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2. Steve,
   Thanks for your reply. With all due respect:

   “Put bluntly, that will mean most docs won’t have the autonomy to have high entrepreneurial earnings, at least not from their medical practices. ”

   Steve, very few of my friends and colleagues have made huge earnings in primary care. What you are suggesting, while maybe somewhat lucrative for the physician, will mean that they are beholden to the protocols and guidelines of the ACO, which means that they are taking care of the chart and the protocol, not the patient. That is why they will be factory workers.
   Certainly we need to focus on doing what is best for the patient, not what is most helpful to the pocketbook of the hospital or lab. But now we are going to a situation where we are paying doctors more NOT to do things. Is this really appropriate? Can we not devise a system that allows doctors to do what is right regardless of pay? How about working for the patient, not the insurance company, the government or the ACO?

3. Answering Perry from April 10….I don’t think most of the docs working today in integrated systems and getting paid a salary (or having a sizable portion of their FFS pay pegged to quality and cost measures) would consider themselves factory workers. And they are paid pretty well, as docs should be after the long hard slog of medical school, etc.

   It’s very hard in our society and culture to argue that docs make too much money…when investment bankers, football players, and movie stars earn tens of millions. But I do think that we need to reimagine the medical profession even as we transform and re-engineer other components on the delivery system.

   Put bluntly, that will mean most docs won’t have the autonomy to have high entrepreneurial earnings, at least not from their medical practices. Let me put it this way, to keep this short: If we can reduce the 15% to 30% of care that is unnecessary or inappropriate by just half over the next decade, we could afford to pay primary care doctors an average of $250,000 to $350,000 a year, and rising nicely with inflation.

4. @emma

   R u going to HIMSS? The folks there will be happy to ignore you as they move on to bigger and better things, such as patient engagement, interoperability, meaningful use, and innovation.

5. Addendum:

   To compare treaming to medical care is consistent with misunderstanding of what doctors and nurses do.

   The systems so described are not fit for purpose. The adverse events, errors, and near misses go unreported.

   This week, the doctor had CPOEed and order for BID potassium with a perameter to hold it if the serum k+ was > 4.6 mg%. the order on my palate was obfuscated by innumerable lines of instructions such that I missed the perameter and gave the potassium supplement when the serum potassium was 4.7, and the next day, 4.9.

   The doctor missed it because the MAR is terribly inaccessible and user unfriendly when accessed.

   The next day, the serum potassium level was at life threatening levels and I was beating on myself.

   Yet, I have no one to report this to, because, no one really cares.

6. Wonderful plan for treating patients with hangnails, or the worried well.

   You fail to consider mandatory reporting of EHR failures, unavailability, and crashes and the deaths and injuries that occur from such.

   When streaming does not work, so what, someone can not watch the Mavericks play!

   Get real and get consent for this experiment.

7. Extreme cryptography paves way to personalized medicine

   http://www.nature.com/news/extreme-cryptography-paves-way-to-personalized-medicine-1.17174

8. I suppose I should go on record, I believe Mark’s opinion is based upon inadequate knowledge and study. A lot of discussion on this topic can be found on the “Paying ’till it Hurts” Facebook page, or in the various writings of Dr Atul Gawande. Or read Malcom Gladwell – The Picture Problem. http://www.newyorker.com/magazine/2004/12/13/the-picture-problem
   Some medical treatment kills. More medicine that can kill is not a good thing.

   I speak as someone who has an almost 20 year graph-spreadsheet of blood readings. But no. I do not leave it up to doctors to tell me what to do with that information. Do you know what that stuff actually means? Are you willing to spend hundreds of hours or more reading about stuff like hematopoiesis or eukaryotic gene regulation? Putting your fate into the hands of one individual who sees you for 15 minutes is risky.

   Can I tell you about the friend who was prescribed powerful medications to deal with her anxiety when she actually had brain cancer?

   Ask any time. I’m happy she is still alive and well. And so am I.

9. What does tomorrow behold?

10. There is no scaling up the bedside interaction to make it cheaper unless it is shorter and the doc/PA/NP does not have to touch the computer.

    If all I have to do was provide care and the scribe/documentor/recorder did all the data entry, we could crank out a lot of quality care.

    The admin types relish the doc at the keyboard doing their bidding for MU and CPOE.

    Someone get it right…I’ll wait.

11. Primary care is a product the patient does not want.

12. Today’s physician assistant is a marvel to behold.

    They are wonderful.
    They are not working for free either.

