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Smart thoughts on health care
Overall, I’d like to see no insurance or government programs for most routine care. I think a retail medical system would end up looking like eye care does now, with lots of variety and innovation. It would also be more convenient and cheaper. This type of primary care would probably be just as effective as what we have now. If people with borderline medical conditions visited the doctor more often (because it was cheap and convenient), care might even be more effective than it is now.
Here is much more. The author has spent most of his life in a wheelchair, and he has a great deal of personal experience with the U.S. health care system.
Posted by Tyler Cowen on June 16, 2007 at 05:17 AM in Medicine | Permalink
Comments
Very interesting essay with lots of good points. Unfortunately, visiting a doctor (a good one) will NEVER be 'cheap and convenient'.
It takes time for a doctor to do good work (BTW, Jerome Groopman's book, How Doctors Think, has excellent insights in this area). Time costs money. Since good doctors have intelligence and skills, any system that tries to drive down the costs of a doctor's visit will 1) reduce the time with the doctor, 2) reduce the 'quality' through lower skill sets, etc.
Doctors function much like a master craftsman--they take their experience and skills to create something new, one patient at a time (note that doctors still have a guild--the AMA). Even today, with all our industrial capacity, if you want something created by a master craftsman (e.g., hand-built furniture) you pay a lot because you just can't hurry the process without destroying the value of the product/service.
If doctors follow the path of most master craftsmen they will move towards three roles: continue to 'craft' for high end customers, design 'industrialized' products, or supervise lower skilled workers. The few with top skills (both medical and customer relations) will be able to provide 'concierge' medicine at high rates.
Some doctors will use their talents to design medical systems which 'industrialize' the process. You can see that happening already with care guidelines.
But most doctors will end up supervising others who cost less (or leaving the profession altogether). Many doctors already use 'physician extenders' to reduce their average time per patient, but patients and more importantly, the payment system, resist. Also, doctors are not generally trained in process management techniques, although that barrier is probably falling with the large number going to business school. We are poised for a proliferation of franchised 'fast care' joints that compete on speed and cost with 'just good enough' quality.
The fly in the ointment, though, is that patients are unique and ethically we can't throw away those who 'don't meet the specs.' Any industrialized manufacturing process has to constrain the input, tightly control the characteristics of the work in progress and discard items that are out of specifications, and reduce the number of variations in the end product. A mature system can produce 'customized' products, but developing systems must start with simpler processes.
On the bright side, there are some services which are being successfully industrialized (mostly in the finance industry). On the other hand, a nascent 'industrialized' health system will have massive inequalities of care, depending on whether the patient 'fits the specs' and it will be difficult for politicians to keep their hands off long enough for the system to mature and satisfactorily serve the great majority.
Posted by: SteveSC at Jun 16, 2007 9:48:28 AM
This very morning, I've decided to take on my ongoing slightly elevated blood pressure, until [? :-) ] I lose some weight. I will go to the strip mall walk-in docs-in-a-box, see an unfamiliar doctor, and walk out with a prescription if (s)he thinks I need medicine. If not, not.
I dislike medical office complexes, appointments (and the nonetheless inevitable wait), the "doctor-patient" relationship (not my idea of a relationship), endless hospital-area construction and elu$ive parking, and everything that goes with these things. Doctors dislike me because I consider them fee-based consultants worthy of courtesy but not blind compliance; therefore scatter-shot coverage allows me to deal with someone not yet developed in that dislike.
And we have really good health insurance. I'd pay out of my own pocket to do it this way.
Posted by: who, me? at Jun 16, 2007 9:54:32 AM
Those are not smart thoughts on health care. Notice that for the crucial points there are no appeals to facts, i.e., statistics. But if you're innumerate, I suppose it would be persuasive.
In the end, that may be all that matters.
Posted by: Russell L. Carter at Jun 16, 2007 11:25:00 AM
My experience with doctors is a lot closer to mirroring commenter #2's comments than commenter #1's.
This, in my opinion, is a highly romanticized notion of what a doctor in this day and age is:
Doctors function much like a master craftsman--they take their experience and skills to create something new, one patient at a time
More often than not, my doctor's office visits leave me feeling as if I've been through some sort of mill. Somehow, we've collectively come to accept this convention that a doctor's time is more valuable than ours - there is an underlying expectation that any appointment made will begin 15 minutes, a half hour, an hour later than the time we have agreed upon - and that the appointment will itself typically last 15 minutes. I have only on one occasion in my life spent more than 15 minutes with a general practitioner or specialist in a single visit.
For general care, the eyecare/retail model feels about right to me.
Of course this doesn't begin to address catastrophic events or other kinds of hospital care.
Posted by: fustercluck at Jun 16, 2007 11:29:29 AM
One big problem is that we have doctors, nurses, and that's it (except in a few states like indiana and wisconsin). We need more nurse practitioners, and various other types of non-doctor specialists.
