• Jena Martin MD

Lies we tell ourselves: Innovation

Updated: Jun 28

Without our market-driven healthcare system, we won’t have world-class American innovation.

Innovation is one of American’s favorite words, especially when it comes to medicine. And fostering innovation in a market based system always crops up as one of the reasons we can’t have universal health care.


I’m paraphrasing people like healthcare economist, Craig Garthwaite, in my opening sentence. He’s someone who no doubt knows lots more than me about economics. His 2017 interview is what inspired this post.


“If the choice is between access to the best parts of the American health care system versus the best parts of any other system, I’d rather be in the United States. Now if we take a more Rawlsian* view and you ask me which system I’d prefer if I didn’t know where I’d end up in society or how much income I’d earn, I’d probably want to be in another country.”

*Rawlsian - a fancy way of saying a justice-focused view.


I agree with his assessment - this is in fact how healthcare is distributed in this country. The best parts of our healthcare get distributed to those at the upper end of society and with high incomes. What was shocking to me about his words was that he was defending this system. This is the system he prefers.


Frankly, I felt like I got punched in the gut when I read his callous words about where he’d prefer to be born, (declining American life-expectancy anyone?) but his honesty is refreshing - we know right where his selfish values start, no need for sentimentality. He acknowledges that the overall care isn’t the point - providing VIP care is what matters. (I would counter argue that our deteriorating healthcare system means that the best parts will suffer too, but he is likely inured to this argument. He must be counting on living in an affluent enough area that if he is in a car accident, he'll be taken to an adequately staffed and funded hospital. In another part of that interview it's clear he thinks of healthcare resources as things to be consumed - a zero sum approach to care. No wonder he wants to make sure he is at the head of the line to use it all up, ignoring that our best healthcare resources are our workers - trained experts. And anyone who knows anything about how care is distributed in a hospital could tell him that creating special VIP work-arounds creates more problems and usually worse care.)


I think healthcare costs need to be controlled and I also don’t want a market-driven healthcare system. I’m interested in dismantling the kinds of arguments he makes - in language that makes sense to non-economists. So in my series of #HealthcarePathologies posts, I’m starting at the rock bottom reason market-believers cling to for maintaining the status quo - Innovation. Sure, they say, our healthcare system is unjust and unequal (that’s redundant) but the best care is delivered in America and that’s because we lead the world in ‘innovation.’


But actually we don’t lead the world in medical innovation - there is an index that measures this, and we are third, after Switzerland and Sweden, and just ahead of the Netherlands and the UK (we lead the UK by 0.43 points, whatever that means). These nations all provide more public health security than we do here, and the UK even has nationalized health care - the actual political left version of a healthcare system.


More from the interview I quoted:

“I'm happy to talk about a willingness to accept less innovation for more access, but you've got to be willing to accept that there’s a trade-off here and then to account for that in our analysis. It might be that the innovation we’re getting isn’t worth the human costs, and that’s a conversation we can have, but there’s absolutely a trade-off, and I’m not sure everyone understands that.”

Innovation is one of those business-school words where the meaning becomes unclear to me, a pathologist and non-business school type person:


in·no·va·tive

/ˈinəˌvādiv/

adjective

adjective: innovative

(of a product, idea, etc.) featuring new methods; advanced and original.

"innovative designs"

(of a person) introducing new ideas; original and creative in thinking.

"an innovative thinker"


Lots of innovation is low value (is that an oxymoron?). Perhaps we should stop using this word and revert to its simpler terms. We could describe things as New, or Advanced, or Original. Each of those might prompt a question - is it truly original? Is it an advancement? For whom? These terms might be easier to measure than Innovative.


When I think of innovation in my work sphere, lab innovation, I think of increasing complexity, new equipment, & more proficiency testing (layers of administrators and procedures) - for minimal patient improvement. And according to this recent article, I’m not wrong.


The article in Health Affairs, Why Isn’t Innovation Helping Reduce Health Care Costs?,explains how technological innovations not only don’t decrease costs - they are designed to drive up costs. And they don’t substantially improve our healthcare system - they are not productive.


It's not just people like Mr. Garthwaite. We’re all complicit - physicians, patients, and science journalists demand the ‘cutting edge’ to ‘leave no stone unturned’ - and fee-for-service builds incentives into medical practice. This cycle of overshooting the level of care we need drives up costs, and with higher costs, people have less access to care.


It's not all types of innovation - the article defines innovation as either low productivity or high productivity - basically, innovation that either does or doesn’t do anything. What we commonly think of as ‘innovation’ in healthcare - the new widgets of lab testing, new diagnostic technology - don’t benefit the system. These are new molecular tests or advances in imaging, eye-poppingly expensive pharmaceutical products for extremely rare diseases, that are developed at the expense of system-wide improvements. They benefit single stakeholders - usually private funders.


According to the article in Health Affairs, industries other than healthcare develop patterns of innovation that improve systems and also lower costs. Innovating processes and delivery of care would reduce administration, and not create more complexity. But we don't prioritize those kinds of changes. How can we, when healthcare economists are most interested in advancing VIP care based on technological widget innovations?


The healthcare business model as is doesn’t work to improve systemic care. We can see now in a pandemic how the scarcity model of healthcare embraced by the people making decisions doesn’t work. We need high value preventative care and health promotion. Rethinking innovation is one tool to get us there.




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