Policymakers stumped about how to lower stratospheric healthcare costs should look abroad, where a number of countries are finding creative solutions to chronic doctor shortages. A new piece in the Economist profiles transformations in the delivery of medicine:
But this demand for health care looks unlikely to be met by doctors in the way the past century’s was. For one thing, to treat the 21st century’s problems with a 20th-century approach to health care would require an impossible number of doctors. For another, caring for chronic conditions is not what doctors are best at. For both these reasons doctors look set to become much less central to health care—a process which, in some places, has already started. . . .The trick is repeated in other areas of health care. India’s LifeSpring hospitals slash the price of childbirth by augmenting doctors with less expensive midwives. The costs are about one-sixth of those in a private clinic. The Aravind Eye Care System offers surgery to about 350,000 patients a year. Operating rooms have at least two beds, so surgeons can swivel from one patient to the next. Most important, for every surgeon there are six “eye-care technicians”—young women recruited and trained by Aravind—who perform the myriad tasks in the operating room that do not require a surgeon’s training.Other problems have inspired other solutions, with technology filling gaps in the labour force. The Bill and Melinda Gates Foundation supports a programme that uses mobile phones to deliver advice and reminders to pregnant women in Ghana. In December the foundation and Grand Challenges Canada, a non-profit organisation, announced $32m in grants for new mobile tools that will help health-care workers diagnose various ailments. In Mexico, worried patients can phone Medicall Home, a “telehealth” service. If a patient needs care, Medicall Home can help to arrange a doctor’s visit. But about two-thirds of patients’ concerns can be addressed over the phone by a doctor (often one only recently qualified).
Many of the most effective techniques may not even be particularly high-tech. Simple home monitors can help health providers keep the number of unnecessary doctor’s visits to a minimum, ensuring that patients come in for emergencies but removing the need for an in-person appointment for regular checkups.Nurses and other assistants can provide care more cheaply than doctors, whose expertise is generally not required for routine cases. Health systems can be reorganized to take better advantage of them:
Workers with a lot less training than doctors can still be highly effective. Physician assistants in America can do about 85% of the work of a general practitioner, according to James Cawley of George Washington University. A pilot programme of rural health-care workers in India—the type that the health ministry wants to expand—found that the workers were perfectly able to diagnose basic ailments and prescribe appropriate drugs. In some areas non-doctors actually look preferable. A review of studies of nurse practitioners in Britain, South Africa, America, Japan, Israel and Australia, published in the British Medical Journal, determined that patients treated by nurses were more satisfied and no less healthy than those treated by doctors.
Naturally, some reforms will prove less effective than promised. Yet the wealth of new ideas is extremely encouraging. More than anything else, the solution to the problem of runaway healthcare costs is innovation, both in medical technology and in the delivery of care to patients. In many other fields, costs have been reduced by bringing the responsibility for many important decisions out of the hands of expensive experts and closer to the consumer. These new techniques provide the first draft of a rough outline on how to create such a system in medicine as well.There is a very long way to go to build a health system that works for the 21st century. Little by little and bit by bit, people are finding ways of moving forward. The one mistake we must not make is to freeze existing structures and practices in place.