Author Dr. Michael Zema On What We Must Do To Improve The US Healthcare System
Each of us is personally affected by the modern health care system and often the complex and ever-changing rules and regulations can make it seem uncompressible. This is why having the expertise of the esteemed physician and author Dr. Michael Zema is extremely helpful in understanding every step of the process.
The extremely accomplished Dr. Zema received his medical degree from Cornell University Medical College and completed his post-graduate Internal Medicine training at the North Shore University Hospital in Manhasset, Long Island. His credentials include subsequent Fellowships in Cardiology at that institution and The New York Hospital Cornell Medical Center in Manhattan, New York.
He is a distinguished Fellow in the American College of Physicians, American College of Cardiology, American College of Chest Physicians, and the American College of Clinical Pharmacology among others, and is a Certified Physician Executive of the American Association of Physician Leadership and a Six Sigma Green Belt in Healthcare.
Dr. Zema has written numerous publications in professional medical journals and, most recently he wrote the comprehensive book, Modern Healthcare Delivery, Deliverance or Debacle — A Glimpse From the Inside Out.
“For many not directly involved themselves in healthcare, their exposure to the system thankfully is often relatively brief, intermittent, and largely gleaned from the outside looking in,” Dr. Zema recently explained. “However, this book is directed at those who dare peek at what’s on the other side of the curtain — healthcare delivery as seen from the inside, looking out.”
Dr. Zema, since the 2020 election healthcare delivery per se has not gotten much attention. Why is that?
With the daily headlines, everyone has been laser-focused on the COVID-19 pandemic and the government’s, insurers, and healthcare establishments’ unprecedented and unrestrained response to this calamity. While necessary and commendable, this behavior has cloaked the appearance of the 800-pound gorilla still lurking in the room — the broken healthcare delivery system — that after COVID-19 fades away once again will be front and center. Witness the September 18 headline in the Washington Post Business Section: “The days of full COVID coverage are over. Insurers are restoring deductibles and co-pays leaving patients with big bills.”
Your well-researched new book Modern Healthcare Delivery, Deliverance or Debacle has a somewhat provocative title. Could you explain your choice of words to our readers?
With the explosive growth that has taken place in modern medical technology coupled with the now palpable ability to unharness the inherent potential of artificial intelligence, deliverance from the illnesses that have plagued mankind may finally be within reach. However, complete fulfillment poses a number of hurdles that must be overcome and await the creation of a delivery system that can facilitate timely, efficient, and appropriate access to healthcare for those in need at a cost that is sustainable.
With U.S. healthcare spending continuing to spiral upward out of control since 1980, now approaching 18 percent of gross domestic product, serious change in the delivery of care will be needed if we are to prevent a financial debacle. Over the years, there have been multiple attempts to rescue the system, applying layer upon layer of relatively ineffectual “Band-Aids” aimed at containing the fiscal hemorrhaging while still attempting to maintain quality. With each layer have come an increasing number of agencies with their myriad of rules, regulations, and administrative gobbledygook, the sheer complexity of which often prohibits requisite navigation within what ostensibly appears to be a feckless debacle.
What has surprised you the most about the public’s perception of healthcare delivery and how did it lead you to write your book?
I was struck by the general community’s naiveté about a subject so fundamentally important to each and every one of us. We all someday will have an interaction with that system in one manner or another — some, but not all of these experiences will be positive. The lack of knowledge and degree of misinformation that abounds was simply astonishing. Not only was this evident among colleagues and acquaintances with whom I would periodically engage in casual conversation, but also, among so-called TV pundits who all too often can’t even seem to properly differentiate Medicare from Medicaid.
Whether healthcare insurer, administrator, practitioner, would-be provider, or patient, each essentially operates within their somewhat exclusive “silo,” often oblivious of the other silos around them, as well as the multiple interactions across these silos necessary to maintain the functionality of our rather complex healthcare delivery system.
My hope was to provide each of these groups additional insights whereby they might navigate more comfortably outside their silo, outside their comfort zone, attaining a much broader perspective of the overall healthcare delivery system.
You’ve mentioned that healthcare delivery today is extremely complex. Why do you feel particularly qualified to comment upon it?
While also having been a patient on the “outside” more times than I might wish to remember, I have spent over forty years in the healthcare arena on the “inside” in one capacity or another, as a physician trainee, a medical practitioner in the Northeast, Southeast and Pacific Rim, member of a hospital medical board, vice president of a physician independent practice association, board member of a physician holding company, pharmaceutical industry and malpractice legal consultant, chief of cardiology at both community hospital and academic medical centers, professor of medicine at two-state university colleges of medicine, and physician clinical reviewer for a large national radiology benefits manager. Needless to say, unlike some other so-called “pundits,” I have actually walked the walk and not merely talked the talk. I have operated in all of the above silos, at times even simultaneously, and at least in that sense feel somewhat uniquely qualified to offer a credible glimpse (at healthcare delivery) from the inside out.
What makes your book different from so many others that have already been written on the subject of healthcare delivery?
Unlike many books on this subject which have been written by and for those directly involved with the administrative or medicolegal aspects of healthcare, my book is directed primarily at the actual providers of healthcare: physicians, mid-levels, nurses, technicians, technologists, clerical staff, and even more importantly those who are or someday will be patients. Today’s modern medicine is data-driven and complex; so, I’m afraid, is its delivery.
