Notes From the Field: I have seen the future of healthcare | Hacker News Reader

Notes From the Field: I have seen the future of healthcare

nextbillion.net

29 pointsippisl41 comments

"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.

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.

"I'm hard pressed to name a single business in which consumers have been well served by call centers."

And certainly not in health support. A doctor/nurse needs to look for clues by looking at patient present physically. His expressions, general health, walk, any marks on his skins etc etc. Sometimes a patient will not tell something really important to his doctor because he (patient) might think it irrelevant.

> I'm hard pressed to name a single business in which consumers have been well served by call centers.

I can't speak for everybody, but I'm a big fan of the fact that my bank-experience is a credit card, an online app with digital signature features and a distant, streamlined call center. I can get someone on the line in seconds, 10 (I think) hours a day, 6 days a week. They can fix 80% of my problems immediately, and escalate the rest, in those cases they typically return my call in <24 hours. My favourite: No faux "we have a special, personal relationship, part of the community"-crap. My previous bank was 20 minutes away and was only open when I was at work. I had to take time off from work to do what I do in three minutes on the phone today.

I have the same opinion of my mortgage holder, except when I get on the phone with them, whereupon I have exactly the opposite of your experience: long wait times, incompetant first-tier support, a total lack of continuity across multiple calls, and inconsistent answers to questions. Fortunately, all I stand to lose from a major snafu with my mortgage is my house.

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).

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.

> I'm hard pressed to name a single business in which consumers have been well served by call centers.

Most of the time that I get on the phone to a big corporation I end up talking to someone in a call center.

There are certainly exceptions (phone company!), but I usually get adequate service. It's fairly common to get very agreeable, friendly, competent service.

We had a dial-a-nurse line in a town I used to live in. We used it several times, it was a very nice resource, and when we moved I missed having it. (That was about 10 years ago--I believe it is shut down now, FWIW.)

I get unbelievably bad phone service from:

* The phone company (for instance, my DSL goes down for 2 days because three tiers of tech support can't reset a DSLAM port without doing a truck roll first)

* My bank (for instance, it takes 1.5 hours in a grocery store parking lot to clear a bogus fraud alert on my debit card)

* My mortgage (for instance, it takes 3 30+ minute calls to successfully confirm receipt of a screwed up mortgage paymetn)

* FedEx (for instance, FedEx can't explain the difference between Freight and Standard shipping, doesn't know that they can't schedule a Freight pickup, and delays a shipment for a day)

* Airlines (for instance, it takes 30+ minutes to confirm that no support tier at Air Canada can fix screwed up seat assignments that take 4 minutes for a gate agent to fix afterwards)

* Taxi dispatches (for instance, I book a car a couple hours in advance, call multiple times to confirm, and find out 15 minutes after my deadline that no order was ever taken)

I'm being serious: I can't come up with an example where phone support involved a call center for me where I've had a good --- or even acceptable --- experience. Call centers are uniformly terrible. I'm convinced this is so because call centers have no incentive to be effective. They are pure cost centers, necessary evils for their owners. That's why so many of them get outsourced, further attenuating any accountability for their work.

Your experience is different than mine. I usually have an acceptable-to-good experience when I call a credit card company, which happens often enough. I have always gotten excellent phone service from my car insurance company (Progressive). YMMV I suppose.

A medical call center like the one described in the article doesn't need to be a cost center. I could easily see them being run as standalone companies.

You're right. I've gotten good results from Progressive. That's my one example.

The issue isn't so much that it's impossible to run a quality call center. It clearly isn't. The issue is that call center economics are rigged to favor operations that poorly serve customers.

The other people in this category (in the US) are physician assistants. As with many things, there is a religious level war over who is more competent.

In my experience, I have had less than satisfactory experiences seeing NP's and PA's, primarily because they clearly did not have the same depth of knowledge in a primary care setting. I remember once wondering if I was being seen by a medical student or something, then I looked at the name tag and saw that he was a PA. (Apply anecdotal disclaimers accordingly.)

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.)

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

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.

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.

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.

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.

Such a service has been running very effectively in the UK for over a decade, called NHS Direct: http://www.nhsdirect.nhs.uk

Can NHS Direct people write prescriptions over the phone?

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.

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.

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.

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.

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".

"It's extremely expensive, in time and dollars, to become a doctor; it takes 10-12 years."

If there were a large increase in medical schools, wouldn't the competition drive the price down?

It would also help if people could receive a greater range of medical treatment from trained professionals who were not full-blown doctors.

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.

This is interesting. Could you elaborate a bit?

http://www.overcomingbias.com/2009/07/meds-to-cut.html

robin hanson consistently blogs on this topic.

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

From first link: Unknown effectiveness - 46%

Unlike other sciences, medicine is mostly empirical science. The "new research" results we get every other day are evidence of this.

Unless we discover a law which governs our sickness and health, we are still in stone age in medicine whatever the progress this field claims.

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.

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

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.

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.

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?

The AMA has actually reduced the number of medical schools in order to control the doctor supply. The AMA is a cartel and nothing more. Lots of people want to go to medical school, but are unable to.

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.

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

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.

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.

I think this provides the best way to move forward in the way we address healthcare: http://online.wsj.com/article/SB1000142405297020425140457434...

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.

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