America has a medical care system not a health care system

As Americans we believe we have the best healthcare system in the world. But think again, it’s really not the truth. We do have superb medical schools, very well trained providers, superb science and technology but the delivery of medical care is just not what it should be. We spend more for healthcare than any other country does on a per capita basis.

And yet when we compare ourselves to other countries, especially developed countries, our outcomes are not better. Our life spans are somewhat shorter than countries such as Japan and our infant mortality is somewhat higher than countries like England and France. We tend to focus on disease and injury but not so much on illness prevention and health promotion. We all recognize that as a society we have some adverse lifestyle behaviors such as overeating a non-nutritious diet, being fairly sedentary, having chronic stress and having 20% of us still smoking. It’s quite clear that the best chance we have for increasing our life span and overall improving our health is to adjust our personal behaviors and to do so at an early age.

We often think of heart disease, cancer and stroke as the major causes of death and, as diseases that cause death, which is correct. But what if we go back further and look at what caused those diseases. The rank order of causes of death according to a study from the Centers for Disease Control in the Journal of the American Medical Association lists tobacco, poor nutrition, lack of exercise, alcohol to excess, infections, toxic agents, motor vehicle accidents, sexual behaviors and illicit drug use as the primary predisposing factors to the diseases that cause death. A look at that list shows that the ones at the top of the list and a number of others all relate to our behaviors.

The diseases that occur have changed substantially over the decades. At the beginning of the 1900’s it was infectious diseases that caused most deaths. Over time they came under reasonably good control with preventive techniques such as immunizations, sanitary sewer systems and clean water systems and then, of course, antibiotics. Meanwhile chronic illnesses such as coronary artery disease became much more prevalent. Even though fewer people smoke than a few decades ago our obesity and our lack of exercise have led to rapid increases in diabetes, heart disease, stroke, high blood pressure and many other chronic illnesses that last a lifetime.

Our medical care system does not deal with health; it really concentrates on illnesses or trauma. In addition more and more illnesses today are chronic and complex, lasting a patient’s lifetime and bearing very high costs. The best way to care for these chronic illnesses is with a multidisciplinary team approach. This is just not the typical way our medical care delivery system is organized. We tend to have a system that relies on a single provider treating an illness – the internist gives an antibiotic for pneumonia and the surgeon cuts out the diseased gall bladder. But patients with chronic illnesses really need multiple providers. For example, the diabetic may need in addition to a primary care physician, an endocrinologist, an exercise physiologist, a nutritionist, an ophthalmologist, a vascular surgeon, a nephrologist, etc. But this team needs a coordinator or quarterback and this is preferably the primary care physician. Good care coordination can direct the patient to the care he or she needs while reducing the number of specialist visits, procedures, tests and imaging — with the result that the quality of care goes up and the cost of care goes down substantially.

So we have a medical care system not a healthcare system. What we need in America today is a focus on health care meaning a greater focus on disease prevention and health promotion beginning in childhood and a recognition that chronic illnesses are the ones that not only last a lifetime but are also the diseases that are driving the high cost of care. These costs can be brought down and can be brought down quite substantially through a better approach to patient care, one that coordinates the care intensively while using a multidisciplinary team approach.

America has a medical care system not a health care systemStephen 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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  • Denise Easthon

    You had me till “immunizations”….”vaccinations” are NOT “immunizations” and they have not contributed to better health.  Look to the rate of chronic disease/syndromes and that will be clear.

    • Brian Curry

      This is just laughably absurd. Of course vaccines have contributed to better health, regardless of the metric used. You can thank vaccines for the fact that you’ve never seen an operational polio ward, or that kids no longer suffer through (and occasionally die) from whooping cough. You use phrases like “look to the rate of chronic disease/syndromes”, but I’d really be interested in exactly what chronic “diseases/syndromes” you think are causally linked to vaccines. Take your time.

