A Time For Revolutionary Thinking

John Haughom MD whiteWe need to design a system of health care that optimally meets the country’s needs while also being affordable and socially acceptable. Clinicians should be at the center of this debate if care delivery is to be designed in a way that puts quality of care before financial gain.

This challenge is too important to be left to politicians and policymakers. There is an urgent need for clinicians to step up, lead the debate and design a new future for health care. Placing professional responsibility for health outcomes in the hands of clinicians, rather than bureaucrats or insurance companies with vested interests, must be an ambition for all of us. We need to find the formula that meets the needs of the patients and communities we serve. A sincere collective effort by committed clinicians to design an effective system will lead to a health care system that has a democratic mandate and the appropriate focus on optimizing the outcomes patients and society need.

As clinicians enter the debate, they should keep three things in mind.

Promote the leadership role of clinicians

We need to help politicians and policymakers recognize the role of clinical leaders in shaping a transformed but effective health care system. Clinicians must redefine the debate so that it focuses first and foremost on patients and health outcomes. Cost effective care can and should be a byproduct of optimal care. Accomplishing this will provide a strong common purpose for efforts to address the challenges of designing outcome-based funding structures and improving access to care.

Explain appropriate levels of care

Clinicians must inform both policymakers and the wider public about appropriate levels of care and the appropriate venues of care. A disproportionate focus on the treatment of acute illness and injury, which consumes by far the most resources, will not serve our country well. Primary care accounts for most of the health care that is delivered in the United States. There are nearly 1 billion visits made to physicians’ offices every year in the United States, but there are fewer than 40 million hospital stays. We need to pursue every opportunity to direct care to the lowest cost venue of care that can effectively address a patient’s needs.

Adopt a data-driven approach to care

Any system must be driven by data, focused on outcomes, and designed to deliver the appropriate level and type of care. The current hospital-centric, overly referral-based system often leads to unnecessary referrals and an over reliance on the most expensive diagnostic tests and treatments. It also ignores other major determinants of health. Health problems related to lifestyle, such as obesity, smoking, substance abuse and diabetes will not be solved by more hospitals but rather through access to primary care physicians, innovations in public health, and lessons from the emerging discipline of behavioral modification.

The best outcomes can be achieved only when the system itself is healthy and built on real partnerships between patients and clinicians. Building a health care system centered on clinical professionalism and responsibility is the only way to achieve such partnerships and to ensure that all patients are well served.

Thanks to some pioneering individuals and organizations such as the Mayo Clinic, Virginia Mason, M.D. Anderson, Partners Healthcare, Texas Children’s Hospital, Kaiser and many others, we can now see enough of the future of health care to have a sense of what it will be. And it is exciting. Empowering. Better for patients and communities. The new ideas, vision, tools and methods capable of supporting meaningful change are falling into place.

A frequent companion of challenges is adversity. As hard as it is, one can view adversity as a privilege and an opportunity. During times of great change and adversity, we cannot control circumstances, but we can change how we view them. We need to lean into the adversity. Many involved in the healthcare profession need to see a glimpse of the future, understand their role in it and be sustained by a sense of hope. It is our responsibility — and privilege — to offer this to them.

In a 1913 speech, Sir William Osler said, “To have lived through a revolution, to have seen a new birth of science, a new dispensation of health, reorganized medical schools, remodeled hospitals, a new outlook for humanity, is an opportunity not given to every generation.”  To paraphrase Sir William’s message, we have an opportunity to witness a new birth of science, a new dispensation of health, a remodeled health system and a new outlook for humanity. Indeed, this is not an opportunity given to every generation. But it has been given to us. It is our revolution.

John Haughom, MD, former senior vice president of clinical quality, safety and IT for PeaceHealth, is a senior advisor to Health Catalyst and the author of Healthcare: A Better Way. The New Era of Opportunity.”

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  2. Accoprding to my point of view We need to help politicians and policymakers recognize the role of clinical leaders in shaping a transformed but effective health care system. Clinicians must redefine the debate so that it focuses first and foremost on patients and health outcomes.

