Recently, I had the opportunity to look at the data for a self-insured employer with a younger workforce and more women than men. Heart disease and related conditions like diabetes and hypertension should be reduced in this kind of employed population compared with other employers— 30% or less. Compare that with a population with an older, male blue-collar workforce where cardiovascular and related conditions lead to 60% of all healthcare spending based on real data from the last year. You cannot know this unless you have access to the all of the detailed data as required under the Consolidated Appropriations Act.
Bill: I want to be a bit provocative here: primary care is not the answer. We have spent our whole careers promoting primary care and family medicine, and we are witnessing the death of both. It’s time to think about promoting optimal medical care for a range of chronic illnesses that most affect our public health, and to create this as a new speciality based on knowledge and science. Our greatest professional problems stem from overspecializing in areas of the body’s diseases. It is overly technologized and extractive, and serves the public poorly.
I get what you are saying. New science and new systems make it possible for clinicians with generalist training to produce fantastic results. Think of it like the army. Everyone gets the same training in the army but then the most effective elements are special operations teams organized around the needs of the mission. Nurse practitioner do 80% of this work magnificently but only if they are part of a special operations team designed for that mission.
Bill: Another excellent piece, my friend. What it will take is the question. I would like to see a major medical school, or perhaps it should be a new medical school?, devote itself and the four years of medical education to the teaching and practice of optimal medical therapy. All graduates would become experts in this field, and would be charged with establishing centers within health care systems for the practice of OMT. Call it a new “specialty” if you must. But put a major focus in this area. One of many billionaires in the US of A could fund this effort. Why not?
I love what you are thinking and you have made my day. Dr. Michael Fine has started a not for profit called Primary Care for All Americans. I just met him yesterday and it is like meeting a mental identical twin. He is working to build an advocacy organization that will provide the necessary push to get advanced primary care over the finish line. He is in Rhode Island and he is an impressive guy. Please join that organization and lend your voice.
Thank you for your common sense commentary. Lots of food for thought when trying to establish protocols for our population of patients in my office as well as throughout our ACO where cost matters!
I am sure that we can help each other. My email address is whbester@gmail.com. I see that you are regional medical director for a national ACO. Nick Heinen at Vestra Health has proven that optimal medical therapy works as a part of a comprehensive solution to improve health and reduce costs. I see that you know Nick. The members seen in Nick's worksite clinic cost half as much as those seen in the broader community in your area. They are in the hospital one fifth as often and in the ER one third as often. We can help each other.
There’s far too much medical research that focuses on the outcomes that don’t matter, because it’s cheap to focus on the near term, and using composite measures makes it look like the drug does “something”, even if that thing is nebulous or irrelevant.
As you’ve said, the outcomes that matter in diabetes are heart attacks, death, etc., NOT glycemic control. The outcomes that matter for high blood pressure are heart attacks, death, etc.
The assumption (and we know what it means when one assumes something), is that fixing the blood glucose or the blood pressure fixes the long term problem, so we end up with expensive drugs that seem to do something in the short term but may or may not achieve the desired long term goal. And then, a couple of years down the road, we start to see the problems with the new drugs, and they get pulled from the market.
Opioids would be another example. Sure, loading people up with oxycodone made them report marginally lower pain scores on a scale of 1 to 10, but the long term goal is whether or not they live productive lives free of addictions, and thats not something that got measured, so the opioids failed miserably.
Bill: I want to be a bit provocative here: primary care is not the answer. We have spent our whole careers promoting primary care and family medicine, and we are witnessing the death of both. It’s time to think about promoting optimal medical care for a range of chronic illnesses that most affect our public health, and to create this as a new speciality based on knowledge and science. Our greatest professional problems stem from overspecializing in areas of the body’s diseases. It is overly technologized and extractive, and serves the public poorly.
I get what you are saying. New science and new systems make it possible for clinicians with generalist training to produce fantastic results. Think of it like the army. Everyone gets the same training in the army but then the most effective elements are special operations teams organized around the needs of the mission. Nurse practitioner do 80% of this work magnificently but only if they are part of a special operations team designed for that mission.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628710/#:~:text=Timely%20and%20appropriate%20clinical%20decisions%20for%20people%20with%20diabetes%20are,considerably%20delayed%20or%20potentially%20prevented.
Thank you. The whole system needs a wake up call. But we also need to take ownership.
Bill: Another excellent piece, my friend. What it will take is the question. I would like to see a major medical school, or perhaps it should be a new medical school?, devote itself and the four years of medical education to the teaching and practice of optimal medical therapy. All graduates would become experts in this field, and would be charged with establishing centers within health care systems for the practice of OMT. Call it a new “specialty” if you must. But put a major focus in this area. One of many billionaires in the US of A could fund this effort. Why not?
I love what you are thinking and you have made my day. Dr. Michael Fine has started a not for profit called Primary Care for All Americans. I just met him yesterday and it is like meeting a mental identical twin. He is working to build an advocacy organization that will provide the necessary push to get advanced primary care over the finish line. He is in Rhode Island and he is an impressive guy. Please join that organization and lend your voice.
Sounds like very reasonable sound advice Dr. Bestermann.
Thanks. It is another great example. The best care is the least expensive care.
Thank you for your common sense commentary. Lots of food for thought when trying to establish protocols for our population of patients in my office as well as throughout our ACO where cost matters!
I am sure that we can help each other. My email address is whbester@gmail.com. I see that you are regional medical director for a national ACO. Nick Heinen at Vestra Health has proven that optimal medical therapy works as a part of a comprehensive solution to improve health and reduce costs. I see that you know Nick. The members seen in Nick's worksite clinic cost half as much as those seen in the broader community in your area. They are in the hospital one fifth as often and in the ER one third as often. We can help each other.
The updated case for optimal medical therapy
https://williamhbestermannjrmd.substack.com/p/the-updated-case-for-optimal-medical
The Vestra Experience
https://williamhbestermannjrmd.substack.com/p/a-great-story-in-american-healthcare
Taking the First Steps with Health Direct Partners
https://williamhbestermannjrmd.substack.com/p/taking-the-first-steps-with-health
A Patient-centered Solution to the Primary Care Crisis
https://williamhbestermannjrmd.substack.com/p/a-patient-centered-solution-to-the
There’s far too much medical research that focuses on the outcomes that don’t matter, because it’s cheap to focus on the near term, and using composite measures makes it look like the drug does “something”, even if that thing is nebulous or irrelevant.
As you’ve said, the outcomes that matter in diabetes are heart attacks, death, etc., NOT glycemic control. The outcomes that matter for high blood pressure are heart attacks, death, etc.
The assumption (and we know what it means when one assumes something), is that fixing the blood glucose or the blood pressure fixes the long term problem, so we end up with expensive drugs that seem to do something in the short term but may or may not achieve the desired long term goal. And then, a couple of years down the road, we start to see the problems with the new drugs, and they get pulled from the market.
Opioids would be another example. Sure, loading people up with oxycodone made them report marginally lower pain scores on a scale of 1 to 10, but the long term goal is whether or not they live productive lives free of addictions, and thats not something that got measured, so the opioids failed miserably.