  • Mary Brighton

    Thanks for your article. I agree with your opinion, the question is what do we do about it? I can recommend that we shouldn’t rely on doctors and other medical professionals to fix our bodies. We need to take control of our own personal health and work with doctors rather than expect miracles.  Coordinate our medical therapies ourselves with the help of a good primary doctor. As Michael Pollan says with his version of the “American Paradox”, “We Americans suffer a national eating disorder: our unhealthy obsession with healthy eating.” And yet, Americans are some of the most unhealthy people and America in one of the unhealthiest nations in the world. We need to move “back to basics” for our lifestyle, slow down, eat locally and less processed foods, practice econutrition, move more, etc. etc. I could go on all day,it is just a personal issue. I live in France and am a practicing dietitian. Even here with all the emphasis on good eating and health prevention things are changing. But, you can see the results of a combination of people taking care of themselves, of access to good medical care and a primary doctor that coordinates your health and knows you. The results are a healthier nation than most countries.

  • Lezlee Maupin White

    As far as I know medical schools are partially funded by the pharmaceutical companies. Traditional Doctors only know how to prescribe drugs and do surgical procedures. Until they learn about nutrition and remember their biology studies we are going to keep doing the same thing over and over again expecting different results.

  • Fred Dempster

    Like so many of us, I came away from my annual physical with that “Exercise” box checked off. At best I’m mediocre and, yes need to improve. Luckily I do get plenty of fiber, vitamins and supplements, and effort to improve eating using Jonny Bowden’s 150 Healthiest Foods. The impact of the article is correct – we do not have a healthcare system, maybe at best it’s a healthcare suggestion system – to easy to ignore the checked off boxes as the follow-up is none, unless the indicators call for meds, but those are not always needed if we practice healthcare.

  • Amber Johnson

    I think we are really far from an actual real health care system because the U.S. government don’t know what to do about our current debt crisis.  I think we should just offer free health care to people like Canada does.

  • Steven Reznick

    It is easy to criticize the medical delivery system but the truth of the matter is that few individuals take responsibility for their actions. When there are consequences we blame everyone but ourselves. We have gutted public education especially in the areas of nutrition, prevention, hygiene and health in the name of cost savings and religious beliefs about discussing reproductive health. We rarely screen for unhealthy lifestyle and chronic illnesses in our schools anymore having eliminated the school nurses programs in most schools. We waive vaccinations and immunizations for ” religious beliefs” rather true scientific or medical data. We serve garbage to our school children in the school cafeterias and lunch programs. We have eliminated physical education or gym programs to teach kids how to exercise and develop a fitness regimen that they may enjoy and that works for them. The children grow up to be young adults and choose not to have a checkup because the co pay might be $25 or $35 the cost of their beers and after hour drinks on the way home from work. The same person who has a smart phone and a flat screen TV says they can not afford a dental exam , cleaning or filling. We require by Federal law hospitals and emergency rooms to treat all comers regardless of their ability to pay ( a humane and sane rule) and then shunt the bill onto the local taxpayers. We encourage the development of insurance company directed health networks paying providers a fraction of their normal payment for the services and then we bitch and moan when they cut the visit time to be in line with the reduced compensation. Then we change doctors each year when our employer changes insurance plans for financial reasons instead of sticking with a good caring practitioner who may advocate for you and advise you for a few dollars more than the new in network physician.We subsidize tobacco but criticize it and recognize how detrimental it is to our health. We wink at under age alcohol consumption and irresponsible alcohol use but never wonder why if drinking and driving is a bad idea, all suburban and rural drinking establishments have huge parking lots? We fight over the right to continue to bear arms but don”t really want to evaluate the individuals buying a weapon for stability or insist that they be adequately trained and educated on the safety and correct use of the weapon before they are sold a gun.  Most of the things that make us sick and ill and worsen the international statistic are within the grasp of the individual. parents and community to control.  They just do not do it and find it convenient to blame everything and everyone else for the consequences

  • Margalit Gur-Arie

    I agree with most of what Dr. Reznick wrote, but I don’t quite agree with the conclusion  that ” Most of the things that make us sick and ill and worsen the
    international statistic are within the grasp of the individual. parents
    and community to control.”
    Many of those things are inflicted on the individual and his/her community by a system which caters to the highest paying special interest. Subsidies for tobacco and unhealthy food are occurring at a federal level. Nutrition in schools (or lack thereof), gym classes, lunch, nurses, health education, etc. are also largely federally imposed, and those that are State imposed are also subject to extensive lobbying of special interests.
    The voice of the individual citizen in this country is shrinking in its importance.

