America has a health care paradox

We have a real paradox in American healthcare. On the one hand we have exceptionally well educated and well trained providers who are committed to our care. We are the envy of the world for our biomedical research prowess, funded largely by the National Institutes of Health and conducted across the county in universities and medical schools. The pharmaceutical industry continuously brings forth life saving and disease altering medications. The medical device industry is incredibly innovative and entrepreneurial.  The makers of diagnostic equipment such as CAT scans and hand held ultrasounds are equally productive.

A few examples.  The science of genomics is revolutionizing medical care in profound ways such as producing targeted cancer drugs, predicting later onset of cardiac disease, offering prognostic data to guide cancer treatment, rapidly identifying a bacteria and its antibiotic susceptibility and suggesting how our diet can actually impact our genes through the science of nutragenomics.

The pharmaceutical industry has brought us the likes of statins to reduce cholesterol, drugs to prevent blood clotting, and the targeted therapies for cancer. The device industry has created, for example, a potpourri of new approaches that have transformed cardiac care. These include angioplasty, stents, pacemakers, intracardiac defibrillators and now even the ability to insert a prosthetic aortic valve through a catheter rather than doing it via open surgery.  And we can now noninvasively image organs in incredible detail and learn about physiology with molecular imaging.

So we can be appropriately awed and proud and pleased at what is available when needed for our care.

But, on the other hand, we have a dysfunctional health care delivery system.

Our current delivery system focuses on acute medical problems where it is reasonably effective. But it works poorly for most chronic medical illnesses and it costs far too much. When the famous bank robber, Willie Sutton, was asked why he robbed banks he replied “that’s where the money is.” In healthcare the money is in chronic illnesses – diabetes with complications, cardiac diseases such as heart failure, cancer and neurologic diseases. These consume about 75-85% of all dollars spent on medical care. So we need to focus there.

These chronic illnesses are increasing in frequency at a very rapid rate. They are largely (although certainly not totally) preventable. Overeating a non-nutritious diet, lack of exercise, chronic stress, and 20% still smoking are the major predisposing causes of these chronic illnesses. Obesity is now a true epidemic with one-third of us overweight and one-third of us frankly obese. The result is high blood pressure, high cholesterol, elevated blood glucose and toxins that lead to diabetes, heart disease, stroke, chronic lung and kidney disease and cancer.

And once any of these chronic diseases develops, it usually persists for life (of course some cancers are curable but not so diabetes or heart failure). These are complex diseases to treat and expensive to treat – an expense that continues for the rest of the person’s life.

What is needed is aggressive preventive approaches and, for those with a chronic illness, a multi-disciplinary approach, one that has a committed physician coordinator. Providers (and I refer here mostly to primary care physicians), unfortunately, do not give really adequate preventive care in most cases. And they generally do not spend the time needed to coordinate the care of those with chronic illness – which is absolutely essential to assure good quality at a reasonable cost.

When a patient is sent for extra tests, imaging or specialists visits the costs go up exponentially and the quality does not rise with the costs. Indeed it often falls. But primary care physicians are in a non-sustainable business model with today’s reimbursement systems so they find they just do no have enough time for care coordination or more than the basics of preventive care.

So our paradox is that we have the providers, the science, the drugs, the diagnostics and devices that we need for patient care. But we have a new type of disease – complex, chronic illness, mostly preventable, for which we have not established good methods of prevention nor do we care for them adequately once the disease develops. And all of this is exacerbated by an insurance system that puts the incentives in the wrong places. The result is a sicker population, episodic care and expenses that are far greater than necessary.

America has a health care paradox   Stephen C. Schimpff, MD is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and consults for the US Army, medical startups and Fortune 500 companies. He is the author of The Future of Medicine – Megatrends in Healthcare and The Future of Health Care Delivery, from which this post is adapted. 

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  • http://twitter.com/USMCShrink Kevin Nasky, DO

    Is there an example–a model–for how to treat chronic illness effectively? Is there a country whose health care delivery system does a spectacular job at keeping chronic illness at bay? If so, what are those countries doing, and what are out barriers to enacting such policies here?

