Amid the battles over a Patients' Bill of Rights, Medicare reform, and
coverage for the uninsured, few have stepped back to take in the dramatic
changes in health care in recent decades. Scientific advances in screening
and diagnostic tools, pharmaceuticals, and surgical procedures have dramatically
pushed up our ability to detect and treat disease at its earliest stages.
But like childhood vaccinations in poor countries, the best medical advances
are useless without an effective way to deliver them and pay for them.
That's why a little-noticed revolution in America -- call it the New Health
Care -- is forcing us to rethink and reform our delivery and insurance
systems.
Consider your heart. If you had suffered from coronary artery disease
in the 1960s, your chances were 50-50 that your first diagnosed symptom
would also have been your last -- a fatal heart attack. At that time, the
cures for heart disease followed the engineering logic that characterized
the industrial age. When hearts failed, doctors tried to bypass diseased
arteries or replace entire hearts. Medical specialists flourished, and
among specialists, heart surgeons were the Brahmins. For Americans alive
at the time, images of the first heart transplant, performed by South
African surgeon Dr. Christiaan Barnard in 1967, are etched in their memories
as deeply as those of Neil Armstrong's walk on the moon in 1969.
Then, as now, coronary artery disease was the nation's No. 1 killer.
Today, heart surgery is still done in hospitals by highly trained specialists
and still costs a lot of money. Health insurance is still designed to
cover catastrophic illness -- to make sure that when "lightning strikes"
you or your loved one in the form of a heart attack or other serious illness,
it doesn't strike your pocketbook with equal force.
But the truth is that today nearly everything else has changed. Most
people now know whether they have heart disease long before they have
a heart attack, and they need New Health Care tools to effectively manage
their condition.
The New Health Care focuses on predicting likely problems, preventing
disease and related calamities, and "care management." It focuses
on screening, support for healthy behavior change, minimally invasive
interventions, and continuous care for chronic health conditions like
heart failure. New Health Care involves helping patients learn from the
Internet and self-help books, through the proliferation of support groups
and peer-to-peer health communications, or even via the barrage of New
Health Care advertising. Thus educated, they can take charge of their
own health.The old health care assumed that "Doctor knows best."
The New Health Care is based on partnership, not paternalism. If the old
care reflected industrial era thinking, in which medical authority was
concentrated in specialists and flowed downward, the New Health Care envisions
information flowing through networked teams of professionals and health
care consumers. The old health care focused on diseased parts; the new
favors coordinated and continuous care of the whole person.
Because we live longer, healthier lives than we did 40 years ago, our
greatest health care needs are no longer for last-minute acute interventions
in hospitals -- when "lightning strikes" -- but for chronic conditions,
like diabetes, heart disease, asthma, Alzheimer's, and arthritis, which
collectively afflict 125 million Americans. Tragically, our methods of
delivering care and our methods of paying for care have not kept up with
our scientific advances or the explosion of chronic care needs. In the
next wave of reform, we need, and are just beginning to see, a twin revolution
in health care delivery and insurance to match the new needs and innovations.
Thanks to laboratory research and epidemiological studies, for instance,
we now better understand the role of risk factors in coronary artery disease.
Consequently, we know that our best defenses against heart disease are
to exercise, lose weight, avoid smoking and, when necessary, take cholesterol-lowering
drugs. Inexpensive medications like aspirin and beta-blocker drugs also
significantly reduce the likelihood of dying from heart attacks. Diagnostics
and therapeutics have radically improved and become simpler, less invasive.
Expensive hospitalizations and surgeries no longer represent the pinnacle
of medical care but the failure of less risky options.
Still, congestive heart failure accounts for over 1.5 million hospital
admissions per year. Why? Because, even though we know better ways to
treat patients, our health care system is not designed to deliver high
quality care on a consistent and ongoing basis, and our insurance system
doesn't reward it. A recent study of elderly heart attack victims showed
that only one in five of the eligible patients was receiving the appropriate
medications. This underuse of well-established medical knowledge is matched
by a parallel overuse of other treatments. Dr. Donald Berwick, who heads
one of the leading national organizations to improve health care quality,
cites RAND and other researchers who estimate that 30 percent of acute
care procedures, including many standard surgeries, are inappropriate.
Government agencies or health insurance companies paid for nearly every
one of those unnecessary procedures.
Alternatives exist and are expanding. A good example of the New Health
Care is a care management system called Health Buddy. Chronic care patients
plug a small, counter-top device into a telephone line that lets them
record their health condition daily. This information is automatically
sent over the Internet to a nurse or care manager who can recommend fast
action based on early warning signs. Patients use Health Buddy consistently
because it is easy to use, and they get comfort from having someone else
monitor their health. In one study of patients with congestive heart failure,
Health Buddy's simple, team-based system reduced hospital stays and trips
to the emergency room by 69 percent and reduced costs by more than $8,000
per patient per year.
We know from numerous studies that this partnership approach to chronic
care is both the best practice and more efficient, but few of our provider
systems are set up to deliver it and few insurers pay for it. Medicare
and most health insurance providers still treat a doctor visit or hospitalization
as the basic unit of transaction. Those twin and intertwined problems,
in delivery and payment, account for most of the wasted lives and dollars
in the health care system.
Health maintenance organizations were originally designed to establish
a comprehensive approach to health promotion and integrated care of chronic
illness. Instead, HMOs all too often took the low road -- emphasizing cost-cutting
instead of managing care. The Patients' Bill of Rights arose as a legislative
corrective for HMOs' heavy-handed tactics and as a way for doctors to
regain some of the authority they have lost.
But no legislation can turn back the clock on the real source of upheaval
in health care. The explosion of new knowledge on illnesses, diagnostic
methods, and treatments is causing vast underlying changes in what is
possible and what Americans expect. The new realities of 21st-century
health care rule out a return to the old-fashioned "Doctor knows
best" approach and demand a fundamental change in the nature of health
insurance.
Health insurance should evolve from a one-size-fits-all model focused
on acute care to one that allows patients to choose providers, services,
and products customized for their health care needs. Care management networks
will provide a set list of best-practice providers and treatment protocols
as a way to help patients better manage chronic illnesses and reduce their
out-of-pocket expenses. Health plans can't afford to just pay for all
the health services we want -- premiums would go through the roof. But
they can help us find the best health providers and care management programs
to help us stay as healthy as possible, and reward continuous improvements
in quality.
The promise of New Health Care is longer, healthier lives. The challenge
to enlightened political leaders is to empower health consumers and push
insurers and medical professionals toward true partnerships with their
patients.
Blueprint Keywords: Extra Chronic Care
