Stephen C. Schimpff, MD

We have a real paradox in American health care.

We have superb medical schools and exceptionally well-trained physicians who are committed to our care. America is the envy of the world for its biomedical research prowess, funded largely by the National Institutes of Health and conducted in universities and medical schools across the country. The U.S. pharmaceutical industry continually brings forth lifesaving and disease-altering medications, and the medical device industry is incredibly innovative and entrepreneurial.

On the other hand, we have a very dysfunctional delivery system for this incredible care. We spend more per capita on health care than any other country, and yet, compared with the health of other countries, especially developed countries, our outcomes are not better. Our life spans are shorter than in Japan, for instance, and our infant mortality rates are higher than in England and France.

Courtesy Stephen C. Schimpff

Our current delivery system concentrates on illness and on trauma, and focuses on treating acute medical problems, where it is reasonably effective, but works poorly to address most chronic medical illnesses. Chronic illnesses consume about 75%-85% of all dollars spent on medical care. The Milken Institute published a white paper a few years ago on chronic illnesses in which it noted that nearly one-half of Americans had one or more, mostly preventable, chronic illnesses. According to this report, these illnesses cost the economy over $1 trillion per year.

Chronic illnesses – from diabetes and coronary artery disease to cancer, and chronic lung and kidney disease – are increasing in frequency at a rapid rate. Moreover, they are largely preventable. One-third of Americans are overweight and more than one-third are obese. Chronic stress is prevalent, and 20% of Americans still smoke. Too many people are sedentary and either overeat or primarily eat a nonnutritious diet. The result is that high blood pressure, high cholesterol, and elevated blood glucose are extremely prevalent in the United States. These and other poor health factors lead to and exacerbate a host of chronic conditions that are difficult to manage, last a lifetime (some cancers excepted), and are expensive to treat.

What we need in America today is to focus on true health care on two fronts. First, not only do we need to diagnose and treat disease and injury when they occur, but we must promote wellness and disease prevention. Second, we need a health care delivery system that truly and effectively coordinates care for patients with chronic illnesses. Both of these shifts require primary care at the helm – with paid time for careful listening and attention to detail – and a multidisciplinary approach that appropriately integrates medical specialists along with nurse practitioners, physician assistants, and other nonphysician professionals.

Refocusing American health care involves and impacts obstetrician-gynecologists as much as any other physicians, because ob.gyns. are uniquely positioned to affect women’s lives and health behaviors from adolescence to childbearing years and early motherhood, and through aging.

Drivers of change

Adverse behaviors and lifestyles and the prevalence of chronic illness in our society are exerting a great force on the health care delivery system and will, therefore, drive substantial change in the system in coming years – more so than the current health care reform. Among the other drivers of change:

• Aging. American society is growing older, and just as in a car, "old parts wear out." Aging brings impaired vision, impaired hearing, impaired mobility, impaired dentition, impaired bone strength, and impaired cognition, all of which need to be managed.

• Consumerism. Patients no longer want to be patient. They are coming to want and expect to be treated as valued customers by primary care providers and specialists. They want good service and expect higher levels of respect. Patients expect their physicians to listen to them and treat their conditions with confidentiality. They also want short wait times in the office, short wait times when calling for an appointment, and short travel distances.

Patients increasingly understand that care is often not as high quality and safe as it should be, and they are expecting actions to make it better. If they perceive nothing is being done, they are increasingly likely to go elsewhere. They also want interaction by e-mail and other electronic methods, and they also are pressing for and expecting a more integrative approach from their providers – an approach that cares for the whole person and incorporates complementary medical modalities where appropriate.

• Professional shortages and expectations. Shortages of nurses and pharmacists have been noted for more than a decade. More and more, there are shortages of primary care physicians, general surgeons, and other physicians, including ob.gyns., especially in rural and urban poor areas. Newly graduated physicians increasingly want little or no administrative responsibility, less night and weekend call duties, a salaried position instead of a private practice, and family time assured.

• Technology. New technologies have made health care delivery much more nimble by embedding tools into smartphones, allowing providers to access information wirelessly, or miniaturizing equipment. Hand-held ultrasound is now available at a price that a single physician can afford. For hospitals, on the other hand, the cost of new technologies like MRIs, CT scanners, and equipment for radiation therapy is so high that in order to stay abreast of trends, hospitals need substantial hard-to-raise capital.