  3. Not at all. I am saying that if good data shows that a peer physician is doing things that are causing patients avoidable harm or leading to avoidable bad outcomes, as professionals we have a responsibility to address it (based on data). Those types of rules went into place in about in a formal way in the US in 1915 and this type of peer review has persisted since. The only real difference now is that we are getting better, more objective data to base those judgments on. Civilized society has to have some rules like this. If people are not hurting others, government should not intrude. If someone hurts or kills someone, a civilized society has to have some way of dealing with it. This is just part of a very old professional code.

    There is a slide I occasionally use that illustrates how far society has progressed on this. Law 215 (out of 280) of the ancient Code of Hammurabi (1780 BC) dealt with physician harm. Here is what it said:

    “If a physician make a large incision with the operating knife and cure it,…, he shall receive ten shekels in money.
    If a physician make a large incision with the operating knife, and kill him,…, his hands shall be cut off.”

    Obviously, I am being tongue in cheek here, but we really have gotten better on professional responsibility to protect patients through peer review, and the better data gets, the more refined it will be. But I do believe we have a responsibility to protect patients from avoidable bad care that does not have data to support it.

    • We have civil and criminal law. We have contracts and courts that adjudicate disputes. Don’t confuse that with the promotion of business models or ideas such as EHR’s that are promoted and enforced through coercion.

      Your line of thought makes one question your willingness not to cross that dangerous line where coercion replaces voluntary action.

      • I have to say that I can truly relate to Allan’s concern about government systems that take on a life of their own and result in loss of freedom (and thus innovation). I just recently was asked by our health-care exchange to provide documentation of income for my 5 year old daughter. I have to write a letter to explain to them that she is only 5 years old and has no income. The agent agreed that this did not seem like a reasonable request but that the “system” needed it.

        Is this just the beginning of what we can expect ahead?

        On the other hand, I have seen too much unnecessary suffering from lifestyle related illnesses to shy away from attempts to reform the pre- ACA system. I have to say that I agree with John when he says that the task ahead is far from easy. But I don’t accept the option of simply trying to turn back to a past that was also failing. This is a challenge that will need to be hammered out over time with the help of people like Allan and John.

        Thank you for the educational exchange of ideas.

        • Well said, Prestor. The data is pretty clear – our current system is being overwhelmed by complexity and is presenting very real challenges. We can – and I believe we will – find a better way that retains the best of the past, yet deals with the issues. There are enough bright, well educated and committed people in healthcare to do it. I strongly believe they are the solution. Not politicians or regulators. You have to understand how healthcare works to fix it. It is a complicated game, but I believe it is solvable.

        • “On the other hand, I have seen too much unnecessary suffering from lifestyle related illnesses to shy away from attempts to reform the pre- ACA system”

          Prestor, in medicine one learns that not everything has a solution. However, sometimes instead of looking for a solution that involves more intervention one can look for the problem.

          In medicine there is one problem that almost all economists agree upon. Third party payer is bad and many will say third party payer is a central problem of our healthcare system.

          Where does third party come from and what does it do? Third party is a result of tax favoritism to employers leading to employer sponsored health care. It is government created and is destructive creating dangerous incentives along with ever spiraling costs. The solution for this problem is not to add more government intervention rather to get rid of the problem. Get rid of third party payer.

        • Prestor… If you would be at all interested in a complimentary signed copy of my book, I would be happy to provide you one. No obligation, but it will give us more to talk about. Best… John

      • We need to have lunch sometime and discuss it. I am not sure I can say it more clearly than I said it above. I firmly believe the solution to healthcare’s issues is engagement of front line clinicians to solve it. Such an approach will serve patients, clinicians and the country well. Coercion rarely, if ever, works. Thanks, Allan. Have a good week. If we ever have that lunch, it is on me! 🙂

        • John, lunch is always good, but you won’t coerce me to eat off of one side of the menu will you? 🙂

          Coercion can be very subtle and if one has the power it is hard to resist its use especially if one thinks they are right.

