Certain analysts are convinced that the majority of large employers will convert to exchange-based purchasing in the next decade and in doing so, they are seeking to invest in firms that seem positioned for these future purchasing trends.

The administrative services that accompany many proprietary online enrollment platforms will benefit exchange managers, creating almost captive relationships as employers see higher frictional costs moving from one exchange to another. Employers may essentially be stuck paying annual administration and commissions as part of an exchange-based relationship. Where a consultant should play the role of trusted advisor to help choose the exchange that is best for their client, firms will now be pushing their people to endorse their own exchanges, and in some cases, promote financing arrangements that defy decades of empirical data — in particular those exchanges that are encouraging employers to convert from self-insurance back to fully insured financing as a means to promote purer competition between carriers. Befuddled HR professionals are increasingly torn between long-term institutional relationships and a nagging suspicion that their consultant is now promoting a model out of self-interest. Now armed with hammers, it appears that every client is beginning to go look like a nail.


Brokers and agents have long enjoyed a too-cozy rapport with their HR and Benefits counterparts in small and mid-cap America. In the world of middle-market brokerage, generalists are often advising generalists and relationships routinely trump fiduciary accountability. Brokers leverage relationship-based trust and are often heavily influenced by how they are remunerated. Some brokers prefer fully insured plans as administrative costs, taxes, fees and commissions are commingled and not as visible to a cursory review of costs. One could argue that commissions by their very nature create conflict of interest. The continued practice of volume and contingent-based bonus payments also clouds the broker’s ability to claim total objectivity.

Most relationship-based employers do not question or understand their broker’s remuneration arrangement or in some cases, may knowingly pay higher commissions to their broker so the broker might serve as an outsourced benefits staff – using headcount that HR could never successfully justify internally because of finance and staffing controls.

Healthcare 2.0 will be characterized by data – lots of data and an increased dependence on compliance and technical resources that will shake the traditional transactional broker profit model to its core. Informed clients will desire transparency and accountability for all services, and judge value based on a numerator of outcomes divided by a denominator of cost of services. Brokers will need to be able to demonstrate actionable interventions, improve clinical trends, assist with optimal financing arrangements (including actuarial support for plan value-setting and financial forecasting), provide strong communications and HR support for concierge and employee engagement tools, and understand healthcare economics expertise to hold insurers accountable for achieving network discounts while limiting hidden margins and fees. Transactional placement skills will be table stakes as the 2.0 broker reinvents themselves as a solutions provider with no embedded conflicts of interest. The big question remains: Is it possible for the broker’s goals to align completely with the client’s goals?

Human Resources

A Human Resources manager facetiously shared with me, “I got into the business because I really liked people and I hated math. I now spend my days with a calculator trying manage a massive human capital spend and I don’t really like people.” If you watch where most HR and Benefits Managers’ feet go, it is not in the direction of disruption and greater intervention into the personal and consumer healthcare habits of employees. America’s C Suite has been surprisingly unwilling to spend the time with HR to understand the root causes of their healthcare costs and instead condones what is now a regular and unimaginative annual cost-containment exercise of cutting benefits and increasing contributions as a means to achieve a workable healthcare renewal price point.

While Professor Reinhart’s gentle rebuke of HR may have been a bit undeserved, it is not completely without merit. Structure has long since trumped strategy in employer healthcare plan management. A good renewal sees very little changing, when in fact, change must occur if behavior is going to change. “Disruption” is a broad, amorphous HR term used to describe anything that creates additional work in the form of employee complaints and additional distractions from the job of doing one’s job. To avoid the steeper slopes of the healthcare cost-containment mountain, those charged with overseeing Human Capital have travelled the easier, well-trod trails of cost-shifting, resulting in the erosion of take-home pay.

Given that 90% or more of America’s HR and Benefits professionals are responsible for healthcare but are not rewarded for delivering low, single-digit medical trend, it’s no wonder that their focus is on where they do get rewarded – limiting noise, smoothing feathers and keeping the planes and trains of human capital running on time.

One HR Manager related, “It’s hard to get management to focus on the complexities of healthcare spend. They want to see the year-over-year costs and whether their doctor is still in the PPO network. They don’t have the attention span or interest in tackling all these issues.” Sound familiar?

So Who Can An Employer Trust?

