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Sunday, August 26, 2012

Who is team leader? Where are the codes for the medical general contractor?

I have been mulling over writing this blog piece for well over a month, never having it quite crystallize. I read a piece in one of my favorite blogs, The Incidental Economist today which served to prompt me to put fingers to keyboard...(http://theincidentaleconomist.com/wordpress/another-hospital-stay-and-whats-not-being-discussed-in-a-polarized-health-policy-debate/).

I live and function in this dysfunctional world. There are lots of very smart and caring people but smart and caring does not trump bad process and bad incentives.  The individual problems associated with care of specific patients are often very complex, but the shared problems across many patients are remarkably simple. We have moved to a team based approach to care, particularly in patients with complex and chronic problems, but there is no team leader. This is evident with nearly 100% of the patients I see. All new patients who I evaluate I ask, "Who is in charge?" The answer is invariably, "I don't know."

Sometimes a particularly assertive physician will assume this role but this is the exception rather than the rule. In the inpatient setting, the move toward hospitalists has created a very short term outlook when it comes to management of patients. They head a team of providers whose job is to get the patient discharged as soon as possible. Don't get me wrong. Many of my hospitalist colleagues are wonderful physicians and if placed within a system which gave them the tools and incentives to consistently do more and extend their impact beyond the hospital stay, they would do so.

Some efforts are being made to do just that in order to avoid readmissions. It is in this realm that these efforts are running into the fundamental problem. Even if the hospital coordination and team creation issue is addressed, when a patient is discharged there is no consistent hand off infrastructure present which leads to a soft landing. When sick patients leave the hospital, who is in charge, what resources do they have at their disposal to address the problems they face, and how well prepared are they to address the problems they will face?

Even without hospitalizations, distributed management of multiple problems facing patients is an iffy proposition at best. We can view various roles in the care of an individual patient much like the roles played by various subcontractors when a building project is undertaken. In order to build a house you need carpenters, plumbers, electricians, roofers, heating air specialists, architects, landscapers, and engineers (and I could go on and on). While some people are ambitious enough to take on functioning as their own general contractors, most of us are willing to pay to delegate that responsibility to someone who we trust will coordinate the activities of all of these subcontractors and look out for your interests. It can and should be money well spent.

We face a similar situation in medicine with instead of plumbers and electricians, we have urologists and neurologists and we have one other major difference. We do not have medical general contractors. Perhaps at one point general internists, family practitioners, and pediatrician filled these roles, but as a rule they do not anymore. As we have moved to more specialization and complexity, we have become more silo'd and fragmented. We are trying to undertake major building and renovation projects with our bodies without the benefit having someone who knows what they are doing in charge. Better information systems and communication are necessary but they are not sufficient. A leader need to be charged with synthesizing the information and addressing the big picture with individual patients.

In almost any other realm of the economy this niche would have been filled with resourceful individuals who see a need and create a service to fill that need. However, in health care the payment system created barriers to responding to this need. First, insurance created the impression that health care services were covered and patients assumed that when they became sick, these sort of services were available through their regular providers. Second, those in the best position to provide these sort of coordination services are ones who have undergone extensive medical training. They have had little incentive to take risks and provide services which are not covered by insurance. Finally, the issues with the present state are even more nuanced since patients assume that this sort of service is already built into the health care system and doctors are reticent to explicitly admit they do not consistently provide them. I suspect that many physicians are reticent to admit this to themselves. 

The concierge movement is addressing at least some of these concerns. It is a recognition that certain physician activities (and perhaps this should not be limited to doctors) are not compensated by traditional insurance and like other non-insured activities such as cosmetic surgery, providers should be able to seek payment directly from patients. This concept generates strong opinions with accusations that seeking such fees is immoral. I have a hard time seeing the logic. Patients need professionals who function as leaders of the teams who manage their medical problems. To create a world where those individuals don't exist is to guarantee that patients will be left holding the bag.

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