Healthcare Solutions, Part I (no promise there will ever be a Part II)

I wrote recently about what I believe to be the two biggest structural defects in the U.S. healthcare system and why Obamacare has no hope whatsoever of being successful in solving them. Obamacare, I opined, is like putting extra syrup on a bad tasting pancake. It may taste a little better for a while, but ultimately a bad pancake is a bad pancake. But, in that post, I offered little in the way of answers. Today, I’d like to start rambling a bit about some answers.

Let’s start with technology. I always hesitate to write about technology in healthcare because it’s kinda what I do for a living. So, when one of my sharp readers corrects my erroneous thinking, it looks a lot worse for me than when I get the bathroom humor wrong. But, here goes nothing.

Stop for a moment and consider all the myriad ways technology has changed your life in the last 10 years alone. Through the wonders of my iPad (a technology I derided, then embraced like it was my third child) I have been catching up on episodes of HBO series I never watched (HBO Go is one of my favorite iPad apps). Most recently, I’ve been watching The Wire, a police/legal drama set in Baltimore. In season 2 (2003, less than 10 years ago), the good guys were eavesdropping on the bad guys’ cell phones. The bad guys figured it out and (literally) tossed their ancient flip phones into the Baltimore Harbor. Then, standing at the Harbor’s edge, the bad guy took out a huge clunky device with an antenna, yanked out a stylus and started tapping on the screen. Bad guy #2 said, “What are you doing?” Bad guy #1 replied, “I’m sending a text message.” Bad guy #1 was nonplussed. And, that wasn’t so long ago. Today, the average teenager sends 1500 text messages per day.

We’ve also made tremendous progress in many aspects of medical technology, particularly in drugs, medical devices, and diagnostics. And, by and large, we’ve made that progress in the face of a hostile and tectonically slow regulatory environment. We have whole new classes of targeted cancer drugs that have made it possible to live many years with what were once quickly fatal forms of the disease. We have new tools and methods for minimally invasive surgeries that have turned what were once life-threatening procedures accompanied by 10 days in the hospital into outpatient procedures with little risk. We have life-saving diagnostic procedures like the colonoscopy, which has made colorectal cancer far more treatable when it is caught early. (Quick diversion: to all my friends over or near 50 (or 40 with any family history), if you haven’t had a colonoscopy, I beg you to go get one. Yes, the prep the night before will make you want to kill yourself, but the propofol is fun (ask Michael Jackson) and it will save your life if you have precancerous lesions.)

All this technology innovation has dramatically improved healthcare, but it has done little to control costs and has, arguably, increased costs in some areas. I say “arguably” because I have not seen a comprehensive study of this issue and I think it would be hard to conduct. There’s no doubt that certain technologies (e.g., expensive imaging technologies that get overused) increase costs, but it is also true that many technologies dramatically decrease costs. The most expensive part of our healthcare system is paying for long hospital stays. Drugs (which account for only about 12.5% of overall costs – a good number to keep in mind when Obama is villifying the big pharma companies) that keep patients out of hospitals are very cost-effective. But, I’m willing to stipulate that technology has probably been, at best, cost neutral to healthcare.

The kind of technology innovation I’m thinking about is more on the delivery side of healthcare. We have done a very poor job of integrating all the phenomenal advances in information technology with healthcare. I actually find it pathetic that 90% of the discussion around “healthcare IT” involves electronic medical records. I mean, c’mon! No matter what airport I’m in, anywhere in the world, I can give American Airlines a 3 letter, 4 digit code (my frequent flyer number) and they can immediately pull up my entire flying history with American. But, if I go to visit my own doctor, who has been my doctor for 15 years, he pulls out a big paper file and flips through pages of handwritten reports. And, worse, when I went to a specialist recently, literally in the same medical office building as my primary care doc, he had none of that information. So, I understand we need to get the electronic medical records piece done, but it seems like little more than the price of admission.

