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.
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.
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.
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.
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.
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.
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.
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.
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