I am a scientist and a medical economist. I have been privileged to work beside doctors in both their caregiving role and their research role for 20 years. I have seen their challenges and tried to build products and services to help. I have deep respect for the challenge of medicine and the committed practitioners.
When I left graduate school in 1988, it was the beginning of the movement from fee for service to managed care. I worked in consulting for both a major pharmaceutical company and one of the pre-eminent health care systems in the U.S. At that time, the great push was to gain control of doctors who worked without external discipline and often paid themselves aggressively with reimbursement. The entire focus of medicine was to make things more efficient but also to control the potential for self-payment. This process was mainly aimed at cleaning up the procedure based physicians who were working reimbursement, making exorbitant incomes and buying islands.
Unfortunately, the combination of specialist doctors and litigation attorneys destroyed this healthy movement of doctors managing doctors. In its place insurance and arms-length rationing through absurd pricing and slow service took its place. It started with the heart surgeons and radiologists, but over time, we have applied these control mechanisms down the chain, including the sparsest individual primary care physician. We have made most physicians piecework employees, much like the butchers that separate meat from bone in the meat packing plants around the world.
Since that time, the number of beaurocrats attempting to make the system more efficient has grown by 1,000 percent while the population of care providers has roughly doubled. We have installed endless computer systems and tried a plethora of ways to make medicine a process of procedures, with boundaries for use and controlled price points. We have convinced ourselves that we can learn much from having a single, comprehensive medical record, compiled by the doctors that diagnose and treat. We have given the businessmen dominion over what is, in reality, a relationship, with appropriate behaviors defined, in the end, by the doctor and the patient, period. In reality, we no longer have primary care, we have primary gatekeeping, followed by secondary procedure delivery. There is no longer room for either a relationship or care.
I believe that for primary care, insurance must reverse completely and can only be driven by the physicians themselves. In 2016, there is no realistic way for a practicing primary care physician to be so inefficient or corrupt that the oversight now in place is demanded. We are wasting a huge amount monitoring people who cannot cheat in any big way. We must dump both the private and government insurance process and its endless monitoring devices and let the primary physicians work in peace to cure as many people in the best way possible. There are places for cooperative behavior, such as wellness programs and obesity clinics, but these must be designed for the benefit of the doctor-patient agreed to goals, not the objective measure of “watchers.”
In my perfect primary care environment, a unit of insurance would be two doctors, monitoring each other for competency, two medical scribe interns, a receptionist, a nurse and a billing expert. This group would be monitored in terms of use of resources in aggregate, but not subjected to individual transaction scrutiny. The entire network of executives trying to make this simple process assembly line efficient would be taken out, and doctors would be considered properly efficient. The savings would be immense; the doctors would be in control of their lives, and any monitoring of medicine would be done mainly on procedural doctors. In time reimbursement would be done in a gentle way for primary care, allowing for flexibility, with strong monitoring happening at the big end of medicine.
Tony Barnes is a medical economist.
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