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Thursday, September 16, 2010

Rethinking multidisciplinary care

I attended a conference whose sole purpose was to bring together experts with experience in running multidisciplinary clinics. None of my previously conceived notions were altered much. There was a very sobering introduction which highlighted two themes. The first was the accountable care organization concept. What we are facing is the construction of totally new models of care which are to be created based upon top down mandates by organizations poorly equipped to assess how they are doing. The second theme was that the growth in health care spending was simply not sustainable meaning that the ACO construction will need to happen in a world of serious cost constraints.

There was lots of discussion, actually very interesting discussion, but there was a serious disconnect. The consensus was that multidisciplinary care was better for patients but the only way to get it was to spend more, not less money. There were many participants who described their own experience with such clinics, and although there were exceptions, most of these models involved having multiple physicians engaged simultaneously. After the conference, I started to run the math. What would it take in terms of  revenue to simply cover the cost of simply the doctors in the room? For circumstances described where there were three specialists in the room at once, let's make a few simple assumptions. The average specialist salary can be conservatively estimated at $200K/year. Assuming they spend 40 hours/week in direct patient care and 50 weeks of work (likely an overestimate), this amounts to 2000 hours. This means to simply cover their salary you need $100/hr per specialist. For the typical institution, the overhead rate is at least 60% and likely closer to 70%. This means the MD costs of $300/hr will require collections of almost $1000/hr. The overhead may be even higher since there may be particular support needs for these clinics.

Irrespective of whether insurers should or could cover these costs, you need to ask the question, can we accomplish the same outcomes using a much less expensive approach. What other activities require the simultaneous activities of multiple six figure professionals delivery service to people, one at a time? It would be nice if we could all hire the equivalent of Michelangelo to paint our living room but most of us settle for the local contractor who might hire a few undocumented workers to save a few bucks.

Virtually all industries have seen tremendous gains in productivity since WWII and in each of these cases the gains have been made by the use of automation and movement away from manual and people dependent processes. One major exception is health care. Within health care we only partly aware of the spiraling costs but because of how our individual incentives are structured, our individual financial gains are directly linked to how much of the insurer's and patient's money we can spend. Our productivity is measured by how much we generate in billings and collections. It is the only way we can keep such an inefficient system solvent.

Getting back to multidisciplinary care, my question is what can multidisciplinary clinics deliver which is not delivered in our present model? One obvious answer is better communication and coordination of care. However, at what cost is it to use the most expensive people in your system in this way?

 I am sure that MacDonald's could hire and pay for Le Cordon Bleu trained chefs to flip burgers and it might improve their food. Geek Squad could hire nothing but MIT PhD's s to repair computers and they would likely raise their quality parameters to some degree.  If we had fast food and appliance insurance, we might end up with these HR placements but that is not the case in the current world. The party line is health care is different and at an emotional level one can easily make this case. At an economic level this is not he case. If we keep up our present course of action we will go broke.

We can create a system with coordinated multidisciplinary care of complicated disease but we cannot design this around such an inefficient use of such valuable resources. We need to identify where physician expertise actually makes a difference and distinguish these tasks from tasks that be be delegated to people who require less training or to machines. In the former category, other industries which were previously reliant upon rare talent who used intuitive decisions making skills to create unique products or services, make huge productivity gains when they could develop rules based processes to replace intuition. DuPont at one point in time had a virtual monopoly on synthetic fiber development business since they basically employed all of the talent who had the skills to develop new fibers using an intuitive approach. The development of better understanding of 3D chemical structure, powerful desktop computers, and software which allowed for modeling at modest cost  put the tools to develop new fibers in the hands of a vastly broader group. It was not necessarily good news for the highly paid chemists but it was good news for those who benefits from the availability of an abundant variety of inexpensive synthetic fibers.

People are expensive and industries such as the auto industry have replaced expensive people with machines which are in fact better suited to do particular tasks. In health care machines such as computers might be ideal for data collection and tracking, flexible learning and testing, and decision support tools.  If we are to carry out the mandate to improve care while saving money, we will need to borrow heavily from other industries which have made large productivity gains. We have no choice but automate and delegate.

You might ask about the human element to health care. It may sound like the future I paint sounds bleakly sterile and devoid of human interaction. It may move in that direction but I suspect we will be pleasantly surprised. Automation of other industries freed up people to do tasks they were better suited for. In the case of health care, I suspect delegation and automation will free up time for valuable problem solvers to spend their time actually solving problems and communicating with patients and other members of the health care team. True multidisciplinary care will happen much more readily when the individual costs are not so prohibitively expensive that the primary focus of the care giving team is to figure out how they can support themselves and not their patients.


  1. Chauncey McHargue M.D.September 18, 2010 at 12:06 AM

    Multidisciplinary health teams also suffer from fundamental management problems in a field where individual judgment and responsibility have always been paramount and will always be necessary. Teams of any sort first and foremost have to have a leader both for direction and accountability and so no matter how much of a cooperative approach is anticipated under this proposed paradigm there will still be one individual who is responsible for authorizing the execution of care plans. In one sense then the multidisciplinary approach is no different than the present system of a primary service and contributing consultants except that we put them all in a room together at the same time. It does however entail significant risks where the formal stipulation of a team leader who lacks in leadership qualities results in a diffusion of responsibility with concomitant chaotic management or an autocratic management style that results in a dysfunctional team dynamic. A similar dysfunctional situation results when the team players are not team players and medicine is a field in which individual ability and judgment and a heightened sense of personal responsibility are essential characteristics for its practice. With a diffusion of responsibility weak or lazy physicians can coast and not be fully committed to the team; arrogant and insecure physicians will engage in disruptive or self-protective behavior; and competent physicians faced with such dysfunctional dynamics with find ways to withdraw. Teams must first function as teams and only leadership can generate and maintain teamwork. Leadership of this type, which the military best exemplifies, is something an institution must select and train individuals for right along with acquisition of other professional skills and do so from the outset of their entrance into a profession. There would need to be sea change in medicine from the admissions process onward to acquire and train leaders to implement an efficient and effective multidisciplinary approach as envisioned. I do not believe this is either possible or necessary. Good cooperative relations between various specialists accomplish the same thing without geographic localization and enforced time commitments. These relationships come about naturally as physicians select out who they find most capable and accommodating to their practice perspectives and style. And in my experience rarely is there ever a true need for a collective meeting of multiple specialists in the clinic or at the bedside to examine and treat a patient. Many of the present day multidisciplinary clinics are more marketing than medical management providing only an illusion of higher intellectual effort. Unfortunately this illusion has great appeal in certain elite circles in and outside of medicine, with no consideration to the cost considerations mentioned above.

  2. One benefit to the patient or a "multidisciplinary team" is convenience. The patient gets to see all the "experts" related to his or her care at once. This is often a "selling point" used by such clinics to attract patients.

    But like the improved communication among providers that the MC discussed, this benefit is likely not worth the added cost.