The enormous cost of healthcare in the United States continues to grow at a rate that is unsustainable, and physicians must recognize the need to reform not only the system, but the way they practice, said the head of the American College of Physicians during the ATS 2011 President’s Lecture on May 17.

“If costs continue at the present rate of growth, the healthcare system is at risk of collapse, and it could affect the entire economy of the U.S.,” Steven Weinberger, MD, executive vice president and CEO of the American College of Physicians, said in his lecture, “Challenges for the Subspecialist in the Era of Healthcare Reform.”

Dr. Weinberger focused on the two primary challenges facing specialists—relating and transitioning to new models of care, and controlling costs.

Besides costs, the forces driving new models of care, he said, are that healthcare quality and patient safety are at unacceptable levels, better coordination of fragmented care is needed, medicine needs to move into the 21st century electronically and medicine should be a team-based sport.

A solution to these problems is the Patient-Centered Medical Home (PCMH) model that relies upon a personal physician representing a patient in a team-based environment. The PCMH has been shown in demonstration projects to offer better care coordination, improved quality and safety, enhanced patient access to care and a payment structure that recognizes services and value, Dr. Weinberger said.

“Medicine needs to move into the 21st century. Virtually every aspect of society has adopted electronics. We are behind the times in medicine and we need to move forward,” he said, adding that another problem is that physicians are taught to “do things on our own. That is not what is best for the patient or the healthcare system.”

PCMH projects have “reduced emergency room visits, hospital visits and the total cost of care,” Dr. Weinberger said. “What we are seeing are improvements in quality of care and in patient safety.”

The next step is to look beyond the PCMH, which is focused on primary care, to the PCMH Neighborhood (PCMH-N). “Lots of other people are involved—subspecialists, hospitals, long-term care facilities and pharmacies,” he said.

The concept of the PCMH-N is better integration of care between primary care physicians and subspecialists.

“There must be improved care transitions from ambulatory to inpatient or long-term care,” Dr. Weinberger said. “There needs to be a mutual understanding of who is responsible for what. We must make sure expectations are met on both ends.”

In the first decade of the 21st century, the healthcare focus was on quality and patient safety, he said. While those will remain important in this second decade, costs have come to the forefront.

“I believe that the main issues as of 2010 have been cost and decreasing the cost of care,” Dr. Weinberger said, pointing to efforts in Congress to change Medicare to a voucher program. “We have to do what we can to decrease waste in system.”

Among the areas where costs can be cut are in reducing preventable and avoidable hospital admissions, and changing approaches to diagnostic testing. Imaging costs have increased 85 percent since 2000 for Medicare and Medicaid patients, he said, adding that diagnostic tests are “misused and overused.” It is estimated that $210 billion is being spent annually on inappropriate diagnostic testing.

To reduce testing, Dr. Weinberger called for more evidence-based guidelines so physicians do not have to make clinical decisions based on their best judgment. While testing needs to be reduced quickly, a long-term goal is to teach trainees to take a different approach to practice.

“It is important to get to trainees early,” he said, to establish better habits in ordering tests. “That culture of being cost-conscious … that type of culture needs to be instilled in residents during training.”

Dr. Weinberger issued a call to action for generalists and subspecialists to focus on cost reduction.

“We are not talking about rationing; we are talking about rational care,” he said. “We are at a crossroads, particularly in healthcare costs. We need to be playing a role. We need to be helping decide which way we go as physicians. We need to be part of solution.”