High Quality, Low Cost HealthCare Video Interview Series: Dr. Stephen Schimpff Talks Chronic Disease
Last week, we spoke with Daniel Wolfson who talked about the Choosing Wisely Campaign and how it raises quality of care by promoting doctor/patient dialogue about testing and screening.
Today, one of our distinguished Advisory Board members, Dr. Stephen Schimpff, gives us his ideas on how we can curb healthcare costs while maintaining quality by better managing chronic disease.
Dr. Schimpff is the author of two books on healthcare and has written numerous exclusive posts for us here on HealthWorks Collective. We thank him for taking the time to share his thoughts for this video series.
And now, Watch the Video:
To see other videos in this series, please go to this page. And if you have a story to tell that can reduce healthcare costs and raise quality of care, please comment below or email me at [email protected] Thanks!
Video transcript (by TranscriptionStar)
Joan: Hello. I'm Joan Justice with HealthWorks Collective. And I'm speaking today Dr. Stephen Schimpff retired CEO of the University of Maryland Medical Center and the former COO of the University Maryland Medical System. Dr. Schimpff is the author of two books on healthcare, and the latest is the future of healthcare delivery. Steve has some definite views on how to curb healthcare cost and maintain a high quality of care and this relate to chronic disease and that constitutes a huge percent of our healthcare cost, so Steve go ahead and tell us your thoughts.
Dr. Schimpff: All right well, thank you very much Joan. I guess we should start with why do, why our healthcare cost rising so much? We all know they are and we hear lots of different reasons. I'm going to say that there are two fine reasons. And or factors that affected and they're in ageing population. You know it's like no I'm getting older and that --
Joan: That's me too.
Dr. Schimpff: And the second thing now is that we have as a society a lot of -- well, let's call them adverse behaviors and like they call them bad behaviors and just adverse behaviors, and you know there's forbiddies [Phonetic] [0:01:24] that's we overeat and of course we don’t eat a really good nutritious diet. Second thing is we get do little exercise. It seems like everybody is chronically stress, and unfortunately 20% of people still do smoke, so you take those four, and there are others, but those are the biggies and then you're just driving literally epidemics of chronic diseases.
And we're going to see this more and more. I mean we know that a third of the population is overweight, a third, another third is actually frankly obese, so you take obesity you take high blood pressure, and these are then driving other diseases diabetes for example or a heart disease strokes, cancers, chronic lung disease. And when you look and you ask the insurance executives where do you spend your money? They say the [Indiscernible] [0:02:14] claims pay 70, 85% go to taking care of these chronic illnesses, so it’s a real problem.
Now, here's where I get it the issue of why the cost are going up. This kind of patient who has one or more chronic illness needs to be treated not by a doc, a nurse, but by a whole team. Let's take the diabetic patient and then overtime an endocrinologist maybe a podiatrist and exercise physiology nutritionist, ophthalmologist maybe its one point the cardiologist they ask you for surgery, so it's a huge team, but any team needs a quarterback somebody to coordinate their care.
My own belief is that is ideally, your personal primary care physician. By the way, I'm not a primary care physician and what's not, but I do believe that they're sort of the backbone of our system, so we need care coordination for those with chronic illness, and of course we need much more prevention to prevent these chronic illnesses from occurring. And that's obviously easier said and done. But you know why are these illnesses so important to us?
I think there's three key things. Once you develop one of these its with you for like diabetes for example, once you have it, you're going to have it all the way to the very end, not certainly some cancers we can cure, but chronic lung disease stays with you, heart disease stays with you. So these are illnesses that once you have and you keep them.
Second thing is they're difficult to manage, and the third thing is because they're going to be with you for a long time, they're hard to manage your expenses, but they're much more expensive than they need to be which is I just where I want to go with us. There's a institute called the Milken Institute. I hope I'm pronouncing it right.
They did the comprehension study at chronic illnesses couple of years ago, and what they found was that its about a 109 million Americans with at least one chronic illness and they project and I'm not, I don’t remember all their details of that this is going up at a rapid rate, and getting just back to our discussion of adverse behaviors, so the cost are high.
They estimated $275 billion a year in direct medical costs and a $1 trillion you know lost productivity from work and everything else, so a lot of my -- just look at Medicare for a second that 85% of Medicare enrollees had at least one chronic illness and 50% had three or more. So, so they're common and common, and its not -- medicine over the last century or so is really focused and this is grown up around acute illnesses. Let me define that a little bit if somebody gets a pneumonia you see a doctor, you get an antibiotic, you develop appendicitis your surgeon get cut off.
Either way when it's done it's done. Chronic illness that diabetes again is with you then you have acute episode, but the whole thing is still with you for a long time. Now, big issue it looks like it got diversion, but you know come back quickly to my point and that is, is the primary care doc is the one who ought to be coordinating the care of these patients and helping with prevention side.
They're not doing it right now, and that's kind of I don’t mean that is a harsh critical statement. Here's the reason. They're in a non-sustainable business model. Their cost had been going up. Now, office cost a lot. Insurance is up, everything goes up, but reimbursements have been flat and this is an old story you know if your income is flat, and your cost go up, you try and make it up in volume.
Joan: Volume sure.
