Critical Debate on the Future of Healthcare

The Paradox of America’s Healthcare System

Outstanding Science and Providers But Dysfunctional Delivery of Care

There is a real paradox in American healthcare and it has profound implications for the health, wellness and medical care you, your family and your loved ones get today.

On the one hand, we have incredible science, technologies, drugs, devices and providers. On the other hand, we have a truly dysfunctional healthcare delivery system.

America has exceptionally well-educated and well-trained providers committed to your care.

America is the envy of the world for its biomedical research prowess uncovering the basic science of human biology, funded largely by the government via the National Institutes of Health and conducted across the county in universities and medical schools.

Image provided by author

The pharmaceutical and biotechnology industries continuously bring forth lifesaving and disease-altering medications.

The medical device industry is incredibly innovative and entrepreneurial. The makers of diagnostic equipment such as CT scans and handheld ultrasounds are equally productive. 

Consider these examples: The science of genomics is revolutionizing medical care in profound ways, such as producing targeted cancer drugs, predicting later onset of cardiac disease, offering prognostic data to guide cancer treatment, rapidly identifying bacteria and its antibiotic susceptibility, indicating whether a drug will work in a specific person and determining if a drug will cause a side effect in that person. 

The pharmaceutical industry has brought us statins to reduce cholesterol, drugs to prevent blood clotting and effective means to control high blood pressure. The rapid development of multiple vaccines and treatments against Covid-19 has been an incredible tour de force.

The device industry has created a potpourri of new approaches that have transformed, for example, cardiac care, including angioplasty, stents, pacemakers and intra-cardiac defibrillators. We even have the ability to replace the aortic valve without major heart surgery. 

Organs can be imaged noninvasively in incredible anatomic detail while also showing their inner cellular workings. The operating room is equipped with devices that make surgery less invasive, more effective and much safer.

Simulation technology has completely changed how trainees learn the basics of procedures from the simple, such as drawing blood, to the complex, such as laparoscopic surgery and cardiac catheterization. Robots are assisting surgeons in open heart and prostate surgery and are integral to today’s large hospital pharmacies and central sterile supply systems.

We may be on the verge of using genetically modified animal organs transplanted to humans for heart, lungs and kidneys.

The electronic medical record allows rapid access to information at any time and place, helps the physician to select the correct medication and dose and speeds up prescription transfer to the patient’s local pharmacy.

Radiology and pathology images can be sent via the Internet to a distant site for interpretation by a specific expert. A video of an ongoing surgical procedure can be evaluated by a distant authority in real time to give advice to the operating surgeon, such as in a battlefield situation far from home. And some surgery can even be done distantly via robotic controls.

We can be appropriately awed, proud and pleased about what is available for our care but to a large degree, we don’t fully benefit because —

We have a very dysfunctional health care delivery system. It is highly flawed and just does not work well.

Image from Peterson KFF Health System Tracker

America spends nearly 20 percent of its Gross Domestic Product on medical care, which is double that of the average of 9.9% for the other 34 economically-developed countries (such as Canada, Britain, France, Germany and Japan) in the Organization for Economic Cooperation and Development. On a per capita basis, America spent ~$12,000 on health as of 2020, which is more than twice the average of the other countries and well above Switzerland, the second highest country in expenditures, at ~$7000.

Despite these expenditures, our lifespans are somewhat shorter with Japan and Hong Kong at the top of the charts averaging 85 years and the United States ranked at number 46 with an average of 79 years and falling somewhat in the past few years. This decline is not for lack of medical advances but is rooted in the social determinants of despair and disease and the linked epidemics of obesity and type 2 diabetes.

There are thousands of preventable hospital deaths each year, and there are ~100,000 deaths due to hospital-acquired infections.

On a direct personal basis, you experience the dysfunction personally in many venues. You pay a high price for your health insurance yet you get only 15 minutes with the doctor. You are frustrated, perhaps angry and the doctor is equally frustrated and increasingly burned out. Tests and procedures are way overutilized. Trips to the ER and admissions to the hospital are much greater than necessary. Plus, these incredible technologies and lifesaving drugs are often used in ways or settings in which the marginal benefit barely, if at all, exceeds the marginal cost.

This is not an enviable record.

A report from the National Research Council and Institute of Medicine, summarized in the Journal of the American Medical Association, found “the health outcomes [of the United States] are generally worse than those of other wealthy nations. People in the United States experience higher rates of disease and injury and die earlier than people in other countries. Although this health disadvantage has been increasing for decades, its scale is only now becoming more apparent.”

Although there is better control of high blood pressure and cholesterol and there are lower cancer and stroke mortality rates, U.S. citizens have a lower life expectancy, higher infant mortality, higher rates of premature birth and thus lower birth weights, a higher incidence of HIV-AIDS, the highest prevalence of obesity and diabetes and the second highest rate of death from coronary artery disease, among other ills. To repeat, this is not an enviable record, especially given the level of expenditures. 

In sum, the paradox is that America has the providers, the science, the drugs, the diagnostics and the devices needed for outstanding patient care. But the delivery of care is dysfunctional at best and far too expensive. You are not getting the full potential of care that could and should be available and you are paying too much for what you do get.

In the articles to follow, I will delve into the what’s and why’s of this predicament along with practical approaches to improvement. Please join me.

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Stephen Schimpff MD
Stephen Schimpff MD
Early career at the National Cancer Institute's Baltimore Cancer Research Center developing new approaches to infection prevention and treatment of leukemia and lymphoma patients. Then the head of infectious diseases and director of the University of Maryland Cancer Center followed by senior leadership positions in the Medical School and Medical System culminating as CEO of the University of Maryland Medical Center. Now the author of 7 books on health and wellness, our dysfunctional healthcare delivery system & the crisis in primary care. Lover of nature. Happily married for 58 years.

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