The “Health Pyramid” Suggests Expanded Medicare and Medical IRAs

Knowing that one’s overall health depends heavily on “Blue Zone” habits, engineers, vaccines, and lay workers, I’ve tried to come up with a healthcare system that puts doctors in their proper place and frees most of us from the expensive bean-counters siphoning off much of the healthcare dollar. Partly inspired by the acronyms in “House of God”, here are my observations and proposed solutions.

My Healthcare Pyramid

Behold my new “Healthcare Pyramid”. Note that the fattest part includes those that live a clean life of neighborly good diet and exercise, next the purveyors of clean air, water, and environment (engineers that run water/wastewater plants, design catalytic converters, etc) while next step are healthcare workers and nurses (the people that address epidemics and do most of the work in a given health institution, like birthing babies and addressing the front-lines of illness). They are followed by medical researchers and scientists (who make the ever-growing lists of vaccines and antibiotics that prevent disease), and at the tippy-top, the 10% that are medical doctors, and 5% the insidious accountants and lawyers that take a too-large cut of your medical dollar. Interestingly, the doctors, lawyers, and accountants (collectively called things like managed healthcare) have little to do with your health outcome, yet make about 90% of the money. Meanwhile, to use “House of God” language, Doctors are besieged by “GOMERs” (Get-Out-of-My-Exam-Room chronic hypochondriacs) using “SWAGs” (Scientific-Wild-Assed-Guesses) along with TURFing (Punting a patient to another dept) and BUFFing (A TURF that bounces back).

Currently a healthy person (Blue Zone Expedient Patient, or BZEP), hears from a doctor and HMO a “Tell them What they Already Know” (eat right, exercise, don’t smoke, get a vaccination, which I call TWAK) and lines them up for the Futile and Expensive End of Life Treatment (FEELT), all for about $20k per family per year (much of which goes to subsidize Poor Unhealthy People who Can’t Afford Medical, or PUPCAMs). We healthy ones may need to concede a rise in Medicare tax (2.5% to 3%) for a “Medicare Option” that would absorb Obamacare and cover about 50% of PUPCAMs and other Americans. But the other 50% (who are BZEPs tired of TWAK and see through FEELT) would be much better served by employer-paid $4000/yr medical IRA accounts with $10,000 deductible major medicals. Doctors may become happier too, with a healthy and cheaper result eliminating a Few Avaricious Middle-People (FAMPs).

First (Bottom) Level of Pyramid, Blue Zone Lifestyle (Good diet, exercise, no smoking/drinking, good friends/family): This is the rather well-known art of clean living, which is the largest part of making us healthy (especially if a healthy mind-set is added). This is more or less available to anyone who has the self-discipline and will-power (yet becoming ever-harder in an increasingly urban society). If genetics is our baseline (and something we can’t control), let’s say this is 30% of the rest of what makes us healthy.

The Mediterranean Food Pyramid, along with exercise, not smoking/drinking, good relations, wellness is the most immediate pathway to a lifetime of good health

Second (Bottom) Level of Pyramid, Clean Environment: We all know the importance of clean air and water, and the critical separation of drinking water from poop. We almost take this for granted now, since much is done behind the scenes using utility and tax dollars. Most of this chore is left to Engineers (mostly Mechanical, Electrical, Civil) who quietly and efficiently build dams, water and wastewater plants, and the art of “clean water” is well-known and mostly well-done. More difficult is the art of “clean air” and “clean environment” (often dealing with Carbon Monoxide, Nitrogen Oxide, Ozone, etc) and toxic metal contamination in soils and food (lead, arsenic, mercury, etc). Clean air took a big step forward in the 70s with the advent of cleaner fuels, cleaner burning engines, and catalytic converters. Of course now, the concerns are long-term warming associated with CO2 and Methane. I’m going to include Veterinarians and Agronomists in this level, since they play such a large part in the safety of our food. Let’s just say that clean air and clean water (and clean food) might be 25% of what makes you healthy or unhealthy, and that perhaps only 60% of the levels of “clean” are currently addressed. As a segue into the next level, let’s say the UN sent a team of any two people to an impoverished village in Africa. Would they send a doctor? No! They would likely send a Civil Engineer (first task to produce clean water and separate waste from clean water) and the next important level, a “Nurse/Healthcare worker”.

