To develop a sustainable model of care delivery, the industry needs a return to its roots — patient-focused care. But we can no longer practice medicine without regard to costs or clinical effectiveness. With expensive technology, pharmaceuticals and breakthrough clinical procedures, there are simply too many opportunities to incur unnecessary costs without improving clinical outcomes.
Substantial changes are necessary for patient-centered care to take root. The industry must examine evolutionary forces that took the focus off patients and consider fundamental changes that include:
- retooling existing payment models;
- providing a new sense of training doctors;
- embracing technology, when appropriate.
How Did We Get Here?
The change in care is illustrated by the location of care delivery. Physicians had a long history of treating patients in the comfort, safety and convenience of their homes. Now, patients must travel to the location of their physicians, whether it's a clinic, an ambulatory care center or a hospital. Additionally, the use of complicated diagnostic and therapeutic technologies has created the need for a centralized care delivery location, since, in most cases, these technologies are not easily — or cost effectively — distributed to nonurban areas. Traveling to receive care has become a necessity.
There also has been a seismic shift in the person who delivers that care. The rise of medical specialties has created secondary and tertiary branches of care that patients must navigate. The burden of piecing together health care has fallen into the hands of patients.
Although the return of house calls may not be practical, opportunities to improve patient convenience and care delivery abound. The use of telemedicine is just one example of how remote patients can benefit from the most advanced clinical practices. The primary challenge, however, is untangling the reimbursement policies that prevent physicians from getting paid for delivering services remotely.
Retooling Existing Payment Models
Many of the industry's financial problems are created by the fee-for-service payment model, which pays according to quantity rather than quality. This encourages physicians to perform more procedures and tests. This is not to say that all physicians are greedy. The majority are looking to increase income simply to sustain their businesses and overcome falling reimbursement. Ordering additional tests or procedures also helps the practice avoid litigation.
The fee-for-service model lacks a way to control spending, which is why health care is now a $2.3 trillion industry that represented 17.6 percent of America's gross domestic product in 2009. By 2019, health care is expected to represent 19.3 percent of the GDP, according to the Centers for Medicare & Medicaid Services.
New payment models need to focus on care quality and patient outcomes, instead of compensating for procedures. We must address the total cost of care. The accountable care organization and patient-centered medical home concepts are a step in the right direction. Adopters of these strategies, however, need to ensure that their efforts are focused on the benefit of patients, rather than merely complying with regulations to gain additional reimbursement.
Providing New Direction for Medical Students
America is facing a shortage of family physicians — the vital professionals who are on the front line of the nation's care delivery system. In fact, the American Academy of Family Physicians estimates that the United States will experience a shortage of 40,000 family physicians within the next 10 years.
After years of education and hard work, the majority of physician graduates enter the workforce shouldering substantial debt. Since the incomes of family physicians have decreased sharply along with declining reimbursement, the choice to become a specialist is substantially more attractive to new graduates. The industry's fee-for-service model and emphasis on directing patients to higher levels of care is driving new graduates away from primary care.
To reverse this trend, the fee-for-service model needs to be abolished, and medical schools need to identify and recruit individuals who are interested in serving the needs of patients, rather than merely securing large incomes upon graduation. We must return to the roots of health care.
Embracing Technology, When Appropriate
Adopting technology involves altering established cultures and abandoning traditional approaches — an often painful but beneficial effort. Consider the following editorial excerpt about the advent of the stethoscope that appeared in the London Times in 1834:
"That it will ever come into general use, notwithstanding its value, is extremely doubtful; because its beneficial application requires much time and gives a good bit of trouble both to the patient and the practitioner; because its hue and character are foreign and opposed to all our habits and associations."
Similar arguments are heard among physicians concerning the use of new technologies, whether electronic health records or video-based surgery. The lesson is that physicians must adapt to succeed in a new patient-focused health care model. Physicians also must evaluate the cost and clinical effectiveness of new technologies. Overcoming resistance to appropriately deployed technology can transform the practice of medicine.
Sowing the Seeds of Change
Implementing these changes will not come easily, but what is the alternative? The nation's current health care model is financially unsustainable, and the industry has all but abandoned its focus on the patient as it struggles to resolve numerous peripheral challenges.
Change is needed, but it may not come in the form of government mandates or financially driven incentives. Instead, change may sprout from a grassroots effort. Employers may declare that they've had enough of the status quo and start to demand more cost-effective benefit programs. Consumers may begin to pressure the health care industry to deliver the high level of service that is typical in retail environments. Physicians may begin to resist all of the extraneous demands and pressures that are placed on them so that health care once again will be about the patients.
These are seeds worth sowing, if the industry is to ever return to its roots — and return to the patient.
Andrew Watson, M.D., M.Litt., F.A.C.S., is the medical director for the Center for Connected Medicine in Pittsburgh.