In Indiana, you or your child is sick (bad flu, etc), you go see a nurse practitioner. He/she is qualified and legally permitted to diagnose basic problems, prescribe antibiotics, or say "rest, drink fluids." This covers 90% of patients.
The rest get pushed up to a real doctor. For the 90% of patients that the nurse practitioner can treat, the cost is $40+cost of antibiotics.
Of course, in NJ (where I live) and most other states, nurse practitioners are illegal.
Posted by: Anonymous coward at Jun 16, 2007 11:39:45 AM
NPs and PAs are great; you don't need specialists to provide routine care.
The "master craftsman" model has big problems for medicine: statistics are important and standardizing care through analyzing treatment and outcomes is a good thing, something doctors have largely resisted. For some of the benefits, see the PA hospital that has made big improvements in, I think, bypass outcomes through standardizing care. A big innovation: checklists to make sure every patient gets appropriate preparation and follow-up. CHECKLISTS. You know, that is old technology. Pilots have been using them to ensure standard preflight safety checks for decades.
The article in the blog referred to is interesting, but I was put off almost immediately by the fact that he does not acknowledge the incredibly complex institutional reasons behind the rise in obesity. They go way, way beyond personal responsibility for weight loss. If he has not read Marian Nestle's "Food Politics" and "What to Eat," he would find them relevant and fascinating.
He is right about some things. My mother is 86. Last year, she needed care for a particular problem. I went to many doctor visits with her, and was not surprised to find 1) coordination between doctors is very poor 2) doctors don't ask the questions they should. It would not be difficult, for example, to ask patients how frequently they go for walks and how far they're able to walk. My mother's mobility has been decreasing for years; I am sure she has never been asked this.
But it's also true that successful interventions are rare. It's hard to change behavior. Even if doctors know what they need to know, they may not be able to do anything useful with that information.
Posted by: Lisa Hirsch at Jun 16, 2007 12:43:50 PM
My biggest problem with the US health care system is that so many medications are gated behind the physician's prescription pad. 90% of the time I see a doctor it's to tell them, "I have X, and I need a prescription for Y." After reviewing my symptoms and medical history they always agree with me and write me the prescription. So why am I paying an extra ~$100 just to get a medication I already knew I needed, for a condition I already knew I had, before seeing the doctor? It's just a waste of my time and money.
Posted by: Jacqueline at Jun 16, 2007 1:22:47 PM
'who, me?' and 'fustercluck' bring up problems that show the breakdown of the master craftsman model. Leaving aside the question of whether ALL docs are capable of being 'master' craftsmen (I think not), the system is preventing even those with the right skills from performing well. We are in the unhappy middle ground where highly skilled doctors are being forced to follow guidelines which may or may not be appropriate while payments are ratcheted down to allow only a few minutes per patient.
The problem is that it doesn't take 8+ years of training to follow a guideline. It is actually easier for a lesser skilled individual to follow guidelines because they are less aware of the exceptions and potential risks, and can thus scrupulously follow guidelines in good faith. The more comprehensive the guidelines in a system, the less it makes sense to pay highly skilled individuals to follow them. It is the essence of industrialization--simplify processes so that less skill and less time is needed. The NPs mentioned by 'Anonymous coward' are an intermediate step. They are still skilled people who see patients one at a time. The big changes in efficiency will come when machines are doing the screening and following guidelines.
This will work OK for the majority of people, most of the time. For example, 'who me?' is unlikely to have a problem causing mild high blood pressure that is immediately fatal if missed. But what error rate are we willing to put up with? The current error rate is probably pretty high (I have seen estimates of about 10% from autopsy studies), and it will certainly go higher in the transition period to an industrialized system. A mature system will undoubtedly drive the error rates way down, but that will take time. As an example, the first automobiles were less reliable, slower, noisier, and harder to care for, in short, they compared poorly to a horse and buggy in just about every dimension. A century later the situation is reversed.
If society made a commitment to industrialize medicine, in 20 years we could have systems pretty close in function to the holographic doctor in Star Trek Voyager for routine problems. The cost per 'visit' would likely be so small it would be supported by advertising. But we are unlikely to get there because the path to that future requires interim systems that demand large investments and have relatively high error rates. The current payment system won't pay for the systems, and malpractice lawyers would likely suck up the revenues of any company that tried independently.
Posted by: SteveSC at Jun 16, 2007 2:53:09 PM
Hasn't bought correct lenses lately has he. Forget the variety of frames (not--it's just as fashion based as women's clothes), it's the sheer cost of the frames that gets me, not to mention the lenses.
Personally, I think docs need to back to being paid in chickens. But then none of you farm either.
Posted by: NeoLotus at Jun 16, 2007 3:31:44 PM
Lisa,
Checklists have been used in medicine forever. Unfortunately, mother nature often forgets to read the book.
