Having your prostate exam in the grocery store … in the produce section

Clinical quality could be killed by the unthinking quest for the value proposition.

There are many clever thought leaders who are helping to shape the future of health care.

One of my personal favorites is Michael E. Porter, PhD, who has taught courses and written thoughtfully about important principles that should underlie our approach to the restriction of costs in medical care.

In his excellent tome Redefining Health Care: Creating Value-Based Competition on Results, crafted with Elizabeth Teisberg, PhD, the very sensible principles of transparency, provision of comprehensive disease management and prevention services, organization around medical conditions, and redefinition of the health plan/subscriber relationship — with an ending of cost-shifting practices — are proposed as potential solutions to the current state of chaos.

Implicit in that overall construct is the improvement of access and the insertion of true value, as distinct from cost/price discrepancies. Who could rationally argue with that set of moves? They certainly make sense to me, and many of the principles in the construction of my own cancer facility, the Levine Cancer Institute, have partly been derived from their algorithms.

However, there also are many less thoughtful, inexperienced folks who seem to have found their way into our professional medical world, including those who have abstract views of what medicine/health care might be (not actually having been directly involved in it), revisionists who ignore or reconstruct the history of the health care industry and lessons learned, and those who have secondary (financial or political) gain from tinkering with a system that they really don’t understand.

No replacement for training

Somewhere in this mix, an idea has emerged — with the trajectory of a runaway locomotive — that physicians may be too expensive for the health care system and, thus, should be replaced by other health practitioners, pharmacists or other less medically trained personnel.

Let me be clear: I have the greatest regard for all of the above — most particularly when they practice within their scope of training and expertise — and I earnestly believe that they can make physicians more effective and sometimes even safer in our own domain.

However, there really isn’t a good replacement for 4 to 6 years of medical training for the basic medical degree, usually augmented by several years of hospital-based internship, residency, fellowship and other supervised practice.

The experience gained from several years of Socratic teaching, as well as hours at the bedside and in the clinic, can’t be replaced by online primers, or by a year of bridging tuition from a school of pharmacy, physical therapy or other health-related professions. Even the advanced training afforded to nurse practitioners, unless highly relevant to the specific domain of work, will afford less background than for the average medical practitioner.

Again, that is not to say that nurse practitioners, working within scope of practice, are less than superb. However, many of the “clinical staff” who find their way into grocery store clinics don’t have that level of training and expertise.

There has been the tacit assumption that the initiation of corner-store groceries and pharmacies — staffed by unsupervised non-medical practitioners, and mostly providing simple urgent care to the populace with coughs and colds and minor ailments — will necessarily produce a vast diminution in cost to the community.

Certainly, the ability to pop into the grocery store and have a quick prostate exam by an enthusiastic pharmacist or family practice nurse will be much easier than awaiting the skilled examination of a urologist, proctologist or family physician with a decade or more of training and practice. Will the outcome be the same?

Convenience vs. quality

There is no doubt that a key driver of health care consumerism today is focused on convenience rather than quality.

However, switching diseases as just one example, repeated treatment of a persistent cough by the same grocer’s employee probably will save the community hundreds of dollars … initially … until the patient presents to a real physician with advanced lung cancer, requiring thousands of dollars in treatment and a lower likelihood of cure. Although many such clinics mandate that their clinical staffs deliver only one round of antibiotics and then refer, there really is no national standard that is mandated to ensure that this occurs.

What really troubles me is the assumption that this type of change will benefit the community financially and clinically without having real level one evidence to prove the point. The few reports that have found their way to publication have presented remarkably short follow-up, and many are quite superficial in their evaluations of outcomes. This is not surprising given the lack of supervision of this burgeoning business model.

Before I’m comfortable to believe that a fully trained physician should be replaced by another variant of health practitioner, who has been trained for a different role, I really would like to see data that address quality and outcomes — including mature financial data — rather than short-term fiscal algorithms. I also would like to see a much more structured approach to oversight and regulation.

It seems to me that the level of federal or state control in this new enterprise is at about the same level as for tanning booths! If this approach is wrong, it could be a decade before we see cure rates of many complex conditions falling (due to delayed diagnosis), accompanied by the anticipated increase in costs of treatment of diseases that present at advanced stages.

Of course, by that time, those who run the “non–doc-in-a-box” operations will have made their decade of profit, and they will have moved on to another industry. Hopefully my dream will come true and they will help our friends in the legal profession to improve their environment … as I think of it, that might not be such a bad thing! Let us not forget that there is always politics awaiting their input!

For more information:

Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, is HemOnc Today’s Chief Medical Editor, Oncology. He also is president of Levine Cancer Institute at Carolinas HealthCare System. He can be reached at derek.raghavan@carolinashealthcare.org.