The last great transition in American medicine occurred in 1965 when President Johnson signed Medicare Medicaid legislation into law. This bill established a safety net for many previously uninsured Americans. It’s worth reflecting on the psyche of our country at that time. We were in a space race with the Russians. Technology was all the rage and healthcare was no exception. As a nation we launched a war on cancer. This belief that better cures based in technology were around the corner shaped the healthcare system we have today. We now have a tech/talk imbalance. Expensive drugs and surgery are prioritized over simple doctor-patient conversations.
Unfortunately, this imbalance has resulted in our healthcare system finishing last compared with other developed nations. Although a minority of Americans with cancer and other select illnesses fare better, a recent study by the Commonwealth Fund showed that for the majority, we spend significantly more and get poorer outcomes compared to like countries.
For example, Australia spends less than half of what Americans spend per capita and still manages to place fourth on overall outcomes.
The current system of reimbursement, largely driven by subspecialty interests, is unlikely to provide a solution. The Affordable Care Act (ACA) is an attempt at a wholesale overhaul. With outcomes-based care and population management at the core of the ACA, in the future Americans are likely to see an emphasis on primary care and nurse navigation. Notably, in the UK where primary physicians control the spending, generalists often make as much or more than specialists. Primary care physicians bear more responsibility but also receive more of a benefit in terms of reimbursement.
Feeling the rules have been changed for them in the middle of their careers, many specialists are threatened by this change. This is understandable. However, as a country we need to find a sustainable way to deliver care to as many Americans as possible. Although some suggest repealing the ACA, the genie is out of the bottle. Business now understands that the tech-driven healthcare delivery system is driving our economy to bankruptcy. The focus has shifted to solutions addressing wellness for the masses rather than often-elusive high-tech cures for the minority. I am not suggesting we undermine cancer research, organ transplantation and other spectacular successes, only that we strive for a rebalancing of the tech-talk pendulum.
Ironically, one form of technology, telemedicine, may play a vital role in this rebalancing. By putting the right person at the right time in front of the patient and their loved ones, telemedicine can address the fear and anxiety we all experience when faced with a threatening illness. Expensive technology, lab and imaging, often used as a surrogate for true clinical expertise, is necessary but not sufficient for care. It is the human connection that provides real reassurance.
I don’t know what the future holds in healthcare. However, I do believe that by enabling human interactions, we may be able to bend the cost curve while improving care for more Americans.