Repairing a broken system: Significant waste and unnecessary care

You hear it all the time: “Health care is broken.” “Health care is wasteful.” “Health care is too expensive.” The problems with health care aren’t just the fault of hospitals, clinics, insurance companies or government. It’s a problem that is bigger than the sum of its parts, and making meaningful changes toward a more sustainable system will require the cooperation of both patients and providers.

“The concept of significant waste and unnecessary care is a complicated problem, and there’s no simple solution,” said Paul Ogden, MD, interim senior vice president and chief operating officer of Texas A&M University Health Science Center and interim dean of the College of Medicine. “The current system (or in many places a lack of a system), physician reliance on expensive testing, and the expectations of patients all contribute to the problem.”

The wrong care in the wrong place

Access to care is one of the largest influencers for driving people to get the wrong care in the wrong place, especially in Texas. Location, availability and a physician shortage are three of the biggest barriers to care. Thirty-five counties in Texas have no physician of any kind, 80 counties have five or fewer physicians and 147 counties have no obstetrician/gynecologist.

This lack of access, combined with a lack of after-hours care, means more people are utilizing more expensive care than they should—like the emergency room. Poor access leaves many families scrambling for care or waiting to seek care only after more serious problems have developed.

Diagnostics and medications

Diagnosis and treatment of patients is often more expensive than it should be. Physicians usually train in academic medical centers that feature the best and latest technology and new treatment discoveries. There is a tendency among physicians to think that more is better, that newer is better and that diagnostic technology is always better. While it may be true that new is sometimes better, it is almost always more expensive.

“Doctors used to be able to spend more time with patients and had a relationship with them,” Ogden said. “If the doctor felt after a thorough history and physical exam that the patient was fine and didn’t need expensive testing, the patients could trust that answer and be reassured. The current system is rushed and fragmented, making that relationship much more difficult.”

“This is really an area where medical schools can make a direct impact,” Ogden added. “The least expensive way to diagnose patients requires skills that we can instill in our graduates and residents. By taking accurate histories and physicals and utilizing bedside ultrasounds and other bedside exams, physicians can help reduce waste within the system. We teach our students to not only be top-notch diagnosticians, but also savvy about what technologies they utilize and the holistic needs of their patients.”

Changing the culture of health care isn’t easy, and changing the mindset of future generations of physicians is just a start. It’s why the Texas A&M College of Medicine wants to do more to change the system and the way both consumers and providers conceptualize and utilize health care. The college has even been examining opportunities for a research, innovation and policy institute dedicated to transforming health care delivery and improving outcomes.

The squeaky wheel gets the grease: The patient culture

We all know the saying, “the squeaky wheel gets the grease,” and it certainly holds true in medical care. Patients who make the most noise get the most attention. And while it’s a problem that makes the system more expensive, it’s a problem that can be mitigated.

There are several levels of health care users within the American health care system. The majority of consumers are basically well and in good health. Many of the problems that they see physicians for (colds, flu and other minor issues) could be handled through less-expensive types of care, such as another type of primary care provider.

The role of the primary care provider network is extremely important. A multi-disciplinary team including nurses, advanced practice nurses, physician assistants and pharmacists can help increase the workforce, provide better cost-effective care and identify more serious issues that need the care of the physician. Primary care networks offer the treatments and preventive screenings that save lives and head off expensive emergency room visits and hospitalizations.

“The majority of the population can be helped the most by improving access to care and keeping them from utilizing the most expensive forms of health care,” said Ogden. “Team approaches and the utilization of nurse practitioners and physician assistants can create more access to care by making treatment available where people need it most. For instance, urgent care clinics, clinics with extended hours, and similar facilities can provide the level care needed.”

Patients with chronic illnesses need an intensive approach to manage their condition and avoid frequent visit to the ER and hospital. Frequent in-home visits, treatment protocols and excellent monitoring and communication can improve management of diseases like congestive heart failure and diabetes. It is a time-consuming process, but it leads to better outcomes, better quality of life and fewer emergent visits.

This population could be better served by implementing some disruptive technologies that help keep the team and the patient on track. Multiple apps are being created to help the patient increase their awareness, education and accountability in their own health. In the near future, some of these apps may allow patients to deal with less complicated issues in their own home.

A small group of patients are considered high utilizers. At about 5 percent of the population, this group has serious but uncontrolled health problems and are the “squeaky wheels” who see physicians more frequently and utilize the emergency room more than any other group. They are often very ill, and often have a number of other issues that make their health even more difficult to manage, such as financial, transportation, education and general access to care issues that require more from the health care system than other groups of patients.

Looking forward

Changing health care is possible, but it will require a cultural shift from the health care providers and patients. Everyone from policy makers to patients will need to not only rethink but also adjust the way they implement and utilize the system. The shift begins with educating physicians to be stewards of patients, for patients to be informed consumers of their own health care, and for medical schools such as Texas A&M to provide innovations in care delivery, training and policy so that everyone can have access to affordable, high quality health care.