• Costs. The costs of care are rising with no end in sight, and none of the current reforms and other proposals offered thus far will effectively curb the increases. This is because most approaches offered by government and insurers do not address the real problems. Patients, in the meantime, are facing greater requirements from employers to share the cost of care. Among employer-sponsored plans, there is an increasing push toward high-deductible-plans, with deductibles in the $1,000-$2,000 range.

The most glaring problem in American health care, however – and the largest driver of change – is the limited time that primary care physicians actually spend with their patients. Most primary care physicians in the United State, including many ob.gyns., are trapped in a business model that forces them to see at least 24-25 patients per day (a total patient load of 2,000-plus). The model typically allows for about 12 minutes of face time with each patient and leaves no time for careful listening, for care coordination, for talking with specialists, or for thinking deeply about diagnostic dilemmas.

When patients have a slightly complex case that cannot be solved in 12 minutes or less, physicians are left no option but to refer these patients to a specialist, which dramatically increases the cost of care delivery.

The changes ahead

There are many pilot programs embedded in the Patient Protection and Affordable Health Care Act that attempt to address health care delivery cost and quality, and perhaps some will bear value in coming years. Overall, however, reform in Washington is largely about medical care financing and insurance coverage.

Accountable care organizations and medical homes are good alternatives to traditional care models and could provide outstanding care, but these options will not succeed unless productivity standards are lowered such that the generalist physician truly has the time to listen, think, prevent, and coordinate. Similarly, capitation (payment of a fixed sum for all care for one patient for 1 year) will succeed only if the rate per patient is sufficient enough so that the physician can sustain a practice while seeing fewer patients and hence spend enough time with each one. Thus far, this has rarely been the case.

In the absence of major changes on the horizon from the government or insurers that put incentives and funding in the right places, health care delivery can only transform in fits and starts in response to the major drivers of change. Although some changes to the current system will be truly transformational, many will only be incremental.

Among the transformative – and one could say disruptive – changes will be change in our hospitals. Certainly more and more can be accomplished in the outpatient setting, but as more people survive longer and have more chronic illnesses, there will be a need for more hospital beds, ICUs, operating rooms, and high technology – the reverse of the mantra of recent decades which proclaimed that we had "too many hospitals and too many beds." Hospitals also will need capital for renovations, new wings, and all the needed technology. With credit tight, smaller hospitals will merge into larger systems, and there will be few stand-alone community hospitals in the coming years.

To compensate for the shortage of nonspecialists and to allow generalists to do what is needed and what they are best at doing, there will be greater use of nurse practitioners, physician assistants, nutritionists, exercise physiologists, and other nonphysician professionals. Physicians will increasingly need to embrace, rather than marginalize, the work of adjunct providers in providing quality interaction with patients, augmenting preventive programs, and enhancing care coordination.

Ob.gyns. will likely find such team-building helpful as they strengthen their efforts to provide preventive care and promote healthy behaviors for women of all ages. The model of a health care team also can help ob.gyns. as they strive to deliver more preconception care and to work with women before and during pregnancy to create optimal intrauterine environments that will lead to healthier offspring. Like family physicians and internists, ob.gyns need time to spend with each patient to learn about her family and the environment in which she lives.

To provide comprehensive preventive care, and to adequately coordinate the care of patients with chronic illnesses, some physicians have decided to bill the patient directly for services and not accept commercial insurance or Medicare. Others have opted to convert their practices to "retainer-based" practices, or "concierge" practices, which are, in effect, a type of capitation without the intermediary of the insurance company. The patient pays a fixed annual fee (usually $1,500-$2,000) for all care provided by the physician. In turn, the physician drops the practice size to about 500 patients; guarantees appointments within 24 hours; provides 24/7 cell phone access; and offers appointments that last as long as necessary, the option of e-mail conversations, and visitations in the hospital and emergency room.

Physicians operating such retainer-based practices report working as many hours as they did before, but say that they are giving superior care and that their patients are reporting a much greater level of satisfaction. The total costs of care come way down because the physician now has the time needed to thoughtfully sort out issues, resulting in fewer referrals to specialists, more lifestyle modifications instead of prescriptions, and fewer tests and x-rays. Hospitalizations are reduced by one-half, and unplanned readmissions after hospital discharge also are significantly reduced.

