Here three prescriptions for improving the U. S. healthcare system that can be implemented by the states and don’t require massive federal bureaucracies to impose or enforce. If they look familiar to you, it might be because I’ve mentioned all of them at one time or another around here. The reforms proposed are:
- Eliminate certificates of need
- Reform scope-of-practice laws
- Remove the regulatory barriers to telemedicine
About two-thirds of the states require one version or another of certificates of need, warrants that a new or expanded facility does not duplicate resources already available. These are obviously anti-competitive. While there is no ironclad proof that competition reduces costs or improves care, there is no credible proof that the absence of competition does, either. CONs mostly serve existing providers and, at the very least, the circumstances under which they must be obtained should be narrowed. How much sense does it really make for a physician to spend a quarter mil to obtain a CON to purchase another MRI machine?
Scope-of-practice laws limit what nurses, nurse practitioners, physicians’ assistants and other similar providers are allowed to do. I’m sympathetic with such regulations but they have problems, too. Here’s an example. Is a PA who finished his or her education and training five years ago really that much less prepared to provide primary care than a physician who was trained 50 years ago? The answer isn’t obvious. I’ve seen studies that suggest that MD degrees have a shelf life. I don’t think that all procedures should be open to nurse practitioners or PAs but I do think the issue needs to be revisited on a regular basis, something the regulatory system just isn’t all that good at.
If it isn’t already, telemedicine is going to be a fact of life, particularly in poorly-served rural areas. It’s already widely performed in some places in the world, e.g. Australia. I know of radiology labs and pathology labs that already send routine stuff to India which means that providers are reaping the economic surplus rather than consumers. If physicians’ and regulatory organizations don’t get out in front of the trend towards telemedicine, it will overwhelm them.
Just on principle I would eliminate CONs, but I am not sure it reduces costs. We got rid of them a long time ago. In response, every dinky hospital in the area developed a heart program. Many of them were doing well below 50 a year. Not good. What we really need to stop is docs owning machines (MRI, CT) to which they can refer patients. A lot of good studies show this increases referrals and costs w/o improving care.
I think you are correct that many Pas, NPs and other practitioners can perform about as well as those a step above them, often docs, after 5-10 years. However, they definitely cannot when just out of training. I don’t know exactly how to make this work, on any sort of regulated basis. We handle this internally. When we think our advanced nurses are ready to practice more independently, we let them do so. There is enough play in the rules that we can legally do so, or at least our lawyer says we can. It lets us cut costs a fair amount, especially for small, rural facilities.
Telemedicine for radiology is pretty old hat. There is probably a bit more to be saved there. Don’t know about pathology. I do know quite a bit about the issues trying to make it work for ICU care, and it will be a while til it works there. It adds costs in that setting.
Steve
ICU is about the last place I would look for telemedicine although I can imagine that augmenting mids shift remote monitoring of equipment might be possible.
The expansion of telemedicine I’m thinking about is more with primary care.
The best single reform would be to require healthcare providers to publish all prices per ICD-10. Then, who cares who owns what machines? That’s like worrying if a Walmart optician directs you to their own eyeglass department after an exam.