Sklar, David P. MD
When we think of health care delivery, what image comes to mind? I think of stories like “The Use of Force” by William Carlos Williams,1 in which he struggles to visualize the throat of a child with suspected diphtheria.
I forced a heavy silver spoon back of her teeth and down her throat till she gagged. And there it was … both tonsils covered with membrane. She had fought valiantly to keep me from knowing her secret. She had been hiding that sore throat for three days at least and lying to her parents in order to escape just such an outcome as this.
In this model of health care delivery there was heroism and courage, good and evil, ignorance and truth, vulnerability and power, all wrapped together in the relationship between one physician and one patient. This was an epic struggle, and I could understand it.
But that was the age of antibiotics, when it seemed that almost any illness could be vanquished with powerful antimicrobials. Now we are in a different age, the age of chronic diseases, in which patients accumulate lists of diagnoses as they age until they are weighed down like a Sherpa collecting firewood as he walks up a narrow mountain trail. Instead of diphtheria, our patients battle diabetes, heart disease, cancer, mental illness, substance abuse, end-stage kidney, end-stage liver, end-stage lung, end-stage dementia, or combinations of all of them. A doctor trained to wrestle with a demon like diphtheria can never find traction against such foes. We need a new metaphor for this age and a new health care delivery model. Perhaps farming or gardening, with their emphasis on planning, surveillance, use of teams, and management of the land, might be better. As for the delivery system, below, I describe five promising models: multiple-illness chronic care teams, disease management, use of nonphysician providers for some nonurgent care, regionalization of systems, and organized systems of end-of-life care.
For those patients with multiple chronic diseases, there must be a system that will identify those most in need of management by a team with various types and levels of expertise. A team is typically made up of nurses, social workers, doctors with expertise in multiple chronic disease management, and pharmacists to help with medication combinations. Some have described this as a patient-centered medical home, and there have been examples of successful implementation of such models. CareMore,2 a subsidiary of WellPoint, has pioneered this type of model with some success, demonstrating reductions in spending as patients with chronic diseases are assessed and placed in a treatment level that can meet their health care needs.
The management of psychiatric illness that often coexists with other chronic illness has been shown to be an important element of successful care plans for patients with multiple chronic diseases or one predominant chronic condition.3 Coordination of mental health treatments with medical management can have positive outcomes in both areas. Unfortunately, we have not traditionally focused much of our medical education curriculum on the role of teams and their various members in care delivery. In this month’s issue of Academic Medicine, Dow et al4 describe how concepts from organizational science can help in the formation and function of health care teams. They discuss important competencies for leaders and followers in teams. These are competencies that we can teach our students that will foster the success of collaborative practice in new care delivery systems. Teams not only work well for patients with multiple chronic illnesses. They also appear to be effective for management of patients with one chronic illness.
For patients with congestive heart failure, specialists in heart failure disease management have developed effective programs through use of multidisciplinary teams. In an analysis of published studies on disease management in congestive heart failure,5 those patients cared for by multidisciplinary teams that used in-person communications had fewer readmissions than did patients with routine care. Sometimes, distance from the source of the expertise may make disease management by teams inaccessible for certain rural populations. However, telemedicine has extended the excellent results of the team disease management model into rural areas by linking experts to rural providers in a standardized way.6 When one disease predominates, such as cancer, the oncologist might become the medical home for the patient and oversee all care needs, with the assistance of other specialists such as psychiatrists to address compliance with medication, psychiatric side effects of medications, or other coexisting mental illness.3
For healthy people, who make up the majority of the population, information systems and new technologies can provide assistance with monitoring basic health status, identifying preventive health needs, and answering other specific health concerns. Acute care access for nonurgent care can be offered in a variety of ambulatory settings by nurse practitioners and physician assistants in addition to primary care physicians. The use of nonphysician providers and Internet information has been identified as a potentially disruptive innovation that could alter both the landscape of minor nonurgent care and also of wellness and preventive care.7,8 Disruptive innovations are typically less expensive than the products or processes they replace, and initially may be of slightly lower quality, but they gradually improve and enlarge their markets until they squeeze out competitors that previously offered more comprehensive benefits but were more expensive.
In the area of acute care, regionalization and networks may yield the best outcomes for time-sensitive conditions.9 These are conditions, such as septic shock, life-threatening trauma, or myocardial infarction, in which the promptness of effective treatment can influence the ultimate outcome. The best example of this is the evolution of organized regionalized trauma systems, which have been shown to reduce mortality from trauma.10 The concept is to bring the right patient to the right place for the best outcome of care through the development of referral networks that take advantage of the relationship between increased volumes of care and better outcomes for the care.11
In addition to trauma care, numerous other conditions have demonstrated relationships between higher volumes of care and better outcomes in such areas as complex surgical procedures (for pancreatic cancer, esophageal cancer, pediatric cardiac) and medical problems like AIDS.11 Networks of local community hospitals and regional centers can develop referral and return protocols so that patients can receive needed complex treatments with the best outcomes and return to their home communities when stabilized for continuing treatment or rehabilitation. There are significant economic and training implications for regionalized care systems that will require further analysis as they evolve.
Finally, end-of-life care, which includes an assessment of options and the provision of palliative care, home care, and hospice care, can reduce suffering and provide patients the ability to die with dignity in accord with their wishes. The delivery of such care can be provided by specially trained nurses, palliative care physicians, and family and community volunteers.12 Approximately 27% of all Medicare spending occurs during the last year of life,13 and many people spend their final days in an intensive care unit receiving futile and painful treatments. Changing the venue of end-of-life care from the hospital to the home with palliative care could provide the twin benefits of better quality of care and lower costs.12
These five new delivery system models—multiple-illness chronic care teams, disease management, use of nonphysician providers for some nonurgent care, regionalization of systems, and organized systems of end-of-life care—are just some of the changes that are currently being considered for our health care system. All of them share the common themes of better coordination and efficiency of a currently fragmented, wasteful health care delivery system. All of them will require a reorientation of our education and payment systems. By envisioning the needed changes in the care delivery system, we can begin to identify how medical education will need to change and what payment systems could provide the correct incentives for change. By envisioning and developing the future care delivery system, we can move ahead with alignment of our educational and payment systems.
Academic health centers have an important role in creating and communicating a vision for the new delivery system by developing innovations and sharing them through articles published in journals such as this one. We at the journal look forward to hearing about our community’s best new ideas. Students and residents will work in these new care systems, and it will be important to consider what changes in their training will be needed to prepare them to work as a member of a team in a chronic care medical home, for example. The development of new care delivery systems offers a challenge and an opportunity to bring together the expertise of our clinical, educational, and research enterprises to create the vision that will drive our country’s future health care system. Although we may not be battling the demons of disease in the same way that William Carlos Williams described, the stakes are no less critical. Heroism in our age may be defined not by whether we can visualize a diphtheric membrane but by whether we can visualize our new health care system and provide leadership to our colleagues and the public to implement our vision.
I would like to acknowledge the retirement of Al Bradford, director of staff editing. Al has been with the journal since 1987 and has worked on many journal features, including letters to the editor. Most important, from my point of view, he edited the editorials of the editor-in-chief during the tenures of Michael Whitcomb and Steven Kanter, and has worked with me on mine. Al has not only corrected my grammar, but has also made sure that my ideas are presented in a cogent and balanced fashion. His erudition and wisdom will be sorely missed. All of us who make up the Academic Medicine team—members of the editorial staff, the editorial board, and the journal oversight committee—wish him the best in his retirement.
David P. Sklar, MD
Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or of its members.
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