We need to move very quickly to leveraging technology for far more innovative delivery of healthcare. In my blog post that laid out the issues with healthcare, I wrote of the adverse incentives in the payment system that encourage patients to visit doctors simply because someone else is paying for it. I also questioned a system whereby “routine maintenance,” akin to an oil change for your car, is paid for by a third party “insurer.” That’s expensive, inefficient, and totally devoid of the market forces that discipline most other markets. I gave the example of taking a kid to the doctor for an ear infection and having insurance pay for it. Let’s stick with the ear infection example for a moment. One of my kids had chronic ear infections as a toddler. Every time he got a cold, within a few days, he was tugging on one or both of his ears. We knew we had to take him into the doc, who looked into his ears with one of those little scopes that have been around since I was a kid, and said, “yup, he has another ear infection.” She would prescribe an antibiotic, which my son would take for the prescribed number of days and the infection resolved.

Question: was it really necessary to go to the doctor every time this happened? That’s a very expensive way to deliver a very simple service. Not only did we take up a 15 min appointment slot, but we used some portion of overhead for the office space, the receptionist, the nurse, etc. And, that doesn’t take into account the lost economic productivity of my wife and me (we were first time parents so we often both went with him) having to take time off work to take him to the pediatrician. On one of these visits, I asked the doc if she could just show me what to look for when she peeks in his ears so maybe we could buy a scope, do that at home to confirm the infection, and have her call in a script. She looked at me like I had just asked her to saw off one of my legs.

But, this idea stuck with me and we’ve had 17 years of technology advancement since my son was little.  So envision this: A two year old with a cold starts tugging on his ears. The parent takes a fully idiot-proof ear scope and puts the tip into the ear canal. The scope is connected to a high resolution video system (which most of us now have on our phones) that records what’s going on in the child’s ear. The parent takes the child’s temperature, blood pressure, and whatever other routine stuff the nurse usually jots down, and enters it, along with a brief description of other symptoms (just as the parent would in the pediatrician’s office). The video and other information is transmitted electronically in real time to the doctor. During a predetermined window of time, which, by the way, could be in the evening or on a weekend, the doctor will review the information, including the HD video of the ear and reply to the parent with a diagnosis and action (e.g., script for antibiotic). The doctor will have the ability to interact on-line or by phone with the parent for follow up questions. But, the doctor may well be conducting this “office visit” sitting in his home office… Bangalore. Very low overhead. Yes, I’m serious.

I probably have doctors all over the country (the thousands that read my blog) gasping for breath right now. I’m sure there’s a “look and feel” to a patient that can’t be fully transmitted using technology and might be lost. But, I’m willing to bet that a whole lot of office visits could be avoided with technology. I actually have a small window into this because I have a good friend who’s a doctor and I have sent him text messages with questions in the past, to which he has responded. Had I not had access to his texts, I would have had to set up a visit. And, without giving you TMI, I was texting about a potentially serious condition. His answer said, in essence, “this is not serious, don’t worry about it.” I get to do this because I’m lucky enough to have a friend who’s a doctor. Why shouldn’t everyone have such access to their physician? I understand that we would have to figure out ways to compensate docs for this type of service, but that’s where the innovation comes in and where government could actually help rather than mess things up with more syrup on crappy pancakes.

I want to use one more example that takes it up a notch. One of the leading causes of death and, thus, one of the highest costs to our healthcare system is heart disease. One form of heart disease is congestive heart failure. Patients with chronic congestive heart failure frequently have acute exacerbations of their ailment and end up in the hospital, often in the ICU for several days. That is a big cost to the healthcare system. Several technologies have been developed that are small implantable devices (think pacemaker) that detect these acute flare-ups before the patient feels the symptoms. This information can then be transmitted electronically to the physician, who can quickly alter the patient’s medication to avert the acute episode and, hence, the hospitalization.

This technology exists today – I’m not talking about some theoretical idea. So, why doesn’t every patient with CHF have one of these implanted? The principle issue is reimbursement. Our healthcare reimbursement system is designed to pay doctors and hospitals for treating sick people. It’s not well-designed for keeping people healthy and out of the hospital. In the arcane language of healthcare reimbursement, there is no “CPT code” to get paid for implanting such a device nor, more important, for the ongoing monitoring of the patient waiting for the next acute episode to be avoided. That’s really bass-akwards.

The good news is that this actually highlights an area where the government can get involved to improve our system. Many CHF patients are older and thus covered under Medicare, the government run payment system for older patients. To get a new technology like this covered by Medicare today would take longer than the expected life span of every CHF patient alive today. Meanwhile, the meter keeps running on the costs of unnecessary hospitalizations of CHF patients. If our government wants to help, how about developing an expedited review system to ensure quick reimbursement of new technologies that can take costs out of the system. And, to my friends in government (if I have any), “expedited” means “get it done in 3-6 months,” not “form an interagency task force that will convene quarterly over the next fiscal year and make a recommendation to the CMS for consideration.”

