I recently sat on a healthcare panel at Trinity University as part of the Centene REACH symposium. It’s always eye-opening to hear clinicians and non-clinicians passionately debate as to what is wrong with health care. Pretty much it was what you would expect. Everybody pointing at everybody else and a few misguided solutions. Seems like there is a lot of this going on lately. I walked away feeling a bit dejected because it is clear that in a room full of executives and health care policy makers in matching blue blazers, red ties, and sensible pantsuits, there is a huge dearth of understanding when it comes to human behavior, and it is human behavior that drives health care costs. Perhaps that’s what happens when the majority of people in charge don’t actually sit in ERs, or work in clinics, or provide mental health counselling to homeless schizophrenics, or have to tell someone they have cancer and that they should get their things in order. You can’t develop that worldview by just sitting in a committee.
It doesn’t mean we clinicians don’t bear some of the blame though.
The trouble is that there is a giant gap in non-clinician insight as to why costs are as high as they are, why we clinicians over-order tests, why people just don’t go to a family physician or put that much stock in preventative medicine anymore, and why families opt for treatments for their loved ones that do little to improve their quality of life. You can only really learn these things by being at the bedside day in and day out.
The suits and ties—especially those with a political bent—use “financial coverage” for health care interchangeably with the “provision” of health care. That could not be farther from the truth. It’s like having a free bus pass only to find out there are no busses and then sit and listen to blue blazer-red-tie-guy and sensible-pantsuit-gal brag about how they got you those free bus passes and it’s the suits and ties on the other side of the aisle that want to take away your bus passes. It leaves those of us in scrubs and white coats banging our heads on the desk and thinking, Holy shit, no wonder we’re in this mess.
Even more concerning is a realization that it drives the clinician away from the discussion. We only have so much in our tank after a day in the trenches and we probably know more about these issues than anyone. We have to be at the table—and I mean the head of the table—making sure we all can enjoy the meal and not just argue over politics because it will just taint Aunt Millie’s green bean casserole.
One thing that is abundantly clear, however, is that most who serve on these panels have zero creativity. Doing the same thing over and over and just looking at it from a different angle is still just doing the same thing over and over.
So, I figured, “to hell with it”—I’m going to offer a few solutions based on 25 years of experience as an ER doctor that I think can radically transform health care in America and create a kind of medical ecology that I believe over time will save billions upon billions in health care costs and will dramatically improve the overall health care of a huge portion of America, and in time we can pass that savings onto the 5% that consume 50% of our health care dollars. So here are my five basic suggestions for saving health care . . .
First off: we don’t need to immediately solve every problem in health care. It can be incremental; it gives us time to figure out what works and what doesn’t. We need to focus our attention on the easy things we can fix. First get the ball rolling and come back to other stuff. Trust me—it’ll free up the resources so that we can repair all the other issues and do it better. It’s why we compartmentalize patients in the ER from low acuity to critical and create different areas within the ER to speed the flow of non-critical patients so they don’t choke the waiting room or overrun our resources and we have to adopt a philosophy at its core that says, “If it’s not simple to do, it simply won’t be done.”
That line should be stamped, in giant, bold letters on the top of every health care policy proposal. Then, as one reads the proposal, if it strays away from that bold type mission statement, it should be immediately torn up and tossed in the trash. Simplicity and reproducibility is paramount.
Yeah, you read that right. If you think preventative care is vital, as do I, then short-term investment will result in tons of long-term savings. Each person—especially Medicare and Medicaid recipients—would get something like a $400 coupon with a barcode identifier. The physician would scan that code and immediately have secure access to your health care info, medical records, etc. He or she would spend about thirty minutes with you, order some basic lab tests if needed, the physician would tear off a portion of the coupon at the end of the visit and give it to you that you could then exchange for 100 dollars in any bank, or ATM, or even use as a form of currency. The other $300 the doctor would immediately toss into his or her bank account—no billing, no processing, no arguing with Medicare or Medicaid. Primary care physicians would come out of the woodwork for this kind of “no-billing, instant-access-to-cash” incentive. They would open their offices on weekends. They would come out of retirement for this kind of payment option. You would probably see an influx in creative office space sharing where specialists might offer up space to generalists for a bit of cost sharing.
