When are doctors truly accountable to their patients?

I had a silver-and-gold Passover. Hearkening back to the old Girl Scout song I learned from my mother:

Make new friends, but keep the old;
One is silver and the other’s gold.

With no space or equipment to have a seder myself, I was nevertheless the lucky recipient of not just one, but two invitations. The gold was thanks to a quarter-century-plus friendship; the silver was from a family we met the week before Passover. Who should I meet at the seder but a legitimate health policy guru, with whom I promptly struck up the first of hopefully many spirited discussions on the state of health care in the U.S. today.

How would you fix it? I asked him.

He responded that he would allow any payment structure at all, except fee-for-service, which he would outlaw.

What’s so terrible about fee-for-service? Doesn’t nearly every other private enterprise in the country operate on the basis of paying for services rendered?

He replied, “But with fee-for-service, there’s no accountability.”

Accountability. I do not think that means what you think it means.

Accountability, according to Dictionary.com,  is “the state of being liable or answerable.”

Being answerable presumably means that when something goes wrong, he who is accountable is the go-to guy for blame. The bit about “liable” would imply a monetary dimension to the exchange.

What does this mean in medical terms? When something goes wrong, someone has to pay? Sounds rather like a rallying cry for the plaintiff’s bar. The problem is that in medicine, the line between doing something wrong and something bad happening is far less straight than may be imagined.

Another issue is that bad things often happen to people which is no one’s fault. Tumors metastasize; organs fail; people even die. (Actually, all of them will eventually.) Where does accountability come into it?

The health care policy guru’s answer: chronic disease management. Diabetes, hypertension, chronic heart, lung, and kidney disease cost way too much. Ostensibly way more than they should. (According to whom, by the way?) When physicians are held accountable for the costs of the medical care they provide, so goes the theory, they will provide … what? Better care? More evidence-based based? More efficient?

We then run smack into the fact that so much of the response to treatment depends on the patient. What about people who keep smoking, refuse to exercise, eat whatever they want? To non-physicians, this is still our fault. “Education” is the perennial answer. Obviously if we had appropriately educated, the patient would comply with our recommendations and get better. At what point are patients ever accountable for themselves?

Apparently the only kind of accountability that counts (at least to health care policy gurus) is for physicians to be associated with organizations that take financial responsibility (also known as risk) for the costs of medical care. And of course, the only reasonable way to take on that kind of risk is to be  part of a very large organization, and assume responsibility for a very large number of people (or, in other words, a population).

These accountable care organizations nothing more than managed care 2.0, resurrecting the failed debacle of managed care from the 1990s, but with more money thrown at them this time around. I’m not holding my breath to see how many of those dollars trickle down to people actually providing medical care to people who are sick and hurt (known respectively as doctors and patients.)

When you stop to think about it, true fee-for-service makes me ultimately accountable to the only person who really matters: my patient. Once you take both government and insurance companies out of the middle (the so-called “direct pay” model, where the patients pay me directly for my services) and it’s just me and them, only then am I truly accountable.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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  • Dr. Drake Ramoray

    This is rich from this guy. Let me get this straight. We will become the only country that BANS fee for service and the only country where physicians can’t collectively bargain. Can’t stop laughing that this is being proposed in a serious format.

    More and more Endocrinologists are dropping diabetes because of the move to pay for performance. The last statistics presented at the AACE meeting has it at approaching 10%. No-diabetes endocrine practices were less than 1% just a few years ago. The truth be told we can’t control a lot of the aspects of life that result in poor outcomes for many diseases (especially diabetes in my world). The government and the New York Times recognizes this but the former won’t do anything about it. There is already a drastic shortage of Endocrinologists. Pay for performance is terrible for patients in underserved areas and bad for doctors who care for them.


    And people on this blog wonder why I talk about keeping overseas jobs on the list. More are going to direct pay which this author supports, and is the way I’m heading. Mandate Medicare/Medicaid, taking insurance, and playing the ACO/PCMH game and I will practice over seas or find another job.

  • annette ciotti

    I avoid church because of guys like that. I give you credit for not walking out of the seder

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    There is a quote that I like regarding this from Pasi Sahlberg, who was the architect of the arguably best education system in the world in Finland. When asked how they can be so successful without measuring and holding teachers accountable for performance, he replied:
    “Accountability is something that is left when responsibility has been subtracted”.

  • QQQ

    “Make new friends, but keep the old;”

    “One is silver and the other’s gold.”

    My mother was also in the girl scouts and still sings the song after all these years! Thank you for bringing it up Lucy!

  • ErnieG

    The “health policy guru’s” comments remind of a saying—“when
    you don’t know what you are talking about, everything is possible.” I could not help but comment that the chronic disease that “cost too much” such as diabetes, hypertension, chronic heart, lung, and kidney disease are many times a result of lifestyle “choices” and many are managed, but not exclusively, with changes in lifestyle.
    To make physicians “accountable” for poor outcome on diabetics is an example of “not knowing what you are talking about”. The “health policy guru” wants to link population health with medical care. I firmly believe these are two separate, but not mutually exclusive, enterprises. Physicians are NOT “health” experts nor are they population disease/health managers. Physicians are trained to recognize and treat medical diseases in individuals. It is a very “private” enterprise- it is you, the patient, and what you can do together. That is not to say third parties have no role; they can manage financial risk of patients, protecting the integrity of physicians, increase understanding of disease and treatment, etc.
    But the current “health policy gurus” do not understand that, for the most part, increasing access to physicians and forcing them to practice “population health” is NOT going to increase the health of a population, nor that the patient-physician relationship, which is the KEY to medical care, is being eroded by silly ventures in ICD-10, EMR, PQRI, etc. In
    sum, it is not getting EASIER for physicians to care for patients, because
    everything is AGAINST improving what I do everyday.
    The reality is that medical care will get worse, because no one wants physicians to practice what they are good at- treating the patient and his or her disease.

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