      • By golly, I think we finally found something we disagree on that we can discuss over lunch! As I am sure you know, the traditional way issues about the quality of care have been handled on medical staffs is through the credentials committees. Having been on such committees and observed the process, I know for sure that if I were in position of needing someone to assess my care with a patient, I would much rather have a respected committee of my peers assess it than police, lawyers and courts. While there are rare instances that criminal law is justified, I certainly do not want non-clinical police assessing my care, and whenever a lawyer gets involved, it is a long, ugly and expensive process. This is why we have such an expensive malpractice liability problem in the U.S. We need to limit that, not extend it. This has nothing to do with EHRs. Separate issue.

        Anyway, love the dialogue. By the way, if you would be at all interested in a complimentary signed copy of my book, I would be happy to provide you one. No obligation, but it will give us more to talk about. Best…

        • Thank you John, but I was describing what already exists as I wish to limit the entry of more government imposed bureaucracies. Just because some of these bureaucracies being thought of might be run or supported by physicians doesn’t make the coercion taste any sweeter.

          • Somehow we aren’t connecting. I am probably not expressing myself well. As I said, coercion does not work. It will not solve healthcare’s issues. I believe only frontline clinicians can do that. More government will not help. They currently bring us the Post Office, Amtrak and the VA system. All of them have major problems and all are losing money. Why would we want to have them take over the most complicated industry in the world that represents 25% of the US GDP? Doesn’t make sense to me.

        • John, you have expressed yourself well maintaining a position on both sides of the line. That is why we continue jousting. This time you say “coercion does not work”, but then you also say “Coercion rarely works well” and other times seem to say coercion is needed when a better solution exists or when doctors are involved in the coercive behavior it’s OK. There is a lot of potential for ‘buts’ and ‘ifs’ inherent in your comments about coercion and that comes out loud and clear.

          You have had ample opportunity to clearly state where you stood without the ‘buts’ and ‘ifs’, but you appeared to sidestep the definitive statement and chose to be more ambiguous. Look at how you handled my responses and questions always responding to keep your options open.

          • Allan… I actually think we are both on the same side of the line. While social media works well, it doesn’t work when you are trying to get sincere and important points across. Those type of conversations really need to happen face to face. Don’t read too much of words like “coercion does not work” vs. “coercion rarely works.” The distinction is subtle but important. I tend to avoid the word “never” because you can always come up with an exception. Coercion is necessary in cases involving things like murder, rape, incest and child abuse because the human behavior is so abhorrent that society has to be coercive. I absolutely do not believe we will solve healthcare’s issues with coercive government behavior. I have spent 20 years engaging clinicians in a very positive way that they find rewarding and fulfilling. When I started, I was young and inexperienced so i was not as good at it. After 20 years, I have learned a lot (not everything, just a lot) as have others. I believe this is the future of healthcare, but we have to engage clinicians in helping address the issues which are very real. If we do not engage, I have no doubt that some group will try to fill the void — nature abhors a vacuum. This is true in society just as much as in science. It would be very unfortunate for patients and society if we cannot all get involved in solutions that i know can work because we are seeing so many examples of it emerging. It is very much in line with physician professional values. It is about us striving to be the best we can be. The vast majority of the many, many physicians i have encountered in my 40 plus year career get up every day with that very goal in mind.

          • John, we might be on the same side of the line but I fear we are going in opposite directions. I guess you want to be perceived as a person that doesn’t believe in coercion or top down control, but there is an important principle involved. You either accept that principle or you don’t.

  4. No. The model I envision will always leave room for innovation. It just needs to be based on data, evidence and what is best for patients (based on data and patient desires). As long as physicians center the discussion and discovery on those things, there should be no need for coercion, but plenty of room for continuous improvement as new knowledge and ideas come along (which they will). I guess I would hedge on one thing, and that is that as physicians we all know that there are a few bad apples. I think far fewer than most realize, but there are some. The way I believe that should be handled is not by a governmental mandate, but rather, clinical peers working with physicians who need to alter their approach. However, that is no different than what good medical staffs have done for decades. If we have a peer physician who seems to be doing things that are not in the best interests of patients, we need to deal with it as professionals. Even those decisions need to be based on good outcomes data. I think you and I are pretty close on all of this.