Dr. Schimpff: So they do two things. One is that I'm not going to go to the hospital and see patients in the hospital anymore. Unfortunately we have hospital it's now they're trying to back stop that. And they say I'm going to see patients for a shorter period of time. I can see more patients in a day, so it’s the -- you know the [Indiscernible] [0:06:21] 12 to 15 minute visit that too many patients get and if your -- have a couple of chronic illnesses and you're on six or seven medications and you come into the doctors office. 12 minutes is not a good thing. It's just -- it's not enough time to really give what I call good care coordination.
So you know what we had to do to lower the cost. We have to deal with our behaviors and we have to deal with ageing. We're all going to keep getting older unfortunately we can't deal with. We can't stop that, but we can slow it down. And you can slow it down just in saying we can deal with the behavior issue.
It's just the same four things. Nutrition and diet, exercise, stress and smoking. As you will show now and just take us the approaches for example you can slow their progress if you exercise on a regular basis and eat a good diet so prevention we can deal with that. Now, what about care group and we need incentives. We need incentives to do those.
Joan: And the relation sure.
Dr. Schimpff: Yeah and sometimes you know our money will work as an incentive so for example if we're employed our employer can offer us wellness programs. And in return for us participating we get a cut in our healthcare insurance, so that's more in at least is a monitoring incentive. So let's get on to like the care coordination issue. I'll give you a quick example of our friend in mine.
This is about 400 miles from where I am, and he called and said see I'm on 23 different medications and just read my mind 23 medications and he said you know I don’t feel good, and being really confusing some of them multiple times a day and I can afford them. I'm well passed Medicare. You know I'm into the dominant world [Phonetic] [0:08:14] thing.
So I said well, look I can't be your doctor 400 miles, but send me the list, and I'll go through them. And having to go through that whole list of course, but he was on three medicines for his high blood pressure and really high doses, so I asked him about that and he said well, every time I go to one of my doctors they check my blood pressure and they cut my medicines. Key was the four were your doctors? I say yeah, doctors yeah. He said four said they all deal with your blood pressure. Always yeah he said you've been going to doctors obviously they check your blood pressure. He said but they talk to teach other.
Joan: No coordination.
Dr. Schimpff: No. Do they send [Indiscernible] [0:08:53] which is I think so. My client has a record? No. So I helped him find a single primary care doc, and within three months he called back and said now I'm on 7 doses from 23.
Joan: A lot better.
Dr. Schimpff: You know it -- but it shows the value of that care coordination that's just one example. So what can be done? In the end you got to fix that primary care physicians business model somehow. So they see a lot of patients. Many will see 1500, 2000 patients you know and that they're paying other patients even more.
If you got a lot of patients for chronic illnesses that number should come way down. My personal wages should be down around 500 or 20, so number one is care for fewer patients, but if you're going to do that, you're going to get paid more per patient and that means which is unlikely that Medicare and commercial insurance will do that, but it would be appropriate I think.
Second thing everybody is talking about now what kind of care organizations or capitation type system. That will take care of it because then you have the time presumably that and you know the dollars are there. The third thing is it just say and when you're doing this now we're saying not going to take insurance anymore, so and that its there [Phonetic] [0:10:24], but you know that can be commercial as well, and they say just you know I'm going to charge you what I think is a reasonable fee just like your lawyer what your tax account what whatever, and by the way that makes you the customer, the physicians again because today the customer, the physician is an insurance company who decides everything.
So anyway so number three is just don’t take insurance and charge inappropriate fee and hopefully then cut back in the number of patients so you have time. And then the fourth one is this retainer-based concept where the doc says I have reduced my practice to 500 patients. I'm going to charge you a fee a 1500, 2000 a year, but in return for that you can come in today or tomorrow for a visit give as much time as you need. Here's my personal cell phone number. Here's my email address you know and so on.
Joan: The cost here is model.
Dr. Schimpff: Yeah I prefer retainer base but some of the urgency [Phonetic] [0:11:20] is fine. And this gives you much better care now, and so there's a but, and the but is hey, I got to pay you the perks, so I didn’t have to pay you before. So I still need my insurance for everything else, so you know it's not so simple, but any of that my quick summary the way it would be this.
This three approaches, four approaches or some combination of them I think will be the future of primary care, and if the -- as now today is this volume you know this volume-based thing if we can get passed that, we can get good care prevention I'm sorry good preventive care, so that we prevent chronic illnesses and the second thing is in for those who have chronic illnesses good coordination of that care.
Combination will bring cost down really dramatically, but prevention takes time before the cost benefit occurs, but the care coordination brings the cost down pretty fast. This is example the 22 drugs or 22 drugs down to 7. Medicare and the patient those of Medicare try to insure, partly insure, and the patient both save the ton of money so that's my thought about chronic illnesses, and what we have to do to bring down cost.
Joan: Great information Steve yeah reducing the chronic diseases is a huge challenge now, and in the future as we go forward we all need to be aware of this and we need to help deal with this really important healthcare issue and thanks so much for the interview and thoughts okay.
Dr. Schimpff: Thanks a lot Joan.
Joan Justice is Executive Director at thePatient Empowerment Network, a global non-for-profit organization dedicated to fortifying the health care consumer with the knowledge and tools to feel more confident playing a central role in decisions that affect their health. Joan has a background in nursing and domestic and international healthcare marketing. Previously, she was the manager of ...