Q&A With Retired UMMS CEO and Author Dr. Steven Schimpff

By Mark R. Smith, EDITOR-IN-CHIEF

Stephen Schimpff, M.D., is the retired CEO of the University of Maryland Medical Center and author of The Future of Medicine - Megatrends in Healthcare. The book delves into scientific advances in medicine such as genomics, stem cell research, vaccines, medical devices, imaging, the operating room and information management.
He is writing a sequel about the "hospital of the future," the changes that are forthcoming in the delivery of medical care, and how physicians and hospitals must (and will) change their methods to accommodate patients. It also addresses how health care reform will impact the delivery of medical care into the future (www.medicalmegatrends.blogspot.com).
Schimpff also teamed with Dr. Morton Rapoport to write "Alignment - The Key to Success of the University of Maryland Medical System (UMMS)." It describes the evolution of the entity in the 25 years since the University of Maryland Hospital was separated from state ownership and university governance, and grew from a struggling single hospital to a very successful nine-hospital system.
He also worked at the National Cancer Institute for 13 years, and later served as a professor of medicine at the University of Maryland Medical School, where he was head of Infectious Diseases, then director of the University of Maryland Cancer Center and later Chief Operating Officer of the UMMS. He is also a professor in its School of Public Policy.
Schimpff, a proud former Eagle Scout, graduated from Rutgers University and Yale Medical School, the site of his internal medicine residency. He is board certified in internal medicine, medical oncology and infectious diseases.

What do you think about the approach the Obama Administration has taken to health care reform?
We are the only country in the developed world that has not assured all of its citizens access to medical care regardless of ability to pay. We need to accomplish that. However, American medical care costs too much on a per capita basis. We need to address that as well.
"Obamacare" made a good start on access, but it basically ignores costs. The result would have been a new, costly entitlement program without cost savings to pay for it.
There are other good things in the Congressional plan, such as abolishing exclusions for pre-existing conditions, but this will only work for the insurers if everyone - including the "young invincibles" - are required to participate and purchase insurance. It's obviously not fair to ask for insurance coverage after you develop a serious illness; it is, however, appropriate to be able to transfer insurance if you change jobs, lose your job, move, etc. Supporting the development of the electronic medical records is a good idea as well.

Your main concerns about the Obama plan were about the lack of a wellness aspect. Can you explain?
Actually, I am concerned about the lack of addressing costs. Wellness programs could be an integral aspect to reducing costs, and the government could encourage incentives to encourage people to make use of wellness programs. Wellness programs have been proven effective in reducing costs, improving health and increasing job productivity. Those offered by Safeway and General Mills are good examples.
We also need incentives for primary care and other physicians to ensure that they take the time needed to coordinate complex chronic illness care. This could go a long way toward reducing costs, since much of the problem is related to this lack of coordination. That results in too many specialist visits, tests, X-rays, procedures and even hospitalizations.

What do you think should happen regarding health care insurance in this country?
I believe medical insurance should be for the highly expensive unexpected event, just like a fire or an auto accident. We should each pay for routine care out-of-pocket, directly to our providers. This would dramatically reduce the cost of insurance, and it would once again be true insurance, rather than today's prepaid medical care. It would be good if government then allowed for Health Savings Accounts, so out-of-pocket costs could be paid with pre-tax dollars.
Since not everyone can afford to make these payments, there needs to be a mechanism to cover these costs for those individuals and families. But even here, it should not be an insurance card, but rather vouchers so that the individual has a direct contractual relationship with their doctor, etc., just as with a lawyer, accountant or other professional. The direct relationship will lead to more prudent purchases.
Of course, the patient is at an information disadvantage with their M.D., but if I'm paying for the service myself, I'm more inclined to ask questions and get more involved. This will save money.

What are your feelings about CareFirst BlueCross BlueShield in general?
It is a good company. It's important to realize that most of what the company does is not provide insurance, but rather serve as the third-party administrator for large companies that self-insure their employees. Basically, they service those companies for a fee.

