Host Dr. Flowers, co-host Robin French, and VIP guest, Michael Zema, MD discuss Dr. Zema’s mission to deliver a much needed message about modern healthcare due to the lack of knowledge and degree of misinformation. He discusses his passion in writing the book to provide his readers a much broader perspective of the overall healthcare delivery system.
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Modern Healthcare Delivery: Deliverance Or Debacle With Michael J. Zema, MD [Episode 38]
Introduction To The Podcast
How are you?
I’m doing great. I’m excited about our guest.
We have Dr. Michael Zema. Dr. Michael Zema is the author of Modern Healthcare Delivery, Deliverance or Debacle: A Glimpse from the Inside Out. Welcome.
Robin, how about you read his bio? I think that’d be great.
I would love that. Dr. Zema is the former Professor of Medicine and Division Chief of Cardiology at the University of Tennessee Health Science Center in Chattanooga. His mission is to deliver a much-needed message about healthcare, a subject so fundamentally important to each and every one of us. The lack of knowledge and degree of misinformation that abounds is simply astonishing. His hope is to provide all of his readers, healthcare insurers, administrators, would be providers and patients additional insights whereby they may navigate more comfortably outside of their comfort zone, attaining a much broader perspective of the overall healthcare delivery system.
Thank you so much for joining us, doctor, and something resonated with me that I wanted to ask you about in this paragraph that she just read. “The lack of knowledge and degree of misinformation is astonishing.” Let’s start right there. I happen to agree with that, of course. I was wondering if you could give us a little bit of thought behind that.
If you turn on the news, whether it be cable or major stations, the so-called pundits who, on the exterior, seem to just exude knowledge are just giving misinformation. Half of them don’t know the difference between Medicare and Medicaid. Even among my colleagues, each one of us operates in our own little silo where if we’re a provider or an insurer or a hospital administrator or a nurse, we do our task and we do them very well, and we have very little knowledge about what’s going on in the other silos. The interconnectivity of those silos is our healthcare delivery system. If you talk to somebody outside their silo, you’ll find out they really don’t know much more than the layperson and certainly no more than the television pundits often. That’s very troubling to me.
We all operate in silos in healthcare, and that disconnection is affecting the entire system.
I use the same terms frequently in our practice at J. Flowers Health Institute in that patients come to us from all over the world looking for answers because they’ve been to some of the best healthcare institutions in the country looking for an answer and leaving with no answer. I’ll use a well-known institution up in the Midwest that will have multiple silos of experts. They go to one expert and they see that expert for an evaluation, and they spend 30, 40 minutes maybe with that person, and then they’ll go to the next person, the next person, and then they send in the central fax line the results of their evaluation. None of them talk to the other silos at all. The patient leaves just as confused or more confused than they were before they went into the system.
The Disappearance Of The Old Family Doctor
We’ve got a million lieutenants in the system. There is no captain. The disappearance of the old family internist, who was the assimilator of all the information from the various consultants, has left a big gap in healthcare delivery.
You had a chapter that that brings me to the Dr. Marcus Welby. Do you remember Dr. Marcus Welby? Talk to the audience about that chapter because he was the man back then.
Marcus Welby, portrayed by Robert Young in the early 1970s on ABC, was that avuncular physician who was not just a healer of body, but a friend, someone that you could confide in, perhaps a healer of even of spirit. He knew the family, knew their history, knew them by name, etc. That has disappeared. We can talk about why that disappeared, but it’s gone. Indeed, when I would talk to some of our house staff in training about that, their answer would be, “We don’t have time for what you did in your generation.” That didn’t make me feel well, by the way. We have to work faster than that now, so we just don’t have time for that. I reminded him of what an old-time physician once said. He said, “A patient does not care what you know until he knows that you care.” True words.
The family doctor who knew your history and cared for generations—that’s a practice that’s disappearing.
