Blueprint for a Gold Medal Health Care System*: *Right here in America, leader of the free world

By Jeffrey Fraser

NOTE: All of the author's proceeds from sales of this book will be donated to the National Association of Free & Charitable Clinics.

If you believe that America has the greatest health care system in the world then this book may cause you to reconsider. The truth is that our health care system is riddled with deeply rooted flaws. It is certainly not the product of intelligent design. Too often it has put profits ahead of good science and cost-effectiveness. Unfortunately, the system is highly resistant to change because of all the powerful players who have a vested interest in the status quo. Nevertheless, Americans deserve better. We have the technology. We have the resources. What is needed is a vision. And a blueprint.

The vision and the blueprint in this book are the product of over thirty years of observations and experience in the field of medicine, from my education and training at highly regarded academic institutions to my practice of neurology at a county-owned safety net hospital in the heart of Silicon Valley.

The solutions to the problems that are afflicting our current system are within our reach. Many of these solutions already exist, but cannot be fully utilized because of the extremely fragmented structure of our health care system and because of the absence of proper incentives for rational best practices. Doctors are burning out, at a rate of up to 50% in some specialties, because at some level they realize that they are working in a broken system. Of course, people are afraid of changes that are needed. Nevertheless, the benefits will be enormous. Better health care for less money will be worth it. No longer will patients, doctors, and insurance companies find sometimes find themselves in a three-way adversarial relationship. This Gold Medal System will restore the doctor-patient relationship to the sacred status that is deserves.

• Language: English
• Publisher: BookBaby
• Release date: Jan 12, 2021
• ISBN: 9781098347857

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©2020 Jeffrey Fraser, MD. All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the author, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law.

ISBN: 978-1-09834-784-0 (paperback)

ISBN: 978-1-09834-785-7 (ebook)

Table of Contents

Chapter 1. My Perspective on the Problem

Chapter 2. The Blueprint for a Gold Medal Health Care System

Chapter 3. Scientific Rigor

Chapter 4. Telemedicine, the Electronic Medical Record, and Artificial Intelligence

Chapter 5. Quality Assurance, Quality Improvement, Peer Review, and Mentoring

Chapter 6. Provider Group Managers: The Cat Herders

Chapter 7. Compassion, Compassion Fatigue, and Burnout

Chapter 8. The New Economies of a Gold Medal Health Care System

Chapter 9. Case Studies from a Gold Medal Health Care System

When the truth is found to be lies,

And all the joy within you dies …

You better find somebody to love

—Darby Slick

Note to reader: Throughout this book, I use the terms doctor, physician, and clinician interchangeably. Furthermore, the reader may infer, whenever I use those terms, that I am also speaking of nurse practitioners and physician assistants, whenever such an inference makes sense. The more generic, all-encompassing term, health care provider, simply sounds too vague for my taste. For example, the counsel health care provider, heal thyself lacks a certain je ne sais quoi.

Chapter 1.

My Perspective on the Problem

I am a physician, and I am embarrassed by our health care system in America. It is unjust, inefficient, and far too overpriced. The promises made by the medical–industrial complex are often self-deluding and sometimes downright fraudulent.

If you don’t understand where I am coming from, read this: America can afford a world-class health system. Why don’t we have one? Our system takes from the poor and working class to generate wealth for the already wealthy, by Anne Case and Angus Deaton, an opinion piece by the authors of Deaths of Despair and the Future of Capitalism.¹ In their article, they describe many of the injustices inherent in our system. Two major flaws eloquently elucidated in their article are striking to me. First is the subtle and not-so-subtle emphasis on profits evidenced by the marketing of services and procedures that are expensive but of relatively low value to the health of the patients. Second is the employer-based insurance system. Not only does this system place a hidden financial burden on companies and citizens alike, it all too often leaves patients uninsured when they need health care the most. The COVID-19 pandemic has shone a harshly critical light on this flaw. They conclude, We are believers in free-market capitalism, but health care is not something it can deliver in a socially tolerable way.²

