Why Don’t We Have a Bridge Across the Medical Quality Chasm?

In the last two posts, I have described the extensive change in the US healthcare system that is required to give Americans a longer healthier life at lower cost. We currently have a system dominated by large hospital systems that focus on rescuing people who have advanced artery disease with chest pain, heart attack, congestive heart failure, stroke, or other complications late in the chronic disease process. We will have longer healthier lives when we identify people with a high risk of these late complications decades earlier in the disease process and treat the diseases that create the need to be rescued. That system will rely on advanced outpatient primary care teams to slow down or interrupt the chronic disease processes that lead to hospitalization.

We have not made those changes for a very simple reason. One fifth of the entire US economy is produced by the healthcare sector. Said another way, one dollar out of every five spent on anything in our country is spent on healthcare. That means that the leaders of our healthcare system are very influential people who command multi million-dollar dollar salaries and have lots of power. The need for change is obvious to everyone who spends ten minutes of serious thought on the subject, but change is always a threat to those who have power, influence, and big salaries in the current system whatever it is.

The best concrete example of this reality can be found in well-known facts about our own military. President Dwight D. Eisenhower was an extremely effective leader. He was the Supreme Allied Commander in Europe in WWII. He led the allied effort to defeat Germany. He became president of the United States. He led the development of the interstate highway system in the US which dramatically improved our transportation of commercial products around the country. He was one of our great leaders and he was an advocate for dramatic change in the way our army is organized after the massive combat death rate of infantry soldiers in WWI. His ideas were spot on and made a great contribution to our victory in WWII, but they represented a huge change in the way we fight and so they were a threat to those with power, influence, and money in the army of the day. His career was nearly over before it had begun.

“Eisenhower’s writings in the Infantry Journal found disfavor with the Chief of Infantry, MG Charles S. Farnsworth, who told young Eisenhower that his ideas were wrong and dangerous. Farnsworth added that if he published anything further incompatible with “solid Infantry doctrine,” he would be hauled before a court-martial. One may remember that during the same interwar era, the Army attempted to stifle BG Billy Mitchell’s revolutionary ideas on airpower. Unlike Eisenhower, however, the Army court-martialed Mitchell for insubordination and brought an end to his distinguished military career.

Eisenhower may have also made a mistake, as far as the Chief of Infantry was concerned, in advocating the replacement of the divisional machine gun battalion with a company of tanks.  The machine gun battalion was motorized, but it did not have cross-country mobility.  Eisenhower wrote how a company of fifteen fighting tanks, and about half the number of personnel and other vehicles required by the machine gun battalion, could provide more effective firepower and maneuver capability than the battalion.  Armed with extra machine guns, the tanks could carry more ammunition and support infantry attacks better, and for a longer time, than the machine gun battalion.  Young Eisenhower had a vision of the future, apparently not enthusiastically shared by the Chief of Infantry, when he stated, “The clumsy, awkward and snail-like progress of the old tanks must be forgotten, and in their place we must picture this speedy, reliable and efficient engine of destruction.”

 Eisenhower was advocating a major change in the conduct of land warfare. Prior to World War II, armies on land would attack across a broad front. Eisenhower was reacting to the unimaginable carnage of WWI, where there were 60,000 casualties in a single day when young British infantrymen walked shoulder to shoulder toward German soldiers armed with repeating rifles and machine guns in trenches protected by barbed wire. These attacks were sheer madness. Eisenhower and Patton advocated a massive change in army structure for the attack. Instead of attacking across a broad front, integrated mechanized infantry and tank divisions would focus on the weakest point in the enemy line, utterly destroy it, and pour through it to race across the countryside 30 miles in a single day. The Germans called the new tactics blitzkrieg or “lightning war.” It was a complete revolution in tactics that was sorely needed. Nevertheless, the leading general in the army opposed it because it was a threat to his influence and power.

It is the same in medicine and that is the reason we don’t have a bridge across the quality chasm. Those who have power and influence in the new system fear the changes that will come with the new system. The stakes are the same too! Because we have not made the changes needed to address chronic disease more effectively, many thousands of people die and become disabled prematurely every year. We can build a bridge across the quality chasm right now. We can have better health at lower cost now, but the current system will never get there. We need massive change. We need the medical equivalent of mechanized infantry divisions coordinated with naval and air power. Every one of us have a stake in moving to a healthcare system that is designed to address the needs we have now. Spread the word and help us move to solve this problem.