Making Sense of Health Care through Analogies

In discussing what’s wrong with health care in America, we often cite statistics—such as the fact that the U.S. spends 16 percent of its GDP on health care, yet has a life expectancy of 77.8 years, below the average of 78.6 years for OECD countries.

But health care is complex, and numbers can sometimes be too abstract to make a lasting impression on people who aren’t health care wonks. Sometimes what really connects isn’t data, but analogies that put health care in terms that everyone can understand. Of course, there are good analogies that illuminate and bad analogies that mislead, so you always have to be careful. Here are a few of the best and worst analogies that I’ve come across:

(1) The Titanic and Inequality. As The Health Care Blog (THCB) noted recently, it’s hard to come up with a more clichéd analogy than the Titanic. It’s really the poster child for much ballyhooed behemoths that collapse because they’re not nearly as state-of-the-art or invulnerable as people assume. But really, that’s a perfect encapsulation of our health care system. We spend $2.4 trillion on health care annually—the equivalent of bailing out Wall Street twice every year. As Shannon Brownlee of the New America Foundation has noted, as much as 30 percent of this bill is “spent on treatments, tests, and hospitalizations that did nothing to improve our health.” And we still have 47 million people without health insurance. This is not a ship that can keep afloat indefinitely.

But as Sarah Arnquist points out in her THCB post, our health care system isn’t akin to the Titanic just because it’s “a big, fancy expensive ship…[that’s] destined…[to] sink”—but also because survival of its passengers (or, in the case of health care, patient and citizens) is predicted by socioeconomic status. While a lot of people died on the Titanic, survival rates were much better for first class passengers (read: richer people) than for poorer folks: 97.2 percent of first class passengers survived the sinking, where as only 54.7 percent of third class passengers got out alive.

Similarly, in the U.S., your survival is predicted by your socioeconomic status. According to the National Center for Health Statistics, education level—which is strongly correlated with socioeconomic status—is “the most consistent predictor of the likelihood of death in any given year is level of education; persons ages 45-64 in the highest levels of education have death rates 2.5 times lower than those of persons in the lowest level.”

Dr. Steven Schroeder from the University of California in San Francisco has also pointed out
that class-related concerns play a big role in determining health. He
estimates that 20 percent of premature deaths in the U.S. are
attributable to social circumstances and environmental
exposure—basically, your quality of life and your surroundings. Another
40 percent is due to behavioral patterns (e.g. diet, physical activity,
substance abuse, etc), many of which are correlated with socioeconomic
status.

These facts make poverty and inequality key points of intervention
in improving overall health in the U.S.—probably more so than even
improving medical care. Still, it’s troubling that access to care—the
“life boats” of our system—is also contoured to income and class
brackets. According
to the Census Bureau, 24.5 percent of Americans who make under $25,000
a year lack health insurance, versus just 7.8 percent of people who
pull in over $75,000. And even when the poor have insurance, they
are less likely
to have access to cutting-edge medical discoveries; they’re more likely
to smoke, more likely to be obese, more likely to live in unsafe or
unhealthy environments. They also tend to be less educated, meaning
that they are less able to manage chronic diseases.

You get the picture: like the Titanic, our health care system, is a
huge, expensive enterprise in which the wealthy have much better odds
of survival and better access to life-saving means. That’s an image
that anyone can understand—and it’s not a pretty one.

(2) Automakers and Prescription Drugs. One of the reasons
why the upper crust has it so much better in health care is that the
U.S. spends about 14 percent of its health care dollars on prescription
drugs. These drugs are largely attainable only to folks with health
insurance and generally don’t do much for the behavioral or
environmental conditions that threaten the health of lower-earning
Americans.

Actually, most prescription drugs don’t do much for anybody, let alone the poor. Last year, Marcia Angell, a Senior Lecturer at Harvard Medical School and the former editor-in-chief of the New England Journal of Medicine, observed
that, “according to FDA classifications, fully 80 percent of drugs that
entered the market during this decade are unlikely to be better than
existing ones for the same condition.”

