WhiteCoat

Radical Ideas to Improve the House of Medicine #1

lucy-doctor-standI’ve been thinking a lot about how to improve the house of medicine.

I have several ideas that are going to get put into several posts over the next week or so.

Here’s idea #1.

People’s perception of medicine as a “free” service has to change.

I won’t go into the discussion about whether health care is a right. It’s like a gun control argument or an abortion debate. Everyone just digs in their heels and shouts at the other side. Strange how the ones who would be forced to provide this “right” to others have different views than the ones who demand the “right,” though, isn’t it?
See also this post about, even if healthcare is a “right,” why – just like every other right afforded to Americans – it shouldn’t be an absolute right.

Whether or not healthcare is a right doesn’t really matter for this idea, though.

What would happen if we did away with licensing of medical professionals and certification of medical facilities? When you think about it, licensing only serves two purposes: it allows the state to extract money from a class of people trained in a given art and it allows for regulation of those classes of people. Ditto for certification. You can argue all day that certification and licensing improve “safety”. I can give you just as many examples of how that argument doesn’t work.

What if we let anyone hang out a shingle and practice medicine out of their garage or their living room? With all the physician extenders performing the tasks that used to be performed solely by physicians, we’re heading down that road already. Get rid of the incremental steps. Jump in head first.

Let my 11 year old forget her paper route and practice medicine – just like Lucy on the Peanuts. She may only make 5 cents per patient, but she would still get paid for her services.

What effect would opening the practice of medicine to everyone have?

Anyone could receive health care from anyone.

Access would improve immediately.

Any patient could choose to go to their kid, the neighborhood witchdoctor, Reverend Bubba, the local Rolfer, or their good ol’ family physician.

But … with no regulation of the medical industry, consumers would then be forced to make a value judgment about the care they receive. It may be a bargain to get psychiatric help from Lucy for 5 cents, but how reliable is what she tells you? Would you rather pay a little more to speak to a psychiatric nurse? Or would you rather pay the “big bucks” to talk to a psychiartist?

We can pay high school kids minimum wage to work in a medical clinic and treat patients for “free.” Patients have access. Patients have timely care. Everything is great. If you want to pay some money, you can see the nurse practitioner and if you want to pay more money, you can see the physician. Maybe there’s a new physician that wants to build a practice and is only charging the going rate for a college grad. That doctor will probably get more patients. Free market at work. Want to sell more product – lower the cost.

To make extra money, someone could set up a couple of beds out in the garage with IV poles and a TV set. That would cost you very little. Would you pay more to be taken care of in a hospital? How about having a nurse tend to your needs? Is it worth more to you if the hospital is deemed “better” at the government’s “Hospital Compare” site? Would you pay more to go to a hospital that is certified by JCAHO? Maybe, maybe not. But the consumer is the one who has to do the research and decide.

If we give patients unlimited availability to health care, then everyone can have “free” or nearly free care. That’s when market forces kick in. If you want a specialist, you have to pay for it. All that training doesn’t come cheap. Maybe the college grad can do a colonoscopy on you for $25, but if you want someone with experience, you have to pay more. Some people will only go to the “best of the best” and those practitioners will be able to charge premium prices.

Once people had access to health care, there wouldn’t be a need for a lot of health care insurance. Then we could get back to what insurance was intended for – catastrophes. Major heart attack? Open heart surgery? Neurosurgery? You could get less experienced practitioners providing your health care “right” to you for free at a county hospital or you could pay a healthcare insurance premium for the more experienced ones to perform surgery at that cushy suburban hospital. Everything is up to the consumer.

Just like everything else in this world, if you can’t afford the premium prices, you’ll still get care – it just won’t be the “best” care.

People on welfare don’t get to live in five star hotels. You can’t use food stamps to eat out at expensive restaurants. Not every accused criminal has a right to representation by Johnnie Cochran or his progeny.

Access to health care shouldn’t be any different, but right now it is the only industry in which, for the most part, the best practitioners get paid the same amount as the worst practitioners. Aside from climbing the academic ladder, there is little financial incentive for most health care professionals to be better in the field. The emphasis is on how quick you can do your job. That has to change.

Removing licensing requirements for the practice of medicine may sound extreme, but extreme changes are what we need before the system collapses.

You can now commence your flaming in the comment section.

