The Doctor’s Customer Is The Insurer - Shouldn't It Be The Patient?

You the patient are really not the customer of your primary care physician. Since the insurer will determine whether and how much the physician will be paid for attending to your needs, you are largely a bystander in the relationship. The doctor’s customer has become the insurer.  

Our system of care is definitely not customer-focused. Doctors truly believe that they have the patient’s best interests in mind and they do. But their work is not customer focused as it is in most other professional-client relationships. You wait long weeks and sometimes even months for an appointment (the national average is 20.5 days), spend long times in the waiting room and are frustrated that you get just 10-12 minutes with your doctor who interrupts you within less than a minute and who recommends you see a specialist but does not personally call the specialist to explain the issue nor to smooth the path for a speedy appointment. All of this because, in the case of primary care, the doctor must see 24-25 patients per day to meet overhead and achieve a personal income of about $170,000. 

As for the insurers, you are not their customer either. Their customers are the ones who pay them - your employer or your government.  And it shows – by our long waits on the phone, by the complex, often hard to understand paperwork and by the frustration when the insurance you thought you had does not cover your latest tests, x-rays or specialist visit. 

So you are not the insurer’s customer nor are you the doctor’s customer. You are a mere bystander. This is hardly the type of contractual relationship you have with your lawyer, architect or accountant. In those situations, you pay them directly. Want more time? No problem, but you pay for it. Want telephone consultation? No problem, but you pay for it. Not so in medicine. You the patient cannot decide and ask for more time or ask to use of email or telephone. Because you are not paying for the time and your insurance will not do so either. It is just not your choice. 

To be clear. Yes, you are paying the physician directly in the co-pays and the deductibles but it is still the insurer that determines whether and how much the physician gets paid. You just get to contribute whatever portion you are told.  

Who is to blame for the current state of affairs? Each party looks to the other but perhaps each should hold up a mirror and take a close look. Nevertheless, here is what physicians think based on a recent survey. Ninety per cent say the medical system is on the wrong track; 83% are thinking about quitting; 85% think the patient-physician relationship is deteriorating; 72% do not think the individual mandate will lead to improved care; and 70% think that the single best fix would be reducing government intrusion. Further, 49% will no long accept Medicaid patients and 74% plan to stop accepting new Medicare patients. Finally, 80% believe doctors and other medical professionals are the most likely to help solve the mess.  

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 of health care is truly dysfunctional. What is needed is fewer patients per PCP so that each gets the time and attention really needed. The PCP needs time to listen, to prevent, to coordinate chronic care and time to just think. This means increasing not decreasing the cost of primary care per person. An increase in costs, yes, but an increase that will dramatically lower the total cost of care. More effective preventive care. More attention to the complex chronic illness with fewer referrals to specialists.  Better coordination of the care of those with chronic illnesses, enhanced prevention such that many chronic illnesses don’t develop. Spending  the time to listen and become trusted as the healers that they could and should be -- all leading to better care at much lower total cost.  

A new vision for our system must make it a healthcare not just a medical care system. It must recognize the importance of intensive preventive care to maintain wellness. It must address the needs of those with chronic illnesses to both improve the quality of care while dramatically reducing the costs of care. And it must be redesigned so that the patient is the customer that he or she should be. And, critically, to make it work effectively, America needs many more primary care physicians – they are and should be the backbone of the healthcare system – who are able to offer outstanding preventive care, care for the vast majority of complex chronic illnesses, offer coordination for those with chronic illnesses and do it in a manner that is satisfying to doctor and patient alike – with true healing along with expert medical care. It’s doable but it means a rethinking of how our delivery system is structured and assuring that PCPs have fewer patients for more time each.  

It is possible but it will require both doctor and patient alike to demand it. There are many ways to skin the cat but the most promising is direct primary care (membership/retainer/concierge) practices. More on this later.

 

My next post in this series on the crisis in primary care will be about today’s impediments to good primary care.