We need to shift US healthcare away from the model of paying to treat sick patients toward keeping patients healthy and out of the most expensive parts of the healthcare system. Technology can play a big role there, but technology will never see the light of day until the payment schema are matched to the way the technology is used. Sadly, Obamacare is all about sticking it to the providers of novel technology (see: Medical Device tax). That’s all about politics – villifying corporate America is one of the chief Obamian campaign themes. Unfortunately, he missed a big opportunity to work with these companies to figure out ways to develop and pay for technologies that will save costs and help patients.

About Bruce Robertson

Bruce Robertson is an amateur writer and professional provocateur
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8 Responses to Healthcare Solutions, Part I (no promise there will ever be a Part II)

  1. Marc Rothman says:


    Another very intuitive post. I enjoy reading them. Just a small point in trying to compare the Airlines with a Doctors office. Doctors tend to be small business men and women. The investment for them to install an EMR system in their offices is a huge part of their overhead, and often prohibitive, relative to the scale of a publicly traded company like an airline. I know many offices who are now implementing these systems into their offices at great cost and having to take out huge business loans to do so. It is economically a painful thing for them to do.

    I do agree with you that in the focus on cost cutting, what is lost is the resolve to invest in technologies and other methods that can lead to greater health and potentially lower costs.


    • Dr. Rothman – many thanks for the kind words and the insightful comment. Yeah, I understand that EMR is a big investment for a small doc’s office. It seems that perhaps the trend is away from small practices that don’t have scale toward consolidation into larger practice groups for whom the payback on investment is faster. I am observing a trend toward hospitals beginning to buy up (or economically partner with) physician practices as well. It will be very interesting to see how that plays out. I’m curious if you’re seeing that in your sub-specialty?

  2. I am alarmed to find myself agreeing with a lot of what you write in this post and your previous cardboard-with-maple-syrup post.

    The medical business has become quite strange. I have a friend who is a violinist, and she is married to a radiologist. I always figured she was on Easy Street, but she is now the major bread-winner in the family. His radiology group employs four full-time staff whose only work is dealing with insurance companies. He loses $45 for every Medicare mammogram he performs.

    Last time I saw my doctor, the phone rang during my appointment. He said he had to take this call from the insurance company, and I listened in as he argued with them. His end of the conversation went something like this (all technical terms are made up): “She came in with fatigue, nausea, flushed skin and blabutia. Those are the symptoms of schmigitis [pause]. When you have schmigitis, you have fatigue, nausea, flushed skin and blabutia. That’s what she had, so the diagnosis is schmigitis [pause]. But those are the exact symptoms of schmigitis, so I can’t diagnose anything else [pause]. She has schmigitis because of the symptoms she has [pause]. Her policy covers medications for schmigitis and that is what she has [pause]. No, she has schmigitis …” etc. Now, I don’t have a medical degree nor the first understanding of anything biological, but when you have a doctor presenting clear evidence that symptoms x, y and z mean diagnosis q, and the insurance company wanting a different diagnosis so as not to have to cover medication costs, you have a big problem.

    The business of medicine is not working. Your comments about the ear infection are right on. Another example: you have a horrible cough (this happens in my family a lot). It came at the end of a cold, right where it is supposed to come. Now you are coughing because your throat is all scratched up, and it is all scratched up because 2 minutes ago you had a coughing fit. So now you are coughing, which will cause more coughing 90 seconds from now. You go to the doctor to get a prescription for something like bourbon in pill form. The doctor has to work you in, making everybody’s appointment late. He spends 10 minutes checking you out. He sticks a tube up your nose, around the bend and down your throat (he bills the insurance company $210 for this and gets $140 – the procedure took him 2 minutes). In the end, he prescribes something like bourbon in pill form. If this happens in New York City (are you getting the sense that this is a true story?), then you the patient have spent 45 minutes getting to the doctor’s office, $40 to park the car, 35 minutes waiting to see the doctor, another 45 minutes getting home, plus some tolls and gas. He has seen you for 15 minutes and is now a solid hour behind schedule. He has an office in one of the most expensive parts of New York (who would go to a doctor in Queens, after all?), and his equipment costs him a fortune. He has to send high bills to the insurance company because they low-ball the reimbursements.

