Healthcare in our nation is on life support. Our costs, whether per capita or as a percentage of GDP, are much higher than other developed countries. Yet our life expectancy is lower, and we rank near the bottom on most other outcome measures as well. ObamaCare was implemented, and Trump/RyanCare has been proposed, as solutions. But they both simply redistribute who pays, without addressing quality and cost effectiveness. That’s inarguably foolish and arguably unconscionable.
The essential problem with healthcare is that it’s not a system. That would be okay if health services lent themselves to free-market dynamics. However, capitalism doesn’t work everywhere. In healthcare, the supplier determines much of the demand. The consumer is generally not capable of assessing value (beyond bedside manner). Plus, the consumer pays only a fraction of the price. Will such an industry be successful if nurtured solely by market forces?
So how can we convert the healthcare industry into an intelligent and highly functioning system? First, formulate the system’s goals. By consensus, these goals would include: optimal access, high-quality care, and low cost – the attainment of which will also lead to improved outcomes. The next step is to devise the strategies that will accomplish those goals.
I believe the pivotal strategy is triage. The etiology of this term lies in the military, from assessing the wounded and prioritizing treatment on a battlefield. However, triage can be a valuable tool off the battlefield as well – allocating patients by urgency and appropriate source for care. Access, quality, and cost are all profoundly impacted by when and where a patient receives care.
So imagine a healthcare system where the first action of a patient confronted with a medical episode is to contact a triage nurse by phone or some form of electronic communication. During a brief interaction, the nurse determines where care would be most appropriately provided. There are a number of options – depending upon urgency, complexity, and some other factors. These are the principal sources for care: emergency room, urgent care center, primary care clinician, specialty physician, telehealth (by phone or video call), and/or self-care. Note that the latter two options are highly underutilized today; they can effectively handle a rather large percentage of clinical problems; and they are considerably less expensive than the other alternatives. Triage is the key to deploying them properly. Additionally, the triage nurse should be able to requisition any obviously required lab tests and/or imaging, to save a wasted visit to a physician that results only in generating that requisition.
Emergency rooms are, by far, the most expensive venue for receiving care. Triage will result in a huge savings in both healthcare costs and patient distress just by directing non-emergent patients to a more appropriate source for their care.
Many other underutilized tools can improve healthcare in cost-effective ways. Among them are: personal health records, computerized medical history, clinician access to medical knowledge bases, clinical guidance systems, electronic-health-record scribes, wellness initiatives, medication-adherence surveillance, health-monitoring devices, and chronic-care-management programs.
When designing a system, all conceivable assets and procedures are evaluated for inclusion. One of the most powerful potential strategies on this front is learning from experience. We should rigorously analyze clinical encounters all across the nation. Tracking their outcomes will enable us to empirically determine what symptoms are correlated with which eventual diagnoses, as well as what treatments actually work best and under what circumstances. Healthcare, like many successful enterprises, can benefit enormously from this Continuous Quality Improvement.
Admittedly, our entire healthcare industry cannot be totally transformed overnight. However, to demonstrate and evaluate this systematized approach, we could launch a “Healthcare System Option.” It would be offered to and embraced by people who are willing to comply with the System’s requirements in order to dramatically lower their insurance premiums, deductibles, and copays. As a valuable byproduct, it will likely improve their care quality and health outcomes.
Presumably, this Option would be designed and managed – initially for an evaluation pilot – by a quasi-government agency, overseen by a Healthcare System Board composed of preeminent leaders in innovative care delivery. Once the Option demonstrates that it can lower cost while improving access and quality, our nation will recognize that we can provide full healthcare coverage with systematized-high-quality service, for all our citizens, at a much lower cost than we currently endure. The time has come to make healthcare all that it can be.
Joe Weber managed the emergency room and outpatient department of Chicago’s Cook County Hospital in the early 1970s. The remainder of his long career has not been quite as exciting.