So, should every physician be mandated to join a salaried group on the premise that it will reduce costs via lower physician salaries and disincentivise excessive testing and imaging? This approach would require a wholesale overhaul of the way physicians practice and acceptance of drastic pay cuts. Besides being unfair and impractical, it would, in all likelihood, dramatically reduce the physician pool and access to care.

As an alternative I would propose that we port some of the features that make systems like the Cleveland and Mayo Clinics and Bassett Healthcare so effective, and integrate those into current practices. In our fragmented health-care delivery milieu tests are duplicated needlessly and incessantly, sometimes testing that could have been avoided in the first place if communication with an expert had occurred. Communication between physicians occurs via faxed records, sometimes illegible (although this is becoming less of a problem with the advent of electronic medical records) and often irrelevant, and directly by telephone under more extraordinary circumstances (even we often have difficulty contacting other busy doctors). Often, when initial attempts to track down results are unsuccessful, it’s easier and less painful in terms of time and effort to reorder a lab or imaging procedure. And if it’s a test the ordering physician performs, there are the added incentives of being able to interpret the data first-hand (good) and get reimbursed (good for the physician, not so good for the system).

 The answer is centralized medical records. I know all the objections. Privacy, Big Brother, etc. There isn’t a system the human mind can devise that doesn’t have its upside and downside. With proper safeguards, I think the potential benefits far outweigh the risks. Not only will reports be available, the actual imaging studies can be reviewed by the physician caring for the patient when necessary. A system for physician-to-physician electronic communication can be incorporated, so the collaborative nature of the integrated clinic systems can, to some extent, be replicated. Generalists could inquire as to the best imaging procedure or diagnostic test for patients that don’t yet require a formal evaluation by a specialist, or in advance if they do, for fewer and more productive visits with the specialist.

There’s no question that implementing and maintaining such a nationwide network would be a major and expensive undertaking. Additional standards would have to be developed and methods of linking existing electronic medical records devised. Security measures would have to be rigorously implemented. It’s also true that incentives to over-order won’t be completely abolished. But I believe the cost savings from more appropriate and less redundant testing would be substantial and ultimately pay for the investment, and overall quality of care would improve, assuming other recommendations for dealing with the global health-care process are not ignored.


NEXT: The Insurers


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