13. We followed the recipe. Not our fault the patient died.

14. You really need a cookie cutter patient for all this to work.

    Good Luck.

15. http://www.huffingtonpost.com/2015/04/10/health-tracking_n_7025018.html

16. “We need 3x (or some multiple, this is a guess ) as many doctors as we have today so that the amount of time spent per patient can increase to better understand and use the dramatic increase in data we will see.”

    I understand the argument that is taking place but I couldn’t let this statement slide without disucussing the implications for cost. Mark, have you ever heard of the cost disease? So, in an era where we need increased productivity in healthcare, you’re suggesting we employ three times as many physicians and ENCOURAGE lower productivity? No discussion in healthcare is realistic unless there is a cost dimension, and just because blood tests are cheaper doesn’t mean physician compensation is any cheaper.

17. See this:
    http://en.wikipedia.org/wiki/Cuban_medical_internationalism

18. “I’d take 2x more docs/nurses/caregivers of some sort to care for elderly and coordinate care for chronically ill…but ONLY at 1/2 the usual cost, on salary, and in context of integrated health systems. ‘

    Steve, please refer to Leonard Kish’s reply above.
    Part of the lure of being a physician has in the past been autonomy, the use of intellect and patient interaction. While we can complain about what doctors make, some think too much, some too little, but the bottom line is, medical education is extremely expensive. If you read comments from primary care docs on Medscape and in the AAFP News Now website, you see profound frustration and disillusionment with the current and future path of medicine.
    What you are proposing is making factory workers out of physicians. You realize that by putting docs in salaried positions, at the whims of administrators and “guidelines”, much of the innovation and independence will be driven out of them.
    In your scenario, I see most care being provided by NPs and PAs and docs as just “supervisors” of care. Not sure I’d want to do that unless a path to retirement.

19. Mark. The first step in creating individual medications or therapies is to gather information. One interesting project along that line is this: https://www.openhumans.org/. There is an international project under development that should provide much better privacy.

    As for training doctors, maybe you should visit Cuba. For decades that nation has earned money by exporting doctors. How do they do that?

20. I’d take 2x more docs/nurses/caregivers of some sort to care for elderly and coordinate care for chronically ill…but ONLY at 1/2 the usual cost, on salary, and in context of integrated health systems. While we’re at that, let’s transform the home care industry — by training home care workers better and paying them a decent living wage. They’ll be needed to take care of influx of aging baby boomers, and future generations who will be living to average age of 90 or more. That’s the kind of “personalized medicine” I’m looking for.

21. Ha!

    It’s me alright! Just setting the stage for a forthcoming post: Please Disrupt!

    I share your skepticism.

22. Dr. Jha, someone’s hijacked your post name, because this reads almost as if you didn’t read Mr. Cuban’s post at all.

    Maybe the hint is that your impostor left off your clinical suffix (“MD”)

    You’re not the type to hurl buzzwords into the bullshit blender (“disrupt”,”innovate”,”paradigms”, oh rly?), so I’m confident the real you will materialize to set the record straight.

    Frankly I can’t think of any posters better qualified than you to explain to the tech titan why his call for a health care workforce infusion of, round numbers, 1.5 MILLION physicians is just headache-inducingly “ill-considered”.

    Anyone who devotes 15 minutes to an examination of the distribution of health conditions and/or health spending knows why it is nonsensical, but sometimes explaining WHY something is nonsensical takes more than the average individual’s patience and/or eloquence.

23. “We need 3x (or some multiple, this is a guess ) as many doctors as we have today so that the amount of time spent per patient can increase to better understand and use the dramatic increase in data we will see.”

    Wondering how 3x the docs spending more time, will cut costs? It’s been shown that more docs don’t create competition to lower prices, they just find ways to creative bill. There are income and lifestyle expectations.

    Also fail to see how Moore’s Law applies to doctors and patient health with understanding that innovation can find better cures, but usually at higher cost to recoup years of investment.

24. Well said on the uptake trajectory and the likely looking back at ‘barbaric’ practices… A guarantee, IMJ. Think ‘pre-anesthesia’ surgical theatre located in at the top of the hospital so you couldn’t hear the patient scream.

    On the 3x doctors thing, the last time the Council of Graduate Medical Education prognosticated, they grossly understated supply without looking at load balancing (primary v specialty) mix and further, the aggressive political activism to exclude an army of ‘mid level’ practitioners (NPs, Advance Practice Nurses, PAs, etc.), all need to factor into the supply/demand equation.

