Make patients more accountable for their own health

Let’s talk a little about health accountability.  Two news items have provoked the following rant: why is it always someone else’s responsibility?

The first item was on NPR. The FDA, reacting to the epidemic of prescription drug abuse in this country, is offering incentives to the pharmaceutical company that can come up with a less addictive painkiller.  Such a drug would be a gold-mine for that pharma company because it could label the drug “proven to reduce the risk of addiction” and make lots and lots of money. Six to nine months ago there was an initiative by some politicians to require doctors that prescribe narcotics to get additional training, a notion that was, thankfully, shot down by the FDA.

The second item was in the New York Times. New York hospitals are moving to take away cost-of-living pay increases for doctors and link pay to quality measures, the so-called pay-for-performance method.  The quality measures include how long a patient stays in the ER, heart attack recurrence, readmission to the hospital, dietary conversations with heart attack patients, patient satisfaction surveys, etc.  This is in anticipation of what the Affordable Care Act may or may not impose.

These are two of the most recent in a long line of examples of health considerations that have become the doctor’s responsibility.  Seat belt use is another.  Smoking is another.  It is not my job to be at your side every minute checking what pills you put in your mouth, how often you buckle up, or how much you’re lighting up.  It is your responsibility.  The problem with addiction, in any form and of any substance, is with the patient, not the doctor, and certainly not the pharmaceutical company.

I don’t control what you put in your mouth.  Efforts to make doctors do more work or use less addictive pills (whatever that means) are missing the real problem, which is addiction itself.  Asking about smoking and seat belt use are now quality metrics, meaning doctors are going to start to get paid based on if they do these things.  But the doctor has no control over these life-style choices, nor should he.  Your doctor is there to treat you when you are sick and provide access to things that can keep you healthy, but the job of being and staying healthy is yours.

When a company or government wants to cut costs, one of the first things they do is examine where the money is going.  The highest cost items are usually targeted first.  Physician pay, as well as nursing pay, are necessarily big cost items and thus tend to be in the firing line.  That’s where the pay for performance thing is coming from.  I am all for paying good doctors, but the quality metrics being used aren’t helpful.  One of the measurements is how fast ER doctors can move patients out.  But that depends in large part on other members and elements of the system over which she has no control.  Another measure is re-admission rates, meaning how often are patients re-admitted within x amount of time being discharged.  This is mostly a function of how many community supports the patient has, and is again not in the physicians control.

My internship year, my first year out from medical school, was miserable in a hundred different ways, but one of the hardest things for me to deal with was the percentage of preventable disease I saw, diseases that are the result of what people have done to themselves.  It is time to make the patient more accountable for his own health.

Shirie Leng is an anesthesiologist who blogs at medicine for real.

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  • AEB

    Thank you! As a head and neck surgeon I am often baffled by the number of patients who continue to smoke after (or even during!) treatment for oral or throat cancer. Obviously this behavior impacts the “quality” of their treatment and outcomes. The idea behind pay for performance is noble, but I am not surprised that it is pretty much impossible to implement in a fair way. I really think as physicians when we embrace the governments control over what is considered quality care we have in essence let them enter into an area that was once sacred – the patient – doctor relationship.

    • Kobukvolbane

      Again. 20% of Americans smoke. But the % of those who have mental illness is triple that. Same with those who abuse other substances. Now I don’t want to hold a head and neck surgeon responsible for their patients continued smoking, but can’t we get help for them? Are we trying hard enough, or are we just wringing our hands?

    • http://twitter.com/FMDGirl Kari Ulrich

      BRAVO!

    • Markéta

      Once we let or allow the government in the middle of the patient – doctor & nurse relationship, we only further reinforce the current stance of lack of personal responsibility – because yet again it will be somebody else’s fault, somebody else’s responsibility and someone else should pay for it. It is very unfortunate measure in this unsustainable healthcare system.

      • SBornfeld

        Mitt–is that you?

  • Kobukvolbane

    I can’t address the metrics, but can’t we do better as health care providers? What does holding people accountable mean? People already are being held accountable–I see people who have not lived up to their pain contracts all the time. Their physician will either no longer see them, or will not give pain medicine, and rightly so. But have we taken the time to learn how to motivate people, or to we just preach to them? Have we considered the Adverse Childhood Experiences study, and the higher rates of illness (of all types) in people who had more than their fair share of horror before age 18? Believe me, I know firsthand how frustrating and disheartening it is caring for addicts. But we can’t disown them. They bear a lot of responsibility, but so do we.

