Rethinking Care for the Chronically Ill - Fixing The Primary Care Crisis
The diseases that a physician sees today are markedly different than the acute illnesses of years past - the vast majority are chronic illnesses such as heart failure, diabetes and chronic lung disease. These are with us for life, are complex to manage and can be expensive to treat. This is a critical transition and dramatically affects how a PCP conducts his or her practice.
An aging population, combined with adverse lifestyles related to nutrition, exercise, stress and tobacco, are driving a rapid increase in chronic diseases. 70-85 percent of insurance claims are paid to treat chronic illnesses.
In 1900, the three most common causes of death in the US were typhoid, tuberculosis and pneumonia-all infectious diseases. In 2010, the three most common causes of death in the US were cardiovascular, cancer and lung disease-all chronic illnesses, mostly lifestyle-related and all largely preventable.
Clearly there is a need for greater attention to disease prevention and health promotion. Our current system tends to leave the treatment of chronic illnesses to specialists. It may surprise you but in most cases, patients would be better off if these diseases were treated by their PCP and his or her office team.
Here is an example of the power of care coordination. Among individuals on Medicare who are admitted to the hospital, about 20 percent will have an unplanned readmission within 30 days of discharge with the percentage higher for some conditions such as heart failure. This is an outrageous number and is a clear marker of a quality lapse. What is clear is that readmissions are much less if the PCP is actively involved in the discharge. The possibility of readmission drops dramatically when the patient is seen by his or her primary care physician within a few days after discharge to review medications and review other post hospital plans and instructions.
However, the issue is larger than this. It is not just a need to deal with chronic illnesses as they occur: the bigger issue is to intervene early to prevent a person with one or more high risk factors from ever progressing to chronic illness. Conceptually that is much different from how many doctors and their offices interact with patients today.
This is the new model of healthcare as opposed to our current medical care model. It requires comprehensive primary care with a PCP who has a limited number of patients under care.