January 13, 2013

A better way for medical care

Colin Read, Everybody's Business

---- — The United States provides some of the best medical care in the world.

Yet, we lag behind some other nations in the use of technology in medical records. Our system imposes upon its residents one of the world’s highest costs, as a share of gross domestic product. We have one of the highest rates of residents unable to receive medical care. And, without major innovation and reform, we will be unable to produce prosperity for our children and health for our elderly.

These seemingly contradictory facts are not surprising, once one understands how medical care is delivered in this country. The system was designed three quarters of a century ago so large companies could attract new workers but without offering higher wages. Employers provide health care by paying insurers, and insurers pay providers to care for workers. It has produced a patchwork system that discourages worker mobility just as corporations are unable to commit long term to their employees. Our system has also evolved to treat the disease rather than the customer, and ties workers with pre-existing conditions to employers rather than to a better skills match.

The good news, though, is that there are some excellent examples of innovation, especially right here in Clinton County.

The strength and weakness of health care American style is that it rewards greatness. A renowned surgeon or specialist, a highly reputable teaching hospital, or an innovative clinic attracts those who demand the best and can afford it. Excellence is rewarded, and prima-donna professors at medical-research centers encourage it. Often, the general practitioner becomes a mere middleman between patient and specialist. There is a distinctive hierarchy, with medical salaries keeping score.

Our system directs more and more of our medical-school graduates to the more scarce and rarified specialties that garner the greatest salaries to pay off their exorbitant student loans. This bias toward the best encourages excellence, but at a price.

The price is that some medical practitioners view themselves more as independent contractors than as medical team members. Their team is like the Yankees — a group of extraordinary athletes who work as a team only because it is sometimes in their shared interest.

Of course, the Yankees win more than their share of World Series. A huge payroll can buy enough talent to succeed.

There is another way. It emphasizes the team over the individual. A medical group in Alaska that primarily serves a Native Alaskan population developed an approach in which a team leader guides a series of nurses and nurse practitioners, general practitioners and specialists, therapists and administrators, all of whom focus on the needs of the patient. The entire team meets to discuss the progress of their patients, and information is fluidly shared among them.

This team approach has reduced costs significantly. Repetitive tests are avoided, better communications ensure more consistent progress, and therapies work synergistically rather than at cross-purposes. Costs are reduced while quality is enhanced, simply by shifting the focus to the patient and the team rather than a collection of individuals loosely assembled around the patient’s disease.

Doctors and nurses at CVPH, health-care providers in Clinton County and the commissioner of health in New York State, Dr. Nirav R. Shah, appreciate this more holistic approach. Our local hospital has been collaborating in teams at CVPH and with primary-care physicians in the North Country to provide the most effective patient-practitioner partnerships for each disorder, with the patient as part of the team rather than a vessel of the disease. Hospital nurses and primary-care physicians assume the significant role of coordinating care among various providers. Information is shared electronically among team members, and the most efficient procedure provider is rewarded accordingly.

Already, the Medical Home family practice/hospital collaboration is gaining national recognition for its focus on the optimal provider of each procedure. Ours may not share the advantages that the Native Alaskan Southcentral Foundation have garnered. After all, the Alaskan provider is often the only medical facility in a town or village. Such co-location of services improves communications and fosters teamwork. And, their system is large, serving almost 50,000 enrollees. The various specialists and providers all work for the foundation, so the foundation has every incentive to use its team effectively, keep its clients healthy and reduce its costs against the fixed revenues it earns for each enrollee.

The greater independence and lack of consolidation among providers in other areas of this country make more elusive some of these synergies. However, our Medical Home model is moving us in the right direction, just as is the agreement for CVPH and its parent corporation, Community Providers Inc., to work with Fletcher-Allen across the lake.

Our commissioner understands that the future of medical care is in cooperation and synergies, not in competition and independence. Dr. Shah furthers cooperation to both increase the quality of health care and stretch dollars. Examples right here show our health-care providers are willing to stretch to the very frontier of the provision of high-quality health care.

This approach makes sense. After all, progress is made not by languishing in the middle, but instead by stretching to just beyond our reach. Now, if only we can fix the rest of the system. More on that later.

Colin Read contributes to, has published eight books with MacMillan Palgrave Press and chairs the Department of Finance and Economics at SUNY Plattsburgh.