We Have Enough Primary Care Docs After All

Posted on January 20, 2009
Filed Under Primary Care in America |

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The Wall Street Journal Health Blog reports that David Snow, the CEO of Medco (the big pharmacy benefits outfit), is “making the rounds to tout his ideas on health reform.” Mr. Snow thoughtfully stopped by the WSJ to give the folks there an earful, and presumably he’ll be doing President Obama’s team the same favor.

Most of us out here in the hinterlands went ahead and held those neighborhood meetings in our homes to talk about healthcare reform, like Mr. Daschle urged us to do, then forwarded our reports to him by Dec. 30 as directed. (The report from DrRich’s meeting urged affordable, efficient, complete, cradle-to-grave healthcare for all, without tax increases, and certainly with no restrictions on our prerogatives as patients. All this could be achieved, we decided, through regulations to stifle greed and waste. Undoubtedly Mr. Daschle is finding our recommendations most helpful.)

But if you’re the CEO of Medco, it appears you don’t have to lay out the big bucks for chips and beer. You can just go ahead and talk directly to the policymakers.

Mr. Snow’s recommendations for healthcare reform center around two major areas. First, demanding “protocol-driven, evidence-based healthcare,” and second, promoting healthy lifestyles amongst the populace.

The second recommendation has DrRich slapping his forehead and wondering, “Why didn’t I think of that?” The American public, being ever malleable and suggestible, would certainly respond in a very positive way to a vigorous public relations campaign, presumably stressing the perils of obesity and smoking, and the great benefits of eating a healthy diet, exercising 90 minutes per day, and taking the simple precaution of insisting upon the careful analysis of your prospective mate’s DNA sequences prior to producing any offspring. Snow doesn’t come out and say it, but since (every parent knows) there’s nothing like peer pressure, one might also consider encouraging Americans to expose individuals who choose not to follow such healthful lifestyle choices to public castigation and ridicule, and wherever possible, discrimination. Call him a Utopian if you will, but DrRich finds this path to healthcare reform quite revolutionary.

But the really astounding recommendation, the one whose implications are truly marvelous, is Mr. Snow’s first. According to the WSJ, Snow believes “the time has come for doctors to follow set protocols on how to treat patients, and to be paid based on whether they do it. Basically, ‘If X, then do Y,’ and ‘If Y, then do Z,’ sort of stuff.”

Objections will be raised to such a policy by certain Luddite physicians, Snow allows, but this can be circumvented by having treatment protocols set by an “apolitical” body, such as the Fed Health board proposed by Mr. Daschle. Clearly nobody could legitimately question the appropriateness of treatment requirements (presumably we’re now far beyond the mere “guideline” state of medical practice) handed down by such a body. Doctors who dismiss such “protocol-driven, evidence-based healthcare” as cookbook medicine can safely (and appropriately) be left on the pavement in a heap. It is time for doctors to get out of the way of medical science.

Such an idea, of course, is meritorious enough on its face, but one must consider its unspoken but profound implications to see Mr. Snow’s true genius.

For, once medicine is finally reduced to a federally-promulgated set of practice rules, based on only the best scientific evidence, then really, what function will doctors actually serve (besides, of course, risking the patient’s health by NOT following the evidence-based “if X, then Y” rules)?

Answer: none.

So not only is Mr. Snow whispering ideas into our new administration’s ears that will simultaneously improve public health, improve medical outcomes, and reduce the cost of healthcare, but also he is solving for them the looming primary care crisis. Indeed, he is entirely eliminating the need for primary care doctors altogether. Why would one need four years of medical school and four years of residency in order to follow handed-down treatment rules? One does not; and indeed, such extensive training tends to put “ideas” into doctors’ heads about professionalism, tailoring medical care to the needs of the individual, and other ritualistic and fundamentally irrational tendencies that steer them toward noncompliance, and therefore, render them entirely unsuited to the tasks that will be assigned to them under Mr. Snow’s plan.

But it’s even better than that. DrRich has already ventured to guess, for instance, that nurses (who, one suspects, the policymakers are relying upon to do the actual “guideline following” once they successfully drive physicians out of the primary care game) are also too contaminated by misguided professional duty to simply and compliantly follow to the letter orders handed down from faceless bureaucrats.

Which is fine, because nurses are also pretty expensive professionals, if you’re trying to reform a healthcare system strapped for cash.

The real beauty of Snow’s plan is that, once suitable treatment rules are established, rules designed from the outset to be clear and pristine, and which will eliminate any need for interpretation, extrapolation, or otherwise creative application on the part of various medical professionals (who likely only inadequately grasp real medical science), then those rules can be applied by anybody. Clerks, for instance.

