An excerpt from The Future of Health Care Delivery.
We Americans like to pride ourselves on having the best health care system in the world, but unfortunately that is not the case. We have a medical (that is, sick) care system—a system that waits until we become ill before it kicks into action—instead of a health care system focused on helping us stay healthy. We give lip service to prevention and, depending on your definition, spend only about 1–3 percent of our $2 trillion in medical expenditures on public health.
By many measures we do not rate favorably when compared to other industrialized societies. Our behavior and lifestyle make us prone to illnesses that are chronic, complex, lifelong, and life shortening, all of which make them very expensive to treat. That $2 trillion is by far more than other nations spend on a per capita basis. We spend almost $8,000 per person per year, about 50 percent more than the next closest developed country, and this expenditure is seriously and adversely affecting businesses, government, and each of us. If benefits including medical insurance are high, then wages will be correspondingly lower. It is a zero-sum game. The government cannot afford what it has promised, either: witness the current debate in Congress regarding the costs of Medicare. And each of us complains bitterly that the cost of care is too high—and that we cannot do anything about it.
Meanwhile, we may be pleased with our doctor but not with the health care delivery system as a whole. Quality is subpar, preventable errors are rampant, and some 47 million Americans are without insurance or access to medical care.
My grandfather was a general practitioner in New York State. He graduated from medical school in 1898. In his day a physician had relatively few tools with which to treat someone; the important part was to make a diagnosis and inform the patient and the family what the situation was and what the course of that illness would probably be like. Yes, he could provide some care, including treating pain with morphine, removing an inflamed appendix, sewing up lacerations, and delivering babies much more safely than could have been done without the assistance of a trained clinician. But during the course of his practice medicine began to change toward a much more scientific basis. To a large degree it was propelled by the influence of Johns Hopkins University School of Medicine and Hospital in Baltimore, Maryland. Founded in the late 1800s, it instituted the concept that medicine was and should be a science and taught a science-based medical program during four years of medical school plus practical training, establishing what we know today as the standard residency training program following medical school. This approach brought about a dramatic change in the way physicians thought about medicine and patient care.
In the course of my grandfather’s practice he saw the beginnings of those changes. Insulin was discovered in the 1920s, the first antibiotics in the 1930s. After World War II, the National Institutes of Health (NIH) began to develop, grow, and distribute large sums of money across the country to various medical schools and within its own organization to conduct basic biomedical research. The result is that today our ability to repair, restore to function, or replace an organ, tissue, or cell has moved ahead at a dramatic pace and will do so even more quickly in the coming years. Concurrently, the pharmaceutical industry became scientific as well, resulting in a continual outpouring of new drugs that can relieve suffering, reverse harm, and cure many diseases while extending our life span. With the advent of the science of genomics, it is increasingly possible to predict the onset of disease before it occurs and thereby create a preventive approach for the individual patient. All of this advancement occurred because of the shift to science-based medicine that was introduced only a hundred years ago.
Another change has happened. This change is very important but it has not been appreciated. In the past, illnesses tended to be “acute,” meaning that they occurred and were treated, and the patients either got better or died. But today, most illnesses are chronic and complex. If a man survives a heart attack, he may still have some damaged heart muscle and so develops heart failure. This condition will be with him for life and will need multiple treatments, many medications, and probably a number of hospitalizations with a stay in the intensive care unit (ICU). This major shift enormously impacts how we should (but mostly do not) organize the treatment of the patient and his or her disease, how we should (but mostly do not) organize the payment system for that care, how we should (but mostly do not) use technologies wisely for care, and how we should (but mostly do not) ensure quality and safety in patient care. This change is profound. Although they are aware of the change toward more and more chronic illnesses, physicians, too, tend to want to preserve their current practice methods, which were developed over the years to handle the simpler acute illnesses, even though the current chronic and complex illnesses require a different approach.
In that same time frame of scientific advancement and the rising frequency of chronic illnesses, we also began to lose in medicine the true connection between the physician and the patient. Most of us patients feel as if we do not get to spend enough time with our physicians. From the physician’s perspective, he or she feels that there is not enough time to spend with an individual patient, not enough time to learn about the family and the environment in which that patient lives and therefore in which the patient’s disease has occurred, and not enough time to focus on preventive instructions or to even talk fully about the plan for caring for a specific illness or problem. Instead, too much time is spent following mandates and filling out forms, often repeatedly; and then they are being paid well less than what their time and effort were worth.
Stephen C. Schimpff, MD is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and consults for the US Army, medical startups and Fortune 500 companies. He is the author of The Future of Medicine – Megatrends in Healthcare and The Future of Health Care Delivery, published by Potomac Books.