There is a substantial downside to improperly designed metrics for measuring quality of medical care. The first downside is that it might not being measuring what you think it is.
The second problem is they run the risk of putting the providers of medical care into the postion of having all of the responsibility for the outcome of patient care but restricted authority to implement needed patient care. If that happens the quality of the available healthcare providers is likely to decline.
The point of it all is that I DON'T WANT ANYBODY, clinical or nonclinical, to tell me what tests I can or cannot order on my patients when I am the only one who will ultimately held accountable in a court of law!I will not allow any MBA wielding pencil pusher with no clinical experience or background whatsoever dictate what I can and cannot do for my patients! I realize that medicine is just as much a business as any other businesses, and bottom lines must be met or kept in check. But the day when a physician loses his or her autonomy at a hospital, it's time to pack up the bags and call it quits, or move on.
Posted by: TJIT at Jun 16, 2007 8:06:05 PM
Lisa,
Obesity is a complex issue. I have to note that obesity has gotten increasingly worse as government has gotten increasingly involved in human nutrition and diet. Furthermore, the use of the BMI as a tool for measuring obesity may have caused an artifactual increase in obesity levels and the increase in obesity may not be as large as advertised.
Beyond diet there have been massive changes in how we work and recreate in the past 20-30 years. This is particularly true with respect to childhood obesity.
Sensational stories on sexual predators, Video games, television, DVD players, playground liabilty, etc. have all had a tremendous impact on obesity in children.
Posted by: TJIT at Jun 16, 2007 8:24:01 PM
Some inefficiencies arise from covering one thing but not another. Here's a true conversation that my wife, an ophthalmologist, had with a patient:
Doctor: You poor vision is caused by two things. If we fix either one of them, you'll be able to see well enough to drive again. First, your eyeglass perscription needs to be changed. Second, you have mild cataracts, that could be corrected with surgery.
Patient: Let's have the surgery; my medical plan does not cover eyeglasses.
Posted by: Bill Conerly at Jun 16, 2007 8:29:01 PM
Anyone who thinks more non doctor specialists would be better needs to look at the actual medical statistics coming out of Britain. nhsblogdoc.blogspot.com is a good place to learn about Britain's medical problems.
I think the idea that most people don't need continuity of care is really foolish. Even in the eye doctor model, I was told that I had high pressure in my eyes, and needed to watch for glaucoma. I was told this once. No other data--no numbers, no statistics, no idea what that meant. I have no way to find the records from my dozen various eye doctors over the last dozen years; would I be able to establish my eye's medical history if there was a concern about glaucoma?
Now move that to something like a heart condition like congestive heart failure, or lupus, or rheumatoid arthritis, or something progressive. The eye doctor model doesn't even provide for continuity of care in the case of serious history, nor a way to even keep track of your history.
Posted by: anonymous at Jun 16, 2007 10:26:00 PM
As an physician let me make some comments:
1. If I saw most patients for more than 15 minutes in a private practice, I wouldn't see enough patients in the day to cover expenses. These expenses include on average a 4 person office staff (all of which we have to pay health insurance and benefits for in order to retain them). The costs of real estate, energy, etc. The cost of computing software to keep things moving smoothly is also expensive. Just the time to write a pile of prescriptions could be a 5-10 minute process. Don't forget I have to spend another 5-10 minutes to meet all the documentation guidelines from medicare. Lets not forget malpractice rates for many folks.
2. In man labor, a good body shop man can make an equivalent income with NO higher education... think about this for a minute guys. The crushed bumper I had fixed on my car for $2500. This is skilled labor that didn't even require a highschool education.
3. Even if we doubled the number of medical school seats in America to increase delivery, you would get a much weaker pool of overall people.
4. There is more literature that comes out PER DAY in my field than I have probably read my ENTIRE LIFE. If you want someone that is willing to maintain that level of expertise... ultimately you must realize that part of the "doctor fee" includes the countless hours spent "keeping up" instead of playing with my children on the weekend.
5. I would also finally like to mention that all this discussion is moot in my opinion anyway. What you guys don't realize is that almost all medical technology is fossil fuel based energy/plastic/chemicals. In the very near future, likely the next 10 years, fuel cost based inflation of medical care will make it so I have to work practically for free or at a loss. When is the last time your political candidates reminded us of this? Where is Michael Moore on this one? Most people miss the whole point... modern medicine without a functional energy source is going to be early 20th century medicine again. I suggest all of you start exercising and quitting smoking, because these things save far more lives than medicine ever will. The world is in for a catastrophic infrastructure failure if world oil production plateaus at any point. You will be more worried about finding food (since most land in the US is fertilized by natural gas products) than you will be about your healthcare. At that point I'll accept your tomatoes, bread, and eggs in exchange for a health checkup.
Posted by: KY at Aug 1, 2007 11:32:41 PM