The Paradox In American Healthcare

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, The pharmaceutical, biotechnology and diagnostic equipment industries continuously bring forth lifesaving and disease altering medications, devices and diagnostics. 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 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.  

Primary care physicians can deal with most of the issues of these patients – if they have the time to do so. But referrals to specialists is often necessary. Primary care physicians generally do not have 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.  

In healthcare 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 on primary care. 

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.

 

A Vision For Health Care In America

In researching  The Future of Health Care Delivery – Why It Must Change and How It Will Affect You, I had in depth interviews with over 150 leaders from across the country including hospital CEOs and COOs, practicing community and academic physicians in both primary care and specialty areas, pharmacists, nurses, insurance executives, health care consultants and many others. But I found what I think is a very good vision and resulting model right at home in Howard County, Maryland.

County Executive Ken Ulman and former health officer Peter Beilenson, MD, MPH created “Healthy Howard” to assist those without insurance.  Their concept was to provide primary care access for all, an extensive network of specialists, community and tertiary care hospitals and a basic electronic medical record. Methods were built in to maintain costs as low as possible. But part of the basic premise was that with these “rights” for the patients came certain “responsibilities” – some limited payment participation and some requirements toward practicing healthy living as well as compliance with treatment recommendations. It structured a good balance between patient rights and responsibilities, between care delivery and a working payment system, between access and effective care.

Howard County, between Baltimore and Washington, is a fairly affluent county with excellent providers and a highly regarded community hospital. Despite affluence, there are uninsured individuals and families. Some could afford insurance but choose to spend their dollars elsewhere. Some are the young invincibles who don’t feel they need it. Others work in the service industry where their employer does not provide insurance and they cannot afford to carry the entire burden. And some are simply indigent.  The question was how to provide for this disparate group in an effective yet equitable manner that would render good quality care at a moderate cost.

Healthy Howard is a county-assisted, community based not for profit organization which collects a modest fee, on a sliding income scale, from its members. In return, each individual gets unlimited access to a primary care physician (PCP). The office employs a care coordinator who works with the PCPs to assist those patients who have complex chronic illnesses such as chronic lung disease, cancer, or diabetes with complications. There is also a pharmacy benefits manager located in the PCP office to assist patients find drugs at the most reasonable price in the community. They work with the physicians to find generics, discuss other effective agents with the doctor or even contact the manufacturer if appropriate to get a reduced price for an indigent patient.

Of course some patients will need to see a specialist physician. Healthy Howard has developed an agreement with the county’s specialists to accept, gratis, these patients with the understanding that the program will allocate the patients across all the specialists in a given field (e.g., cardiology or orthopedics) so that no one physician has an excessive burden.  Howard County General Hospital, being part of a unique system in the state of Maryland, has always accepted indigent patients but under the agreement with Healthy Howard, the hospital forgoes any attempt to collect from these patients.  Further, since the hospital is part of the Johns Hopkins Health System, an agreement was reached with Hopkins to accept any patient that needs tertiary care at no charge.

These might be termed the “rights” of the patients. But there is also some participation required in order to be part of Healthy Howard; these are the corresponding “responsibilities. In addition to the modest sliding scale fee, each patient is assigned a health coach with whom he or she must meet on a regular basis. The coach works with the patient to develop a plan for healthy living. This might include attending a smoking cessation program, attending a gym for exercise or working on a diet plan. Together patient and coach develop a plan of action with benchmarks at various intervals. The patient meets with the coach periodically to compare actual results to the benchmarks.

The coach is there not just to measure results but to assist and to help break down barriers. Sometimes just some encouragement is all that is needed; sometimes referral to a specialist such as a nutritionist is helpful; and sometimes a more involved approach is required. As Mr. Ulman described to me, imagine an overweight lady who wants to participate in a fitness program at the local health club – to which Healthy Howard has worked out a special free arrangement. But she says cannot attend because her daughter is a single working Mom and so she, the grandmother, must babysit the child. No problem, the coach finds a fitness center that also has built in day care, breaking down the barrier that had to date prevented success.  The idea is that the plan will help overcome barriers yet still expect responsibility to meet objectives.