Trust and transparency must be the currency that anchors the employee benefits marketplace of tomorrow. No one in a corporate HR and Benefits role can afford to be seen as a friend and not be seen as a fiduciary. Stakeholders – insurers, consultants, brokers, providers – are all scrambling to preserve their roles as trusted B2B advisors while nervously anticipating a growing consumer market. While public exchanges limp along and blue states and red states fight over the notion that reform is succeeding, employers will be on their own for the foreseeable future – forced to revisit their vision, strategy and structure for healthcare and benefits. In the end, it’s all about aligning incentives. If a CEO tells his/her HR team that 2015 bonuses hinge on managing medical costs to a 3% trend or less – without raising contributions or reducing benefits – one wonders whether friends will become overnight fiduciaries.

In the months and years ahead, employers will find themselves wandering among the tall trees of monolithic insurers and a dizzying new roster of online and consumer engagement tools. It will be all about alignment of interests and holding people accountable for results – not bedside manner. Purchasing will require a lot of homework, faith and a strong sense of the corporate values of the partners you choose to help you shape your plans.

If ever there was a time for honest, unfiltered advice, it’s now. The search is on for affordable healthcare and for stakeholders who are beholding only to their client’s interests to get costs under control

A False Summit?

A False Summit?

While a divided Congress met at the Blair House to attempt to reconcile differences, America hunkers down , chilled by cold economic winds and unnerved by the gathering storm brought on by fiscal shortfalls and unsustainable deficits.  As our elected officials argued over a way forward, it was obvious that there would not be enough common ground found to chart a coherent course that improves access, reduces medical trend and moderates ballooning federal and state deficits driven by increasing obligations to existing entitlements through Medicare and Medicaid.

In between stumping and finger pointing, inconvenient truths tumbled like falling rocks on the heads of policymakers locked in the heated debate over whether to begin reforming healthcare by expanding access to 30M Americans or by addressing the underlying cost drivers of a system that all unanimously agree needs fixing.  While Kent Conrad ( D-ND), and Paul Ryan ( R-W ) came across as lucid scouts describing the decades deep crevasses of entitlement deficits and the imprecise orienteering of CBO accounting, other Congressional exemplars reinforced our belief that they were simply no longer fit to lead a next generation of climbers eager to move up the mountain.

The sad truth is we face a formidable obstacle in healthcare reform.  It is a Darwinian wilderness where the strong survive and individuals are unevenly protected.  It is a foreign land where neophyte consumers believe that “quality care” is getting unrestricted access to all the services that they believe they need for as low an out of pocket cost as possible. A diverse ecosystem of for profit and non profit stakeholders seek to accommodate this insatiable expectation and in doing so, assert that they create great value through the services they provide.  It seems no one believes they are part of the problem. Yet, people continue to die from exposure.  We fail to rope in the most vulnerable among us and have sadly become more indifferent to their personal tragedies.

We are in desperate need of reform but experiments such as Massachusetts that seek only to expand access to the uninsured  have taught us that the summit of universal coverage cannot be conquered without an underpinning of affordability.  They will end in financial disaster. The ropes that safely bind us to a fiscally sustainable path must be anchored by employer based insurance and woven with universal reforms in reimbursement, Medicare/Medicaid, access, consumerism and stakeholder engagement. The entire process must be reinforced with chronic disease management,  transparency and balanced regulation of the small and individual insurance markets.

Enormous time has been spent vilifying insurers, as if to convince us that aggressive oversight of payers can somehow fix our healthcare system.  Singling out a particular stakeholder as the primary barrier to our goals of quality, access and affordability is the reckless equivalent of telling an obese person that they can lose all the weight require simply if they just stop eating bread.  The mountain’s crest offers no easy access. The route is marked by tombstones of idealistic reformers who fell short of their objectives.  Stakeholders must recognize that we are all part of the problem but we do possess a map that can safely lead us to the top.   Ironically, many of the legislators attending the Blair House summit actually helped contributed to the treacherous conditions in which we now find ourselves – as we consider a future where public and private healthcare expenditures exceed an insurmountable 20% of our GDP.

