The U.S. health care system is an inefficient maze of bureaucracy, redundancies, and waste. As a practicing physician, I see firsthand how these inefficiencies frustrate both providers and patients, inflate costs, and undermine the quality of care. If we are serious about transforming health care into a system that works for everyone, we need bold, outside-the-box solutions. Here are just some of the most glaring inefficiencies I see that could be reformed to streamline medicine, cut costs, and improve outcomes.
1. Create a universal medical license
Why do doctors need a separate medical license for each state they practice in? This outdated system creates unnecessary barriers to care and is a relic of a bygone era. We don’t require separate driver’s licenses for each state, so why should medical professionals face such obstacles? Even with an interstate medical license compact that makes state licensing a wee bit easier, physicians are still required to get licensed in multiple states and pay the fees associated with this.
To modernize the system, we need to either:
- Establish a universal medical license: Create a nationwide medical license that allows physicians to practice in any state.
- Recognize state licenses across the U.S.: Alternatively, recognize state-issued medical licenses across all states, removing geographic restrictions on where doctors can practice, much like a driver’s license.
This change would improve access to care, especially in underserved areas, and facilitate the growth of telemedicine, allowing doctors to treat patients in different states without state-specific licensure barriers. By modernizing the medical licensing system, we can increase access to care, reduce administrative burdens, and support the growth of telemedicine. It’s time to update the system to reflect the needs of today’s health care environment.
2. Create a universal telehealth license
Telemedicine has the potential to revolutionize health care by bridging gaps in access, particularly for patients in rural or underserved areas. However, outdated state-specific medical licensure laws create unnecessary hurdles. These restrictions prevent doctors from providing care to patients who travel across state lines or live in areas without access to specialists, delaying treatment and worsening health outcomes. This includes patients already established in physician practices who travel out-of-state for multiple reasons.
Medicine is the same no matter where you are in the country, yet state laws make it difficult for physicians to deliver seamless telehealth care nationwide. Patients deserve continuity of care—whether traveling for work, on vacation, or living in a different state than their provider.
A federal telehealth licensure system would solve these problems by allowing doctors to practice virtually across all 50 states with a single license. Such a system would:
- Improve patient outcomes: Removing licensing restrictions would allow patients to receive timely care from their trusted providers, even if they are out of state.
- Increase access to specialists: Patients in underserved areas could easily consult with specialists located in other states, leading to better management of complex or rare conditions.
- Encourage innovation: Telemedicine would expand more rapidly, fostering efficiencies and creating opportunities for innovative care delivery models.
- Require insurance coverage: Insurers should be mandated to cover telehealth visits from out-of-state providers, ensuring patients are not financially penalized for using virtual care.
For states hesitant to adopt a federal standard, Florida provides an excellent model. Florida’s telemedicine licensure system allows any physician with a permanent medical license in another state to obtain a telemedicine license in Florida at no cost. It is simple, efficient, and eliminates unnecessary barriers, enabling physicians to provide telehealth care to patients physically in Florida, perhaps for vacation or for temporary residence (such as snowbirds). If a federal telehealth license is not implemented, other states should follow Florida’s lead to make the process simple and accessible.
State-specific licensure laws are relics of a pre-digital era. A universal telehealth license—or the adoption of streamlined, state-specific models like Florida’s—would modernize medicine, improve access, and ensure patients can receive the care they need—anytime, anywhere.
3. Reform the Joint Commission
The Joint Commission imposes burdensome and arbitrary requirements that create more paperwork than progress. For example, hospitals face overly detailed sedation documentation requirements, while other equally critical procedures require far less oversight. Similarly, annual competencies and training, such as HIPAA training, are redundant for experienced staff who already understand these rules. A more efficient system would tailor training and assessments to actual needs rather than rigid, one-size-fits-all schedules.
Other inefficiencies include:
- Discharge paperwork: Hospitals must provide extensive instructions that patients often discard before leaving. Instead, discharge materials should be concise (1-2 pages) and focus on actionable, essential information.
