A bit more of a very rough and simplistic vision of health care reform

1) No one involved in the direct clinical care of patients likes the health-care system right now.  I live in China and work in a Chinese public hospital and I can tell you that the feelings of doctors, nurses, patients and hospital leaders is 80% congruent with what we are experiencing in the US! 

2) There are many contributing factors, but I would argue that the fundamental illness is a problem of doctors needing to see too many patients in order to generate what they consider to be fair compensation for their years of training,the daily challenges of their jobs and comparisons with their professional peers.  This makes doctors unhappy, patients unhappy and produces huge amounts of unneccessary (and harmful) medical care. 

3) Most estimates suggest that somewhere between 20-40% of all medical resource use is unnecessary – waste.  BUT doctors and hospitals currently have little to no incentives to curtail waste – because the current reimbursement systems only rewards production.  Sure, there are some programs tinkering at the edges of the envelope to reward “value”, but they are not making much of a difference right now. 

4) The reimbursement structure for health care is so far and away NOT a free market that it seems quite irrational to pretend otherwise.  Most doctors work in a “piecework” economy and the price for each piece of work(patient encounter, procedure) is almost completely determined by CMS, and RUC.  Yes, there are a few intrepid souls who have moved to a completely insurance-independent model and I applaud them, but that is not the reality for most of us (again, essentially the same situation here in China).  So, let’s not pretend otherwise:  we are largely determining the incomes of doctors by setting these prices.  If we are determining the incomes of doctors, shouldn’t we have a conversation about what those incomes “should” be? 

5)Imagine you could do the following:

a) eliminate most of the overtesting and overtreatment – the physicians net productivity (in terms of health care VALUE) would stay the same, but the number of patients/office visits/procedures/tests ordered would drop by 30%.  The amount of support staff, time spent on the phone, tests reviewed, time in the hospital, etc would also drop similarly. 

b) find a way to maintain the income of physicians in this scenario.  We would be “producing” the same amount of value after all.  This probably means a largely fixed salary (based on that conversation we should be having?) with a modest “balanced scorecard” of potential incentives (maybe 20% at most)  including quality, patient experience, productivity, teaching/training, etc. 

I am not proposing any technology “moon shots” here.  Doctors in the audience:  would you be willing to trade in your lottery ticket for a 7-figure income for a decent 6 figure income with a job that is fulfilling and sustainable?