

Notes From the Field: I have seen the future of healthcare - ippisl
http://www.nextbillion.net/blog/notes-from-the-field-i-have-seen-the-future-of-healthcare

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ledger123
"And trained lay health workers, paid perhaps a fifth of a doctor’s salary,
handle 80% of the calls, so only 20% get passed on to doctors."

This is what need to be done in an organized way even without a call center. A
lot of patients don't need a person with knowledge of every tissue/bone, salts
and systems knowledge. Just the diagnostic knowledge for common ailments.

In most of countries today a patient goes to a doctor (with 4-5 year
education) and then to a specialist with a complicated issue. We need to add
another "doctor" category which 1-2 years education to filter the patients.

The problem is that this idea will be vigorously opposed by the doctors
associations/cartels who are going to lose because of reduced number of
patients.

~~~
tptacek
We already have this facility in the US. They're called nurse practitioners.
Walgreens runs clinics staffed with them. They can run a strep culture,
prescribe antibiotics, and presumably handle 80% of the rest of your medical
problems.

Nurse practitioners may be the future of US medicine. That'd be a good thing.
A 400 seat medical call center, on the other hand, seems dystopian. I'm hard
pressed to name a _single_ business in which consumers have been well served
by call centers.

~~~
kellishaver
Agreed. Nurse practitioners are a great addition to the medical field. They
can handle most common problems and are well-trained enough to know when to
refer you to someone higher up the chain. All the nurses in our school system
are NPs now. This pretty much guarantees good, basic healthcare to all of the
kids in the school district. They can all get their annual physical from the
school NP and if a kid comes in to see the nurse and has, for instance, strep
throat, the nurse do the strep test and write out a prescription for
antibiotics and the parents, who may not have insurance, don't have to pay to
take their kid to the doctor (granted, they still have to pay for the
medication, but this is still a huge cost-saving service for a lot of
uninsured families).

~~~
whatusername
That sounds fantastic. I had a slight ear-infection the other day and couldn't
be bothered going to the doctors for a antibiotics prescription. Even if it is
free/cheap (Australia). Being able to skip the doctor part would be great.

Also - We've used the "Nurse on Call" call-centre a couple of times. It's been
a good experience. Reassurance if it's not a big deal, and a referral to a
doctor (or an auto dial to an ambulance) if it is.

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patio11
This is too good an idea to allow to be legal, along with a few other things
which would take cracks at the guilds.

(e.g. We have people with masters degrees who are, at this very moment, using
scissors on construction paper to prepare for class. This is the tip of an
iceberg of waste which would be alleviated... if we were willing to reduce
non-trivial proportions of those very politically influential workers to the
wages appropriate for someone who cuts construction paper with scissors.)

~~~
tptacek
You think medical care provided by effectively anonymous caregivers over the
phone is a good idea?

~~~
patio11
We do it in the status quo in a few very limited fashions: for example, many
hospitals have a line for new parents to call in where they will get a nurse
who will listen to them, calm them down, and tell them that $SYMPTOM is within
normal operating parameters for their new infant and that they should not
panic unless $CONDITION happens. My sister in law is a maternity nurse, and
she works on one of these. She's a wonderful woman who would be equally
wonderful talking you through it if you were in Calcutta when calling her. I
assume there is some wonderful woman in Calcutta who can do the same. That
would free my very expensive sister in law to do stuff which more uniquely
requires her considerable expertise.

90% of medical care is low-skilled well-understood grunt work. Much of it is
readily identifiable as such. There are huge structural disincentives from
building our medical care processes to take advantage of this.

~~~
tptacek
So, like I said upthread, we're already in the process of divesting day-to-day
care from actual MD's. Go to a Walgreens clinic next time you have a sore
throat. Even if you have strep, you'll get taken care of without ever setting
foot in a doctor's office.

It's easy to see that taking the load off overqualified, overly expensive
doctors is a good idea, which is why this idea is actually being implemented.

What I'm more interested in is whether we think it's a good idea to have those
providers working in call centers. Because, from what I can tell, the
economics of call centers are almost exactly opposed to customer care.

~~~
dantheman
I think a call center is a good idea -- you can call in with your symptoms and
they can tell you that it's minor just take some Tylenol and enter the
symptoms into the system. They can also tell you that based on your symptoms
to call them back if the the condition continues, if you start to experience a
fever, etc.

I've called the doctor before (talked to a nurse), and told her my symptoms
and asked if I should come in -- they said that if the condition persisted
then I should come in, but there were a lot of people with the same flu in the
area and rest/fluids would take care of it.

I think the more we can standardize medicine the better, it is a mess of a
science. With machine learning and the rapid pace of new sensor development
hopefully we'll be able to get more automated care -- that can be reviewed by
a doctor/nurse to make sure it's ok.

The economics of call centers are no different than having nurses on staff --
how many people can you treat an hour.

