Squeezing out the doctor? Not by a long shot

Evidence undermines the Economist title. Just like the New York Times and New Yorker long articles, when the Economist speaks, it looks weighty and credible. But the Economist’s Squeezing out the Doctor article is mostly about what the writer has just discovered -- which has been the case for years, but without his knowledge. Take this example, which clearly impressed: “Patients are much happier to monitor themselves at home with gadgets bought online than they used to be [really!], and gadget-makers think there is a huge potential for growth in taking the trend further. Philips is trying to crack Japan with emergency-alert devices for the elderly.” Hmm. Philips has marketed this type of product ever since they bought Lifeline 7 years ago. The PERS industry is a 20-year-old market disconnected from MDs that needs a responder to opt for a next step. And it is reimbursement of doctors (or lack thereof) that hampers progress in the overhyped telehealth market, that everything-but-the-kitchen-sink world spanning ‘robotic surgery to patient-to-patient email.’ 

Delegating tasks does not eliminate oversight. Doctors may have nurses as care coordinators, but that no more squeezes out the doctor than an electrician squeezes out the general contractor. And doctors have little interest in divesting power even when they delegate tasks. Doctors make the most money based on (their own) face/specialty time with patients. With remote monitoring and telehealth pilots a-plenty – see British telehealth study about saving 6000 lives – will the most recent study be the one that causes policy change across the globe?  Don’t bet on it. For another big bucks but low impact initiative, see CMS initial innovation grants -- that went to established large players. How nice, but CMS actual incentives are for doctors-in-your-face and face-to-face, which block any real change. And since doctors (see AMA) are the ultimate influencers of change in health policy and reimbursement, who seriously believes a near-term change is in the works?

The presence of technology does not guarantee change. The Economist article (for which no author, perhaps wisely, is named) demonstrates the gee-whiz naïve view of technology as transformative for changing processes and responsibilities. But that rarely happens unless precipitated by a crisis of resource availability (rural areas) or cost constraint (emerging markets).  Where resources are available and in some cases oversupplied, technology is locked within pilots, with decision makers (see doctors) still awaiting real proof. Meanwhile, in the physical world, see examples where the doctor is being squeezed – but by other doctors. See the competition for lucrative cardiac patients in cities like Boston or New York.

The future telehealth transformation -- it's in the hands of policy-makers (aka doctors). Imagine the title of a future Economist article – “Telehealth Declared Viable by Doctors. Subtitle: Reimbursement debate ends, CMS cites proof positive study, reverses reimbursement ratio for face-to-face visits and remote monitoring. Doctors, far from being squeezed out, benefit by being able to use technology to ‘treat’ many more patients, boosting their income substantially.  Telehealth vendors see endless market opportunity.” Will pigs fly?

Managing care at home

Physicians are working hard at treating patients as effectively as possible. The problem is patients, especially aging patients, are not being consistently and regularly managed once they leave the office. If or when we are able to communicate with more patients effectively through the use of digital technology we will need RNs who are able to step into an as yet to be named or defined role and build a panel of patients working with either a group of docs or multiple family docs in a patient centered structure that promotes and produces ongoing almost daily management. Google + is coming along, Skype less capable, nanobots that transmit physiologic data that helps us see ischemic or hemorrhagic strokes by changes in pressure etc., multiple ways to better manage and keep healthy those 78 million aging adults in their homes all will be here soon! How do we pay for this? Create an insurance policy for nursing care the model is long term care policies that actually should be paying for care as we edge towards the end of life not nursing homes. Insurance for nursing care in home was the brain child of Lillian Wald, this is not radical just reinvented for use with digital technology. We need to start inventing and stop politicking!

Technologies for family members

Independently living seniors want to be independent yet avoid the anxiety of loneliness. The family members also want to remain engaged with their loved-ones even if they are geographically dispersed.

Now we can use a collection of Internet and other technologies to achieve these goals in a cost-effective manner. We therefore looked at many tools and build a new Internet service Nclaves (http://www.nclaves.net). It is still in a early release stage.

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