Other weaknesses of our system have been glaringly highlighted by the COVID-19 pandemic. If you are unconvinced, read this: What the coronavirus crisis reveals about American medicine: Medicine is a system for delivering care and support; it’s also a system of information, quality control, and lab science. All need fixing.³ In particular, consider the author’s scathing critique of our failure to realize the true potential of the electronic medical record (EMR) due to the fact that American medicine operates primarily in a fee-for-service world. Speaking of the COVID-19 pandemic, the author points out the frustrating experiences of his colleagues as they realize over and over again that the EMR has been co-opted by health systems administrators and billing departments as a means of maximizing revenue capture. As a result, doctors wind up needing to document trivial information in a bloated note, such that the more vital information—information crucial to other doctors caring for that patient—gets lost in the weeds.⁴ Equally tragic is the realization that the EMR could be a revolutionary tool for conducting on-the-fly research on specific diseases (including especially new diseases like COVID-19) and their symptoms, complications, and treatment results. Unfortunately, leveraging the advantages of big data is currently impossible because of privacy concerns, poorly designed EMR systems, and a highly fragmented health care system. In its current form, the EMR is certainly not designed primarily to facilitate rapid searches based on symptoms, diagnoses, complications, or outcomes. Finally, we miss out on another huge potential advantage because of the shocking truth that the EMRs of different health care facilities often don’t interface with each other, so that doctors often have either to wait for outside records to be hand-delivered or to duplicate tests done previously.

I am a neurologist, and I am discouraged by our health care system in America. In fact, I was so discouraged, I burned out. According to a 2020 Medscape survey, 42% of physicians across all specialties reported burnout.⁵ Burnout has been described as long-term, unresolvable job-related stress that leads to exhaustion, cynicism … and lack of personal accomplishment.⁶ Among individual specialties, neurology came in at number two, with a burnout rate of 50%. Doctors are burning out because they know that they are working in a broken system, a system that does not reward them for providing compassionate, evidence-based care. If you are skeptical, read Doctored: The Disillusionment of an American Physician, by Sandeep Jauhar, MD.⁷ Here is a blurb from Dr. Jauhar’s own website:

"Hoping for the stability he needs to start a family, Jauhar accepts a position at a massive teaching hospital on the outskirts of Queens. With a decade’s worth of elite medical training behind him, he is eager to settle down and reap the rewards of countless sleepless nights. Instead, he is confronted with sobering truths. Doctors’ morale is low and getting lower. Blatant cronyism determines patient referrals, corporate ties distort medical decisions, and unnecessary tests are routinely performed in order to generate income. Meanwhile, a single patient in Jauhar’s hospital might see fifteen specialists in one stay and still fail to receive a full picture of his actual condition.

"Provoked by his unsettling experiences, Jauhar has written an introspective memoir that is also an impassioned plea for reform. With American medicine at a crossroads, Doctored is the important work of a writer unafraid to challenge the establishment and incite controversy."⁸

I’ll say it one more time. I am embarrassed and discouraged.

I have a vision for a world-class health care system. What qualifications do I have that might lend some gravitas to my proposal? I am not an academic. I have published three articles in peer-reviewed medical journals: two shortly after my residency and one recent article in the journal Pain Medicine.⁹ Mainly, my qualifications are based on my experiences during almost thirty years of practice at Santa Clara Valley Medical Center (SCVMC), a large public hospital in the heart of Silicon Valley. I completed my residency in neurology and a fellowship in electromyography and neuromuscular disorders at the University of California, San Francisco (UCSF) in 1991. I have been involved in the clinical training of Stanford medical students and neurology residents throughout my thirty years at SCVMC. I have talked to fellow physicians, primarily neurologists, who have worked in the Kaiser system, in private practice, and in the world of academic medicine at UCSF and Stanford. I have long admired the Kaiser Permanente system. Kaiser Permanente is an integrated managed care delivery system. In