The final film in the epic Star Wars saga, “Star Wars: The Rise of Skywalker” hit theaters this weekend. It should have had fans around the world buzzing. Instead, many of them are either yawning with disinterest, or speculating on YouTube about just how bad the last installment in the 40-year-old series might be. The critics have panned the film in early reviews, with Rotten Tomatoes pegging the critical score at a meager 58%. What happened to Star Wars?
As a doctor, movie lover, and proud tech geek, I often see parallels between work and my other hobbies.
When I think about Star Wars, especially what has happened to the franchise after the Disney acquisition of Lucasfilm in 2013, some stark comparisons to the U.S. health care system come to mind. Our system is in many ways fragmented, bloated with administrative expense and, if we’re candid, mismanaged at the macro level. Star Wars has followed a similar path since the new Disney trilogy was launched in 2015 that, in my view, accounts for many of the problems the franchise is currently suffering from.
Star Wars vs. the medical system
Rewind to the first Star Wars movie (now called “Episode IV: A New Hope”), you’ll find a far different production than the $200 million extravaganzas produced by Disney. “A New Hope” debuted in the summer of 1977 and went on to become one of the highest grossing films of all time. It featured a clear plot that pitted good against evil, realistic (for the time) special effects and, most importantly, substantial character development inspired by timeless mythological storytelling. Moviegoers were thrilled, and many of them went back to the theaters to see Star Wars again and again.
“A New Hope” was followed up by two excellent sequels that continued the saga in 1980 and 1983, both which adhered closely to the formula established in the first film.
Fast forward 42 years, and you have a far different Star Wars. The basic elements of an action-adventure set in space are the same. Unfortunately, the iconic film series is now packed with a multitude of characters (some important, many not) and bloated storylines that ping-pong viewers between concrete plot development and over-the-top action sequences. Some moviegoers are satisfied on the surface with the glitz and fancy CGI, but true fans of the series complain that their underlying expectations weren’t met by the fragmented stories and lack-luster character development. Moreover, the new films now also incorporate elements of current politics that feel out of place in a story meant to transcend time.
Health care in the 1970s was, in many ways, the starting point for the system that we have today. I believe it has followed a similar course to Star Wars. The bill that laid the groundwork for what we now know as Medicare and Medicaid was being implemented, and President Richard Nixon unveiled his plan to require employers to offer health insurance to employees while providing subsidies to those who had trouble affording medical care.
The U.S. health care system made sense. It was becoming clear, affordable for most people, and was set to provide the best medical care in the world. With these legislative imperatives, it appeared everyone’s health care needs were now going to be met.
However, like the unravelling of Star Wars, bloat began to seep in to the health care system. A bevy of laws required more governance and more administrative staff to ensure compliance and reimbursement for medical services. One can chart the growth in how expensive U.S. health care has become by simply looking at the growth of the ratio of administrators to doctors since the 1970s.
According to a Harvard business Review blog post by Robert Kocher, there are now 10 administrators for every one doctor in the U.S. today. And 95% of new hires in health care aren’t doctors or nurses, they are administrative hires that have little to do with caring for patients. This represents a growth rate of over 3,200% from where we were in 1975:
By the late 1990s, national health care spending in the United States had sky rocketed and accounted for 12.1% of total GDP — the highest thus far in the history of the country. Fast forward to the 2010′ and the introduction of the Patient Protection and Affordable Care Act, commonly known as the ACA, which had the potential to dramatically improve the system. Unfortunately, this potential came along with new ACA requirements for electronic medical records, dramatically increasing workloads on physicians with little discernable benefit for patients. Moreover, expanded regulation and insurance benefits mandated by the ACA resulted in even more administrative expenses.
While the ACA did successfully increase insurance coverage, the additional costs were often borne by patients in the private insurance market in the form of skyrocketing insurance premiums and higher out-of-pocket deductibles. Today, the health care system now consumes an eye-popping 17.8% of GDP.
As was the case with the growth in Star Wars film budgets under Disney, bigger and more expensive didn’t necessarily translate into better health care. Bigger in health care has led to a reality in which my fellow doctors have their attention diverted into electronic medical records and away from patients, a situation that has contributed to an epidemic of physician job dissatisfaction and burn out.
The following decade was one in which political divisions and competing reimbursement models created an ever more convoluted and fragmented approach. The system is again poised to be a political football in the 2020 presidential election. Recent polling suggests that health care is the number one concern among U.S. voters.
Yet it is tragic that the U.S. now ranks amongst the lowest among developed nations for health care, despite spending the most. This reality is shocking, given that the U.S. is widely acknowledged as having some of the best doctors in the world, along with the most advanced medical technologies and therapies.
As in the new Star Wars, which due to bad management decisions from the top of Lucasfilm has had a rotating cast of directors and writers, there are too many competing stakeholders in the health care system for the average patient to even keep track. And as major tech companies begin moving deeper into the industry, they have inadvertently ignited controversies over patient privacy. Drug costs that many Americans simply can’t afford are another pain point. Against this backdrop, it’s easy to see why the system leaves so many feeling insecure and vulnerable.
In the movie business, the focus should always be on the audience. Giving the audience thrilling films that transported them to a galaxy “far, far away” is what made Star Wars successful in the first place. The analog in health care is a laser focus on the patient. Delivering the best care possible is what made the U.S. health care system the envy of the world. With the potential re-thinking of the health care system in 2020, my hope is that we can regain that patient focus by simply letting doctors do the work they love.
And as for “Star Wars, The Rise of Skywalker,” smaller might be the future. After all, who doesn’t love the Internet’s latest sensation, Baby Yoda?
Amit Phull, M.D., is medical director and vice president of strategy and insights at Doximity.