    • “As long as physicians center the discussion and discovery on those things, there should be no need for coercion…”

      Are you saying as long as the physician plays ball there should be no need for coercion? That is coercive in itself. …

  5. Coercion rarely works well at any level. On the other hand, honest engagement generally works and works well. That has been a formula that has served me well for many years. The only caveat I will add is that physicians will have to get better at working collectively. We will not have a role in designing new models of care if we have a half million physicians all going in a different direction. We need to focus our debates on good data, evidence, and most importantly, what is best for the patients we serve. If we do that, we will have the system we want.

    • Then we agree. All that is left is what happens when you find the ideal solution and the government agrees with you. Will that be the one time coercion works well?

  6. John, I too appreciate this ongoing dialogue. If only we could agree as to what amounts to coercion we would be on the same team. I favor some of the ideas you mention, but I quiver at the thought of government directly or indirectly mandating solutions of this nature.

    • Allan… Actually, I think we do agree. The reason I advocate so strongly for clinicians to engage is because the last thing we need or want is a governmentally imposed solution. The very flawed ACA is a recent example of that but far from the only one. As long as physicians leave a void, we can very much expect more in the way of flawed programs. Front line clinicians need to design care based on good data and the best available evidence. We may have honest disagreements about what “good data” and “evidence” is, that is a good dialogue to have. As soon as we start doing this broadly will be the day that we begin to see a rational and workable system emerge. Perhaps where we might disagree is on how likely that is, or at least, how near term. I am seeing more and more evidence of groups of clinicians who are interested and willing to go down this road and adopt modern improvement methods. In addition, while our data systems need to continue improving in many ways (especially EHRs), the data and analytical tools at our disposal now are vastly better than when I started in healthcare 40 years ago. It used to be hard for me to engage and excite my peer physicians with these tools, but not any more. Now it has become pretty easy to get them excited, and these tools are improving at a very rapid rate.

      Thanks again for the honest exchange of ideas.

      • ” As soon as we start doing this broadly will be the day that we begin to see a rational and workable system emerge. “

        …And if in your opinion or the opinion of our government that the emerging system should be promoted you will fight any coercion to make that system a reality for we recognize that such coercion means the destruction of even a good system and should be forbidden in a free society.

        Thank you as well.

  7. Prestor

    Thanks for your thoughtful words. Well said. I strongly agree with you. We need to migrate to an incentive system that incentivizes health and outcomes, rather than for doing procedures. This will greatly accelerate the migration to a profession-based practice that focuses on outcomes.

    • That is essentially correct. Bu,t that we have a need doesn’t doesn’t mean we have a valid proven solution. We need innovation, but the coercive methods being used inhibit innovation. Government plays to the tune of the voter, not the innovator; to the large companies, not the innovator; to their friends and relatives, not to the innovator.

      • Allan and Prestor… I appreciate your ongoing dialogue. This is good for healthcare. We need more physicians engaging in just this type of conversation. I believe healthcare and patients will be better served if good clinicians work at designing good solutions. If we just try, I think patients will listen — maybe not the government, but patients. While designing a workable incentive system based on outcomes will be far from easy, I do believe it is where we need to go and the end result will benefit both physicians and patients. I strongly believe that healthcare is blessed with the brightest, best educated and committed workforce in the world. Other industries have been transformed with far less. We need to get together and figure this one out. Thanks again for the opportunity to converse and debate the issues.

  8. ,,Any system must be driven by data, focused on outcomes, and designed to deliver the appropriate level and type of care”

    I feel this is mostly neglected at universities or in academic sphere in general.

  9. We do not need all this healthcare.

    Start there with your revolution. People will not buy it. Why should they get it free. It is dangerous to go to the hospital.

