Making America Healthy Again: Getting Started

Making America Healthy Again is a great idea. It is achievable. You will know that the current administration is serious about that slogan when they change our health system to address chronic diseases earlier and more effectively. The great opportunity lies in outpatient primary care. Chronic disease generate 86% of healthcare costs in this country. We could cut that number in half. Our American healthcare system costs twice as much and delivers much poorer results compared with other systems in the developed world. Is Make America Healthy Again a slogan, or is there a strategy to achieve the goal. We will soon know.

We spend 4.5 trillion dollars a year on healthcare. Despite that immense spending, twice as many American adults die of cardiovascular disease per 100,000 patients compared with other developed countries. The data in the link from the Wall Street Journal is stunning. Imagine the impact of cutting that spending in half while Making America Healthy Again. Our system is the very definition of high cost and poor results. We can Make America Healthy Again but that will take much more than slogans and wish fantasies. It will require deep structural reengineering. Fortunately, we already have a guidebook to help us get there.

The National Academy of Science was founded by congress in 1863 at the height of the Civil War to advise the government and other policymakers on scientific matters that are important to all of us. They have done an exceptional job. The National Academy of Medicine (NAM) is the medical arm of that organization. They consistently deliver advice to congress that is focused on what you need rather than what insurance companies and their Wall Street owners need. They wrote a guidebook to Make America Healthy Again in 2001. Congress and other policymakers have totally ignored their recommendations. You will know that the current administration is serious about Making America Healthy Again when they adopt the steps in this guidebook.

The National Academy of Medicine did not sugarcoat their initial assessment. You can get a great idea of what is needed just by reading the executive summary. “Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case. Crucial reports from disciplined review bodies document the scale and gravity of the problems. Problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm.

They go on to identify the fundamental problem. “For several decades, the needs of the American public have been shifting from predominantly acute, episodic care to care for chronic conditions. Chronic conditions are now the leading cause of illness, disability, and death; they affect almost half of the U.S. population and account for the majority of health care expenditures.” This problem has only gotten worse. Best practice care for chronic conditions occurs in independent outpatient primary care teams. Since the NAM report was published nearly 25 years ago, this situation has only gotten worse.

Instead of independent primary care teams focused on ongoing treatment of chronic diseases, our healthcare system is increasingly dominated by huge monopolistic hospital systems that make more money when they don’t treat the most common related chronic conditions of high blood pressure, obesity, diabetes, and chronic kidney disease more effectively to keep people healthier and out of the hospital and away from expensive tests and specialists. These huge systems own virtually all primary care in their service area to assure that when patients need acute, episodic care for their heart attacks and strokes, they get their care in their hospital system. Rather than keeping people healthy and out of the hospital, our system waits for a crisis like a heart attack or stroke to put Americans in the hospital for expensive care, tests, and specialty visits. Our government policy contributes directly to the dominance of hospital systems in our communities. You will know the administration is serious when they begin to curb the dominance of huge hospital systems.

Virtually all primary care doctors work for huge hospital systems because Medicare pays primary care doctors working in hospital-owned facilities 125% of what they pay independent primary care for the same evaluation service. Medicare pays twice as much for surgery done in a hospital facility compared to surgery done in an outpatient surgery center. This huge difference in payment makes it possible for hospitals to pay primary care doctors much more than they can earn in an independent practice out in the community. Primary care only consumes 5% of healthcare spending, but they direct 80% through their referrals. This one policy assures the dominance of huge monopolistic hospital systems.

In my work to make best practice care of chronic conditions more widely available, I have found it much easier to make progress with independent primary care groups. I have made very little progress with very large hospital systems. The most powerful progress with best practice treatment for chronic disease will be made in independent primary care groups. A system dominated by huge hospital systems is a barrier to progress. Simply changing payment so that independent clinicians are paid the same price for the same service can make a huge difference. It would reduce Medicare spending by $15 billion a year. It would reduce premiums and cost-sharing for Medicare beneficiaries by $9 billion a year. It is just that simple.

You will know that our government is serious about Making America Healthy Again if they change payment policy to at least pay independent primary care physicians the same price they would get working for the huge hospital system. They would do even better for the most common chronic diseases if they paid independent primary care doctors what they pay them now with an opportunity to make 30% more if they achieve a blood pressure of 140/90, an A1c of 8, and LDL cholesterol of 100 on a statin, while not smoking, and taking an aspirin if they have artery disease or chronic kidney disease using a protocol of best practice medications to achieve those goals in patients with diabetes. That one change would dramatically improve chronic disease management.

Huge hospital systems are very powerful. The American Hospital Association is very powerful as well. These are special interests that perpetuate the medical swamp. We will not have better health at lower cost until we confront these special interests and do what is best for us— the American people. There is much more to this story, and I will continue it in my next post. Making America Healthy Again is a worthy goal. You will know the administration is serious about it when they begin to redesign health care around the recommendations of the National Academy of Medicine. If they don’t do that, it is all hot air, slogans, and wish fantasies and we will continue to pay more for care that does not work for us.