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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