    • http://twitter.com/FMDGirl Kari Ulrich

      Great points, I agree disowning them is not the solution. Disowning a patient only contributes to the problem. Again I think we both are responsible, me as a patient you as a physician. Addiction is never easy, and we need to ask why are these patients not holding up to their pain contracts? Is it that they are selling their medications and why? Have they built up tolerance and do we need to change their plan of care? Are we offering the support they need to deal with pain. Do they have access to integrative medicine? Can they afford integrative medicine. Physicians have to support and educate, but patients have to participate. That is the bottom line. Physician have an average of 10 – 15 minutes with a patient, is that really enough time to address the multitude of needs an addict has? The patients are in your office with a need, but do physicians have the time or do they have the patients to deal with a complex case. Are we lacking the tools necessary to give the patient a fair shot. How many addicts have you referred to message therapy, accupuncture, reiki, where do they learn the art of coping? This is where we are failing, we are unable to provide the necessary tools the patients needs. This is where patient accountability comes in, are they participating?

      • Kobukvolbane

        Nice response. I hasten to say I am not a physician, but a nurse. I work on an inpatient psych-detox unit. Where I live, some patients in a great deal of pain sell their medications because they desperately need money. Some patients get bad news, or just get stressed out, and they take their remaining supply (“That was really stupid”) and so break their contract.

        Some patients are just playing a gullible physician. I’ve worked in a physician office where that was happening, too. If a physician gives out 80 Percocets a month to a patient who comes in complaining of abdominal pain after a “botched surgery”, even if they did that 5 years ago, and they’ve now stopped that practice, the reverberations of that continue.

        • http://twitter.com/FMDGirl Kari Ulrich

          What is really great about social media is that you have physicians, nurses and patients discussing the issues together. Sharing different perspectives, and learning. From this educated desicions and solutions can be made. Do you think the FDA or the hospitals in New York used the above in planning their decision about the future of narcotics?

          • Kobukvolbane

            I don’t know anything about the hospitals in New York, but yes, I think the FDA thought something had to be done. Have they ruled on it yet? I know the recommendation was made. I’ve read that in Great Britain, all kinds of pain medicine, including drugs like ibuprofen, are sold only in very limited quantities–a few days worth at a time.

          • http://twitter.com/FMDGirl Kari Ulrich

            It is a slippery slope between limiting patients medication and not giving adequate pain management to the patients who truly need it.

          • PWrn

            it requires careful assessment which takes longer than 15 minutes.

      • http://www.facebook.com/leslie.napolitano.3 Leslie Napolitano

        I am a critical care nurse who has taken care of more overdose patients than I care to count who come in in that condition like clockwork every 1-2 months. It is always followed by the same scenario: off the ventilator, wake-up time, tearful apologies to their families and friends along with the promises to clean up, then off to a rehab or psych facility to finish their course of treatment. A vicious and usually never-ending cycle. I once worked PACU in a level I trauma center where I heard a patient threaten the doctor that if the doctor didn’t prescribe more narcotic pain Rx for him, that he was going to just get out ‘and do more blow’. This is the attitude that is so prevalent today.
        There is a pervasive attitude as well in this country that ‘the other guy’ is responsible for other peoples’ behavior.
        And speaking of people who have been through very traumatic experiences: these are people who deserve all the treatment and support we can give. HOWEVER! It should always be stressed that self-sufficiency and self-reliance is the goal. Sadly, this will never be attainable for some people. My sister’s in-law family has some mental health issues that require a lifetime of the person being constantly monitored by some sort of government agency.
        We are not unsympathetic. What we are is exhausted of people playing the system at the expense of others and to the detriment of all.

