Welcome to Descant
Updated: Dec 2, 2020
Our aim is to ultimately make the health care system better by challenging status quo thinking, exploring the evidence, and engaging in fruitful dialogue about reform ideas.
Welcome to Descant! I am so excited to be creating and launching this website with my good friend and “health care soul sister,” Joyce L. She has inspired me over the years with her tireless energy for all things health care and science. She is passionate about doing the right things, exposing bad actors, and making the health care system work better for everyone. Without her pushing me outside my comfort zone and encouraging me to think bigger about what we could create, Descant would not be a reality. So I want to start by saying, “Thank you, Joyce!!”
Our aim here is to ultimately make the health care system better by challenging status quo thinking, exploring the evidence, and engaging in fruitful dialogue about reform ideas. As a first step toward that end, I would like to share with you how I view the health care system.
I think about health care as an interaction between a patient and some provider of health care, such as a physician or hospital. At this most basic level, a patient has a health care need or concern, contacts the health care system (for example, by scheduling a visit with a primary care physician), receives health care services, and then the services are paid for. The patient is a health care consumer and to that extent health care providers, because they provide a service are essentially businesses. They determine what services to offer and assemble the components, just as other types of businesses do. They offer and provide services to patients that engage with them; they get paid for providing services, and they manage their business. My focus on physicians and hospitals as fundamentally businesses is not meant to dismiss or make light of the amazing and wonderful things they do to take care of patients. But in my view, the financing of health care, that is, the business aspects, are at the root of the enormous problems and dysfunctions we have in US health care today. I believe looking at it as a business can be a useful way of exploring what is wrong and how we can make it better.
“Not only is expertise needed, dialogue is also needed, desperately needed. As one of the largest segments of the US economy, health care touches everyone, yet different people and businesses are impacted very differently."
To round out the health care “system” we have elements that I think of generally as infrastructure. I use the word “system” broadly and generally – I do not mean to imply we have a true system or something like a well-oiled machine, but we do have components beyond patients and providers. By health care system, I just mean the totality of what’s needed for patients to be able to receive care from providers. And while I’m explaining how I use various words, let me say a bit about “provider.” I prefer to stay away from the term because physicians find it offensive and I understand why, given how some people have used it. Occasionally I feel provider is the best term, and I try to use it only in the very broadest sense of an entity that provides health care services. When I’m talking about an entity that is a person (when I’m not including hospitals, for example), I try to use “clinician” or some other term.
Back to infrastructure elements. I view the existence and distribution of the various doctor’s offices, clinics, hospitals, and other types of health care providers as a type of infrastructure. It needs to be in place before the patient can start the process by engaging with someone about a health care need or concern. Infrastructure includes businesses that supply and support health care providers. It also includes laws and regulations relating to health care, as well as insurance companies, government programs, research (such as clinical research and health services research), and public health activities. This list may not be comprehensive; I’m sure others could add to it.
So my view of the health care system could be described as Patients / Providers / Infrastructure. One reason I like thinking of it this way is that it emphasizes the primacy of the doctor - patient relationship. It essentially says there are physicians and patients and then everything else is sort of relegated to an “other” bucket (which I’ve labeled infrastructure). Going a little further to emphasize the doctor-patient relationship, I could rename the second bucket as Physicians* where the asterisk indicates it includes everything and everyone (hospitals, nurses, etc) that provide care, emphasizing that the physician, in consultation with the patient, should be driving the bus. My fundamental view of the health care system, then, is Patients / Physicians* / Everything Else.
Obviously, this is a dramatically simplified view. I’ve not mentioned patients’ families, employers, Medicare or numerous other important elements of health care in the US. But I believe Patients / Physicians* / Everything Else could be a useful framework. I am a big picture thinker. I often return to frameworks like this when thinking about various issues, to remind me to ask whether we are addressing the fundamental issues, the big picture. We don’t want to get so focused on a narrow set of details that we forget about the big picture.
In this framework, I have purposefully de-emphasized paying for health care. Certainly, that’s where a large share of the complexity and challenges are today. It is my view that most of the complexity, dysfunction and inefficiency of the US health care system are rooted in poor decisions we have made through the last several decades regarding how we pay for health care. As a health actuary and health services researcher, the financing of health care is where my expertise lies. While I’m sure we’ll spend some time at Descant talking about why our system is so dysfunctional, I am most interested in improving it. With high prices and high levels of spending, with often poor quality and little control over what happens to them in the health care system, people are being hurt and many businesses can no longer afford to provide health care benefits to their employees. It doesn’t have to be this way. We can, we must do better. All of us, individuals and families, businesses and government, have other needs and other budget priorities besides health care, but health care eats up a very large chunk of budgets for many, and often we are not getting much value compared to what we pay.
This is what motivates me: the system is a mess in many ways, particularly in ways related to the financing of care, which is where I believe my expertise best positions me to help make a difference. But not only is expertise needed, dialogue is also needed, desperately needed. As one of the largest segments of the US economy, health care touches everyone, yet different people and businesses are impacted very differently. What is one person’s spending is another person’s income. There are no easy answers from an evidence standpoint, and certainly no easy answers from a political standpoint. But we must evaluate the evidence together, examine all of the impacts of reform across the system, and openly discuss the trade-offs that must be made to improve the US health care system. To that end - please join us as we tackle these complex and difficult issues that are so vital to our future.