These changes, while quite disruptive, are, in the long run, bright spots on the horizon. While the cost of joining a retainer-based practice is out of reach for some individuals, the retainer system gives proof-of-concept to insurers and the government, who thus far have been too short-sighted to pay more per patient for primary care, and consequently have paid more across the entire spectrum of care. If such models could be adapted for wider use through the reallocation of insurer dollars, it would improve value for everyone.

The extent to which the retainer model will prevail in terms of physicians’ desires and expectations – as opposed to the options of becoming employed or joining large group practices – is uncertain. It is likely that we will see multiple shifts. Certainly, however, the future for delivering care to complex, chronically ill patients lies largely in multidisciplinary team-based care, with primary care physicians – including ob.gyns – serving as the quarterbacks.

Ultimately, key players will need to make it all happen so that we can have a delivery system that serves us well and costs us less. In the meantime, just as is happening in many large clinics, in certain specialty care centers, and in some primary care practices today, there is much that individuals and a combination of the leaders in medicine can do to keep the transformation moving.

Dr. Schimpff is the former chief executive officer of the University of Maryland Medical Center, Baltimore, and is a voluntary professor of medicine at the University of Maryland School of Medicine. He consults for the U.S. Army, medical startups, and Fortune 500 companies. Dr. Schimpff said he has no financial disclosures.

We have a real paradox in American health care.

We have superb medical schools and exceptionally well-trained physicians who are committed to our care. America is the envy of the world for its biomedical research prowess, funded largely by the National Institutes of Health and conducted in universities and medical schools across the country. The U.S. pharmaceutical industry continually brings forth lifesaving and disease-altering medications, and the medical device industry is incredibly innovative and entrepreneurial.

On the other hand, we have a very dysfunctional delivery system for this incredible care. We spend more per capita on health care than any other country, and yet, compared with the health of other countries, especially developed countries, our outcomes are not better. Our life spans are shorter than in Japan, for instance, and our infant mortality rates are higher than in England and France.

Courtesy Stephen C. Schimpff

Our current delivery system concentrates on illness and on trauma, and focuses on treating acute medical problems, where it is reasonably effective, but works poorly to address most chronic medical illnesses. Chronic illnesses consume about 75%-85% of all dollars spent on medical care. The Milken Institute published a white paper a few years ago on chronic illnesses in which it noted that nearly one-half of Americans had one or more, mostly preventable, chronic illnesses. According to this report, these illnesses cost the economy over $1 trillion per year.

Chronic illnesses – from diabetes and coronary artery disease to cancer, and chronic lung and kidney disease – are increasing in frequency at a rapid rate. Moreover, they are largely preventable. One-third of Americans are overweight and more than one-third are obese. Chronic stress is prevalent, and 20% of Americans still smoke. Too many people are sedentary and either overeat or primarily eat a nonnutritious diet. The result is that high blood pressure, high cholesterol, and elevated blood glucose are extremely prevalent in the United States. These and other poor health factors lead to and exacerbate a host of chronic conditions that are difficult to manage, last a lifetime (some cancers excepted), and are expensive to treat.

What we need in America today is to focus on true health care on two fronts. First, not only do we need to diagnose and treat disease and injury when they occur, but we must promote wellness and disease prevention. Second, we need a health care delivery system that truly and effectively coordinates care for patients with chronic illnesses. Both of these shifts require primary care at the helm – with paid time for careful listening and attention to detail – and a multidisciplinary approach that appropriately integrates medical specialists along with nurse practitioners, physician assistants, and other nonphysician professionals.

Refocusing American health care involves and impacts obstetrician-gynecologists as much as any other physicians, because ob.gyns. are uniquely positioned to affect women’s lives and health behaviors from adolescence to childbearing years and early motherhood, and through aging.

Drivers of change

Adverse behaviors and lifestyles and the prevalence of chronic illness in our society are exerting a great force on the health care delivery system and will, therefore, drive substantial change in the system in coming years – more so than the current health care reform. Among the other drivers of change:

• Aging. American society is growing older, and just as in a car, "old parts wear out." Aging brings impaired vision, impaired hearing, impaired mobility, impaired dentition, impaired bone strength, and impaired cognition, all of which need to be managed.