Along with this, we need to have a national health care license which allows physicians to practice across state lines without the added expense of getting individual state licensures but still allow states the individual power to police doctors and remove their state privileges should they not practice up to that state’s standards. This, in turn, should also involve tort reform to incentivize doctors to practice in states with the most historically physician-unfriendly malpractice records. This will metaphorically provide more buses and seamlessly increase the flow of doctors to underserved areas.
Documented, end-of-life discussions would be a mandatory component of the visit for all people over the age of 65. We have to get people into the mind-set early on as to how they want to approach their end-of-life discussions. We clinicians have failed miserably in this arena. We have to be more proactive and brave in discussing the reality of our patients’ mortality.
Get a group of doctors together from every specialty and ask them to pick a couple drugs that they would write for free if they could. My bet is that insulin, Metformin, Lisinopril, Plavix, Eliquis, a statin, a few antipsychotics and mood stabilizers, a couple antibiotics, Mirena, synthroid, and others would be on the list. Have the government buy the patents for these medications, sub-contract the pharmaceutical companies to manufacture these medications, and give them for free to American patients. The drug companies would maintain ownership outside of the US if they choose to, and we would also significantly limit the liability for the manufacturers of these products within the continental US. Ship the medications directly to the patient from the manufacturer. I hear there is a company called Amazon that does something like this. You can also get a spiral slicer, baby wipes, a bottle of Old Bay seasoning, and some dental floss delivered at the same time. Every few years the list can be revisited as technology changes.
“Access to care” is tossed around all the time. Everyone in medicine knows what the roadblock to access really is, though, especially as it relates to children. It’s simply moving people from Point A to Point B. That’s the roadblock. Not finances. Also, outside of getting their kids vaccinated, a yearly health care visit is simply not a priority for most people anymore. It should be, but it’s not. Mom is working and Dad is working, they got a travel baseball tournament this week, other kids are at home, no babysitter, no ride, kid can’t get off school, car’s broken down, just look it up on Google, etc., etc., etc., etc. So, I suggest we get rid of these excuses and bring the mountain to Mohammed. All schools especially those with high-risk populations (heavy Medicaid high-poverty districts) should have pediatric offices, adolescent health, child psychology, and even dental services IN THE SCHOOL ITSELF. Over the course of the school year each child can be given the option of being seen at school for a well child visit, updated vaccines, dental care, diet and nutrition, drug and alcohol and mental health counselling, and yes . . . even birth control. Certainly, parents can opt out and would be encouraged to meet the child at school in conjunction with the physician. But we need to create a culture early on where the doctor becomes an integral part of the American education system and where medical care ecology founded in preventative care becomes as commonplace as recycling aluminum. A healthy child misses less school, becomes better educated, makes better choices, and becomes less of a burden on society in the long run.
So there you have it, some easy first step fixes. Make it simple, incentivize doctors and patients, provide some free medications, build more buses, and create a medical ecology culture from the ground up starting in schools. It’s not that complicated.
Or we can toss on a blue blazer, a red tie, a sensible pantsuit and brag about how our side got your side a free bus pass.
Dr. Louis M. Profeta is an emergency physician practicing in Indianapolis. He is a national award-winning writer and one of LinkedIn's Top Voices and the author of the critically acclaimed book, The Patient in Room Nine Says He's God. Feedback at firstname.lastname@example.org is welcomed. For other publications and for speaking dates or inquiries visit louisprofeta.com.
Dr Louis M. Profeta is an emergency physician practicing in Indianapolis. He is one of LinkedIn's Top Voices and the author of the critically acclaimed book, The Patient in Room Nine Says He's God. Dr Louis holds a medical degree from the Indiana University Bloomington.