I was reading a blog about health policy and the failings of the ACA rollout posted on CNN. The author spends time talking about how much we want to change our health care system. And how, since change is hard, no one should be surprised by the pains accompanying this change, particularly in terms of individuals loosing their current insurance policies due to the rollout of the ACA regulations on what health insurance policies must now cover.
As I have thought about this, I think the issues need to be reframed. While everyone in general seems in favor of health care reform, there has been little thought given to what that means or should look like. It is my opinion that we really don’t want to do away with our current health care system — we want to modify it to fit current needs.
What we really need are three simultaneous health care delivery systems. We already have the best system in the world at treating acute illness. If you have a heart attack, or are in a car wreck, or get appendicitis, there is no better place in the world than the US.
But if you have diabetes, or hypertension, or had your heart attack 15 years ago, what you need is a disease management system, which is very different than acute care. We don’t do that well there. That is because disease management is actually a very young science which is not taught particularly well to physician trainees.
I am a cardiologist, and spent nearly all my training in the hospital dealing with acute illness. But in my clinical practice, I spend a majority of my time in my office dealing with chronic disease management: my patients with heart failure, or high blood pressure, or known coronary disease, or who had their heart attacks weeks, months, or years ago. How often should they be seen? What is the best therapy to prevent acute exacerbations or recurrences of their disease? Is one class of medication better than another at keeping them “stable” and out of the hospital? Do routine tests help, hurt, or make no difference at all? Our system is starting to grapple with these issues, but only just starting.
The third pillar that we need, which we do exceedingly poorly, is disease prevention. What tools do we have, and what do we need, and what works, and what doesn’t? This approach is in its infancy.
What makes health care so complex is that individuals move between these three aspects of a health care system with sometimes rapid, sometimes unpredictable, and sometimes urgent necessity, and often may need all three aspects simultaneously. Take someone who has an MI: they suddenly find themselves needing acute. Afterwards they need chronic disease management for their coronary artery disease. And of course these chronic disease states will have acute exacerbations at some frequency.
But that same patient may also now live long enough to develop cancer, or a neurological disease, or have a car wreck. So while they passed beyond disease prevention for cardiac care and now are in a cardiac disease management bucket, they may still be in a disease prevention bucket in another area — such as cancer prevention. People may often be in multiple buckets at once: disease management for their hypertension and high cholesterol, disease prevention for the risks of heart and vascular disease, and acute care for a herniated disc, or acute appendicitis, or the flu. It is very hard to engineer a health care solution that recognizes that an organization as complex as a human being can be in several of these buckets at once, and that each requires a simultaneous but somewhat different approach in terms of optimizing care.
We desperately need our system to get a better grasp on how to prevent acute and chronic disease, and how to manage chronic disease better, more cheaply, and with better outcomes. But we don’t want to let go of our system’s ability to deal with episodes of acute illness — while this transformation occurs. That is the real danger with these social engineering attempts at transforming, reforming, or trying to reshape the health care system.
J. Russell Strader is chief, cardiovascular services, the Medical Center of Plano.