Based on my experience as a physician and a clear understanding of how doctors think and interact. Their motivations to act. To order. To care for patients. Fix the following, and you start on the road to fixing disease care costs.
1. Remove failure to diagnose as a legal basis for a lawsuit.
To spend billions on testing "just to make sure" when your medical training says you already know the answer. The testing that is the result of that 0.5% chance you are wrong. No matter how much we try, we will never get it right 100% of the time. And that 0.5% unattainable goal is what drives much of the testing. As a society we need accept failure as a part of success. Some people may die, but many more will die as we bankrupt our system of care.
Unmanaged expectations are bankrupting our system.
2. Make futile care determinations legally binding.
Withdrawal of support in futile situations would not be a legal basis for a lawsuit. Refusal to escalate care could not be a basis for a lawsuit. If you want all care all the time, we will end up with no care, all the time.
Unmanaged expectations are bankrupting our system.
If I can access a patients data base, I can get it right more often with less error and less testing. If the patient can update their own EMR data base of personal information, I can get it right more often with less error and less testing. If you have every primary care office, every specialist office, every hospital, every nursing home using EMR's that don't communicate, you have, in effect, a country of doctors who all speak different languages. Communication saves money
4. Establish a high speed medical Internet for digital imaging accessible by all players
Place the EMR on this high speed Internet. Along with it, place all digital imaging. If my patient had an MRI 1000 miles away on vacation, I want to know about it. If they had one last week at the outpatient radiology center in town, I want to know about it. Repeat testing happens because it's just easier than waiting for records. Doctors frequently only trust themselves or other doctors they know well. So a film is much more important than a verbal report of the film. We need to see the films ourselves or it will get repeated. Because trusting an unknown physicians
Communication is key.
5. Establish a national patient narcotic database for access by all physicians.
One of the most common medical complaints is pain. Pain is a symptom. A very subjective symptom. It is wrought with abuse potential. Combined with the fear of failure to diagnose, evaluating pain is expensive and is one of the most difficult jobs of all physicians. Knowing how much narcotic a patient is using and when and where they are filling it saves money.
6. Make inpatient treatment of alcohol or drug abuse mandatory for any qualified admission related to abuse or overdose.
If you are entitled to spend my tax money, I am entitled to see you in rehab, as many times as it takes. Drug abuse is expensive to the system in so many ways.
7. Fund chronic disease management interventions
In the current system, every aspect of care is fragmented. The primary care doc. The specialist, the pharmacy, the economics/social factors of care. Coordinating new models of disease care delivery will save money. Real time decisions with all players present makes decision making unified. A care plan visit . Not an office visit.
Our hospitalist group has daily am rounds with pharmacy and social work. We can save hundreds of thousands of dollars a year, in pharmacy costs alone. WIN-WIN. One hospital. One hospitalist group. Think of the savings. The reason docs don't talk? Everyone is too busy. Pay for coordinated care and you will be amazed at the results.
Communication saves money.
In the current system of diagnosis related group (DRG) a hospital is reimbursed the same (essentially) whether a patient is hospitalized for 2 days or two weeks for the primary diagnosis. Pneumonia? 2 days? Same payment as a 2 weeks stay. In other words money loser. Most primary care doctor admissions break even or lose money to the hospital. Not the case with procedural based admissions. Total knee arthroplasty? Cash cow. Unequal distribution of profit potential based on disease creates skewed market forces for competition. Surgical centers. Heart hospitals. This results in the creation of profit gradients within illness groups. Competition creates value and lowers costs. It should be spread equally in the hospital system.
I need hospitals competing for my pneumonia patient, not just the arthroplasty patients Once you have hospitals competing for my non surgical/procedural patients, you will have new found competition and cost savings that go with it.
9. Accept that all people are not created equal.
If you talk to 20 doctors you get 20 opinions. Who's right? They all are. There are many ways to get to the final conclusion. And the final conclusion may be different. 20 patients? You may have 20 different definitions of quality. Of outcomes. Of expectations. Of needs. A 40 year old with heart failure will have different expectations than an 87 year old with heart failure. And they will respond differently from interventions, medications. They will have different outcomes, defined by the patient.