  • http://twitter.com/FMDGirl Kari Ulrich

    As a patient with a chronic disease I agree with you 100%! Doctors are a patients expertise and help guide our decision making. Patients make choices and doctors should not be held accountable for the choices we make. I also do not want the FDA nor pharma practicing medicine. It is not their place to do so. My physicians are educated to help me make the decision if I need pain medication or not. I understand this issue has many grey areas, but patient responsibility must be addressed both by insurance companies and the government. The answer for chronic pain is not to assume every patient is addicted or abusing. That only hurts the patients that are active participants in their health care. Holding patients accountable is the only real solution to this problem. We need to ask ourselves where is our system failing in pain management. Throwing money at pharma is not the answer neither is making the physician and pharmacies accountable for patients actions. Patients are accountable for their actions, just as much as physicians are responsible for giving quality health care.

    • Kobukvolbane

      I’m a nurse, not a physician, but if I were a physician, I would tell you that narcotics are a lousy choice for chronic pain. The price is too high.

      • http://twitter.com/frasputin Fat Rasputin

        I also have a rare chronic condition and for the first three years after diagnosis I spent every making moment focused on treatment. There are no drugs approved by the FDA to treat it and there will probably never be and none of the treatments tried have been effective. I have come to the point now where I focus on quality of life which has brought me into the arena of managing the pain from the disease. I have heard a lot of what is not the answer, what is the answer?

        • http://twitter.com/FMDGirl Kari Ulrich

          I also have a rare disease and chronic pain. My quality of life has changed dramaticly. The answer, advocating for yourself, participating fully in your care and get support. Don’t be afraid to get help when you need it. Does this ease the pain you experience? No, absolutely not. But it does give your mind a break if you are able put the pain aside for a while. Unfortunately many chronic pain patients are labeled as addicts when they are NOT. Hence my answer, patients need to be responsible for the decisions they make. Do patients pay the price when doctors don’t take the time to work with a complex issue, Yes! Chronic pain patients are often stereotyped when acute pain arises. We all have experienced this and the fear that goes along with it. So what is the answer? Shared responsibility, open communication, and trust between patient and physician. Once you loose any of those components it breaks down the care you will receive. I don’t think a physician should be completely responsible for the actions of their patients. Patients need to take responsibility for their care. It is not easy, it is demanding and exhausting. Medication is only part of the solution and we as patients must be mindful of this.

          • http://twitter.com/frasputin Fat Rasputin

            Thank everyone for responding, I have looked into several none drug related pain management arenas but unfortunately insurance will not cover those and that is a discussion for another time.

          • Kobukvolbane

            In my area, there is a group of psychologists who offer free services in return for community service. There may be in your area as well. Or barter. You never know.

          • http://twitter.com/FMDGirl Kari Ulrich

            My point exactly! This is where the medical community is failing. We need to be proactive and focus on prevention… No more wait and treat a complication. Integrative medicine should be offered at every medical clinic as part of the patients over all care. I understand the cost is great to the patient, message therapy $100- 200 a week, dietician, $50-75 a session, therapy $3-400 a session every other week, accupuncture $75 a session…the list goes on and on. Many patients in my community have there whole salary go to health insurance, there is no extra at the end of the day to pay for integrative services. It is easier for the patient to take pain medication and call it a day. There are many resources out there that can be tapped into but are not, patient responsibility again comes into play. Are high risk patients taking on that responsibility? Are they advocating for themselves? When I am in great pain I know I do not advocate for myself, thankfully I have a long relationship with my physician who can guide me through these times.

          • http://twitter.com/frasputin Fat Rasputin

            Sorry for the tardiness of my reply, I am unfortunately disabled from my illness and there is not money for any treatment that is not covered by insurance. I advocate and avail myself of everything that I can and I think you have to be careful not to put people in a box that they are not advocating for themselves.

          • http://www.facebook.com/people/Deb-Cambria/1571005317 Deb Cambria

            Doctors practice as they are paid. NOT what is best for the patient.

          • http://www.facebook.com/people/Deb-Cambria/1571005317 Deb Cambria

            I know no nurse who thinks anyone with real pain and takes pain medication is an addict. There are more abusers than not.

        • Kobukvolbane

          I definitely agree with Kari that educating yourself is important. Cognitive behavioral therapy can work very well for some types of chronic pain. This changes how you think about pain. It’s effective for depression, too. It’s a lot of work and a lot of effort. Not knowing your condition I wouldn’t know how to advise you specifically. I’m sorry you have a rare chronic condition. I hope you can find some relief. I just don’t know how effective narcotics are. I’ve met one or two people who take them and who work and live a normal life. Maybe there’s more, and I just don’t see them because they are living a normal life. But evidence does point to opiates being ineffective for chronic pain.