Healthy Howard, as its name implies, will mean healthier participants a few years down the road. The primary care physicians, with help from the coaches, will give attention to prevention thus lessening the burden of chronic illness in the future. And they will give careful care coordination for those with chronic illnesses now- thus lessening the current cost burden by reducing the need for specialist visits, excess tests and imaging and unnecessary drugs

And it worked. Now a few years in, there has been a 35% reduction in ER visits and a 50% decline in hospital admissions. Enrollees are healthier and more behaviorally motivated to maintain good health. Sufficient success to substantiate the awarding of a federal contract to utilize these principles  to create a state-wide consumer operated health insurance plan (a CO-OP) for the ACA Maryland insurance exchange based on the principles of 1) having the vast majority of care provided by primary care, 2) using bundled or capitated provider compensation and 3) using evidence-based medicine.

Healthy Howard, as its name implies, means healthier participants. Its great value is as a vision of health care delivery that incorporates improved quality, reduced costs and excellent access in return for a modest fee and a commitment to living a reasonably healthy lifestyle. Rights and responsibilities working together. It is a good vision to use as a starting point.

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.

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 of these adverse behaviors is high blood pressure, high cholesterol, elevated blood glucose followed by 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. Nor do they have the time to listen carefully or think deeply about a problem; so the response is to send the patient for a test or to a specialist.

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 disease develops. 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. 

Transformational and Disruptive Changes Are Coming to the Delivery System

More chronic illnesses, more diseases of old age, consumers demanding more quality and safety, physicians no longer in typical private practice, and high deductible health care polices are each about to cause major changes in the practice of medicine and how it is delivered to patients. Will this come about smoothly or, more likely, with some serious hand wringing? 

Health care delivery will change substantially in the coming years. This is not because of reform but rather due to a set of drivers that are exerting a great push and pull to the delivery system. Some of these changes will be quite transformational and some will be very disruptive of the status quo. What are these drivers?

 

One of the most important is that there will be many more individuals with chronic illness. The Milliken Institute offered a white paper a few years ago on chronic illnesses and noted that nearly one half of Americans had one or more chronic illnesses, most of them preventable and  which were costing the economy over $1 trillion per year and rapidly rising.  

These are diseases like diabetes with complications, heart failure, cancer, or chronic lung disease. What is apparent is that they are mostly due to adverse lifestyles. Eating a non-nutritious diet -- and too much of it combined with a sedentary existence leads to obesity. One third of Americans are overweight and another one third are frankly obese. Add to this chronic stress and that 20% still smoke and there is an effective recipe to produce chronic illnesses. Chronic illnesses will make up a greater and greater proportion of all medical ailments as time goes on. And of course they are more difficult to manage, generally last a lifetime and are inherently expensive to treat (although there is much that can be done to reduce the costs of care.) 

A second driver of change is the aging of the population. The American society is growing older and just like a car:  “Old parts wear out.” Aging brings on visual and hearing impairments, mobility difficulties and diseases like osteoarthritis, Alzheimer’s and other chronic illnesses that, as best we know today, are not due to adverse lifestyles but are tied into the aging process. 

Another driver is the increasing demand for medical services. Perhaps this is saying the same thing another way. More aging and adverse lifestyles create more disease and the need for care. 

Consumerism is becoming – finally – more and more of a driver of change. Patients are coming to want and expect to be treated like a valued customer. Like the movie where he shouted “I can’t take it any more,” now “the patient is no longer willing to be patient any more.” What do the patients want? They want service, good service. They increasingly understand that quality and safety are not ideal so they are looking for and expecting high levels of quality & safety. Perhaps the most important one of all is respect, respect for their person, confidentially, and the quality of their care. But also patients want convenience & responsiveness. They don’t want to have to travel long distances, wait long times in the “waiting room,” nor be put on indefinite telephone hold. They want interaction by email and other electronic methods.   And finally, patients increasingly expect to have a closing of the information gap – they expect the playing field between patient and doctor to be much more level in the future. 

