Saturday, January 21, 2006

Where's the Beef?

It's my impression that the health care crisis we are experiencing is really a paradigm shift. The current older, traditional and fully established model for delivering health care is grudgingly giving way to an emerging model. I have to admit when this first occurred to me I was using nothing more than gut instinct to guide this impression. It may not seem like much but it was just enough to allow me to drop my pre-existing ideas about the causes of much of the problems in medicine. More importantly it gave me the freedom to explore different reasons for the current state of affairs rather than succumb to the usual rhetoric heard within the medical culture. It is not uncommon to hear of just about anyone involved in the health industry today as greedy, selfish, uncaring, incompetent, parasitic, incapable, needy, whining and inhuman. The list goes on and each of these words is used to describe doctors, lawyers, nurses, hospital administrators, insurance companies, pharmaceutical companies, CEO's, politicians, and even patients. Are we all really that terrible? I don't think so. Have you ever walked into a very warm environment? Let's say a committee meeting room and the air conditioning wasn't working. No sooner does the meeting start and everyone is at each other's throat. If you're fortunate and the air conditioner turns on and the room cools off, what happens. The meeting calms down and everyone starts treating each other more cordially. I think an emerging paradigm for health care delivery is the source of our discord. It is the factor we can not see but can certainly feel. I haven't convinced you have I? Let me try it from a different approach. You decide if I'm on to something here or not?

In medical school I was taught that the fundamental basis of our health care system was built upon the patient-physician relationship. That bond was the focal point. Without it and the entire system would collapse. A patient would develop a symptom of a disease process and seek the advice and treatment from a physician. The physician would diagnose the disease process and prescribe a treatment. It was a very simple formula and it works most of the time. It has served the interests of both patient and doctor very well for hundreds if not thousands of years. This fundamental relationship is under attack. There are two main reasons for it and both have to do with the rising costs in medicine.

The first cost to be dealt with is the cost of the encounter with a physician. Managed care and Medicare have whittled away at this for years but there is only so much they can do in the long run. The costs of medical school, residency, medical liability, and practice overhead continue to rise. Physicians are beginning to cost too much for certain services. The solution is to change the nature of the encounter from patient-physician to patient-provider. A provider can be a physician (MD/DO) or they can be a nurse practitioner (NP) or physician's assistant (PA). It doesn't take as much to train an NP or PA so each patient-provider encounter will not cost as much. An interesting model for this is beginning to develop in several major cities in the United States in the form of Minute Clinic. These are clinics that are based in either the bigboxes (Target, Cub Foods Store) or major pharmacies (CVS, Bartell Drugs). They are walk-in clinics that target common, relatively easy to treat illnesses (e.g. sore throat, ear infection, bladder infection). They promise quick, affordable and convenient care. While the clinics are overseen by an off-site physician, they are run by NP's and PA's. You can walk in, go shopping, be evaluated for your bladder infection and walk out with your groceries and prescription in hand. The entire encounter is guided by proprietary software (Artificial Intelligence) embedded in their electronic medical record (EMR) which is based on national clinical practice guidelines. These guidelines are thanks to the hard work of The American Academy of Family Practice, The American Academy of Pediatrics and The Institute for Clinical Systems Improvements. Interestingly they promise "autonomy of practice" on their web site for the NP's and PA's they are recruiting as future employees. I'm not sure how they can say this when the artificial intelligence is guiding the patient-provider encounter. It kind of reminds me of the old Texas politician who once said, "If these boys get any smarter we're going to have to water them twice a week." OUCH! Oh who am I to judge? They will be getting great benefits and of course flexible scheduling. (Sorry, there I go again, waaa, waaa, waaa.)

The second cost that will be addressed with this type of approach is probably the more important of the two and I alluded to it in the above paragraph. A few years ago an older, wiser doctor once pointed out to me that most of the direct costs of medicine flow from the physician's pen. What he meant by that was the treatments and prescriptions we write for our patients are what drive the costs in medicine. In the old days hospital admission orders, drug prescriptions, physical therapy, consultants, operations, length of stay and outpatient clinics and rehab referrals all came as a result of what the physician recommended. Control the pen and you control the costs in medicine. Again, managed care and Medicare whittled away at this but they are beginning to reach the point of diminishing returns. What if, instead of physicians driving this process we displaced them with someone who could be guided? Maybe someone who is willing to work for much less? Maybe in time patients will come to trust the artificial intelligence guiding the encounter and would be willing to be assessed by someone of even less training and cost? It could happen and I believe is happening. I think this is a trend line and there are sure to be others if this is the direction the emerging paradigm is going. The trend goes something like this. A service is initially provided by high cost biological intelligence (MD/DO), followed by lower cost biological intelligence (NP/PA) guided by artificial intelligence (AI) and finally completely provided by even lower cost artificial intelligence (AI). If so then the fundamental basis of our health care system will become a patient-AI relationship. I know that may seem pretty far out there and I may be stretching things a bit but what if? We don't talk about these things but I believe we need to start. I'm not saying I'm for it or against it but I think this begins to explain some things we are experiencing. Society has been hammering away at the patient-physician relationship for years. This may be the reason why. If so then I think the emerging paradigm will definitely be stronger. I would just like some assurance it will be better.

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