President-Elect Barack Obama's quote, recently made on NBC's Meet the Press, is illuminating in relation to healthcare modernization.

Rahm Emanuel, chief of staff, puts it another way. "Where there is crisis, there is opportunity."

Clearly, this new administration will come to Washington with an aggressive healthcare reform agenda and a "window of opportunity" attitude, created by current economic circumstances.

In all likelihood, this healthcare reform movement will produce significant change throughout the healthcare landscape. All stakeholders will be affected. All aspects of healthcare financing, reimbursement, insurance, pricing and delivery models will be impacted.

Many of the details, of course, remain uncertain. The aim of this issue of FUSE is to make some assumptions regarding the impact that healthcare modernization may have on the current delivery model, with a focus on primary care. We will then briefly examine how the pharmaceutical industry could possibly better align with these trends.

The case for reform seems pretty clear. The U.S. is the only developed country without health coverage for all of its citizens. 15.3 percent of the population lacked health insurance in 2007.¹ Perhaps as significant, are the additional 25 million Americans who are under-insured. According to a recent Commonwealth Trust Study, 79 million Americans are unable to pay their medical bills² and more than half of those people were insured.

The justification for healthcare modernization extends well beyond coverage and access. By 2017, healthcare expenditures are expected to consume nearly 20% of GDP or $4.3 trillion annually. Despite these spiraling costs, Americans aren't realizing the benefits of these extraordinary per capital expenditures. The US ranks last out of 19 industrialized countries in unnecessary deaths³ and 29th out of 37 countries in infant mortality.⁴

I guess some facts just need repeating before they stick.

Currently in the pharma and general health industries there is a tremendous amount of attention and resources being directed and invested in attempting to get closer to the patient. In fact, I've even heard the term "owning the patient relationship" as a priority for many pharma companies. In general, pharma's focus on building stronger relationships with patients is undeniably a good thing. Whether or not the industry has the necessary resources, data, expertise, delivery model relationships, and leverage to truly provide value added services to patients and effect positive outcomes remains to be seen. If, in the end, only more drugs get sold, then once again the industry will be vulnerable to criticism, particularly in this era of reform.

During the last decade, managed care organizations have invested substantial resources in patient/physician-centric solutions targeting chronic care management. These interventions are very comprehensive but have proven to be only marginally successful. By comparison, MCOs are capable of deploying far more significant resources, expertise and leverage over stakeholders than the pharma industry's drug-centric methodologies. Having said that, I would not advise the pharma industry to abandon its quest to get closer to patients, but rather, I would suggest that approaches and expectations of these endeavors be realistically calculated and communicated.

First, let's establish some assumptions regarding likely trends in the US healthcare delivery model during the next three years:

Let's assume that strengthening the role of primary care and chronic care management would be the cornerstones of innovation in the delivery model. And, for good reasons: Currently, 45 percent of the population has a chronic medical condition (half of which are polymorbid).⁵ Among the Medicare population, 83 percent of individuals has at least one chronic condition and almost a quarter have at least five co-morbidities.⁶ The US has 87 primary care physicians/100,000 lives, but this ratio has been trending down as primary care residency positions go unfilled and current PCPs leave medicine.⁷ In Massachusetts, 42 percent of internists surveyed in a recent study have closed their practices to new patients. Average waits for routine appointments with PCPs in Massachusetts increased by over 50 percent since 2006.

This combination of the demand for chronic care management and the decline in PCP availability is at the core of our nation's healthcare delivery crises. This situation will only be exacerbated by any healthcare reform initiative which would flood the delivery system with new insured patient populations. All stakeholders in the US healthcare system need to recognize and address this fundamental imbalance in the system.

PCPs (family medicine, general internal medicine, general pediatrics, nurse practitioners, and physician assistants) will be at the hub of this emerging, patient-centered approach to care, in the broad context of the total medical care delivery system. This patient-centered approach is not about Web 2.0, DTC, DTP or CRM. Rather, it's an expanded concept in which each patient will have an ongoing relationship with a personal physician, who will lead a team of providers at the practice level to manage the continuous care of the patient. In this medical home⁸ model, the PCP will act as the first-line interface for all healthcare related issues and take responsibility for and coordinate all aspects of a patient's care. In this model, patients are active participants in their health and healthcare. The practice has a patient-centered, relationship oriented culture that emphasizes the importance of meeting patients' needs.

Most patients want a strong relationship with a primary doctor.⁹ More specifically, patients want three things from their general practitioner:

• First is communication - bi-directional, as frequent as necessary and not necessarily always in person.

• Second, they want to feel like they're in a partnership with their doctors, and that their beliefs and feelings are being listened to, taken seriously, and acted upon.

• Third, patients want personalized health promotion and support from their doctors. These would include sound advice, helpful information and education oriented materials and guidance on how to maintain good health.

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