Third Level of Pyramid, Nurses and Healthcare workers: This next level not only staffs most of hospitals, but also the vast number of health workers (people who inspect food establishments, epidemiologists, etc). You might say this is good value, since they are much cheaper than doctors. In the aforementioned African village scenario, a nurse would be a better fit than a doctor, administering vaccines, doing basic exams and checkups, helping train village lay workers to assist with births, infections, and broken bones. This level would evaluate patients for surgeries (probably transferred to the nearest city) and keep a lid on any potential epidemics. This level may be 15% of overall healthcare, and quite effective, both in a cost and efficacy respect.

Fourth Level of Pyramid, Pharmaceuticals and Medical Researchers (Mainly Producing Vaccines and Antibiotics): This next level is growing and may soon be the Second Level (trading places with Nurses and Healthcare workers), as vaccines are becoming a major preventative force. People have forgotten the days prior to vaccines and antibiotics, when infectious disease was the primary cause of death (up until about 80 years ago). Soon, there may be vaccines that prevent most cancers and viral infections, and even vaccines that extend life. Antibiotics have waning efficacies (thanks to overuse and antibiotic resistance), yet you’ve got to figure that science will continue to make new and better ones. In addition to these important medicines, there are ever-better pain-killers and drugs that combat the large family of auto-immune diseases. These medicines are produced by an important group called Medical Researchers, who exist in Colleges doing research, private labs, and Pharmaceutical labs. Let’s say this is 15% of what makes us healthy, and growing.

Sure Doctors are important, but they (and their expensive bean-counting health maintenance organizations) should be the last resort of a healthy lifestyle (unless you want TWAK and FEELT from FAMPs)

Fifth Level of Pyramid, Doctors in HMOs: This is by far the most expensive, and perhaps least of what makes us healthy. When the first four levels are fully understood, it makes you wonder why we all have been conned into paying 90% of our healthcare dollar for maybe 10% of our healthcare needs. This is not a criticism of Doctors, per se, but more of the vast medical care system that surrounds them. Typically, you go in for a checkup once a year, much of it telling you what you already know (TWAK), to live a Blue Zone lifestyle (or BZEP, Level 1) and administered by a Level 3 employee. You then leave for a Level 4 remedy (most often a vaccine), and the Doctor/HMO/Level 5 gets paid even though Levels 1–4 do most of the work. Then, at end of life, you generally get the expensive (and futile) end of life treatment (FEELT), with all the bells and whistles that Level 5 is really good at. You get charged a great deal of money for all this, so as to pay for the poor and unhealthy PUPCAMs and the HMO. The Doctors don’t even like this system much as most of the remaining dollar is taken by the greedy (and unnecessary?) HMO accountants and lawyers, the FAMPs.

Sixth Level of Pyramid, Accountants and Lawyers in HMOs: This is currently about 40% of medical cost, and needs to be reduced to about 5%. Seriously, health should be primarily between you and your family, society, and conscience (Levels 1–2), and next between you, the healthcare workers and effective medicines (Levels 3–5). If not, something is seriously wrong, as it is never appropriate to “bill or sue your way to good health”.

The Way Veterinarians Handle Healthcare: Strangely, the Veterinary Care system offers a clue as to what should change. They have insurance in the pet business too, but most don’t have it and pay out of pocket, negotiating as to level of care and price (this is important). At the front end, its mostly simple exams and vaccines (as it should be, paid for by insurance if you have it). Meanwhile, there are low cost public service vaccinations and neuters for low-income pet owners. If something bad happens (hit by car or end of life), the Vet business has evolved specialty clinics for after-hour emergencies, oncology, surgery, etc., where you either pay the relatively high deductible on your insurance or negotiate an end-of-life deal (which is often euthanasia). Occasionally, there is a chronic condition of which insurance presumably pays for a lifetime of medicine. See how simple? No bean counters or ambulance chasers, mostly just you and the Vet! No HMO smokescreen (the “we want you to lead a healthy life” stuff…bullshit! They make more money on you if you’re sick all the time! Vets largely don’t care about making your dog a hypochondriac GOMER).