    And while we are comparing ourselves to other developed countries, it would be useful to also note that our increasing health expenditures seem to correlate rather nicely with an increase in inequality in the US compared to all those other developed countries. As most Americans are getting poorer (and poor is a relative term), we are starting to look more like the not so developed countries.

    • Steven Reznick

      It is within the power of parents to influence how money is allocated in their children’s classrooms. While the voice of the individual citizen may be less powerful , they still can vote and campaign for individuals who support issues that benefit their health and welfare. 

      • Margalit Gur-Arie

        Yes, I supported candidate Obama who ran on the creation of public insurance for those who want it and opposed Hilary’s individual mandate solution. And here I am today…..
        It doesn’t matter what they say they support. Whatever the Robber Barons want, is what will be done.

  • Anonymous

    In response to your  “America has a medical care system not a health care system”, in which you point out that we can trace the top causes of death in the US back to specific behaviors, but perform poorly at addressing those behaviors, I would note that the behaviors mentioned should be addressed, earlier, more clearly, and more frequently by the educational system, the government, parents, community organizations, individuals, and every health care provider as well as anything or anyone claiming to be a “healthcare system” or part of a “health care system”.

    But most Americans do know that the high risk behaviors listed confer a higher risk.

    That’s right. I’m going to go ahead and say that I do not find it common that patients themselves do not absolutely know the list of high risk behaviors, and know that these behaviors confer significant risk. I acknowledge, that I am reporting my own observations. Absolutely true. I’m going to remark on my experience, nonetheless, to engage this too long and too often “overlooked” discussion

    I do not find that patients cannot spontaneously report this list of high risk behaviors among patients who have engaged in and successfully ceased engaging in the same behaviors, nor do I see fail to see the same ability among patients that did not in the past but at some point do ultimately end up among those who also engage in the same high risk behaviors, nor do I even find the knowledge of high risk behaviors to be any different in those patients who are actively engaged in one or more of the same behaviors and do not wish to change their behavior now, or do not feel they can succeed in changing.

    Earlier, better, and more frequent education and promotion of healthy choices is absolutely better.

    But, we are actively ignoring that despite knowledge, many people are not succeeding at CHANGING.

    It seems America has gone a long way to identify, publicize, and reinforce at more medical visits WHICH behaviors Americans would improve their health by ceasing, or never starting.

    But I dont meet Americans, patients or otherwise,  who do not know that smoking cigarettes, excessive use of alcohol, use of other substances, lack of implementation of safer sex practices, and lack of improved diet and exercise habits are ALL health risks. I dont come across this any longer.

    People have trouble making these changes. We have to acknowledge this issue as well. It is not shameful, and ignoring this aspect — the difficulty people have achieving the changes they do now know will improve their health — is not helping anyone.

    For some, clarification of steps that would be reasonably employed in effecting the desired change, and some follow up dedicated to reviewing such a plan, as well as targeted adjustment of the plan accounting for results or lack thereof, would help. For some it might do the trick.

    But for many people, the barriers to change are not embedded in the list of changes. In fact, the prompt to engage in higher risk behavior is not embedded in that list of behaviors either. Individual patients do need individualized attention to discern and address their underlying reasons for a host of behaviors that we also commonly find in the very same patients who are having trouble reducing, stopping or maintaining behaviors that we all know would both decrease medical risk, as well as mental health. Many of the patients we find having trouble with these identified risks, are struggling with a host of other behaviors and feelings that are also causing them medical and mental suffering.