          • http://twitter.com/frasputin Fat Rasputin

            Thank you for your reply, I do not if it is relevant for the conversation but I have neurosarcoidosis. I would agree that one of the best things I have done is seek treatment for the depression that has accompanied this chronic disease. That being said there are days that I can either take opiates or I can watch my wife cringe while I cry out in pain. The opiates do not eliminate the pain but they allow me to not cry out. I do not take the opiates everyday not because of fear of addiction but fear of building up a tolerance and not having anything for the pain. These are not abstract concepts for the patients that live them.

          • Kobukvolbane

            Absolutely not an abstract concept for you. You suffer additionally because others abuse those drugs. I assume you see a pain specialist. When people say they fear addiction (this was my post-surgical patients when I worked in that setting) I would ask them, if their pain disappeared tomorrow, would they want the drugs. If the answer was no, they were not addicted. Being habituated is different–it’s just a physical thing. Take care–and do study up on pain. Non-pharmacological methods are not trivial. This is what not only some patients, but also some colleagues who suffer from pain, tell me.

        • http://www.facebook.com/people/Deb-Cambria/1571005317 Deb Cambria

          Severely changing one’s diet is very helpful as is not taking too many prescription meds…all have side effects, most do not do much good. TREAT underlying condition

  • dnarex

    It is fine to say we patients should take responsibility for our health but doctor’s holier than thou attitudes make it extremely difficult. You have your prejudices and if a patient’s preference for a specific treatment does not match those prejudices, you basically tell that patient to go to hell. In some cases, where the patient’s preference would clearly put them in jeopardy, non-treatment is justified (first, do no harm) but when you carry that attitude to a refusal to work with a patient, you are no longer acting in that patient’s best interest.
    I will give one example, Armour Thyroid. My wife has been taking this for several years and it works well to treat her hypothyroidism. Every time she has to see a new doctor, it is the same story. She has to fight to get a prescription because doctors have been told, falsely, that Armour is not reliable and that synthetic thyroxin is the treatment to use. It should be a no brainer, this works for her, write the prescription. As an experienced patient she is probably more knowledgeable on her own disease than some newbie doctor but because that doctor has those two letters after their name, they think they are the ultimate font of knowledge.

    If doctor’s aren’t willing to share responsibility, they can hardly whine about having to take all the responsibility.

    • http://twitter.com/FMDGirl Kari Ulrich

      Not all physicians have an holier than thou attitude. Many are empathetic to the needs of patients in pain. I have experienced both physicians who work as part of my team, and other physicians that talked at me and did not include me in my plan of care. I can only be responsible for my part. I did not advocate for myself when the physician talked at me, and did not include me in my own plan of care. I take complete responsibility for that. I failed in communicating my needs, he failed in actively listening. We both had a responsibility, but who paid the price? Me. The doctor failed by not giving quality care. Just like not all chronic pain patients are addicts, not every doctor fails at sharing responsibility. Why should every doctor pay the price? Why should every patient be treated the same when it comes to pain? Instead of disciplining doctors and throwing money at pharma, lets do more research into personalized medicine. Lets all take responsibility.

      • Markéta

        I couldn’t agree more, thank you for your post. As an RN who dispensed detailed discharge instructions over and over – you are admitting the same patients w/I 2 weeks for non-compliance, or see them at the office still eating M&Ms instead of carrots and still smoking

    • http://www.facebook.com/leslie.napolitano.3 Leslie Napolitano

      People make the mistake of thinking that because they are the ‘expert’ in their own situation that they ‘know more than the doctors’ about a condition or medication. My first question is: does your wife see an endocrinologist? My next question is, how many doctors has she seen? Not every patient reacts the same to a medication and a persons physiology does change over time. I didn’t react to my thyroid Rx 10 yrs. after I started taking it and had to be changed to something different. The human body is dynamic.

      And I’m going to write something that I hope you won’t take the wrong way but I feel it has to be asked: is it possible that your wife is blaming her thyroid for something that it may not be responsible for? Hormone replacement is very tricky and complicated.

