Thomas Bodenheimer

Coordinating Care — A Perilous Journey through the Health Care System

Patients with chronic illness often receive care from multiple providers in multiple settings and require coordination of their complex care. This report assesses the quality of the coordination of care, describes barriers to coordinated care, and discusses some solutions to improve care coordination in the United States.

Primary Care: Current Problems And Proposed Solutions

In 2005, approximately 400,000 people provided primary medical care in the United States. About 300,000 were physicians, and another 100,000 were nurse practitioners and physician assistants. Yet primary care faces a growing crisis, in part because increasing numbers of U.S. medical graduates are avoiding careers in adult primary care. Sixty-five million Americans live in what are officially deemed primary care shortage areas, and adults throughout the United States face difficulty obtaining prompt access to primary care. A variety of strategies are being tried to improve primary care access, even without a large increase in the primary care workforce.

From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider

The Triple Aim—enhancing patient experience, improving population health, and reducing costs—is widely accepted as a compass to optimize health system performance. Yet physicians and other members of the health care workforce report widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs. Burnout thus imperils the Triple Aim. This article recommends that the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.

Confronting The Growing Burden Of Chronic Disease: Can The U.S. Health Care Workforce Do The Job?

The U.S. chronic illness burden is increasing and is felt more strongly in minority and low-income populations: in 2005, 133 million Americans had at least one chronic condition. Prevention and management of chronic disease are best performed by multidisciplinary teams in primary care and public health. However, the future health care work-force is not projected to include an appropriate mix of personnel capable of staffing such teams. To prepare for the growing chronic disease burden, a larger interdisciplinary primary care workforce is needed, and payment for primary care should reward practices that incorporate multidisciplinary teams.

High and Rising Health Care Costs. Part 1: Seeking an Explanation

Rising-health-care-costs has become a household wordand worryfor the general public, governments, and employers who purchase health care for their employees. In 2002, the United States spent

High and Rising Health Care Costs. Part 2: Technologic Innovation

5267 per person for health care. Switzerland, the second most expensive health system, posted a per capita figure of

The Teamlet Model of Primary Care

3445, two thirds of the U.S. amount. The third, fourth, and fifth most costly health systems, those of Norway, Canada, and Germany, reported 2002 health expenditures per capita less than 60% that of the United States. The United Kingdom, a frugal system, spent

In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices

2160 per person in 2002, 41% of the U.S. amount (1). Not only does the United States outspend other nations in health care, but U.S. health care costs are growing rapidly. From 1988 to 1993, U.S. health expenditures rose by 9.7% per year. Following a slowdown from 1993 to 2000, costs jumped by 8.5% in 2001, 9.3% in 2002, and 7.7% in 2003 (2, 3). The health care sectors with the most rapid growth in cost are prescription drugs and administrative costs of private health insurance (each increasing at 11% to 16% over the past 3 years). Hospital and physician expenditures have been growing at annual rates closer to 7% to 8% over the past 3 years (3). The federal government projected an average annual growth rate of 7.2% through 2013, with health expenditures (Table) rising from

Goal-setting for behavior change in primary care: An exploration and status report

1.6 trillion in 2002 (14.9% of gross domestic product, the value of all goods and services produced in a nation) to

As good as it gets? Chronic care management in nine leading US physician organisations.