    There is, in fact, a medical discipline that is particularly charged with understanding and treating what is largely referred to as “behavioral health” (without regard to preference for wording). We need to stop stigmatizing Psychiatric care, and curb the prevailing trend to attempt to reduce the availability of adequate psychiatric care, or limit the time devoted to such care, to the point of rendering some options useless, in favor of helping patients to achieve the goals that we have identified.

    Does everyone need a psychiatrist. No. Should the patients who are telling us they know what they should be doing to improve their health, and they know they want to do these things, yet they continue to fail in their efforts despite making them, be denied the benefit of Psychiatric evaluation? I do not think so. If we are committed to helping patients achieve health, every health care provider needs to dispense with any bias or preference that would lead us to fail to offer the appropriate care to the appropriate patients, that ultimately, we already agree “should” be life saving. 

  • Anonymous

    America does not have a health care system nor a medical care system, but a profit-driven medical industry.    Lacking universal access to health care and health education, we will continue to pace behind the health status of other developed countries which spend far less.

  • Anonymous

    To call what we have a “system” is very generous. It’s more like a patchwork quilt. Some of the patches are made of rich, luxurious fabrics, while other patches are very threadbare and barely holding together. 

  • Brett

    While I agree that Americans need to worry more about health promotion, it is not the physician’s job to continually monitor people.  Our citizens go to the doctor when they are sick, not for questions about health promotion.  Yes, I realize there are the exceptions.  However, how many actually take the advice of the health care professional when it comes to exercising and improving one’s diet?  In spite of the immense amounts of torture we, as Americans, put our bodies through, our numbers are virtually on par with the rest of the world.  The only one I find of concern is infant mortality because they are brand new to the world, but again, how much stress was the fetus under during gestation?  How much work was the mother doing?  What did she eat?  Did she overeat?  Did she get gestational diabetes?  The factors are much too numerous to say we are comparing apples to apples.  The fact is, we DO have the best system in the world, and this is why everyone comes here to practice.  I am so sick of the pharmaceutical/greedy doctor accusations and conspiracy theories.  They are beyond ridiculous.  The arguments FOR socialized medicine are uneducated at best.  Go speak to a health care provider from a socialized medical country.  Go speak to the people who need surgeries for years without receiving them.  We already have to do things like sending patients home to receive steroid injections in failing joints for months before their insurance companies will fork over the cash for surgery.  We send patients home on 24 hour EKG monitoring to prove they need defibrillators in spite of the fact that everyone around worth his/her salt knew it was necessary before ever sending the patient home.  These examples run RAMPANT in socialized medicine, and people die or experience increased morbidity because of them.  If you think the insurance companies are bad, wait until it is a federal agency determining what you have to do to PROVE you need treatment.  The bottom line is, people are free to abuse their bodies until they are sicker than hell.  They are then perfectly okay to come in expecting miracles despite having ignored all the health promotion techniques health care providers have attempted to push on them.  That is what FREEDOM means, and it also means the health care system will be stretched to its capacity day in and day out because they come in so run down and sick.  The fact that we do so well should stand as a testament to the skill and expertise of every health care provider in this country.

  • Anonymous

    As a person with non-obesity related diabetes, I really take exception to the constant nattering about diabetes. It is NOT necessarily a lifestyle-related disease, and people are NOT to blame for developing it. There are already clearly defined genetic factors, increasing knowledge about gut, adipose and brain hormone dysfunctions, and lots of forms of diabetes which are, in general ignored in the general rush to castigate people for developing diabetes.

    Now, if I were hearing that better diet (and a really good diet has not yet been defined by scientists, who are still groping their way to understanding nutrition), and moderate exercise (which is all anyone has time for) were good for the population at large, that would be fine, but singling out people with diabetes for blame is not only unfair, but inaccurate. 33.8% of the American population is obese (not including those who are just overweight), yet only about 8% have ANY kind of diabetes. So, clearly, obesity is NOT the cause, and watching all the fingers pointed at the obese is disturbing to say the least. As I said, I am not obese, and I really do object to the general use of the word “diabetes” without any qualifiers, such as Type 2, or obesity-related. And even then, the blame and shame game doesn’t work.

