Archive for the '“It’s Time We Talk…”' Category

A Straight Face Test for Health Care: Would Patients Pay for This?

Health care in America is fracturing right down the middle, and doctors are going to have to figure out if or how long they can straddle the divide between what patients want and what the Government and Corporate America want them to have.

Up until this point, the momentum has been with the payers, Medicare and the insurance industry. But the more heavy-handed they become, the more inevitable the public backlash is becoming.

It will come down to this, a kind of “straight face test” for health care: Would patients pay for this?

The Annual Wellness visit, better named “Medicare’s Non-Physical” and some forms of “Population Management” are examples. Both are great ideas; an annual health review and planning session as well as doctors maintaining an overview of, and reaching out to, high risk groups of patients – in theory neither would be anything to argue with.

But the way it has to be done today, if we want to get paid, micromanaged from afar through bureaucratic edicts, is alienating the patients this was all intended to benefit.

Totalitarian Health Care is Doomed

I grew up and went to medical school in a socialist country. I admit Sweden had a kinder, gentler, soft-core socialism, but I also visited and followed the news about the Soviet Union, the Baltic states, East Germany and the former Czechoslovakia.

American health care, as manifested by Medicare and the big insurance companies, is more and more starting to look like my visit to the Soviet Union with my surgery class in 1977. The most striking example of disregard of individual customer preference I saw was at a very large restaurant near the Red Square. The sour-faced, haggard breakfast waitstaff told our group bluntly that we could all have either coffee or tea, but they could not accommodate individual orders for different beverages.

The “planned economy” of the Soviet Union collapsed, and I suspect its counterpart in American health care eventually will, too. I think our system will split in two: One system for what patients see value in, and would pay for, and another system, which the politicians want them to have, but which most people would have nothing to do with if they had any say in where their healthcare dollars go.

Two dichotomies are driving this inevitable split down the middle of our healthcare system: First, the improbable marriage of public health and medical care; and, second, the opposing ideals of standardization and individualization.

Public Health vs Medical Care

It is insanely inefficient to mandate that highly trained physicians, with an “opportunity cost” of $7-10 per minute in primary care, and multiples of that in many procedural specialties, carry forth the nation’s public health agenda with their patients one by one during their office visits. Medicare’s requirement that we document an intervention for every patient we see with a Body Mass Index over 30 is a glaring example of that. Having our nurses or other staff members do that isn’t much better. Our teams have a lot of tasks and routines to maintain proficiency in, and since obesity affects a large proportion of our society, it would be better addressed on a national, cultural and political level. It suddenly became our job, it seems, as health care professionals, because whoever had the ball before us failed at fixing the problem. But soft drinks and breakfast cereals are made by big, powerful corporations, and our Government lacks the guts to reign them in. So, someone thought, let the docs spin their wheels for a while; they don’t have enough to do.

A healthcare system designed for setting fractures, treating pneumonias and removing appendixes is ill suited for treating societal ills. Quite frankly, it doesn’t pass the straight face test: Ask citizens if they want their health insurance premiums (or out-of pocket costs in a Direct Primary Care model) to cover à la carte anti-obesity campaigns or if that should be included in State and Federal budgets. I know what the answer will be.

The difference here isn’t subtle: If public health is financed through workers’ insurance premiums, its cost is more evenly spread, and thus affects middle and lower income people more than if it comes out of corporate (think Pepsi, Coke, General Mills and Ocean Spray) and progressive personal income taxes.

Standardization vs Individualization

There is a rapidly growing interest in personalized health care in America today among patients and health care entrepreneurs. Genetic profiling is now used in choosing which medications to prescribe, for example.

At the same time, payers are tying reimbursement to doctors’ adherence to blanket recommendations (read “Evidence Based” treatments) derived from large population studies that were designed to find lowest common denominators: In general, for example, low dose aspirin, beta blockers, lower blood pressures and blood sugars are helpful, but we are now seeing that there are more and more subgroups of patients who don’t have the expected benefits from any given “Evidence Based” intervention. In some cases, people are harmed by them. As long as Medicare and the insurance companies hold the purse strings – actually, dole our own money back to us according to their standards – the welfare of a few is routinely sacrificed for the benefit of the many.

