Next in a series.
We have a real paradox in American health care. 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 and biotechnology industries continuously bring forth lifesaving and disease altering medications. The medical device industry is incredibly innovative and entrepreneurial. The makers of diagnostic equipment such as CT scans and hand held ultrasounds are equally productive. 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 very dysfunctional health care delivery system. A fascinating paradox. One wonders just why it is that Americans tolerate this paradox of incredible medical advances and outstanding providers yet a dysfunctional delivery system.
Our current delivery system was designed over the past century or more to deal with acute medical problems — where it is reasonably effective. What is meant by an acute illness? Consider the pneumonia that a single internist can treat with antibiotics, an appendicitis that can be cured by the surgeon or the fractured arm that can be casted by the orthopedist. But our medical care system works poorly for most chronic medical illnesses and it costs far too much. Chronic illnesses are ones like diabetes with complications, cancer, heart failure and neurologic illnesses like stroke.
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 which combined with the long term effects of behaviors 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.
Most of today’s chronic illness care does not utilize a true team but rather a hodge-podge of specialists that are not working in a unified manner. Primary care physicians 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. Over time, most chronic illnesses will need a team of caregivers.
Consider a patient with diabetes who may need an endocrinologist, , nurse practitioner, podiatrist, nutritionist, personal trainer, ophthalmologist and perhaps vascular surgeon and cardiologist and many others as well. But any team needs a quarterback and in general the person is the primary care physician. He or she needs to be the orchestrator as much if not more than the intervener. This need for a team and a team quarterback for the patient with a chronic illness is much different than the needs of the patient with an acute illness where one physician can usually suffice. It is this shift to a population that has an increasing frequency of chronic illnesses that mandates a shift in how medical care is delivered. Unfortunately, our delivery system has not kept up with the need.
When the famous bank robber, Willie Sutton, was asked why he robbed banks he replied “that’s where the money is.” In health care the money is in chronic illnesses. These consume about 75-85% of all dollars spent on medical care. So we need to focus there.
Since most chronic illnesses are preventable, what are needed are aggressive preventive approaches along with attention to maintaining and augmenting wellness. This would reduce the burden of disease over time and greatly reduce the rising cost of care. Unfortunately, America places far too little attention and far too few resources into wellness and preventive. Most primary care physicians do not give really high level preventive care. Yes, they do screening for high blood pressure and cholesterol and for various cancers and they attend to immunizations. But this is not enough. Patients need counseling on, at least, tobacco cessation, stress management, good eating habits and a push toward more exercise. They need an admonition to not drink and drive, not text and drive and to buckle up. They need to be reminded that dental hygiene today pays big dividends in the later years of life. And they need someone to really listen closely to uncover the root cause of many symptom complexes as in the story given in the first of this multipart series.
When a patient is sent for extra tests, imaging or specialists’ visits the expenditures go up exponentially yet the quality does not rise commensurately. 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 not have enough time for care coordination or for more than the basics of preventive care. And they just do not have time to listen and think.
So the paradox is that America has the providers, the science, the drugs, the diagnostics and devices that are needed for outstanding patient care. But the delivery is not what it should or could be. The result is a sicker population, episodic care and expenses that are far greater than necessary. The fix is change the reimbursement system to get PCPs the time needed to listen, to prevent, to coordinate and to just think. This will lead to better care and less expensive care.
The next post in this series will be about customer focus.
Stephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and is the author of The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.