Would You Run Your Business This Way? 

Newt Gingrich and James King, M.D.

If the U.S. health care system were a business, it would have filed for bankruptcy long ago.  No company could survive by offering its customers skyrocketing prices, poor quality and limited access.  However, that is exactly what we get in health care today.  
 
Consumers, employers, doctors and policy-makers have had enough. They want change that goes beyond tweaking a broken system. They want dramatic change. A change that replaces today's fragmented, costly paper-based approach with a cohesive, modernized system that improves individual health, coordinates care and reins in costs.

One of the most important changes is reestablishing -- and then improving -- the doctor-patient relationship. Today's system violates this sacrosanct relationship. It squeezes time from every visit, forces physicians to focus on insignificant matters (when compared to the health of their patients) and prioritizes acute-based sickness over preventive health.  Which is a little like an auto mechanic telling car owners that it is better to wait until their car engines seize up than to schedule regular maintenance.

There is a model that can fix these problems, and it goes by many names -- a personal preventive care center, patient-centered primary care or simply the patient-centered medical home.

This model encourages consumers to develop a strong, ongoing relationship with their primary care doctor with the shared goal of improving individual health.

Physicians' responsibility is to provide health services that focus on wellness, to help prevent chronic illness and its complications, and to intervene when acute illness or accidents occur.

In addition to this focus on wellness, another hallmark of the medical home concept is for physicians to help coordinate the services consumers receive in other sectors of the health system.  

By delivering information that follows the patient, the physician's office becomes the "library" that contains the history of the patient's care, from hospitals and subspecialty physicians to home-health agencies and long-term care providers.  

This approach overcomes one of the most inefficient and deadly aspects of the current system: the fragmentation of care where treatment occurs in isolation with virtually no information about a patient's past.

To serve this role, and to truly provide patient-centered primary care, physicians must adopt health information technology. Technologies like electronic health records allow physicians to connect with other stakeholders in the system, share information and better coordinate the delivery of care. It is impossible to do this with paper medical records.   

The use of technology can also track whether physicians are meeting quality measures, promoting the use of evidence-based medicine and utilizing clinical decision-support tools. It can also offer convenience to patients through same-day appointments, group visits and secure online services such as appointment requests, patient history updates and reports of lab results.

Are there results that prove the benefits of this concept? Absolutely. Look at North Carolina's Medicaid program. The state spent $20 million in payments to 3,500 primary care physicians to participate as pilot personal preventive care centers. Through reduced hospitalizations, better control of chronic disease and the reduction of complications, this investment saved Medicaid more than $231 million in 2005 and 2006.  Better health at lower costs.  

The medical home concept can work for business as well. IBM reports that, compared to industry norms, its health care premiums are 6 percent lower for family coverage and 15 percent lower for single coverage since the company implemented patient-centered primary care programs. And the employees? They reported high satisfaction.

These are not mere anecdotes. Since the 1990s, researchers at the Johns Hopkins University School of Public Health and the World Health Organization -- among many others -- have demonstrated that access to primary care delivers better health at lower costs. Primary care reduces death rates for all causes, including heart disease, cancer and stroke; lowers infant mortality rates and low birth-weight babies; extends life expectancy; and lowers total costs of care.

We can only dream of these results with our current system.  It invests in the wrong priorities, pays too much for the wrong services, and delivers poor outcomes. Unlike a private business, health care cannot file for bankruptcy. We have to make it work. Models like the medical home, which improve quality while lowering costs, must be part of the turnaround.     

Former House Speaker Newt Gingrich is founder of the Center for Health Transformation. James King, M.D., is president of the American Academy of Family Physicians. The Academy is a member of the Center for Health Transformation.

Tips to Control Your Costs

Health insurance helps you pay for the medical care you need. However, health insurance has become more expensive as health care costs have risen. In fact, the Kaiser Family Foundation reports that health costs have increased 78% since 2001. The high cost of health care has created financial difficulty for millions of Americans. Contact Your Elected Officials

However, there are steps you can take to help control your health care costs.

Choose the right plan.

When choosing health insurance, make sure you understand all the options and the terms (see chart below). Think about what kind of care you needed in the past and what you might need in the future. That will help you decide whether you need an insurance plan with a lot of options or if one with fewer options would work for you. Fewer options generally mean you pay less. So, for example, HMOs are generally less expensive than PPOs but have more rules.

You also need to think about what you can afford to pay each month in premiums and what you can afford for co-pays each time you go to the doctor. So, for example, a plan with higher premiums will generally have lower co-pays.

It's also important to ask about a plan's limit on out-of-pocket expenses. This is the total amount of your money you would have to pay. Without such a limit, you could end up with large medical bills if you need to be hospitalized or need expensive care.

The most important thing is to ask questions. Don't sign up for a plan you don't understand. If you have insurance through your job, the human resources staff should be able to help answer your questions.

Understand what your insurance covers.

Different types of insurance plans cover different things. Generally the more a plan covers, the more you pay in premiums. The types of care that the plan will pay for are called "covered services." Most plans require that you get approval ahead of time for certain services. If you don't get pre-approval, you generally have to pay for them out of your own pocket.

Most plans also have a list of services they will not pay for. You have to pay for these out of your own pocket too.

It is important that you understand exactly what is - and isn't - covered by your plan. If you aren't sure, don't assume that something will be covered. Call your insurance company and ask.

Understand your right to appeal a denied claim.

When an insurance company decides not to pay the bill for a service you've received, it's called denying a claim. You are then responsible for paying the bill yourself. (This is why it's a good idea to make sure you know exactly what your plan covers.)

