Making Medicine a Calling Again

[rev ronin]

If you were to redesign medicine from the ground up, or, more realistically, restart a similar/parallel profession (Like Osteopathy was a century ago) that emphasized medicine as a profession (in the classical sense) and vocation (again, in the classical sense), what would you change?

Let's assume for the sake of brainstorming that you can modify laws such as intellectual property or labor laws, oh and criminal punishments for violators, just to be thoroughly unrealistic.  And just to make it more difficult, let's make sure the fundamental anthropological assumptions and practices are broadly acceptable to all major world religions (except for utilitarianism, which is what the current system is beholden to) even if they're inspired by one particular tradition or another.

[rev ronin]

Ok, since this isn't drawing responses, I'll lead off:

1) Eliminate clinician compensation based on clinical decision making.  That's a very broad statement, and a hard one to envision interpreting effectively, but the impacts of compensation shattering the illusion of impartiality are widespread in the current system:

• Free lunches for the entire office staff if the prescribers listen to a spiel on a new drug or device.
• "Eat what you kill" compensation for surgeons.
• Bonuses for using or not using costly diagnostic or treatment modalities.
• Public health bonuses, e.g., pediatricians getting compensated for vaccination rates.

 

[ventana]

Have been thinking of this but such a huge issue. 
 

I think going upstream to insurance reimbursements. 
 

The “facility fee” from insurance needs to paid to every single provider.   Eliminate the 20% bonus payments that the hospitals get over private practice docs.  In fact I would support paying the physician owned practices with less the 5 providers a bonus 10%(on top of the 20% facility) to compensate for small practice size. 
 

pay all primary care clinicians the same amount (no more 85%)

mandatory residencies fir all PA and NP entering primary care and passing USMLE3 for IM or PCP for full independence 
 

remove all the stupid data driven nonsense pay for data points/pqrs/garbage.  
 

create a COLA adjusted universal reimbursement rates.  Would likely be around 150% of Medicare current rates.  
 

universal insurance for all.  Not a fancy policy, just good basic coverage 
 

disallow for profit hospitals and venture capital ownership. Enforce “not for profit” tax status in community hospitals that currently are run as for profit. 
 

what do all these do?

it brings back the small practice that is nimble and cares about the patients. 

it brings patients back into the office to seek preventative care 

it allows for more parity among PA NP and DOc   A well managed patient is a well managed patient no matter who did it  

 

 

with all these occurring you will get an exodus of providers from the evil corporate world  back to private practice   The corporations loose power    
only things it does not address is drug prices  but a national coverage and formulary could do that   

 

 

[sas5814]

is "surgical removal of egos" too big an ask?

[rev ronin]

Not to take away from Ventana's excellent post, but on my list, here's #2:

Reintroduce patient privacy; stigmatize/de-normalize data sharing and ostracize/expel practitioners who violate patient privacy.

Right now, everyone who bills insurance violates patient privacy by disclosing TO THE INSURANCE COMPANY the ICD-10 codes, let alone chart notes.  Most of you are so used to this that what I've just said seems crazy: Insurance companies make the rules, they pay the bills, they have a right to ask what they're paying for.

No, they do not. Or rather, it's our Hippocratic obligation to not give it to them.

Patient autonomy requires both the ability to make a decision and to freely enact a decision. There's a concept in contract law called a contract of adhesion. It's an unequal and theoretically unenforceable because there really was no choice in the matter by the party with less power. Software licenses are a great example of these, but all insurance terms and conditions fall into the same bucket. Do you really have a chance to negotiate with your health insurer? No, you do not. They set the terms, take it or leave it.

To the extent that any medical professional shares information with an insurance company on the premise that the patient freely consented, they have made a counterfactual assumption with respect to patient autonomy.

Now, that may screw up billing, but that's not our concern. Our job is not to make sure there's an economically viable way to run a healthcare economy, our job is to keep our patients' secrets secret.

[SedRate]

Just some thoughts that first pop into my head, most are La-La-Land fantasies and unrealistic in today's society:

Remove underlying for-profit goal of medical practices and hospitals

Sever the tie of health insurance to employment

Adjust penalties when not meeting metrics

Reduce admin overhead, reduce chart bloat

Reduce medical litigation 

Increase societal engagement in health and wellness

Stabilize and improve transparency across rates

Put the cost of medical training onto someone other than the soon-to-be provider

[rev ronin]

3 hours ago, SedRate said:

Reduce medical litigation

[...]

Put the cost of medical training onto someone other than the soon-to-be provider

When was the last time a shaman got sued?

It sounds like a nonsensical question, but the role of healer as a part of the community is something corporatized, bureaucratized medicine has lost.  Within the memory of living individuals, doctors were still solo practitioners who were part of their community. They may not have been as ridiculously wealthy as some specialists are now, but they lived in and with their communities. They were curbsided in the grocery store, at kids birthday parties, at church... because they were known and respected.

When your PCP is part of your community, a man or woman with a family you know, who will be at the funeral and weeping with you for a stillborn child or a missed diagnosis... only an ice cold robot could sue him or her.

[SedRate]

47 minutes ago, rev ronin said:

When was the last time a shaman got sued?

It sounds like a nonsensical question, but the role of healer as a part of the community is something corporatized, bureaucratized medicine has lost.  Within the memory of living individuals, doctors were still solo practitioners who were part of their community. They may not have been as ridiculously wealthy as some specialists are now, but they lived in and with their communities. They were curbsided in the grocery store, at kids birthday parties, at church... because they were known and respected.

When your PCP is part of your community, a man or woman with a family you know, who will be at the funeral and weeping with you for a stillborn child or a missed diagnosis... only an ice cold robot could sue him or her.

Exactly. Personally, I'm worried about anyone and everyone sueing so I avoid handing out any advice unless I'm specifically evaluating and billing them for said complaint. Same with pts who come in for a post-op and ask about something else. I tell them that I can't. Long-gone are the days when I can tell people they'll be fine and not worry and save everyone a visit or weeks of waiting to get in to see someone, if they can even afford it...