A recent poll as of mid-May 2020, found that health care is the number one concern of voters in the United States and for good reason. Americans pay twice as much for shorter lives and higher infant mortality compared with people who live in other developed countries. In other words, we are paying more for healthcare that does not meet our needs. Consider this:
- 50% more American babies die on their first day of life than in all other industrialized countries combined. Further, 21,467 infants die in the US each year.
- White Americans have infant mortality that is worse than Cubans. And twice as many black babies die.
- Life expectancy in the U.S has not kept pace with other wealthy nations. In fact, life expectancy decreased every year between 2014 and 2017.
Black voters should be even more concerned. Blacks die and become disabled at a younger age than other Americans. The reasons for voter concern are clear. That is the other end of the George Floyd story.
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Cost of care
We spend almost 20% of GDP on healthcare. Other developed countries spend roughly 10%, and Singapore spends just under 5%. Citizens of Singapore live longer for less money.
High cost for inferior results is the definition of low value. The high cost of American healthcare is wrecking budgets at every level—governments, employers, and families. A half-million Americans file bankruptcy annually due—at least in part—to medical expenses. Healthcare spending diverts money away from infrastructure, education, research, and other vital investments in the United States.
It does not have to be this way. While examples of high-value care—better health at lower cost—are rare in the United States, there is one outstanding example to examine. Eighty-six percent of American healthcare costs are related to chronic disease.
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Southcentral Foundation – an example of high-value care
The Southcentral Foundation is a large healthcare organization that provides care for Native Americans across a huge area of rural Alaska. It’s important to note that Native Americans have a higher chronic disease burden compared to other populations. Roughly twice as many are diabetic.
Despite that, Southcentral provides excellent care for half of the amount of money spent on other patients in that state. How do they do that? Let’s examine some of their key differentiators:
- The patients own the Southcentral health system
- They are respected as customer-owners
- And, they help determine clinic priorities and activities
- Native culture, particularly storytelling, is an integral part of the care delivery
Further, the clinic standard is very high:
“Perfect care delivery in a perfect way for every Alaska native person every time”. (introduction in Swedish)
Patients are guaranteed an appointment within 24 hours via any modality they chose:
- video call
- in person
Only 15% of the quality reform visits are in the clinic. The other 85% take place remotely.
When Southcentral started redesigning their system, their quality scores were in the lowest 25%. Now, they are among the best in the country. Infant mortality is down 58%. Deaths from heart attacks and strokes have been cut in half.
Patient satisfaction is 97%. Many Native Americans—including the CEO—are employees. Employee satisfaction is 95%. Staff turnover is half the industry standard.
Success is based on a trusted long-term relationship
Their success is built upon the idea that an “effective, trusting long-term relationship” is the most important factor leading to the desired outcomes:
- controlling cost
- managing chronic disease
- improving the overall health of the people.
It takes time and people to build that relationship and trust. Their primary care teams are resource-intensive. Each team includes the following:
- a primary care doctor
- a case manager,
- a case manager assistant, and
- a medical assistant.
The six teams in each clinic have one manager, front desk, and a call center. Each clinic also has key ancillary staff:
- a pharmacist
- mental health counselor
- social worker
Their structure is a higher cost primary care operation but the result is lower overall spending. The Southcentral Foundation is a great system.
Singapore looks for best practices around the world
Singapore is a country that looks for best practices around the world. This has allowed them to take healthcare improvement to the next level.
Research, innovation, and strategy are keys to the way they do business. And, their approach to healthcare is no different.
Health leaders from Singapore visited Alaska to see firsthand what the Southcentral people were doing. They took away some important lessons. They bought into the need for relationship and trust as keys to successful chronic disease management.
However, they did not apply these high-resource clinics to everyone. Half the population is healthy and generates almost no cost. Remember, chronic disease is where the money is. Singapore applied its high-resource clinics to patients with chronic disease. They have one of the longest lifespans in the world for 5% of GDP – half of what Southcentral spends.
More refinement can reduce costs even further
Our discussion to this point has described innovation in the system of care. There is one more refinement that can reduce costs even further.
There are equally serious deficiencies in the clinical care of chronic diseases. New science and integrated protocols can add to the excellent gains in Alaska and Singapore.
It is well documented that there is a 17-year gap between the latest scientific knowledge and its broad application in clinical practice. The most important of these deficiencies is around optimal medical therapy for chronic disease.
