Robert M. Centor, MD
While thinking about how to answer this question, I have changed my list several times. My first list included malpractice reform, but I have since decided that although malpractice is a major issue, it does not make my top 3.
The best way to address such a question is to consider the biggest problems with our current healthcare system. In addition to malpractice, I have weighed issues such as transitions of care between different sites, medical training, and continuing education. However, I must restrict my list to 3, so here are my top issues in 2006: access to excellent generalists; accurate, complete patient data; and better pharmaceutical data.
My first reform would be to create an agency to perform unbiased research on proposed new drugs. Each pharmaceutical company would have to help fund this agency, but it would need to be kept free of drug company influence. The agency would have the responsibility of determining drug safety and efficacy as well as determining relative efficacy of different drugs.
We need such unbiased evaluations of candidate new drugs. Our current method of letting drug companies do studies to present to the US Food and Drug Administration sets too low a standard. We need large enough studies to have a sense of side effects. We need comparative studies that elucidate the possible benefits of a new drug compared with current options.
This agency would give us valuable information that could inform physician and patient decision making. The agency would also take responsibility for post-approval surveillance for adverse reactions. Taking that responsibility away from the pharmaceutical industry should improve safety and give less biased information on how a new option should fit into our armamentarium.
Next, I would mandate universal electronic medical records (EMRs). In the 21st century, our lack of accessible medical information is regrettable. I work in the Veterans Affairs (VA) system, which has the best electronic records. After Hurricane Katrina, we had several New Orleans refugees admitted to our hospital in Birmingham, Alabama. Because of the national VA database, we had access to all old records, which allowed us to provide accurate care without having to repeat many tests.
Some critics argue that having a nationally integrated EMR system will raise civil liberty issues. Proponents (like me) counter that such a system will prevent many medical errors, decrease repeat testing, and prevent many narcotic scams.
For physicians to provide the highest quality care, we need all the data available on a given patient. We need to know all the prescriptions, all the previous tests, and diagnoses. Without an integrated EMR, we are making unnecessary mistakes.
Finally, I would scrap our current physician reimbursement system and develop one that fits our free market economy. We should change from an encounter-based system to a time-based reimbursement system. Our current system encourages physicians to take shortcuts. We all know that if we can squeeze in 1 or 2 more patients each day, we will benefit financially.
I believe that patients understand the concept of paying for a physician's time. Many patients would prefer a 30-minute appointment rather than a 15-minute appointment. Our current system does not allow them to pay extra to spend the necessary time. Many patients would like to communicate using email. I like the idea, but my time is valuable. Would they pay for email communication?
I believe we should make explicit what our time is worth. If I am worth $120/hour (and given overhead, that is not an unreasonable estimate), then a 10-minute visit (perhaps for a sore throat or a urinary tract infection) would cost $20. A 30-minute visit (which would be appropriate for many adult patients having multiple medical problems) would cost $60.
This system will work if offices require cash payments (credit cards accepted). The savings from not billing insurance companies are huge. Also, such a system adds great transparency to healthcare delivery.
I have dreamed of major changes in our system. The old Southern saying -- "If it ain't broke, don't fix it" -- does not pertain to our current healthcare system. It is broke, and it needs fixin'. We must think outside the box. We must be creative for the health of our patients.
Medscape Med Students. 2006;8(2) © 2006 Medscape
Cite this: What Are the "Top 3" Changes Needed to Improve US Healthcare? - Medscape - Nov 14, 2006.
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