  • Lillian Pickering

    As an RN of 40 years duration, I believe we are not using a resource that could accomplish more wholistic care for all US citizens at a lower cost, and that is the use of RNs to oversee preventive well-person care.  An experienced RN can see the “big picture” for his/her patients, and can anticipate ill-health consequences that are likely to occur based on the patient’s medical problems, and he/she can then steer patients to the needed education, lab tests, other diagnostic tests or specialists.  He/she can also tie together the info gleaned from multiple care providers, and put it together for a patient in a way that the patient can understand (i.e., not in “medicalese”).  Of course, all this would be done in partnership with a physician, but it would certainly save physician time while serving patients much better than they are now served.
    Re causes of our poor outcomes:  yup, look to politics.  Follow the money trail, for greed is what drives our capitalist system.  And if you want to blame government, blame INEPT government such as the bizarre system we have now, in which congresspeople and senators wage a power war, instead  of serving the people of the US.  Nothing useful gets done, but corporations (oh, I mean “corporation-persons”) do reap some benefits regularly.

  • Anonymous

    “We often think of heart disease, cancer and stroke as the major causes of death and, as diseases that cause death, which is correct. But what if we go back further and look at what caused those diseases. The rank order of causes of death according to a study from the Centers for Disease Control in the Journal of the American Medical Association lists tobacco, poor nutrition, lack of exercise, alcohol to excess, infections, toxic agents, motor vehicle accidents, sexual behaviors and illicit drug use as the primary predisposing factors to the diseases that cause death.” 
    Incorrect. We all die; it cannot be prevented even if you “eat right”, exercise, don’t drive, don’t use illicit drugs or alcohol to excess, and are careful about sex.   Heart disease, cancer and stroke all increase with age regardless of lifestyle.  As a physician, I cannot write “old age” or “multi-system organ failure” as the cause of death on a death certificate.   Many cancers cannot be significantly prevented by lifestyle changes – breast, ovarian, uterine, colon, pancreatic, leukemia, lymphoma, prostate – these are among the most common causes of cancer death.   Those who die of infections (sepsis, pneumonia) often times are advanced in age with dementia. Alzheimer’s has moved up to #6 as “cause” of death – it has passed diabetes (#7).
    The challenge for the society and the healthcare system and medical care system is to address the multiple chronic age-related problems of advanced age and how to address end-of-life care. 25% of Medicare expenditures go to the last year of life – much of it for futile care that does not prevent death.

  • Anonymous


  • Anonymous

    Behavioral changes amongst individuals is difficult enough, but correcting the American health care system requires a societal change in the manner in which health care is administered. We, as Americans, are driven by capitalism which at times is incongruent with the necessary alterations that our health care system needs. A large part of our economy operates by treating illness instead of preventing it. Pharmaceutical companies, insurance companies and healthcare providers benefit more when patients are sick instead of well. This is the fundamental change that needs to occur. Accountable Care Organizations are the latest attempt to move us from an ill-based system to a wellness-based one. However, this concept sounds all to familiar to the failed HMO’s of the early 1990′s. I am certainly not suggesting a movement towards socialized medicine, but in some manner America’s Heath care system needs to reward prevention and wellness instead of illness.

  • Anonymous

    The failure of HMOs in the 90′s was the the failure of for-profit HMOs.  Lots of references and studies available on-line.  Kaiser, Group Health Coorperative and others remain models of coordinated and organized care where efficiencies and attention on costs and quality help keep members’ costs down.