In considering the rhetoric and reality of our circumstances, we must understand why the current House, Senate, GOP and Presidential proposals are false summits for conquering our current healthcare crisis.   Congressional leaders, desperate for re-election, will simply not commit to an honest discussion of the risks and realities of fixing healthcare. To conquer the mountain of public and private healthcare spending we must belay our way with:

1)   Reimbursement reform – 30M uninsured people will be entering a healthcare system that is graduating less than 2% of its medical school graduates as primary care doctors. This means no care coordinator to assist those who have historically accessed medicine through the most expensive setting in America -the emergency room.  Massachusetts as the first state to adopt universal coverage and individual mandates has discovered in their first years of universal coverage that ER visits are increasing by 8%-10% as individuals – now covered – default into old patterns of access.  The rural and urban family practice physician is disappearing as a disproportionate amount of federal, state and private sector reimbursement is going toward specialists and facility care and their treatment of chronic illness – – instead of its prevention. We must restore the role of the primary care provider as the control point and care coordinator for a first generation of consumers committed to health improvement. Reform should focus on higher reimbursement and educational incentives to study and practice primary care.

2)   Medicare and Medicaid reform – If the US government were an insurer, it would have been seized years ago by regulators for serial underfunding of present value obligations.  To propose $500B of physician fee cuts while promising seniors no benefit cuts and an expansion of the presently unfunded Medicare part D prescription drug program is irresponsible.  To even qualify to expand its role in covering more Americans, Medicare and Medicaid need to address an estimated $ 100B  in annual fraud, abuse and overtreatment.  The current programs achieve “ affordability” by rationing reimbursement to doctors.  Another 21% in fee cuts will only reduce the number of doctors willing to accept payment from the federal government. The ethical and moral no man’s land surrounding end of life care in America make funding the last six months of life in the US, more expensive than five decades of life preceding them.

3)   Access Reform – Consumers must accept and be willing to enter into medical home/gatekeeper delivery systems where primary care providers coordinate care and authorize access to specialty and tertiary care services.  Over 110M Americans access the healthcare system through the emergency room each year.  More than half of these individuals are insured but not under the care and control of a primary care provider.  Self-referrals and self diagnosis is leading to overtreatment of insured individuals – consuming, according to Overtreated,authored by Shannon Brownlee, as much as $700B each year that might otherwise be available to finance care for the uninsured and the underinsured.

4)   Consumer Reform – With 60M Americans overweight and slowly descending into lifestyle based chronic and catastrophic illnesses, we are not requiring those who might be eligible for expanded coverage to engage in healthier lifestyles.  Asymptomatically ill and chronically unstable individuals are more likely to incur catastrophic claims.  5% of Americans treated in Medicare and private insurance consume 50% of all services.  Subsidies and minimally credible coverage mandated for the uninsured should include plan designs that require biometric testing, lifestyle coaching, and compliance rewards for managing chronic conditions. Consumers must be limited in their ability to sue a treating physician if that doctor has followed evidence based medicine guidelines for treatment.

5)    Stakeholder Reform – There are myriad opaque pricing and payment practices that plague the $ 2.2T healthcare system.  Transparency of services should not just extend to insurers but to brokers, agents, hospitals, pharmaceutical benefit management, specialty and other third parties who play a role in the healthcare delivery chain.  Affordability must focus on demanding value for payment.  You cannot improve what you cannot measure.  Consumers, employers and government are often ignorant to cost shifting, clinical variability, hidden remuneration and perverse incentives that threaten to compromise the objective treatment, advice and service support that must characterize a world class system.

The Blair House healthcare gathering reinforces our notion that Congress understands the logistical complexities of fixing healthcare but in its failure to find common ground, it was merely a false summit.  While our public policy guides argue on the best way forward, we lose confidence that neither group is actually carrying the essentials necessary for quality care to survive. The prevailing sentiment among Democrats is to follow the uncertain fiscal direction of Massachusetts choosing a less intimidating path of achieving universal access before tackling the more jagged and dangerous step of affordability reform.  The GOP has counseled a conservative route to the top – opting for an incremental and sluggish pace with no clear timeline to ultimately conquer the peak.

It remains to be seen whether Congress and the American people will fatigue before conquering healthcare.  For 180M Americans covered by employer-sponsored healthcare, the fear of leaving their base into the unknown thin air of change creates doubt and concern.  For 45M uninsured, the prospect of climbing higher seems a worthwhile alternative to their current circumstances.

