Last month I laid out four issues that should be addressed to help recreate our system of care before we launch any of the current proposals for health care reform. The essay got a lot of response and many people contacted me asking for specific actions to take in the four areas. To review my main points from last month, our health care system is about 40 percent more costly than any other in the world, has enormous problems with patient safety and quality and leaves most people, patients and providers alike, befuddled as to how it works and disenchanted with the experience of working in it or consuming its service. So, how is paying for the 40 million uninsured to get the same expensive, poor service going to make things better, unless the plan is to drive what we have into economic meltdown faster? My questions were around the capacity of the system, growing burden of chronic disease, practice organization and models and the growing misalignment of the larger system of institutions.
The impulse to build more hospitals, train more physicians, create new pharmaceutical products to expand the capacity of the system is understandable, but does it really make sense to build more of everything we currently have if we know that there are big problems with the way the system works today? Shouldn’t we at least be asking what needs go unmet today and where new capacity should be added or, a far more challenging question, what types of new capacity need to be added? For instance, in many specific locations the nation is experiencing a raging epidemic of pediatric dental disease. In the face of this reality, does it make sense to prepare more young men and women with the skills to serve the bungalow-based smile clinics that serve the suburbs? Instead, shouldn’t we align the training with the needs of community clinics to organize and deliver a broad range of preventative and therapeutic services to the population that is experiencing the epidemic?
The same question could be asked about medicine; does the need for medical or surgical sub-specialists outstrip the need for general physicians to meet the needs of an aging population? But the new medical schools and residency programs that are likely to grow in the coming decades will expand the model that we currently have, providing more practitioners to serve the system as it is. And is propping up that system the best investment we can make? We need a better way to look at the needs of consumers as they are, not at the desires of the providers to continue as they have been. Such change will not take place at the national or federal level; the will, the perspectives, as well as the policy levers to make change simply do not exist there. The type of change I’m suggesting will need to be a state or regional activity in which data about a population’s current and projected health needs are discussed publicly to determine where investments would be best made. The outcomes of this discussion will need to be integrated into policy and action by the lay leadership on the boards of health departments, hospitals, and health plans and by the general political leadership. It cannot be left to the incumbents within the health care institutions to make these changes.
The examples I have used for increasing the capacity of the system are in large part ways we could expand it to serve those not currently in the system. We need more creative ideas to produce outcomes that make a difference, rather than continuing to add the same old inputs and expect a different result. But there is one pressing problem that cuts across insured and uninsured populations alike: the orientation toward treating acute disease in the face of a mounting burden of chronic disease. The bias toward treatment is understandable given where we have been, but hospital admissions, clinic visits and other similar interventions to address chronic disease waste precious resources. The treatment bias depletes the investment in prevention which leads, of course, to earlier onset of acute dimensions of diseases and cheats individuals out of years of good health. Today we try to pipe prevention through our expensive and ineffective treatment system, which is not sustainable. Later, when treatment is needed we carry it out in the most expensive and now dangerous place possible, the hospital. We need new mechanisms of taking the marvelous professional skills and competencies of America’s health professionals into new venues. The information and care management technologies that are emerging will allow treatment to migrate to the community and home and, in the process, develop new roles for families and individuals in the care process. This progression of care should be embraced, not thought of as second class.
Responding to those who are underserved and those who have chronic disease will require new practice organizations and models. We need practice models that are radically redesigned with a critical eye focused on three criteria. First, what is the desired outcome? It should be clearly stated, shared by all involved in the delivery of the service, incorporate the patient and be the benchmark against which all progress data are collected and shared. Second, the model must reach the desired outcome in the most effective and least expensive way possible. Finally, these models need to be aggressively responsive to the needs of patients.
The fourth suggestion I made last month was to align the institutions that are a part of the larger health care context. Until legal restrictions are removed and public and private payers recognize the necessity of this, the nation will spend too much on care and have a poor return on its investment. At the policy level leadership is needed to create incentives to align and integrate. Health professions education should include examples and demonstrations of how professionals and organizations should work together. In professional organizations, strategic redirection needs to take advantage of this opportunity for realignment, not continuously recreate the ways of the past. Regions can bring real political and economic leadership by insisting that their health care organizations come together around a common purpose. Without these changes, health care will continue to grow ever more burdensome.
How the health care workforce is selected, educated, trained, regulated for practice, organized for service and compensated are perhaps the most important dimensions of reconfiguring health care in the U.S. Just building more of the same and hoping for the best will not help the nation transform our health care system in order to provide care for all in a way that makes sense.