Healthcare Matters

We all know the definition of insanity. Einstein had his own twist on the same thought, stating that a problem will never be solved with the same mindset that created it. Kay Plantes, a MIT-trained economist has suggested that Einstein’s thinking is “sorely needed” to address the coming shortfall of physicians.

In fact, it’s a supply chain problem and the supply chain for producing US-trained physicians is broken. It’s expensive and restrictive. Health care reform is not only making prevention and early treatment the focus, but it is making such care available to more people, adding up to 300,000 more patients into the primary care funnel. The Association of American Medical Colleges estimates the shortage will total 62,900 fewer doctors than needed by 2015, rising to over 150,000 by 2025, and this excludes the impact of the new healthcare law. There are about 950,000 US physicians today, with shortages existing already in may rural locations.

Ms. Plantes wisely points out that, under the current way of thinking, the solution to this problem has been framed as “how do we create more physicians?” But she plays the contrarian and argues that we could find better, quicker solutions by asking two alternative questions: (1) “How do we design our health care system to be less physician-dependent?” (2) “How can we use whatever physician resources we have more effectively?”

Her thinking is right out of the total quality management (TQI/TQM) handbook. Instead of designing a manufacturing process that needs to execute perfectly to produce an acceptable quality product, why not design a product that can be effectively produced via a more tolerant and easier to manage process?

Here are Ms. Plantes 10 ideas for easing the physician shortage. She admits to borrowing the underlying concepts from what businesses in other industry sectors have been doing for a long time, whenever faced with a scarcity of resources:

• Deploy nurses and physician assistants, who are less expensive to train, to manage more care. Physician assistants can do 85 percent of the work of general physician practitioners.
• Shift our physician payment system from a pay-per-procedure model to a pay-per-episode of care model, creating incentives for providers to reduce unnecessary procedures.
• Hold a national conversation on end-of-life care plans. As a nation we spend too much money extending life by weeks while hurting quality of life among the very elderly and burdening resources that could be used elsewhere.
• Reform malpractice laws to reduce defensive medical procedures while, at the same time, intensify US government efforts to reduce Medicare and Medicaid fraud.
• Create financial incentives for people to stay healthy and better manage chronic health care conditions. While women should not be charged more for health insurance than men, shouldn’t smokers and obese people be obliged to pay more for insurance?
• Expand “care co-ordination” services to better manage chronic care, reducing episodes that demand costly interventions. This is especially important for those with multiple chronic diseases.
• Use telemedicine to create early alerts for patients and caregivers, when problems can be solved using fewer resources. Medical monitoring company Phillips completed a randomized trial of telemedicine solutions in the UK, reducing Emergency Room admissions 20% and mortality 45% among 6000 patients with chronic conditions. Fortunately digital healthcare is a rapidly growing US industry.
• Combine process efficiency with technology capabilities to increase physician efficiency, allowing for lower cost, higher quality care. IBM’s Watson is being programmed to more rapidly identify differential diagnoses. Extended reliance on imaging software, networked computers and robotic surgery instruments could lower costs while also helping address rural healthcare shortages.
• Dramatically alter physician payment systems and medical school tuition models to increase the supply of primary, pediatric, and internal care physicians relative to specialists. One of the inherent problems in healthcare is that supply creates it own demand. Is it any wonder that the US, with far more specialists relative to primary care physicians than other nations, spends more on healthcare and has poorer population health?
• Empower consumers to be smarter buyers of healthcare by making cost and outcome information broadly available.

These are all good ideas that have been discussed repeatedly in this blog. And it’s inarguable that the Affordable Care Act embodies many of these concepts. But as Ms. Plantes points out, these changes “demand a willingness of physicians to lose some power.” And that’s the ten thousand pound elephant in the room.

ACOs and PCMHs represent networked care delivery models that leverage technology and existing clinical, operational and administrative resources in ways that can actually scale beyond whatever ideal previously existed that defined what the physician-to-patient ratio ought to be. It’s a better, more robust process of care delivery that interconnects and aligns an entire ecosystem of providers, medical product companies, payers and everyone in between.  It’s a good idea, but it will only move as quickly as the slowest player.

Leading healthcare systems, physicians, payers and policymakers understand this and are leading the charge. Say what you will about ObamaCare and/or the potential for its repeal. But the kind of reform to primary care delivery that is going on in the US right now should, in fact, help fix the physician shortage –the right way. And it seems completely implausible that a repeal to the PPACA would or could stop this momentum.

Source: Kay Plantes is an MIT-trained economist, business strategy consultant, columnist and author.

—Tom Finn