Our healthcare system still behaves as if opening blockages in stable patients with heart artery disease will save them from dying or having a heart attack. You’ve probably heard someone you know say something like:
“Thank God they found that blockage, I could have dropped dead any minute.”
It is a deeply held belief reinforced by the actions of the healthcare system. Patients with stable coronary artery disease are routinely treated with stents and coronary artery bypass (CABG) instead of intensive medical management.
Stents vs. optimal medical therapy
Yet we have known since 1995 that heart attacks usually don’t occur in arteries with enough blockage to merit a stent. In fact, stents add nothing to best-practice medical treatment (optimal medical therapy) in stable patients. It is optimal medical therapy (OMT) that keeps you from dying or having a heart attack.
Even so, as I have said, patients with heart artery problems still get their stents, but they don’t get optimal medical therapy. That is especially tragic because cardiologists who made major contributions to this new science proposed “making optimal medical therapy” a new universal standard of care” 5 years ago.
Heart attack victims who get OMT are 90% less likely to die and their care costs $21,900 less when compared with others in the same facility who get the usual care most patients receive. The benefits are equally impressive in high-risk type 2 diabetes, and by extension to other cardiovascular and related diseases.
Next Generation Primary Care
There is every reason to move to the next generation of primary care. Change is afoot in the United States, and medicine should join the party.
Think of the benefits if we freed up 15% of GDP. If we just cover everyone in the current system, we will increase the debt and perpetuate a broken system. If we make the needed changes, we can cover everyone for less money.
The legal term is “knew or should have known.” American leaders know about the Southcentral Foundation in Alaska. The clinic has received the Malcolm Baldridge award twice.
Further, Don Berwick, former CMS administrator and long time advocate for improved healthcare quality, identified that organization as the best example of healthcare reorganization in the country. Surely, he would love to see their work replicated over the country. So, why hasn’t it happened?
As always, it is about power and money. One of every five dollars spent in the United States goes to healthcare. If we dropped that to just over a dollar, that would impact many in healthcare very badly but it would be great for everyone else. That is the challenge.
The way out of the healthcare crisis is clear. Will we take it? Will you insist on it?
William H. Bestermann, Jr., MD
William H. Bestermann Jr., MD is a board-certified internist who has practiced preventive cardiology for more than 20 years. His core expertise is consistently producing optimal medical therapy (OMT) for cardiovascular and related conditions. He does this by using evidence-based care processes consistent with best practices.
He looks at OMT as a product. He understands how health care organizations can combine new systems, new science, and new payment models to produce that product much more consistently. That combination can be standardized, scaled, and industrialized. These new systems combine teams, protocols, population health tools, clinical/financial analytics, and provider training. Certain clinical interventions reduce clinical events more than they impact the target risk factor.
Dr. Bestermann has developed integrated protocols that combine those interventions which maximize impact on weight reduction, minimize drug interactions, and reduce side effects. When these systematic interventions are combined, they dramatically reduce the cost of care, prolong life, and delay cardiovascular events.
Dr. Bestermann wrote the first article on a systematic, integrated approach to the metabolic syndrome. He collaborated later with multiple academics and community leaders in a more detailed article on metabolic syndrome science and treatment. He proposed a new mechanism of action for metformin explaining its impact on cardiovascular, events, cancer, and aging.
He supervised an advanced medical home team within Holston Medical Group for cardiometabolic conditions that contained an ambulatory care residency for PharmDs. The team managed high-risk diabetic and hypertensive employees of Eastman Chemical Company.
He is also a senior clinical advisor for the Quality Blue Primary Care initiative at BCBS of Louisiana. That effort reduced hospital admissions, length of stay, and specialty referrals while lowering per member per month costs. He has personal experience producing OMT in multiple medical settings.
He has become convinced that only evidence, data, and transparency can deliver us from the low-value healthcare that prevails across the United States. There are many vendors making claims regarding their clinical and financial success. Most of those claims are not valid. Almost no one is consistently applying optimal medical therapy to patients with cardiovascular and related conditions in a way that prolongs life, delays cardiovascular events and reduces costs. Dr. Bestermann submitted his approach to the Validation Institute and received their stamp of approval.
In addition to being a contributing author for The Doctor Weighs In, Dr. Besterman also serves on the TDWI Editorial Board, where he medically reviews articles submitted for publication.