Blueprint for a Gold Medal Health Care System* (eBook)

Chapter 1.
My Perspective on the Problem

I am a physician, and I am embarrassed by our health care system in America. It is unjust, inefficient, and far too overpriced. The promises made by the medical–industrial complex are often self-deluding and sometimes downright fraudulent.

If you don’t understand where I am coming from, read this: “America can afford a world-class health system. Why don’t we have one? Our system takes from the poor and working class to generate wealth for the already wealthy,” by Anne Case and Angus Deaton, an opinion piece by the authors of Deaths of Despair and the Future of Capitalism.1 In their article, they describe many of the injustices inherent in our system. Two major flaws eloquently elucidated in their article are striking to me. First is the subtle and not-so-subtle emphasis on profits evidenced by the marketing of services and procedures that are expensive but of relatively low value to the health of the patients. Second is the employer-based insurance system. Not only does this system place a hidden financial burden on companies and citizens alike, it all too often leaves patients uninsured when they need health care the most. The COVID-19 pandemic has shone a harshly critical light on this flaw. They conclude, “We are believers in free-market capitalism, but health care is not something it can deliver in a socially tolerable way.”2

Other weaknesses of our system have been glaringly highlighted by the COVID-19 pandemic. If you are unconvinced, read this: “What the coronavirus crisis reveals about American medicine: Medicine is a system for delivering care and support; it’s also a system of information, quality control, and lab science. All need fixing.”3 In particular, consider the author’s scathing critique of our failure to realize the true potential of the electronic medical record (EMR) due to the fact that American medicine operates primarily in a fee-for-service world. Speaking of the COVID-19 pandemic, the author points out the frustrating experiences of his colleagues as they realize over and over again that the EMR has been co-opted by health systems administrators and billing departments as a means of maximizing revenue capture. As a result, doctors wind up needing to document trivial information in a bloated note, such that the more vital information—information crucial to other doctors caring for that patient—gets lost in the weeds.4 Equally tragic is the realization that the EMR could be a revolutionary tool for conducting on-the-fly research on specific diseases (including especially new diseases like COVID-19) and their symptoms, complications, and treatment results. Unfortunately, leveraging the advantages of big data is currently impossible because of privacy concerns, poorly designed EMR systems, and a highly fragmented health care system. In its current form, the EMR is certainly not designed primarily to facilitate rapid searches based on symptoms, diagnoses, complications, or outcomes. Finally, we miss out on another huge potential advantage because of the shocking truth that the EMRs of different health care facilities often don’t interface with each other, so that doctors often have either to wait for outside records to be hand-delivered or to duplicate tests done previously.

I am a neurologist, and I am discouraged by our health care system in America. In fact, I was so discouraged, I burned out. According to a 2020 Medscape survey, 42% of physicians across all specialties reported burnout.5 “Burnout has been described as long-term, unresolvable job-related stress that leads to exhaustion, cynicism … and lack of personal accomplishment.”6 Among individual specialties, neurology came in at number two, with a burnout rate of 50%. Doctors are burning out because they know that they are working in a broken system, a system that does not reward them for providing compassionate, evidence-based care. If you are skeptical, read Doctored: The Disillusionment of an American Physician, by Sandeep Jauhar, MD.7 Here is a blurb from Dr. Jauhar’s own website:

“Hoping for the stability he needs to start a family, Jauhar accepts a position at a massive teaching hospital on the outskirts of Queens. With a decade’s worth of elite medical training behind him, he is eager to settle down and reap the rewards of countless sleepless nights. Instead, he is confronted with sobering truths. Doctors’ morale is low and getting lower. Blatant cronyism determines patient referrals, corporate ties distort medical decisions, and unnecessary tests are routinely performed in order to generate income. Meanwhile, a single patient in Jauhar’s hospital might see fifteen specialists in one stay and still fail to receive a full picture of his actual condition.

“Provoked by his unsettling experiences, Jauhar has written an introspective memoir that is also an impassioned plea for reform. With American medicine at a crossroads, Doctored is the important work of a writer unafraid to challenge the establishment and incite controversy.”8

I’ll say it one more time. I am embarrassed and discouraged.

I have a vision for a world-class health care system. What qualifications do I have that might lend some gravitas to my proposal? I am not an academic. I have published three articles in peer-reviewed medical journals: two shortly after my residency and one recent article in the journal Pain Medicine.9 Mainly, my qualifications are based on my experiences during almost thirty years of practice at Santa Clara Valley Medical Center (SCVMC), a large public hospital in the heart of Silicon Valley. I completed my residency in neurology and a fellowship in electromyography and neuromuscular disorders at the University of California, San Francisco (UCSF) in 1991. I have been involved in the clinical training of Stanford medical students and neurology residents throughout my thirty years at SCVMC. I have talked to fellow physicians, primarily neurologists, who have worked in the Kaiser system, in private practice, and in the world of academic medicine at UCSF and Stanford. I have long admired the Kaiser Permanente system. Kaiser Permanente is an integrated managed care delivery system. In the Kaiser model, a capitation payment model of reimbursement is used. In the capitation payment model, the providers receive a fixed amount of money per patient; this is paid in advance, for a defined time, whether the member seeks care or not. Ideally, patients who have little utilization will naturally balance out with the patients who have higher utilization. There may be co-payments and deductibles, but otherwise the system cannot generate more revenue by providing more services for its patients. As a result, there is an incentive to provide care in the most cost-effective way possible, and this incentive in turn leads to innovation in delivering care more efficiently. I have spoken with a Kaiser physician who has been deeply involved in the design of their EMR, and in embedding within that EMR, a set of fully integrated decision-support tools—just one example of innovation leading to greater efficiency and better care. At the same time, I have seen how Stanford Medical Center—after struggling mightily with financial woes in years past—has evolved into a commercial success while, unfortunately, sometimes sacrificing the practice of sound, science-based medicine. In short, they offer unnecessary testing and costly consultations for problems that could be handled by a phone call between the primary care provider and the specialist, as is routinely done in the Kaiser system. More ominously, in the Stanford Pain Clinic, they sometimes offer ill-advised invasive procedures that are not supported by clinical trials.

I have witnessed the difficulties others have faced trying to survive in private practice, especially in solo private practice. Physicians at SCVMC are all on salary, and for that I have been grateful. Nevertheless, despite an attractive benefit package, there is a high rate of burnout and turnover of physicians at SCVMC, and it is much higher than it was fifteen years ago, especially among primary care physicians (PCPs). I believe that the main cause of this high burnout rate has to do with the pressures resulting from an increase in panel sizes (mandated by hospital administration in order to keep the hospital viable). In my opinion, PCPs at SCVMC lack the support, resources, and tools necessary to achieve a level of efficiency sufficient to make the job truly satisfying.

I have taken care of grateful patients, and I have taken care of angry patients—patients who have lost trust in the system. I have taken care of many, many patients who can be counted among the “worried well.” Such patients often need nothing more than a dose of gentle but firm reassurance. More challenging are those patients who, suffering significantly from anxiety, depression, and loss of hope, find their way into a neurology clinic because they are troubled by a host of psychosomatic complaints. Doctors need to be better educated and better supported to meet the needs of...