Again, applying the straight face test, patients wouldn’t want to pay us for delivering care to them that was designed or chosen to help someone else, just so we could show off high compliance rates. If doctors are held in too tight a grip of uniformity by the conventional insurers, patients in this new era of deepened insight into the variation of disease expression will take their money to providers and insurers who will respect their preferences.

A Moral Compass

The straight face test has to be our moral compass as we work our way through our daily allotment of twenty-odd patient encounters with fifteen minutes to spend as wisely as humanly possible.

People can vote their politicians out of office, they can form cost sharing cooperatives or sign up for Direct Primary Care. But we, physicians, need to make sure we don’t forget who ultimately are our customers. Even without politicians and insurance conglomerates there will always be doctors and patients. May we never lose our trust in each other.

It’s Time We Stop Comparing Health Care to Manufacturing

From ancient times, doctors have appreciated that, for all their similarities, no two patients are exactly alike. This understanding is what made physicians act like, and earn society’s respect as, professionals.

The commercialization of health care has brought in managers from other industries and other branches of academia, and their rise to power has been predicated on their ability to treat patients and doctors not as individuals, but as small cogs in the new health care industry.

There is no doubt that healthcare today is an industry, but I disagree with the notion that it can be closely compared with manufacturing.

In manufacturing, every aspect of production is built around standardized processes and standardized raw materials. But in health care, the “raw materials”, people with illnesses and risk factors we doctors seek to mitigate, are all different. And the processes often involve judgement calls and compromises between different objectives when patients have more than one disease.

Compare this to two types of carpentry:

Some carpenters build houses on empty plots of land, according to detailed architectural drawings, using standard sized lumber, creating homes that are identical, square and uniform. Novice carpenters learn relatively quickly how to build such homes, because the manufacturing process is consistent and predictable from one brand new home to the next.

Healthcare is more like old-house restoration than manufacturing. Put another way, real patients are more like old houses than new tract homes.

I have recently had reason to watch a master carpenter and a master painter turn a 1790 house and barn from a neglected near-dilapidated state into an inviting and comfortable home. Almost everything these two craftsmen did was improvised. Every flaw or asymmetry they tackled inevitably lead to another one that could not have been anticipated, let alone described with enough detail in architectural drawings or engineering diagrams for someone without decades of experience to tackle. Every decision these men made almost automatically and with little fanfare was a judgement call or an impromptu recreation of some antique detail; the carpenter chose lines to work from so that the house seemed straighter to the eye than if he had followed his level, and the painter filled gaps in the antique moldings with joint compound in a way that made the house seem tidy and whole but still showing its age.

When restoring a 200 year old house, there are no perfect squares or true plumb lines. The walls are never even and the floors are never level. But that doesn’t make such a house less livable, or less beautiful. It adds to its value. Manufacturing principles don’t apply when you set out to restore an old house, and the same holds true in holistic primary health care. Putting new drywall over a wavy plaster and lath wall is quicker than preparing the original surface for fresh paint, but the result breathes life and history into spaces that are now ready to live on with renewed purpose and dignity.

In medicine, whether it is doing plastic surgery, treating aging patients with three or four chronic medical conditions or counseling a patient facing life-changing circumstances, the manufacturing model can only cover the most rudimentary basics. It is the skill and experience of the practitioner in balancing all the variable manifestations of disease in real people that makes their treatment a source of healing.

Even the most predictable patient care processes, like taking out somebody’s appendix, don’t quite lend themselves to the manufacturing analogy. In medicine, the first step is not how to begin to remove the appendix; it is making the decision whether to do it in the first place. That isn’t always a straightforward, scientific decision, even with today’s imaging tests. It sometimes comes down to a judgement call here, too.


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

BOOKS BY HANS DUVEFELT, MD

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