If your insurance company denies your claim, you have the right to challenge the decision. This is called appealing the claim. Before you decide to appeal, read your insurance company's appeal process. This should be explained in your plan's handbook. Also, ask your doctor for his or her opinion. If your doctor thinks the service was medically necessary, he or she may be able to help you with the appeal.

Improve your health as much as possible.

People with poor health need more medical care. Often they have to pay more for health insurance too. If you take care of your health, you can save money.

To stay well, don't smoke. If you smoke, quit. Eat a healthy diet and exercise. If you are overweight, talk to you doctor about losing weight. Also, if you have a chronic condition, such as heart disease or diabetes, work with your doctor to manage your illness and prevent more serious problems.

Don't use the emergency room like a doctor's office.

The emergency room is the place to go for life-threatening emergencies like a heart attack or stroke. For problems like the flu or an earache, your doctor's office is probably a better choice.

Make sure you know what to do if you need your doctor in the middle of the night or on a weekend. If your doctor's office isn't open at these times, ask about other options like urgent care or after-hours clinics. These appointments may cost a little more than a visit to your doctor but are still less than a trip to the emergency room.

If you need help deciding whether to see a doctor right away, you can get advice from 24-hour telephone hotlines. Most insurance plans and many local hospitals provide this service. Find one in your area and keep the number by your phone.

Preventive care and wellness visits when combined with healthy life choices can keep you and your family happy and healthy. The Center for Disease Control calculated the direct medical costs associated with physical inactivity as $29 billion in 1987 and nearly $76.6 billion in 2000. They also found that regular physical activity is associated with taking less medication and having fewer hospitalizations and physician visits. Learn more at CDC's Chronic Disease Prevention site. Contact Your Elected Officials

What can I do to keep myself healthy?

The choices you make about the way you live are important to your health. Here are some choices you can make to help yourself stay healthy:

• Don't smoke or use tobacco.
• Limit how much alcohol you drink.
• Eat a healthy diet.
• Lose weight if you are overweight.
• Exercise regularly.
• Don't use illegal drugs.
• Practice safe sex.
• Control your cholesterol level.
• Control high blood pressure.
• Stay up-to-date on immunizations.
• Protect your skin if you're out in the sun.
• Use seat belts (and car seats for children) when riding in a car or truck.
• See your doctor regularly for preventive care.

What can my doctor do to help me stay healthy?

In addition to treating you when you are sick, your doctor can follow a program designed to help you stay healthy. This program tells the doctor which preventive services are needed for people at different ages.

What is a "preventive service"?

A preventive service might be a test, or it might be advice from your doctor. Preventive services can include the following:

• Tests (also called screenings) to check your general health or the health of certain parts of your body
• Regular measurements of weight, cholesterol levels and blood pressure
• Advice about diet, exercise, tobacco, alcohol and drug use, stress and accident prevention
• Immunizations - shots - for both children and adults
• Special tests at certain times in your life, such as during pregnancy and after age 50

Will my doctor tell me which preventive services I need?

Yes. Follow your doctor's advice about checkups, about healthy life choices and about medicines that prevent health problems, such as blood pressure medicine. Preventive services are sometimes offered in your community (for example, blood pressure tests at the local shopping center). If you're not sure you need the service being offered, ask your doctor.

Who pays for preventive services?

Most health insurance companies pay for at least some preventive services. If you aren't sure what your insurance will cover, read your health plan's patient manual or call the health plan's office.

What preventive services do women need?

Adult women should have their weight, blood pressure and cholesterol levels checked regularly. They should also have a Pap test at least every 3 years to screen for cervical cancer starting at age 21 or approximately 3 years after they have sex for the first time. After the age of 40, women should have a mammogram every 1 to 2 years to screen for breast cancer. After the age of 50, they should also be tested for colorectal cancer. These are routine tests that everyone should have. If your doctor orders these tests for you, it does not mean he or she thinks you have cancer. Your doctor will also make sure you have all the shots you need.

Your doctor may give you advice about exercise and diet. For example, your doctor may tell you how much calcium you need to prevent bone problems, or he or she may talk to you about taking folic acid before you get pregnant and lowering the fat and cholesterol in your diet. Your doctor may also give you advice about alcohol and drug use and sexually transmitted infections. As you get close to menopause, your doctor will talk to you about hormone replacement therapy. Your doctor may also talk to you about injury prevention practices, such as using seat belts and having smoke detectors in your home.

What preventive services do men need?

Adult men should have their weight, cholesterol levels and blood pressure checked regularly. Men older than 50 should be tested for colorectal cancer. If your doctor orders this test, it does not mean he or she thinks you have cancer. This is a routine test that everyone should have. Your doctor will also make sure you have all the shots you need.

Your doctor may talk to you about the importance of diet and exercise, testing for prostate cancer and avoiding alcohol, tobacco, drugs and sexually transmitted infections. Your doctor may also talk to you about injury prevention practices, such as using seat belts and having smoke detectors in your home.

What preventive services do children need?

Shots are one of the most important preventive services for children. Shots (also called vaccines) protect children from diseases such as polio, measles and mumps. Your doctor will check your child to make sure he or she is growing and developing properly. Your doctor will tell you what you can do to keep your child's teeth healthy. Your doctor may also give you advice about how to keep your child safe from accidents and injuries (for example, using car seats and seat belts and keeping your child away from poisons and electric outlets). Your doctor will also talk to you about teaching your child healthy eating habits and exercise habits. Your doctor can tell you how to teach your child about the dangers of drugs, alcohol and tobacco. You can also ask your doctor for tips on how to talk to your teenager about avoiding pregnancy, sexually transmitted infections and AIDS.