    Also, the ‘Moore’s Law comment by Nick is right on too.

    Again, while I disagree with Mark Cuban from a health policy and health equity POV, I don’t think his forecast is without merit and he most definitely gets the tech end of this calculus.

    More important is his willingness to engage, which I admire and wish others would model v. hide behind the wall of one’s their often ’emperor has no clothes entourage’.

    Cheers Mark!
    Gregg
    @2healthguru

25. Great post Mark.

    To summarize, we must disrupt, innovate, personalize the medicine, change old paradigms and get the government and bureaucrats out of the way.

26. Great piece. As a practicing primary care doctor, agree with many of your points.

    The challenge will be (a) who will train the next generation of doctors and how will they be trained – will it be forward thinking towards this newer future or simply how it has been done in the past, (b) will Americans value the new way of medical care? I remember going to a bank teller as a child to get withdrawals, then ATMs in college, and how Apple Pay / Paypal where dollars and funds change without interaction with a bank institution.

    Though for years, the science for annual physical exams for patients who are healthy, no medical problems, and have no symptoms shows little to no benefit, people still want to have them. Simply one example of how hard it can be to change in health care – people do want that connection between doctors. What care looks like in 2040 must be radically different than today – work by Dr. Devi Shetty gives glimpse into that future. Will Americans be willing to do that? http://forbesindia.com/article/work-in-progress/devi-shettys-affordable-health-care-services-now-in-cayman-islands/39383/1

    Yet change is necessary because our current trajectory is not sustainable.
    Forcing patients to higher deductibles isn’t the answer. Perhaps they will choose an alternative way of care because they have no choice. It will however be important to ensure that whatever they spend, it will be value added. We have seen in the past how companies tried to shift retirement costs to employees and the theory that they would be better off never panned out. This cannot occur in health care.https://thehealthcareblog.com/blog/2011/03/07/why-consumer-driven-health-care-will-fail/

    Rather better health and medical care will be through many of the innovations entrepreneurs are pushing.. Hopefully it will be with collaboration with forward thinking doctors and others. I have been to two start-up conferences already and it isn’t clear that will happen….https://thehealthcareblog.com/blog/2012/08/31/vinod-khosla-technology-will-replace-80-percent-of-docs/ AND http://www.kevinmd.com/blog/2013/09/health-care-lens-technology-entrepreneur.html

    Because the complexity of the individual person, the myriad of illnesses, global travel (think Ebola in the United States) means we need everyone from all facets to work together to make care higher quality, more affordable, and more accessible.

    The best book, IMHO, on framework on how to do that is by Professor Clay Christensen of Harvard Business School who is often recognized as discovering the “disruptive innovation” phenomenon….http://www.amazon.com/review/RI1GGV2COT7YN/ref=cm_cr_dp_title?ie=UTF8&ASIN=0071592083&nodeID=283155&store=books

    Davis Liu, MD

27. First, I have to say that I have been riveted by this discussion since it first started on Twitter – where I weighed in with an observation about wallet biopsies.

    I have a lot of respect for Mark’s willingness to continue to engage, and to clarify his position, and I’ll say that I felt like he and I were miles apart at the start. Reading this way-more-context-than-140-chars-allows tells me that he and I are on exactly the same graf of the same page when it comes to what the combination of technology and personalization will deliver to the healthcare sector over the coming decades.

    Not that I’ll be doing quarterly blood testing any time soon – Theranos ain’t in my nabe, and even if they were, they still require an RX for testing, which means office visits and co-pays – but I share his vision for the future.

28. I agree with some of the comments that we may need fewer doctors as two changes occur – technology that really affects outcomes and efficiency (aka workflow) and new care models, like patient-centered medical homes. In new care models, physicians act as team managers and don’t have to see every patient on every visit. They are also rewarded for outcomes, not volume.
    Also, patient activation/engagement in care, will result in joint decision making and joint responsibility for health.

29. I have a rare stage 4 cancer for over 10 years… There are a few factors involved in getting really good healthcare other than a PPO plan and not HMO….1. The rich will continue to get better care because they can afford it. 2. Your ability to speak up as an advocate for yourself and work the system…. As if it were your business.. Because it is your new job. 3. Logging and recording your care in an analytical process to keep yourself and others accountable for your care. 4. As always … Think out of the box in your care. The system is a mess and will continue to be a mess regardless of the role of technology in th future.

