<<  <  >  >>

There is a lack

preventable injuries, heart attacks, and commu-

Introduction

nicable disease fall, more people live to reach a

of coordination

stage where multiple breakdowns occur at

of care in the

once.

Reasonable people disagree about how best

United States,

Fifty years ago, the typical patient encoun-

to finance health care. However, everyone

tered one doctor and was treated for a single

agrees that health care delivery in America is

particularly

complaint. Today, the patients who use the

highly inefficient. Patients do not see outcomes

for patients with

most services are being seen by multiple spe-

commensurate with our country's sharply ris-

multiple health

cialists and treated for multiple ailments.

ing health care expenditures. Credible estimates

Americans have been shifting their priorities

suggest that one-third of health care spending

problems.

is wasted.1 Measures show quality of care often

from other material goods to health care, as

falling short of best practices.2 Estimates of

reflected in the fact that the share of health care

medical error rates are alarmingly high.3

spending in national income has roughly dou-

bled over the past generation. Perhaps related to

Those macro-level indicators of inefficien-

that, the share of health care expenses paid for

cy are reinforced when one examines health

out of pocket has plummeted over the past 50

care delivery from a process perspective. There

years, while the share of expenses paid for by

is a lack of coordination of care, particularly

third parties has climbed to over 85 percent.8

for complex patients with chronic illnesses or

multiple health problems. Late-stage care and

All of America's health care financing

mechanisms are under stress. The cost of pro-

treatment of chronic illness together account

viding insurance is rising in Medicare and

for perhaps three-fourths of all health care

spending.4 Fee-for-service payments are widely

Medicaid, as well as in the private sector.

viewed as distorting medical treatment.5

Company-provided health insurance is becom-

Existing fee-for-service systems discourage

ing a major proportion of employee compen-

doctors from "wasting" time interviewing and

sation. Medicare and Medicaid face an increas-

ingly bleak financial future.9 This has led to

examining patients, fail to reward prevention,

increasingly frequent and often crude attempts

and encourage doctors to overutilize certain

types of equipment and procedures.6 There is

to reduce physician compensation, even as the

considerable friction between doctors and

demand for care increases.

their remote "supervisors" from Medicare,

Medicaid, and private insurance companies.

Delivery Lags Technology

The use of information technology, such as

electronic medical records, appears to fall far

short of its potential.7

Given all of these trends, it is not surprising

that the traditional model of medical delivery,

in which the doctor is trained, respected, and

The Times,

compensated as an independent craftsman, is

They Are A-Changin'

anachronistic.

When a patient has multiple ailments, this

Several trends have converged for which

traditional model breaks down. There is no

the current institutional framework for

longer a simple doctor-patient or doctor-

health care delivery is not well prepared.

patient-specialist relationship. Instead, there

Technological innovation and increases in

are multiple specialists who have an impact on

specialized knowledge have dramatically

the patient, each with a set of interdependen-

altered everyday medical practice. The challenge

cies and difficult coordination issues that

of complex patients has increased, in part as a

increase exponentially with the number of ail-

result of that progress: more conditions have

ments involved.

become treatable, thus more patients have mul-

Today, the typical patient is more like

tiple diagnoses. As death rates resulting from

Arnold's late father. Prof. Merle Kling was

2