Despite taking 23 – yes, almost two dozen! – prescription medications, my friend Henry did not feel well. Plus, the expenses were beyond his means as a retiree, even with the help of his Medicare Part D drug coverage. Why so many medications? The short answer: He had four different doctors, each writing prescriptions, often for the same diseases, but not in concert with each other. Once Henry got a primary care physician to coordinate his care, it was but a few months until he was down to seven medications. After that, he began feeling much better, and he was saving himself (and his insurer) a substantial amount of money each month.
Henry was fortunate to find a primary care doctor who would devote the time needed to fully understand his many problems, including his social/psychological issues. With an attentive PCP, he had much less need for various specialists, but as the need arose, the PCP was there to coordinate his care.
Unfortunately, most primary care physicians do not have enough time for careful listening and contemplation nor for delving into anxiety and family issues that may precipitate an exacerbation of heart failure. For example, concern about a sick adult child might be underlying the heart failure flare. Some physician recommended changes in medications will help but what is really needed is attention to his deepest concerns.
Adequate time between patient and doctor, especially the patient with one or more chronic diseases and the primary care physician (PCP), is essential. Developing a population that values healthy lifestyles and government actions designed to assist in prevention is equally crucial. Unfortunately, we have none of these three in today. PCPs are too busy; we don’t take care of our health and wellness; and government is AWOL.
Since most chronic illnesses are preventable with simple lifestyle modifications (I know, easier said than done), we need aggressive attention to preventive approaches and maintaining and augmenting wellness. Physicians (and other members of the healthcare team) and patients working together can make significant inroads here. This would reduce the burden of disease over time and greatly reduce the rising cost of care.
But that is not enough. Government, in its many forms, needs to assist. Addressing lifestyle needs as done over the past few decades with tobacco is critically important. But, unfortunately, the American government places far too few resources into wellness and preventive care, whether regarding school lunches, employer wellness programs, insurance rebates for healthy living, or many other possibilities. And as the pandemic clearly demonstrated, there has been decades of inadequate public health funding, from the Centers for Disease Control (CDC) to state and local health departments.
Individuals all too often and for many reasons do not follow basic approaches to general wellness, including the top five: sound diet, adequate exercise, stress management, enhanced sleep, and no tobacco/ moderate alcohol.
Living in “food deserts,” unsafe neighborhoods that prohibit effective exercise and augment stress while tempting illicit drug use all conspire toward less wellness and poor health with later chronic illnesses. Marketing tobacco products in these same neighborhoods has often left islands of continued smoking.
All of us are bombarded daily with marketing that touts ultra-processed foods high in fats, refined white flour, salt, and sugar. Think of most sodas with their high levels of sugar; fruit yogurts that always add sugar; those packaged snacks loaded with all the wrong ingredients plus others you never heard of; those buns in the mall that smell so good from their cinnamon and butter but are mostly sugar and white flour.
Think also of most breakfast cereals. Even the ones you might assume are healthy often have substantial sugar added, and most only use refined white flour, which is almost equivalent to eating sugar. Unfortunately, government, unlike tobacco, puts little or no restraints on such marketing of blatantly unhealthy foods.
We all love French fries, hot dogs, fried chicken, and high-fat content hamburgers. Fast food outlets know what we like and do their best to not only attract us but seduce us to buy more. “Get a double for only half price.” One of my favorite stories relates to iced tea. We stopped at a fast-food place to take a break from traveling and get a drink. My wife got a black coffee; I ordered an iced tea. “Large or small?” I said small but she looked at me skeptically and said that the large was only a few cents more. I didn’t want to tell her that a large would run right through and we would have to stop again sooner than planned, so I just reiterated “small.”
“Sweetened or unsweetened?” “Unsweetened, please.” “You should get the sweetened; it is $1, and the unsweetened is $2.” I insisted on unsweetened, and she looked at me as though I was the stupidest customer she had ever encountered. She gave me a small cup, and I went over to the other counter where you could take from the sweetened or the unsweetened containers. I could have said “Sweetened,” paid less, and taken the unsweetened. Later, in the car, I looked at the receipt. She charged $1 me for a “sweetened iced tea.” So kindly toward this foolish old man.
But why should sweetened cost less than unsweetened. Because once the sweet taste is in your mouth, you will want more – either at this stop or the next. The company knows it and so lures you back with a “reduced” price. It is a “nudge” but in the wrong direction. Another example of good marketing but lousy policy.
Assuring medical insurance for all Americans is an important goal, but it is far from sufficient to ensure we all get the best or even adequate care. For example, what good is an insurance card in your pocket if you cannot access a PCP in your neighborhood, one that has the time needed to give you the care you need. So instead, you go to the local emergency room, which, although well intended, is no substitute for a personal physician or nurse practitioner.
America needs a new vision for healthcare delivery:
It must become a health care, not just a medical care system. It must recognize the importance of intensive preventive care to maintain wellness, and it must do so prospectively from the perspective of the population, not just an individual who appears in the doctor’s office. The keys are straightforward – good diet, adequate exercise, reduced chronic stress, enhanced sleep, no tobacco, moderate alcohol, good dental hygiene, and careful driving. Add to these – blood pressure control, cholesterol management, cancer screening, and combined, these will prevent most chronic illnesses.
For those who do develop chronic disease(s), the PCP needs the time to attend to the complexity of care and, when necessary, there needs to be excellent specialist coordination by the PCP. This will improve the quality of care and dramatically reduce the costs of care.
Because the PCP does not have enough time, the patient who already has a chronic illness is often sent for extra tests, imaging, or to see one or more specialists. As a result, the expenditures go up exponentially, yet the quality does not rise commensurately. Indeed, quality often falls. Again, Henry’s story is a good example.
Henry’s story points to another problem – clearly, America has a medical care system, not a health care system. American medical care focuses on a disease once it has occurred but focuses relatively little on maintaining health and wellness.
Healthcare must be redesigned so that the patient is the customer. Today the insurer controls. That makes no sense, including no financial sense, no quality of care sense, and certainly no patient or doctor satisfaction sense.
Very critically, America needs many more primary care physicians (and other primary care providers such as nurse practitioners) – the backbone of the healthcare system – who can offer outstanding preventive care, care for most illnesses, and care coordination for chronic illnesses when necessary. Unlike today’s insurance system, they need to be reimbursed for their efforts in a manner that allows for adequate time for each patient and their total healthcare needs. It must be satisfying to doctor and patient alike, with true healing in addition to expert medical care.
All of this requires a change in the conceptual approach to insurance coverage; to what PCPs believe their function is or could be, to your understanding of what excellent primary care can be, and to everyone’s understanding of the importance and effectiveness of preventive care to maintain health and wellness. These are major changes in how we think and act about healthcare. It will not come easily or quickly but desperately needs to begin the change process now.
It also requires government to change its approach to healthcare, to see it not just as an insurance problem but as an opportunity to improve the health and wellness of all citizens.
It is doable, but it means rethinking how we perceive health, wellness, healthcare, and how our delivery system is structured.
In the following articles, I will address the How’s to achieve real healthcare.