    Healthcare is sold based on fear. People should not be terrorized into either having or voting for healthcare.

    Give people their money to spend as they see fit and get honest charges into place. Help those that need real assistance.

    Quit engineering behavior that is none of your business.

    People should be free of your meddling.

    • Agree. Turning the whole world into a patient is going to send costs into uncharted realms. Prevention, at least medical supply side style prevention, is way oversold.

      “Health problems related to lifestyle, such as obesity, smoking, substance abuse and diabetes will not be solved by more hospitals but rather through access to primary care physicians, innovations in public health, and lessons from the emerging discipline of behavioral modification.”

      Let’s just take smoking. The greatest degree of change had to do with 2 major forces: economics and culture. Those smokes are expensive and getting worse. So are the premium penalties from insurance. It is not cool or socially acceptable to smoke any more. It is universally perceived as unhealthy. This did not happen because of physicians doing motivational interviewing.

      The reason tobacco did so well for so long is that the government and industry, hand in hand, developed an unprecedented delivery system for this product. In effect “socially engineered”. It persists to this day, where government and industry work hand in hand to keep tobacco “safe” for many generations to come.

  10. I agree the way to improvement is data driven. To that end we need to know how we are spending our health care dollars now, at least the public your and mine dollars. That means publishing what it costs per patient per year for each provider as every charge is tied to some provider number. I was encouraged when the Medicare data became public and looked forward to the same transparency for Medicaid but Oh how quickly the storm blew by. Maybe we can still hope for more in depth mining of this data by journalists such as those at the Wall Street Journal after all they led in requesting this information become public. Now at least lets find a way so the consumer can really find out if his local providers are running a Chevy or a Lexus dealership and then also what their recall and reliability rates are, Surely the Republicans who believe the marketplace is the solution to our health care cost problems can help constructively work out this problem instead of just waging an ignorant fight against any attempt to help provide care for all of us.

  11. “The best outcomes can be achieved only when the system itself is healthy and built on real partnerships between patients and clinicians. Building a health care system centered on clinical professionalism and responsibility is the only way to achieve such partnerships and to ensure that all patients are well served.”

    This ship has, unfortunately, sailed and there is not another one coming into port. The revolution we need begins with some truth telling: the “system” we have stinks and is built around the economic self-interest of the (clinical and non-clinical) people who run it; and, our government has been an enabler of this all along. Peter1 is completely correct when he points out that we need revolutionary bi-partisanship. Compromise, however, requires that all the players involved be willing to sacrifice something for a greater good. That ship, too, has sailed. Good luck turning it around.

  12. Before we get “revolutionary thinking” from medicine we’ll need revolutionary thinking from our politicians.

    We don’t need revolutionary thinking, we need revolutionary bi-partisanship.

    • “We don’t need revolutionary thinking, we need revolutionary bi-partisanship.”

      What a great and quotable line!

      I’m so 100 % in agreement!

      • I certainly agree that we need a functional bi-partisan political class. But even if they were more functional, politicians do not understand the process of care.

        Clinicians need focus on what they are experts on – managing the process of care. Modern improvement methods coupled with good access to data can and will challenge healthcare for the better.

  13. You honestly think Partners Healthcare with its highway robbery fee schedules is a good model for the rest of us?

  14. Although I agree with Robert Cato’s view that “We need to start being more honest about our current situation if we hope to carve out a better one for the future,” I also agree with Dr. Haughom’s emphasis on adopting a data-driven approach to healthcare.

    A month ago I authored a blog post titled “The big elephant in the health care room” (http://www.ontierrahealth.com/sample-page/) in which I raise the very question of financial incentives as Cato. I proposed that ultimately we need a model of health care that focuses on quantifying and improving health as opposed to the current emphasis on quantifying and treating disease.

