The changes
I proposed in the organization of health care would bring down the cost
significantly. However, I think changes in the delivery of health care beyond
what is done anywhere else could have further benefits in reducing the medical
industrial complex starting with . . .
Health maintenance: When you
first walk in to your doctor’s office the first thing that happens is - data entry.
You give your demographics and your insurance information and now in a
new wrinkle they ask if you are anxious or depressed, if you smoke or if you
drink. This happened to me at my orthopedist’s office. None of this data
collection requires the skill of a doctor.
Furthermore, the most effective solutions involve specific programs or
providers that address those specific problems – the mental health counselor
for those who are anxious or depressed and substance cessation programs for
patients who drink or smoke. Adding some
simple vital signs and basic blood work would identify problems and direct
patients to resources that would actually help them. All of this could be done with an app without
the input, and cost, of a high priced health care provider with an advanced
degree.
Computer medicine: Doctors do
two things; diagnose, which is pattern recognition, and treat, which always
involves risk/benefit analysis. Both of
these processes are precisely what computers are good at and very probably
could supplant the clinician. For a
variety of real technical as well as emotional issues that could be a stretch.
However, at the very least computers could render a second opinion. As an
example, radiology is all about pattern recognition. In England mammograms are
read by two radiologists. In a study
they had a computer do the second reading and got results comparable to two
radiologists. [1]
Technical care: Sometimes
diagnoses or treatment require procedures or surgery. Sometimes these procedures require operator
discretion such as a lot of general surgery and neurosurgery. For example, a
surgeon doing exploration and excision in the abdomen for cancer must identify
the cancer and its extent and decide what and how he must remove what he has
found. However, a lot of procedures and surgeries are routine repetitive. I
would submit that technicians trained for the specific task could do a lot of
these.
For example, back in the 90’s
when sigmoidoscopy was the standard screening procedure for colon cancer Canada
had trained nurses do the procedure with results, as would be expected
comparable to doctors.[2]
I
would submit that there are a large number of surgical procedures that are
chronically repetitive could be done at least as well by trained technicians as
it is by doctors with nearly a decade of training past medical school.
Surgical
outcomes are most highly correlated with operator experience[3],
and manual dexterity.[4]
[5]
Neither of these qualities are screened when candidates are judged by
standardized testing.
I
would suggest that procedures such as colonoscopies and arthroscopies and
surgeries such as cataract operations and joint replacement could be done by
technicians based on their manual dexterity and their demonstrated expertise
over time. Training and even a healthy low six figure salary would be a
fraction of the cost of the current arrangement.
To
the best of my knowledge no developed country does any of this but that isn’t
to say that it can’t be done and in a fixed cost health care system there would
hopefully be the motivation to experiment in this direction.
In
my next installment I will talk about some odds and ends but mostly about
malpractice.
