A Health Care System or a Medical Care System? - The Future of Healthcare 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.1 Employers complain that medical insurance reduces profits, and the fact is, it reduces wages, since businesses set a limit on employees’ total compensation. 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 now beginning 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. The United States is the only industrialized country to have this problem. Of course, we need to recognize that having insurance is not the same as having access to a physician; it is only the means to pay if one can find a provider. Politicians and the media focus on the access issues predominantly, cost issues somewhat, and the issues of quality, safety, and prevention and public health only rarely.

In the past, illnesses tended to be “acute,” meaning that they occurred and were treated, and the patients either got better or died. If your child developed strep throat, the pediatrician prescribed an antibiotic, and it got better. If you developed appendicitis, then your doctor referred you to a surgeon who operated and threw away the inflamed appendix, and you were cured. 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). It might even get to the point of his needing a heart transplant. Other examples are diabetes, rheumatoid arthritis, many cancers, chronic lung disease, kidney failure, and so many other diseases seen frequently today. 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, but most of the approaches to health-care reform do not address the implications of this shift to chronic, complex, lifelong illness, perhaps because it has not been well recognized. 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. They seem busy and distracted and not able or willing to listen to our stories. 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.

Complex, chronic diseases do not go away, and when they can be cured, the possibility of a subsequent problem (heart failure) or recurrence (cancer) is real. Many chronic illnesses will be with the patient for life. They require many different practitioners with differing skills, which all need to be coordinated, to care for them. But in America today, the care for these complex, chronic illnesses, which consume more than 70 percent of all medical care expenditures, is definitely not addressed in a coordinated manner except in a few centers and practices. This lack of coordination of chronic illness care means that the care is not up to its potential quality levels, given our knowledge base and our excellent practitioners, and that the costs are much too high. The expenditures rise because patients are shuttled to too many specialists, receive unneeded tests and X-rays, and may even undergo unneeded procedures. We need to find a way to change our delivery system so that it delivers coordinated, compassionate, and safe care to individuals with these complex, chronic diseases.



Last Modified: December 13, 2011

Copyright (c) Stephen C. Schimpff, MD