There is a developing consensus that the products available in the current health care market are woefully inadequate when it comes to delivering integrated care. There are no shortage of policy wonks who weigh in in the subject and substantial revenues are slated to be deployed in the health care reform act for demonstration projects attempting to develop new products.
I do not think I am in a position to predict what will come as a product of all these effort, whether it will be better than what we have, or even whether we will be able to measure anything meaningful that will tell us unambiguously that it is better or worse. I know we will get spin and lots of it. I do have the benefit of being able to look back at the past and see what I think are the biggest mistakes in terms of creation of the wrong incentives.
Let me set the stage by asking a very basic question. Why such a focus on multidisciplinary endeavors? What is missing presently that will improve if we use a multidisciplinary approach? What is a multidisciplinary approach? I would argue that we have such a multidisciplinary approach now. Most patients I see with one or more chronic problems have many physicians caring for them. It is simply not a thoughtful and coordinated multidisciplinary approach. What we are missing is thinking, reflection, and the communication required for optimal problem solving.
This is a consequence of a payment system which values reflection, judgment, communication, and coordination of care at zero. Health insurers do not want to pay for duplicative services and it makes sense that they not pay for more than one colonscopy or CAT scan. However, this is extended to E&M services which is where the multidisciplinary will thrive or fail. What is the consequence of refusing to pay for more than one service for thinking, reflection, and coordination? When the team cannot be financially rewarded for functioning as a team, the life expectancy of the team is likely to be very short.
The question then becomes, how do create a system which has financial rewards for the very things we say we value? I am not sure how this will be accomplished but I can be pretty sure how it will not be accomplished. It will not be accomplished by continuing to use our present administratively set pricing and service definition structure. It will also not likely be solved using the structure of demonstration projects done within health care entities which are constrained by regulatory straight jackets and have a vested interest in maintaining the status quo. True innovation will disrupt what we have now and will come from entities who have not made huge capital investments in infrastructure best exploited using the old rules. Digital photography did not come from Kodak. Desk top computing did not come from Cray. Innovative small cars did not come from GM.