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Friday, July 23, 2010

Barriers to multidisciplinary clinics and care

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.


  1. Chauncey McHargue M.D.July 23, 2010 at 5:21 PM

    Yes but I'm sure that if the government had poured billions of dollars into Kodak they would have developed digital photography, and similarly Cray with government support would have given us computers and other digital devices as good as Apple. And your last example is flatly contradicted by the fact that the government is underwriting GM to the extent that they virtually own the company and in particular is pouring billions into development of innovative small cars like the GM's Chevy Volt that goes 40 miles on a single overnight charge and only costs less than $50,000.

  2. I was not arguing that the Feds will make good investments leading to innovation. They will invest in companies that are incapable of true disruptive innovation. Read "Billion Dollar Lessons" by Paul Carroll.

  3. Chauncey McHargue M.D.July 26, 2010 at 1:20 PM

    MC—I was reinforcing your theme and making the same point sarcastically. Although when it comes to government programs ethanol in gasoline seems like a good idea notwithstanding a few minor criticisms of the program on today's WSJ editorial page. (Never take my comments at face value.) Thanks for the addition to my reading list though. And speaking of the WSJ, James Taranto stole your Underpants Gnome analogy in one of his columns last week, though come to think of it maybe that represents a fundamental underlying principle of state run economic ventures.

  4. Chauncey McHargue M.D.July 26, 2010 at 2:04 PM

    Oh, and incidentally, as part of my living will I have a provision to the effect that if I ever buy a Chevy Volt I am to be considered brain dead and active euthanasia is to be instituted forthwith.