Master Class

The future of health care delivery


We have a real paradox in American health care.

We have superb medical schools and exceptionally well-trained physicians who are committed to our care. America is the envy of the world for its biomedical research prowess, funded largely by the National Institutes of Health and conducted in universities and medical schools across the country. The U.S. pharmaceutical industry continually brings forth lifesaving and disease-altering medications, and the medical device industry is incredibly innovative and entrepreneurial.

On the other hand, we have a very dysfunctional delivery system for this incredible care. We spend more per capita on health care than any other country, and yet, compared with the health of other countries, especially developed countries, our outcomes are not better. Our life spans are shorter than in Japan, for instance, and our infant mortality rates are higher than in England and France.

Courtesy Stephen C. Schimpff

Dr. Stephen C. Schimpff

Our current delivery system concentrates on illness and on trauma, and focuses on treating acute medical problems, where it is reasonably effective, but works poorly to address most chronic medical illnesses. Chronic illnesses consume about 75%-85% of all dollars spent on medical care. The Milken Institute published a white paper a few years ago on chronic illnesses in which it noted that nearly one-half of Americans had one or more, mostly preventable, chronic illnesses. According to this report, these illnesses cost the economy over $1 trillion per year.

Chronic illnesses – from diabetes and coronary artery disease to cancer, and chronic lung and kidney disease – are increasing in frequency at a rapid rate. Moreover, they are largely preventable. One-third of Americans are overweight and more than one-third are obese. Chronic stress is prevalent, and 20% of Americans still smoke. Too many people are sedentary and either overeat or primarily eat a nonnutritious diet. The result is that high blood pressure, high cholesterol, and elevated blood glucose are extremely prevalent in the United States. These and other poor health factors lead to and exacerbate a host of chronic conditions that are difficult to manage, last a lifetime (some cancers excepted), and are expensive to treat.

What we need in America today is to focus on true health care on two fronts. First, not only do we need to diagnose and treat disease and injury when they occur, but we must promote wellness and disease prevention. Second, we need a health care delivery system that truly and effectively coordinates care for patients with chronic illnesses. Both of these shifts require primary care at the helm – with paid time for careful listening and attention to detail – and a multidisciplinary approach that appropriately integrates medical specialists along with nurse practitioners, physician assistants, and other nonphysician professionals.

Refocusing American health care involves and impacts obstetrician-gynecologists as much as any other physicians, because ob.gyns. are uniquely positioned to affect women’s lives and health behaviors from adolescence to childbearing years and early motherhood, and through aging.

Drivers of change

Adverse behaviors and lifestyles and the prevalence of chronic illness in our society are exerting a great force on the health care delivery system and will, therefore, drive substantial change in the system in coming years – more so than the current health care reform. Among the other drivers of change:

Aging. American society is growing older, and just as in a car, "old parts wear out." Aging brings impaired vision, impaired hearing, impaired mobility, impaired dentition, impaired bone strength, and impaired cognition, all of which need to be managed.

Consumerism. Patients no longer want to be patient. They are coming to want and expect to be treated as valued customers by primary care providers and specialists. They want good service and expect higher levels of respect. Patients expect their physicians to listen to them and treat their conditions with confidentiality. They also want short wait times in the office, short wait times when calling for an appointment, and short travel distances.

Patients increasingly understand that care is often not as high quality and safe as it should be, and they are expecting actions to make it better. If they perceive nothing is being done, they are increasingly likely to go elsewhere. They also want interaction by e-mail and other electronic methods, and they also are pressing for and expecting a more integrative approach from their providers – an approach that cares for the whole person and incorporates complementary medical modalities where appropriate.

Professional shortages and expectations. Shortages of nurses and pharmacists have been noted for more than a decade. More and more, there are shortages of primary care physicians, general surgeons, and other physicians, including ob.gyns., especially in rural and urban poor areas. Newly graduated physicians increasingly want little or no administrative responsibility, less night and weekend call duties, a salaried position instead of a private practice, and family time assured.


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