• Consumerism. Patients no longer want to be patient. They are coming to want and expect to be treated as valued customers by primary care providers and specialists. They want good service and expect higher levels of respect. Patients expect their physicians to listen to them and treat their conditions with confidentiality. They also want short wait times in the office, short wait times when calling for an appointment, and short travel distances.

Patients increasingly understand that care is often not as high quality and safe as it should be, and they are expecting actions to make it better. If they perceive nothing is being done, they are increasingly likely to go elsewhere. They also want interaction by e-mail and other electronic methods, and they also are pressing for and expecting a more integrative approach from their providers – an approach that cares for the whole person and incorporates complementary medical modalities where appropriate.

• Professional shortages and expectations. Shortages of nurses and pharmacists have been noted for more than a decade. More and more, there are shortages of primary care physicians, general surgeons, and other physicians, including ob.gyns., especially in rural and urban poor areas. Newly graduated physicians increasingly want little or no administrative responsibility, less night and weekend call duties, a salaried position instead of a private practice, and family time assured.

• Technology. New technologies have made health care delivery much more nimble by embedding tools into smartphones, allowing providers to access information wirelessly, or miniaturizing equipment. Hand-held ultrasound is now available at a price that a single physician can afford. For hospitals, on the other hand, the cost of new technologies like MRIs, CT scanners, and equipment for radiation therapy is so high that in order to stay abreast of trends, hospitals need substantial hard-to-raise capital.

• Costs. The costs of care are rising with no end in sight, and none of the current reforms and other proposals offered thus far will effectively curb the increases. This is because most approaches offered by government and insurers do not address the real problems. Patients, in the meantime, are facing greater requirements from employers to share the cost of care. Among employer-sponsored plans, there is an increasing push toward high-deductible-plans, with deductibles in the $1,000-$2,000 range.

The most glaring problem in American health care, however – and the largest driver of change – is the limited time that primary care physicians actually spend with their patients. Most primary care physicians in the United State, including many ob.gyns., are trapped in a business model that forces them to see at least 24-25 patients per day (a total patient load of 2,000-plus). The model typically allows for about 12 minutes of face time with each patient and leaves no time for careful listening, for care coordination, for talking with specialists, or for thinking deeply about diagnostic dilemmas.

When patients have a slightly complex case that cannot be solved in 12 minutes or less, physicians are left no option but to refer these patients to a specialist, which dramatically increases the cost of care delivery.

The changes ahead

There are many pilot programs embedded in the Patient Protection and Affordable Health Care Act that attempt to address health care delivery cost and quality, and perhaps some will bear value in coming years. Overall, however, reform in Washington is largely about medical care financing and insurance coverage.

Accountable care organizations and medical homes are good alternatives to traditional care models and could provide outstanding care, but these options will not succeed unless productivity standards are lowered such that the generalist physician truly has the time to listen, think, prevent, and coordinate. Similarly, capitation (payment of a fixed sum for all care for one patient for 1 year) will succeed only if the rate per patient is sufficient enough so that the physician can sustain a practice while seeing fewer patients and hence spend enough time with each one. Thus far, this has rarely been the case.

In the absence of major changes on the horizon from the government or insurers that put incentives and funding in the right places, health care delivery can only transform in fits and starts in response to the major drivers of change. Although some changes to the current system will be truly transformational, many will only be incremental.

Among the transformative – and one could say disruptive – changes will be change in our hospitals. Certainly more and more can be accomplished in the outpatient setting, but as more people survive longer and have more chronic illnesses, there will be a need for more hospital beds, ICUs, operating rooms, and high technology – the reverse of the mantra of recent decades which proclaimed that we had "too many hospitals and too many beds." Hospitals also will need capital for renovations, new wings, and all the needed technology. With credit tight, smaller hospitals will merge into larger systems, and there will be few stand-alone community hospitals in the coming years.

To compensate for the shortage of nonspecialists and to allow generalists to do what is needed and what they are best at doing, there will be greater use of nurse practitioners, physician assistants, nutritionists, exercise physiologists, and other nonphysician professionals. Physicians will increasingly need to embrace, rather than marginalize, the work of adjunct providers in providing quality interaction with patients, augmenting preventive programs, and enhancing care coordination.