Couple this with a healthcare delivery system that has evolved piecemeal over nearly three-quarters of a century, and you can begin to appreciate the formidable task of presenting in a comprehendible fashion the pertinent milestones that have occurred. To better demonstrate their relevance to everyday life, where possible I have attempted to introduce these developments using patient-simulated examples quite characteristic of the interactions regular folks can be expected to have with the healthcare system. Plenteous footnotes allow the reader access to the medical jargon necessary to fully appreciate what might otherwise be difficult concepts. The book can be read in whole or in parts depending upon the background, interests, and needs of the reader — there is, something for everyone.
You say there is something in your book for everyone. Can you give us a peek at what types of issues are discussed in some of the chapters?
Of benefit to all is a primer on health insurance including how both medical providers and hospitals get paid for their services. The education, training, licensing, and credentialing of the cadre of individuals functioning under the auspices of the nursing department including the Certified Nurse Assistant or “nurse’s aide,” Certified Medical Assistant, Licensed Practical Nurse, Registered Nurse, Clinical Nurse Specialist, and Certified Nurse Practitioner are presented helping the reader fathom the panoply of letters — CNA, CMA, LPN, RN, CNS, CNP, DNP — which otherwise might merely resemble just alphabet soup. The history, current, and potential future roles of the nurse practitioner, physician assistant, and hospitalist in the delivery of U.S. healthcare are revealed.
In a chapter entitled “Convenience Care,” the history and current status of the retail medical clinic and urgent care center are presented along with their potential impact upon cost, convenience, quality, and continuity of healthcare delivery. Also examined are the roles of telemedicine today and potentially in the future, including legislative, regulatory, costing, and quality concerns that must first be satisfactorily addressed before this venue is ready for prime time. Chapters dealing with the electronic health record, quality and value in healthcare, and the drivers of healthcare costs are better directed at those involved with the delivery of healthcare itself but are presented in such a fashion that with a bit of effort others can follow along.
What are some of the drivers of healthcare costs that stand in the way of attaining a healthcare delivery system that delivers high quality, is more equitable, and still nevertheless remains fiscally sustainable? At this point in time, can the system be fixed?
This is a convoluted question to which I devote the last few chapters of my book. As it has evolved piecemeal over nearly a century, healthcare delivery today is complicated. Anyone who believes that its multiple ailments are amenable to a simple solution, be it Obamacare v2.0 or Medicare-for-All, is at best naïve and at worst just foolish. As H.L. Mencken once stated, “For every complex problem there is a solution which is simple, direct, and wrong.”
I point out that “waste,” as best exemplified by the performance of needless services may be the final common pathway for a certain number of cost drivers such as the practice of defensive medicine, and the potentially self-serving fee-for-service payment model by which most providers are still compensated today.
Please tell me more about this.
Interestingly studies across various populations have revealed that up to one-third of care provided has been either of equivocal value or inappropriate regardless of whether care had been provided in a single-payer or fee-for-service environment. Other heavyweight contributors include the excessive administrative costs associated with a multi-payer system, and the various financial barriers to patient care, the latter ultimately trickling down to the lack of a fiscally and politically acceptable form of universal healthcare.
Are there solutions for these problems?
Yes. For these and others, I offer potential solutions designed to maximize value without diminishing quality. Examples include an expansion of “safe harbors” for medical liability, enhancement of front-end clinical decision support tools, and addition of a separate value metric to an appropriateness score by which to judge clinical situations and their dollar reimbursement. While solutions such as these, might themselves be criticized as mere clones of already existing interventions, in my opinion, they can be made sufficiently distinct so as to be worthy of a trial.
More draconian in their reach might include replacement of the traditional medical negligence standard by a gross negligence standard, “health courts” replacing regular judges and juries with specialized judges making binding determinations drawing upon advice from “neutral” experts, replacement of the fee-for-service (“eat what you kill”) payment model by a capitation environment whereby a set amount of dollars per patient enrollee per contracted period is allocated to a physician or group of providers whether or not the enrollee ultimately has sought care, and replacement of the current multi-payer system by a single-payer such as “Medicare-For-All.”
What else do you want to share with us about your book?
In my book for purposes of clarity, I discuss these separately but make the point that in reality many of these drivers are inexorably interlaced, and as such, any potential solution to one will have requisite effects upon the others.
For many of these drivers to be meaningfully mitigated, if not expunged, a change in behavior on the part of the physician is going to be necessary. I discuss the motivations which must be in place to effect such a change in provider behavior. Why is this necessary? Because these individuals are the gatekeepers of healthcare resources that ultimately result in downstream healthcare costs.
While hospitals may provide the needed infrastructure and insurance companies and healthcare organizations the needed administrative support, it is the physician or alternate healthcare provider who serves as the gatekeeper for the patients’ entry into the healthcare system. Without the healthcare provider, there can be no healthcare delivery, no use of healthcare resources, no healthcare outcomes, and of course, no resulting healthcare costs.
Where can we find your book?
In print, you can find it available at your favorite bookstore, Amazon, or Barnes & Nobles. As e-books, it is available at Amazon Kindle, Barnes & Noble’s Nook Books, Google Play & Apple Books.