William H. Bestermann, MD
Posted 11/30/12 on Medscape Business of Medicine
Knowing is not enough; we must apply. Willing is not enough; we must do.
-Johann Wolfgang von Goethe, From the introduction to Crossing the Quality Chasm
The landmark 2001 document from the Institute of Medicine’s (IOM), Crossing the Quality Chasm, should have guided us out of the healthcare cost-quality crisis. It argued that the root cause of our difficulties has been a failure to meet the needs of patients with chronic disease. We have not solved this crisis because we have almost entirely ignored the recommendations for reform found in that document.
The claim that we have the best healthcare in the world is correct only if you have an acute condition. If you are having an event, such as a heart attack, our system can provide an emergency stent — for as much as $50,000 — that will open the blocked artery, immediately relieving the pain and saving your life. We are really good at rescue medicine-crisis medicine.
But acute conditions generate enormous costs only because we have not addressed the chronic condition earlier, interrupting the disease progression that produces the acute events. Since most healthcare cost growth over the past 2 decades has been related to patients with 4 or more chronic conditions, this should be recognized as the foremost issue in healthcare reform.
In fact, the IOM charged that, despite the central role of chronic disease in most pain, disability, death, and cost, care continues to be designed around the needs of providers and institutions, and most patients with chronic conditions do not receive the care they need. A 17-year lag in implementing new scientific findings results in highly variable care.
That cardiologists favor coronary stenting over optimal medical therapy — that is, managing vascular disease using $4 drugs and recommended lifestyle changes — provides a powerful case in point.
Richard Bohmer, the only physician on Harvard Business School’s faculty, points to the disconnect between what we know and what we do. In his book Designing Care, Bohmer says that we often lack scientific evidence that tells us what we should do for a patient. Even worse, we don’t do what we know works.
“Interventions demonstrably without benefit continue to be delivered, and known beneficial therapies are under-prescribed, both resulting in measurable patient harm. For instance, in spite of consistent evidence that optimal medical therapy is as effective as percutaneous coronary interventions (stents) in preventing death and reducing the risk of myocardial infarction, the latter continues to be used in patients with stable coronary disease.”
The cost-quality implications of this specific failure are staggering.
The science and systems exist today to dramatically improve care and lower costs, but we choose not to make the required changes. Eleven years ago, the IOM identified 15 priority chronic conditions — many are interrelated and include several cardiometabolic diseases, such as diabetes, high cholesterol levels, hypertension, ischemic heart disease, and stroke — that urgently required system redesign. Patients who have these conditions are also likely to have kidney damage leading to dialysis, aortic abdominal aneurysm, atrial fibrillation, leg artery obstructions leading to amputation, congestive heart failure, diabetic eye damage, and neuropathy. The most common patient type with 4 or more chronic conditions has diabetes; hypertension; hyperlipidemia; and 1 or more complications, such as congestive heart failure or angina.
At the molecular biology level, these conditions are interrelated; thus, risk for acute events begins early. We know that prediabetic patients often have hypertension and high cholesterol levels. We also know that the risk for heart attack and premature sudden death begins in the prediabetic stage, when the fasting glucose level is just over 100 mg/dL. In other words, we can often identify the patient at high risk for heart attack decades before the acute event.
The mechanisms of disease are very similar for all of the conditions listed above. Unhealthy dietary habits, obesity, and cigarette smoking activate signaling pathways that govern cellular growth, proliferation, programmed cell death, and inflammation. Cell death contributes to loss of liver cells and cirrhosis, or pancreatic beta-cells and diabetes. Growth pathways may make the artery thicker and the heart larger, leading to hypertension and congestive heart failure.
The focused chronic-condition team in a primary care medical home can provide a comprehensive management solution for these patients. They can block this signaling with lifestyle and pharmaceutical interventions, using an evidence-based protocol. This approach has favorable effects on all of the priority conditions previously listed, whereas a stent addresses only a single segment of a blocked artery.
Currently, most patients of this type see a primary care doctor who sends them to a neurologist for their carotid stenosis, a cardiologist for their angina, an endocrinologist for their diabetes, a gastroenterologist for their fatty liver, and a nephrologist for their renal insufficiency. The resulting care is fragmented, expensive, and far less effective than it could be. The chronic-condition primary care team is a special operations unit that can better address all of these conditions concurrently. Specialty referral is required only for instability or threatened acute events.
Unfortunately, our system functions as if the past 25 years of evidence has never developed. Cardiologists often tell catheterized patients with stable angina with mild blockage, insufficient for a stent, that they are safe and that the problem is not serious — they behave as if it is all about the blockage, and this is a very misleading message, especially to women. A National Institutes of Health-sponsored study of women with chest pain showed an increased risk for heart attack and death, even in women with no obstruction. I often see women with recurrent chest pain who have been told that if there is no blockage, there is no problem. Even worse, they do not receive appropriate medical treatment.
Established science, not opinion or belief, must drive patient management. Why don’t we do the right things? Old scientific paradigms die hard, yes, but there is a darker truth. The wrong approaches are more lucrative.
The harsh truth is that we continue to provide inappropriate, expensive care to millions of patients with very serious consequences. Six times as many women die annually of coronary disease as die of breast cancer. Most of these deaths are preventable.
Talk about reform and patient-centeredness is hot air as long as we ignore the science and focus on benefit for professionals and institutions. Stent technology dates to the day of rotary telephones and has been proven ineffective in most situations, yet we still deliver that technology for financial gain. Most care organizations have not redesigned their programs to emphasize optimal medical therapy for vascular patients. Until we confront this and related issues we will be stuck with a high-cost, low quality, low value system.
Of course, we cannot obtain appropriate patient care without first addressing healthcare’s financial incentives and lack of transparency in cost, quality, and safety. Just as the current financial crisis was precipitated by bankers who knowingly promoted flawed, complex financial instruments to private investors who lacked the sophistication to understand them, many patients do not have the background to understand very complex care alternatives, like stenting vs optimal medical therapy. In addition, they typically are not provided with truly informed consent. In the face of ethical collapse and predatory professional practices, only strong regulation can protect the public interest and prevent catastrophes that affect every aspect of US life.
All healthcare purchasers and taxpayers have a stake in ensuring that we develop the systems to produce appropriate care. Many treatments can be provided most effectively in primary care offices with cheap generic drugs, often stopping disease progression. This approach is much less expensive and more effective, making it a terrific value.
In my own field, the guardians of the status quo have argued that optimal medical therapy does not exist — that patients won’t do it, and providers can’t deliver it. Our focused primary care chronic condition team has produced optimal medical therapy for hundreds of very sick patients in Appalachia simply by making every effort to follow the IOM’s recommendations. We find that very few patients want to be overweight and sick. Most will make good progress when they are provided with proper, consistent guidance and tools. Enlightened policy can dramatically improve health and reduce costs today.
All of these considerations point to the need for a new, more robust primary care system that can serve as the foundation for effective healthcare reform. Currently, primary care is weak and fragmented. Moving to a more effective, lower-cost system will require mobilizing and aligning all primary care interests and purchasers to overcome the entrenched resistance to the reforms so desperately needed by our patients, our purchasers, and our nation.
William Bestermann, MD is a preventive cardiologist at the Holston Medical Group in Kingsport, TN.