Tuesday, December 15, 2009

Cultivating new models of health care

I'm a big fan of surgeon-author Atul Gawande, and I eagerly devour each of his new pieces on health and health care reform in the New Yorker. So it was somewhat surprising how difficult it was for me to digest his most recent essay, "Testing, Testing." In a nutshell, Gawande argues that it's okay for the Senate version of the health reform bill to have no "master plan" for controlling the skyrocketing cost of care because health care is to agriculture as family physicians are to family farmers. Huh? This sounds like a bad analogy-type question from the SAT, not a serious argument. But it would be a mistake to dismiss Gawande's suggestion that farming and health care have more in common than one would initially think:

Much like farming, medicine involves hundreds of thousands of local entities across the country—hospitals, clinics, pharmacies, home-health agencies, drug and device suppliers. They provide complex services for the thousands of diseases, conditions, and injuries that afflict us. ... Knowledge diffuses too slowly. Our information systems are primitive. The malpractice system is wasteful and counterproductive. And the best way to fix all this is—well, plenty of people have plenty of ideas. It’s just that nobody knows for sure.

The history of American agriculture suggests that you can have transformation without a master plan, without knowing all the answers up front. Government has a crucial role to play here—not running the system but guiding it, by looking for the best strategies and practices and finding ways to get them adopted, county by county.

Other notable physicians have recently proposed that primary care practice could be revitalized with the help of a "primary care extension service" analogous to the successful U.S. Agricultural Extension Service. In a plenary address at the 2007 spring conference of the Society of Teachers of Family Medicine, family physician Kevin Grumbach noted:

Just as family farmers were once the nation’s major agricultural providers but are now an endangered species, we know that 75 years ago the majority of physicians in the US were general practitioners, but by the end of the 20th century, family physicians and other generalists had become a distinct minority of physicians. Just as family farmers find that few of their progeny are becoming farmers, we find half as many US medical school graduates are entering family medicine residency programs now as were a decade ago. The dominance of a reductionist paradigm in medicine has devalued the work of primary care and its integrating function for whole-person care.

So what's the solution? How can whole-person care survive in a specialist-dominated U.S. health system? By encouraging lots of experimentation, said Dr. Grumbach, and rethinking the essential functions of a family physician within a health care team. But most practices don't have the time, resources, or expertise to accomplish this practice transformation on their own. Financial incentives should help, but like Drs. Grumbach and Gawande, leaders from the Agency for Healthcare Research and Quality argued in a 2009 editorial that a government-supported extension service would speed the pace of innovation.

Admittedly, it's tough in these times to imagine that a government-sponsored anything could effectively control costs in health care or any other important sector of our failing economy. But regardless of the lack of political will on Capitol Hill, Dr. Gawande's latest article still provides food for thought about the best means of cultivating more effective models of health care in the U.S.