Wednesday, May 11, 2016

What Should Doctors Do?
Don’t do nothing, do somethingl
David Coombes,  Health Care Consultant

What should doctors do to combat political and cultural forces working  against them?  
These forces include:
·         Takeover and control of care by government,  managed care,  hospitals, and insurers,

·         rise of corporate care and management outcomes and pay-for-performance using data   as the only alternative  to traditional  doctor-patient relationships,

·         dehumanization of care with replacement of clinical judgment  by value and data and evidence based population  health studies,

·         condescending mindsets  by current political powers that stress progressive ideologies  rather than more conservative views,

·         the American culture with its simultaneous  shifts towards the net-based information age and towards a secular rather than a conservative society.
A Discussion with Lee Beecher, MD

Today  I had an enlightening discussion with Lee Beecher, MD, a 77 year old psychiatrist,  who , in his position as head of the Minnesota Patient-Physician Alliance,  and in political fights at the nationa level to preserve and strengthen cognitive specialists,   is seeking to articulate  conservative views in a book he and Dave Racer,  a Minnesota publisher, are writing.
Doctor Beecher says the debate on the future of health care in America  hinges on four issues.
1)       Choice -  Freedom of choice by patients and physicians as to what type of care or practice  they desire without government and third party control. 

2)     Continuity -   Continuity of care  across the health system among  doctors,  hospitals,  and employer and government health plans.
3)     Competence -   Who is competent and responsible to deliver this care, which involves credentialing  and who is qualified to deliver care.

4)     Conflicts of interest -  With managed and government care, which are often  essentially the same,  how to resolve the question of what is good for the “system” or the corporate entity,  and what is good for the patient?
These issues are not easily resolvable . Ultimately they will  depend on political resolution by American voters who oppose ObamaCare by 55% to 45% margins.    These issues may partially go away with a GOP President or with ObamaCare repeal but will continue to fester no matter who is elected President.  If repeal occurs,  the big issue  for an alternative market-based plan will be how to subsidize  the 20 million  uninsured who have signed on through the exchanges and Medicaid.
Beecher Questions
Doctor Beecher asked me these questions,  which I shall try to answer briefly.

·         How to recent medical graduate see their roles as physicians.   And if so, how will they act and react?
I believe they see their role as adapting to present realities by  pursuing specialties that allow them to lead a balanced life with time for family and personal pursuits  and enough income to pay off their educational debts, which average $150,000 to $200,000 at time from medical school or residency programs.     The preferred specialties are the so-called ROAD specialties (Radiology,  Ophthalmology or Orthopedics,  Anesthesiology , Dermatology), and preferred  place of work is as an employee of a large specialty group or  integrated health system or hospital.

-       What do patients think about the quality of time spent with physicians?

I think patients prefer time spend in a personal relationship with a physicians  rather than with a physician assistant or nurse practitioner.   I think they trust physicians more than government.   I think they are in the process of revolting against and rejecting ObamaCare because of its unaffordable premiums and deductibles and its narrowing of physician choice.    But no matter what they think,  they do not know what to do about it  or to contain their anger and anxiety.

-       What should physicians do?

That is the $2 trillion question, the likely cost of ObamaCare over the next 10 years if the ACA survives the election in the present form.

    -    What  should  physicians do?  

 They should:

1.       Concentrate on areas where physicians  have leverage-  the number of Medicaid ,  Medicare,  and ObamaCare exchange patients they can accept without losing money and that jeopardizes the viability of their practices.     Once these numbers reach 50% of non-acceptance,   voters will demand more access.

2.      Focus on creating  on collaborative  physician organizations that offer consumer convenience and lower costs -  outpatient  “focused factories,”  urgent care centers,  ambulatory care surgery centers,   mental health  centers ,  addiction centers, specific disease-related centers.    The operative word here is “focused.”   Broad philosophical approaches,  tirades against progressive policies of high taxation and loss of freedom, are not likely to work.

3.      Form and lead physician lead organizations,  like the Minnesota Physicians and Patient Alliances and  Unified Physicians and Surgeons Associations (Look them up on Google).

4.      Focus  on:

n  Broadcasting the news to influential opinion-makers that ObamaCare has been bad and unpopular in the eyes of physicians and patients and voters.  Give these broadcasts credibility by  going to Physicians Foundation  vast national surveys of physicians and patients and by showing that both disapprove  of ObamaCare in significant  numbers.

n  Joining or forming national organizations that show  how the deleterious effects on health reform on physicians are contributing to widespread physician  shortages and decreasing access.  One such organization is the Unified Physician and Surgeons Association, which addresses  issues like interference in doctor-patient relationships,  the  unrealistic credentialing process, excessive regulations driving up physician costs,  mandatory and “meaningful” electronic  health records,  the tort reform.   And remember: patients  trust organizational protests more than individual’s  discontents. 

n   Considering creating new collaborative and creative relationships with hospitals,  the 800 pound health care gorilla in most communities.   For example,  have hospitals subcontract psychiatric services for continuous  follow-up care.  Make hospitalists aware of psychiatric and geriatric services outside of the hospital.  Alert hospitals to the existence of Health Leads,  a 10 year company that provides referrals to social services,  medical transportation services,  home visits,  housing availability , job training by making it possible for physicians  in hospital clinics to “ prescribe” these services  with the help of  college volunteers  who set up “help desks” on site and seek out and refer patients to these service.

n    Have concierge and direct cash and direct primary care physicians   set up relationships with employers who through  HSAs and other means are seeking  cheaper and more direct and more personal and employee-pleasing services by bypassing traditional 3rd parties.   Encourage  large  employers to set up on site practices manned by primary care physicians and nurses, which have a history of saving 20% to 30% on employer health costs.

n  Thinking hrough how physicians might use the Net and Information  apps more  effectively  to make care more useful, more efficient,  more convenient, and more personal,  for patients.   These apps which already exists might include such things as Skype consultations,    virtual visits,  health status evaluation,  health promotions,  and marketing of dispersed, focused, doctor-run  outpatient centers in convenient locations with ample parking. 
Keep in mind two tectonic shifts  are going on simultaneously , one, consolidation  and centralization in hospital settings,  and two,  decentralization into dispersed centers  outside the realm of government and large integrated organizations.   Several  examples come to mind:   the growth of direct cash and concierge medicine with bundled services and the establishing  and marketing  of ambulatory  surgery centers, both of which  provide care at a fraction of the cost of hospital surgeries and with a hell of lot less bureaucratic impediments.  Finally, explore, promote, and develop cyber-visits, cyber-diagnosis, cyber-workups,  cyber-interviews,  cyber-consultations and cyber-imaging evaluations with the end game of referral to  physicians for face-to-face  2nd opinions.

Concluding Remarks

I’m reminded of the story of husband and wife watching their children play in the newly laid concrete sidewalk.   The husband is livid.   The wife says, “But dear, I thought you loved children.”   He replied, “ I do,  in the abstract, not in the concrete.  I am suggesting and recommending that we stop the abstract conservative ideological  grousing and go down to the sidewalk with younh millennial physicians and young IT nerds who represent the future in order to  take  positive concrete actions.

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