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A Modest Proposal

by Emily Friedman

First published in Hospitals & Health Networks OnLine, October 5, 2004

Let's just take health care offshore. No more irritating encounters with patients, no more angry nurses or strikes, no more sick people messing up the system.

It came to me in a flash earlier this year. I had been sent the wrong power cord by a computer company that makes a big deal about its supposedly award-winning customer service. (I would hate to know who lost that award!) I was trying to explain that the cord sent to me was for a different model of machine; the response I received, from someone who apparently lives in a galaxy far, far away, was, "It says here [on the screen] that if your battery is not fully charged, then you should...."

Let's Go Offshore

And it came to me: Let's solve many of the problems that are vexing health care by taking the enterprise offshore. After all, everybody's doing it; I have dealt with offshore customer service representatives who work for everything from airlines to software outfits to housecleaning agencies (an unsolicited call, I might add--I clean my own home) to cable television. The company saves money, the profits soar and who cares if the service is terrible or that people are working for slave wages half a world away? Who you gonna call?

Most important, none of the bigwigs has to worry about ever again being confronted by an angry customer or a dissatisfied employee. Offshoring provides executives with almost complete insulation from any kind of accountability. That would be even better than the approach taken by Richard Scrushy, former CEO of HealthSouth, who claimed that he was not responsible for the massive frauds and scandals involving his corporation because he was an absentee executive who spent most of his time on his estate in Florida and didn't really know what was going on at the firm.

This model would be perfect for health care. But we shouldn't rush into it willy-nilly; people might object. So let's implement it in stages.

Easy Steps First

First, we should automate all communication with patients and families. So many health care organizations do that now, what with automated telephone menus, Web sites and computerized appointments and consultations, that few lay people will probably even notice. They have gotten used to being unable to talk to a real human being within the health care system.

Next, we send the physicians to the spot I have chosen as the site for the virtual health care system: the Grand Duchy of Fenwick. Although they won't be making much money and will be sitting in front of computer screens all day, they will also be immune from frivolous malpractice lawsuits and won't have to deal with uppity patients who have their own ideas about their care. If you don't like what a patient is saying or asking, you can just terminate the connection. Besides, it is so difficult to get in to see physicians these days, especially if you have public coverage, that this arrangement might afford patients more contact with doctors than they have now.

The third stage would be to send nursing to the Grand Duchy. This would be possible because so many health care organizations have stretched their nursing staffs painfully thin that many patients no longer expect anyone to answer a call button. Furthermore, this will solve the problem of the United States' recruiting nurses from many nations where they were desperately needed. This way, we can send them back to where they came from while still employing them, albeit at a fraction of what they were making here. The fourth stage will be the robots and other automation. A patient who for some reason is not content to have his or her care provided over the Internet can go to a virtual clinic or virtual hospital, where he or she will be greeted by a robot and escorted to the proper machine. Samples for lab testing can be submitted to the lab machine, symptoms displayed to the diagnostic machine, medications provided by the pharmaceutical machine. If there is a need for injections or other forms of care, there are two options. We can provide interactive computer terminals where patients learn how to give themselves injections or do minor surgery on themselves. After all, "consumer-directed health care" is all the rage these days. For more complicated surgeries, there are robots that can be operated by physicians based in Fenwick.

Oversight can be provided by clinicians and administrators in the Grand Duchy, and on-site maintenance can be entrusted to low-paid techs who are located in secure bunkers so no one knows who or where they are.

Unresolved Problems

There are obviously a few problems that still need to be worked out, but I think I have found solutions to most of them. One is emergency care. The do-it-yourself model can work here as well, and specially programmed trauma robots can assist patients who don't happen to be conscious. After all, most emergency department visits are not for heavy trauma; many, in fact, are simply patients who have nowhere else to turn for primary or secondary care. And that brings up another benefit of this proposal: Many of the 100 million annual emergency department visits are made by uninsured, low-income patients. All we need do is arrange for the robots and automated care machines to be activated by a credit or debit card. No tickee, no washee. Furthermore, because offshore clinicians probably aren't liable under EMTALA, we can dump the uninsured out of our virtual emergency departments with impunity.

Childbirth might be an issue, but we must keep in mind that women were having babies on their own long before high-tech health care came along. Furthermore, the United States continues to have among the highest rates of infant and maternal mortality in the developed world, especially for people of color, so it isn't like we're doing such a hot job protecting mothers and children as things are.

Another challenge is how to provide hospice and palliative care virtually, given how labor-intensive and hands-on these services tend to be. Keep in mind that most of these services are provided in the home, so there are workable options. One is simply to extend the cooperative care model that has become increasingly popular, and instead of offering friends and families the chance to help care for their loved ones, we should simply require them to do so. After all, in many nations, prison inmates are dependent on friends and family for food, clothing and bedding, so there is precedent. And we can provide CD players free of charge to the dying, accompanied by soothing CDs of comforting words and easy-listening music. For those who have no one to take care of them, there is always assisted suicide.

The pathologists might complain that under this system, there is no way to conduct decent autopsies, but because no insurer or government entity is willing to pay for them, we are hardly doing any autopsies now. If a few people get away with murder, well, heck, there's money to be made!

As for the many buildings that used to house hospitals, physicians and long-term care, they can always be converted to other uses. Given the emergence of "niche" specialty care for the privately insured and "boutique" health care that charges large sums to patients who want timely appointments and physician visits longer than 30 seconds, it seems to me that there is a marvelous business opportunity here. Patients willing to pay whatever the market can bear can still be treated in person by real physicians and nurses--provided, of course, that they have ready cash.

And if there is still excess capacity, we can simply expand executive and board areas, adding amenities such as putting greens and hot tubs.

Great Results

Just think of what we can accomplish with this revolutionary proposal! Health care employers will no longer need to worry about strikes or unhappy employees; if these Third and Fourth World workers don't like the job, they can be replaced in a matter of minutes. There are a lot more where they came from.

More important, no one working in health care will ever again have to touch a sick or injured person, listen to a child whimper in pain, comfort the family of a person who is dying, explain a horrible patient safety disaster or deal with a "difficult" patient. If they don't like how we do things, we can simply crash their computers--if they even have computers. If they don't, all the better; they will have no recourse at all.

And thus we will finally have a system that has become what so many pundits, economists and theoreticians have been envisioning for years: efficient, hugely profitable, antiseptic and totally devoid of any direct human contact. Now, that's what I call progress!

First published in Hospitals & Health Networks OnLine, October 5, 2004

Emily Friedman 2004

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