- Hallway clutter rules: Hospitals are cited for temporarily storing critical items, like crash carts, in hallways, even when these placements improve emergency response times.
- Bathroom signs and labels: Mandating specific signage on patient bathrooms—down to font size and placement—does little to improve safety but consumes administrative resources.
- Refrigerator temperature logs: Requiring manual logs for medication refrigerators, even when automated systems exist, adds redundant labor.
- Poster taping standards: Hospitals are penalized for trivial issues like how posters are taped to walls, which have no bearing on patient safety.
- Overdone cleaning documentation: Staff must log every cleaning task in minute detail, even for routine, repetitive work, instead of trusting automated systems or common sense.
The Joint Commission’s focus on checklists rather than outcomes stifles innovation and wastes resources. Accreditation should prioritize evidence-based practices and real-world patient outcomes—like reducing infection rates and readmissions—rather than micromanaging trivial details. Instead, they come up with standards that may seem helpful, but have no merit to support the extra work necessary to complete the tasks. Streamlining these standards would free up valuable time and resources, allowing providers to focus on what truly matters: delivering quality patient care.
4. Reevaluate Certificate of Need (CON) laws
Certificate of Need (CON) laws require health care providers to get state approval before expanding services or opening new facilities (such as CT or MRI scanners). Hospitals are required to apply for new inpatient beds, even when these same hospitals are overcrowded without space to accommodate all of the patients that require admission. While designed to control costs, these laws often stifle competition, limit access to care, and hinder innovation. By restricting market growth, they lead to higher prices, fewer choices, and longer wait times for patients.
To improve the system, we need to:
- Reform or repeal CON laws: Remove unnecessary barriers to expansion, allowing health care providers to respond to patient needs and increase competition.
- Encourage competition: More providers in the market would drive down costs, improve quality, and expand patient options.
- Promote access: Removing CON laws would allow facilities to expand into underserved areas, improving access for rural and low-income populations.
- Support innovation: A more competitive environment would incentivize new health care services and improve efficiency.
Repealing or reforming CON laws would foster innovation, increase access, and lower costs by encouraging healthy competition in health care.
5. Simplify health insurance processes
Doctors and hospitals spend an inordinate amount of time dealing with insurance companies, particularly with prior authorizations—a process that delays care and creates unnecessary administrative burdens. Patients and providers alike suffer when critical approvals are held up by restrictive business hours or inefficient systems.
If Congress is unwilling to eliminate prior authorizations altogether, then at the very least, insurance companies should be required to provide 24/7/365 access to decision-makers who can process these requests. Delays should never prevent a patient from receiving timely care, especially in urgent or emergent situations.
Further, prior authorizations should be automated, standardized, and integrated into electronic health records (EHRs). Providers should not have to navigate multiple portals or systems to get approval. A unified, national system would ensure consistency, reduce confusion, and save countless hours spent on redundant processes.
Other inefficiencies to address include:
- Immediate pre-authorization decisions: Insurance companies should have strict deadlines (e.g., within 24 hours) to process all non-urgent requests. Urgent requests should be decided in real-time during the consultation.
- Quick and specialized appeal processes: When pre-authorization or payment denials occur, there should be a streamlined process for appeals that ensures the case is reviewed quickly and by a physician specializing in the relevant field. For instance, a cardiologist should review a heart-related procedure denial, not a generalist unfamiliar with the nuances of care.
- End redundant re-authorizations: Many treatments require repeated prior authorizations for ongoing care, even when conditions remain unchanged. These renewals should be eliminated for chronic conditions or long-term therapies.
- Transparent denial processes: Insurers should provide clear, evidence-based reasons for any denial and offer immediate access to a simple, physician-led appeal process.
By holding insurance companies accountable and streamlining these processes, we could reduce administrative waste, ensure fair and timely decisions, and allow health care providers to focus on delivering high-quality patient care.
