Dr Rangel is looking for comments on medicine, so here is my view of the primary problems. From time to time I discuss details. This is the framework within which those details fit.
The overall problem with the medical system is that it is not meeting the goal of delivering a high level of patient health at a reasonable cost. Major contributing factors are:
1) Medicine lacks a mature quality system. There are some early efforts like evidence based medicine and early efforts at process improvement, such as those found at Mayo. But on the whole there is no widespread understanding of the processes used in a quality system.
This is not very surprising considering how recently these efforts started. It takes many decades for an industry to develop a mature quality model. The Japanese auto industry began theirs about 1950, and even now there is regular improvement visible in Japanese automobiles. The American automobile industry started their efforts in the 1960's and although improvement is visible, they still have a long way to go.
2) The quality system invented by the politicians and lawyers has proven ineffective at meeting this goal. This is hardly a surprise. They've not had success anywhere. The tort system never delivered high quality in automobiles, electronics, or anything else. The tort system is primarily effective as a means of controlling the sociopaths that are also high functioning individuals in society.
If we used the medical malpractice approach to automotive quality we would discover who worked on a lemon car, pick a selection of those workers, empty their bank accounts, and fire them. This practice of blaming the workers was tried (somewhat less dramatically) for quite a while in the auto industry. It was a complete failure and has been replaced by a more effective quality system.
3) There is a mismatch between the decision making, financial responsibility, and beneficiary. For example, the primary beneficiary of employee medical insurance is the employee. The decisions about what coverage is obtained are made by the employer. Even with the best of intentions, there will be an inefficiency due to the mismatch between employer perceptions and actual employee desires. In practice, this mismatch is severe and made worse whenever financial pressures significantly influence the decision making.
I think that the emerging concierge medicine is the leading edge of a change towards matching these back together. The HSA's may also encourage a better matching of roles and responsibilities.
4) The ignorance and naivete of the patients leads to a misunderstanding of responsibilities, made worse by external societal factors. The patients' own failures often cause substantially worse health. Some of this is ignorance. Some of this is the naive belief that "there will be a pill for that". Only a small part is patients' mental deficits, e.g., Alzheimer's. I see little indication of significant change here. There are responsible people and irresponsible people, about the same mix as when I was growing up. Before antibiotics and immunizations the diseases of irresponsibility were a minor health factor. Now they are a major health factor.
5) The expectations of patients are unrealistic. You will get old and die. There are incurable diseases. Bad things do happen. General anaesthsia is occasionally fatal. Diseases don't always respond as expected.
6) Direct providers (especially doctors) are not accustomed to working in a team, are not well trained for teamwork, and their work structures are very badly designed. Effective teamwork is more often punished than rewarded by their employers, payers, etc. Yes, everyone thinks that they are an effective team, but start looking at the reality. In a high functioning team would patient handoff and transfer be a major problem?
7) The notion that "someone is to blame" interferes substantially with all the efforts to make improvements. Blame is useful when controlling sociopaths. Blame gets in the way of improving a quality system. Dealing with this will require changes in societal attitudes.
Solutions? There are many small steps that can be taken. I'm involved in some of them. The global strategy is to restructure the system so that a modern and effective quality system can be made operational.
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