Strange as it may sound, the Veterinary Pet Insurance concept, with a sort of Medicare (Medicow?) option for the poor and otherwise not on employer plans, may be a good option, as deductibles force patients to shop.

What Should Happen in US Healthcare: Potential solutions range from “Single Payer for All”, similar to Canada, etc, where everyone gets “free” medical care (but our Medicare deduction goes from 2.5% to 5%?). This would lower prices (at least in the short run) as currently the money HMOs lose on Medicare patients is compensated for by gouging the other patients…“Single Payer” would force all medical care to be paid from the same government schedule. But, the system would produce long wait times as the clutter of unhealthy people thinking the doctor can help them will grow (once again, Levels 1–4 help cheaply, Level 5 not much). Meanwhile, most have employer-paid plans that give them medical choices, and which they’re happy with (even though employers are requiring ever-higher deductibles to control their costs). The solution? I suppose that healthy, Level 1–4 people must concede that they’ll have to pay for the 50% that are slobs in our society, much the way 50% of us pay about 90% of the Nation’s taxes. Presuming that the healthy 50% have employer assisted medical, it makes great sense to accept the employer “Medical IRA” that puts about $5k per year into a tax-fee medical account, while also giving you a $10k deductible major-medical plan (this saves the employer money and if you’re healthy, you win too). You have to negotiate for services, but if you’re reasonably healthy not so bad. Meanwhile, your Medicare tax will probably go up to about 3% (if you’re lucky) to subsidize the “Medicare Option” for everybody else, who has little clue as to how to stay healthy in the first place, and is willing to line up in queues at the County Hospital for their illusion of health (actually a kind of holding cell for the ever-larger groups of disenfranchised/mentally ill/drug addicted/clueless immigrants/criminals). Many doctors will happily exit the HMO zoo in favor of concierge practices that make them more money by sort of aping the Vet care system. Perhaps for further savings, the Blue Zone BZEPs can come up with a glorious end-of-life death chamber (complete with a movie of all your accomplishments and ramp leading to a bright light…actually a death-ray). The PUPCAM facilities will have to be very nice (on the order of beachfront cottages with great food, jet-skis and rock concerts) so as to keep the PUPCAMs occupied, and presumably the BZEPs and their doctors will be willing to pay that freight so as to keep them out their plans (and their front lawns). The 50% number may be legislated, and there will presumably be some migration of BZEPs to PUPCAMs (people who become lazy and exit their ambitious health regimens in favor of a life of drugs and beach volleyball) and PUPCAMs to BZEPs (the upwardly mobile seeking better bodies, mates, and jobs). Government sponsored “basic care” may become the domain of the Walmart/Costco/CVS machinery, reaching more people (with exams/vaccines) and lowering costs.

As such, the Blue Zone BZEPs using healthy TWAK (and their doctors) will have opted out of the system that makes lower income PUPCAMs rely too heavily on illusory end-of-life FEELT, all run by greedy FAMPs. However, it may be worth the higher BZEP taxes if this can all Keep Restraints On Chronically-ill Service-suckers, or KROCS.

If you’re as confused as I am about all these medical acronyms*, here’s a convenient reminder:

GOMER-Get Out of MY Exam Room

BZEP-Blue Zone Expedient Patient

TWAK-Tell them What they Already Know

FEELT-Futile and Expensive End of Life Treatment

PUPCAM-Poor Unhealthy People who Can’t Afford Medical

FAMP-a Few Avaricious Medical People

KROCS-Keep Restraints on Chronically-Ill Service-suckers

* All with apologies to “The House of God” author Samuel Shem



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Vern Scott

Scott lives in the SF Bay Area and writes confidently about Engineering, History, Politics, and Health