That's 20 docs and 20 patients. 400 possible permutations of the process and the measured outcome. Finding that 1 out of 400 is The Art of Medicine. Accepting this premise accepts that all people are not created equal. Shackling the delivery of health care with undefinable goals and and expectations adds money to the system of health care delivery.
10. Quality should be defined by the patients pocket book, not government
In a market economy, patients decide what value they want. Cheap? Expensive? Value? The consumer decides how to spend their mighty dollar and they accept their value for their dollar. In medicine we are told what we can get. Every one is in the same hurried, fragmented, dis conjugated care. Why? Because Medicare says to doctors, if you accept this insurance, you have to accept it in full. You may not charge the patient more.
There are no rings of value. Unfortunately, not everyone is created equal, and there will always be variations in health and income. Rich and poor. Chronically healthy and chronically ill. The current system is all or nothing. Take Medicare in full, or leave it. The ability to find a middle ground and allow the patient to decide what they want to pay is present in every other service we as consumers can buy. But not our health care.
When you bring together happy doctors and happy patients good things happen. The current hurried, fragmented care model is expensive and adds to unnecessary referrals and testing. Allow the patient to decide what they want to pay for. What they value.
11. Make outcomes transparent.
Define them and present them. Let the patient decide what is important to them.
12. Make prices transparent.
Competing on price in a free market economy always leads to better value and lower costs.
You can't run a business on a capitalistic cost structure with socialist reimbursements. The paths are crossed and primary care is leaving in droves. The one true cost savings to the system is dead.
13. Make patients responsible for more.
Turn FREE=MORE into MORE=expensive. If you create cost structures to the patient that minimize their contribution, you will get entitled patients who expect everything for nothing. This is bankrupting our system. Make the patient responsible for a greater portion of their costs. Not everyone buys a Lexus because not everyone can afford it. We live in a system where everyone wants the Lexus, everyone is entitled to the Lexus, whether they need it or not. If you want the Lexus, you pay for a Lexus.
14. Equal access to mental health services.
Make mental health services indistinguishable from other health care services provided by the policy. Mental illness costs money. Gobs of it. Fund the treatment of mental illness appropriately and you bring uncountable cost savings.
15. Allow balanced billing by physicians.
Physicians compete on price and value, and services provided. More time with patients saves money.
16. Drop E&M coding.
Doctors need to document what they feel is important not what they need to get paid. The coding rules, regulations are a fiasco. It adds billions in costs, rejections, agitation, stress and distress and is all based on the assumption that doctors are bad people looking to commit fraud. E&M coding is a LOSE-LOSE system of care.
17. Make multimedia communication a billable and encouraged form of interaction for chronic disease management.
The vast majority of folks I care for in the hospital are overweight and diabetic. Many smoked most of their lives. Admissions related to poorly controlled diabetes, rising weight in heart failure patients, poly pharmacy confusion, Diseases which need frequent contact with physicians to remain "stable". But guess what, nothing is billable. Phone Calls? Nope. Email? Nope. You have to have a face to face to get paid. Why should your doctor take time out of their busy schedule of every decreasing reimbursement to call you. To email you.
For free.
The incentive to prevent exacerbation of illness is missing. You get what you don't pay for.
18. Tax credit for goal BMI range
Call it bribery. I don't care. If it makes people lose weight, you save uncountable dollars to the system.
19. Take a Stand on EMTALA.
Any patient who "comes to the emergency department" requesting "examination or treatment for a medical condition" must be provided with "an appropriate medical screening examination" to determine if he is suffering from an "emergency medical condition". If the patient does not have an "emergency medical condition", the statute imposes no further obligation on the hospital.
A screening exam does not constitute a full work up. Emergencies are known at the time of presentation. But the basis for this overhaul must fall back on rule #1. You can't be sued for failure to diagnose. An emergency will be treated. Non emergencies will not.