      Having said all that, I would encourage you to find a doctor you can work with. Ask any nurse you know who you think would be a great doctor for you in your location. Most of us know a lot of physicians.

      Good luck. I sense your frustration.

    • http://www.facebook.com/people/Deb-Cambria/1571005317 Deb Cambria

      You are right in that doctors do not understand “alternative” treatments and stick to the same old thing…but it is the patients responsibility to find a doc who does and stick with him/her

  • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

    Good article. However, if patients were held accountable (which I agree with by the way) it would cause a major outcry of things like that it goes against their freedom of choice and the right to refuse a treatment. We know a number won’t comply with treatment regimens for various diseases as given in examples by some of the other posts, so what would you recommend be done as part of the process for holding patients accountable for their choices and actions because they choose not to comply with recommended treatment? I ask this because one of the reasons a person can get kicked out of a clinic is not complying with a recommended course of treatment for a disease process that a patient has.

    • http://twitter.com/FMDGirl Kari Ulrich

      Patients have the right to choose, but it should not be at the expense of the physician. If the physician is giving all options available to improve the patients health and the patient refuses to take responsibility for their health why should a physician be punished? Patients freedom of choice should not be linked with physician pay.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        Kari, you are correct that patients have the right to choose. And I also agree that it should not be at the expense of the physician. That’s why I asked about how one would go about holding a patient accountable for the choices that they make. I read an article about 6 months or so ago that said that in Hungary if Diabetic patients refuse to comply with treatment regimens for their disease they can be let go from the clinic. Does that make it ok for a doctor to do that? No, of course not. Unfortunately it’s happening.

        • http://twitter.com/FMDGirl Kari Ulrich

          I am thinking what makes me compliant as a patient, is the overwhelming need to lead a better quality of life, it comes from within. I am concerned that non-compliant patients may feel they are not worthy of health, or it is to difficult for them to maintain due to financial, psychological, or environmental factors. As patients we have a choice, it can be a difficult and exhausting navigating your health with a chronic disease, but it is ultimately the patients responsibility. How to hold a patient accountable, that is not the complete burden of the physician. How do we hold patients accountable? I think it needs to come from within the patient. Patients need to feel valued and supported by the medical community. We are quick to judge the book by its cover, again complex patients are unique and require a enormous amount of time from multidisciplinary team. For high risk patients having a liaison such as a patient advocate maybe beneficial.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            Kari, what you said about the being concerned that non-compliant patients may feel that they are not worthy of health, or it is too difficult for them to maintain due to financial, psychological, or enviromental factors is spot on. It is exactly why when I read the article I cringed that this was going on.

            You are also spot on about the fact that patients need to feel valued and supported by the medical community. And also spot on about the fact that how quickly one can judge a book by the cover without thinking more about this so as not to judge because as you said complex patients are unique and require an enormous amount of time to care for by a multidisciplinary team. And I especially agree with you on the having a liason. That is definitely of high priority when it comes to situations like that. Very well said.

    • http://www.facebook.com/shirie.leng Shirie Leng

      Really? Kicked out of a clinic? I have never heard of that happening. A patient has every right to refuse treatment. They can still be my patient. I just don’t think that I should then be responsible for that patient outcome.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        Yep, really. I had not ever heard of it happening before until I read the article and as I just told Kari it made me cringe. Because just like you and she said the patient has the right to refuse to treatment or to choose not to comply. This is a very delicate situation of among many that comes in to play when dealing with the healthcare system which is why we all need to work together to figure out how to solve some of these issues.

  • http://twitter.com/davisliumd davisliumd

    Agree that patients should be accountable. However, is it not reasonable to consider that the epidemic we have, like obesity, is simply not due to bad choices but other systematic issues that nudge us into less than ideal outcomes? When does personal responsibility stop and understand ping biology and psychology start? Recent NY Times piece makes a disturbing and fascinating rws on the food industry… What is their corporate responsibility to the public and issues challenging the health care system?

    http://www.nytimes.com/2013/02/24/magazine/the-extraordinary-science-of-junk-food.html?hp&_r=0

    • Kobukvolbane

      Good point. Also, a lot of the petroleum and coal based toxic chemicals that are in our air, our water, and our soil interact with each other and cause endocrine disruptions. Perhaps obese people could be in part victims of the industries responsible for this. Corporate responsibility here as well?