Professional shortages are also definite drivers of change in the delivery system. There have been shortages of nurse and pharmacists noted for more than a decade. More and more there is a shortage of primary care physicians (PCPs) and also general surgeons. These shortages are more acute in rural areas and urban poor areas.

Combined with shortages are changes in professional aspirations and lifestyles. More and more physicians want and expect to have more time for family and recreation. And they no longer want to run their own private practices. They prefer to be employed with little if any administrative burdens. Indeed the number of PCPs in a typical private practice arrangement has declined precipitously in recent years. And since so many patients coming to the ER today are uninsured, many physicians are no longer willing to take call unless on a contract with the hospital. Most physicians are willing to accept that some patients will be of limited means but they are not wiling to be overwhelmed with non paying patients.  

And among many other drivers of change is that patients will have greater requirements toward a direct share of costs. Today we have mostly “prepaid” health care, meaning that our insurance covers most everything, minus a low deductible or co-pay, from routine exams and well baby care all the way to a heart transplant. Among employer sponsored plans, there is an increasing push toward high deductible plans, with deductibles in the $1000-2000 range. Even some Medigap plans have high deductibles corresponding with much lower premiums.  

These are but a few of the drivers that will change the delivery of health care in dramatic ways in the years ahead. I discuss them in much more detail in The Future of Health Care Delivery – Why It Must Change and How It Will Affect You with data obtained through over 150 in-depth interviews of medical leaders from across the country. It is fair to expect that physicians, patients, hospitals, insurers and employer/government sponsors will be challenged to adapt.

My next post will examine what these drivers of change will actually cause to happen to the delivery system.

 

 

Use It or Lose It: The Price of Inactivity

Do you need a good incentive to exercise? Check out this set of pictures. They may well surprise you.

We all know we should exercise. It feels good during and we feel even better after. We know it burns calories and that our bodies were meant to be used. But all too many of us are sedentary; it just the result of modern life. One result, combined with eating too much, is that one third are overweight and one third are frankly obese. And many of us believe that as we age we will just naturally loose muscle mass and strength. It turns out that is just not correct. We can indeed preserve muscle mass and strength.
A really well trained athlete has little fat in or around his or her muscles. But a person that does not exercise sees his muscles wither and fat take up the space. That is the obvious conclusion from the images shown below.
More and more Americans are living into what used to be called “old age.” With older age often comes various illnesses, many of them chronic such as diabetes, heart failure or cancer. But these chronic illnesses are often preventable with a good diet and moderate exercise. So to is the “sarcopenia” or muscle loss that comes with aging in a sedentary person.

Wroblewski and colleagues at the University of Pittsburgh evaluated persistent exercise over the years. Their study was reported in The Physician and Sports Medicine journal, September, 2011 and sent to me by Frank Jannotta of Harbor Physical Therapy.

Five men and 5 women were recruited in each 10-year age category (40–49 years, 50–59 years, 60–69 years, and ≥ 70 years). Each was an avid exerciser. They were evaluated for their health history, exercise patterns, body composition using the “Bod Pod” and MRI scans of the thighs. The researchers found that despite the age differences, these individuals did not have a significantly different amount of intramuscular adipose tissue; their body fat, BMI, fat mass and muscle mass were all similar. Clearly, continued exercising into the 70’s maintained muscle mass in these individuals.
Here are three images taken by MRI scanning, i.e., a cross sectional picture. They are of the upper leg to show the quadriceps muscle, the large muscle on the front of the thigh that allows us to lift our leg and bend our knee when we walk or run.

The first image is of a 40 year old triathlete. The second is of a 74 year old sedentary person. And the third is of a 70 year old triathlete. The differences are obvious. Use it or lose it. Muscle to flab.