6. Overhaul and redefine the malpractice system
The current malpractice system in the United States punishes doctors for errors often driven by human limitations, system flaws, and the uncertainty inherent in health care. These errors should not be equated with negligence, but rather seen as unavoidable in a complex system. Punishing providers for human error fosters blame, stifles transparency, and hinders improvements in patient safety.
Malpractice should focus on cases of gross negligence—willful harm or reckless disregard for care—rather than routine errors or systemic issues. Shifting the focus from blame to learning promotes a culture of improvement and transparency.
New Zealand’s no-fault health insurance system provides a useful model, where patients harmed by medical errors are compensated without proving negligence in court. This approach reduces legal costs, promotes transparency, and encourages learning from mistakes, benefiting both patients and providers.
Key reforms should include:
- No-fault compensation systems: Provide compensation without requiring proof of negligence, reducing emotional and financial burdens on patients while promoting transparency.
- Pre-litigation review panels: Establish neutral panels of experts to evaluate claims, ensuring only legitimate cases proceed and reducing unnecessary litigation costs.
- Safe harbor protections: Make physicians immune to punishment who follow evidence-based guidelines to reduce defensive medicine practices and encourage best practices.
- Fair caps on non-economic damages: Maintain reasonable caps on non-economic damages to prevent excessive settlements, keeping malpractice premiums stable and ensuring a balanced health care system.
By adopting these reforms, we can create a more transparent and cost-effective malpractice system that prioritizes patient safety and encourages systemic improvements, rather than punishing unavoidable mistakes for being human in a flawed system.
7. Improve price transparency
The lack of transparency in health care pricing leaves patients in the dark, unable to make informed decisions about their care. Imagine walking into a restaurant and not knowing the cost of your meal until months later—this is the frustrating reality of health care today.
Patients deserve to know the price of services, medications, and procedures before committing to them. However, the current system is riddled with opaque billing practices, hidden fees, and wildly varying costs for the same procedure depending on the provider or location.
A critical issue is the price disparity between what hospitals charge insured patients versus those without insurance. Hospitals often charge 5-10 times what insurance companies pay due to negotiated prices with insurers. This creates an unfair burden on patients who are uninsured or underinsured, contributing to rising health care costs.
To fix this, we need:
- Enforced upfront pricing: Hospitals, clinics, and pharmacies should be required to provide clear, itemized pricing for services and medications before care is delivered.
- Standardized cost comparisons: Create user-friendly tools that allow patients to compare prices across providers in their area, just as they would for other major purchases.
- Simplified billing: Bills should be transparent and easy to understand, with clear explanations of what patients owe and why, avoiding the confusion of surprise charges.
- Penalties for non-compliance: Enforce fines for providers and insurers that fail to meet price transparency requirements, ensuring accountability.
- Standardized prices based on area data: Hospitals should be required to charge standard prices based on prior data of costs in the area, such as the information provided by fairhealth.org, to ensure fair pricing for uninsured patients and reduce the overall cost of care, with adjustment for inflation.
Transparent pricing would empower patients to shop for care, encourage competition, and ultimately lower health care costs. Health care should not be a financial guessing game—it’s time to give patients the tools they need to make informed choices.
8. Reform pharmacy benefit managers (PBMs)
Pharmacy benefit managers (PBMs) are intermediaries between insurers and drug manufacturers, designed to negotiate lower prices for medications. However, they often inflate drug prices and keep rebates for themselves, driving up costs for patients. This practice prioritizes profits over patient care, steering patients toward higher-priced drugs in exchange for larger rebates and limiting access to more affordable options.
To address this, we need:
- Increased transparency: Require PBMs to disclose the rebates they receive and how savings are allocated, ensuring that rebates are passed on to patients.
- Regulated rebate practices: Ensure rebates from manufacturers are passed on to insurers and patients, lowering overall costs.
- Competitive pricing and open formularies: Encourage PBMs to use open formularies, offering patients access to cost-effective drugs.
- Independent PBM models: Explore PBMs operating independently from drug manufacturers and insurers to eliminate conflicts of interest and prioritize patient well-being.
