Primary care, specialty care: what about health?

Three “Perspectives” in the September 6 issue of the New England Journal of Medicine address different, but clearly related, aspects of the transformation of health care. I have previously discussed one of them, “Becoming a physician: the developing vision of primary care" by Barnes, and Comfort in Social determinants key to the future of Primary Care (September 22, 2012). The two others are "What business are we in? The emergence of health as the business of health care"^[1], by Asch and Volpp from the Wharton School of the University of Pennsylvania, and "From Sick Care to health care -- re-engineering prevention into the US health system" by Marvasti and Stafford.^[2] Taken as a whole, the three provide some significant insight to the current US healthcare delivery system, the changes that need to be made in it, and the way we will get there.

Asch and Volpp discuss the need to shift from "what can we produce" (health care) to "what do people want" (health). They use the parallels of the failure of major industries (railroads in the last century; Eastman Kodak in this) to make this distinction. Each of those industries made the mistake of confusing what they produced with what people wanted when they bought their products. Thus, railroad companies provided railroads, when customers wanted transportation of goods and people; when alternatives (trucking, air) became available they were unable to adjust (although in Europe they did a pretty good job). Similarly, Kodak made film when what people wanted was to store images of their lives. Asch and Volpp do not mention that the ad agencies got this right (“we create memories”) but the corporation did not move into the digital age early enough and, last year, went into Chapter 11 bankruptcy.

The “health care” industry provides, at best, health care, but more often just medical care, and most especially disease care. People seek it out because it is what available; what they want is health, to not be sick, in pain, disabled. This is of course why “mainstream” medicine is not the only source of treatment people seek. It explains the allure, and extensive use, of products of the “alternative care” industry, which ranges from degreed practitioners like chiropractors and naturopaths to long-used herbal and other cultural treatments dispensed by various methods (botánicas and the Internet), to Eastern medicine such as acupuncture, to religious rituals including American Indian healing, Catholic exorcisms, and the rituals of Santeria, Candomblé, and Voodoo derived from Africa, to straightforward quackery. “Integrative medicine” is an effort by traditional western medicine to employ many of these techniques and traditions. While we probably would actually prefer the diagnostic and treatment magic of Star Trek’s doctors, we’d certainly like the magic pill, elixir, injection, herb, or prayer that would heal all our ills – preferably with no real or sustained effort on our parts, and without side effects. Interestingly, while “alternative” medicine is seen as more “holistic”, it is in fact often more biologically reductionistic, using interventions (e.g., enemas, diet changes, supplements) to cure social and psychological problems (see my 2005 piece “Towards a definition of holism” in the British Journal of General Practice).^[3]

Perhaps this is all “quackery”, or just some of it is and others are not. In mainstream American medicine, something doesn’t become a real disease until there is a test for it – or better yet a drug for it – thus the medicalization of many things that people have experienced as part of the mortal coil for thousands of years. Some things that were accepted as “part of life” (and death) are now diagnosable and treatable; others might be in the future. But those of us in the “health care” industry need to understand that folks will only buy what we are selling if it is, on the whole, the most effective way for them to get what they want: health.

Marvasti and Stafford discuss the need to change from a system designed to treat acute conditions and acute exacerbations of chronic diseases to one in which, in Fries' model, of "morbidity compression", "in which the disease-free life span is extended through the prevention of disease complications and the symptom burden is compressed into a limited period preceding death." This dovetails well with what I have discussed above; people want to be healthy. They recognize that they are going to die, but they want to do this quickly, painlessly, and at the end of a long and healthy life. As a loved one of mine who is closer to this than many puts it, “someday I just won’t wake up”. Morbidity compression. If he is lucky, if we are all lucky, that will be how it happens.

But right now, our health care system is in fact designed to treat acute conditions and acute exacerbations of chronic disease, not to maintain the care and the health of people who have not yet developed chronic disease or are stable. More to the point, our system does this because this is what is paid for; we are just scratching the surface of the ideas of “chronic disease management”. In fact, we pay so well for acute interventions that hospitals are hiring acute “interventionalists” at extraordinary salaries compared to their colleagues in the same specialties that actually manage people over time. For example, “stroke neurologists”, or sometimes interventional neuroradiologists, who can inject clot-busters into the arteries of people with acute strokes make perhaps 2-3 times what a neurologist who just manages chronic neurologic diseases does (not that much more than regular radiologists, who are overall much higher paid); this is because the hospitals that employ them are so highly reimbursed for these procedures.

The need to manage actual people, especially when they have chronic disease, not just an acute episode, is obvious to most of us. It may even be obvious to the insurance companies and other payers, to the hospitals who support the acute interventionalists, but so far they haven’t changed what it is that they pay for, what it is that is financially incented. I write a lot about primary care, but it is not only primary care. Commenting on my last piece, Social determinants key to the future of Primary Care, a neurologist colleague who cares for people with Amyotrophic Lateral Sclerosis (ALS), Lou Gehrig’s Disease, a terrible and always fatal degenerative condition that satisfies almost none of the criteria for “morbidity compression”, wrote:

But the group health care model is also the best for chronic rare diseases managed by subspecialists....this is what we do in ALS clinic on Monday mornings. You should come visit, Josh, at 8 when all the folks (speech therapy, physical therapy, occupational therapy, social workers, dieticians, equipment providers, respiratory therapy) meet with the neuromuscular neurologists to discuss each case. Then we see them and all weigh in and we give patient a printout with advice from each. But, alas, there is no way to pay for this without support from local and national foundations....Medicare doesn't cover it by far.

I wrote back:

Of course. In this sense, you are sharing the same issues as primary care doctors -- you are managing patients, not just a single episode of disease. Certainly ALS is a disease, but it is a chronic one that takes over people's -- and their family's -- lives, and requires not only complex and interdisciplinary, but long-term, management. Indeed, the concept of the medical home was developed in the 1960s by the specialty pediatricians managing kids with chronic diseases such as cystic fibrosis, juvenile diabetes, and sickle cell, which share with ALS the fact that there is one disease that dominates the lives of the patient and their family; to care for it requires managing not just the disease but working with the whole person and their family. It can also (but is not always in practice) be true of HIV clinics.

This is less true of many other adult diseases, which often co-exist --diabetes, hypertension, congestive heart failure, chronic lung disease, depression, arthritis -- so that one specialist is not interested in (or perhaps capable of) managing them all -- thus primary care for adults, geriatricians, etc.

It is virtually not at all true of those who do radiology, anesthesiology, single-time consults, or one-shot surgery, or one-shot-into-the-cerebral artery neuro-interventionalists. Or, to be short, any of the folks making a lot of money for single things, while the stuff that you do in ALS clinic is not paid for.

This is insane. We do not have a health system, and we do not even have a health care system. We have a medical care system, with the emphasis on the medical. It is fine to pay for an episode of care, but it is much more important to reward care.

---

[1] Asch DA, Volpp KG, “What Business Are We In? The Emergence of Health as the Business of Health Care”, NEJM 367(10);887-89. DOI: 10.1056/NEJMp1206862

[2] Marvasti FF, Stafford RS, “From Sick Care to health care -- re-engineering prevention into the US health system", NEJM, 367(10);889-91. DOI: 10.1056/NEJMp1206230

[3] Freeman J, “Towards a definition of holism”, Br J Gen Pract. 2005 Feb;55(511):154-5. PMC1463203