Solving for X Without Fully Examining the “Why”

Have you heard? The healthcare system is “broken.” It’s certainly not a new statement – in fact, it’s something you may have heard from Heal the System before – and it’s definitely something we’ve all experienced. Two columns were recently published in the Triangle Business Journal (Part 1, Part 2) by Blue Cross Blue Shield NC leadership, adding another voice to the growing call for change. But we aren’t throwing shade at anyone or entity willing to stand up for action. It takes guts and vision to make such a commitment. We’ve been calling for healing for quite some time. Welcome to the table.  

So, this isn’t a clapback. It also isn’t an ovation. Because it’s not enough to just diagnose something as broken and address the related symptoms without examining the break itself. That requires adhering to certain standards of care –  agreed upon practices and principles that lead to discovery and the appropriate treatment plan. Otherwise, we just temporarily soothe the pain – or shift it to some other entity – without repairing the actual injury. 

What is the standard of care in this case? Among the most important is taking a full history and comprehensive examination of the problem in question. In part, that means realizing that framing the challenges facing the healthcare system primarily in terms of costs is limiting and dangerous.  

Relying on debunked talking points on North Carolina’s place in the national healthcare cost rankings doesn’t help, either. One of the Blue Cross NC columns referenced North Carolina as “one of the, if not the most expensive states in the country for health care.” What that mischaracterized research actually reveals is that North Carolina employers shift a higher percentage of insurance premium costs to their employees than any other state in the country. That’s the real story. More recent studies, including one published by Ascendient this spring, showcase the state and its providers in a much more favorable light.  

This isn’t a “gotcha” moment. It would be unfair to take that particularly juicy piece of data and point the finger at insurers or employers as the villains. We didn’t find ourselves in this place of crisis because of one actor, and we won’t make progress in silos. Health insurance costs have ballooned – only a quarter of small employers in North Carolina can even afford to offer it at all to their employees. That’s unfortunate. It’s also incredibly complicated. 

We also have to stop thinking about healthcare as if it were any other market-based good or service. There’s no point in comparing healthcare to a gallon of gas or the cost of a house, as highlighted in the TBJ articles (and our friends in the payor industry do routinely), because the regulations, cost-models, and demands aren’t remotely the same. Hospitals and health systems can’t generally raise prices at-will due to regulated responsibilities within broader ecosystem. What is paid and reimbursed may look different from one facility to another, even in the same town. It’s true – it’s also by an agreed upon design. Much of that difference comes from specialization, the overall complexity of care, and patient mix. And market sensitivity or not, the suggestion that such price differentials by location occur only in healthcare settings for similar services is disingenuous.  

Which brings us to the trouble with transparency – not as a useful tool, which it can be for patients, providers, and payors – but rather as the reflexive answer (or panacea, if we want to get fancy) to system barriers and limitations in care. Blue Cross NC says “managing medical costs starts with knowing what they are in the first place” – but so much of healthcare is individualized. Estimates have value for planning purposes, but they’re inherently limited by circumstance and the unknown. As many have learned from car and home maintenance, sometimes looking under the hood or in the crawl space reveals other legitimate issues. Having a sense of what something costs is important, but it often reveals little as to why.  

And we must probe the larger why. Numbers can’t lie. Interpretations are more fungible. Focusing too much on cost becomes a distraction. Don’t get us wrong, we need to make healthcare less expensive for all – but our collective work to do so is the equivalent of merely treating the swelling surrounding the break. It may help us see the issues underneath, but it isn’t necessarily the cause. 

What do we do when something breaks? In the case of a broken bone, additional steps in the standard of care would require imaging and analysis. How severe is the fracture? Is it open, closed, displaced, compound, or complex? Is it sufficient to set, splint, and cast, or will something more invasive be needed with the assist of plates, screws, and rods? What’s the estimated timeline for recovery? Are there factors that will make that recovery more difficult? What’s the commitment to rehabilitation? How do we follow up?  

We won’t be able to apply the best treatment until we fully understand the fracture itself. That process won’t be easy or comfortable. The variables are many, and we agree that everyone – from providers to payors to suppliers and regulators – plays a role. What benefits one party has to be workable for all, and we can’t know what that is until our concentration aligns. That means looking at the whole picture, not just the most convenient frame. 

Our commitment is to those hard conversations, accepting that we may not know as much as we assume, and being prepared to change our mindset as appropriate to ensure a thriving healthcare system that supports everyone. 

Healing can be painful. It can also be wholly restorative. It always takes time. And we don’t have any more to waste.