- Oversight and accountability: Implement stronger oversight with regular audits and penalties for PBMs that fail to pass on savings or manipulate prices.
Reforming PBMs will reduce costs, promote transparency, and ensure patients benefit from lower medication prices.
9. Eliminate outdated Medicare rules
Medicare’s three-day inpatient rule requires patients to be hospitalized for three days before they can receive coverage for skilled nursing care. This leads to unnecessary hospital stays, higher costs, and potential complications for patients. Modifying or eliminating this rule would allow for more flexible and cost-effective care, benefiting both patients and the health care system.
To improve Medicare, we need to:
- Eliminate or modify the three-day inpatient rule: Remove the arbitrary requirement for a three-day hospital stay to qualify for skilled nursing care, focusing on clinical needs instead.
- Increase flexibility in coverage: Allow patients to access skilled nursing care based on their condition, not rigid rules.
- Encourage alternative care settings: Expand coverage for home health care and outpatient rehabilitation, which can be more cost-effective and lead to faster recovery.
- Reduce hospital readmissions: Allowing earlier transitions to skilled nursing care may reduce readmissions and improve recovery outcomes.
- Focus on outcomes, not just procedures: Shift Medicare’s focus from administrative rules to patient outcomes to provide the most appropriate care at the right time.
By modernizing Medicare and removing outdated rules, we can reduce unnecessary hospital stays, lower costs, and improve patient care.
10. Improve fragmented care coordination
Fragmented care coordination remains a major issue, contributing to inefficiencies and higher costs. For example, primary care physicians often need input from specialists but lack an easy, efficient way to get that input. Specialists are not always readily available to answer questions or provide recommendations that could help primary care providers manage patient care without requiring a referral, helping avoid unnecessary specialist visits. This kind of real-time consultation is common in emergency departments but is often lacking in primary care settings.
Additionally, patients are often sent to urgent care or the ER for tests or procedures that could have been handled through outpatient care. A big issue is that patients often don’t know where to go or who to call when they need something, creating confusion and leading to inappropriate care choices.
To improve this system, we need solutions such as:
- Centralized call centers: Establish call centers staffed by trained telehealth providers (physicians and advanced practice practitioners) rather than nurses to assess patient needs and direct them to appropriate care, reducing unnecessary ER visits.
- AI-driven triage: Use AI systems to assess symptoms and help direct patients to the right level of care, whether that’s urgent care, a doctor’s visit, or the ER.
- Real-time specialist consultation: Create a system where specialists are available to provide advice to primary care physicians on whether a referral is necessary or if they can manage the patient’s care with added recommendations. This would avoid unnecessary specialist visits while ensuring patients receive appropriate guidance.
- Diagnostic centers for care coordination: Adopt models similar to Kaiser’s diagnostic centers that effectively route patients to the appropriate place or tests, ensuring they receive care at the right time and in the right setting.
- Enhanced nurse training: Provide additional training for nurses to ensure more accurate decisions about care referrals and improved communication between providers.
- Telehealth integration: Integrate telehealth to allow remote consultations with specialists and providers, reducing the need for in-person visits.
- Clear referral guidelines: Establish clear protocols to avoid unnecessary ER or specialist referrals and improve care efficiency.
Optimizing care coordination by making timely, expert input readily available will reduce delays, unnecessary visits, and improve patient outcomes, all while lowering health care costs.
A call to action
These inefficiencies aren’t just frustrating—they’re costing lives and billions of dollars. Issues like incentivizing preventive care, changing the RVU payment system, and streamlining electronic health records (EHRs) nationwide are three other examples, and there are many more. While organizations like the AMA continue to lobby for change, only small, incremental fixes have been made. It’s time to think bigger and challenge the status quo.
Policymakers, industry leaders, and innovators—those who have successfully disrupted other industries—must now focus their attention on transforming health care. Let’s not just start the discussion but take actionable steps to change. The system is ready for innovation, and with the right reforms, we can build a health care system that is efficient, affordable, and centered on what matters most: the patient.
Greg Gafni-Pappas is an emergency physician.