There are a lot of things that are broken about the American healthcare system. I think one the main problems can be summed up by observing that most parts of the system are not really designed to make people healthy, take care of patients, or even make patients feel satisfied (sometimes they are not the same!)– rather, the system is mostly designed such that the people getting paid are always trying to get paid more and the people who are doing the paying are always trying to pay less.
Normally, these instincts generate efficient and interesting markets that in turn produce quality products that consumers choose from, but not in health care! That’s a post for a different day. Rather, I want to zero in on one very simple change that would probably save everyone money but the doctors.
I’m a primary care doctor. I love being a primary care doctor. I cannot imagine anything else I’d rather do with my life. I spent 7 years (each of which was quite expensive, in different ways) being trained as a primary care doctor. However, a lot of primary care doctors spend their time doing annual physicals or well child visits.
Both of these things are of questionable value in the first place– the most important thing you get out of a well child visit is the shots, and the most important thing you get out of an adult physical is the blood pressure check and your cancer screening. But even if you accept that it’s good to take a half-day out of work or school to wait in an office and have someone bill your insurance to meet all of these requirements, there’s no reason a doctor needs to do it!
Look at this list of things that the U.S. Preventive Services Task Force thinks are really solid and evidence-based. This is the stuff where the data is fairly clear: everyone should do what’s on this list if they want to stay healthy. None of it requires a medical degree. Most of it really doesn’t even require someone like a nurse practitioner or a physician’s assistant (more on that later).
We could hand all of the stuff that involves nothing more than checking a box to order a test or procedure over to the computers, who could mail you a letter when you’re due for your next pap smear, mammogram, or blood pressure check. When it’s due, you could go to any place licensed to do them and get whatever you’re due for taken care of in less time. If something’s found on screening, they could have someone on site to talk about it and refer for appropriate care. Since the government mandates that insurers pay for this anyway, they could probably just fund local health departments to get it done and take insurers out of the picture entirely. Or the government could continue to subsidize insurers, which would pay for their own computers to do this. Saves less money, but still an improvement.
All of the stuff that involves asking questions or changing behaviors– smoking, obesity, etc.– is not well-addressed in a 15-minute visit with a doctor like me who spent 7+ years learning how to talk smarter than the average patient. Doctors are good at lots of things, but unless they’ve been specifically trained, someone like a community health worker is probably better at engaging people where they are and helping them do what they need to do to get or stay healthy. Other countries use them both to ensure that people get their boxes checked and to deal with stuff that doctors aren’t trained to do. I wrote more about this here.
Now, primary care doctors will argue that preventive visits help you to establish relationships with patients and families that come in handy when those patients get sick. This is a good argument, but unfortunately it’s not really prudent to invest hundreds of thousands of dollars training people to deal with complex medical problems and then pay them lots of money to do something that a computer and someone from the community can do more efficiently. For the doctors who like building relationships with their patients, they can build relationships with sick people or people who want to spend money for the privilege of having a relationship with their doctor.
The bigger issue is that the current rent-seeking regime requires a doctor somewhere in the mix to sign off on the box checked, even if a physicians’ assistant or nurse practitioner does the work. (They are cheaper, but still overqualified.) Quite frankly, this idea will face resistance because it means less money for doing easy things. But we should still do it. I wrote a more detailed explanation of how this could work out here.
Paul Ryan, if you’re listening, here’s something you can stick in your ACA replacement. It’s cutting out a burdensome regulation, creating tons of jobs for people who would only need a little bit of post-secondary education, and saving money. Liberals should also love it because as long as it’s appropriately funded, everybody will get the preventive services they need. It’s not going to fix everything, but it’s at least a step in the right direction. It’s a win-win for everyone but the doctors like me, who would probably lose some money, but they could make it up by seeing more people who are really sick.