- The Washington Times - Wednesday, January 29, 2003

DURHAM, N.C. There is a health-care crisis pending that is even more urgent than the challenges threatening Social Security and as precarious as was the recent dot.com bubble.
Soaring health-care costs strain industry and government as we struggle to emerge from the current economic slowdown. Prospects for containing double-digit inflation in health-care expenses look grim under pressures of expensive new medical technologies; an aging population in search of more services; and more than 40 million uninsured, with hundreds of thousands more of the employed joining these ranks. There is, moreover, widespread dissatisfaction among physicians, patients and payers. Left as it is, the future of health care will be bleak, indeed. Yet, discussions about health care do not confront the central issue of how to fix the system. Let's face it: What we have now is unsustainable, and we need to begin talking about transforming how health care is delivered.
The problem in health care today is less medical know-how than how care is delivered and paid for. Our fractionated health-care system doesn't use available knowledge to prevent disease, and our current reimbursement mechanisms actually prevent improvements that could lower costs. Both health-care delivery and health-care reimbursement need to be addressed. We cannot expect to fix one problem without fixing the other. Both problems are, however, solvable, and the application of emerging medical capabilities plus aligned reimbursement methodologies can do this.
The practice of medicine experienced a major transformation over a century ago, when emerging sciences, for the first time in history, began to provide a foundation for treating disease. And now, post-World War II investments of $1 trillion in health-related research enable new approaches that can yet again transform medicine, so that it is capable of not only treating diseases but predicting their likelihood and preventing them from occurring.
The disease-prevention approach, known as prospective health care, could radically improve outcomes while decreasing costs. Our capabilities to do this are increasing dramatically with advances in genomics and technology. Such advances make it possible to replace our current reactive, sporadic treatment of disease with personalized health planning that allows individuals to avoid illness and needless, late-stage expensive treatment. Prospective health care could save lives and money, and we have the ability to do it now. Instead, we are currently spending more than 75 cents of each health-care dollar for the treatment of late-stage chronic disease, which in previous years may have been unavoidable, but with current capabilities are often preventable.
The cost implication of this becomes apparent when we consider the full range of chronic diseases, from diabetes to cardiovascular disease. One-hundred-twenty-five-million Americans suffer from at least one chronic condition; a number that grows as our population ages. Chronic diseases account for $1 trillion in health-care expenditures annually. Since they develop over time, we have windows of opportunity to prevent them or to reduce the damage they cause, thereby improving outcomes, decreasing expenses and providing sources for funding the uninsured, who now access health care through expensive emergency rooms.
Isn't it ironic that we have invested heavily in technologies for improving health without developing a health-care system to benefit from it? Today, physicians generally see patients when they are ill, and the goal is to find the problem and fix it. Most physicians work in small groups rather than as integral components of a greater health-care system, and few patients are engaged in their own care. This does not enable the best medical practices and contributes to financially inefficient health-care delivery. Instead, our disorganized health-care delivery system rewards the treatment of sporadic major interventions but not health planning.
Providers who would rather practice preventative medicine cannot afford to implement prospective health care models because they don't get reimbursed for their expenses. For example, early intervention and preventative measures can allow a diabetic to avoid blindness, renal failure and limb loss. Yet, payers fund hemodialysis and limb amputation, but barely fund preventative programs. Hence, physician offices are not organized to provide prospective health care.
As costs spiral out of control, prospective health care offers a fundamentally new orientation preventing disease, rather than only treating it after it occurs. To make it work, patients will be provided with individualized health plans tailored to their lifestyles, environments and susceptibility plans that provide clear analysis of what steps might be taken to prevent the diseases to which each is most susceptible. We need to help patients take far more responsibility for their own health, much like the level of responsibility we each accept for planning our retirement and managing our financial wellbeing. Additionally, we need to organize health-care providers into teams to offer patients the information they need, as well as the right treatment at the right time.
Do such approaches really work? Pilot programs at Duke and elsewhere dealing with diseases as diverse as diabetes and heart failure suggest that they improve outcomes and decrease cost. To broaden these approaches, we need a coalition of providers, interested parties and payers to develop pilot prospective health-care models and determine which work best. I suggest that we start with the best-practice care for common, chronic diseases such as diabetes and cardiovascular disease. Such programs are well within our capabilities and could save an estimated 40 cents of each health-care dollar while providing better outcomes for patients.
It is sad that initiatives to improve health-care delivery are barely discussed in political debates over health-care costs, which are usually mired in issues that nibble around the margins. We need to address the more fundamental goal of getting the best health value for each dollar spent. We are currently squandering hundreds of billions of dollars annually on an ineffective delivery system while more Americans become uninsured.
Now is the time to establish a rational, more cost-effective health-delivery system based on the tremendous new knowledge and technology that we possess for health-risk analysis and prevention. Without an effective health-care delivery system and reimbursement mechanisms to support it, we will spend more money, yet trivialize the potential for improving our nation's health. This will needlessly increase the drag on an economy that is struggling to emerge from its' current slowdown.
We have the know-how to do far better we need the leadership and will to do it.

Dr. Ralph Snyderman is president and CEO of Duke University Health System, chancellor for health affairs at Duke University, past chair of the Association of American Medical Colleges and president-elect of the Association of American Professors.

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