14 Responses to “Radical Ideas to Improve the House of Medicine #1”

  1. One question, what happens in the case of Emergency Medicine? I mean, if I just got banged up in a car wreck, I don’t really have the time, or even the ability (if I’m unconscious) to do any research and make a decision. ERs would have to have some kind of standard of care.

    When you move to a new town and have children, you research the school systems before you move, right? Towns with better school systems have higher property values and are more desirable. Why shouldn’t it be the same for hospitals/emergency departments?
    Besides, I already see this problem in the rural hospital where I moonlight. If you’re in a bad car wreck in the country, you’re getting flown to a regional trauma center. You don’t have to make the choice – it’s made when you hit the door. Ditto for strokes. Ditto for MIs. Flew out a fractured cervical spine and a heart attack when I was working there yesterday.
    You *would* get to choose if your injuries are minor, though. Do you want to let the medical assistant set your ankle fracture for free or do you want to pay beaucoup bucks to be transferred to the teaching hospital and have the head orthopedic attending physician do it?
    May seem an odd way of thinking, but it’s already happening in doctors offices when you get same day appointments with NPs versus having to wait several weeks to see the physician.
    We have to think outside the box.

  2. Brad says:

    Brilliant idea. One of many that would certainly begin to relieve a heavily burdened system. I’m looking forward to more ideas.

  3. HyperAl says:

    Less extreme case scenario. Let’s just get rid of State licensing. You pass your boards or completed an acredited training program then you should be able to practice anywhere in the US, or the world even. Same should go with other professions.

    Let’s get rid of JCAHO as well. Can you imagine how many more patients we can see if we don’t have to spend 30 minutes or more documenting everything. Does that really improve quality of care? I would rather spend that 30 minutes with a patient.

  4. When you move to a new town and have children, you research the school systems before you move, right? Towns with better school systems have higher property values and are more desirable. Why shouldn’t it be the same for hospitals/emergency departments?

    I don’t disagree, I just know that not all emergencies happen near home, so all of that research would be moot. I’d want to know that the protocols for emergency response will route a person to the nearest facility best suited to treat the trauma.

  5. Anonymous says:

    What happened to professionalism? All you are doing is turning yourselves into whores, high class whores maybe but whores nonetheless.


    It appears that your definition of “professionalism” is requiring someone to get good grades all through school, go into more than $250,000 in educational debt, work 100 hour weeks for 4 years while in medical school taking out additional loans to survive, work 100 hour weeks for another 4 years of residency training at less than minimum wage, and then use all their hard work and training to provide free care to people that routinely abuse their bodies or who engage in self-abusive behaviors. Yeah. Sign me up.
    While you’re at it, why don’t you come over and clean up my house, wash my truck, babysit my kids, cook my meals, and take dictation for my blog entries? Maybe if you act in a “professional” manner, I’ll let you have the dinner scraps.
    Get real.
    How does expecting to be paid for services amount to “whoredom”? Using that definition, any trade that provides services for a fee (prostitution included) should also be considered whores. Hear that? All you lawyers, plumbers, school teachers, priests, police officers, firefighters, babysitters, professional bloggers, and all you other laborers better clean up your act.

  6. cynic says:

    Brilliant!!

    If medicine is a “right” which it is not, then legal counsel should be a right. They are both necessities in given situations. If someone has the right to health care, I have the right to not go to jail or lose my house over a medical complication.

    I also agree with Al in that licensing is nonsense. Likewise, has anyone ever heard of someone failing they recert boards? I have yet to see it happen. It is just another way to milk another $ 1000.00 + out of physicians, for a bs piece of paper that says “I am not senile yet.”

    JACHO needs to go, end of story. Tort reform needs to be implemented, and the AMA needs to get their heads out of their asses and take back medicine.

  7. keepbreathing says:

    Anonymous, you’re funny. After all, if we were professionals, we’d never do things like use the restroom or eat lunch between patients, because after all, how dare we take time away from seeing deathly ill people to attend to our mere mortal needs? Why would we demand pay for doing this? Clearly the altruistic satisfaction from doing good to so many extremely grateful people every day should be sufficient. Demanding pay for skills is like…well, like anything else, but we’re “special,” right? Why, when a plumber comes to your home and demands money for his skill, it’s ok…but when we demand pay for doing our jobs, it’s different? Please!

