Health System Crises Meet New Model of Care in Speaker's Worldview

Chronic disease burden. Explosive health care costs. Fragmented care. These elements plague the U.S. health care system. How to heal it? Try the new model of care proposed in The Future of Family Medicine report.

Robert Graham, M.D., issued this challenge during the Residency Assistance Program Workshop for Faculty and Staff of Family Medicine Residencies April 3 - 5. The executive vice president of the Academy from 1985 to 2000, Graham is a professor of family medicine at the University of Cincinnati, where he holds the Robert and Myfanwy Smith Endowed Chair.

"In the middle of the 20th century, doctors tried to fix what was broken. It may have had to do with infectious disease, trauma or end-of-life care, but it was acute intervention," Graham said during the Thomas L. Stern, M.D., Lectureship, "The New Model in a New World: Opportunities, Dangers and Imponderables."

"If you take a snapshot of complaints Americans have today, it's chronic disease," Graham said. "It's not just emphysema and congestive heart failure. Chronic disease is obesity. Chronic disease is AIDS. Chronic disease is cancer. The benefits of medical science that we've recognized within the last 20 or 30 years have changed episodes into continuum."

What does that mean for the family physician?

"The responsibility and the challenge for the family physician -- for any physician now -- is to manage a patient within a continuum of illness and do so successfully," Graham said.

Graham displayed graphs depicting the natural progression of chronic disease as an upward-swelling curve spanning diagnosis; early disease not interfering much with a patient's lifestyle; chronicity, with disease becoming more of a burden; and the point of failure, typically marked by very intensive application of resources.

The curve portraying the current model of disease progression was steep, clearly illustrating the correlation between increasing disease burden and increasing health care costs incurred.

People who, in the past, experienced incidents that would have been fatal relatively rapidly now have added years of productive life, Graham said. "But the cost goes up."

It's in everyone's interest -- that of patients, physicians and payers -- to decrease the burden and cost of disease, he explained, showing a much flatter curve for disease progression as the desired goal.

Focusing on the burden, the physician says, "What I want is for my patients to suffer as little as possible," Graham explained. Preventive care may address risk factors and exposure to disease. Lifestyle changes or medication may ease the burdens posed by the chronicity phase.

The health care cost per person per year in the United States is now almost $5,000, with about 15 percent of the gross domestic product being spent on health care, said Graham. He noted these aspects of the health care environment:

"In the midst of our uncertainties and anxieties about student interest in family medicine and about funding for graduate medical education, I think the environment of medical care in the United States and the changing roles of purchasers, patients and physicians may be creating an opportunity for family physicians to make a contribution that is unique," Graham told about 715 residency faculty and staff.

He noted aspects of the new model of care proposed in the Future of Family Medicine report, starting with continuity of care. "You can't have real impact on prevention and managing chronicity in a fragmented, occasional-contact system," Graham insisted. "You've got to have integration. That has been a strength of family practice all along."

The new model will be electronically seamless, with technology making patient information available to health professionals on a 24/7 basis, said Graham. A few months after a visit, he suggested, the family physician might e-mail the patient, "I'm wondering whether this (plan) has worked. Are you satisfied? Do you have any concerns?"

Graham asked, "How many in this audience have been on the Internet doing some sort of transaction after 10 o'clock at night?" Some 60 percent to 70 percent raised their hands. "That's what patients do. That's what we do," Graham said. "Patients will expect us to respond to their e-mails within 24 hours. It'll be a real asset for the physician to put together a system of interventions with patients that are not necessarily visit-based."

In fact, said Graham, "The unit of care can't be the office visit. The unit of care has to be the patient-physician relationship."

He held out this hope: "I think patients and payers will look at our new model and say, 'That has exactly what I'm looking for.'" Namely, it is more cost-efficient and more patient-centered, and it has better clinical outcomes and higher patient satisfaction.

"The new model has real answers for the problems and issues we're facing," said Graham.