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How to sink a ship

Medical Staff Affairs Monthly, April 9, 2008

A three-panel banner of large posters loomed high over the passenger waiting area of Union Station in Washington, DC. Unfortunately, the sponsor of the posters was not identified. The message strung across the three posters went something like this:

"A few chronic diseases account for 75% of healthcare costs."

"The U.S. healthcare crisis will not be solved."

"Until this is resolved."

In recent columns, current challenges facing the U.S. healthcare system have been discussed-including a national shortage of primary care physicians and general surgeons. Given this shortage, the question becomes not only who is available to coordinate and comprehensively manage the care of patients with the chronic diseases accounting for 75% of healthcare costs, but is anyone even interested? There are a number of challenges to improving medical care for patients with chronic diseases.

First, there are too few primary care physicians. Period! It has been estimated that for a primary care physician to provide best-practice, evidence-based care to an average panel of 2,000-2,500 patients would require 17 hours per day (assuming the physicians had nothing else to do). The reasons for the decline of entrants into primary care medicine, as noted several months ago, are complex. But primarily, it's about money and time.

Second, most medical and surgical specialists are neither trained nor particularly interested in this patient care challenge. They have consciously chosen to know a lot about a little and not vice versa. They play their instruments well, but symphonic conductors they are not.

Third, the growing rise of mid-level providers, including advanced practice nurses and physician assistants, may offer some relief. However, in many cases, these individuals are turning to retail clinic settings for basic, acute protocol-driven primary care or are employed by hospitalist programs as extenders for inpatient care. This is important work, but what about ongoing maintenance in the ambulatory setting to decrease or prevent the necessity for a costly inpatient admission?

Fourth, chronic disease patients often are a resource drain and a financial loser for hospitals already strapped for margin. Hospitals strategically seek out sexy clinical service lines or services with a higher contribution margin than chronic medical diseases. Although examples of hospital-based disease management programs can be found, one has to search for them.

Fifth, payments are still misaligned toward procedures and surgeries, as opposed to chronic medical care. The promise of managed care to intervene in the long-term outcomes of a population of patients never materialized. The frequent, often annual, switch of employer-based healthcare insurance is not conducive to disease management and prevention.

Sixth, disease management programs exist in sporadic fashion, often offered by companies providing services through payers or hospitals. Despite this, there is no evidence of consistent inroads into the management of the 20% of patients accounting for 75% of costs-patients with diabetes, obesity, heart failure, smoking-related conditions, and so forth. As if to add insult to injury, in February 2008 CMS prematurely shelved a 3-year pilot disease management project, claiming that the participants failed to meet criteria for improving clinical quality, increasing beneficiary satisfaction, and achieving target savings. The five participants were care-management companies, accounting for 68,000 beneficiaries in this trial.

Using an analogy, The Greeley Company works with many medical staffs and hospitals across the country on multiple issues, including bylaws. In many instances, existing medical staff bylaws are a relic of days gone by and no longer serve a useful function to physicians or hospitals. The question is always: Do you patch up a flawed set of documents, or do you rip them up and start over? To do the latter requires vision, leadership, and fortitude.

Similarly, on a national scale, do you continue to patch up a fundamentally flawed healthcare system that is a relic of days gone by and no longer serves the majority of patients, physicians, and hospitals, or do you rip it up and start over? To do nothing would appear to be a formula to sink the whole ship. Despite the lack of attribution, the Union Station banner probably has it right that the U.S. healthcare crisis will not be solved until the problem of chronic disease is resolved.

Where are the leaders? Now more than ever, strong medical and healthcare leadership is required. The Greeley Company has long provided medical staff leadership training to help prepare the leaders of today and tomorrow. Let us know if we can be of help. Until next time, be the best that you can be.

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