My grandfather was an old family practice physician down in deep South Texas. I grew up as a little boy with my grandfather making house calls. Patients came to his home. Patients, of course, he was at the hospital frequently, but in his private practice, he treated multiple family members of families and generations of families and knew the medical history of every single one of them.
I always just watched him as a kid during the summer. I spent every summer in his office working in my grandfather’s medical practice. It was a small medical practice in Alice, Texas. It was amazing seeing that. He retired when he was 92 years old, and I remember the day he closed his healthcare practice. It was this somewhat informal but formal closing of the vault and walking away. It was a really sad day for the town. They threw a little parade for him. I don’t think there’s been a physician like that since he retired. I own his medical bag from the entire time he practiced medicine. He has this beautiful alligator medical bag that I cherish, and I have all of his prescription pad and everything in it, and it’s one of my most prized possessions. I think you’re referring to the way he practiced.
As you know, that’s what drove a lot of physicians to retire early or to go into concierge medicine because they had no third good option.
What’s your take on concierge medicine in 2021, and your thought on concierge medicine and what it provides in the population in which see a concierge physician?
I think it came out of the time pressure in the patient visit. Let’s go back and say where did the 12-to-15-minute visit come from. It probably started with rvus from CMS, from Medicare. Before that, of course, physicians were compensated by reasonable and customary charges. The hmos jumped in in the late ‘80s and ‘90s as they partnered or took over practices and put a 7- to 10-minute limit on the amount of time spent during the patient encounter practicing.
Physicians were faced with a quandary. “My expenses are going up,” and they were during that time period. “How do I keep my income from falling? I can either do more services or more testing,” but the primary care physician was somewhat limited. How many visits could he cram into the hour? Things started to change, and we now have, on average, a twelve-minute visit in primary care with the amount of time spent discussing with the patient, the findings, the recommendations, and the next step being 90 seconds. Physicians, we took an oath and we look at that and say it cannot be done properly that way.
We looked at where our dollar was going. In this country, $0.73 out of $1 goes toward the patient care, and the rest is in billing, insurance and administrative costs. We said, “Let’s cut out the middleman. Let’s cut out the insurance person. Let’s start offering a better service to our patients.” That’s where concierge medicine came in. Number of different business models of concierge medicine, but they’re all probably better than what the physician has as an alternative.
I see a concierge physician in my own life for my own physician. The reason that I did that is I read your book typically; we’re used to going in and seeing the physician. The time started cutting down, and then the nurse practitioner or PA came in. We didn’t even get to see the physician anymore. I was like, “I’ve had it. I want to see my doctor,” and in order to do that, I had to join a concierge practice.
Every once in a while, you just reach that line and say, “No further, please. I’m out.”
Grading Modern Healthcare
You wait weeks and weeks to go see this physician, and you get there, but you don’t even see them. You see someone that they’ve handed you off to. You talk about that in your book. If you had to give today’s modern healthcare a grade, what would you give it? Not concierge medicine because that’s the way to go. What would you give it, do you think?
I’d probably give it a C for effort and a D-minus for outcomes and efficacy because I think we’re failing and the intelligent physicians and other providers know that we’re failing. We just don’t know how to cure the problem.
Physicians know the system is failing, but don’t know how to fix it. We’re stuck in a broken healthcare model.
Is that why we have a physician shortage right now? Is it because we’re just failing, and they’ve all become discouraged? The US has a physician shortage, right?
Yeah. The physician shortage, actually, it goes back a number of decades. The handwriting was on the wall, I think starting in the ’60, ‘70s and ‘80s, as more and more physicians went into specialty practice and less and less in primary care. Of course, you had LBJ’s war on poverty where he wanted to get primary care out to a greater number of Americans. You had the corpsman coming back from Vietnam. The nurse practitioner and the PA movement came at the right time, if you will, for the physician shortage.