Ob.gyns. will likely find such team-building helpful as they strengthen their efforts to provide preventive care and promote healthy behaviors for women of all ages. The model of a health care team also can help ob.gyns. as they strive to deliver more preconception care and to work with women before and during pregnancy to create optimal intrauterine environments that will lead to healthier offspring. Like family physicians and internists, ob.gyns need time to spend with each patient to learn about her family and the environment in which she lives.

To provide comprehensive preventive care, and to adequately coordinate the care of patients with chronic illnesses, some physicians have decided to bill the patient directly for services and not accept commercial insurance or Medicare. Others have opted to convert their practices to "retainer-based" practices, or "concierge" practices, which are, in effect, a type of capitation without the intermediary of the insurance company. The patient pays a fixed annual fee (usually $1,500-$2,000) for all care provided by the physician. In turn, the physician drops the practice size to about 500 patients; guarantees appointments within 24 hours; provides 24/7 cell phone access; and offers appointments that last as long as necessary, the option of e-mail conversations, and visitations in the hospital and emergency room.

Physicians operating such retainer-based practices report working as many hours as they did before, but say that they are giving superior care and that their patients are reporting a much greater level of satisfaction. The total costs of care come way down because the physician now has the time needed to thoughtfully sort out issues, resulting in fewer referrals to specialists, more lifestyle modifications instead of prescriptions, and fewer tests and x-rays. Hospitalizations are reduced by one-half, and unplanned readmissions after hospital discharge also are significantly reduced.

These changes, while quite disruptive, are, in the long run, bright spots on the horizon. While the cost of joining a retainer-based practice is out of reach for some individuals, the retainer system gives proof-of-concept to insurers and the government, who thus far have been too short-sighted to pay more per patient for primary care, and consequently have paid more across the entire spectrum of care. If such models could be adapted for wider use through the reallocation of insurer dollars, it would improve value for everyone.

The extent to which the retainer model will prevail in terms of physicians’ desires and expectations – as opposed to the options of becoming employed or joining large group practices – is uncertain. It is likely that we will see multiple shifts. Certainly, however, the future for delivering care to complex, chronically ill patients lies largely in multidisciplinary team-based care, with primary care physicians – including ob.gyns – serving as the quarterbacks.

Ultimately, key players will need to make it all happen so that we can have a delivery system that serves us well and costs us less. In the meantime, just as is happening in many large clinics, in certain specialty care centers, and in some primary care practices today, there is much that individuals and a combination of the leaders in medicine can do to keep the transformation moving.

Dr. Schimpff is the former chief executive officer of the University of Maryland Medical Center, Baltimore, and is a voluntary professor of medicine at the University of Maryland School of Medicine. He consults for the U.S. Army, medical startups, and Fortune 500 companies. Dr. Schimpff said he has no financial disclosures.

We have a real paradox in American health care.

We have superb medical schools and exceptionally well-trained physicians who are committed to our care. America is the envy of the world for its biomedical research prowess, funded largely by the National Institutes of Health and conducted in universities and medical schools across the country. The U.S. pharmaceutical industry continually brings forth lifesaving and disease-altering medications, and the medical device industry is incredibly innovative and entrepreneurial.

On the other hand, we have a very dysfunctional delivery system for this incredible care. We spend more per capita on health care than any other country, and yet, compared with the health of other countries, especially developed countries, our outcomes are not better. Our life spans are shorter than in Japan, for instance, and our infant mortality rates are higher than in England and France.

Courtesy Stephen C. Schimpff

Our current delivery system concentrates on illness and on trauma, and focuses on treating acute medical problems, where it is reasonably effective, but works poorly to address most chronic medical illnesses. Chronic illnesses consume about 75%-85% of all dollars spent on medical care. The Milken Institute published a white paper a few years ago on chronic illnesses in which it noted that nearly one-half of Americans had one or more, mostly preventable, chronic illnesses. According to this report, these illnesses cost the economy over $1 trillion per year.

