Sunday, June 29, 2008

idea for better health care

The strongest criticism of consumer-driven healthcare is that consumers lack the knowledge necessary to make informed decisions, especially given the complexity of the choices presented before them. There is something to this. Then again, people know relatively little about how the thousands of available computers or restaurants, but they are able to make relatively sound choices. Why?

We have Consumer Reports. We have expert advice. We have friends. We have the internet, with thousands of customer ratings and reviews.

With health care? Not so much.

Outcomes reporting is getting better, but still isn't particularly actionable for your average patient.

And while I'm not of the camp that believes it's impossible to assess the quality of physician care, hospital management, or health care plan, I will agree that adequate information is not currently available (thanks in large part to those vested in protecting their care monopolies). So while I'll continue to push for more information and health care results sharing at every level of the health care system, I am also interested in providing patients with more leverage in the mean time.

Arnold Kling has written about the need for a "single case manager" for "when a complex patient enters the healthcare delivery system."

I'd go a step further.

Currently, insured patients choose a general practitioner (also known as, primary care physician, etc.), who, in theory, manages their care; the doc will give you a physical, make sure you're blood pressure's at a decent level, etc.

Of course, most of these tasks are actually done by a nurse, with the GP popping in for a quick hello, write a prescription, or hand out a referral.

This dynamic is not only grossly inefficient, but it fails to deliver the expertise that would most improve a patient's health. I would like to see the GP hand over a lot of his/her clinical duties to the nurses (which means buy-in from the American Medical Assocation...), and take on managerial duties.

I envision patients choosing between different GP corporations who would advise patients on which insurance plan makes the most sense for them, which specialists delivers the best value, how to choose between a generic drug and a more expensive brand drug, and sets up appointments at local clinics (e.g., Wal-mart one-stop shops or more expensive, more typical practices).

It would be relatively inexpensive, as one GP could oversee the health management of hundreds of patients a year, with the assistance of health care professionals (you don't need to be a GP to gather information, or setup appointments, or chart blood pressure; just like you don't need a construction team of architects to build a house).

The GP would be a health advisor, similar to a financial advisor (tangentially, I think if you want to help poorer people, subsidizing financial management could improve outcomes substantially).

What do we lose in this system? Well, for those that can afford going to see a quality GP regularly, you might not get a physician with as much experience as your current GP giving you a checkup next time around. Not because you wouldn't be able to find an experienced GP to do so, but because you would also have the option to have a nurse provide the same service at a fraction of the cost, and you'd probably go with the cheaper option.

Why? Well, because your GP advisor would break down the costs and benefits associated with each of your health care decisions, and provide you with simple, straightforward choices. Have I completely worked out this system yet? No. But I think its the right direction.

Related posts: value-based health care, real chance for health care reform


Andrew Cheesman said...

one question: why have things evolved this way if they're so inefficient? i'm not trying to argue that things are best the way they are simply because they are that way, but there's been a thought process here. i'd suggest that GP's pop in for the quick hello in order to minimize the amount of time that they need to spend per patient, thus maximizing the number of patients they can see. it might be a tribute to the quality of your own health that you don't need to spend more time with one, but i know that when i've been stricken with a malady, the amount of time that i've spent with a GP (or other physician) has increased.

also, the computer/health care comparison suffers one main weakness - computers are a relatively low-risk investment, and health care choices are not. i'd suggest that both the number of poor or poorly-informed computer choices and the number of issues caused by those choices are higher than you think.

Publius said...

That is a very good question, and I think the answer underscores my greater point.

The current GP model has evolved from the early days of the "town doctor" who was the only game in town for medical treatment. He was the surgeon, the pathologist, oncologist -- everything.

Obviously, this has changed dramatically. Now the GP serves mainly as the 'gatekeeper' for specialists. If you have a stomach problem, as I have, they talk to you for five minutes, ask you a series of yes/no questions, send you down to the lab to take your blood, and give you a referral for a gastroenterologist.

My first point is that the value-added by actually seeing the GP in this situation (over a registered nurse, for instance), like most situations, is relatively small.

Nuanced medical opinions have already been taken out of the hands of the average GP, and GPs have been instructed to send patients off to specialists.

I think the GPs do have a value to add, but they should emphasize general patient management rather than specific patient one-on-one interventions.

I'll put it this way, I want an architect who knows how to manage the workers who will properly construct my home, I don't want an architect who wastes his time hammering in nails, when any of his workers could do that at a much lower cost.

And re: computer/health care opinion, you are correct in stating that computers are a relatively low-risk investment. That said, it's relatively quick and easy to find out which computers are considered to be the best value for money, or best of class, and also the worst.

We have only begun even measuring which hospitals have the most preventable deaths, and those numbers aren't known.

So while I'm sure there are bad computer choices or book choices, I think you are underestimating just how handicapped patients are in "choosing" care providers.

It's easier to find a book I like but have never read nor heard of the author than it is to find out that my hospital is one of my region's worst for hospital acquired infections.