Building a Healthcare System from Scratch, Part 1: Jobs

This series explains my framework for understanding healthcare systems. For ease of reference, I call it my Healthcare Incentives Framework. I use it to make sense of everything I see happening in a healthcare system. And one could use it to build a healthcare system from scratch. Each subsequent post builds on all the prior posts, so I strongly recommend reading them in order. For convenience, here are links to parts 2, 3, 4, 5, 6, 7, and 8.

I developed the majority of the Healthcare Incentives Framework over 5 years (2010 – 2014), during which time I was thinking/reading/studying about healthcare policy almost every spare thinking moment. I just had this insatiable drive to make sense of the evidence I was reading as well as what I was seeing in the world. It was the ultimate puzzle. Luckily, my wife was patient and convincingly interested in my thoughts, which I shared almost daily. Every time I came up against a phenomenon that I couldn’t understand or explain within the context of the greater Framework I was developing, I would struggle with it in my mind, sometimes for weeks, until I figured out what it meant and how it fit. Most of the posts on this blog came as a result of those struggles, and everything I now write about health policy is based on the foundational understanding encapsulated in this Framework.

The Healthcare Incentives Framework starts by enumerating the jobs you want a healthcare system to do for you. Initially, it seems like only two jobs: prevent disease and treat the disease that cannot be prevented. But, because incentives work differently for different kinds of prevention, I will split that job into cost-saving prevention and cost-effective prevention.

Cost-saving prevention saves more money down the road than it costs up front. For example, maybe hiring someone to visit the homes of people with really bad heart failure will prevent enough hospitalizations that it more than compensates for the salary of the person doing the home visits.

Cost-effective prevention ends up increasing total spending–that is, the money saved (if any) doesn’t outweigh the upfront investment–but the benefit is large enough to justify that investment. For example, screening for colorectal cancer costs a lot, but it catches a lot of cancers early and saves enough lives that the investment is worth it. The exact definition of what’s cost-effective and what isn’t depends on the society, but the metric used is the cost for each quality-adjusted life year you gain ($/QALY).

In addition to those three jobs related to maximizing health, and because healthcare is characterized by rare, unpredictable, potentially financially catastrophic treatment episodes, a healthcare system must also provide financial protection in the form of risk pooling.

And, finally, most people in most societies believe a healthcare system has a responsibility of providing these services even for people who cannot afford them, so equitable access (as defined by the society) can be added as the fifth and final job of a healthcare system.

The utility of enumerating these jobs will be seen in Part 2, when we will look at which parties in a healthcare system have financial incentives to perform which jobs.