Chronic illnesses – from diabetes and coronary artery disease to cancer, and chronic lung and kidney disease – are increasing in frequency at a rapid rate. Moreover, they are largely preventable. One-third of Americans are overweight and more than one-third are obese. Chronic stress is prevalent, and 20% of Americans still smoke. Too many people are sedentary and either overeat or primarily eat a nonnutritious diet. The result is that high blood pressure, high cholesterol, and elevated blood glucose are extremely prevalent in the United States. These and other poor health factors lead to and exacerbate a host of chronic conditions that are difficult to manage, last a lifetime (some cancers excepted), and are expensive to treat.

What we need in America today is to focus on true health care on two fronts. First, not only do we need to diagnose and treat disease and injury when they occur, but we must promote wellness and disease prevention. Second, we need a health care delivery system that truly and effectively coordinates care for patients with chronic illnesses. Both of these shifts require primary care at the helm – with paid time for careful listening and attention to detail – and a multidisciplinary approach that appropriately integrates medical specialists along with nurse practitioners, physician assistants, and other nonphysician professionals.

Refocusing American health care involves and impacts obstetrician-gynecologists as much as any other physicians, because ob.gyns. are uniquely positioned to affect women’s lives and health behaviors from adolescence to childbearing years and early motherhood, and through aging.

Drivers of change

Adverse behaviors and lifestyles and the prevalence of chronic illness in our society are exerting a great force on the health care delivery system and will, therefore, drive substantial change in the system in coming years – more so than the current health care reform. Among the other drivers of change:

• Aging. American society is growing older, and just as in a car, "old parts wear out." Aging brings impaired vision, impaired hearing, impaired mobility, impaired dentition, impaired bone strength, and impaired cognition, all of which need to be managed.

• Consumerism. Patients no longer want to be patient. They are coming to want and expect to be treated as valued customers by primary care providers and specialists. They want good service and expect higher levels of respect. Patients expect their physicians to listen to them and treat their conditions with confidentiality. They also want short wait times in the office, short wait times when calling for an appointment, and short travel distances.

Patients increasingly understand that care is often not as high quality and safe as it should be, and they are expecting actions to make it better. If they perceive nothing is being done, they are increasingly likely to go elsewhere. They also want interaction by e-mail and other electronic methods, and they also are pressing for and expecting a more integrative approach from their providers – an approach that cares for the whole person and incorporates complementary medical modalities where appropriate.

• Professional shortages and expectations. Shortages of nurses and pharmacists have been noted for more than a decade. More and more, there are shortages of primary care physicians, general surgeons, and other physicians, including ob.gyns., especially in rural and urban poor areas. Newly graduated physicians increasingly want little or no administrative responsibility, less night and weekend call duties, a salaried position instead of a private practice, and family time assured.

• Technology. New technologies have made health care delivery much more nimble by embedding tools into smartphones, allowing providers to access information wirelessly, or miniaturizing equipment. Hand-held ultrasound is now available at a price that a single physician can afford. For hospitals, on the other hand, the cost of new technologies like MRIs, CT scanners, and equipment for radiation therapy is so high that in order to stay abreast of trends, hospitals need substantial hard-to-raise capital.

• Costs. The costs of care are rising with no end in sight, and none of the current reforms and other proposals offered thus far will effectively curb the increases. This is because most approaches offered by government and insurers do not address the real problems. Patients, in the meantime, are facing greater requirements from employers to share the cost of care. Among employer-sponsored plans, there is an increasing push toward high-deductible-plans, with deductibles in the $1,000-$2,000 range.

The most glaring problem in American health care, however – and the largest driver of change – is the limited time that primary care physicians actually spend with their patients. Most primary care physicians in the United State, including many ob.gyns., are trapped in a business model that forces them to see at least 24-25 patients per day (a total patient load of 2,000-plus). The model typically allows for about 12 minutes of face time with each patient and leaves no time for careful listening, for care coordination, for talking with specialists, or for thinking deeply about diagnostic dilemmas.

When patients have a slightly complex case that cannot be solved in 12 minutes or less, physicians are left no option but to refer these patients to a specialist, which dramatically increases the cost of care delivery.

The changes ahead

There are many pilot programs embedded in the Patient Protection and Affordable Health Care Act that attempt to address health care delivery cost and quality, and perhaps some will bear value in coming years. Overall, however, reform in Washington is largely about medical care financing and insurance coverage.