The emergency room has become an incredibly expensive way to practice exclusion medicine, not emergency medicine. After 10k worth of tests, the patient goes home knowing what they don't have, not what they have. The ER is not the place to practice diagnostic medicine.
It is for emergencies. EMTALA has screwed up the whole system.
20. If a screening medical exam (vital signs/triage) fails to show an emergency, and the patient wishes to proceed with ER workup they will be charged a deposit up front.
Nonrefundable, but may be applied to insurance deductibles. If there are no insurance deductibles, it is non refundable none the less. Deemed not an emergency? Then you have to pay for the privilege to see an emergency doctor.
TURN FREE=MORE in to MORE=EXPENSIVE
21. Quadruple Medicare premiums and establish Medicaid premiums for those who smoke.
Random drug testing for cotinine. If you are entitled to smoke my money away, I am entitled to see you pay for it.
My Black Jack 21. Twenty-one things to start the process of driving down costs.
12 Outbursts:
evil hr lady is correct, waist measurements and the other determinates of metabolic syndrome may be a better way of determining risk. also i would tell ladyk73 that nearly all of her interactions at the er were appropriate. her feelings of "awkwardness" tells me a something about her upbringing, she does not want to bother anybody. she would be one of those people i would work hard for as i would surmise she would appreciate it
You forgot the most important one. Stop treating healthcare as a "system". It's just a series of products that individuals should purchase, or at times organizations. Don't discuss it as a "system" because "systems" typically need societal solutions - ie. universal healthcare.
It doesn't matter what the overall cost of healthcare is. What matters is what it costs Joe Smith, Jane Doe, etc.
Spoken by someone in the trenches. I could not agree more. The ABUSE of the " system" by citizens just trying to obtain care is phenomenal. I too am a Hospitalist. Our fellow citizens are just trying to obtain care, yet they ( and us) are just "pawns" in the insurance-big pharma- gov't "medical-industrial complex". The big guys could give a rat's @ss about the public health. They are there to make money ( not bad by itself unless it jeopardizes someones health) and at the end of the day could care less about the public. The patient's abuse the " system" because they can , with oodles of lawyers to " ride shotgun" protecting the public from the " providers". This " system" is so out of control I don't know where to start. I fear for my parents, children, my neighbors and myself that in the future we will have a system so screwed up no person in their right mind will enter the healing professions. Everyone will be a lawyer, drug peddler, IT support person, administrator,or device salesperson and the person who really wants to help the patient will be so marginalized that he/she won't have sufficient funds to fill the gas tank to make it to work each day. Hopefully some group of persons will have the intestinal fortitude to "fix" the system prior to a complete collapse. Sorry for the philosophical rant.
Alright....I try to be a good patient. I have some silly questions.
If I think I have "urgent care" at hours that doctor's offices are not open...would I be sent away? Like if I had a ferral cat bite, a sewing machine needle in my leg, thinking I nearly broke my arm, and feeling suicidal?
These are all reasons I went to the ER that I felt stupid for going, but they all happened at weird hours of the day.
The only time I went to the ER that I felt like it was an emergency was when I was 13 and having an asthma attack that nearly sent me to the ICU.
Okay...for the BMI thing...if you are taking drugs for asthma and bipolar...that make you fat fat fat...would you point and laugh?
I've gained so much weight...I hate it.
I took liberties and posted a link on a couple forums I frequent.
Look forward to an avalanche of comments (and traffic!) ;-)
always go with good and registered doctors...and if you are going to take prescription drugs like viagra, cialis or levitra then you must carefull beofre taking drugs from pharmacy...must consult with doctors before taking any kind of medication..
Admittedly, I have arrived in the ER post-midnight for something which was not a life-threatening emergency. About 5 weeks after a round of high-dose steriods for MS, I was feeling not so well. My face was hurting and by the evening started to breakout with little 'pimples.' Later that evening my Mom, who lives near by, took one look at me and said -- Shingles.
