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. Health care delivery is dysfunctional. 

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. Insurers note that it is these diseases that account for about 70-85% of claims paid.  

Our medical care system does not deal with health; it really concentrates on illnesses or trauma. It is a “sick-care” delivery system. 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 multi-disciplinary 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 to work well, 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. Unfortunately, PCPs who are mostly working in a non-sustainable business model have all too little time to give this needed care coordination; that is a topic for a later post. 

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 needs to shift from a medical care to a health care system that focuses on health and wellness and for those with chronic illnesses cares for them with a well-coordinated multi-disciplinary team. The result would be greater satisfaction for patients and providers alike, higher quality and lower costs.

 

Check out The Future of Health Care Delivery- Why It Must Change and How It Will Affect You from which this post was adapted.

 

 

 

America Has A Health Care Paradox

We have a real paradox in American healthcare. 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 industry continuously brings forth life saving and disease altering medications. The medical device industry is incredibly innovative and entrepreneurial.  The makers of diagnostic equipment such as CAT scans and hand held ultrasounds are equally productive.   

A few examples.  The science of genomics is revolutionizing medical care in profound ways such as producing targeted cancer drugs, predicting later onset of cardiac disease, offering prognostic data to guide cancer treatment, rapidly identifying a bacteria and its antibiotic susceptibility and suggesting how our diet can actually impact our genes through the science of nutragenomics.   

The pharmaceutical industry has brought us the likes of statins to reduce cholesterol, drugs to prevent blood clotting, and the targeted therapies for cancer. The device industry has created, for example, a potpourri of new approaches that have transformed cardiac care. These include angioplasty, stents, pacemakers, intracardiac defibrillators and now even the ability to insert a prosthetic aortic valve through a catheter rather than doing it via open surgery.  And we can now noninvasively image organs in incredible detail and learn about physiology with molecular imaging. 

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 dysfunctional health care delivery system where quality is inadequate, costs are too high, outcomes are subpar and no one is the customer. 

Our current delivery system focuses on acute medical problems where it is reasonably effective. But it works poorly for most chronic medical illnesses and it costs far too much. When the famous bank robber, Willie Sutton, was asked why he robbed banks he replied “that’s where the money is.” In healthcare the money is in chronic illnesses – diabetes with complications, cardiac diseases such as heart failure, cancer and neurologic diseases. These consume about 75-85% of all dollars spent on medical care. So we need to focus there.

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, etc., leading 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 manage and expensive to treat – an expense that continues for the rest of the person’s life. 

What is needed is aggressive preventive approaches and, for those with a chronic illness, a multi-disciplinary approach, one that has a committed physician coordinator. Providers (and I refer here mostly to primary care physicians), unfortunately, do not give really adequate preventive care in most cases. And they 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. 

When a patient is sent for extra tests, imaging or specialists visits the costs go up exponentially and the quality does not rise with the costs. 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 no have enough time for care coordination or more than the basics of preventive care. 

So our paradox is that we have the providers, the science, the drugs, the diagnostics and devices that we need for patient care. But we have a new type of disease – complex, chronic illness, mostly preventable, for which we have not established good methods of prevention nor do we care for them adequately once the diseases develop. And all of this is exacerbated by an insurance system that puts the incentives in the wrong places. The result is a sicker population, episodic care and expenses that are far greater than necessary.  

This paradox, the dichotomy of excellent providers and science yet a dysfunctional delivery system, is at the root of today’s cost and quality crisis in medicine. It is amazing that Americans tolerate it.