    My suspicion is that the rate-limiting step to managing chronic disease is the PATIENTS reluctance to comply with treatment recommendations (med compliance, lifestyle modification, etc.), and that no policy, no matter how well though out or well funded, can modify that crucial piece.

    • Elle Gee

      If the remedies being offered by doctors are not being “complied with,” perhaps the remedies need to be re-evaluated. There is a presumption that lifestyle modification is easy – and all one need do is “comply” with the doctor’s orders. This is complex – and requires the right attention. Telling a patient to change a lifestyle is not the same as providing the assistance and tools to do so. If you tell a cancer patient to take chemotherapy and then put all kinds of obstacles in the way of the provision of said therapy you can’t very well say that the patient is at fault for failing to cure his own cancer – well maybe you would. I have no idea what your motives are.

      • Anonymous

        Lifestyle modification is not easy but only the patient himself can take the initiative and follow through on it.  There is nothing a doctor can say or do to make his patient loose weight, eat healthy or exercise.  Everyone I know who was successful at losing weight had some sort of eureka moment when he or she decided enough is enough – I’m going to loose this weight and get healthier.  The only help they needed was the encouragement from the people in their lives.
        The company I work for is charging smokers more for their insurance.  Why only smokers?  Maybe people with unhealthy BMI’s should pay more too.  Collectively obese people probably consume more healthcare dollars than smokers anyway.  That may be an incentive for some people.

        • http://twitter.com/civisisus civis isus

          I believe you’ve missed much of Elle Gee’s point. Insufficient attention has been given to the barriers that make following MDs’ orders challenging. Happily that is changing – but too frequently in spite of, rather than because of, systematic efforts.

          • http://twitter.com/USMCShrink Kevin Nasky, DO

             What are those barriers, and what can physicians do to remove them?

          • Elle Gee

            1. Acknowledge that the barriers exist. They are (among others) – lack of access to grocery stores that stock healthy foods at prices affordable by many;  - lack of education on what “healthy” is;  - lack of a safe area for “free” exercise (like sidewalks or a park in which one may safely walk or play).
            2. research and identify resources that will assist patients in achieving their goals when you cannot do so yourself.
            3. become involved in the public health movement that is working to help communities overcome the very real obstacles they face in achieving and maintaining healthy lifestyles
            4. Since education is one tool that helps – do more than say “change your lifestyle, or you will die.” Create a support group or educational program (or provide financial support to programs that exist already) that helps your patients to learn about healthy options. Take into account the lack of access. Address these very real concerns. Help find solutions. Maybe it’s lobbying for a change in a bus route, or for a large grocery store in a particular neighborhood.

            This is hard to do, and takes committed leadership. Saying “just do it” is easy – but does not solve the problem. Since patients come to doctors for help in solving problems they cannot solve themselves it stands to reason that doctors may have a responsibility to provide solutions that work – not aphorisms that don’t – even if the solutions are not precisely “medical.” I checked your website and you seem a sincere and committed physician. Surely you would be quick to offer a change of approach if you saw that a recommended therapy wasn’t working.

          • Apurva Bhatt

            I work for a large integrated health care system. All of the patients that I see have access to free or nearly free weight loss classes, nutritionists, weight management literature – all available ~ 30 feet away from my office.  There’s also online weight management resources that I direct them to if they want more convenience.  Nearly all are middle class or above in their income, and they all live in a safe neighborhood with easy access to hiking, parks, a lake, bicycle paths, and other areas to freely exercise.

            With all of these amazing resources and few legitimate barriers to getting healthy, the majority of my patients are nevertheless overweight, and about 1/3 are obese (roughly mirroring the national average).