~~~
tptacek
A doctor's office --- or even a regional medical center --- has different
scaling pressures than a call center. Call centers are centralized. They're
more strongly incentivized to:

* Ramp up new hires as cheaply as possible

* Keep staff maximally interchangeable and minimally accountable

* Keep their resources as close to oversubscribed as possible

A doctor's office has these same pressures, but on a much smaller scale. It is
a big deal for your doctor to hire a new full-time nurse. Patients will
interact with staff face-to-face and at length. As busy as the office gets
during busy hours, there are prolonged lulls.

Call centers also win several extra problems that a doctor's office doesn't
have:

* Terrible continuity across multiple calls

* The need to talk lay people through basic medical testing (ever tried to do tech support for someone who doesn't know how to use a mouse?)

* The personnel management problems of having multiple tiers of support staff.

I don't have any arguments about standardizing medicine. If you reread
anything I've written today, I'm in favor of the nurse practitioner model, and
I see the problem with relying on full-service medical doctors. I just think
call centers are terrible for consumers.

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patrickgzill
I think he misses the point, a lot; and that this is rather unnecessary to
begin with, at least in the USA.

First question to ask in the USA is:

"Why are there quotas on medical doctor training?"

If you create scarcity, what do you expect will happen?

ISTR back in the 1990s the Clinton administration crowing about how they were
helping NY State reduce the number of medical school admittances.

~~~
tptacek
Even if we made it as easy as possible to get a medical degree, we wouldn't
solve the scarcity problem. It's extremely expensive, in time and dollars, to
become a doctor; it takes 10-12 years.

~~~
yummyfajitas
So we would solve the scarcity problem 10-12 years in the future.

Currently, for every person accepted by medical school, there are
approximately 2 people _with almost identical grades/scores_ who are rejected.
This suggests we could roughly triple the supply of doctors if we put effort
into training more.

~~~
tptacek
I wasn't suggesting that relaxing restrictions wouldn't help because it would
take 10 years to see the effects. I was suggesting that there are other
significant obstacles to recruiting people into the medical profession besides
accreditation.

Consider also that if you tripled the number of doctors, supply/demand says
doctors will make less money, making the prospect of suffering through 10-12
years of training (and N years of low-wage work) less attractive.

Again, medical care _should_ be less lucrative for providers, and I agree that
we _should_ make it easier to become doctors. I just think that the long-term
scalable solution for this problem has to involve more than just doctors. It
only takes 4-6 years to become a nurse practitioner.

~~~
detst
Remove the requirement of a bachelor's degree for acceptance into medical
school. Integrate anything they see as necessary into the medical program
itself. That's 4 years of their life they can have back.

I had a friend that went to a prestigious European medical school for a 6-year
program right out of high school. Is he any less qualified as a doctor than
someone that spent twice as long to get to the same point?

Or compromise and make the students prove themselves for 2 years before being
accepted into the med program. 8 years, they're done and "well rounded".

------
nazgulnarsil
the elephant int he room on the healthcare debate is that studies
overwhelmingly show that greater access to health care does not result in
increased general health. this is because more than half of current "best
practices" in the western medical community are actively harmful, are of
completely unknown effect, or are known to do nothing.

~~~
ledger123
This is interesting. Could you elaborate a bit?

~~~
nazgulnarsil
<http://www.overcomingbias.com/2009/07/meds-to-cut.html>

robin hanson consistently blogs on this topic.

<http://www.overcomingbias.com/tag/medicine>

~~~
tptacek
A Hanson suggestion from that post: bring in practitioners from places with a
low-cost standard of care so they can impose those practices on American
medicine.

I'm a broken record, but: that's another benefit of nurse practitioners. They
aren't equipped to prescribe exotic, unproven, or advanced medications;
instead, they're equipped to provide an 80%-solution standard of care and to
recognize when to escalate past that. If NP's were the normal first tier of
care for most patients, we'd get better resource allocation simply by
eliminating an opportunity for carelessly wasteful decisions from overworked
doctors.

