A much-talked about way to reduce our health care costs is a new emphasis on paying physicians for outcomes. This notion quickly segues into the implication that physicians do not communicate with their patients about treatment options, and if physicians talked to their patients, the patients would give the physicians better grades in patient satisfaction. And of course, by all means pay physicians based upon patient satisfaction. There seems to be some fantasy here that if physicians discussed treatment options with their patients, patients would always choose the “right” treatment, that is, the one that saved the most money for health care providers.
David Chase, in his Forbes article “Health Systems Ignore Patients at Their Own Peril” notes that one study showed hospital admissions were reduced more than 50% when patients, especially patients with chronic conditions, were in control of their medical decisions.
This may well be a perfectly good statistical study, but there are several problems with generalizing about the results. First of all, the assumption is that physicians do not spend time discussing treatment options with patients. Possibly in large corporate medical organizations where the revolving door must accommodate four to six and eight patients an hour, practitioners don’t spend as much time as they need to with patients discussing possible treatment options. My suspicion is that this isn’t a physician problem, but a corporate medicine problem.
There are many physicians who really do discuss treatment options with their patients, often at great length, even though the current pay-per-procedure model does not compensate practitioners adequately—if at all—for this time spent explaining treatments to patients. But these are physicians who allow their patients to spend more than 15 minutes with them and explain patient options at great length despite not getting paid to do so.
There is another problem with studies like these. The notion that patients, given control of their own medical decisions, will choose the course which keeps them out of the hospital is just plain naive. What are physicians supposed to do with the patients who deny they are diabetic (yes, many do), the patients who refuse to go to the hospital (yes, many do), or the patients who simply refuse to be compliant with any medical recommendation (yes, there are many).
I am humbly suggesting that practitioners have long—and many still do—spent a lot of time discussing treatment plans with their patients. But physicians cannot force patients to choose the option which statistical studies may well show keep patients out of the hospital and therefore demonstrate a greater than 50% reduction in hospital admissions.
Trying to design reimbursement schedules with the intent to force patients to make the optimal choice for their health, that is, the “right” choice according to good business practices, seems a bit draconian to me.
I suggest that what this study really demonstrates is the difference between corporate medicine controlled by non-physician MBAs and those medical facilities owned and controlled by physicians.
In order to solve the problems with health care in this country, we are going to have to look at the underlying causes of the problem. Health care in became dysfunctional when physicians agreed to turn the control of their decisions about patient medical care over to non-physicians more interested in denying care to keep costs down than in patient well-being.
Note: I wrote this article in 2012, eons ago in health care time. In 2012, David Chase wrote “The Marcus Welby/Steve Jobs Solution To The Medicaid-driven State & County Budget Crisis.” This article povides a remarkable introduction to the notion of Direct Primary Care and how it had been used in places to provide reasonably priced basic health care to Medicaid populations.