A sufficiently intelligent clerk with, say, 18 months of vocational training in a suitably regulated educational institution, will be ideal for Mr. Snow’s system. One can develop an army of such individuals quickly and cheaply, certainly quickly enough to assume the responsibility for dispensing “protocol-driven, evidence-based” healthcare as envisioned by Mr. Snow, assuming that it takes at least a few years for all the doctors and nurses to finally realize what has been done to them.

And given their slowness to realize what has been done to them so far, we will probably have that time, and more.

Here’s a more detailed discussion of why centralized authorities cannot dictate the practice of medicine (at least, not effectively).

Comments

8 Responses to “We Have Enough Primary Care Docs After All”

  1. Katie B. on January 21st, 2009 9:50 am

    Right, you don’t even need nurses. You just type in your symptoms into a computer and it pops out the medication, like a vending machine. I cringe thinking that the government would get control of treatment decisions - there’s always a political hand to be played in that.

  2. Dan on January 21st, 2009 10:07 am

    After all, according to the President, we are going to “restore science to its rightful place and wield technology’s wonders to raise health care’s quality and lower its costs.” What could be simpler?

  3. Trusted.MD Network on January 21st, 2009 10:36 am

    Why would the Med-Fed board be immune to “regulatory capture” and undue influence…

    Tom Daschle is promoting the idea of a Federal Health Board that would in his words:

    ” set standards for benefits and quality for federal program and insurance.” he continues:…

  4. NG on January 21st, 2009 12:21 pm

    Dr. Rich, in all seriousness, you could go to the extremes of either God-like, non-accountable individual provider decision making or total clerk administered protocol driven healthcare, and both would be likely not the best. We have tended more toward the former so far in the American system, and I do not see accessible, accountable, sustainable, and stellar results from that system. The results from a protocol driven system are unclear, but I would guess it has to do with the merits of the protocols. Like everything in life, the best answer is likely somewhere in between these two, but please don’t imply that the God-like provider decision making has done us well!

  5. DrRich on January 21st, 2009 12:52 pm

    NG,

    I don’t fault you for not being familiar with my writings on this matter. Few are. I believe that the doctor-patient relationship can only be resurrected if patients take for themselves a full measure of partnership in such a relationship, and not submit to either doctors or the feds as the ultimate authorities on what’s best for them. But as I say, I never assume that readers of my blog will be familiar with my body of work, nor do I assume that they should be.

    But really, not only is this particular post not meant to imply that god-like doctors are just the thing, it, in fact, does NOT imply that, in any manner whatsoever.

    If you immediately dismiss any arguments against medical-practice-by-the-book (and only by the book) as docs merely complaining about their impending loss of divinity, you might be inclined to accept at face value the arguments of the other side - and (this post tries to point out) look where that logically leads you.

    Rich

  6. Trusted.MD Network on February 5th, 2009 1:40 am

    Health Wonk Review…

    Welcome to the Health Wonk Review on the Health Business Blog.
    Pharma’s foibles
    Big pharma is in bigger trouble. Here are a few glimpses of what they’re trying to do about it.
    Health Care Renewal provides a textbook example of what ails pharma-spon…

  7. The Potentially Fatal Consequences of Allowing Insurance Companies To Direct Health Care - Liberal Values - Defending Liberty and Enlightened Thought on February 7th, 2009 3:36 pm

    [...] The Covert Rationing Blog takes this argument to its logical conclusion that there would be no need for primary care doctors if heath care consisted of merely following evidence-based treatment protocols. For those who do have not figured out the problems with this approach from this mockery, others have more explicitly criticized this belief. [...]

  8. John Luster on March 11th, 2009 11:41 am

    Darn! If physicians would just stop thinking and stick to the protocols for all the toxic soup of drugs we insist are the treatments of choice for our ills, then everything would be OK! Thank God for P4P! Now we can enforce this!!
    Better yet, let’s get rid of them and give ourselves a bonus!!

    Let’s see, the head of Medco, who whose company has profited mightily through the drugging and bankrupting of America and our senior citizens think WE’RE the problem? Yes, perhaps we are, for drinking the Pharmaceutical Industry Kool-Aid and believing that the solution to every problem and symptom was a drug. Take a hike, Mr. Snow, and if you really care about things, why not make Medco a non-profit, tell your executives to take it easy on that benefit package this year, and tell us the plan for reducing the cost of necessary drug treatment for our citizens.

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