Commoditizing medicine

About five years ago I heard a fascinating talk by Harvard Business School Professor Clay Christensen that applied his well-know “innovator’s dilemma” reasoning to health care. In a nutshell the idea was that tertiary care centers should keep pushing the envelope on complex diagnoses and treatments and that over time diagnoses (though maybe not treatments) that had initially been considered complex and challenging should be systematized and therefore able to be carried out in less expensive settings by less expensive staff. The progression would go from academic medical center to community hospital to doctor’s office to retail clinic.

Clay was interviewed recently by the New York Times where he covered this ground again –lamenting the lack of progress- and also gave a clue as to why there is a shortage of convenient, low-cost diagnostic settings in Massachusetts.

We haven’t moved the health care profession into a world where nurses can provide diagnosis and care. Regulation is keeping the treatment in expensive hospitals when in fact much lower cost-delivery models are available…

In Massachusetts, nurses cannot write prescriptions. But in Minnesota, nurse practitioners can. So there has emerged in Minnesota a clinic called the MinuteClinic. These clinics operate in Target stores and CVS drugstores. They are staffed only by nurse practitioners. There’s a big sign on the door that says, “We treat these 16 rules-based disorders.” They include strep throat, pink eye, urinary tract infection, earaches and sinus infections.

These are things for which very unambiguous, “go, no-go” tests exist. You’re in and out in 15 minutes or it’s free, and it’s a $39 flat fee. These things are just booming because high-quality health care at that level is defined by convenience and accessibility. That’s a commoditization of the expertise. To have those same disorders treated in Massachusetts, you’ve got to go to a regular doctor, go through a long wait in their office, you go in and see the doctor for two minutes. He says, “You have an earache,” which you knew already, and then they charge you $150.

The whole interview is worth a read if you have the time.

January 11, 2007

11 thoughts on “Commoditizing medicine”

  1. I’m all for making health care cheaper and easier but seriously, does he think it can be all be simplified down to the point that nurses (untrained in dx) could dx cancer/mi/etc etc. My wife is a nurse and she’ll be the first to say that the avg nurse doesn’t have the know-how to write prescriptions. It takes a lot of training to be able to dx and prescribe medicine . . .like 4 years of med school (hint hint). Why stop at nurses, lets simplify medicine so that CNAs can manage the ICU. Better yet, we’ll make it a volunteer service like small town EMS. yeah, thats the solution.

  2. I am assuming that David is referring to Nurse Practitioners as that is who runs minute clinics. And I have heard they are not “booming” at all and many close shorty after opening. The problem is that an ear ache often does not equal an ear infection. And urinary frequency often does not equal a urinary tract infection. An NP with their equivalent of 12 weeks of clinical training does not have the knowledge base to know what comes next. So now the person is out the $39, the cost of an ABT they didn’t need and back to their PMD for further evaluation. Many, many things in the complex human being do not follow programed decision trees or people could treat themselves using a computer and skip the doctor and the NP.

  3. Clay is lamenting that medicine has not been able to systematize knowledge to make dx doable by non-physicians. On the other hand he seems to be assuming that MinuteClinic and the like have actually been able to make it happen. There’s a bit of a contradiction there.

    My own experience with NPs hasn’t been great. If I’m going to seek medical care I’d rather do so from an expert (or more than one), even for something that seems simple.

    On the other hand I do think a less well-trained person with a proper decision support tool could be quite effective.

  4. Not only are we out additional costs in Mad Hatter’s example, but we’ve also prescribed another useless antibiotic.

    I started typing thinking that I could make an argument for a mixed system, but that’s essentially what we have already: one doctor who sees you for

  5. NPs write prescriptions in MA. I’ve worked with some excellent ones, that do exactly the same work I did. I’ve worked with some lousy NPs too. I’ve also worked with lousy docs.

    best,

    Flea

  6. So Clay is contradicting himself. But the reason Medicine can not be turned into a logical decision tree is the same reason that it is an Art and not a Science. It is rarely that simple. There is a lot of Gestalt involved with making medical decisions.

    And Flea, I agree there are some excellent NPs but they are probably excellent because they were nurses for 20 years first and have a lot of clinical experience and common sense.

    Oh, and as far as a doctor getting paid $150 for a kid with an earache? Where? I’m moving there. Part of the reason doctors fees are higher than the Minute Clinics is that we are not being supported by CVS and we have to jump through so many hoops to get paid at all. Have to pay extra staff and that increases overhead increasing the price of the visit.

  7. Not only are we out additional costs in Mad Hatter’s example, but we’ve also prescribed another useless antibiotic.

    I started typing thinking that I could make an argument for a mixed system, but that’s essentially what we have already: one doctor who sees you for 5 minutes and twenty nurses who handle most everything but the paperwork.

    It’s unfortunate that the way it seems possible to cut costs is via somewhat drastic measures.

    (this was somewhat cut off the first time I tried to post this; I suppose that’s fates way of telling me I shouldn’t be posting comments from work. Thank you, David, for emailing me!)

  8. jps made a good point about the style of medicine where you get 3-5 minutes with the doctor and clinical staff handles the rest as the doctor tries to see 6-8 patients/ hour to try to make a decent wage.

    But there is a “new” style of practice reemerging where the doctor is working with minimal staff and spending more time with the patient taking care of all the needs at the time of the office visit instead of just the sore throat they came in with. This is the most cost effective style of medicine. The problem is that it takes longer for everyone, no 5 minute quickie; but worse, doctors have trouble getting paid for this style anymore than if they just treated the sore throat despite taking much more time and dealing with many other issues. The fees all get “bundled” together.

  9. About 60 years ago, nurses were not allowed to give injections (only the expert physicians could)! Now mid-level providers (NP’s and PA’s) are administering complex anesthesia, suturing wounds, and treating complex neurological conditions in hospital settings. I am a Nurse Practitioner and when I worked in a pediatricians office I was admitting patients to the hospital. Granted there was always physician supervision available, but I was doing THEIR job. And getting paid crapola for it, to boot.

    Now I work in a convenient care clinic. I have a limited scope of practice and verifiable evidence-based guidelines for diagnosis and treatment. My job is boring, but I get paid well and the public’s response to what I do, for the price they pay has been overwhelmingly positive.

    I probably have prescribed antibiotics for middle ear effusions, but what does the research say about physicians doing the same???????

    It seems to me, that if you were a physician you would be pleased with the move of mid-levels to retail clinical settings. Our scope of practice is severely limited, much more so than when we worked for docs in their offices or in hospital settings. And when a patient presents to us with conditions that are beyond what our company defines as our scope of practice, we MUST refer to physicians.

    “There is a lot of Gestalt involved with making medical decisions” I have to agree, but what makes physicians so arrogant to think that only they can practice the Art of medicine? Seems to me they are the same ones that want to hire mid-levels and pay them crap to do their jobs!

  10. David, just to let you know I’ve referenced this post on my most recent blog entry. (Couldn’t find trackback facility so am letting you know this way).

  11. This post is inspiring, fresh and ultra awesome! You have a very progressive looks. Reading this blog is a great pleasure.

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