The unintended cost consequences of patient centered care

I’ve just come back from my semi-annual renewal in my belief that family medicine is the foundational solution to make healthcare more affordable in America: the interim session of the Texas Academy of Family Physicians. The most important activity at these meetings is the networking: the chance to bounce ideas and experiences off colleagues from around the state.

The issue of cost came up and two colleagues in private practice told similar stories. One recalled a patient on Medicare who wanted him to approve a prescription for diabetic shoes. She had no problems with her feet such as calluses, ulcers, or nerve damage that might make a pair of $400 diabetic shoes reasonable. She was mailed an announcement by a diabetes supply company that her doctor could prescribe her free shoes. Best the physician could tell, free shoes was the only motivation for her request. The family physician refused to prescribe the shoes, asked her if she thought if was fair that her friends and neighbors would be the ones actually paying for the shoes, and told her to spend $100 on a good pair of casual shoes.

The other colleague told a similar story about a woman on Medicare with COPD (emphysema) who wanted a motorized scooter. The Medicare criteria say these chairs are reasonable to help people move around their house, which she had no difficulty doing. The woman wanted a scooter so she could cross the street more easily to buy snacks, beer, and cigarettes at the convenience store. This family physician also said, “No,” and suggested to the patient that a better use of her energies would be spent quitting smoking.

The mainstream news this past week included the story of a doctor in Dallas who billed over $300 million dollars in fraudulent home health claims. Every profession and element of society has bad people, and physicians are no exception.

However, these conversations remind me that there are legions of family physicians who do the right thing in spite of the emotional repercussions of disappointing or angering patients, and losing income if the patient decides to see another physician. Caring about the impact of their decisions on the overall well-being of the healthcare system is part of family physician’s DNA, at least the 99% who are decent and ethical. Our formal research in this area came to similar conclusions, with other examples of this system- and cost-consciousness such as denying requests for the “purple pill” or MRIs for typical episodes of acute low back pain.

A more patient-centered healthcare system comes with unintended cost consequences when patients expect to receive what they want when they want, or else they’ll mark low scores on their patient satisfaction surveys and just find another doctor who will give them what they want (urgent care doc-in-the-boxes leap to mind). I hope the payers come to the realization that a more important goal than patient-centeredness is that all physicians support a “system-centered” healthcare system. It just comes natural to family physicians, and the payers should support them in every way they can.

Richard Young is a physician who blogs at American Health Scare.

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  • doc99

    It could be argued that Michael Jackson received Patient-Centered Care.

  • eijeanMD

    I appreciate your examples of how patients are not stand-alone consumers of health care. If all health care  can be picked up at will in a store, like broccoli or cars, we would be facing a greater cost crisis, not to mention a serious safety problem as well. Medical decision-making is a partnership effort between the doctor and the patient. The focus needs to be on restoring and strengthening that core clinical team.

  • southerndoc1

    Patient centered care guru Dr. Donald Berwick:

    ‘Evidence-based medicine sometimes must take a back seat. First, leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat. One e-mail correspondent asked me, “Should patient ‘wants’ override professional judgment about whether an MRI is needed?” My answer is, basically, “Yes.” ‘

    Sometimes I just feel like giving up.

  • Myron Pulier

    A professional should serve the best interest of the client, but within the scope of practice. Concern about “society’s” interests or that of a 3rd party payer corrupts this and is confusing. However, “scope of practice” provides a rationale for not going beyond one’s professional status and to pervert one’s professional powers to prescribe something not medically indicated just to keep from losing or antagonizing a patient. A physician is not an agent, salesperson or broker and should not trick components of the healthcare system, such as pharmacies, equipment suppliers or insurers at a patient’s behest. Of course evidence-based medicine alone provides insufficient guidance, but this does not justify substituting pandering to a patient for exercising medical judgment.

    Concepts of scope of practice and professional role clarify the ethics here and obviate the need to appeal to society’s interests, which rarely override those of the patient (exceptions being where the patient is dangerous and should be quarantined or involuntarily committed to a hospital).

    • Richard_Young_MD

      Myron,
      All professionals work within a system of constraints. While this may be confusing, the fundamental driver of our exorbitantly expensive healthcare system is the existing doctor-patient relationship: that all services be provided no matter how rare the benefit or expensive the service. We need a new ethics for this relationship to bring costs down. If we don’t our children and grandchildren will be crushed by the debt created by the excesses if this generation.
      Richard Young, MD

  • http://twitter.com/horizonred Carmel Martin

    In any health and social system, rationing will take place and it needs to be overt. When it is covert and delegated to the frontline decision makers, it reflects badly on them. the unintended consequences of accountable care and medical home models is that the financial risk i.e. rationing is shifted to the provider.

  • http://twitter.com/horizonred Carmel Martin

    Every change or adaptation has unintended consequences – the smart approach is to continually anticipate and refine, use feedback loops and refine and watch for emergent phenomenoa

  • http://www.thehappymd.com/ Dike Drummond MD

    This is one of the core stressors of a doctor’s day … translating population based data to a decision regarding an individual … AND how that decision interacts with their payment mechanism. AND I agree that we family doctors somehow inherited this gene that keeps us acutely aware of the population level implications of our one-patient-at-a-time prescribing decisions.

    You do the best you can. You can’t make everyone happy. The payment mechanisms make no sense. Keep Breathing.

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

  • Sapphire Storm

    I think the tone of this article is very condescending. The doctor could have said: examining your records and the condition of your feet; I don’t believe you need these shoes so I can’t prescribe them. He should never have said: Do you think it’s fair that your neighbors should pay for your shoes! The author has totally missed the point of patient centered care. It does not mean you go along with these types of “anecdotes” (which, funny enough is not a good basis for the patient to give stories because they are considered anecdotal). It means you listen to your patient and base your care on what the patient needs. You don’t judge or offer righteous opinions of your own. It’s pretty disgusting actually; why should a doctor feel he or she is in such a position? This is such an old style way of thinking; doctors and priests revered in the past as all knowing father figures (sorry, there were not many women doctors way back when). Please. This article is really a waste of writing and has no bearing on the subject of patient-centered care.

  • Dorothygreen

    To me this article is basically about equipment (and I’ll include pharmaceutical) companies and their advertising.  This is what should be banned.  In the scooter ad the guy always tells the listener  – and I got it free. Lap band ads are all over the place – don’t take responsibilty for what you eat – just get a my pill or surgery.  

    The “patient” needs to be as responsible as the doctors.  Thes ads should be outlawed as should  advertizements for unhealthy food.  Other parts of the tobacco model should also be implemented to begin to change our SAD (standard amercian diet) - it is the basis for most of our sickness.  Both examples of patients given in this article had diseases that probably were preventable in the first place. 

    I applaud doctors who tell the patient like it is – its about time.  Don’t necessary have to be harsh.   Why not start keeping a record of such encounters.  In fact, it seems this SHOULD be part of health reform.  Tell the patient you are obligated to report to the HHS that he or she was being given some misleading medical information.  

  • KET85

    I heard that the ACP published an article that showed the association of high patient satisfaction with lower quality of care. So often, giving in to patient’s demands is counter productive to promoting good health.
    Insurance companies are getting wiser to the cost issue also. My Pediatrician colleagues now how to show positive laboratory proof for their antibiotic use. No more Z-pak pacifiers for all those ‘colds’.
    Interesting times.

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