The real paradox in American health care

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.

The real paradox in American health careStephen 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.

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  • Dr. Drake Ramoray

    I don’t think its a dysfunctional paradox as much as it’s a dysfunctional payment scale (not the same thing as payment system). While you could make the case you don’t need a doctor to tell you to eat correctly (we aren’t really telling people anything they can’t or shouldn’t have learned in middle school health class) but the bottom line is the system doesn’t pay for those things. For time spent I get paid very little to see a diabetic as opposed to biopsing a thyroid nodule. The system doesn’t pay to manage chronic conditions it pays to cut things out, biopsy, and burn things.

    Procedures pay well, so docs gravitate to procedure paying specialties. When you add all the red tape, prior authorizations, social components, and need for the patient to invest in their own care it’s a much better gig from a lifestyle and financial perspective to perform cardiac caths all day as opposed to being the primary care guy dispensing lifestyle modification advice. That is why med students increasingly choose not to into primary care (or Endocrine for that matter).

  • futuredoc

    Agree. It is a very dysfunctional payment system, one that leaves the PCP with all too little time with the patient. Time is critical to listening, to preventing, to thinking and to coordinating care. Payers need to appreciate that paying for this time will not only improve quality but will ultimately reduce total costs of care.
    Stephen Schimpff

  • ninguem

    What do you call two physicians?

    Paradox.

    • NPPCP

      Man…. You’ve been on it the last couple of days!!

  • buzzkillerjsmith

    As a primary care doc, I am the quarterback of the health care. Of course everyone on the offensive line is a 96 pound weakling and if I were able to find a running back stupid enough to take the handoff, I’d give him the ball and run for the locker room, get me a beer, and shake my head at the poor dumbass getting smeared by the defense. But no one will take the ball, dang it.

    • Suzi Q 38

      You’re just going to have to run it in for the “touchdown yourself.

  • Dorothygreen

    How you explain this is not the issue. The issue is twofold. First, we do not have affordable, universal health care. And we will not until there are government price regulations on basic services for all the major players. They can not be market driven. Period. No other country does this to their population. We either have to have a single payer ie Canada or insurance (better for US) like Switzerland. We the people can read the articles that come out about the hospital master charges, unnecessary tests, Medicare fraud, folks bankrupt because of high health costs – the ACA has not solved all of this and won’t. Not because the idea of insurance is bad, but because it is not based on the principle of outlawing private insurance and negotiation of prices for drugs, equipment, physician and hospital cost first through the gov for basic care. It won’t mean that physicians are paid less well, it means a leveling out among physicians in a geographic area – in the insurance model there is choice – it costs more and there are other aspects that in the long run help both physicians and patients, costing patients and government far less than the existing hodgepodge.

    The second issue is the Standard American Diet. “Doctors don’t get paid for telling folks how to eat”. How much good does it do as long as what is out there to eat is poor nutrient, cheap and addictive, and doctors get paid for prescribing drugs. The American eating culture needs reform to reform health care. This issue is a public health issue akin to smoking. Yes we still have a 17% rate of tobacco smokers but that is down from a peak of 60% – no longer the major risk factor of chronic preventable disease. Now, we have an even more sick population because of our eating culture. Those who still smoke have to pay a tax. A tax that politicians want to use in every way but give back to those of us who are paying for chronic diseases with the root cause subsidized cheap food.

    Physicians need to get on the bang wagon about our awful state of nutrition in this country as they did with cigarette smoking. It was not a matter of “being paid” to discuss smoking with a patient, it was a responsible thing to do for the health of the country. Where is your lobby for this against the beverage and big food giants who are producing junk food with taxpayer subsidies?.

    Most other rich countries are taxing unhealthy food in some way or another – now even Mexico, So, get the AMA and other physician associations to let folks know you are fighting for their lives like you did with tobacco smoking.

    This is urgent. The new nutrition information is in the making. You have until June 2 to respond. The only significant change is that folks will know how much is added sugar to processed food. Big deal. I bet most physicians eat quite healthy because you know what happens when you eat cheap processed food on a regular basis. Tell your patients this in one sentence – I don’t eat much processed food because it has a lot of sugar, refined grains that turn to sugar, or a lot of salt and the animals are fed corn which is bad for them so their meat and fat is bad for you. There should be community programs everywhere to help folks kick the habit of the SAD, it cannot be done in a physicians office.