Accountable care organizations and medical homes are good alternatives to traditional care models and could provide outstanding care, but these options will not succeed unless productivity standards are lowered such that the generalist physician truly has the time to listen, think, prevent, and coordinate. Similarly, capitation (payment of a fixed sum for all care for one patient for 1 year) will succeed only if the rate per patient is sufficient enough so that the physician can sustain a practice while seeing fewer patients and hence spend enough time with each one. Thus far, this has rarely been the case.

In the absence of major changes on the horizon from the government or insurers that put incentives and funding in the right places, health care delivery can only transform in fits and starts in response to the major drivers of change. Although some changes to the current system will be truly transformational, many will only be incremental.

Among the transformative – and one could say disruptive – changes will be change in our hospitals. Certainly more and more can be accomplished in the outpatient setting, but as more people survive longer and have more chronic illnesses, there will be a need for more hospital beds, ICUs, operating rooms, and high technology – the reverse of the mantra of recent decades which proclaimed that we had "too many hospitals and too many beds." Hospitals also will need capital for renovations, new wings, and all the needed technology. With credit tight, smaller hospitals will merge into larger systems, and there will be few stand-alone community hospitals in the coming years.

To compensate for the shortage of nonspecialists and to allow generalists to do what is needed and what they are best at doing, there will be greater use of nurse practitioners, physician assistants, nutritionists, exercise physiologists, and other nonphysician professionals. Physicians will increasingly need to embrace, rather than marginalize, the work of adjunct providers in providing quality interaction with patients, augmenting preventive programs, and enhancing care coordination.

Ob.gyns. will likely find such team-building helpful as they strengthen their efforts to provide preventive care and promote healthy behaviors for women of all ages. The model of a health care team also can help ob.gyns. as they strive to deliver more preconception care and to work with women before and during pregnancy to create optimal intrauterine environments that will lead to healthier offspring. Like family physicians and internists, ob.gyns need time to spend with each patient to learn about her family and the environment in which she lives.

To provide comprehensive preventive care, and to adequately coordinate the care of patients with chronic illnesses, some physicians have decided to bill the patient directly for services and not accept commercial insurance or Medicare. Others have opted to convert their practices to "retainer-based" practices, or "concierge" practices, which are, in effect, a type of capitation without the intermediary of the insurance company. The patient pays a fixed annual fee (usually $1,500-$2,000) for all care provided by the physician. In turn, the physician drops the practice size to about 500 patients; guarantees appointments within 24 hours; provides 24/7 cell phone access; and offers appointments that last as long as necessary, the option of e-mail conversations, and visitations in the hospital and emergency room.

Physicians operating such retainer-based practices report working as many hours as they did before, but say that they are giving superior care and that their patients are reporting a much greater level of satisfaction. The total costs of care come way down because the physician now has the time needed to thoughtfully sort out issues, resulting in fewer referrals to specialists, more lifestyle modifications instead of prescriptions, and fewer tests and x-rays. Hospitalizations are reduced by one-half, and unplanned readmissions after hospital discharge also are significantly reduced.

These changes, while quite disruptive, are, in the long run, bright spots on the horizon. While the cost of joining a retainer-based practice is out of reach for some individuals, the retainer system gives proof-of-concept to insurers and the government, who thus far have been too short-sighted to pay more per patient for primary care, and consequently have paid more across the entire spectrum of care. If such models could be adapted for wider use through the reallocation of insurer dollars, it would improve value for everyone.

The extent to which the retainer model will prevail in terms of physicians’ desires and expectations – as opposed to the options of becoming employed or joining large group practices – is uncertain. It is likely that we will see multiple shifts. Certainly, however, the future for delivering care to complex, chronically ill patients lies largely in multidisciplinary team-based care, with primary care physicians – including ob.gyns – serving as the quarterbacks.

Ultimately, key players will need to make it all happen so that we can have a delivery system that serves us well and costs us less. In the meantime, just as is happening in many large clinics, in certain specialty care centers, and in some primary care practices today, there is much that individuals and a combination of the leaders in medicine can do to keep the transformation moving.

Dr. Schimpff is the former chief executive officer of the University of Maryland Medical Center, Baltimore, and is a voluntary professor of medicine at the University of Maryland School of Medicine. He consults for the U.S. Army, medical startups, and Fortune 500 companies. Dr. Schimpff said he has no financial disclosures.