            I can’t recall the last time that an honest discussion about their weight problem, including helping them identify “barriers” actually made any difference.  They by and large continue along the same unhealthy path, and their health continues to worsen.  As the poster above mentioned, the only times that I’ve seen a person break out of this “rut” is when they have that “Eureka” moment.  Sadly, too often that moment is when they first get diagnosed with diabetes,  develop irreversible joint arthritis, or have their first heart attack or stroke.  Surprisingly, even these events rarely lead to permanent changes in their behavior, and often they return to their old habits after the initial “shock” has worn off.

            I’ve sadly come to the conclusion that the only significant barrier that the majority of my patients face is their own apathy and unwillingness to change.  While I continue to guide them and counsel them, I’m not sure how much of an impact this truly has.

      • http://twitter.com/USMCShrink Kevin Nasky, DO

        This isn’t about ascribing fault or blame. I wholeheartedly concur that lifestyle modification is not easy; quite the contrary indeed! I’m simply stating that we–doctors and patients alike–shouldn’t continually beat ourselves up for less-than-stellar results in managing these chronic conditions. The author stated: “Overeating a non-nutritious diet, lack of exercise, chronic stress, and
        20% still smoking are the major predisposing causes of these chronic
        illnesses.” Besides giving advice and guidance, how is a doctor–any doctor–supposed to ensure his/her patients aren’t eating poorly, are exercising, are making efforts to reduce their stress? What is the expectation here? I would argue that the expectations are bordering on the absurd. Should we have health coaches follow patients around? I mean, seriously, how much can we really be responsible for?

    • Anonymous

      Well said Kevin! I agree that we can design and tweak and then tweak again all these various protocols but there comes a point in time where the limiting factor is the patients own desire, determination, dedication, and discipline and overall self accountability. I believe the steps are in place where the overall direction of future healthcare will simply overwhelm the individual with all the tools and evidence of what they SHOULD do and choose. Will they will be the question that persists simply because of the human element.

    • http://pulse.yahoo.com/_VM5ZKYTEEAO4KZZG23W3HL2ERQ marc

      Chronic diseases are better handled in countries with strong, universal and free to access primary care systems, such as the UK.  

    • Anonymous

      I’ve never studied it, but I suspect that as long as recommendations from the medical world are at odds with what the larger culture or society present as desirable or acceptable, there will always be a disconnect.  How many times has a prime-time TV show highlighting, say, obesity or hypertension (both can be diet-related), been interrupted by a commercial for McDonalds, The Olive Garden or Applebee’s?

      You also make a terrific argument for the existence of case managers – a role assumed relatively recently by the nursing profession since physicians didn’t have time (or, perhaps, weren’t reimbursed?) for it.  Good luck on getting that back from the nurses.

  • Angelea Bruce

    CMS recently made exactly the wrong decision by excluding registered dietitians as providers for obesity management.  They recognize and reimburse RDs for the dietary component of diabetes management, but not for other weight- and diet-related conditions.  Until money is spent up-front for prevention, making evidence-based nutrition counseling accessible and affordable to the majority of the population, our country will continue to chase its tail when it comes to preventing and treating these diet- and lifestyle-related chronic diseases.

  • http://www.facebook.com/robert.j.ducharme Robert J DuCharme

    Well said. It is imperative that patients have simple, easy access to primary care doctors early so they can control and fight those chronic diseases that turn into more uglier problems later on. Diabetes, hypertension, etc. can be cared for if the patient has access to affordable primary and preventative care, as well as wellness education.

  • Anonymous

    It’s not only the declining reimbursement that is affecting medical students’ aversion to matching into primary care, but the declining respect (which for some of us stings more than the shrinking bottom line).

    When patients are billing their doctors for being late and making blanket accusations about doctors being greedy, it should come as no surprise why so many med students shy away from those specialties. So while the insurance companies are partly to blame, patients who make it less appealing for doctors to practice in primary care are in the same boat.

  • Anonymous

    My primary care doctor (PCP) has been practicing family medicine for over three decades. He always tells me, primary care “today” is not rocket science. It’s basic triage that can easily be performed by mid levels in a clinical environment. He says that his primary care practice is about 85 percent routine stuff and the remaining are referrals. His malpractice insurance encourages him to refer the serious cases to a specialist. He says, primary care does not need to be so expensive. He says, the VA does primary care for a third the cost. The VA uses mostly mid level professionals to do primary care. If you want to deal with the “health care paradox” we have today, you can start with how primary care is delivered. Face it, primary care is nothing but over priced triage.

