Wednesday, March 26, 2008

Physician culture, effect of culture Doctor’s Dilemma: A One-on-One or One-on-Many

Traditionally doctors see patients one-on-one. That’s how doctors and patients like it. Medicine, after all, is a personal matter between doctor and patient. Unfortunately, health care managers say having highly trained doctors “process “patients one-by-one is an inherently expensive and inefficient proposition."

After the 1980s, times changed. The managed care mindset and the “corporatization of medicine” brougt a different perspective to the table. Managers sought to restructure medicine, rationalize care, and bring down costs. Surely, managers say, doctors could “manage” more patients more efficiently. The assembly-line metaphor may be apt here.

To make their point, managers refer to books like Reengineering The Corporation(Michael Hammer, 1993). The idea as applied to medicine is to foster productivity by having doctors oversee more patients. In the industrial world, managers note, one manager can effectively supervise 7 to 10 people. Why should medicine differ?

Now experts say a corporate manager can oversee 30 people or more (George Anders, “Overseeing More Employees – with Fewer Managers,”Wall Street Journal, March 24, 2008). This is done by having managers share knowledge, pay employers more, create teams, and communicate frequently through e-mail, the intranet, and web conferences Surely doctors can do the same.

I have never been confident you can equate medicine to industry, or covert it into an industrial mode. Doctors see themselves as doctors, not managers. Nevertheless, there may be options for restructuring medicine to make the use of physician time more efficient and productive.

Here are some options that are proposed, with my predictions of the likelihood of their happening.*

1) Status quo, no basic change, with one-on-one relationship under current third party payment system, 50%

2) One-on-one relationship with new practice designs (concierge, cash only, canceling HMO contracts, physician ownership of fee-for-service facilities), 15%

3) One-on-many relationships with group visits for patients with common problems or diseases, 5%

4) One-on-one relationships with doctors focusing only on complicated patients requiring physician expertise, 5%

5) One-on-one relationship with “Teamlet Model” –the transition from a lone physician to two person team – doctor + coordinating person (nurse, retrained medical assistant), 3%

6) Combination of one-on-one and one-on many relationship with physician being paid as the central coordinator, or quarterback, for care, sometimes called “medical home” model, 5%

7) Combination of one-on-one and one-on-many in larger integrated systems, 7%

8) Combination of one-on-one and one-on-many with enhanced coordination of care between primary care doctors, specialists, hospitalists, ERs, hospitals, families, 5%

9) One-on-one with patients entering complaints, data, or histories by direct email or through physician web sites, sometimes called asynchronous care. 5%

• If either a single-payer system of a consumer-driven dominates over the next five years, all bets are off. I would place the odds of either of these events occurring at about 5% each.

Take your pick. Only one thing is for sure. None of these options are likely to be adopted throughout the physician community.

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