  • Sarah Stone

    Is it even true that other countries focus more on illness prevention and health promotion?  I doubt it.  Americans have adopted bad behaviors.  Many are self-destructive.  It’s a societal problem.  That’s not the fault of the healthcare system and fixing it through the healthcare system is not possible.  People know they should eat balanced diets with quality whole foods, not processed junk.  People know they should exercise.  People know they should smoke or drink in excess.  The healthcare system should not be used to reiterate these things, over and over again, in individual “preventative health” visits.  That would be extremely expensive and likely ineffective.  Doctors cannot make decisions for Americans on every aspect of their lives.  People make their own decisions and need a sense of personal accountability.  I’m not sure how we could possibly get Americans to make drastic lifestyle changes.  More intensive health education in schools might be helpful, but schools are already overwhelmed with education standards.  That seems to have helped with attitudes toward smoking.

  • Sarah Stone

    You say the best way to deal with chronic medical problems is with a mulch-disciplinary team approach.  You then say our current system doesn’t operate that way. You point out that currently specialists provide specialty care (internist – pneumonia, surgeon – cholecystectomy).  OK, no argument there.  You again state that patients with chronic illness need multiple provides (implying this improves care) and list 6 providers that you think would optimize the care of a diabetic, in addition to a primary care provider.  You say the PCP should coordinate the care with these 6 specialists.  You say that good coordination will reduce specialist visits and tests, and thereby improve outcome.  But earlier you said that patients with chronic illness NEED multiple specialists.  Good coordination and appropriate sub-specialist and other care provider visits may very well lead to better care and improve patient outcomes.  I don’t see how good coordination will lead to fewer specialty visits, as you claim, since you’ve made it clear that you feel high quality care of chronic illness patients should involve multiple specialists.  Your idea of quality care (even if superbly coordinated) will lead to increased specialist visits and substantially increased cost of care.  Saying that it will decrease specialty visits and decreases costs makes NO sense.

    In a perfect world, I see where your plan could make sense and decrease costs in the long-term if it reverses or stabilizes the diabetes.  If the diabetic suddenly eats a perfect diet, those nutritionist visits would certainly be worth their costs.  It’s a good idea to refer them since that really do need that guidance and you can’t possibly provide that much counseling yourself.  Unfortunately, many diabetics will continue to eat crap and money will be wasted, but it is nice to make an attempt to get them to change.

    It would be really nice if a diabetic got on a good consistent exercise program and didn’t stray.  We all know how likely that is.  You don’t need an exercise physiologist on board to make this attempt.  You’re not looking at elite athletes here.  Telling your patient to take a daily walk would be a good place to start.  Depending on their local climate, a gym might be a better option, and they usually offer a free consult with a trainer.

    Is the vascular surgeon, ophthalmologist, or nephrologist reallllllly going to change the patient’s outcome?  Or are they just going to acknowledge that their organs are failing and maybe recommend some symptomatic intervention?  I certainly understand having a diabetic consult with all those specialists.  That’s defensive medicine.  That’s how country operates.  You want to share liability.  However, it’s just plain expensive.

    An ideal diabetic patient visits their PCP, endocrinologist, and would take their meds, eat well after seeing the nutritionist, and exercise daily.  They would likely have a good outcome and the healthcare dollars would be well spent. 

    The PCP and endocrinologist of course are necessary to manage diabetes,
    but their best efforts are lost on a patient who doesn’t take their
    meds.  A non-ideal diabetic patient would choose not to take their meds (but fill their prescriptions on time with their Medicaid), continue eating garbage, refuse to exercise (and ask for a handicapped parking permit since they have a “medical condition”… further decreasing their physical activity).  Their condition would spiral out of control, prompting more specialist visits, tests, procedures, medications they won’t take, infected ulcers, expensive antibiotics and home healthcare for those infections, etc.  Healthcare dollars in hopes of preventing disease progression are not well spent on these patients.  These kinds of patients as very common, as we all know.  The best coordination in the world won’t change a thing.

    I’m not saying we shouldn’t offer the “best” care to all patients.  I’m saying that doing so WILL be expensive.  It also won’t guarantee good outcomes.  This is reality.  You’re too idealistic.

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