    • Anonymous

      Please no one should waste their time replying. The internet desperately needs a filter.

      • Anonymous

        Truth needs a filter? Social media needs to be constrained? So, your opinion matters but we can squelch the opinions of others? Sounds like a Republican concept, huh?

      • Anonymous

        I am offended by this post.  Really…you want to filter someone’s ideas because you don’t agree?

        My experiences with primary care parallel what davemills555 has described.  It’s interesting we can’t have an adult conversation about this.

        • Anonymous

          I have no idea what your experiences are but if it includes such insightful comments like “…primary care is nothing but over priced triage”, my wish list remains the same. 

          • Anonymous

            Face it, primary care is a scam. No bang for the buck. Expensive triage. If a patient comes in for care and it’s not something simple like a flu shot or removing a wart, it gets referred to a specialist. I’d sooner go to WalMart for my wart removals and flu shots and pay less! The ACO model will do exactly that. When big-box health care comes to town, the competition will be too intense. Small office docs can’t compete and will simply dry up and blow away. 

          • Anonymous

            Isn’t that the issue, you don’t know what my experiences are?  I had a tick bite, and after a few months of festering, I was referred to a dermatologist for a simple punch biopsy.  Every serious medical condition has been referred out with my PCP playing a maintenance role.

            With a high deductible plan, I often go to a nurses clinic for simple things.  The care is fine.

            I don’t know about the ACO’s.  As for big-box healthcare, I don’t know why medicine should be immune from this trend that every other industry has gone through.  Market based healthcare will bring it faster.

  • Anonymous

    As a 25 year practicing primary care physician and the CEO of a 500 physician group I have seen the joy of practicing medicine dissipate especially over the past 10 years. Some will say it is because physicians are not making as much as they used to but I believe that is too cynical. That is an approach that I have and will never take. The changes needed in health care to make it serve the good of more in the population as pointed out so well in the above article are complex and for sure not easy. We have to find a way to reward physicians for spending time with the chronically ill and also to commit to preventive care so that more chronically ill will not flood the system in the next two decades. By allowing primary care the time to do this will serve a couple of important objectives. I believe it will increase those new physicians who chose primary care and studies have shown that when there is an increase in primary care in any area, especially metropolitan, the quality and cost move in a positive way. Secondly, and most satisfying to me, is that physicians will enjoy what they are doing again. This after all is why most of us went into medicine in the first place to make a difference. Well done in pointing out these problems Dr.Schimpff.

    • Anonymous

      “We have to find a way to reward physicians for spending time with the chronically ill and also to commit to preventive care so that more chronically ill will not flood the system in the next two decades”

      ?????

      We’ve found the way. It’s called better pay.

      Everybody knows that’s the answer, but no one gives it anything more than lip service.

      Why not stop the navel-gazing and do it in your group?

  • Anonymous

    It is important to distinguish between obesity-related Type 2 diabetes, and thin Type 2, MODY, LADA and Type 1 diabetes, which are NOT preventable in any way as yet. It is also important to acknowledge that “prevention” of Type 2 is hype, because none of the studies have lasted more than a few years, and in the case of early-onset obesity-related Type 2, it could seem like the disease has been prevented after 3 or 5 years, but what about 20 or 40 years down the line? The results aren’t in yet.

    So little is known about Type 2 — it is still, as yet, unknown whether the obesity reveals the genetic tendency to Type 2 or vice versa. If obesity CAUSED Type 2, then we would have that 33.8% of the population which is obese also developing Type 2, but in fact, ALL types of diabetes account for only 8% of the population, so there HAS to be something else going on, and we DON’T KNOW if it’s preventable. Perhaps food additives are involved, or maybe pollution, but the fact is that we don’t know.