How do drug companies get away with releasing new drugs that are no
better than the drugs we already have? Consider the following scenario,
presented by Health Beat’s own Maggie Mahar back in May: 

“[I]magine a society that lets its automakers oversee crash tests on
new models, allowing the industry to report results, as it sees fit, to
government and consumers. Sometimes, an automaker might not reveal the
outcome of a test that turned out badly, deciding that the dummies in
the vehicle were too short–no wonder their chests were crushed!

“In other cases, a company might postpone reporting on crash test
results for a year or two, hoping that later trials would turn out
better. In these cases dozens of trials might be required in order to
achieve the desired outcome. The car maker would, of course, pass along
the additional cost, in the form of higher sticker prices. In this
society, crash tests are not run and paid for by an independent entity
like our National Highway Traffic Safety Administration (funded by
taxpayers) or the Insurance Institute for Highway Safety (funded by
auto insurers). Instead, the auto industry itself finances and controls
the trials. Automakers also provide most of the funding for the
government agency that rules on car safety.

"Finally, under this system, head-to-head comparisons of cars in a
similar weight class are frowned upon. Such trials would create winners
and losers—and who wants to be a loser? Instead, each company tests its
own cars, and when outcomes finally are published, they tend to be
excellent.” 

Sounds ridiculous, doesn’t it? But this is essentially the dynamic surrounding the prescription drug industry. Without a public
comparative-effectiveness institute in place to test
drugs in head-to-head trials, our health care system lacks an objective
assessor of drug efficacy. There is no third party to regularly report
which drugs work best—and thus, which ones should be covered by
insurance and which ones are useless.  We waste billions covering
unproven, ineffective treatments. We let drug companies test their
drugs however they want and, to a large extent, report whatever they
want. They just need to show that their medication is better than
taking nothing, and if that takes a many, many trials to prove, than
those costs are passed onto consumers in the form of higher drug prices (which our
government can’t negotiate). Further, thanks to the billions of dollars
they can lord
over medical journals, drug companies also heavily influence the
publishing of results. Even the FDA isn’t immune to their influence:
every year, the agency takes in about $300 million from drug companies looking to speed up approval for their products.

Would you feel comfortable buying a car that received safety approval
from its manufacturer only because the company chose to report the one
crash test out of a hundred that it actually passed? Or pay more
because the automaker had to run one hundred expensive tests in order
to eke out some semblance of quality from its product? Of course not.
But that’s what happens with prescription drugs.

(3) Consumer Goods and Medical Treatments. Thinking about
how automakers would operate under the prescription drug model
highlights the startling regulatory structures (or lack thereof)
surrounding the pharmaceutical industry. But the car-as-medicine
analogy only goes so far: it’s very helpful for understanding
system-wide issues, but from the perspective of the patient, health
care is unlike any other commodity.

This is a hard thing for some people to grasp, most of all the hardcore
advocates of consumer-driven medicine—i.e. a health care framework in
which people have high-deductible coverage and health savings accounts,
and shop around for the cheapest care, the same way they would for a
new car.

For example, in a 2007 interview with Health Affairs,
Harvard Business School professor Regina Herzlinger—a long-time
advocate of consumer-driven medicine—insisted that automobiles were
proof that consumerist health care was the future.

“[I]n the automotive market, you can pick 240 models—different engines,
styles of cars, colors, etc,” said Herzlinger, who wants to see a
similar proliferation of customization in treatment packages. Further,
“we need consumer-friendly information, so consumers can know how good
their doctors and hospitals are,” she said. “Armed with information
about cars, consumers drove General Motors, essentially, to bankruptcy,
without really understanding technical details.”

In other words, according to Herzlinger, we need to think about health
care the same way we do cars: as a product about which we can learn
enough to decide what we want, how often we want it, and how much it
should cost.

But as I’ve noted in the past,
this just doesn’t make sense for health care. The only criteria that
most of us can understand in order to “arm ourselves with information”
are profoundly unscientific ones, like doctor availability or office
environment (both of which are actual categories in the ‘Zagat’s Guide
to Doctors’ that some insurance companies are giving to customers).
This doesn’t tell you much about whether or not a particular doctor can
help make you healthier—and isn’t that really the point?