Even right now, if you look at the AAMC, the American Academy of Medical Colleges, they’re telling us that the increase in physicians that we can expect between now and 2030 is about one half of 1% per year. Whereas the increase in PAs and NPs is averaging 5% per year each. Do the math here, and you can see where we’re going by 2025.
I just read an article. There is a record number of African Americans applying for medical school more than ever at this point. I wonder what you might attribute that to.
I’m glad to see that, because I actually looked at the national figures a while ago in medical schools. What we have is a great increase in the number of Asians. Particularly females, but Asian males also. African American females now comprise about 5% of medical students, but African American males are still down at 3% or less. That’s encouraging to see that.
When I went to medical school, I’m embarrassed because obviously, you can look up where I went. We had some 92 students in the first year. We had 2 African Americans, both male, and we had 4 females totally all White. Everybody else was a White male. Not good for the population that has to be served. We’ve come a long way, and I think this is the first year where actually female medical students have actually topped the number of male medical students.
I read that. I thought that was pretty darn amazing. Absolutely. A lot about what you write about is the flawed doctor-to-doctor and doctor-to-patient communication. What do you mean by that? I think I know what you mean by that, because I talk to my own patients about it every day. That lack of communication and that expectation of a physician just to, “I’ve got a hurry,” but what do you mean by that lack of communication?
It’s twofold. We have a doctor, doctor problem, and a doctor patient problem. Since I’ve alluded to some earlier things, let’s talk about the doctor patient problem first. If you’re going to spend 90 seconds discussing your findings and recommendations with the patient, and the next step, by definition, you have a doctor-patient communication problem. I’ve got to tell you, I’ve practiced down South here now for more than ten years. People down South are very amicable. It could take you five minutes to say hello down South. They want to talk about their grandbabies and this and that. That’s just the way it is. In 90 seconds, you’ve got to be kidding. That’s a real issue.
Try to reach your doctor. My son, I won’t divulge his medical condition, but he can try to reach his physician who’s very well-qualified. A hundred publications and peer review journals, etc., you can’t get through. You get the NP, you get the RN, you leave a message, you type something into the portal, you can’t talk to your doctor. That’s one half.
Now, how about doctor, doctor? That’s not much better. I even wrote a little editorial in our local newspaper about it some years ago. I remember the time when primary care would call me in as a cardiology consultant. He would spend 2 or 3 minutes on the phone telling me briefly about the case. I would do the consult, discuss things with the patient, and then return the call and spend 2 to 3 minutes discussing my findings and recommendations with him. It does not happen anymore.
When I asked our primary care here, “Why don’t you call me and tell me about the patient,” he said, “It’s in the EMR, the electronic medical record. Read it on your own. If you don’t, I’ll call somebody else as a consultant.” Really, that’s the way we treat each other. Can we expect the insurance companies to treat us any better?
Let’s talk about chapter six, the New World Order. Convenience Care. Tell the audience your views on this.
When retail medical clinics and urgent care clinics first came on the scenes, I remember I was in training. I’m not going to give away, but I remember our medical directors, and we all would disparage them a bit. We used to call them doc in the box. “The patient’s going to go to the doc in the box,” like it was Wendy’s to pick up a hamburger, but again, they were product of what we allowed to happen in medical care delivery. If you’re going to call your doctor and say, “I’m really not feeling well. I have a low-grade fever,” and be told, “I have nothing today. Give us a call tomorrow because something may open up,” then people are going to look for an alternative to feel better.
At this point in time, I’ve changed my mind. I’ve used them. I’ve sent my family to them. They have some pluses. They certainly have some minuses because of continuity of care issues. They have some potential minuses with regard to costs for the healthcare system. Due to the lack of continuity, the patient often, after doing the retail care visit will then see the physician anyway in the office, his or her physician, a week later. You get another charge to the national healthcare expenditure. It may not be saving money. It may be another layer, if you will, of healthcare expenditure, but I understand how it came about now.
