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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.
