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Surviving the New Economics of Health Care

Public Affairs Forum

July 25, 2012

An interview with Dr. David O. Meltzer, chief of the Hospital Medicine Section and director of the Center for Health and Social Sciences, University of Chicago

Ed English: Welcome to PA Forum. I'm Ed English, and today I'm joined by Dr. David Meltzer of the University of Chicago, and we will be talking about an interesting approach to the doctor-patient relationship in American medicine. Dr. Meltzer, welcome and thanks for joining us.

Now, you feel patient care is better served through one doctor maintaining a close relationship with a single patient than fragmenting it among many doctors or many specialists. So can you speak to the benefits from a health standpoint?

David O. Meltzer: Sure. I think that there are benefits to continuity in the doctor-patient relationship, and to make sure that we take advantage of those benefits I think is important that we try to do a better job of focusing on maintaining continuity of care in the doctor-patient relationship. Now, that doesn't mean that people only have one doctor; they can have multiple doctors. But it means that when there are opportunities for a single doctor to provide care, as opposed to having many different doctors provide care, that it's something that we should consider.

So I'll give you an example. It used to be that people had a primary care doctor who took care of all the dimensions of the health care—they'd care for them in the clinic when they were sick, they'd care for them in the hospital when they were sick. Increasingly in the U.S., people have had a clinic doctor who saw them when they were in a clinic, but then a different doctor that sees them in a hospital, and maybe a different doctor every time. It's that kind of discontinuity that I think is dangerous and harmful to patients.

Now I don't want to be single-minded about it, though, because I recognize that there are some things that are specialized care, and when you need a specialist, you need a specialist. So no matter what kind of great relationship I might have with my primary care doctor I don't think I want them doing neurosurgery on me. So it's a balance.

And what I'm advocating for is more careful thought about the balance, in particular, thinking of strategies to maximize the value of continuity—coming through things such as the forces I mentioned, trust, interpersonal relationship, better communication, and better knowledge of the patient.

And in fact, there are some wonderful studies showing that patients who are cared for by doctors with whom they have a longer-standing relationship have lower costs, less hospitalization, less use of the intensive care unit at the end of life when presumably it's not going to produce such benefits for people. And so I think there is the potential that there could be significant economic savings from having improved continuity in the doctor-patient relationship, particularly for these frequently hospitalized patients.

English: So how would you see this approach working with the Affordable Care Act?

Meltzer: So one of the areas I've been particularly interested in promoting improvements in the continuity in the doctor-patient relationship is for these patients who are frequently hospitalized. And we've been developing a new model of care to try to promote this. The model is based on an observation that over time primary care doctors have been less frequently caring for patients in the hospital and the reason that we think that's happening is because these primary care doctors don't have enough patients in the hospital at any given time to justify making the trip. And so what we are trying to do in the new model of care is have a set of doctors who focuses on only patients at high risk of hospitalization, but cares for them both in the inpatient setting and in the outpatient setting, and because they are focusing only on patients at high risk of hospitalization they will have enough patients in the hospital every day that they can spend their mornings in the hospital, they can spend their afternoons in the clinic, just like doctors used to, and provide that, sort of, ongoing care.

Now, the way this ties to the Affordable Care Act is that the cost savings that would come from that model would be from eliminating hospitalizations. But right now hospitals are paid to hospitalize people, so there's no business case to invest the money to build this new model of care. So one of the nice things about the Affordable Care Act is that it provides funding to support innovation projects supported by the Center for Medicare and Medicaid Innovation that allow people to test new models to figure out if they are going to work. And so we have been funded by the Center for Medicare and Medicaid Innovation to study this project, and so we are in the process of developing it and working with them to refine it, and then, ultimately, figure out whether it produces better care.

English: Very interesting. Dr. Meltzer, thank you for your time today. And thank you for joining us on PA Forum. You can see this video and other PA Forum videos at our website, frbatlanta.org.