Telemedicine And The Future Of Virtual Healthcare
You highlight telemedicine, telehealth, and virtual healthcare in your book. What’s your take on it?
I think it’s here to stay. I think the pandemic has lit a fire under CMS. Medicare had always been the laggard. Private insurers and Medicaid had picked it up pretty well even before the pandemic. They knew its limitations, but they were using it. CMS was using it as a pittance. It had so many requirements on where you could render the telemedicine service. I think that’s going to change. There’s a move underway in Congress, again, to have it changed. My own feeling is technology may help here. As a physician, I have a real problem when I can’t examine the patient. History is very important. The five fingers that I talk about in my book, the history, the physical, the lab data, etc. History is number one, but physical exam is number two.
If I can’t lay hands on both from a diagnostic and therapeutic laying on of hands, the patient is missing something here. Technology is trying to do it. We’ve got the technology now that will allow an NP, a PA or a technologist to go in there with the proper toys, if you will, and record heart sounds, take pictures of the eardrum and things like that, and do, if you will, home visits with telehealth to a physician or specialist. It’s not around the corner, but maybe those technological breakthroughs may take away some of the reticence that physicians like myself have of doing pure telehealth visits. I think they have a role, it’ll be increasing, but the laying on of hands, as we all know, is itself curative. Placebo of laying on of hands, and the reassurance is never going to be there from a telehealth visit.
Laying hands on a patient is irreplaceable. Telehealth may be increasing, but it lacks the healing power of touch.
What was your impetus for writing the book? I know what the idea was, but what made you say, “I’m going to sit down and write this book. It’s the right time, and is it important to get this news out there?”
As Robin had alluded to earlier, again, I thought the amount of misinformation out there was bad and was getting worse. I do watch the news. I do talk to my colleagues. I do stay up with modern medicine, and I said, “Somebody needs to put this into print. We need to get our arms around the issues that are facing us.” When I looked at the books that were written, they were written for healthcare administrators, for attorneys. They’re not written for providers of healthcare and/or their patients. That was the impetus. I said, “You’re going to have to do it because no one else is going to take the time to do it,” and it was a very time-consuming project.
Was this your COVID-year writing?
COVID years, plural. Yes, it was. Writing and reading. While I am a certified physician executive and Six Sigma certified, I still am a provider. It was my silo. I had been department heads, but again, that’s my silo. What was going on outside my silo. To me, it was an education. I had to educate myself first before I’m going to put things into print to try to help other people understand.
Advice For Finding The Right Physician
What advice would you give our audience out there who does not have a concierge physician or a close relationship? Even your own son who has you as a father, but still has a difficult time accessing his own physician. What’s your advice to people reading in finding the right physician, finding the right relationship, and getting through to your physician?
Number one, scout around in your provider network. Go online, read the reviews from patients, vital health, health grades, etc. None of them are perfect. That’s for sure. If you do 3 or 4, you can narrow your list down, then go. You’ll know on your first or second visit whether this is a match or not. If it’s not, don’t be satisfied. Keep going. More than likely, if you find the provider that we’ve talked about, he or she’s going to be somebody over age 50, more than likely. There are exceptions. Stay with them until they retire. If that doesn’t work, give a good look to concierge medicine and see if it’s a fit for you.
The last question that I had for you is, two of your chapters in your book are titled Better Healthcare For Less 1.0 and 2.0. What do you personally believe needs to be done for us to achieve better healthcare for less?
In 1.0, I basically discussed the things that have failed. Paid for performance, accountable care organizations, bundled payments, even Seema Verma, the outgoing CMS director, on a WebMD conference in October 2020, admitted that of the 34 pilot projects at the CMS Innovation Center has started since 2010, since the Affordable Care Act approved the innovation center, only 5 out of the 34 had successfully reduced costs. Only 3 of the 5 had reduced costs to the extent that they could possibly go nationally with it. She admits that it’s been a failure.