  • Dave

    Seatbelt laws aren’t nanny laws like the other ones though. If you don’t buckle up and you have a wreck, you’ll get ejected from the car – which would only hurt you. But you can land in the road and make the accident even worse when a 3rd car has to swerve to miss you and hits someone else, or you could just fly straight into another car and hurt them. Seatbelt laws aren’t for the protection of the driver – they’re for other drivers.

  • Wy Woods Harris

    I know that health awareness and health accountability is a road less traveled and I am convinced that the faith community will have to choose more environments and events to storytell and storylisten to make a difference.

  • Guest

    Last year I needed an opiate when my back went out. i went to my physiatrist, who told me he is having all his patients take a drug test with each prescription. I said fine, but I’m unemployed and can’t afford to pay for both the office visit and drug test, so I need to know that I will not be out of pocket for the lab test. The doctor said my insurance would cover the drug test. A month later I got a bill for $1,500 from the lab that did the drug test, becaus–of course–my insurance didn’t cover the unnecessary test. I spent the next month fighting and screming with the lab and the doctor over the bill. Eventually, the doctor wound up eating the bill.

    • querywoman

      $1500 is a severely overinflated charge for a drug test! Employers would not be using them for routing pre-employment screening at that charge!

  • CaliforniaMFT

    Last year I needed an opiate when my back went out. i went to my physiatrist, who told me he is having all his patients take a drug test with each prescription. I said fine, but I’m unemployed and can’t afford to pay for both the office visit and drug test, so I need to know that I will not be out of pocket for the lab test. The doctor said my insurance would cover the drug test. A month later I got a bill for $1,500 from the lab that did the drug test, because–of course–my insurance didn’t cover the unnecessary test. I spent the next month fighting and screming with the lab and the doctor over the bill. Eventually, the doctor wound up eating the bill.

  • http://www.facebook.com/leslie.napolitano.3 Leslie Napolitano

    I am a critical care nurse (>35 yrs) who lives in the oxy/roxy capital of the world and I 100% agree with this physician, as do ALL of my co-workers (and yes, I DO speak for them with confidence re: this issue). Nurses have been taking care of repeater and ‘professional’ patients for years who are in the hospital every month, usually because they believe it’s their ‘right’. The feel absolutely NO responsibility for their own health. From the prescription and street drug abusers to the middle-aged person who thinks they don’t need to modify their lifestyle after a heart-attack, these people are the parasites of a health care system that has cornered itself into a real mess because they are ruled by a government that uses ‘political correctness’ to great advantage. The surveys used by Medicare are a joke. And now there is talk about physicians asking patients if they have a gun in their home? And possible penalty to the doctor if there is an incident and they didn’t report it?
    It’s time for those of us in healthcare to fight back. If anyone knows of any organization to be affiliated with re: this issue specifically, please let me know:bbleslie03@yahoo.com.

    • jaylbee

      My husband had a heart attack. He won’t change his lifestyle except for going to the doctor for checkups and taking the medication he is prescribed. Is he really looked upon as a parasite?

      • http://www.facebook.com/people/Deb-Cambria/1571005317 Deb Cambria

        yes

    • http://www.facebook.com/carolyn.querales Carolyn Querales

      Repeat offenders and parasites!! Sad but true, as an admissions RN in acute care I also see the revolving door. It is so frustrating to spend time and energy caring for people who don’t put in the same time and energy for their own health. I have wondered for a long time where the patient responsibility is in all this! Thanks for the post!!

  • Bfloyd

    As a chronic pain patient after accidental co2 poisoning , I ended up on methadone which by the way is a very underused pain control drug. I had 100% nerve pain and was on fire and saw best of best. 30 days at mayo etc. it was my gutsy Nurse Pratirioner who got me off oxy and tried methadone and gave me my life back.. Unfortunatly I had a sever flair up of nothing anyone has seen in my area.. If I had not done my own homework and forced my issue that now there taking serious .. I have had nothing but buy

  • Randy

    This article seems to be intentionally combining multiple issues into one so the same conclusion can be drawn. First, mixing CMS quality measures and objective measures is improper. They aren’t used the same way. I agree that punishing doctors (or hospitals) for length of ER stay or readmission rate is ridiculous due to the multitude of factors involved. But smoking status is not a quality measure – it’s an objective one. One simply has to ask if the patient smokes, record the answer, and the measure is met. But beyond that, there’s an important point here. Patients are absolutely ultimately responsible for their own health and well being and no doctor should be “punished” for a sick patient. But if you have become so jaded that you no longer believe that you should be an active participant in your patient’s ” job of being and staying healthy” then you might consider hanging up the stethoscope. You are part of the well-being team.