    I think we are dealing with two issues here. One is insurance companies, the other is law suits. I’ll flesh it out. Feel free to skip to a more interesting website.
    Anyway, the insurance companies make money when you pay your premium. They lose money when they pay for your care. I know you, Bruce, have a lot of faith in free enterprise, but many insurance companies turn down very reasonable claims. You have to fight to get them to cover stuff, as in the case of my story two paragraphs up. Now it may be that society actually benefits from this, in the following way. When your insurance company denies your claim, they end up with higher profitability. The more claims they deny, the more profit they make. Investors reap the benefits of that profit – it pays for the retirement of our citizens. That, however, gives you no benefit with your medical issue now.

    As for law suits, the reason your doctor can’t just send you a prescription based on a phone conversation is that, if your kid doesn’t have an ear infection but actually a brain infection causing ear irritation, and you have the wrong medicine, you will sue your doctor’s ass and win a huge settlement. This also leads to spiraling medical costs, since your doctor maintains a truly gigantic malpractice insurance policy that costs him a fortune. Many obgyns are no longer doing the ob part of the job – the insurance is just too expensive.

    You and I agree that this is a huge mess. If you are the president, you have to ask yourself how to fix it. You see that insurance companies are not making life easy for the patient, but you do believe in “free markets.” Perhaps in your heart (not yours, I know) you would like to see a single payer system, which, from all I hear, works great in Canada and in France (granted both are much smaller countries than ours). You know that will never get through the Senate. You know there are people in the Senate who think if you just deregulate the entire system, the market will correct any problems. Insurance companies will emerge that are fair and offer good value to consumers; those companies will survive, while others will die. Of course, during the course of that happening, many people will be screwed. You fear (rightly) such volatility. If you are a Democratic president, you are pretty sure the other party will oppose any idea you put forth. You need a grand compromise, at least as a beginning. Something that can pass, that begins to address the issues, that opens the way.

    What do you get? You get cardboard pancakes with syrup. You hope that eventually the pancake recipe will get fixed. Once you’ve got your pancakes, people will start demanding baking soda. After a few years, even the Tea Party will have to support baking soda.

    Will this happen? I doubt it. The system is too messed up. It’s hard to be optimistic about the country right now.

  3. Debbie Phelan says:


    I love your articles. My friend Bonnie passes them on to me. You are so right in so many things you say. I just have some short comments. Medicine isn’t always practiced the same in every part of the country. I lived most of my life in D.C. If I had a problem, I called my PCP or specialist (who I will say both knew me for at least 5 years and we have a great patient-doctor relationship), if I had a problem, they would come to the phone, question me, and 8 times out of 10, no reason to go to the office. When I got my test results, the docs called me and talked to me about them — no need to schedule an appt. and meet with the dr. to get the results as so many do. If I had a problem with the insurance company not wanting to pay for the meds my drs. thought I needed (instead of the cheaper meds the insurance company preferred), my drs. would pick up the phone, call the insurance company and talk with them and send them any doctors’ notes needed so I would get the proper meds.

    If I had a problem and was “freaked out,” like you, I’d just call my docs at home (even though they aren’t my good personal friends, they are my “friend” and advocate). Not a problem — especially because I didn’t abuse it.

    My drs. are great diagnosticians. If I had a problem, they’d take as long as I needed to explain what they thought was going on and what my otpions were — even if it meant taking 30-45 minutes with me and running behind. In the end, I made the final decision with my dr. about what course of treatment I wanted and if I thought it was REALLY NECESSARY for further medical tests. Likewise, when I went to my dr., if he or she was running behind, I didn’t mind waiting because I knew they would take their time with me.

    Believe it or not, medicine is practiced efficiently in D.C and you have the best medical care available to you.