    Only when doctors begin to see profit from keeping individuals healthy will we have a hope of stemming our descent into disease-care madness that we are currently facing. This is the “elephant in the health care room” that clinicians only get paid when we get sick. We need a model that merges health insurance with medical care such that doctors can get paid for keeping patients healthy. I call this a Health-Margin model of health care because it looks to health for the profit margin rather than to illness.

    Does this make sense? Do you see the elephant?

    The data driven model will be the key to shifting from disease-care to health-care and I believe the quantified self movement will play a role in this with devices such as Fitbit that are the tip of the iceberg.

    • “a model of health care that focuses on quantifying and improving health as opposed to the current emphasis on quantifying and treating disease.”

      I understand the treatment of disease, but ‘improving health’ is something that for the most part is outside the scope of the physician other than perhaps telling someone not to drink, smoke, or take drugs and to lose some weight all of which can be done by lay people. While I’m at it we should tell them to get vaccinated as well.

      But on this subject you say: “Only when doctors begin to see profit from keeping individuals healthy will we have a hope of stemming our descent into disease-care madness that we are currently facing.”

      I’ll bet you have a lot of problems listing additional things doctors are needed for to keep individuals healthy. Why is that? The purpose of a physician is to treat disease.

      True benefits in health are mostly obtained by increasing the standard of living instead of spending so much money on all types of consultants that add little but feed off the healthcare system.

      • Exactly, Allan.
        People don’t need docs to keep them healthy. They need information, incentive and motivation. They also need basic nutrition, housing, and clean water, and yes some vaccines.
        The idea that health insurance=healthcare=health is not correct. While health cannot be bought, the basic necessities that promote health do have a price. Until we are willing and able to address those issues, giving every American insurance or a doctor is beside the point.
        I doubt anyone is really willing to pay a price for “keeping them healthy”.
        They are more willing to pay to limit or cure the disease.

        • Thanks Perry, I think the reason Prestor S. didn’t reply with that long list of what only doctors can do to prevent the healthy from becoming sick is that the list is very short. Vaccines are number 1 on that list followed by number 2 which I can’t think of.

          I am always surprised at some people’s expectations. I am doubly surprised that those expectations don’t disappear considering the fact no one ever seems to come up with that long list.

          The same is true with the falsity that health insurance equals healthcare. It doesn’t and there is proof of that, but we keep hearing the same people repeating the same mantra.

          • OK Allan and Perry, here is what I was thinking. In the old days, people would wait until they got sick before going to the doctor, and that was a viable model. Then things progressed a bit and people now go in for checkups where doctors attempt to detect early signs of disease. However, this model is still too costly for America and is weighing us down.

            I keep pointing to “the elephant in the room” that I think we should discuss a little more. Incentives. I find that when we establish the wrong incentives things can get out of hand even when the initial intention is good. Thus Perry’s comment that we do not need doctors to keep us healthy has a good intention of keeping doctors out of our private lives. But the problem with this, in my view, is that doctors are in the best position of any profession to begin to quantify health rather than disease. So here is my short list of things doctors can do to help people like me improve my health:

            1) Doctors are in a better position than the average person to establish a biometric health index. For example there are some tests that provide a chronological vs biological age. Something to this effect would allow the average person to regularly track their level of health with their doctors help, and come up with targets for improving their health index. I believe the role of doctors in helping to establish a credible biometric health index is critical to the next revolutionary change in health care.

            2) Doctors can begin to promote tools that help people to better track symptoms and relate symptoms to environment and lifestyle. For example I am using an app now named mySymptoms by SkyGazer Labs that may be able to help me find correlations between lifestyle choices such as diet and exercise, and symptoms such as acne, bruxism, bloating, etc, This is a data-driven model of pursuing health much as a detective would. Because of their training doctors could play a huge role in guiding their patients in this regard rather than just saying it is to complex of a task and limiting themselves to treating symptoms.

            3) Doctors can take a more wholistic approach to health in order to help patients find root cause of illness rather than to focus on treating symptoms. For example, an elderly person comes in with signs of asthma, but never had asthma before. They can give them a medication, but in one case I found the potential problem was that the elderly person had not changed their heating filter for over a year due other health issues. There is currently no incentive for a doctor to pursue this cause to its root.