3.6 trillion by 2013 (18.4% of gross domestic product) (4). It is undisputed that U.S. health expenditures are high and rising, but the mechanisms behind these phenomena are a topic of debate. Table. How Are Health Care Costs Measured? This article begins a 4-part series on health care costs. The series presents a variety of perspectives on costs and cost-control strategies. An overview of a complex topic, written by a noneconomist for noneconomists, the series addresses the following questions: Are high and rising health care expenditures a serious problem, or is the national preoccupation with health care costs excessive? Why are health care expenditures higher in the United States than in other countries? Why are health care expenditures growing so fast? What strategies are available to slow the rate of growth of health expenditures? Do any strategies exist that enable physicians to reduce costs while improving or protecting quality? Articles 1, 2, and 3 address the first 4 questions through discussions of 7 different perspectives on health care costs. The final article searches for health policys Holy Grail: cost-containment strategies that protect or improve health care quality. A Quick Synopsis of the Health Care System Four major actors occupy the health care stage: purchasers, insurers, providers, and suppliers (8). Purchasers, including employers, governments, and individuals (some of whom are patients), supply the funds. Insurers receive money from purchasers and reimburse providers. The government can be viewed as an insurer or a purchaser in the Medicare and Medicaid programs. The term payer refers to both purchasers and insurers. Providers include physicians and other health professionals, hospitals, nursing homes, home care agencies, and pharmacies. Suppliersthe pharmaceutical, medical supply, and computer industriesmanufacture equipment, supplies, and medications used by providers. Each dollar spent on health services represents an expense to payers and revenue to providers and suppliers. Payers generally wish to reduce the dollars flowing into health care, while providers and suppliers want to increase those dollars. Payers want to contain costs; providers and suppliers resist cost containment. That conflict is the fundamental battle in the health care economy. Secondary skirmishes complicate this battle. Although insurance companies are payers and try to reduce reimbursements to providers and suppliers, they want more money from purchasers. Providers and suppliers may engage in ferocious conflicts; for example, hospitals purchasing pharmaceuticals negotiate for a low price while pharmaceutical manufacturers demand a high price. Providers may face off against one another. If a physician group receives a capitation payment from an insurer, primary care physicians and specialists may fight over how much of the capitation check goes to each group. Health care costs represent a battleground among competing interests (Figures 1 and 2). Figure 1. Where the health care dollar comes from, 2002. Figure 2. Where the health care dollar goes, 2002. Varying Perspectives on Health Care Costs The literaturescientific, commercial, and popularon health care costs contains a variety of perspectives on why costs are high and how to control their growth. While few analysts adhere to only 1 of these views, the perspectives can be grouped into 7 categories. High and rising costs are not such a serious problem. High and rising costs are a problem, but they are created by factors external to the health care system. High and rising costs are caused by the absence of a free market; the remedy is to give patients more responsibility for costs of care and to encourage competition among health insurers and providers. High and rising costs result from medical technologies creating innovation in the diagnosis and treatment of illness. High and rising costs are in part the result of excessive costs of administering the health care system. High and rising costs are explained by the absence of strong cost-containment measures. High and rising costs are the result of the market power of health care providers. I take each of these perspectives in turn and examine some arguments pro and con, linking differing cost-control strategies to some of these perspectives. In this article I cover the first 3 perspectives. In a few cases, agreement among analysts is substantial. In other cases, disagreements are profound. Perspective 1: Costs Are Not a Serious Problem Some articles have argued that high and rising health expenditures present some difficulties but are not a serious problem. These writings point out that health care improves health outcomes, provides jobs and income, and delivers services that people desire; thus, increased health expenditures may be a good rather than a bad thing. Moreover, if the general economy is expanding, increases in health spending may not reduce spending on sectors outside the health care economy (9-11). Organizations and individuals touched by the reality of costly health care do not share this opinion. Most employers, for whom the purchase of employee health insurance is an expense rather than a revenue, are anxious to reduce insurance premiums (12-14). If premiums were lower, employers could augment employee wages, reduce consumer prices, or increase profits (15, 16). Expanding government health expenditures create budget deficits and crowd out spending for education, police, fire, and other services (15). Rising costs increase the number of uninsured people through 3 mechanisms: Employers stop offering insurance to their employees (14, 17, 18), employees decline employer-offered health insurance because they cannot afford the employee share of the premium (19), and people are dropped from Medicaid as state governments respond to increased costs with eligibility reductions (20, 21). For the large proportion of the population that is uninsured or underinsured, higher costs make physician visits, preventive services, and prescription drugs less affordable, particularly for poor persons, elderly patients, and those in ill health (22-26). When costs rise and governments reduce reimbursements, institutions serving as the safety net for the uninsured may close their doors (27). These effects of rising costs demonstrate that increased cost often means decreased access. In summary, while rising costs may not create major problems for the economy as a whole, they do negatively affect employers, employees, governments, and patients. Perspective 2: High Costs Are Due to Factors External to the Health Care System High health care costs might derive from factors outside the health sector rather than from characteristics of the health care system itself. One such external cause is the state of the overall economy. International comparisons of health spending consistently show that the level of health expenditures per capita is closely associated with total GDP per capita. In other words, richer nations spend more per capita on health care than poorer nations (28). Although no one disputes this association, one key fact stands out: The United States is a striking outlier (Figure 3). For example, the U.S. GDP per capita is 150% that of Sweden, but U.S. health spending per capita is 240% that of Sweden (28). The same relationship is found between the United States and almost all other developed nations (29). The U.S. outlier status suggests that high and rising costs in the United States cannot be explained simply by invoking GDP per capita. Figure 3. Health expenditures and gross domestic product ( GDP ) per capita, 1998. Another possible external cause for rising health case costs is the aging of the populations of developed nations. Given that people older than 75 years of age incur per capita health expenditures 5 times higher than those of people age 25 to 34 years (30), it is logical to assume that nations with a higher proportion of elderly people would have higher per capita health expenditures than nations with younger age distributions. Research, however, consistently shows that this demographic trend explains only 6% to 7% of health expenditure growth (30-32). A cross-national regression analysis of the effects of aging on health spending found no significant relationship between the percentage of elderly persons in a nations population and national health spending (28, 30, 32). Several factors explain this finding. The fraction of the population age 65 ye