Perhaps more importantly, unlike other commodities, you can’t divorce
health care from the patient. The consumer is part of the product. Last
year I discussed
how the success of diabetes patients in self-managing their disease is
contingent on levels of education and self-confidence. More educated
people are better at decision-making and can more readily exercise
foresight, which help them better manage their chronic diseases. More
self-confident people are more likely to work toward treatment goals
and see progress in their self-management.

In other words, how you engage with and respond to medical treatments
is part and parcel of not just your physiology, but even your
psychology and emotions. By contrast, it doesn’t matter if I have a PhD
or a GED—a car will still get the same mileage. Likewise, it doesn’t
matter if I hate myself or have a huge ego, a new television will have
the same resolution. But in medicine, the patient’s body and mind help
determine the outcome, and that’s not something you can shop around for
before you engage with doctors. 

From the perspective of consumer choice, there’s not really any other
good that’s analogous to health care (maybe education). It’s misleading
to present medical treatments as being analogous to other, more
commercial, commodities that consumers can cherry-pick at their discretion.

(4) Handymen and Primary Care Physicians. Consumerism often directs us toward high-end, specialized goods—but in health care, this sort of innovation fetish can prove dangerous. In fact, one of the least sexy areas of health care is primary care, yet it’s also one of the most important.

The best analogy for explaining why primary care is central to better health  comes from Wendy Lynch, writing for the Health As Human Capital Foundation:

“I use a wonderful handyman, Jim, when things go wrong at our house. He
is a former contractor who has experience in plumbing, electrical
wiring, heating, roofing, tile, and many other general fix-it talents.
His best attribute, I think, is an ability to know—or quickly
assess—whether a problem is serious. Because Jim knows our house, he
occasionally notices a loose board on the deck or a leak somewhere.
This allows us to fix things we wouldn’t have otherwise noticed until
they grew worse. The WORST news I can get from Jim is ‘you need a
specialist,’ because that means the problem is likely serious and
expensive. Because I pay for it myself, I want expertise, but at a
reasonable price.”

Like Jim, “a primary care professional is a generalist; a person who
knows how to triage and prevent future problems, within the context of
my preferences and needs. He reduces the need for six different
professionals to deal with six types of problems. He can handle the
majority of usual maintenance and fixes and does so cost-effectively.
And, he is less likely to refer me to someone else for a minor issue
‘not in his area,’” as a specialist might. 

Unfortunately, U.S. primary care is in a state of crisis. Between 1997
and 2008, the number of family medicine residency positions filled by
medical school grads dropped by 50 percent. In 2000, 14 percent of new
grads chose primary care; by 2005, only 8 percent did so.

The reasons why primary care has become less popular over the years? Less money, more stress. A recent Journal of the American Medical Association article pointed
out that between 1997 and 2006, annual compensation of dermatologists
increased by 97 percent; for gastroenterologists, 78 percent; and for
radiologists, 65 percent. Over this same period, pediatricians saw a
jump of just 32 percent; internists 30 percent; and family medicine
generalists a mere 21 percent.

Part of this disparity comes from the fact that the Medicare
reimbursement schedule—which is used as model for private
insurers—rewards highly specialized, technical work rather than
preventive care, coordination of treatments, or “cognitive medicine”
that involves talking patients through situations and answering
questions—all of which are the key functions of primary care. Worse,
because these duties are so interactive, they often happen after hours,
and as the number of primary care physicians drops, the remaining ones
will see their workload increase. Meanwhile, America’s supply of
specialists keeps ballooning: today we have three to four times as many
specialists as we do generalists. Given that 22 percent
of our health care bill goes to compensating physician services, it’s bad news for health care spending that the ranks of expensive
specialists is growing while more cost-effective generalist care is
dwindling.

It’s also bad news for patients’ needs. In housing maintenance terms,
the dearth of generalists and glut of specialists in our health care
system is like having fewer handymen and a surplus of exterminators. We have
fewer people to take care of the problems that make up the bulk of our
needs, but a lot of costly specialists eager to bear down on rarer, more
extensive crises.