            You are correct that I am expressing a need to expand the role of the physician into improving health and profiting from improved health of patients. I think people will pay for this just as they currently pay for insurance while they are healthy. The baby boomer generation is tired of the traditional approach and we need a truly revolutionary view of health care,

          • People do get ill and injured. That is simply a reality. And if a family member or friend of mine gets ill or injured, the first thing they or their family member ask is “Who the best physician and hospital we should use?”

            One of the most-cited statistics in public health is the imbalance of social investments in medical care compared with prevention activities. Approximately 95 percent of the trillions of dollars we spend as a nation on health goes to direct medical care services, while just 5 percent is allocated to population-wide approaches to health improvement.5 However, some 40 percent of deaths are caused by behavior patterns that could be modified by preventive interventions. Genetics, social circumstances and environmental exposure also contribute substantially to preventable illness. It appears, in fact, that a much smaller proportion of preventable mortality in the United States, perhaps 10–15 percent, could be avoided by better availability or quality of medical care.

            Up until now, clinical care simply has not had the tools that allow them to be more effective in prevention, genetics. However, that is changing. As healthcare rapidly enters the realm of Big Data, it is likely that we will discover new knowledge, tools and techniques that will allow us to have an impact in this critically important area.

          • Prestor, you provided tangible evidence of only one item, asthma. The rest is either hypothetical or already being performed by M.D.’s. Much of the latter stuff can be done by lay people.

            Your asthma example is none other than what you portray as a “descent into disease-care madness”. Telling patients to change their filters or use hypo allergic things is also part of that medical “madness” you decry.

            Our list remains the same”

            1. smoking control, exercise, weight control, diet etc. plus handholding
            2. vaccinations

            I await your additions. The healthy patient should go to the doctor and what else do you think he should do? Biometric indexes already exist and are used, but physicians involved in clinical medicine cannot go further than present knowledge permits. I don’t think we want patients to be given 2 month appointments with their physicians only to be told to exercise.

          • Allan, I appreciate your feedback so let’s see if we can process what I am trying to communicate a little better. Let’s stick with your list for now.

            “1. smoking control, exercise, weight control, diet etc. plus handholding
            2. vaccinations”

            This is a general list of things that doctors can tell ill or non-ill patients to do to improve their health and the results of which can be monitored through clinical testing, correct?

            Do you believe that if a doctor invests his or her time and effort into a rigorous program to promote and quantify outcomes of the items you mentioned above that they should receive compensation if the rate of insurance claims from his patients decreases? Or should insurance agents keep all the profit?

            My whole point is not really how long the list is, but whether doctors should be able to increase their financial profit from keeping patients healthy thus creating a greater incentive for them to pursue health rather than disease. Of course doctors will always be at the forefront of treating disease, but I feel there needs to be a greater incentive for them to fully participate in the prevention of disease as well to help balance out the incentives.

            A revolutionary model of health-care must take a very close look at the incentives doctors have for taking a more proactive role in keeping their patients healthy over the long haul. My previous reference to “disease-care madness” comes from the simple observation that there are many more financial incentives for treating disease than for aggressively targeting health. We need a health care model that helps to flip this equation.

          • Prestor, yes, 1&2 are almost the complete list so let me explain from my perspective. True preventative care is very limited. Early diagnosis is looking for disease to be treated so those patients are not healthy patients. Physicians treat illness or look for disease to treat.

            Who should keep the profit? Physicians work to earn money. Patients hire physicians to, as you put it, keep them healthy, but in reality it is to diagnose and treat disease. The two of them should determine the price. Either of them have a right to utilize the services of an agent. Insurance companies make money by removing risks from the patient.

            There is no adequate established way to compensate physicians for performance. Risk analysis is in its infancy. Each patient and each physician is different which complicates the issue. We are not dealing with widgets. There is information asymmetry, but the bureaucrats suffer the same problem with an additional one which is lack of knowledge of what is happening on the ground.