    I moved to Pittsburgh 3-l/2 years ago (the land of the giant UPMC – University of Pittsburgh Medical Center). WHAT A NIGHTMARE! It’s like having the Federal Govt. running your healthcare. Drs. up here try to order tons of unnecessary tests, CT scans, etc., for the slightest problem. I end up calling my drs. in D.C., talking to them and we decide what to do. Medicine is practiced (for the most part — not with all drs.) like socialized medicine up here. UPMC has electronic medical records — unlike D.C. I’ve NEVER gone to one of the UPMC drs. where my records were accurate. It must take them 8 or 9 months to update what I tell them when I see them (they type in your information at each visit into the giant all-knowing UPMC database). I’ve had a preview of what socialized medicine will be — and it scares me to death. I don’t see the drs. that often, but if I really have an issue, I make a trip to D.C. to see doctors who know how to practice medicine, but now the gas is getting so high, how long can one keep doing that?

    One example: Got my yearly mammogram. One radiologist said I had “calcification clusters” — every woman knows that could very well be a sign of breast cancer. I paid to get a 2d opinion. That radiologist told me, “Your case is not clear. It COULD be classified as calcification clusters or I could classify it as simple calcifications. I’m going to say it’s simple calcifications.” Bruce, I’m sure you’re guessing what I did next. I called my PCP in D.C. He told me to bring the films to him and he’d have the top D.C. radiologists look at them for me. He did. Everything is fine. I can’t tell you how much I miss the service of health care I received all of my life in D.C. It will never be the same again, and if Obamacare is upheld, GOD HELP US! We won’t be living long lives like my 100-year old Grandmother did!

    When I first moved here, I made several appointments to “interview” new doctors. You’ve got to have a doctor where you live, and you don’t want to be looking for one WHEN you get sick. I went to about 6 PCPs — what a nightmare. They insisted I get a physical, didn’t understand why I was there to meet with them to possibly establish as a new patient, and I could go on and on. I finally found a PCP after 3 years that I think I can partner with in my healthcare, You get the picture. It’s a nightmare!

    I’d love to see you or anyone do an article about the Medical Information Bureau (MIB Group). What a SHOCK it was to me when my husband lost his medical insurance, and we had to apply for single payer health insurance policies in January. That’s how I found out about the MIB Group and all of the information they’ve been gathering on us for years. They’ve been in business for over 105 years. Even though I had worked for doctors — and some of my friends are doctors — I and they had never heard of them. Here are some links:

    Lastly, for anyone who has not had to look for a single payer health insurance policy since the POTUS signed Obamacare info effect, you have NO IDEA what one has to go through to get insurance. The press put out the benefits since Obamacare has been passed and how you cannot be denied health insurance, etc., is BS! Sure, you can get insurance, but if you are not healthy (or if your state doesn’t have a policy for people with pre-existing conditions), you are going to be paying through the roof — I’m talking $850 a month just for the premiums with a $5,000 deductible before they pay for anything except the yearly “well visits.” And that is for one person who is healthy. (I went through this so I know.)

    Keep on writing! I love to read anything you have to say!


  4. rodneynorth says:

    Wow – there’s a whole lot of writing here. I’ll have to read it tomorrow on my long flight to the W. Coast. In the meantime, here is a little something that might relate somehow (even if it is from the NY Times – not your favorite news source).
    It’s about America’s obesity problem (something you’ve touched on before), which, of course, is expanding our health care costs, and diminishing our quality of life, at a scary rate. More specifically it is about why it will always be very hard to defeat obesity.

  5. Terri Robertson says:

    You may disagree, but if we really need to look more at prevention, then we need to read the article Rodney mentions and others like it very carefully and look at the industrialized food system in the US and change it.

  6. Debbie Phelan says:

    Frank Bruni may be right in his article that you posted Rodney. Thanks! But I invite anyone to come and visit me in the Pittsburgh area. I moved back here after a 35-year career in D.C. The drs. up here tell me this is the Obesity Capital of the U.S. — especially Butler County, PA. I myself have never seen so many people weighing in at 250 to 300 lbs. in my estimation. People’s eating habits — and the restaurant choices — are atrocious here! I’ll give you one example: The Pittsburghers put fries on everything. French fries on sandwiches, on salads — you name it. They have the more unhealthy eating habits here compared to any other city I’ve ever visited or lived in. Some of the problem is people just can’t seem to make healthy lifestyle choices. I’ve never seen anything like it! And, yes, I have seen how the food system in the U.S. has changed since I was a kid. NOT GOOD AT ALL! Salt and sugar is added to everything. UGH!

  7. Pingback: Obama’s Failures….And There are Many | Bruce's Blog (til I come up with a catchier name)

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