Is Medicine Being Practiced with an Inappropriate Business Plan?

The health care delivery market is overrun with specialists and super-specialists resulting in high-tech doctors offices and cookie-cutter general hospitals, a plethora of unnecessary diagnostic and therapeutic procedures, soaring costs, and long waits for patients to get an appointments and then, arriving for it be seen. Separating patents on the basis of the difficulty to diagnose and treat their health problems would seem a sensible approach to trying to increase efficiency and lower costs, while at the same time, allowing increasing quality.

Most problems that patients present to health care providers officers and clinics are simple and straightforward, easily recognizable from training and experience. (1) In these cases the diagnosis is made by pattern recognition (2) and the treatment can follows protocol. It has been shown that less sophisticated providers treat patients less expensively than specialists, provided the providers have been trained to recognize and successfully deal with the problem the patient has. [3].

Stratification of care can make health care delivery more cost-efficient and consumer-friendly. In addition stratification, by unloading the more sophisticated providers, allows them to devote themselves expeditiously to patients who require a higher level of expertise. [ref.] Patients with simple, common medical problems, treated by properly trained NP's and PA's, should improve the efficiency of health care delivery without damaging its quality.

But how to define whom NP's and PA's can safely treat unsupervised? One of the doc-in-the-box companies has apparently found an answer. MinuteClinic has a list of what its providers will treat. This definition makes MinuteClinic's NP's and PA's consistent and reliable. The list of what they will do is listed below.

Obviously doc-in-the-box care is at the bottom rung of a health care delivery stratification ladder. But for what it does it's quicker and less expensive than an ER and patient satisfaction is high. I don't know if they train their practitioners to recognize medicine's "red flag" diagnoses, those life or limb threatening conditions that require immediate or at least urgent care. This knowledge should be part of the training for all practitioners at al levels of expertise.

One assumes the doc-in-the-box patents are quite able to get around and are not seriously ill. It is interesting that MinuteClinics do not deal with trauma. For what they do, it seems like a more efficient "way to go" for those with appropriate insurance. The hospital walk-in urgent care clinics are more comprehensive but the waiting times to see someone is frequently long. This is because we are mixing the seriously ill with the mildly sick.

There is no question that our current health care delivery business plan is inappropriate for most patients. Clayton Christensen, the Harvard Business School guru chronicled the fall of over-bloated sophisticated commercial enterprises felled by innovators with simpler business plans. In his book, "The Innovator's Dilemma" (1997), he discusses how industries, based on ever-improving technical advances, eventually become too sophisticated and expensive for the majority of their customers. Christensen thinks health care delivery has reached that point. So do many others.

There is no doubt that pattern recognition alone will not make all diagnoses, but it will make a large number because he majority of problems patients come with are common and easily recognizable. And in these straightforward cases, the best-practices treatment protocol will work almost all the time. Only patients with more sophisticated problems need to see more sophisticated practitioners.

To maintain quality we need to define what the various levels of primary care practitioners should be able to diagnose and treat and train them accordingly. We need diagnosis-based job descriptions at all levels of medical practice, which we teach to.

Most patients do not require health care practitioners with 11 or more years of training after high school, including 2 years of advanced basic science study and 3 or more years of years of residency. To be efficient, our health care business plan should save specialists for the patients who need them.

A word about hospitals and efficient, cost-effective care

Except in rural areas, the general hospital trying to be as many things as it can to all patients is no longer a viable business plan for efficient, quality care, for the majority of patients. Of course we need tertiary medical centers, to can deal with patients with serious multi-organ problems but we don't need so many. Most are clustered together in big cities. Many specialty hospitals, focused ambulatory clinics, freestanding surgi-centers and doctor's offices, and disease-specific treatment teams are delivering greater value (long-term outcome divided by cost) then the medical centers. We need to stop blindly defending the general hospitals and medical centers and insist that all providers and in-patient facilities compete on value.

Eric Radin, MD
Marion, MA

MinuteClinic treats Allergies (ages 6+), Athlete's Foot, Bladder Infections(Females, ages 12-64), Bronchitis (ages 10-64), Cold Sores (ages 12+), Deer Tick Bites (ages 12+), Ear Infections (ages 5+), Impetigo, Minor Burns- Rashes- Skin Infections- Sunburn, Pink Eye and Styes, Poison Ivy (ages 3+), Ringworm, Sinus Infections, Strep Throat, SwimmerÂ’s Ear (ages 3+), Swimmer's Itch, Warts (ages 5+), will test for Flu, Mononucleosis, and Pregnancy, and offers vaccinations.