The risk of getting to the top too rapidly is fiscal edema and a Darwinian rationing as we realize that we have finite resources.  If we move to slow, additional fellow climbers may perish from inaction.  One thing is for certain.  Storm clouds are gathering and conditions are deteriorating. We are in the “death zone”.  We have to go up or go down.

We simply cannot remain here.

Waiting For Dr Godot

If you think healthcare is expensive now, wait until it is for free.” – PJ O’Rourke

On the eve of sweeping health reform legislation, it is hard not to notice the glowing skyline in Washington as policymakers ignite their torches, grab their pitch forks and race as a mob toward for-profit stakeholders who many feel have created, perpetuated and benefited from our highly uneven, inflationary and inconsistent system of healthcare in America.

Over a quarter century, I have consulted with and led employers, consumers, hospitals, physician groups, attorneys, pharmacuetical manufacturers and insurers.  My personal epiphany prompting me to become more vocal about America’s need for systemic change did not spark in the middle of an inflammatory contract negotiation with a major hospital or flash during a heated employee meeting as we announced yet another deductible, co-pay and contribution increase.  My burning bush occurred on a gurney in the hallway of British National Health Service (NHS) hospital where I lay for 20 hours deathly ill with pneumococcal pneumonia.

After moving to London with my young family, we decided to opt for public care.  After all, I was curious to experience  the NHS and with three kids under eight, we were constantly under siege with myriad colds, earaches and symptomless fevers.  Best of all, it was free. Our neighborhood NHS family practice clinic was always crowded but convenient.  Other than the occasional drug co-pay, we never received a bill.  Yet, something was not quite right.  My doctor always looked as if wild dogs or the Inland Revenue Service was pursuing him.  I broke down during one examination and asked him how much he received from the National Trust for each patient to provide basic care.  ” Not nearly enough, Mr.  Turpin. Not nearly enough” He said absently while peering into my ear with a pen light.

In the bleak midwinter of our first English February, one of my kids came home with a nasty flu that raged through the house, flattening even my indefatigable wife who I considered indestructible.  I was travelling on the Continent and needed to return early to play Florence Nightingale to the family influenza ward.  As everyone slowly recovered, rising like Lazarus from the dead, I took ill and within one day, was coughing up blood and bedridden with a raging fever.  After a brief visit with my GP, he called an ambulance and I was taken to casualty (Emergency) in a local NHS hospital. I was admitted and deposited on a gurney in a hallway alcove as I waited to be transferred to a hospital room.  There was one problem.  There were no beds available.

The ER was utter chaos with sick elderly and acute care victims in every conceivable location.  The doctors were tireless and clearly dedicated but overwhelmed.  Through the haze of illness, I watched the trauma triage go on for hours.  My wife briefly appeared with the kids to visit.  

As she surveyed the floors strewn with bloody gauze and the frenetic ballet of emergency medicine, she mouthed to me with her little finger near her chin and thumb next to her head,” I will call you later ” and fled the hospital as if it was a haunted house. In my delirium, I could have sworn a giant staph germ escorted her to the door.  “Sorry you could not stay, love.  I am staphoccocolus bacterius.  Don’t worry he’s in good hands. Let’s do lunch.”

Doctors came and went in four-hour shifts.  My principal worry was the harried Casualty staff’s inability to remember that I had a Penicillin allergy.  I repeatedly mentioned my allergy to anyone who would make eye contact with me and twice awoke to catch a well-intentioned new doctor putting me on an amoxicillin drip.

In the early hours of the following morning, I was taken to a room that I shared with seven other of my new closest friends.  There was a poor woman dying of stomach cancer and an attempted suicide.   The bathroom smelled like Grand Central at 6pm and to my horror, there was no TV.  My pulmonologist appeared followed by graduates that shuttled behind him like ducklings crossing a Kent country road.  ” How is the pnuemo” he asked my Filipino nurse ” He is getting better, sir. Aren’t you?” she remarked looking at me. I wasn’t sure if this was a rhetorical question or a new affordability technique in stiff upper lip  British medicine called “self fulfilled prognosis”. 

I was suffering from pleurisy – the equivalent to a burning knife inserted in between your ribs each time you inhale.  I was also very unhappy.  I was in what felt like an overcrowded youth hostel and I wanted some bedside manner.  After all, damn it, I was American.  I wanted the head of pulmonology from the best London hospital to consult with me and give me his mobile and home phone number.  I raised my hand to ask the doctor a question and he flashed a perfunctory smile and said, “right”.  He turned and left the room.

