— The focus shouldn’t be on quantity over quality
by Arthur Lazarus, MD, MBA
This post originally appeared on Kevin M D
I was having a conversation with a colleague about a state-funded Medicaid managed care organization (MCO). She told me that the mental health performance measures used by the state to evaluate the MCO were all “placement and provider issues,” such as the amount of time children spent sleeping on the floors of social services offices or languishing in emergency departments (EDs) before being transferred for treatment or placed into foster homes.
The performance measures used by state officials also included the number of adults waiting in hospital psych units to be transferred to state hospitals and the number of children and adults waiting at home to receive outpatient services or enhancements to current services.
“This is not how MCOs should be measured,” my colleague said.
“How disgusting,” I replied. “Medicine has become the McDonald’s of healthcare – drive-through services, where the only thing that matters is throughput and not quality.”
“To make matters worse,” I continued, “politicians and lawmakers created the resource shortage in the first place by failing to recognize the mental health crisis and plan for it by allocating more dollars toward essential services. Now they blame MCOs and everyone else for the service bottleneck. If that’s not a case of the pot calling the kettle black, I don’t know what is. Perhaps we should all take out construction loans and build more hospitals and residential and assisted living facilities?”
I admit, this is not an original idea. Health insurers have been dabbling in the brick-and-mortar business for years and, vice versa, provider-based organizations have ventured into the world of health insurance. It’s just that there is such an intense push for healthcare to be more accessible to patients, especially psychiatric patients.
After all, the lack of access to evidence-based mental healthcare is the root cause for the mental health crisis in America. We must act urgently to overcome common yet difficult barriers to treatment — geographic, financial, cultural, structural, and social (poverty, education, support networks, etc.) — and do a better job of integrating psychiatry and primary care medicine.
Perhaps we should follow McDonald’s lead. McDonald’s pioneered the fast-food industry and is known for its efficiency and accessibility, being available worldwide. McDonald’s is also vertically integrated — meaning that the fast-food chain processes the meat itself, grows its own potatoes, and transports its own materials.
With the rise of telemedicine and retail clinics in locations like pharmacies and supermarkets, the future of medicine is already beginning to resemble the fast-food industry with “fast medicine.”
The comparison of modern medicine to McDonald’s illustrates many trends and issues in healthcare apart from accessibility and integration, such as the drive (no pun intended) for standardization and consumerism and the over-reliance on technology. Here are some ways in which medicine has become the “new McDonald’s” of healthcare:
Standardization: Just as McDonald’s has standardized menus and processes across its outlets, healthcare has seen a significant rise in standardized treatment protocols and guidelines. This is meant to ensure consistency and quality of care. However, critics argue that it might lead to impersonal care and overlook individual patient needs. It’s no wonder rival Burger King came up with the slogan “Have it Your Way” (abandoned in 2014 and now “You Rule”).
Drive-through approach: The pressure to see more patients in less time can lead to a fast drive-through approach in healthcare, where the focus is on quick, high-volume service rather than personalized care. This can result in rushed appointments and a lack of comprehensive care. It’s not uncommon for office staff to instruct patients to wait “curbside,” in the hallway, at the end of a visit for their paperwork, lab slips, and other business.
Consumerism: Like McDonald’s, healthcare has also seen a shift toward consumerism. Patients are increasingly viewed as consumers or “clients” who are told they have choices in healthcare providers and decisions. But instead of delivering care that is person-centered, the emphasis on consumerism has aided marketing by rebranding healthcare. Interstate billboards advertise hospital ED wait times, but how good is the quality?
Cost efficiency: Both McDonald’s and modern medicine strive for cost efficiency. In healthcare, this often means a focus on reducing hospital stays, increasing use of technology, and streamlining processes. However, this drive for efficiency can sometimes compromise patient care and outcomes by neglecting education and prevention and increasing medical errors and staff burnout.
Dependence on technology: Just as McDonald’s uses technology for order taking and processing, healthcare has become increasingly dependent on technology for patient records, diagnostics, and treatment. Soon we’ll be selecting treatment options from kiosks, like keying in our choice for a Big Mac over a double cheeseburger — sorry, “super-size” is no longer available.
Fragmented care: Similar to how a McDonald’s meal is often made up of different components prepared at different stations, healthcare can often be fragmented with different specialists treating different conditions. This can lead to issues with coordination and continuity of care. Incorrect medications due to multiple prescribers are the McDonald’s equivalent of receiving a hamburger with mustard and relish when you asked for ketchup and pickles.
While fast-paced medicine has some advantages, it also poses many challenges, as above. The psychiatric sequelae of assembly-line practice are most concerning, because 15-minute “medication checks” are generally insufficient unless coupled with psychotherapy, and even then, split treatment is less than optimal. As Army psychologist John Rigg has said, “Medication doesn’t fix this stuff.”
In addition, the mental health system is on the brink of collapse after decades of defunding and financial diversion, causing community services to dry up. De-institutionalization was a noble experiment, but it neglected the serious and persistently mentally ill individuals who now fill our prisons and seek the warmth of sidewalk steam grates during the winter.
It’s critical for policymakers to consider both the medical and mental health needs of vulnerable children and older adults and balance these with personalized, quality care. I worry about our healthcare system and the politicians tasked with deciding how to fund it when they have no direct experience working in these systems and do not appreciate the gaps in service, let alone the effects of workplace distress and violence.
To make any sense of our healthcare system, lawmakers need to experience a “Big Mac Attack.” They need to have their access revoked to the drive-through lanes at McDonald’s lest they continue to equate fast food with fast medicine.
Arthur Lazarus, MD, MBA, is a member of the editorial board of the American Association for Physician Leadership, an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, and a former Doximity fellow.