Written by Alejandro Badia, MD, FACS
Friday, 14 June 2013 17:11
Much debate is currently focused on healthcare reform, with emphasis on controlling costs, increasing access, while maintaining quality. While a daunting challenge, it is clear that the basic premises currently recommended to achieve this are fundamentally flawed. A very different approach may be necessary.
The following points run contrary to current goals yet seem to work on a small scale. Why not expand this to a national, or even global, level?
For starters, the recent focus on increasing primary care medicine may actually be more costly. While a necessary part of our medical infrastructure, the primary medical specialties need to work more closely with their subspecialized colleagues. This will paradoxically decrease health care costs in the long run.
The exponential explosion of medical knowledge has clearly made it impossible for a physician to have even a cursory knowledge of all specialties, let alone subspecialties. The result is that a general physician will often miss the diagnosis, and currently more relevant, will expend much greater resources in order to arrive at the diagnosis; let alone formulate the appropriate treatment plan.
For example: It is not uncommon that a patient presents to me, a hand specialist, with wrist pain. While my experience and clinical acumen will often lead me to the diagnosis immediately by just listening to the patient’s complaints, the patient who comes from a primary doctor may come see me with an MRI already performed, a battery of blood tests, and perhaps even a course of physical therapy already in progress. The problem is that this patient may simply be suffering from DeQuervain’s tendonitis, a very common condition responding to a single corticosteroid injection in 80% of cases as per the scientific literature. I am so confident about the result that these patients are typically not even given a follow-up appointment. Hence, the difference is clear: the subspecialist makes the diagnosis much faster, with superior resolution of the clinical problem and at much less cost, utilizing less testing and imaging studies.
The issue is that this same scenario applies in nearly all fields of medicine. Even in other orthopedic areas, I as a hand surgeon would be completely out of my league if evaluating a patient presenting with something as common as intractable low back pain. This diagnosis alone occurs in 65 million Americans and costs our society more than 100 billion a year! If I feel ill prepared to manage this problem as an orthopedist, how can a general internist or perhaps even a chiropractor be sufficiently qualified to ensure that they are not missing spinal stenosis, a midline herniated disc, or perhaps a spinal cord tumor? It is clear that each diagnosis, whether glaucoma, lymphoma or renal hypertension, should be managed by the appropriate specialist; from the outset and until symptom resolution/management.
A further problem is the intrusion of non-trained, essentially laypersons, into the fabric of American medicine. This means that non-medical personnel are frequently interfering with care or serving as “cost-controllers” when they are really superfluous. Do physicians really need a pencil-pusher “authorizing” care when their staff calls the insurance carrier to essentially ask permission to perform a procedure or order a test?
This layer of bureaucracy is redundant and not cost-effective. It slows the process and adds cost to the system. Are MDs not the best barometer of whether a test is needed? Are physicians not subjected to the most arduous training and education of most any profession while, in most cases, maintaining a certain ethical standard dictated by a professional oath of conduct and enforced by medical societies? The amount of money, and time, saved by avoiding this validation step would greatly offset the occasional physician overutilizer, or even unscrupulous provider.
A major cost issue remains the overly prominent central role that the hospital systems continue to assume. This is very likely due to the powerful hospital lobby and is something that needs to be gradually scaled down. The answer is not only to move feasible services into the outpatient care realm, but also to make them increasingly specialized. A major hospital system in Miami area has long recognized this fact and astutely formed a large network of efficient and accessible outpatient urgent care and diagnostic centers. Ophthalmology and endoscopy centers long ago have realized this gain, and furthermore, free market forces have actually driven down costs in many scenarios. A multi-disciplinary team can most effectively, and prudently, address clinical problems.
KNG Health Consulting found in a seven year study that moving a variety of surgical procedures into ambulatory surgical centers (ASCs) away from hospital centers, greatly decreased the cost of treatment. Despite concerns to the contrary, there was no overutilization, or even greater self-referral of patients, even when physician-owned.
Over-burdensome government regulations, such as Stark I and II laws have unfortunately inhibited this growth not allowing potential cost savings to be realized. Further expansion of government bureaucratic control would be even more detrimental.
The current hypothesis suggests that specialized centers contain not only ASCs, but also all the necessary diagnostic, consultation, and rehabilitative services under one roof in order to promote efficiency, while delivering the most optimal care possible. Clinical studies can also be performed optimally in this environment, where large cohorts of patients with similar diagnoses can be studied, and patient outcomes can be over more successful, as well as cost efficient. Patients would have the opportunity to select these centers of their own accord, and be treated if appropriate, or referred by a system of less specialized physicians, or even clinical nurse practitioners, who could best determine what venue the patient should pursue. This “one stop shopping” concept represents a common sense approach to health care.
Referring to our previous example, a middle aged laborer complaining of low back pain would be seen, perhaps even without an appointment, in an orthopedic urgent care center. An orthopedic physician assistant, or preferably, a family practice physician with training in musculoskeletal medicine would do a cursory physical exam, order appropriate tests such as an X-ray, and have the spinal orthopedic surgeon see the patient in follow-up if initial analgesics, NSAIDs and bed rest do not resolve the problem within several days. That specialist would then determine if further testing is truly necessary, such as an MRI to look for a disc herniation or other problem. He may be referred to a chiropractor for manipulation, a physiatrist or perhaps a physical therapist if appropriate. If surgical microdiscectomy is indicated, that too can be done in the same facility. All this would likely be done within several visits, if the patient is not discharged earlier, and the multitude of patients with similar conditions would sharpen each practitioner’s clinical skills.
All one has to do is ask a patient who has been seen in this type of facility what their opinion is. Patient satisfaction tends to be high. This approach can be used for many different areas of medicine. We have seen the advent of orthopedic urgent care centers around the country in select markets. We have recently seen OrthoNOW open in the Doral area, blazing the trail for this concept in South Florida. We simply need to expand on what we already know.