By Dr. Larry Chiaramonte
In the past two years we have come through a bruising debate about how to reform the health care system in this country. As someone who has worked on treatment of allergy and asthma, both in the trenches of clinical and hospital practice and in research, I have watched this train wreck happening. Yet, what we have learned about the treatment of allergies and asthma has much to teach about the treatment of chronic asthma and that knowledge can be applied to treatment of other chronic disease in America as the details of health reform take shape.
At present the treatment of asthma in America is extremely fragmented. The emergency room, primary care physician, pulmonary specialist, allergists, hospitals and intensive care units, and the labs that provide support work still largely function independently with their own bottom lines the focus of their attention. The result is the familiar, sad scorecard: 17% of GDP, half again as high as the next highest country, Switzerland, with administrative costs as high as 30%. I also suspect that some costs will get higher in the short term as different players jockey for advantage. Implementing electronic records and other changes will be expensive and take a long time. Practices will combine to better afford these changes, but they will also gain bargaining power for higher fees.
It is critical that with all this finance-oriented activity, we not lose track of the goal of better patient outcomes. With a chronic disease like asthma, we would be best served by creating focused facilities that offer one-stop convenient inexpensive care, as described by Regina Herzlinger of Harvard Business School describes in her book Market Driven Medical Care, where best practices are routine, where communication of patient information is exchanged instantaneously among medical personnel, and where professionals are paid for better outcomes, not for procedures. I have no doubt that the rewards in cost savings, and in better public and individual health, would be considerable. Dr. Ehrlich and I see evidence every day that suggests this would happen. Herzlinger points out that 80% of the total cost of asthma care is caused by the worst 20% of asthmatics. An integrated facility will allow a more intense focus on these patients, and it would prevent patients in lesser stages of disease from joining that unfortunate group. The buzzword now is “medical home.” Sounds great in theory, but I’m still concerned that these organizations will still miss the point of dedicated asthma care and amplify the mistakes that have aggravated our asthma epidemic.