    • Fred Ickenham

      This is in error. The OUTCOME is all that matters to CMS. Advising the patient is insufficient. Since the doctor/nurse cannot control the patients’ behavior, and yet is by statute responsible for it (thus the term “Acountable” in ACOs), failure is predetermined if lowering costs depends on this plan, as it does.

      • Randy

        With all due respect, you’re incorrect with regard to what I specifically mentioned. Working on both Meaningful Use and ACO reporting is what I do for a living, and I know the ins and outs of the measures pretty intimately. For the record, I was referring to the MU objective smoking measure, which requires ONLY documentation of smoking status to be met (and is not part of the ACA…it’s from the ARRA passed in 2009). The ACO smoking measure requires ONLY documentation of smoking status and tobacco cessation counseling if a smoker. Outcome is neither mentioned nor indicated. One need only review the readily available documentation on the CMS web site. But no matter really…if you read my comment it was actually about accountability…that of the physician, who can and should remember that they play an active role in a patient’s ongoing well-being.

        • Fred Ickenham

          I hope you are correct, but JAMA editorials by Dr.Emanuel, an archirect, indicate otherwise. The thrust of the article above is that clinicians will be held responsible for outcomes of bad choices that patients make. Dr.E believes that CONSTANTLY contacting them by every electronic means, plus office and home visits, will achieve this laudable but impossible goal, to say nothing of the immense unremunerated time commitments involved. If total per capita costs rise as a result of self-indulgent patient choices, ACOs are penalized more or less, depending on the ACO track.
          ‘ … programs that attempt to improve the care of beneficiaries with chronic conditions face a major challenge in motivating people to change their health habits regarding diet, exercise and other self-care behavior,” wrote Lyle Nelson of the CBO’s Health and Human Resources Division.’
          There are better ways to reduce costs. For example, avoiding redundancy could be achieved if interoperability standards were mandated, but they are not. Also, it’s not possible to achieve substantial savings without tort protections for following parsimonious care guidelines, and to able able to discharge noncompliant patients, but that is actually not doable in our system.
          So here are 2 better (but not legislated) ways to achieve the desired goals but those stakeholders are too powerful; better to beat up the clinicians.

          • Randy

            Fred, I don’t disagree much on anything you’ve said here. I find it rather ridiculous (as I said in the OP) to hold physicians accountable for things beyond their control. Places where this is blatantly evident are in cases like CMS reducing payments to hospitals for high ER readmission rates (something I am seeing where I work)…yet the criteria for why it happens are so loosely defined that such punishment is often inevitable (especially in a place with an unusually high Medicare patient base). I don’t believe in the punitive system at all. But again, this was not even close to the point of my OP. Again, I was and am pointing out that the author ought to re-think how engaged to be in ongoing patient health maintenance. Not because there’s potential financial backlash for not doing it, or because it’s somehow the sole responsibility of the patient…but because it is part of a doctor’s role in long term treatment of a patient.

  • Christine Hayek

    Accountable Care as this conversation discusses relies on not only the physician to be accountable for the patient care but also the patient. I agree a physician can only do so much but I disagree with the statement above that a physician is only responsible to treat you when you are sick. Consider this analogy, as a physician you probably utilize an accountant. A good accountant will assess your total finaical picture and advise you on how to best reduce your tax liability. Yes, you may not realize you need an accountant until you feel the effect of the big tax bill but after that you would probably meet with the accountant from time to time to ensure you are doing everything possible to avoid large tax bills in the future. You ultimately have the responsibility to act on the reccomendations but you certainly would also find a new account if you did not see improvement. Patients rely on their physcians for their expertise in the field of medicine and to advise them before they get sick. Healthcare is a service provided for a fee, any other product or service a consumer purchased would be under the scrutiny of quality and the level of service received. Why not Healthcare? I mean we are talking about one of the most significant components to life right?