            Patients do learn and make smart decisions. As a group they probably make excellent decisions (“The Wisdom of Crowds”, James Surowiecki)

            Today, because of all the variables medicine is part art so there are very few non physicians that can make good medical decisions. Thus today physicians are at the center with a lot of would be non physicians that would like to act as if they were physicians. The problem is they aren’t and many are merely trying to sell their wares complicating the system even further and injuring the patient at the same time. Things might change in the future, but today we are nowhere near such change.

            In the more recent time frame the medical sector has been targeting early diagnosis while the researchers put together knowledge about our genes, cytochrome system etc which will revolutionize medicine and potentially devise methods to keep people healthy adding to the short list that presently exists. Early diagnosis has a lot of dead ends and a lot of it leads to horrendous costs. Time will help to “flip this equation”.

      • Correct. Turning doctors into very expensive public service announcements that only play for one person at a time is not going to work.

    • I definitely believe we need to quantify more. Historically, we have not had good control over our data, but that is thankfully changing. As healthcare goes digital, and implements EHRs, we will have the opportunity to understand and manage care far more effectively, Analytics will dramatically shift away from reporting toward predictive and prescriptive practices dramatically improving the ability of healthcare providers to help the ill and injured. Even more importantly, it will create the possibility for truly personalized healthcare by allowing providers to impact the biggest determinants of health including behaviors, genetics and environmental factors.

      • ” Historically, we have not had good control over our data, but that is thankfully changing.”

        Unfortunately things are not changing for the better because of the meddling that goes along with the coercive use of top down thinking. Physicians are drowning in useless data spending their time looking at a computer screen instead of the patient. The one good thing is if one wants to find a nurse they don’t have to look in all the patient’s rooms. They can immediately find the nurse typing in front of a screen.

        • Respectfully, I suspect you have not seen the analytical power that is now possible for frontline clinicians to better support the patients they serve. These tools include modern data presentation tools that allow clinicians to quickly see important patterns in the data that have never been possible before. Would you like a demonstration? They are readily available on the web.

          • Respectfully, when physicians rely too much on glitzy high tech and not enough on their brains they have a tendency to err badly. Fortunately most physicians know how to rely upon both. But, when the high tech becomes entangled with coercive top down technologies generally all suffer.

            I need no demonstration of high tech being around it all my life. That being said today the data is being forced into a computer in an awkward way that changes the data and the interpretation. Not all that different than the Heisenberg Principle.

            If one likes their nurses all in one place lit up by the EHR data on the screen that is their choice as is the choice of speaking to a physician whose eyes seldom meet the patients, but have that glow from the computer screen.

            I prefer a little less coercion and a lot more common sense.

  15. this type of “revolutionary thinking” encompasses several critical business elements that physicians are not equipped to tackle, mainly, change management, business model redesign, culture change managment, risk managment, financial incentive restructuring, organizational design, governannce, among others. To think that physicians must lead this revolution on their own is exactly what retains the status quo. Without conquering the fundamental financial incentives – and utilizing a certain business acumen to do so – then doctors will never completely change their behaviors. Banking on altruism and empathy to pave the way of reform is a bunch of crap, to be quite honest. We need to stop living in this ferry-tale land where all of America’s docs are benevolent providers that care only about the patients health. Look around the country – the higest prices are located in areas where hospitals/providers have the greatest concentration of market power. yes, it can work in pockets, like the examples you outlined, but even then, organizations like Partners still have exorbitantly high prices, and are trying with all their might to gobble up everyone and everything in their path. Acting like it’s ok bc they are providers and they only care about the health of the patient is a dangerous, destructive path. We need to start being more honest about our current situation if we hope to carve out a better one for the future.

    • Thank you for you comments. I don’t share your somewhat dim view of physicians. The countless clinicians I have encountered through my long career work tirelessly for the patients thy serve. The vast majority are driven by excellence and sincerely want to deliver the best possible care. Using modern methods they disease by disease

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