Implementation of a rational system of medical care

The patient entered her private solo physician’s office and handed her medical ID card to the doctor.  He put the card in his desktop reader and reviewed her medical history.   All of her visits, vaccinations, medications, tests, x-rays etc from all providers were inscribed on the data chip in the card.  The card also included insurance and billing information.  At the end of the visit, he updated her information on the ID card at his desk and returned the card to the patient.  The completed entry on the card was processed centrally and the physician received his payment in a few days, no rejections or delays possible.

Is this story a science fiction fantasy?  No, this is an everyday routine patient encounter in France and it is similar in several other countries.

In fact offices can get by in France without even one administrative assistant.  Contrast this to the hordes of billing specialists we have in this country.  Why are we in the US light years behind in the implementation of a rational system of medical care?  Why do we have a system that is so fragmented that efficient and economic practice is impossible?  Why does the average American physician have to spend an ever increasing percentage of his day in administrative tasks and billing hassles while having to hire an ever increasing number of billing and insurance specialists to keep up with the ever changing requirements?  All this is in the setting of an American ‘system’ which eats up nearly twice the GNP of other European and Asian countries who yet manage to have better patient outcomes than we do.

One possible solution is that we need a national health system.  That could solve the problems but implementation of the French system does not require a unified governmentally controlled system.  All it takes is a national mandate that all insurers are standardized and follow the same rules.  In the US we have Medicare, Medicaid, the VA system, 50 states, and probably over a thousand insurance companies all with different rules, regulations, and requirements.  Obama will spend many billions on encouraging electronic medical records (EMR) but it won’t accomplish a fraction of what a much simpler implementation can do with standardized rules.  The financial encouragement and penalties the Feds are proposing will not lead to transportable records and unified billing.   What the Feds should do is develop one standardized system, give it to all providers for free or at nominal cost, and then require that all patients, providers, and insurers use it.

What stands in the way?  We seem to have political paralysis on this most vital of issues.  Our system is almost entirely for profit, yet two of the most widely supported and efficient systems are non profit government run, Medicare and the VA system.  Indeed the VA system is as close to ‘socialized medicine’ as could be imagined.  Vested interests i.e. for profit health insurers have spent fortunes deriding Obama’s relatively modest and incomplete final bill as socialized medicine.   This is despite the fact that public option was defeated.  When fully implemented the majority of Americans who don’t have Medicare, Medicaid or the VA will still be dependent on insurers whose main responsibility is to their shareholders.  They’re under no mandate to provide affordable health care for all.   Instead of a discussion on how to reorganize our health system into an efficient economical system for the entire population, we get totally spurious criticisms, most famously the “death panels.”

The new regulations under Obamacare will make health insurance more available, but will do nothing to make medicine more economical and efficient.   The coming mandates to implement EMRs will effectively force most physicians to either join large groups or to retire.  Doctors will earn a bonus for implementing EMRs, but the requirements to earn the bonus are so complicated that even some of this country’s largest private systems have said they cannot implement it.  As it stands doctors will be increasingly penalized for failure to implement an approved system, though no one really knows exactly what is required.  Clearly the government itself should design a system and make it available to all at an affordable price.

Other proposals such as forcing doctors to document quality of care and putting the financial onus on them to do it will only accelerate the trend of forcing small groups out of practice.  Where I practice many long and well established practices are selling out to hospitals.  We are clearly on a path that will see the end not only of solo practices but of smaller group practices as well.  I did not go to medical school to spend my days overseeing business management.  It’s nigh time we developed a system that allows doctors to practice medicine and simplifies the business aspects instead of making them more complicated with every passing year.

Joel Sherman is a cardiologist who blogs at Medical Privacy, A Patient Oriented Discussion.

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  • Joel Sherman MD

    The example given above is from TR Reid, The Healing of America. I should have noted that in the example given, the physician did not have any need to keep patient files in his office as the patient brought them with.

    • anonymous

      If the plan is for the physician not to keep a copy of the patient’s records, then we need malpractice reform in addition to everything else you mentioned. Who knows whether the patient might alter the records and blame the physician for something completely random!

      • Joel Sherman MD

        Anon, I’m not an expert on the French system, and not speaking French makes it hard to research any question. But it would be difficult for a patient to alter their ID card as the change would have to be made centrally as well. Don’t think any doctor would disagree that malpractice reform is needed no matter what system is implemented.
        I don’t know if all French physicians keep no patient records or if this particular physician was an exception.

  • pcp

    Excellent post. How do we convince the EMR/ACO/corporate medicine gurus that they are pushing medicine in exactly the wrong direction?

  • Emily

    Eliminating the thousands of different rules and rates would be helpful to consumers too. It’s frustrating to try and figure out what anything costs because it’s not the same for everyone.

    I like this idea, but how do the French protect their privacy and prevent fraud with that card? Couldn’t a nasty hacker invade someone’s medical records or steal the card and get services for non-French citizens?

  • paul

    who would be taking a massive paycut to switch to such a system and how will we convince them it’s for the greater good?

  • ninguem

    CMU = Couverture Maladie Universelle. It’s their Medicaid.

    Médecins Sans Frontières runs clinics withing France itself, plus Italy, Spain and Belgium, for their own poor and illegals unable to access care.

    Sounds like things are, overall, pretty good in France. Lest you think they don’t have their own problems with unequal access, you might want to look it up in their own press.