~~~
nazgulnarsil
this is the wal-mart/CVS solution which Hanson is a big fan of as well.

------
mattchew
It may be the future of healthcare in a lot of the world, but not in the U.S..
Our health care interests are too entrenched. This would be too disruptive.

Probably this is already illegal in the U.S., or cost prohibitive if you tried
to staff the phones with workers who would be legal. I wonder if one could
legally hack the system by using a call center located _outside_ the U.S. . .
.

Of course, the public could be turned against something like that pretty
easily. Just publicize the hell out of the first person who dies due to a
mistake that came from the call center. Congress would pass a law the next
week.

Another commenter suggested that our medical system needs a "reboot". Oh my
yes. But I don't see how we're going to get one.

------
samd
I think something like this is inevitable in our country, no matter how much
primary care doctors dread it. We simply will not have enough of them to care
for everybody in even the very limited way they do now. We are all used to the
hour long waits and 10 minute sessions with our swamped primary care doctors.
That will only get worse when tens of millions of previously uninsured people
enter the system. The amount of doctors produced by our medical schools has
remained nearly constant for more than a decade, and new openings add only
about 100 doctors per year (about 1 school per year). We need to either pay
primary care doctors more money to draw doctors in from the specialties, add a
lot more medical schools, or somehow use technology to make health care much
more efficient. Since the first two have been available options for years
without being implemented, I think we will fall back on the last one.

~~~
ugh
That’s odd. I know long waits (not quite ten hours, maybe one, two or three)
from specialized doctors here in Germany, not ever primary care doctors. I
have to wait maybe thirty minutes for my primary doctor, probably not at all
if I call him up in the morning and go there later the day or the next day.

I know that the reverse must also be true for some rural areas in East
Germany, an unattractive area with low pay and hard work where the doctors are
slowly dying out and nobody wants to replace them, but that really seems
limited to rural East Germany.

Why is that?

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ZeroGravitas
The UK equivalent is NHS Direct.

<http://en.wikipedia.org/wiki/NHS_Direct>

I've had several positive interactions even though, unlike most of rural
India, I'm 5 minutes from a major hospital.

------
xtho
"Clinical decision support systems" have been a test bed for AI since the
1980s at least. For whatever reason they never catched on.

~~~
JunkDNA
There are isolated cases where clinical decision support can work well. The
best example of this are the ones that analyze prescriptions for dangerous
combinations or mistaken quantities (too much for age, weight, etc...).

The reason they haven't caught on in the general case is because medicine is
full of unique edge cases, and like much of AI, teaching a machine about all
of them becomes exceptionally difficult.

------
cookiecaper
There are many reasons health care is so expensive right now. Among them the
expense of equipment and equipment operators, the expense of education, the
expectation of huge salaries (often $200k+, always $100k+), the complexities
of private and socialized insurance programs and the complications in
collecting payment from insurers and then patients, and so on.

Modern medicine is really, really messed up. I think the whole thing needs a
reboot, and everyone involved needs a reality check.

As far as the article is concerned, I definitely don't think "phoning it in"
is the answer, and I don't think that solution addresses any of the issues
listed above. We need to reset everyone's expectations.

Law and decree may help temporarily, but they'll just find ways around it, and
the government can't pay them off forever. We need a real solution to this and
no one's coming up with any.

~~~
dantheman
I think this provides the best way to move forward in the way we address
healthcare:
[http://online.wsj.com/article/SB1000142405297020425140457434...](http://online.wsj.com/article/SB10001424052970204251404574342170072865070.html)

It starts by addressing systemic issues:

1\. Remove tax advantages from corporate plans

2\. Allow people to see what their treatments cost -- pay for results instead
of doctor anguish (the current way medicare works -- a truly horrible system).

3\. Allow people to buy insurance from anywhere in the country.

4\. Change the expectations of health insurance -- it covers disastrous
problems. For everyday maintenance it's up to you, and you better make sure
you do it because your catastrophic health insurance will raise your rates
significantly if you don't take care of yourself.

5\. If you have something happen that would be considered "a preexisting
condition" for other providers your provider sets up a fund for you that
covers that. For instance if you have cancer -- the health insurance you have
at the time of diagnosis will cover the costs.

None of these need government mandates, they just need the government to get
out of the way.

If you look at Lasik eye surgery costs the technology has gotten better and
the price has declined -- that's what happens when people shop around, which
is the majority of all healthcare dollars.