I lay with an oxygen mask for a day drifting.  I awoke and saw the face of a colleague from the office.  It was as if he was a Red Cross worker checking on prisoner conditions per the Geneva Convention. He had lived in London as an ex-pat for five years and was appalled with my circumstances.  ” What are you doing down here? ” He whispered.  I gave him a pathetic look of incredulity and started blinking to him in Hanoi Hilton Morse code “ g-e-t  m-e  o-u-t  o-f  h-e-r-e”. 

He returned and was talking fast, “we have gotten you into private care and we have to transfer you.” He disappeared so quickly that I was uncertain if he had been a hallucination. I awoke again and was being moved.  I expected to be shuttled into an ambulance taken across London to Great Portland Street to a private hospital where most ex-pats delivered babies and accessed private care for routine and elective procedures. 

I was pushed on to an elevator by a Jamaican orderly who said in heavy Brixton accent, ” dis is yah lucky day mate.” The only luck I could fathom at this point was getting a room that did not smell.  The elevator rose up just one floor and opened to a well-lit, beautifully decorated foyer where two eager nurses smiled and gathered around my gurney.  “Mr. Turpin, we are so sorry about your illness and time down there“. Down there?  Even the staff seemed to consider my two-day tour of duty in Casualty as tantamount to one of Dante’s levels of hell.

But it got better. The same aloof pulmonologist who a day early had treated me like a flank steak referring to me as the ‘pnuemo’, grinned and shook my hand.  Mr. Turpin, I am Dr. G. Let me help you to your room.” The Jekyll and Hyde switcheroo was not lost on me.  Apparently, Dr G hit from both sides of the plate – public and private.  Personality and bedside manner came with private care.  My private room had a clean bath, cable television and a phone where I could call and order food.  It was like the Ritz Carlton. 

The doctor sat on my bed and shared my X-rays and described in pedantic detail my serious brush with death.  It was as if he had all the time in the world.  “You are over the worst of it but the inflammation and scarring will last quite a while. Once you are released, you can see me Tuesday next privately or in three weeks through the NHS.”

I was released the next day and chose to see Dr G privately for all my follow up care.  I was in constant pain from the pleurisy and the reassuring ability to access my doctor when I needed to see him was worth the significant out of pocket expense.  I was paying for the fast pass privilege of his time and attention.  My bill for the entire episode of private care delivery was well over $2000. I saw no bill for my 48 hours in Casualty.

It was interesting to reflect later on my experience. On one hand, the NHS triaged my condition, treated meet and summarily moved me out quickly to convalesce at home. If value is outcomes divided by cost, the NHS produced the most value. 

Yet, when I introduced my own subjective expectations as a consumer – hospital conditions, bedside manner, access to specialists and information, all subjective intangibles that Americans insist are essential elements to the numerator of outcomes, one might give the NHS barely a passing grade. 

As we watch Congress debate in the weeks and months ahead the future of our healthcare system, I worry that not enough of the 180 million privately insured Americans understand the difference between outcomes and access. We cannot possibly understand the downstream effects of some of the changes that are being proposed to our system.  US healthcare is in need of a major overhaul but we need to attack the factors that are driving the cost of care higher. Malpractice, overtreatment, poor lifestyles, reimbursement policies of insurers, major differences in clinical quality of hospitals and doctors and an insatiable consumer demand for immediate and unimpeded access are bloating our system. If one were to judge our identity by our budget, the US is essentially the world’s largest insurer with its own army. 

Swinging the pendulum too far in the opposite direction with national oversight, artificial price controls,  the erosion of private insurance by expanding government sponsored plans to over 44 million uninsured without tackling the underlying causes for rising costs may be more than most Amercians can bear. 
We will in effect be trading a public/private cat’s cradle bureaucracy for a single payer with little effect on true cost drivers.  Anecdotally, we already have a glimpse into what government healthcare might look like with Medicare. Ironically, if you ask most seniors, they would tell you they love Medicare but fear socialized medicine. Go figure! 

Change is in the wind and we will all be required to modify our behavior.  However, we should join the discussion and engage our Congressional representatives in the debate.  If we are not vocal or vigilant, we may wake up one day on that gurney in a hospital wondering what the hell happened to our health care system.