Knowing that beginning anti-viral meds quickly would increase their effectiveness, I went to the local ER, even taking a pillow for the wait. The doctor diagnosed shingles, laughed at my pillow, checked my corneas, wrote the appropriate prescriptions, and sent me on my way to the nearest 24-hour pharmacy.
I was able to begin anti-viral meds at least 10-12 hours sooner than if I had waited until the morning to MAYBE get into my doctor's office. Interestingly, the hospital bill was considerably less than what my insurance allows and my ER copay almost covered the visit in full.
I was certainly thankful to have the option of timely attention and did not object to the personal increased cost for the visit.
I like #20 a lot. Even if it's not a ton of money, (say, $10-$25 of your $50 ER copay), it will make people think twice about coming in.
I also like cost transparency. If I know how much drugs cost, even though my copay's the same, I'll choose the less expensive one (as long as it's equally effective).
ladyk73's post made me think--I would say a possible broken bone would be the definition of an emergency, especially if it happened after hours.
Anyway, we took the offspring to the emergency room when she broke her arm (6:30 p.m.). No one laughed at us, and within 30 minutes she was in x-ray.
That was off topic, but with everything but BMI, I agree. BMI doesn't account for people with lots of muscle, or other such things.
Like I said, triage determinations are made at the hospital. You are not expected to know what an emergency is.
As for the BMI, being in your target BMI gets you a tax credit.
Not being in your target BMI gets you neither reward nor punishment.
Why would I point and laugh? I don't laugh at fat fat fat people.
I think unmanaged expectation could apply to all your points. EMT will not solve everything is folks merry their way through life thinking that medicine will fix them if they abuse their bodies.
However, I've seen enough folks do Rehab, over and over again -even at pricey places like Betty Ford- to think that entitlement to endless Rehab is a mistake.
Drug and alcohol problems need help, but throwing the person out or in jail or cutting them off is sometimes the only solution.
It does not cost much to sit in a church basement and hear a message that gets you sober.
Your first point reminds me of something I read recently about complete symptom remission as an unreasonable goal of psychotherapy, especially in treating depression. By accepting that complete symptom remission is unrealistic and undesirable, clients can be treated with fewer meds and fewer side-effects.
I understand the frustrations with medicare and medicaid, but the problem with providing "cheap" health care to the poor and "good" health care to the wealthy is that the sickest people are often the poorest, and much of the time health problems prevent people from working or making money. Im sorry if that sounds overly simplified, but can it really be said that the life of a wealthy person is worth more to society than the life of a poor person? Restricting access to quality health-care to the minority of the opulent sounds like a nifty way to start a class war, if you ask me. heh. I realize the question is more "how to make it work" rather than "how to make it fair", but our hybrid public/private system is definately part of the problem. The "Market, in its infinite wisdom" can't be trusted to run things fairly any more than the government, in my view. The recent behavior of the pharma industry is a good example. If it's a private enterprise, shareholder return will come first, public welfare will come second, and fines will be paid in lieu of compliance with the law if it turns out to be a better business decision. It's interesting how the MDs always seem to be the ones agitating for privatized health-care, you guys sure cleaned up after de-institutionalization of psych care, and then there's the AMA coining the phrase "socialized medicine" to scare people away from HMOs...but I think to say that "solving the problem of how to provide health care is too complicated to understand, and the market is too complicated to understand, so the market can solve our health care problem" seems somewhat funny to me. The rest of the industrialized world is showing us that public national health care is possible even with limited resources. We're in a much better position, or at least we will be once we scale back our military funding, and we're in a good position to show the rest of the world how it's done.
Some of the things you mentioned, like bonuses for doctors and institutions that decrease BMI and convert smokers to non-smokers feature prominently in "socialized" health care systems. For all the glaring faults those systems have, we can learn from those mistakes, and we have the resources to implement it better, it's just a matter of properly allocating those resources. Handing it over to private tyrannies seems like a poor solution to me.
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