30. Not sure we need more docs trained, or just more primary care. Direct Primary Care, may have an answer, and concurrently put patients more in charge.

    http://time.com/3643841/medicine-gets-personal/

    Quite simply, if you want more docs, pay them something reasonable to do what they really enjoy doing (and it’s not wrangling insurers).

    From TIME article:

    “When people say this is going to worsen the physician shortage, Umbehr says, “No. The current system is worsening the physician shortage. The ship is already sinking. We probably talk to 10 doctors per week who are burned out, going bankrupt, ready to retire years before they ought to. And when they see they can take better care of their patients and never deal with insurance companies again, and earn $210,000, $220,000, $250,000 per year, you’re going to see physicians flocking.””

31. 3x the number of docs? It sounds like what you’re talking about is a massive productivity shock for capital, not for labor. If that’s the case, then increasing time spent with the patient isn’t useful. Labor (especially in hc) is notoriously non-productive (you can do the calculations yourself — pull BLS numbers on total employees in health care and divide by number of patients for instance; it’ll be remarkably stable).

32. @Mark doesn’t mean doctors.

    He means “doctor-people”

    People who are like doctors and perform doctor functions,

    Mark, if you stick around, one of the things you’ll discover about healthcare is that a lot of people in this conversation think the problem with healthcare is doctors. Most of those people are selling something. And that something is generally a product that is designed to replace doctors.

    (Most of the rest see doctors as the human face of the health system they’ve had a bad experience with. Easier to blame a doctor than to blame a )

    Now, strictly speaking, I am market driven guy – like any good Bubba – and there’s nothing wrong with coming up a good idea and becoming an advocate for a solution. The problem is that people underestimate the human dimension.

33. Platon 20 I agree partly with you. As I responded to this post [ Initially at Radiologists vs Mark Cuban ] physicians [Internists] today are spending more time complying with mandates than treating patients even while the patient is in the room. I don’t deny some of your other contentions as well.

    Mark was talking about 3X the number of physicians. Does it have to be 3X the number of M.D.’s? That is an expensive proposition and might be a waste of scientifically inclined human capital. Innovation is what will shift the cost curve leading to both a reduction in cost and the human capital that we waste. That specific innovation will likely come from the technology sector and not from the bureaucrats in Washington.

    On another matter is the 20% blockage operated on if there are no symptoms? If so can you state the institution? I think that comment represents a bit of exaggeration.

34. When Moore’s law does prevail, won’t diagnosis and some treatments become algorithms? Maybe we need 1/3 the doctors ..

35. Mark, you don’t seem like a guy who sucks up after he screws up but that’s the way this came across, after the barrage on Twitter about getting lab values every quarter. Now you’ve swung too far in a different direction, perhaps in an attempt to appease the docs you pissed off?!?!?

    The one constant of every successful value based care model (the way the system is shifting, thankfully) it’s that it needs fewer doctors, not more.

    The perceived shortage today is an actionable paradox: The system is designed for over-utilization while at the same time under serving those in need. Individuals with persistently complex, chronic conditions, often with poor social conditions and behavioral health co-morbidities dont’ get the social support and primary care they need and therefore need radically more specialty level care. When the highest risk 10% of a population gets actual,good primary care supported by care managers, social workers, etc., hospitalizations and specialist visits drop by 40%.

    In today’s healthcare system we have too few doctors. In a functioning system, we have too many. Let’s focus on building a functioning system and stop perpetuating the broken one.

36. I think Mark brings up some interesting points.

    But I think we need less doctors not more.

    When we mass produce doctors, what happens? They start “treating” people who are not sick. That’s why Manhattan has cardiologists who chase people around trying to cath people who have 20% blockages in their arteries, whereas people in Montana with a shortage of cardiologists dont get cathed until their blockages are 95% or higher.

    So does roto-rooting somebody’s coronary artery blockage at 20% really improve their health? No, it makes their health WORSE because you expose them to all kinds of risk from the procedure with minimal gain.

    We dont want doctors chasing around customers looking to do stuff to them. We should maintain a shortage of doctors so that they spend their time focusing on very sick people, not chasing around healthy people looking to make a buck off of them.

37. Awesome Post and Interesting stuff too.

38. Hi MARK, you’ve really did an innovative post and i like this informative stuff.