Employers and the Public: The Future of Primary Care

Paul Grundy's affable, homespun persona does not diminish his pragmatic, studied view on why the U.S. healthcare system delivers such comparatively mediocre results at more than double the cost of the world's 25 most expensive healthcare systems.

Grundy, who serves as global director of healthcare transformation for IBM and is known as the "godfather" of the Patient-Centered Medical Home initiative, recently sat down with me to discuss the current state of medicine.

Pointing to a speech he made in Wichita, Kan., in 2010, Grundy observed that "…the American experiment at providing 'high-end' specialty care (without any effort to provide comprehensive, robust preventive and primary care that is integrated with care management) - has failed us all."

Five years later, with the exception of scattered initiatives, most of which have been as ignored as they have been successful, nothing much has changed. "Appropriate reimbursement for enhanced primary care is a continuing failure," Grundy said.

Denmark, to which Grundy serves as a healthcare ambassador in a continuing role from his days as a diplomat for the U.S. State Department, is his favorite example of how to do things right. His argument does not advocate socialized medicine. It is one of common sense.

Both governments, the U.S. and Denmark, subsidized the transition to EHRs. Denmark required a functioning interoperative system so any doctor can treat any patient at any time. The U.S. mandated the same policy, but it was so badly written that the reality is the exact opposite.

Another divergence in the two systems is that, in Denmark, primary-care physicians are paid more than specialists. In the U.S., primary-care physicians are not only the lowest paid, their reimbursements are being further reduced. In Denmark, with doctors in charge of patient care instead of hospitals, truly integrated care and primary care are at the heart of the system - hospitalizations plummeted dramatically, more than four of every five hospitals closed because they simply became unnecessary. If your first thought was that care is severely rationed under such a system, compared to the U.S., Danes are, and stay, healthier - not only at less than half of the economic cost, but with far less loss of quality of life, and, life itself.

Americans recoil at the concept of government control of healthcare. Yet, the reality is that U.S. healthcare is so controlled and regulated that almost a trillion dollars per year is spent on regulatory forms, reports, and compliance - 31 percent of the entire cost of healthcare. Almost another trillion dollars, 30 percent, is wasted by over-utilization encouraged by a system that rewards treating sick people and starves those responsible for making and keeping them well.

No one gets a pass. "You see," Grundy points out, "the terrible truth is … if money can be made off of your body, most likely it will be."

Getting the U.S. government, press, and pundits to see common sense is another challenge. The "evils of socialized medicine" and "personal choice" and "bureaucrats deciding what constitutes your healthcare instead of doctors" are favorite rallying cries. It is a fair bet that personal choice for families, physicians, and employers would involve getting better care at a fair cost.

The most brilliant solutions are the most simple, and Grundy does not disappoint. Getting American hospitals and physicians to cooperate in a system similar to that used by the rest of the developed world is most often compared to "herding cats." Grundy's take is simple, "If you want to herd cats, you just have to move their food."

I asked Grundy what he felt the outcome of the hospital system and insurance consolidation movement will be. "Hospitals are going to have to become health plans to survive," Grundy responded, "And, there will be a lot of collateral damage in the process."

Grundy has a different vision for America. One where employers and the public will come together to drive change - they are already are on their way. Plus, Grundy makes a strong argument: Employers and the public buy the food, and are in a position to move it.