  • PWrn

    Addiction is a disease, not a lifestyle choice.

  • PWrn

    Addiction is a disease, not a lifestyle choice. As an MD you are responsible for the drugs (and their effects) that you give to your patients. Anything less is lazy and incompetent care. As an RN and the mother of someone who became addicted to pain medication after a car accident, I continue to be amazed by and disappointed by the lack of education and awareness in the medical community of this epidemic disease.

    • http://www.facebook.com/people/Deb-Cambria/1571005317 Deb Cambria

      insurance needs to pay for all types of care not just what is allowable and doctors need to be better educated out of their little boxes. Insurance companies have created this problem by setting up standards of care that are supposed to be safe but create Payable care boxes that doctors will not go out of…it is an absurd and terrible system. Patients need to learn for themselves…don’t trust the docs or the hospital or the government to do it for you

  • http://www.facebook.com/people/Rakesh-Sethi/660597510 Rakesh Sethi

    I believe we need changes on both doctor/patient sides. However, health care reform of any kind will not succeed without prevention in it. And prevention will only happen if the people proactively participate in their wellness everyday. People must change how they approach their health today. This requires a change in the “belief system” about health, shift in their health attitudes. The question is how do we inspire this change?

  • Joyce

    Doctors are providing a service. They should be held accountable for the results of their work. Stop whining. Doctors are absurdly overpaid.

  • querywoman

    As an adult, I have always been responsible for my health care.
    Years ago, with a skin condition that severely affected my ears and the rest of my body, I visited a public hospital emergency room.
    I already had received a referral to the ENT clinic for a few months later.
    I asked the ER doctor for a dermatology referral.
    He said, “Ma’am, I don’t know if you can be seen sooner.”
    I replied, “I don’t care. I am responsible for my health, NOT YOU, and I still want a dermatology referral.”
    He nodded and made the referral.
    I did get seen quicker in dermatology. Later, I found out more about the system. A doctor should write, “Patient needs to be seen as soon as possible,” instead of, “Next appointment available,” on the referral slip.
    I am still responsible for my own health. My skin disease includes a lifetime of medical neglect. So, I referred myself and now see the director of dermatology at a large church hospital in my city, who manages the condition so much better.

  • Jim C

    I agree with Dr.Le wholeheartedly about addiction.However I do not think that we should be paying Dr’s on the bases of how many pt’s they see,this could cause errors and actually be the cause of why pt’s revisit the emergency room in such a short time.As for the addiction to prescription narcotics,it is my belief that they should let these drugs be legal.I know what people are saying but look at this my way.If narcotics were legal it would empty the jails by at least 50%,and the government could charge taxes,this could more than likely lower the deficit t least 35% in ten years,and decrease the budget every year.When I said above I know what you are thing and saying about this,the government said the same thing during prohibition,but when they legalized alcohol there wasn’t that many more alcoholics and with drugs people will not be killing themselves with homemade meth.

  • Michael Shaffer

    If we’re going to get into a p4p system, it should start with the legislators mandating it. They should not be allowed to set rules or budget for systems outside their immediate scope until the stop borrowing money from foreign nations only to lend and spend it in other foreign nations (and at times the same nations we borrow from), and tax the American people to pay the interest on the loans. I’m all for accountability, but before Washington looks for ways to hold others accountable, I’d like to see them figure it out there first. I’ll have a lot more confidence in their ability to come up with solutions when they begin solving their more basic ones with budgets (stop spending what you aren’t earning!).

  • Guest

    Are you going to punish them if they don’t listen to you or agree with your view of accountability. ‘If only you knew what I know then, you’d realize how stupid you are’

  • http://www.facebook.com/zeegoman Iain Buchanan

    Interesting point of view. Are you going to punish them if they don’t?

  • http://www.facebook.com/gianetta.norwood Gianetta Norwood

    I have been a nurse for 22 years and understand your point of view but unfortunately it is too black and white for such a complicated system. Everyone can point fingers to someone; unfortunately nothing is getting solved;
    only more policies written, and more pay cuts.
    I