Where do we go from there? In 2.0 in the last chapter, I say what are the main drivers, of course, because that’s what this is all about. They hide it under the guise of quality, but it really is cost. Quality in our healthcare delivery system is still one of the best in the world. What’s the proof of that? The marketplace. Where do the Shahs and the Sultans all come to have their medicine? They come to the US. That means that the quality ultimately is here, but problem is the cost of maintaining it. At 18% of our GDP and growing it is not sustainable. A number of organizations have shown that the next highest cost per capita when normalized for GDP is 40% to 50% lower than us.
The rest of the world’s doing it for less than we are. What are the main drivers? Waste, unnecessary performance of services. In the fee-for-service model, you eat what you kill, if you will, you’re going to “kill” more. They’re going to do more things because you’re reimbursed on that basis. We can try to morph the fee-for-service system with appropriateness criteria, value-based criteria. I talk about both of those morphing tools in the book. We can change it and go to capitation.
That will certainly put some skin in the game for the provider. Remember, the provider is the head of the ship here. Without the provider, there are no services. Without those services, there’s no healthcare delivery. Without healthcare delivery, there are no costs. The provider is the gatekeeper. How do you change provider behavior? That’s what we discuss in that chapter. Defensive medicine, a big cost. How do we approach that? Tort reform.
The trial lawyers have one of the biggest lobbyists in Washington DC Right. Bigger than the AFL-CIO. Bigger than the doctors. Bigger than the teachers. Bigger than the entertainment industry. Good luck with having effective tort reform. Lastly, administrative costs. We talked about this earlier. $0.27 on $1 is not going toward clinical patient care. Here’s where the single payers keep coming back and they have a point. In the single-payer model, administrative costs would be cut considerably. Of course, there are the downside issues associated with the single-payer model, which are also discussed by me in that last chapter.
Universal healthcare, yes or no?
When we talk about single payer, ultimately, we’re talking about the bigger issue of universal healthcare. It’s single payer is universal healthcare in disguise. Whether universal healthcare is a right or a privilege, I discussed that in detail in the last chapter. Now, I wonder what our Founding Fathers thought in the Declaration of Independence in the Bill of Rights. It really can’t find that individualized healthcare is there, but if you poll even physicians, providers and look at single-payer, years ago, you find no more than 40% probably were in favor of it.
I think that’s up over 50% now as providers are getting fed up with running the marathon around all the objects that they have to do and all the hurdles that they have to jump over. As I point out in the book, just like same sex marriage, things change when the American people finally say, “The system is bad enough as it is. We need to move on, put our baggage aside and take a look at the pros and cons of single-payer,” which ultimately is going to be universal healthcare, which is what single payer is in disguise.
Thank you, again, for being on the program. Everyone, again, the book is Modern Healthcare Delivery, Deliverance or Debacle: A Glimpse from the Inside Out. Michael J. Zema, MD, thank you.
Available on Amazon and Barnes & Noble.
Also available on all the platforms online, all of them.
We would love to have you as a guest in person sometime soon. Thank you so much for what you did. That’s an amazing book, and all the best to you.
Thank you.
Thank you so much for having me on and helping me get the word out.
Thanks so much.
I’d like to remind everyone that there are numerous platforms to find our show, YouTube, Apple Podcasts, SoundCloud, Spotify, Stitcher, and iHeart Radio. Please help us out by subscribing to our show, liking it, and sharing it. Thank you. Thank you Dr. Flowers. Thank you, Dr. Zema. See you next time, everyone.
Important Links
- Dr. Michael Zema
- Modern Healthcare Delivery, Deliverance or Debacle: A Glimpse from the Inside Out
- Barnes & Noble – Modern Healthcare Delivery, Deliverance or Debacle: A Glimpse from the Inside Out
- YouTube – Understanding The Human Condition
- Apple Podcasts – Understanding The Human Condition
- Spotify – Understanding The Human Condition
- iHeart Radio – Understanding The Human Condition
