Clear objectives and aligned incentives – for patients, practices and payors

Our country is facing tremendous challenges not only in healthcare but also in the economy, and the two issues are interrelated. In order to produce the right solution, we must first correctly identify the problems. The healthcare solution must have the patient in mind first as well as the misguided payment system, rampant health disparities, volume and procedural-based reimbursement, and practice-based technologies that are stuck in the last century.

This year in the United States we will spend over two and a half trillion dollars on healthcare and yet we have one of the lowest quality systems in the developed world — with over 40 million people uninsured and disparities in care and outcomes that are unconscionable at any level. American companies are challenged to be competitive for many reasons, but the financial burden of spiraling healthcare costs are a major factor. Medicare is predicted to go broke with the increase in both the population age and the incidence of costly chronic diseases. Medicaid cannot be sustained at current levels, and already leaves many behind.

While there are many victims, there is not one culprit in the current healthcare crisis. To fix the healthcare system and address a major vulnerability of the US economy is no easy task. The solutions will be complicated and involve balancing many stakeholders with self-serving interests.

No solution to the healthcare crisis in the US will succeed without the support and involvement of the consumers of health care — the patient. We currently have a system that often places itself directly between the patient and medical care. This creates a confusing system where the patient often has no direct connection to the one paying for the care, and the entity paying for the care is empowered to decide what is best for the patient. To make matters worse we also have a system that does not reward wellness and healthy habits or make preventative care readily available. We must have a system that directly empowers the patient to take responsibility for his or her wellness and well-being.

The United States has a payment mechanism that is working exactly as it was designed to work— rewarding volume and procedures. The problem is that there has been inadequate regard for quality or outcomes. It's tempting to equate more with better when it comes to healthcare. We have a system that pays more for Dr. "Highly Credentialed" even though "highly credentialed" means taking care of only one organ system or one disease. We have a private payment system that spends over 30% of its precious healthcare dollar on administration. Not only that, but much of a medical practice's time and resources is also spent trying to combat and navigate that highly complicated system.

The disparities in the care provided in our current system cannot be allowed to continue. Too much care is rationed or denied because of ethnicity, income, education level or a host of similarly unacceptable factors. Our country has not made quality healthcare a priority of the government, as it has security and roads. There are many reasons why we have disparities in healthcare in this country but many of them are the result of a lack of access to quality care.

The delivery of healthcare today has too many complexities to allow the "paper-based" world of yesterday to continue. Yet still the majority of medical practices have paper-based medical records. There are many reasons for the lack of technology: from self-serving technology companies that are overly proprietary, to a lack of government leadership on interoperability and standards, to a healthcare system that has been slow to embrace technology due to a lack of resources, inadequate problem-solving solutions and overall poor understanding.

As reformers and representatives work through a review of our US healthcare system, it will be easy, in the name of consensus, to put off meaningful solutions or to create a process where the self-serving stakeholders have too much input. While I have no doubt the political forces in play will be significant if not nearly overwhelming, our nation's needs are clear: America needs a lower cost, high quality, value-conscious health care system that is sustainably financed and available to all.

Fortunately, the path to meaningful change already exists. That path is the concept of the Patient-Centered Medical Home. Every patient without exception deserves, indeed should demand, a personal relationship with a primary care provider. That provider should be rewarded for preventing disease and promoting wellness when possible, while at the same time effectively and efficiently managing and coordinating care when needed. We must invest in health information technology, pay for prevention and support care coordination with the best interest of the patient in mind. The measure of success should be true improvements in outcomes, not volume and procedures. Hospital and sub-specialty care should be paid for only when appropriate – and again – according to improved outcomes and based on need, not volume and procedures. Branded medications should only be approved and paid for if they are appropriate and have a defined value in the care of an individual patient. We have a government healthcare system that works and provides relatively good care, called Medicare. It should be available to anyone who has no other option.

To my mind, the greatest challenge to addressing the woes of the US healthcare system within the framework of the Patient-Centered Medical Home concept is the viability and continued availability of primary care in this country. The ranks are dwindling rapidly with physicians retiring earlier and fewer medical students choosing primary care as a career due to inadequate reimbursement and unreasonable work expectations. Primary Care physicians are best positioned to focus on the needs of the patient, coordinate and collaborate appropriate care, work in a team environment, promote wellness and manage chronic diseases. The system must pay for what the patient and the healthcare system needs based on outcomes and results, not volume and doing "things" to patients. Technology must be moved forward with our government defining standards and interoperability with no exception and then find a way to bring technology to medical practices in a meaningful sustainable way to address the challenges of primary care. Primary Care physicians must be allowed to take care of patients and not spend the majority of their days with paperwork that results in restricting care and maximizing stakeholder profits.

There is no argument: the healthcare system in this country must be fixed and it must provide easily accessible, affordable care for all. The Patient-Centered Medical Home concept provides an excellent framework, a common language and the opportunity for change. A strong primary care system in this country is the critical success factor and the answer to our nation's healthcare dilemma. We have a primary care work force in this country that is ready to help by providing the care patients need when they need it. But primary care physicians need support and primary care needs correctly aligned incentives at all levels to make it happen.