Improving U.S. medical care while holding down costs will require vision and innovation. Short-sighted adjustments that perpetuate longstanding ways of practicing medicine won’t bring about the changes needed.
That was the message delivered May 4 by Steve Miller, M.D. ’83, in the 2018 AOA Lecture at the UMKC School of Medicine. Miller is senior vice president and chief medical officer of Express Scripts, a large pharmacy benefits manager based in St. Louis.
Miller used St. Louis to illustrate the importance of vision — and the peril of lacking it. At the turn of the 20th century, St. Louis was the Gateway to the West and a city on the rise. It had the first U.S. skyscraper, the Wainwright Building, and in 1904 the largest World’s Fair ever. But the city was about to be eclipsed because of its decision backin the mid-1850s against building a railroad bridge over the Mississippi River, betting on river travel remaining more important than the promise of a transcontinental railroad.
St. Louis had violated an important principle, letting existing resources limit its vision. And, Miller said, “When you don’t have the right vision, others are going to do something about it.”
Today, Miller said, U.S. health care has the same problem of limited vision, spending far more than other developed countries but without better outcomes. A system designed by physicians for their own convenience has limited innovation, to the point where examining rooms look much as they did 100 years ago, and physicians see about the same number of patients as they did in the early 1900s.
Against that stagnant productivity, he said, 12,000 minute clinics have sprung up, but not with any evidence of better results or lower costs. There’s evidence that, for example, they overprescribe antibiotics and don’t produce better health care. But they are growing, he said, because their hours and convenience are what people want.
Medicine has improved greatly in other ways, Miller said, often involving his company’s area of expertise, pharmaceuticals. For example, he said, better medicines have virtually eliminated operating on peptic ulcers, once among the most common surgeries, and also have greatly reduced the number of heart bypass surgeries.
Miller said his company, Express Scripts, besides managing pharmacy benefits, is also the third largest pharmacy company in the U.S. Its automated pharmacies, he said, have improved convenience and greatly reduced errors in the dispensing of medicines. And as a large benefits manager, his company works to hold down drug prices by increasing pharmaceutical makers’ bidding for its business.
Working to hold down prices is becoming even more important, he said, because the pharmaceuticals being developed now are mainly specialty drugs, with the promise of effectively treating relatively rare illnesses.
So the possibilities are exciting, he said, but vision will be crucial to finding innovative ways to make breakthroughs affordable and accessible for everyone.