Indeed, a specialist-heavy system encourages patients to head straight
toward hyper-focused, costly expertise, rather than first going to an
experienced generalist who can help us nip many of our problems in the
bud. Paying specialists so much more—and doing little to encourage
growth in primary care physicians by, say, forgiving med school loans
for students who choose family medicine—creates few incentives for
doctors to become regular care
providers for patients. Over time, fewer of us will have access to a
‘Doctor Jim’ who knows us, knows what’s appropriate, and can help
coordinate our needs. We’ll get less timely, cost-effective care– and
more fragmented, expensive care.

Health care is an exceedingly complex—and often misunderstood—field.
But it’s also something in which everyone has some interest, and
rightly so. Sooner or later, it affects all of us. So it’s important to
pinpoint the most striking, universally resonant ways of communicating
just what’s wrong with our health care system. Talking through
analogies—good and bad alike—is a good place to start.

5 thoughts on “Making Sense of Health Care through Analogies

  1. “Indeed, a specialist-heavy system encourages patients to head straight toward hyper-focused, costly expertise, rather than first going to an experienced generalist who can help us nip many of our problems in the bud.”
    ———–
    If we step back from this idea and think a bit, one cannot help but wonder why patients buy into this. If going to specialists results in more uncomfortable and expensive medical processes and not better results longer term, why would patients do that. It is not just the specialist heavy nature of the system, IMO, but that fact that patients believe they are getting better care via specialists. I have seen this over and over, especially with the WWII generation of Medicare folks. Therefore the real challenge is to the educate patients to want the primary care alternative and demand to get what they want!

  2. kudos on highlighting the handyman analogy for primary care, I think it really hits the nail on the head.
    Countries who try to manage costs centrally realize the value of having problems handled at the generalist level when possible. that’s why the majority of physicians in those systems are primary care. I think the primary care/specialist ratio in our country is one of the main drivers of our higher costs.
    Unless we re-emphasize primary care (putting the money where our mouths are) we are likely to continue on the same path.

  3. The problem is we have a money-driven society. The discussion about the Mayo Clinic the other day highlights the issue since this seems to be only one of a handful of health facilities which isn’t money-driven.
    As most of the excesses now being displayed show there is no mechanism for countering this model. Any attempt to rein in the single minded pursuit of money is deemed “socialism” by the critics (bailing out banks excepted).
    So, all the plans being discussed assume that our system will continue to try to maximize profit. This means leaving most of the insurance layer intact, doing nothing about overspecialization, doing almost nothing over the corruption of basic research and the patenting of everything from genes to processes, and doing nothing to control costs by the federal government.
    Obama’s plan is designed not to rock the boat, while McCains is designed to throw even more people out of the health system altogether.
    If you want an analogy:
    There is now some evidence that the owners of the Titanic knew that the ship didn’t meet specs concerning the strength of the rivets holding the hull plates together. It was the failure of these rivets that allowed the plates to separate and made a small hole into a disaster.
    So the Titanic disaster was, yet another, example of loose regulation and the pursuit of profit above everything else.

  4. Something I always find ironic. We talk about CDHC in the same vein as purchasing consumer goods. If we had more transparency, etc, patients could make better choices.
    Tell me this then. If everyone can pick up Consumer Reports, why would Viking refrigerators command the price they do (check out their reliability–horrendous), buy Mercedes autos (again, Japanese trump them most of the time), or purchase name brand cereals (store brands often better at significantly less cost).
    Bottom line: 1) people dont look 2) advertising and brand appeal trump other factors very often, 3) word of mouth potent, ie, “isnt this great.” . There is a lesson there.
    See interesting report:
    http://www.kff.org/kaiserpolls/upload/7819.pdf
    Long way to go.

  5. think the metaphor that works best is from Rashomon where folks touching different parts of the elephant (pardon my politics) come away with very different impressions. the majority of americans are insured and care about their rising costs, but have less interest in the problems of the uninsured. many analysts believe too much is done by an irrational and cost-insensitive system, but that doesn’t resonate with the patient population. one reason little progress is made on the problem is our lack of agreement on what it is.