The number of people older than 65 is projected to double in the next 30 years. That means over 10k people will be entering Medicare every day. The 85 year-old and greater population will be ten times greater in 2050 than it was in 1950 which means we have many more people aging through Medicare longer. I believe healthcare’s biggest challenge is not a lack of agreement on the need for change; the biggest challenge is getting all the pieces to work together. There are several forces driving the need for change in healthcare delivery.
1. Primary Care Overwhelmed – From 2015 to 2020, the primary care workforce must grow 25% to ensure healthcare access for all Americans. Primary care physicians have a growing responsibility for new types of care coordination. Ten years ago there was not as much thought as there is today about Primary Care. Instead, specialty and sub specialty physicians were really the growth direction of the physician marketplace. As a result, we have fallen further behind in the numbers of primary care physicians even while the demands for their time grow.
2. Medicare Not Sustainable – By 2024, Medicare spend is projected to reach $858B or $55M per day. The U.S. pays for high cost chronic usage from a small percentage of people who may be truly benefitting from Medicare programs. We also have a significant portion of the population who don’t receive care at all. Caring for chronically sick patients accounts for 94% of Medicare spending each year. We must get better and more efficient with coordinating care for chronic illnesses.
3. U.S. Overspending for Inadequate Outcomes – The U.S. spends hundreds of billions on healthcare and, yet, Americans are sicker than most countries around the world. We are spending twenty times more than Cuba to have the same life expectancy of 80 years. It isn’t that we aren’t spending enough; we are not spending it right. We need better treatments and programs for chronic illness. It could be as simple as getting people who are prescribed medications to take them every day. Imagine the difference that could make in hospital readmissions.
4. Acute Care Over Utilized – If we can shift more care to take place where a patient lives, we can significantly impact our overall spending. By shifting healthcare spending from costly acute care settings to more cost effective in-home care, the U.S. can significantly impact overall spending (e.g., hospital per night cost is $6,200 vs $135 per visit in an in-home setting).
5. Antiquated Incentives – Today one of the system’s biggest flaws is that we pay for utilization and not for outcomes or the quality of care. We are tax subsidizing hospitals which have the highest reimbursement, while raising taxes and cutting reimbursement rates on less expensive solutions. This incents over-utilization and fees for tests and services. However, we know that personalized, home-based and coordinated solutions achieve far better outcomes.
6. Limited Vocabulary – The current definition and application of “post-acute care” seems to be about getting patients back to not having care at all. The term connotes both a short episode of care and one designed to have an end point related to the completion of an illness or procedure. We need to make home care not mean post-acute care because it is a different kind of care. The power of home care is the ability to cost effectively reduce or prevent re-hospitalizations, initial hospitalizations and the occurrence of new / additional acuities.
7. No Right Structure – We need to incent structures to do the right things and get the right outcomes, not to simply consolidate and grow greater share of the dollar. There is a proliferation of approaches and ideas for how to provide quality care at a lower cost. Different structures like ACOs, MSOs, health systems, multi-specialty physician organizations, and others are being created as people go about it in various ways. The common denominator driving these new structures unfortunately is largely based on finding financial incentives to protect profits, because reimbursements are being cut. That is great economic thinking but it is not outcome-based thinking. Becoming outcome focused will help show us which structures are working, could work, or might never work.
8. Live Longer – Longer life means patients live with disease and illness longer. An outcomes focus on disease can improve life expectancy. If we are successful at helping people live longer, we have to get really good at managing chronic illness. What if we approached the top chronic illnesses the way we have worked on cystic fibrosis? Cystic fibrosis use to have an average life span of 18 years. Today, we have more than doubled and in some cases almost tripled the life expectancy. This was achieved by treating cystic fibrosis with a multi-modal approach to manage every aspect of life including physician care, education, nutrition, exercise, and lifestyle. No new drug is singly responsible for the improvement in life expectancy. It is the approach of tackling all aspects of the disease that is having the greatest impact.