    • pcp


      I don’t think the poster is saying that the French system is perfect. I think he’s just showing that the US is headed in a direction dominated by corporate/industrial medicine that is the exact opposite of “patient-centered.”

  • Joe

    Indeed, we have corporate centered care.

  • soloFP

    The technology exists, but people seem afraid of big brother. A universal medial records system and universal payment system would be great. Currently we have fragmented notes, reapeated studies and tests, and duplicate office visits that waste time and money. Why do I have to document on each hospital H&P the past, family, social, and review of systems on the same patient that was just there 3 weeks ago? Why not simply state H&P reviewed with the additional information added? Why do I have keep getting so many bullet points and systems reviewed at each office visit to get the correct CPT code for the level care? Patients simply want their care and meds, but Medicare and Insurance are using outdated CPT codes from the AMA to ruin the medical system. It also makes no sense to wait 30-50 days or longer to be paid at a different rate from dozens of different insurance companies for the exact same care. Why does one company state my work is worth $40, but the other says the same visit is worth $70? Why do I have to prior auth CTs/MRIs for the patient, as it is not my insurance? If a patient really wants that brand name PPI med, let the patient call the insurance company and fill out the 10-20 questions on the prior auth form. The current system encourages inefficiency and time wasting. If it was simply all self pay with insurance tocover catastrophic events, the costs of medicine would go down greatly.

  • Norm

    So you think the VA system is a well run system? Let me tell you about my recent annual physical at the VA. The actual hands on physical took at most two minutes, she looked in my mouth & ears (she did tell me I had clean ears, that made me happy because I was really worried about that.) She listened to my breathing and heart, the rest of the time she sat at the computer making her report about my physical. Blood was drawn for lab work. Two days later I received a call from the nurse at the VA, she verified I was the patient and proceeded to tell me my lab test showed I had diabetes and the doctor wanted to put me on metformin. I asked what my values were, she said my bg was 126 and my A1c was 6.8. I told her I would see my regular physician in 4 months and we would discuss it.
    Now a little background, in November my bg was 124 and my A1c was 6.1, I had a tooth infection for several months, I took a course of antibiotics and delayed further treatment until I got home to see my dentist.( I understand infections can raise blood glucose.)
    Now I ask you, how many of you physicians would start a patient on cholesterol meds, blood pressure meds or diabetic meds with just one test. Would you not do a second test to rule out lab error or a momentary fluke in lab values? Would you have your nurse call the patient and tell them they have diabetes and the doctor wants to start you on a drug? Or would you perhaps have the nurse call the patient and tell him his blood sugar was a little high and the doctor wanted you to come back in for another test and reevaluate the situation? At that time would you not talk to the patient, do another test and if diabetes is confirmed, talk about diet and exercise and managing diabetes?

    • Margalit Gur-Arie

      Oh, but this is textbook ACO care. Team work where the nurse practices at the top of her license; avoiding redundant visits because a lot can be done without “face-to-face” wasteful encounters; and you have to keep that A1c under 7 or you will score badly on the quality measures. There was probably a protocol for this somewhere.

      • pcp


  • Joel Sherman MD

    Norm, no system is perfect and none is better than the actual physician you are seeing. I have many patients who use the VA system to obtain their medications and they all seem happy with it. As a physician I hated the VA when I worked in one decades ago when I was in training. Big clinic care is not my preference that is why the French system appeals to me enabling small practices and personalized care with minimal administrative hassle. The examples of Medicare and the VA are presented only to illustrate that governmental solutions, which appear to arouse immense hostility in this country, actually can work. Millions of Medicare patients have high satisfaction rates with it. The French system is consistent with both solo practice and large clinics. Ours is not.

  • buzzkillersmith

    Public rhetoric notwithstanding, the main purpose of the medical system in this country is to make money for powerful interests. What’s good for average people doesn’t enter into it much, except insofar as it affects profits for the powerful. (And I count medical subspecialists among the powerful. Primary care not so much.) The same could be said for finance, energy and any number of industries. If you want a medical care system whose main goal is providing medical care, the easiest way to go it is to move to Canada or Europe. Here in the US you’ll be waiting a long time.

  • Marc Gorayeb, MD

    Operating under the “same rules” inevitably means concentration of power in the hands of the federal government. Most Americans don’t like living under the thumb of federal bureaucrats. It may not be convenient or efficient, but federalism is the backbone of our nation. Those who advocate for the homogenization of our 50 societies need to get re-acquainted with our history. Our constitution is not a quaint anachronism, and despite efforts to the contrary, the Commerce clause can’t be used to disable the rest of the document.

  • Dr Sam Girgis

    The VA system is nation wide. If a veteran from New York is on vacation in California and is hospitalized at a VA hospital, his medical record is available to the California physicians. Why can’t we use a similar system for all patients in the US? What’s taking so long to implement such a system? A nationwide system will help patients when they are treated by multiple physicians. It will also prevent medication duplications, and adverse medication interactions (when different medications are prescribed by different physicians). It will also deter the drug seeking patients who travels from hospital to hospital in search of narcotic medications. The list of benefits goes on and on… It’s time to move on to a national medical record system.

    Dr Sam Girgis

  • pao

    YES,we can do it >>>the solutions are available when we seek Focused, Flexiable,Fast,and financial prudent options above special-interests driven plans. Simple… if we could just put what is in the best interest of the patient first and forget the political and self-serving ways & meansof avoidance of the health care crisis .

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