    So, in our ignorance, maybe we need to be a little gentler with people who develop obesity or Type 2, because maybe it could have been prevented or delayed, or maybe it couldn’t have. Diabetes of any type is a tough disease to live with, and oversimplifications about it only harm patients’ self-esteem

  • http://twitter.com/GottaBNimble Chris

    We are becoming functionally illiterate in health. Many take literacy to mean reading.  Many take reading to mean decoding, or take it up a notch to mean decoding with comprehension.  But to be functionally literate one needs to connect contextual meaning to what we comprehend.  To empower positive health behavior from the patient’s perspective the buzzword is “engagement” but again why aren’t patients engaged?  Change and innovation are symbiotic as well.  As decoding does not necessarily equate reading, innovation does not necessarily equate positive behavior change.  Its a systemic issue of disconnection between all the constituents and their measurements of success. Depending on the perspective, we are succeeding or we are failing. 

    We have been looking at the wrong measures of success for too long but we are beginning to take notice because the price we are paying is becoming too painful to bear.

    For example, Dutch Kids Pedal Their Own Bus To School – http://lnkd.in/BtpJf5 – is this efficient, effective? from what perspective?

    Robbery EPIC FAIL in Rotterdam! – http://youtu.be/8WhvJDnxw-U – was this safe, smart?

    The Dutch measure success differently and it is systemic.  As a community they do what we wish we could, but instead, we “…Keep Seeing the Same Movie Over and Over Again”- http://ti.me/yTghL3

  • Anonymous

    I am delighted that so many took the time to comment on my post. Whether you agreed or disagreed with my comments, this has been a good discussion. Thanks to all. More posts on this topic to follow.
    Stephen Schimpff

  • Anonymous

    There is no disagreement that the advances in medical technology has generated a growing number of specialists, broadening the gap between the primary care physicians and specialist without addressing the ethical issues that were raised.  The fundamental ethical violation is that the patient is treated as a biological sample to test the quality and efficiency of the new technologies.  In addition, without allowing adequate time to evaluate objectively the significance of the new technology in term of securing a diagnosis or establishing a treatment protocol, insurance companies are only concerned with the monetary value the new diagnostic tools.  The inability of specialists or primary care physicians to come to consensus over the validity of new diagnostic tools enhances an undignified treatment of the patient and leaves the imagination open to fictional scenarios of human experimentation.  It is time to reconfirm that for centuries medicine was providing relief to the pain and suffering of the diseased without focusing on the ability of the diseased to pay or their ability to overcome an episodic phase of their disease.  Rather medicine focused on preventing the expression of the disease.  In this lies the paradox.

  • Anonymous

    “Committed physician coordinator”–I like it.  I don’t really want to do it for a living, but I do like the phrase.
    I suspect the CPC would be paid a fraction of what he or she could earn as a sub-specialist and would be subject to administrative and financial pressures that would markedly increase the risk of chronic daily headaches.   What a lousy job. Remember, it’s supply and demand.  Demand by itself does not suffice.

  • http://www.facebook.com/people/Edward-DiCarlo/678027285 Edward DiCarlo

    Much has been written so far, but the one thing that seems most important is that we have no definition of “healthcare”.  My experience informs me that most people I ask give many definitions for this term – too many indicating a significant level of confusion.  But – most people have a better idea of what “medical care” is – they see a doctor or go to a clinic / hospital for a medical problem.  Most don’t distinguish between acute and chronic – medical care is medical care.  I think that physicians are better trained to deal with medical care, even given all the issues already mentioned concerning chronicity.  Physicians may be in positions to ask about and suggest proper behaviors regarding general health, but the schools, personal trainers, and others are better positioned to actually affect the every-day practices of people as they attempt – or don’t attempt – to maintain a decent level of physical health.  Proper education regarding healthy life-styles does not naturally fall into the sphere of physicians – not enought “face-time” for that, but physicians can certainly ask and maybe even cajole.  “Committed physician coordinator” sounds nice, but maybe what we really need are “committed personal trainers”.