What about retainer-based or concierge medical practices?
Primary care doctors have had flat incomes for most of the past decade, yet their office costs are rising. The result is frustrated doctors who work longer hours and see more patients for less time to keep their income level. And they're burning out.
So some docs have opted to charge their patients an annual retainer (usually $1,500 to $2,000) in return for limiting their practice to 500 patients (instead of more than 1,000), being available the same or next day for office visits, availability by cell phone 24/7, etc.
This is a new (but rapidly developing) trend. It will continue unless and until the insurers (commercial and government) pay a reasonable amount per visit and pay for giving prevention advice and chronic care coordination. If they don't do that, there will many fewer primary care physicians in the future.
So it would be money well spent. A small amount of money here would potentially save a lot in specialist and hospitalization costs down the road. Meanwhile, we will see more and more primary care practices go the retainer route.

Why are medical care costs so high and rising so fast?
Not for the reasons usually given, such as greedy doctors, hospitals, insurers and drug companies. The real reasons are an aging population, adverse behaviors that are causing complex chronic illnesses, lack of good coordination of care for those with complex chronic illnesses, inadequate attention to prevention, inadequate attention to quality and safety, excess testing, procedures, etc. - "to be complete." That's really defensive medicine.

If you could write the health reform bill, what would you include?
We need health care reform. There are three elements that should be carefully considered. First, medical care is too expensive. There are some reasonably straightforward approaches to improving the quality and safety of care that would reduce costs going forward.
Second, insurance today has morphed into prepaid care and there are all too many people without insurance. We need to return to true insurance, and we need to find a way to get them coverage. And third, we must find a way to lead healthier lifestyles to prevent serious chronic illnesses in the future.

What can be done to address costs?
Costs can be addressed by creating the proper incentives to ensure that those with complex chronic illnesses (i.e., the illnesses that cost the most to treat) have good coordination of their care. It needs to be rendered by a multi-disciplinary team orchestrated, usually, by the person's primary care physician (PCP). Creating incentives to give good preventive care by PCPs will be important in the future, since about 70% of the most important chronic illnesses (heart failure, diabetes with complications, cancer, etc.) are preventable.
We have to come to grips with our adverse behaviors. A third of us are overweight and another third are, frankly, obese. We don't exercise enough, we are stressed, and our nutrition is poor. About 20% still smoke. Many have poor dental hygiene from not brushing and flossing and others drink and drive or text while driving. These behaviors lead to the most serious chronic illnesses, and these are the ones that cost the most to treat. They last a lifetime.
We need to find ways to reverse the trend, because otherwise there will be literal epidemics of heart disease, cancer and strokes, plus many others.

What is your opinion of Howard County's Healthy Howard health care plan?
I think it's a very positive plan that balances people's right to have health coverage, no matter their financial status, with them having the responsibility to lead a reasonably healthy lifestyle.
Each individual, for a small fee, gets unlimited access to primary care, along with specialty care and hospitalization at Howard County General Hospital. Each person gets a health coach who guides and assists them with matters such as weight control, nutrition, exercise and smoking cessation.
The coach will also help the patient overcome barriers to success. For those with complex chronic illnesses, an individual in the primary care office will assist coordinating their care, including helping to find the least expensive medications and coordinating referrals to other providers.

How should people be paying for their health expenses?
Everyone should have insurance. But insurance should be for catastrophic illness. We should pay for basic care out-of-pocket with tax-free dollars. This will mean that insurance is much less expensive and individuals will insist that their providers give the best, but only necessary, care, tests, procedures and X-rays. No one should be excluded because of a pre-existing condition provided that they have held insurance during the past 12 months or so (i.e., don't expect to buy insurance for the first time only because the house is on fire, so to speak).
Those who cannot afford to pay for basic care and preventive services should receive tax credits to cover the cost. Businesses, churches and retirement communities, among others, should offer wellness programs that assist individuals with smoking cessation, diet and exercise. Incentives via insurance premium reduction will assist to create healthier lifestyles.
Combined, these measures will assure everyone of insurance, better quality medical care and greater health.