Rx for Health Care Reform

13. Putting Doctors Together

164 13 Putting Doctors Together In his book From Chaos to Care, David Lawrence, MD, a pediatrician and chairman emeritus of Kaiser Permanente, describes the odyssey of a fictional asthma patient named Rebecca.1 Between the ages of two and six, Rebecca was a regular visitor to the emergency room (ER), because neither her pediatrician nor any of the specialists to whom he referred her could figure out how to control her asthma. Her doctors communicated poorly with one another and often disagreed about her treatment. She was hospitalized a few times, and during one hospital stay, almost died from an allergic reaction to an antibiotic. The next time she went to the ER, a doctor was about to prescribe the same antibiotic for a cold, because he didn’t have access to her inpatient medical record; she avoided harm only because her father had written down the name of the drug she was allergic to. When she was six, Rebecca’s parents switched to a group-model HMO similar to Kaiser. While Lawrence doesn’t minimize the problems they had at first in dealing with a large, seemingly impersonal clinic, he sketches out a scenario for improving this little girl’s care: After placing Rebecca on a drug regimen recommended by the latest studies and giving her written instructions for self-care, her new primary-care physician sent her to a specialized nurse who took time to explain in detail what she and her parents had to do. The HMO also offered a twenty-fourhour call center, a support group for parents of asthmatic children, and a visiting nurse who would make sure there were no asthmatic “triggers” in Rebecca’s house, such as dust or cat hair. When Rebecca got sick again and had to go to the ER, the ER nurse and the doctor who saw her had immediate access to all her records on their computers. Her medication was adjusted, and her parents were instructed to pay closer attention to the readings on her peak-flow meter. With extra help from a call-center nurse and a pharmacist whom they Putting Doctors Together 165 met at their daughter’s next office visit, Rebecca’s parents eventually became adept at caring for her. They no longer had to rush her to the ER, because she was able to control her asthma. Most Americans are not in group-model HMOs, and that form of health care delivery is not likely to grow. But Lawrence’s story—a composite of many actual cases—demonstrates the huge difference between what an organized care delivery system can do and the care that a physician in a small practice can provide. Inefficiency and Waste According to the Institute of Medicine (IOM), the fragmentation of health care is a prime reason for medical errors, waste, and inefficiency. “The health care system as currently structured does not, as a whole, make the best use of its resources,” the IOM reports in Crossing the Quality Chasm. “There is little doubt that the aging population and increased patient demand for new services, technologies and drugs are contributing to the steady increase in health care expenditures, but so, too, is waste. Many types of medical errors result in the subsequent need for additional health care services to treat patients who have been harmed. A highly fragmented delivery system that lacks even rudimen‑ tary clinical information capabilities results in poorly designed care processes characterized by unnecessary duplication of services and long waiting times and delays” (emphasis added).2 The IOM advocates a vast reorganization of health care delivery centered on the leading chronic diseases, such as cancer, diabetes, heart disease, hypertension, and emphysema. Among the components of this reorganization are improved coordination of care, better information systems , new financial incentives, the use of guidelines based on scientific evidence, disease management, team-based care, performance measurement , and the availability to consumers of reliable, useful quality data.3 If physicians, hospitals, and other providers could pull this off, patients would receive high-quality care far more often than they do today . Lives and money would be saved, and health care would be more affordable. But it’s impossible to accomplish these goals without organizing health care providers into larger, more tightly knit units. Today, the only health care organizations in most communities are hospitals; in a few areas, there are also physician groups large enough to serve as hubs for the local medical community. Most physicians belong to health-plan...