“Hospitals today are typically responsible for the largest portion of spending in health care, but we expect that within 10 years, care will move from the hospital into the community and the home.” This link to an article in the New England Journal describing the American health system we should have in 2030. We have to do some heavy lifting to get there.
Several of my recent posts have pointed to an American healthcare system that does not serve us well. My only purpose in pointing to the deficiencies is to ultimately point to a much better, much less expensive healthcare system.
We can easily begin the move now. Our healthcare approach is dominated by very large hospital-based healthcare systems. It has not worked, and it will not improve our health or lower our cost. We need to move forcefully now to a much more outpatient focused approach that keeps us healthier and out of the hospital. Our new independent outpatient systems should emphasize advanced primary care practices.
1. We must move to independent outpatient systems that identify people at high risk for chronic disease or patients who already have chronic disease and intervene strongly to preserve their health and keep them out of the emergency room and hospital. We still have a health system that is focused on the very late acute complications of chronic illness. Independent outpatient advanced primary care practices using best practice care processes can keep us healthier and reduce the late complications of chronic illness and the need for ER visits and hospitalizations.
2. Our current approach is dominated by very large hospital systems. We thought very large health systems would bring economies of scale, but that did not work out. We must begin to move away from this model as quickly as we can. It is another one of those medical ideas that made perfect sense, but it did not work. These systems will never give us better health at lower cost. In this country, financial incentives determine what happens and the financial incentives for big hospital systems and everyone else are not aligned. This misalignment is profound. Very large hospital systems make more money when more patients are admitted (heads in beds.) They make almost nothing from keeping you healthy and out of the hospital. They make more money from specialty visits and the related very expensive tests and procedures. They make very little from providing optimal medical therapy to keep you from having a heart attack or stroke. They make more money from ignoring optimal medical therapy and allowing you to develop acute catastrophes like heart attack and stroke. That is horrible for you and those who pay your bills. It does work for them. That is the biggest barrier to a new system that provides better health at lower cost.
I have treated the highest-risk, highest cost patients with chronic cardiometabolic disease for my entire career. Optimal medical therapy (OMT) for patients with diabetes reduces heart attacks four-fold and strokes five-fold compared with the current system (usual care). Advanced primary teams using systems and protocols deliver this care most effectively. Nurse practitioners and pharmacists can do 80-90% of the work. Eighty-five percent of the work can be done remotely. Our system pays for your care of chronic disease like diabetes and high blood pressure when you take off from work, drive to one of the palatial buildings in the big health system and wait for an hour to be seen. A big part of the cost goes to build and maintain those palatial buildings. Blood pressure measurements are more accurate at home. Glucose levels can be measured at home. The need to take off work, travel to the facility, get a baby sitter, and pay for these palatial facilities are huge barriers to care that makes us healthier longer. Imagine how great it would be if we could treat you at home or at work and remove those barriers that make care difficult for you. Big hospital system that dominate our approach are a barrier to progress.
3. We have ignored the new science that makes primary care services the most effective services. Our current system is organized around organ systems and specialists that focus on those organ systems. That model dates to the day of the rotary telephone 70 years ago. For example, cardiologists are specialists who treat the heart and neurologists are specialists who treat the brain. So, if you have a heart attack, you see a cardiologist. If you have a stroke, you see a neurologist. That arrangement made sense seventy years ago when we just understood that a heart attack kills heart muscle, and a stroke kills brain cells. Now we know that the same changes in gene regulation, related increased oxidant production, and molecular biology cause all chronic disease including the “risk factors” for heart attack and stroke. These include diabetes, high blood pressure, high cholesterol, and heart attack and stroke themselves. It is all related. When the advanced outpatient primary care team uses lisinopril or losartan and spironolactone or eplerenone to treat hypertension, they are not just lowering your blood pressure, they are blocking precisely the increased oxidant production and molecular biology that causes high blood pressure, diabetes, heart attack, stroke, chronic kidney disease, and heart failure. Statins for cholesterol and metformin for diabetes do the same thing. The new science makes it possible to keep the entire body healthier—every cell and every organ. Our entire health system is an anachronism—a throwback to an earlier understanding of the function of the human body. Implementing this new science in independent advanced primary care teams can help give us longer lives at lower cost.
4. We have devalued primary care. Most other countries have healthcare systems that are still based in outpatient primary care. We place much more value on specialty care, hospital care, and complicated, expensive, dramatic procedures. As I explained in point 3, new scientific discoveries mean that, more than ever, primary care is the most valuable care. We understand the gene regulation and related oxidant excess well enough now that we can improve the health of every cell and organ in the body. We can finally address human health as it really is—a whole body integrated system rather than organ by organ. That is primary care. Primary care is care that addresses the whole body and every organ system together. The ability to prolong a healthy life exists now. The ability to treat arterial disease much more effectively to prevent heart attack, stroke, chronic kidney disease, and amputation exists now. We will always need specialists for people who don’t get the message or won’t understand it. We will always need hospitals for the same reason, but the path to a longer healthier life at lower cost for most of us lies in independent outpatient primary care teams. It is past time to roll up our sleeves and begin. We will never have better health at lower cost in this current system.
These issues are clear cut and the current system is not serving us well. The first duty of any clinician is to be an advocate for their patients. That includes pushing for an overall system that is patient-centered and meets their needs. The current system prevails because of politics and policy. By policy, hospital systems can charge much more for the same services compared with an independent physician group. That extra money gives them much more power to hire doctors and other clinicians. That is the reason that independent physician groups are becoming rarer by the day. For example, a nerve block done in a doctors office costs $256 and $701 in a hospital outpatient department. Hospital facility fees are another big issue. One patient saw a rheumatologist for a $30 steroid injection. The hospital tacked on a $1,262 facility fee. A $350 facility fee was added for a video visit in addition to the usual visit charge. The justification for these higher charges is the need to build and maintain these palatial facilities. As I pointed out above, most treatments for chronic disease can be provided remotely. Paying the same price for the same service would make it much easier for us to move to better health at lower cost.
Please join us in pushing for that changes urgently. It will make all of our lives better.
Thank you! Along with the measures listed in the post we need to emphasize prevention. The abysmal response of the US to the COVID-19 pandemic is a perfect example of what happens when politicians and ignoramuses are not vigorously challenged by scientific truth. In particular there needs to be a vigorous campaign to ensure maximum use of vaccination together with education to counter superstition and disinformation and mandates to ensure compliance.
We also need thoughtful reform of our public health system, top down starting with the CDC. (Did you know that as late as 2021 -the last time I looked- they had no internal organization dealing with airborne transmitted infections?). Local public health authorities need more visibility and authority. For entertaining insights into this, read Michael Lewis' The Premonition.
Thank-you for your thoughtful article and enlightened ideas. Whether it be in a hospital, assisted living or home (often better), we need to restore TRUST. As long as that road remains closed, we're stuck. The silence regarding "Covid Vaccine Deaths" must end!
https://open.substack.com/pub/dee746/p/nicu-trends-continue?r=1g1b1r&utm_campaign=post&utm_medium=web