This proves that being older need not mean having no muscle tone. The difference between the two triathletes and the sedentary 74 year old are striking. It is clear that even an older person who exercises can maintain good muscle tone. And although this is of a triathlete, just good regular activity that combines both aerobic and weight bearing exercise will maintain those muscles up to the very last breath. And it means better health, long life, and much less chance that a fall will lead to a broken bone.

Use it or lose it. Here is the proof.

The Implications of Chronic Disease

I have written frequently about the importance of chronic illnesses. Most of us are just not aware that their incidence is rising - and rapidly. We tend to think instead about acute illnesses and injury but chronic illnesses are now not only common but last a lifetime once developed and are inherently expensive to treat. On top of that there are enormous losses in quality of life, personal productivity and economic impact on the individual and society.


The Milken Institute quantified some of these issues in a research report a few years ago. They evaluated cancer, diabetes [presumably type 2], hypertension, stroke, heart disease, pulmonary conditions and mental disorders. Here are some of the key findings:

• “More than 109 million Americans report having at least one of the seven diseases, for a total of 162 million cases.

• The total impact of these diseases on the economy is $1.3 trillion annually.

• Of this amount, lost productivity totals $1.1 trillion per year, while another $277 billion is spent annually on treatment.

• On our current path, in 2023 we project a 42 percent increase in cases of the seven chronic diseases.

• $4.2 trillion in treatment costs and lost economic output.

• Under a more optimistic scenario, assuming modest improvements in preventing and treating disease, we find that in 2023 we could avoid 40 million cases of chronic disease.

• We could reduce the economic impact of disease by 27 percent, or $1.1 trillion annually; we could increase the nation's GDP by $905 billion linked to productivity gains; we could also decrease treatment costs by $218 billion per year.

• Lower obesity rates alone could produce productivity gains of $254 billion and avoid $60 billion in treatment expenditures per year.”

To me the important point is that “each has been linked to behavioral and/or environmental risk factors that broad-based prevention programs could address.” Restated, we as individuals need to take responsibility for our own health. Not every illness is preventable, but a very large percentage are. It is up to us to eat a nutritious diet in moderation, exercise our bodies, seek ways to reduce chronic stress and avoid tobacco. These four steps would make a huge difference in our health and our lives.

Meanwhile, we each need to have a primary care physician and that physician needs to accept the responsibility to assist us with our prevention strategies and to coordinate our care should we develop a chronic illness. This will mean better health and much lower costs.

Misconception - Primary care physicians do not deal with the expensive aspects of medical care so they can have little impact on reducing medical expenditures.

Two major reasons for cost escalation are lack of good care coordination of those with complex chronic illnesses and inadequate attention to prevention and screening. PCPs are key to both of these but they have too little time per patient and are not paid for either activity.

About 5% of all healthcare expenditures go to PCPs but they can have a major impact on the other 95%, especially with good care coordination of chronic illness and with a focus on prevention. To fix this, PCPs need to be incented [paid] to deliver care coordination for the chronically ill and good preventive care to all of their patients. This could have a very high return on investment and a huge impact on total costs. It is a logical place to begin to address the high costs of medical care in America.

Complex, Chronic Illnesses That Last A Lifetime

Our medical care system has developed around diagnosing and treating acute illnesses such as pneumonia, a gall bladder attack or appendicitis. The internist gave an antibiotic for the pneumonia and the patient got better. The surgeon cut out the gall bladder or the appendix and the patient was cured. But as the population ages, more and more individuals are developing what I will call complex, chronic diseases like heart failure, diabetes, chronic lung disease or cancer. These are diseases that remain with the individual for life and these diseases and patients need a different approach to care. These patients need long term care, not episodic care; they need a team-based approach where one physician serves as the orchestrater or quarterback and manages the myriad physician specialists and the other caregivers to allow for a unified, coordinated care management approach. And these diseases are very expensive to treat today; 70% of our medical care expenditures go to treat 10% of us, those with these chronic illnesses of health care costs in America. As I will describe in detail later, it will take a new approach to organizing the care of these patients to both improve care and reduce the costs. But the new approach actually exists in some locations – the need is to understand what works and then replicate it nationally.