Dr. Welby, Dr. Watson and the Future of Health Care

Brett Sparks, February 10, 2016

You’re sick and call your neighborhood doctor’s office. You are connected to Dr. Welby. You’ve known Dr. Welby for years. Dr. Welby sees your family and many of your friends. He asks about your dog by name, listens to your health complaints and then says he will send a prescription to your pharmacy. If you’re not better in a couple of days, he would like to see you in the office.

The next day, you call back with a question and are connected to Dr. Watson instead of Dr. Welby. Dr. Watson accurately summarizes your visit with Dr. Welby and also asks about your dog by name. Dr. Watson listens to your question and provides a detailed answer including options based on how you feel in the coming days. Dr. Watson reminds you that you should be seen in the office if you don’t feel better.

The difference between Dr. Welby and Dr. Watson? “Dr.” Watson is a machine. Watson has encyclopedias of knowledge regarding best practice, evidence-based medicine at its fingertips. Watson is always on call, never incurs overtime and never complains about his patient load.

Sound crazy? IBM doesn’t think so. Their web site touts the power of Watson (CLICK HERE). While the video focuses on making research trials accessible to patients, the reality is that primary care health care corporations see Watson as a method of effectively triaging patients. The above scenario with Watson in your neighborhood doctor’s office is unlikely—unless your neighborhood doctor has already joined a corporate practice.

“What about Dr. Welby?” you ask. “Won’t Watson hasten the demise of the traditional neighborhood doctor?” Watson won’t hasten the demise, but it might throw a few handfuls of dirt on the grave. The traditional neighborhood doctor depicted in Norman Rockwell paintings and sitcom television is already, basically, dead. The majority of physicians owned their practices in 2000, but it is estimated that less than a third of physicians owned their practices in 2013 (CLICK HERE). The majority of physicians now work for hospitals, large corporate practices or insurance companies (CLICK HERE). Given the changes in health care, the chances of the pendulum swinging in the other direction are small.

The demise of Dr. Welby was partially due to regulatory changes. When Dr. Welby started practice years ago, he didn’t have to worry about OSHA, HIPAA, the American Recovery and Reinvestment Act of 2009, the ACA or the host of other regulations applying to health care practices today. Dr. Welby’s office manager was concerned with the basics of running an office, such as ensuring that office and medical supplies were available, taking care of the staff and paying the bills. Today, Watson’s office is run by a team of administrators including a Compliance Officer, HR Manager, IT Director and Risk Management Lead to navigate government regulations.

Dr. Welby was also done in by insurance company reimbursement. Primary care was under represented in the creation of the coding/billing system that communicated medical services in number format (CPT codes). As a result, reimbursement favored procedures done by specialists over the management performed by primary care. Lacking the big ticket billing items of specialists, primary care was encouraged by insurance companies and vendors to add services–only to watch as the reimbursement for the additional services was reduced or eliminated altogether. Today’s reimbursement favors quality population management–think the Accountable Care Organizations supported by the Accountable Care Act–that exclude physicians like Dr. Welby.

Finally, because Dr. Welby didn’t have the market strength to command increased reimbursement, the only way for Dr. Welby to generate even the same revenue when faced with falling reimbursement was to see more patients. Each cut in reimbursement or additional cost created a need to see even more patients. Each equipment investment that was no longer covered by insurance created a need to see even more patients. Each additional government regulation and its associated cost created a need to see even more patients. Over time, Dr. Welby went from seeing 18-20 patients a day to seeing 50-60 patients a day without any increase in take home pay. In fact, Dr. Welby was further in debt at the end of his practice than he was at the beginning of the practice due to the large carrying costs of operating the practice.

As Dr. Welby’s practice disappeared, corporate practices thrived. They added the Dr. Welbys of the world and new physicians who wanted nothing to do with the business side of medicine, (and who knew nothing about the autonomy of ownership, the work of building a practice or the joy of identifying a patient as their own). This horizontal expansion in markets was coupled with vertical expansion into specialties, urgent care facilities, hospices and hospitalists. Larger corporate practices contracted with larger insurance companies for larger populations of patients. These contracts were far more lucrative than any contract offered to Dr. Welby.

And so Dr. Welby said goodbye to the practice he started years ago. Most Dr. Welbys joined the corporate practices that put them out of business or began competing in the market as a different type of practice. Neither option is the same as the practice Dr. Welby knew for so long. Both options damaged Dr. Welby’s rapport with patients. Corporate medicine prioritized patients based on preferred contracts and sought to diminish the physician-patient relationship, (to reduce physician leverage), while concierge practice limited the number of patients Dr. Welby could see to the first 600-1,000 who could afford the retainer fee.

It is unclear if the system will ever produce more Dr. Welbys. Dr. Welby went through medical school and residency, set up practice and was hands-on involved in the care of his patients. Dr. Welby saw the direct impact of his management decisions on patient care. Dr. Welby had a rapport and a connection to his patients that Watson will never emulate. Many patients are going to miss Dr. Welby.

Dr. Welby’s peers in the corporate world have spent more time building templates and care processes than they have spent building patient rapport. The corporate physician’s patient experience led to their management career–and led to leaving direct patient care behind. The corporate world is full of MDs without patients. They are not Dr. Welby—they are more like Watson.

And when all of the Dr. Welbys are gone from the health care system–or relegated to isolated practices for those with the means to afford them–the rest of patients will be just part of the population being managed by the corporate practices, the insurance companies and the government. Maybe Watson will work out. Computers are amazing. Maybe the new generation of patients won’t know what it’s like to have rapport with their physician that hasn’t been programmed. Or maybe we’ll be left with something like this (CLICK HERE).

©2016, Brett Sparks, e3Business.