Our Unsustainable Culture of Medical Specialization
Patients with multiple chronic diseases receive overall suboptimal care, and their disjointed treatment plans result in redundancies and inefficiencies that put disproportionate pressure on our health care system.
Adam Smith would have described our health care system not with his invisible hand, but with a pin-maker. In The Wealth of Nations, a parable about a pin-maker elucidates the benefits of division of labor: while a person working alone scarcely makes 20 pins in a day, a team of 10 that divides up shaping, sharpening, and painting pins can produce tens of thousands of pins per day. Workers become more efficient as they specialize by developing a skill, creating new technology to aid them, and not wasting time switching between tasks.
Our medical system mirrors this 200-year-old model: just as each member of Smith's pin-making team masters discrete tasks, each doctor masters an organ system, surgery, or aspect of patient care. The cardiologist sees patients with heart problems, the psychiatrist depression, the oncologist cancer, and they all purportedly treat these respective diseases better than a single general physician.
Over the past 30 years, economic pressures have forced even primary care, long the last bastion of the generalist, to split duties between full-time hospitalists and outpatient clinicians. As Smith would have predicted, these divisions of labor cure single diseases and manage routine care with the quality and efficiency.
Yet, these benefits break down in the face of problems that cut across the divisions; namely, people with multiple chronic diseases. These patients, said to have multimorbidity, see a different specialist acting in isolation for each condition. Additionally, because clinical care guidelines and randomly controlled research trials typically focus on patients with only one disease to avoid confounding variables, specialists rarely know how treatment they administer interacts with other concurrent treatments. This fragmentation results in frequent adverse reactions to drug combinations, redundant or ineffective care, and overall poor health outcomes.
Not only do multimorbid patients receive suboptimal care, but the unnecessary hospitalizations, redundant tests, and disjointed care they receive put disproportionate pressure on our health system. A 2010 report from the Robert Wood Johnson Foundation suggests that the 75 million Americans with multiple chronic ailments, a quarter of our population, account for 65 percent of all health expenditures.
Patients with multiple chronic diseases are not an anomaly; they are quickly becoming the norm. Recently, a group of researchers in Scotland examined the healthcare usage of 1.7 million people -- nearly a third of the country. Their findings, published in The Lancet, suggest that 23 percent of Scottish people have multimorbidity, roughly the same percentage as in the United States, and that this percentage increases drastically as people age.
By age 65, the average person has two or more chronic diseases, and people living in poverty reach this mark nearly 10 years earlier. As both the percentages of the population living in poverty and over 65 years of age continue to rise, handling patients with multiple chronic ailments will continue burden our health system. Unless something changes, this care will drive total healthcare costs out of control.
The Affordable Care Act seeks to find solutions to curb the runaway spending and poor outcomes surrounding multimorbidity. Lost in the discussion over death panels and individual mandates, the ACA awards $1 billion to the Centers for Medicare & Medicaid Services to fund new models of payment and delivery of care that save money, improve health outcomes, and scale rapidly. More than 100 Healthcare Innovation Awards were bestowed in May and June, with 10 focusing on multimorbidity and dozens of others on related problems. Department of Health and Human services projections predict savings of nearly $2 billion over the next three years, with any successful projects being approved for replication across the country .
One recipient, at the University of Chicago, aims to reduce cost for the most expensive and frequently hospitalized patients by undoing the division of labor in primary care. Led by Dr. David Meltzer, this project returns primary care physicians to splitting the day between the hospital and outpatient settings seeing a cadre of the highest risk patients -- primarily those with multiple chronic conditions. Both to make splitting time more feasible and to strengthen the doctor-patient relationship, these "comprehensive care physicians" (CCP) will see 200 patients each instead of a typical load closer to 2000. During the half of the day in the hospital, the CCPs will attend to any of their hospitalized patients and help coordinate care between specialists.
Additionally, Meltzer hypothesizes that many patients receive unnecessary care that lowers quality of life in their final days because a of breakdown in the doctor-patient relationship. By having a trusted doctor present in the hospital, the most vulnerable patients will receive superior care at a lower cost.
Whether Meltzer's system provides a solution for effective and efficient care for multimorbidity remains to be seen. Between the 107 projects, some are bound to lead to systems that improve upon the status quo. By supporting challenges to the existing structures and providing incentives to scaling successful projects, the Affordable Care Act may earn its name.