As an account of his personal experiences, Discovering the Cause and the Cure for America’s Health Care Crisis: A Physician’s Memoir, Roger H. Strube, MD, succeeds in describing the personal experiences that shaped his vision for the future of health care. But if you’re looking for the “cure” promised in the title, you may have to wait for his promised next book.
In the preface, the author notes that the book is not intended to be an academic paper. His goal was to enable a layperson to understand the cause of the crisis. He intends to release a second book that would include more technical information and his opinion on how the healthcare system should be changed.
The forward is written by Wesley R. Wallace, MD, a retired orthopaedic surgeon and former medical director of the Health Plan and the Medical group, a part of Dartmouth Hitchcock. Dr. Wallace shares the author’s concerns about the utilization of resources and sustainability of the current U.S. healthcare system. He also supports the author’s analysis of the current system and proposed changes.
This book is based on the author’s recollections of his education, years in private medical practice, and experiences in healthcare administration. After graduating from Marquette Medical School in 1968, Dr. Strube entered a 1-year internship with plans to pursue a residency in either orthopaedic surgery or radiology.
The 5 additional years of residency and the stressful schedule of night call and emergency department coverage required for orthopaedic surgery were factors in his decision to go into radiology instead. But after completing two thirds of the radiology residency, he made the decision to enter a general practice.
After 2 years of group practice, Dr. Strube opened a solo practice in Wisconsin. It was this practice experience that gave Dr. Strube his first exposure to the realities of trying to cover overhead in a fee-for-service environment. When Medicaid rates for office visits were reduced to the point that he could no longer cover his overhead expenses for these patients, he stopped billing Medicaid and limited the number of Medicaid patients he saw.
He also realized that Board certification was a necessity for long-term success in practice. The newly formed American Board of Family Practice offered certification without completing a residency. Candidates were required to meet specified continuing education requirements and successfully complete a written examination. Through this mechanism, Dr. Strube became Board certified in 1977. His practice administration experiences also included the purchase of a practice and part ownership of a computed tomography scanner.
Dr. Strube’s introduction to managed care administration was through his role organizing an independent physicians association (IPA) in 1980. He left clinical practice in 1985 to begin a new career in administrative medicine. Since then, he has held a variety of medical director positions in several different organizations and been involved in utilization review and quality assurance, primarily in health maintenance organizations (HMOs).
Dr. Strube believes that physician decision making is flawed because physicians rely too heavily on memory-based decision making. He argues that it is impossible for physicians to recall the vast amount of medical information available. He advocates for the full integration of electronic, problem-oriented medical records with fully integrated medical support tools. He believes that this is the most important step toward establishing high-quality, cost-effective medical care.
Dr. Strube advocates establishing reliable metrics and reporting results in publicly available facility and provider report cards. It is his opinion that discussions about consumer-based health care and cost control through competition without report cards are meaningless. In his view, Congress needs to require universal, single-payer funding for health care and to have private, not-for-profit claims-processing organizations administer the program.
For readers who are contemporaries of Dr. Strube, the book may provide an opportunity to recall early experiences in medical education and residency. Unfortunately, the book is short on substance in its analysis of health care in America. The author’s healthcare administration experience has been primarily in an HMO environment, which substantially influences his perspective.
I found it interesting that he relied on his memory to recount his clinical and administrative experiences, while simultaneously criticizing the use of memory-based decision making by practicing physicians. He proposes solutions to the healthcare crisis without providing substantive evidence to support his positions.
Many factors must be considered when designing the ideal approach to future health care. A reader seeking a well-researched, factual analysis of the current healthcare system and meaningful comments on the impact of various solutions will be disappointed. Perhaps the author will provide a more comprehensive, researched analysis of the options in his planned next book on the subject.
Stephen A. Albanese, MD, is a member of the AAOS Now editorial board and professor and chair of orthopaedic surgery at Upstate Medical University, Syracuse, N.Y.