A toxic environment for delivering health care

A long time ago, when I worked in Sweden’s socialized health care system, there were no incentives to see more patients. In the hospital and in the outpatient offices there were scheduled coffee breaks at 10 and at 3 o’clock, lunch was an hour, and everyone left on the dot at five. On call work was reimbursed as time off. Any extra income would have been taxed at the prevailing marginal income tax rate of somewhere around 80%.

There was, in my view, a culture of giving less than you were able to, a lack of urgency, and a patient-unfriendly set of barriers. One example: Most clinics took phone calls only for an hour or two in the morning. After that, there was no patient access; no additions were made to providers’ schedules, even if some patients didn’t keep their appointments, not that there was a way to call and make a same-day cancellation.

As my father always said: “There must be a reward for working.” But, high productivity can sometimes mean churning out patient visits without accomplishing much, or it can mean providing unnecessary care just to increase revenue. For example, some of my patients who spend winters in warmer climates come back with tall tales of excessive testing while away.

A recent Wall Street Journal article offers an interactive display of doctors who collect the highest Medicare payments. The difference between providers in the same specialties across the country makes interesting reading. It is hard to imagine that many individual doctors are billing Medicare more than $10,000,000 per year.

So it might make sense to insure against paying for excessive care by also demanding a certain level of quality.

But defining quality is fraught with scientific and ethical problems, since quality targets really aren’t, or shouldn’t be, the same for all of our patients.

The scientific community, for example, knows that elderly diabetics with “ideal” blood sugars are more likely to suffer harm or die than those with sugars that are a little higher. Even though the American Diabetes Association has embraced higher blood sugar targets for older diabetics, many healthcare organizations’ quality assurance programs treat all diabetics the same and penalize doctors who individualize treatment goals in accordance with the scientific evidence or common sense.

In almost every area of medicine there are individual nuances that must be considered if we are to best serve each of our patients. It is ironic and very sad that, right now, those who pay us are looking for simple (or simplistic), universally applicable quality targets just as the explosion in our understanding of genetics is promising to usher in the era of “personalized medicine.”

Up until now, the gold standard of scientific research has been to prove which standardized interventions work best for large groups of patients, even if there are subgroups that aren’t helped at all by them.

Who should define the “quality” measures of our work?

The central question for how doctors might be paid for quality in the future hinges on the priorities of whoever holds the purse strings. Insurance companies, if we overlook profit motives that also exist, prioritize population management. They pay for what works for most people, knowing full well that some patients will not get the best care for their individual situations, for example when certain medications are not covered. Politicians also favor the population view of health care.

If patients pay us directly, they expect us to deliver the care that works for them. If the government or an insurance company pays us, they expect us to deliver care that meets their standards, because they don’t trust the patients — their constituents and customers — to know what is best for them. And their focus is to have us do what helps most of our patients, even if some are not helped and some, or many, aren’t happy with what they are getting.

With all the political talk about “patient-centeredness” during the current health care reform, may I suggest that patients need to be given more choice about how their health care dollars are spent. With limited choice and no responsibility, patients tend to feel entitled and deprived at the same time. This creates a toxic environment for delivering health care. I have never met a patient who felt in partnership with his or her insurance company — ever. And I don’t expect to.

In order to maintain what partnership is left today between doctors and patients, we need a cost-quality paradigm that is shared by patients and providers. We also need to foster and maintain a sense of stewardship that is elusive if all that is at stake is someone else’s money.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

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  • Dr. Drake Ramoray

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    “The scientific community, for example, knows that elderly diabetics with “ideal” blood sugars are more likely to suffer harm or die than those with sugars that are a little higher. Even though the American Diabetes Association has embraced higher blood sugar targets for older diabetics, many healthcare organizations’ quality assurance programs treat all diabetics the same and penalize doctors who individualize treatment goals in accordance with the scientific evidence or common sense.”

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    This is very true and something that I have been harping about for some time. Pay for performance is more pernicious than this though because in its current state it does not take into accout patient demographics, socioeconomic status, and practice location. The current payment formula compares a wealthy executive with diet or Metformin controlled diabetes, to a rural farmer (or homeless inner-city) patient with a 6th grade education and transportation issues. The current pay for performance schema doesn’t discourage you from seeing patients, it discourages you from seeing unhealthy poor patients in underserved areas.

    http://www.nytimes.com/2014/04/28/us/politics/health-laws-pay-policy-is-skewed-panel-finds.html?_r=1

    • LeoHolmMD

      Good article. Confirms the dedication to a type of backdoor rationing that is taking place. Punishing those that would take care of the sickest among us. Pretty low.

      • Patient Kit

        Punishes those docs who continue to care for the sickest AND punishes the sickest who will find it harder and harder to find a doc who will treat them. Double whammy! And it deftly deflects the blame for this backdoor rationing off of the (non) payers and unfairly onto docs and patients. We need a chart to sort out all the mounting unintended consequences from all of the fully intended consequences. Long lists, both.

  • Eric W Thompson

    Excelent perspective and unfortunately one that will probably be largely ignored.

  • Gaspere (Gus) Geraci

    Defining quality is the ultimate question. The reality is that while there may exist “standards” for any particular disease, what is quality for an individual may be vastly different. Therein lies the “art” of medicine, and therein lies the conundrum for society. Darn devilish details.

    What if the patient feels quality is living in a drug induced haze? If they’re otherwise healthy? If they have a terminal disease?
    Tight diabetic control in any age person with a terminal disease makes no sense.
    We can define good quality in both these situations, but will always miss the exception.

    Great commentary “country doctor.”

  • T H

    Clear, concise, and cogent: this is an excellent argument. While you are preaching to the choir, Country Doc, I don’t think it is going to win the hearts or minds of the PTB. Unfortunate as that is.

  • Acountrydoctorwrites

    Even Medicare and Medicaid are putting population management ahead if individual patient care these days…