As a primary care physician who’s worked in the trenches for 31 years, I’d like to offer some advice to Jeff Bezos, Warren Buffett and Jamie Dimon as they prepare to tackle the health care system.
If you want to improve health, increase access and lower the cost of health care, you need to emphasize primary care at all levels of the system: individual patients, patient populations, insurance companies, pharmaceutical companies, and hospital systems.
To put this into perspective, consider the cost of American health care compared to outcomes.
In 2015, the United States spent almost three times the amount on health care as countries with comparable incomes. This data was reported by the Organization for Economic Corporation and Development (OECD), a group of 35 countries with advanced economies that works to promote economic development. According to the Commonwealth Fund, a private foundation that conducts independent health care research, compared to other countries with advanced economies, Americans pay more for health care, but have worse outcomes; they see physicians less often, are hospitalized less often, and have the lowest life expectancy.
Constructing a new health care paradigm requires addressing many different stakeholders: patients at different stages of life who have different health care priorities, including the most vulnerable — the uninsured, minorities, the elderly. At this point, our system is structured so that young and healthy people don’t feel that health care is a priority in their lives. But good health requires a lifetime of effort.
So how do we change? Practically speaking, this means de-emphasizing the visit-based model, fee-for-service incentives, and developing flexible spending opportunities for primary care providers.
- Healthy children, adolescents, and young adults need wellness care; vaccinations; education about substance abuse and safe behaviors, and help in developing good habits and a positive self-image.
- Middle-aged adults need annual wellness physicals; evidence-based testing; and management of highly prevalent conditions, such as diabetes, coronary heart disease, and high blood pressure. They also need education about healthy behaviors and medication management to reduce disease complications, improve quality of life and reduce costs.
- Senior citizens are living longer, healthier lives, but longevity comes at a high price. Twenty percent of the chronically ill consume 80 percent of health care dollars, much in the last six months of life. We must make certain that all adults complete a living will while they are still able to clearly state their wishes. Senior citizens must also receive support from outreach services that place “boots on the ground” to help them avoid social isolation. We must address both financial and physical barriers to good health by supporting telemedicine, and making it easier to pay for medical equipment and retrofitting homes that are unsafe.
These goals —at every stage of life— are easily identifiable and readily achievable; their implementation will dramatically bend the cost curve, and help achieve the triple aims of improved patient care, better access, and lower overall per capita costs. But in order to encourage compliance, we must offer patients incentives to pursue the goal of good health at home, in school, and in the workplace.
Employers need to understand the role they play in the health of their employees. Beyond the trend to offer financial incentives for documented biometric screening and wellness encounters with the healthcare system, employers must work to promote and maintain healthy environments. The workplace is a “home” as much or more than where we live with our families. Our work “habitat” should include innovative options such as walking/standing desks, ergonomically supported work environments, and lifestyle and nutritional education.
The healthcare system is currently undergoing tremendous consolidation. Many of the current changes are designed to maximize return on investment, but in many cases they are not delivering better value. We are seeing the costly deployment of technology and extensive advertising for “centers of excellence,” but the cost of these services are cloaked by a complete lack of price transparency.
Technology will play an essential role in scaling up necessary change, but the central driver of change is the physician/patient relationship. Pharmaceutical costs are growing at an alarming rate and further erode patient trust. Procedure-driven health care services need to be assessed for the value they bring to the patient and not to the system.
Here is my prescription for change:
- An emphasis on primary care with front-loaded financing to allow for flexible non-visit based but rather value-based care delivery. We should consider doubling the percentage of health care dollars devoted to primary care, which currently hovers at 5 percent. These additional dollars should be spent on essential services that have demonstrated value, such as patient education, in-home remediation, and transportation vouchers.
- Population-targeted care priorities that address age and gender specific health care needs in the right place at the right times
- Holding health systems and pharmaceutical treatments to the highest standard of value- driven evidence-based services and patient outcomes.
Mr. Buffett, Mr. Bezos and Mr. Dimon: Best of luck on your mission to build a better healthcare system for your employees, dependents and retirees. We are all watching with great interest.
Andrew Selinger MD is Chairman of the Department of Family Medicine at the Frank H. Netter MD School of Medicine at Quinnipiac University.