Ours is a provider-oriented system. Doctors like me and (former) hospital executives like me hate to admit it but it is true. Consumerism will slowly but surely drive it toward being a patient-oriented service model. What do patients and their families want from the health care delivery team? First and foremost is respect followed by service given in a high quality, very safe manner. Patients expect that the information gap will be closed. They increasingly expect convenience including rapid appointments, short waiting times and short driving distances. And patients increasingly want and expect (even though it may not be paid for by insurance) good communication including use of email or text messages. That is all to the good but again this will be very disruptive of the status quo.
There is a slowly but surely shift in three important ways that patients are cared for: 1) the use of multi-disciplinary teams coordinated by a PCP to treat patients with chronic illness; 2) immediate transfer of patients with acute life threatening illnesses like strokes and myocardial infarcts; and 3) patient self referral to specialty centers for treatment of complex chronic illnesses like cancer or multiple sclerosis.
Multi-disciplinary team care is a coming change to treat patients with chronic diseases. Here is the way care is generally delivered now. Imagine a patient with diabetes. Over time he or she will need to see an endocrinologist, an exercise physiologist, a nutritionist, an ophthmologist, and perhaps a nephrologist or vascular surgeon. What happens all too often now is that the patient is told to see this specialist or that and is left to make their own appointments and hope that the specialist will know what is needed for their care. Each is likely in a different part of town, does not communicate with others on the team and, although doing his or her best to care for the patient, is just not cognizant of all the issues that make up this patient’s total care needs. The result is excess tests, images and procedures leading to higher costs yet lower quality.
It is much better when the PCP actively manages this entire team. It would be ideal to have each team member in close proximity but this is likely impractical most of the time. But it can become a virtual team. The quality of care goes up and the costs go down. Multi-disciplinary team care is much better for the patient but it needs to be a true team, not disjointed. This type of team care is becoming increasingly common but many physicians are not on board – it changes their long held practice approaches so converting to true team based care with a PCP coordinator is quite transformative of the care system.
Immediate transfer to the most appropriate setting for the patient with an acute, life threatening illness will become more and more common. Today, it is well accepted that the best care of the trauma patient is to send the patient directly to the most appropriate facility for care. For a less severe injury such as a broken leg, the local emergency room will be fine. For more severe trauma the patient can be sent to a regional trauma center. And for very severely injured individuals, transport, possibly by helicopter, to a level 1 trauma center within the “golden hour” is lifesaving.
There is growing appreciation that the stroke patient likewise needs to be sent to a center that is equipped 24/7 with staff and technology to rapidly access and treat within just an hour or less. Not all hospitals can offer this capability and so those that cannot need to arrange immediate transport to the nearest qualified center. Unfortunately this only happens rarely today leaving many patients who could be effectively treated out of luck.
And it has become increasingly apparent that a patient who is having a heart attack should be immediately taken to the cardiac catheterization laboratory for angioplasty and possible stent placement, stopping the infarct before irreparable damage has occurred. Once again, all too few patients are offered this opportunity today. They may be transferred eventually, but not soon enough to offer optimum opportunity.
This type of immediate transfer to a center of excellence is very disruptive of the long held methods of caring for strokes and myocardial infarcts but the change needs to occur.
Individuals that learn they have a chronic illness like cancer are increasingly taking the time to learn about options. Discussions with others with the same illness and searches on the internet render the patient or the patient’s family much more sophisticated and ready to ask questions of their providers. More and more the patient is directing where he or she wants to go for specialty care and many are realizing that those that use of a multi-disciplinary team approach is far superior. Consider a patient with breast cancer. She could, over time, be sent first to a surgeon, then to a radiation therapist and later to a medical oncologist, each with their own concept of what would be best for her condition. Or she could go to a center where she meets with the surgeon, the radiation therapist and the medical oncologist all at one time. They then – once understanding her needs and desires as an individual – offer her a joint plan for care. Now she knows all the steps along the way and what to expect and she has met her caregivers. Likely, she has also met a nurse practioneer who will be her guide throughout the coming months of treatment and follow-up. (For some examples check out the University of Maryland Greenebaum Cancer Center approach to team care.)
This is better care for the patient but a real change in delivery style for the doctors. Educated consumers will come to demand it over time.
These are but a few of the disruptive and transformational changes in health care delivery that can be expected in the coming years. They will render the delivery of care much better and less costly.
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, published by Potomac Books.