Slaying the beast

In my last article I introduced you to "the hidden beast" in health care which is the fact that we lack enough physicians in our country to handle our growing and aging population. I may be a bit pretentious in claiming that I have ideas on how to slay the beast but I do have some very specific ideas. These ideas will require patients, physicians and the various insurance companies to undergo a dramatic shift in how we interact.

First, we must accept that there is no way we can create enough healthcare providers to meet our upcoming demands. How do I know this? Training a physician takes approximately twelve years after high school on average. If we start today, and we should, encouraging kids in junior high and high school to begin thinking about medicine and mentoring them through the education process and simultaneously expanding medical school enrollment to allow for this influx, under the best of circumstances we will begin to bring these young doctors to you in 2025. Now, these kids are pretty bright and I think they probably read the same articles I do that Medicare will go bankrupt somewhere around 2018. I wonder how many of them are interested in being professional physician volunteers. By the way, they will probably owe somewhere in the neighborhood of $500,000 for this privilege.

Ok, so that idea may not work. Well, we could just make the existing doctors work harder. We can continue dropping reimbursements so they will be incentivized to work harder and see more patients. Oh, wait, that's what Medicare has been doing for the last 10 years and it hasn't worked. On top of this, I hear patients everyday complaining their doctor has no time for them and how can an office visit last only five to ten minutes. I guess people might be even more disappointed if the visit lasted one to three.

Perhaps we need to think a little "outside the box". I suggest we try to make our doctors more efficient and incentivize this efficiency. For example, attorneys, accountants, and countless other professionals are compensated for services that are not face to face. Did you know that insurance companies have created reimbursement codes for a doctors phone calls or emails to a patient? But, here's the zinger, they pay zero dollars for this service. Every physician deals with this issue differently. The majority will not provide any significant treatment or planning over the phone or by email but rather require face to face contact. Many will notify patients of lab results and x-rays by phone, or at least have their office staff do it. Some will require a return appointment to discuss results. I suspect it really depends on how busy they are.

Furthermore, the forward thinking members of our congress created the Health Information Portability and Accounting Act of 1996, better known as HIPAA. Part of this legislation prevents your doctor from emailing you if either email company does not use encrypted secure servers. If your medical information makes it into the wrong hands the fines for your doctor can be tens of thousands of dollars. I suspect this may represent a bit of a disincentive to your doctor as well.

I suggest that compensation for non face to face care be established and that the government "encourage" email companies such as Google and Hotmail to have special servers that are for the delicate transfer of this information. Just by enabling me to email a patient that his x-ray was fine would be a huge improvement in efficiency.

Now let's get a little bit controversial. Many of you are thinking what about a greater use of physician's assistants (PA's) and nurse practitioners (NPs)? I think that this is a great idea, but, we have to recognize the skill levels that each of us has. PA's and NPs typically have two years of training beyond their undergraduate degree. They are very well suited to managing routine health issues including annual check ups, uncomplicated diabetes and hypertension care, treatment of routine respiratory infections, etc.. Unfortunately, many doctors use these vital assistants as substitute physicians and place responsibilities on them that are inconsistent with their experience and training. On the other hand, I think that it is a terrible waste of resources to use highly trained physician's to do these activities.

In fact, I find it ironic that over the last twenty years there has been a huge push for physicians to become primary care providers. We are taking our best and brightest and encouraging them to focus on the least complex care. In fact, if your doctor sees you for five minutes to tell you that you have a viral upper respiratory infection he is paid practically the same amount  as if you come in coughing, and wheezing with pneumonia. Yet the two situations result in a very different amount of complexity and time required.

I would suggest we establish clear expectations on patients with appropriate incentives in the way of copays and deductibles that pushes them toward PA's and NPs for routine care and incentivizes the doctor to pick up the most complex patients they can. In fact, I suggest that we push more of our doctors to specialize. There is far too much information for someone to handle in a general way. When I was in medical school there were about five commonly used blood pressure medications. Now there are twenty categories each having dozens of medications. In fact, many doctors trained in primary care fields have left their practices to become hospitalists. Hospitalists get to focus on hospitalized patients, i.e. those that are the most ill, because the care is rewarding, the hours are structured, and once cured the patients return to their original practitioner. This model could be expanded with a far better structure for reimbursements.

In the ideal world easy routine care could be provided by a PA or NP. Those who don't respond would see a physician and in some situations one who has specialized in the area of concern and get placed on appropriate care. Once cured or on a treatment plan the patient would then return to their original caregiver, freeing up the physician/specialist to move on to the next complicated case. In addition, the PA or NP would have lower level assistants reporting to them who routinely communicate with patients to make sure that they are taking their medications as well as setting up even lower level visits for just checks on those issues that need chronic monitoring.

The entire health care system would be changed from it's current design which is flat and wide to a pyramid with the doctor at the top and all of the other caregivers below. By doing this we could successfully do more with less. And, I suspect, we may even save a few dollars. I know that what I suggest is radically different from what we are used to. In fact, some people may feel offended at my assessment. But, that is why I have established this blog. I encourage anyone to help come up with better ideas. And perhaps if we are very lucky we can help change this situation.

Best of luck to us all in slaying the beast!

Return on Wednesday and I will post the first chapter of "Virestorm". I am hoping to provide an interactive entertaining way to share a story that I have been working on in pieces for the past year. I will use your input to help steer the characters and action to a hopefully exciting finale.