    Anyway, Whitecoat, I for one like your idea. People can get what they pay for, and they will get exactly what they pay for if “free care” becomes a reality.

  8. [...] Posted by keepbreathing in Uncategorized. trackback Dr. Whitecoat has an excellent idea up at Whitecoat Rants about how to radically improve the house of medicine. I quote: Just like everything else in this [...]

  9. Nurse K says:

    FYI, I’ll diagnose your personality disorder/factitious disorder/anxiety variant for free if you’ll just agree to forgo unnecessary testing to prove you really are as CRAYZEE as a Chihuahua swimming in a pool of mercury.

  10. Rogue Medic says:

    I was having a similar discussion with one of the ED doctors a few nights ago. The hospital recently doubled the size of the ED, but they are on divert as much as they were before the expansion.

    All of the increased requirements fall entirely on the ED, so the rest of the medical profession looks at the ED as the Sudetenland. They never really liked you guys, anyway. It will never affect them.

    Since the patient to nurse ratios do not apply in the ED, but do everywhere else, the patients are in a holding pattern in the ED until someone is discharged upstairs. The doctor was not even especially busy, hence the opportunity to chat. He had assessed all of the patients, written their orders, and was waiting for some VIP to come in by personal transportation. Something bound to make everything run more smoothly. :-)

  11. Tim says:

    This is a pretty silly post and this is what I think is the silliest sentence:

    “People on welfare don’t get to live in five star hotels. You can’t use food stamps to eat out at expensive restaurants. Not every accused criminal has a right to representation by Johnnie Cochran or his progeny.”

    So a poor person going to the closest ER after getting their face smashed in during a car accident is comparable to eating at Ruth Chris’ and staying at the Hilton Waterfront?

    And this sentence is flat-out wrong too:
    “Access to health care shouldn’t be any different, but right now it is the only industry in which, for the most part, the best practitioners get paid the same amount as the worst practitioners.”
    What about law (ironic since you mentioned Johnnie Cochran in the same post and he is certainly not the “best” in his industry)? What about business? What about politics?

    • WhiteCoat says:

      “So a poor person going to the closest ER after getting their face smashed in during a car accident is comparable to eating at Ruth Chris’ and staying at the Hilton Waterfront?”
      No, you’ll always get a minimum level care in the *ED*. But someone going to the ED after a car accident might not have access to dental surgeons to fix their chipped teeth, plastic surgeons to make their scars as small as possible, maxillofacial surgeons to make sure their facial fractures heal perfectly, ophthalmologists to get the glass chards out of their eyes, and many other specialists that might be needed to provide nonemergent care.
      Medicare reimbursement is the yardstick against which most payments to physicians across the United States are measured.
      Everyone gets paid the same in law? You’re telling me that all attorneys performing similar services from backwoods Tennessee to Washington DC get similar rates for their “billable hour”? Riiiight. Business? CEOs have standard salaries across the US? Politics – I’ll give you that one. Hadn’t thought of it.

  12. Sarah says:

    wow. that certainly fits the bill for “radical.” two things spring to my mind in response: along with market forces would come marketing. in today’s commercial climate, and given the complexity of modern medicine, I can see that getting pretty scary. to what degree might health care professionals succumb to the “customer is always right” mentality, once patients became customers? I know the salesperson at the department store is lying when she says the jeans fit me well. I wouldn’t want to worry about whether my doctor were encouraging my tentative self-diagnosis just to keep me happy with his/her service.
    my second reaction is a little different. There seems to be a societal cost in providing such a strong incentive for everyone with health concerns to make the most money they can possibly make. Just because this scheme would make maximum money accumulation a positive incentive for physicians, wouldn’t revolutionize all other professions in the same way.
    so I guess my first reaction is that we’d be set back to pre-modern medicine (pay a “doctor” for his ability to persuade); my second, is that we’d be set back to an even more antiquated form of society (the more responsible you are, the richer you are, since wealth is security — pursuing a less lucrative calling than opportunity allows is just foolhardy).
    can’t say I’m happy with the current system, but this doesn’t look like a fix to me…

  13. Here is a list. It cuts costs 50%, gives the uninsured top of the executive level health coverage, and ends medical mistakes. It is simple. Get rid of the lawyer.

    http://supremacyclaus.blogspot.com/2009/06/lower-health-care-cost-by-50-by-getting.html

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