Thursday, November 14, 2013

Three Health Care Systems

I was reading a blog about health policy and the failings of the ACA rollout posted on CNN (the link is:    The author spends time talking about how much we, the people who live, work, and need healthcare in America, want to change our healthcare system.  And how, since change is hard, no one should be surprised by the pains accompanying this change, particularly in terms of individuals loosing their current insurance policies due to the rollout of the ACA regulations on what health insurance policies must now cover.  

As I have thought about this, I think the issues need to be reframed.  While everyone in general seems in favor of healthcare "reform", there has been little thought given to what that means or should look like.  It is my opinion, based on discussions with patients and colleagues alike, that we really don’t want to do away with our current health care system; we want to modify it to fit current needs. 

What we really need are three simultaneous health care delivery systems. We already have the best system in the world at treating acute illness. If you have a heart attack, or are in a car wreck, or get appendicitis, there is no better place in the world than the US. But if you have diabetes, or hypertension, or had your heart attack 15 years ago, what you need is a disease management system, which is very, very different than acute care. We don’t do that well; in part, that is because disease management is actually a very young science which is not taught particularly well to physician trainees. I am a cardiologist, and spent nearly all my training in the hospital dealing with acute illness. But in my clinical practice, I spend a majority of my time in my office dealing with chronic disease management: my patients with heart failure, or high blood pressure, or known coronary disease, or who had their heart attacks weeks, months, or years ago. How often should they be seen? What is the best therapy to prevent acute exacerbations or recurrences of their disease? Is one class of medication better than another at keeping them “stable” and out of the hospital? Do routine tests help, hurt, or make no difference at all? Our system is starting to grapple with these issues, but only just starting.

We are great at acute care. We are trying to rapidly learn best practices in disease management to care for those with chronic disease who drive most of these healthcare costs. And the third pillar that we need, which we do exceedingly poorly, is disease prevention. What tools do we have, and what do we need, and what works, and what doesn’t? This has not even begun to be discussed in the medical literature, and should be.
One of the complicating factors in health care, however (versus other production oriented endeavors like systems engineering, for instance) is that individuals move rapidly between these three aspects of a healthcare system with sometimes rapid, sometimes upredictable, and sometimes urgent necessity. Many people who haven’t paid any attention to disease prevention, for instance, suddenly find themselves needing acute care – say by having a  heart attack. Then afterwards they now need chronic disease management for their coronary artery disease.  Perhaps they now have a form of heart failure too, and need disease management for that. And of course these chronic disease states will have acute exacerbations at some frequency. But that same patient may also now live long enough to develop cancer, or a neurological disease, or have a car wreck. So while they passed beyond disease prevention for cardiac care and now are in a cardiac disease management bucket, they may still be in a disease prevention bucket in another area – such as cancer prevention.  People may often be in multiple buckets at once:  disease management for their hypertension and high cholesterol, disease prevention for the risks of heart and vascular disease, and acute care for a herniated disc, or acute appendicitis, or the flu.   It is very hard to engineer a healthcare solution that recognizes that an organization as complex as a human being can be in several of these buckets at once, and that each requires a somewhat different approach in terms of optimizing care.  

We desperately need our “system” to get a better grasp on how to prevent acute and chronic disease, and how to manage chronic disease better, more cheaply, and with better outcomes. But we don’t want to let go of our system's ability to deal with episodes of acute illness – everything from broken bones to heart attacks, appendicits, and the like – while this transformation occurs. That is the real danger with these social engineering attempts at transforming, reforming, or trying to reshape the healthcare system.

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