Saving Medicare From the Inside Out

A suit armed with a MBA showed up one day at the medical clinic the Phantom ran at a large New England Hospital,  and announced he was shutting down the clinic. It turned out when you looked at the overhead--the rent on on the space, its exam rooms, the salaries of the nurses and doctors, the maintenance of the facility, the clinic was in the red. 
"Oh?" the Phantom replied. "Have you talked to the heads of the in-patient services?"

Never ask a question unless you know the answer in these circumstances--since the Phantom was head of one of the two in-patient services, he knew the MBA had not spoken with the heads of those services. The in-patient services, i.e. the wards where patients admitted to the hospital were admitted, depended on three sources for admissions: The Emergency Room, the private practice doctors and the out patient Medical Clinic. By far, the biggest number of admissions came from the Medical Clinic.
Shut down the Medical Clinic and you've got empty beds on the wards and a lot of nurses and doctors and janitors with nothing to do. And then you'll see some real red ink on the system's ledgers.

"Have you spoken with the head of Radiology?  How about the clinical laboratory? Or the heads of the subspecialty clinics?"

No, the MBA had to admit. He he simply looked at the columns for the Medical Clinic expenses and receipts. 

"Maybe you ought to talk with those people, or maybe with your boss before you make a mistake which knocks the bottom out from under the monument here," the Phantom said, "And before you lose your job because you didn't understand what 'downstream' revenues mean. Ask radiology how many dollars flows to them from Medical Clinic. You shut Medical Clinic down and you'll see some hurt in a lot of other departments."

That MBA never showed up again, and the Medical Clinic remained open. 

Even now, in large organizations which employ thousands of doctors, MBA's who have no real understanding of value, inter dependency, downstream effects are wrecking havoc on these for-profit companies, on not-for-profit organizations, on "voluntary" (not for profit) hospitals,  which own physician practices.  These MBA's are the fools who rush in, who simply do not know what they do not know.

At university hospitals, where a hierarchy of physicians manage medical care and services, the physicians in charge use the MBA's to solve problems MBA's are better at solving--like getting the best price on a new MRI machine, or getting Blue Cross to understand why it would actually save money all around if a patient spent an extra day in the hospital after his coronary bypass.  

When you look at where money is wasted across vast systems, there are things which are obvious to any doctor in the trenches, which have escaped notice from "health planners,"  MBA's, "managers" and a host of government people who simply do not understand the system from the inside.

So now we have "indicators" of "high quality" in medical care, which include patient satisfaction surveys and readmission to hospital rates.

If  President Obama sent out a team of "spies" to hang out in hospitals and doctors' offices they would see areas where real money could be saved. They would have to wear scrubs, and sit around at midnight in ER's, on the wards, in the operating room suite coffee rooms, or at the bars across the street from the hospital, where doctors are tired enough, loose enough to really tell the truth.

It was disquieting to read about Mr. Obama's reaction to a New Yorker article by Atul Gawande in which Dr. Gawande reported his conversations with doctors who thought their colleagues were doing coronary arteriograms and other procedures for the money and not because patients really needed them.  it was disquieting because it revealed Mr. Obama does not know how to get untainted information--and Dr. Gawande's article did not fall into that category, despite his best intentions. Dr. Gawande was more ingenuous than either he or the President knew.  

Exceptional cases do not make for good policy or for good law. Dr. Gawande did not understand the system he was writing about. Best intentions, poor results.

Here is some of what you would hear, if you sent the right people to ask the right questions: 
1. There are procedures and expenses which are substantially overpaid because you do not need to be a doctor to do them but you are paying for a doctor.  These procedures could be learned by technicians in 6-18 months and done at a small fraction of the cost:  colonoscopy (current price $2500, could be done for $150), endoscopy ($1500 could be $100) , virtually all dermatology biopsies, excisions($500 could be $25) and a load of other procedures.  
2. Much of what is called quality, even in orthopedics, is simply checklist stuff and could be done for every patient by people with high school educations who are strictly supervised.  
3. There are things which really do require a high level of cerebral function and which draw on a lot of stuff you need to have gone to medical school for and these should be paid well--reading MRIs and CT scans and plain Chest Xrays, most of radiology falls into this category. The reading fees ought to be high (say $200) , but the fees for the MRIs and CT scans could be a tenth of what is charged ($200 instead of $2000). There is no reason the radiology department should pay off its MRI in 6 months or should make ten times what any other department makes.  Radiology departments have a monopoly in each hospital--there is no competition. But radiology is one of those costs which could be out sourced and real competition for the readings could occur. A CT done in Silver Spring, Maryland can be and today is read in India, by an American trained radiologist, and the report sent by email to the ER back in Maryland, every bit as fast as the doctor reading that scan from his home in Silver Spring can do it. 
 If you had no pressure applied on you as a health czar, you could convert dermatology into a specialty done by physicians assistants and nurse practitioners and you could lower radiology fees by 2/3. This would mean putting radiologist's on straight salaries and taking control of their equipment. 
4. You could improve quality of care enormously by simply appointing and paying a physician in each specialty to systematically review charts on a daily basis to be sure patients were not simply "processed" as if they were profit centers, but actually had their needs met. You would, for example, look at the primary care doctor who saw a patient with four problems, solved none of them but farmed out every problem--"turfed"-- each to a different specialist for consultation. You could stop paying primary care doctors for being traffic cops and start paying them to actually render meaningful, high quality care.

 5. You could set up a regular  conference to review of each case admitted to the hospital,  to be sure each patient who was admitted really needed to be admitted and to be sure what happened to each patient, while in the hospital was efficient and proper. This is the system teaching hospitals once had. It kept every doctor looking over his or her shoulder and it meant maximal efficiency because everyone knew someone was watching.

6. You would remove all "vanity medicine" from community and university hospitals and force the vanity doctors to set up their own hospitals as they have in England. Facelifts and cosmetic procedures are done in private hospitals, separated physically and financially from "real" hospitals for sick patients.  Plastic surgeons doing reconstructive surgery would be in the "real" hospitals, getting well paid, but the high thread count plastic surgeons doing cosmetic surgery would have to play that game on their own, outside the system we all pay for.

7. You would spend much more money on paying doctors who know what good is, to oversee the work of other doctors, and you would cut the non physician non surgeons out of the picture of quality control.  

8.  Employment of business people in health care organizations, would be limited and their function would be under the control of doctors rather than placing the money people in control.

In short, you would let the pilots tell you how to organize your air traffic control system, the engineers tell you how to build bridges and you'd protect doctors from people who have other agendas--making money, running for office, the "managers" who have been raping the system for their own career advancement.

9. You would place in charge people whose operating first principle is "Put the Patient First," and you would make them answerable to the money people, but not subservient to the money people.

10. You would, by doing all this, transform our medical system from one which has been the best in the world for 1% of our population but way behind England, Germany, Italy and a host of other countries for the 99% of citizens. And you would cut the cost of our system to a third of what it costs now.

Never happen.
But it's nice to dream.