If those who have the money are the ones with decision-making power, why not let patients have both? As government and insurers debate over who should grant permission to doctors about which treatments and care regimens are acceptable, why not award ultimate control to the person in the best position to decide—i.e., the person receiving the care?
Consider this story:
In a radio interview last month, I heard two doctors (specifically, both called “interventional cardiologists”) debating the merits of their preferred approach to unclogging heart arteries. One followed guidelines based on evidence that when patients are stable, medications are as effective—and often safer in the long term—than placing a stent in the artery. The other has a “bias” toward stents, and places an average of seven a day. He says that when he sees the blood flow increase immediately, he knows it helps the patient immediately. Both doctors insist that money has no influence on how they practice, and if it influences some doctors it only happens at a “subconscious” level.
While it was unsettling to hear two doctors interpret sound research so differently, it was not surprising. The most disturbing aspect of the interview was the part they DID agree about:
THEY choose what the patient needs most; THEY have the freedom to decide what procedure to perform on behalf of their patients; and “THEY just don't want the government or insurers telling them what to do.”
Not once did either doctor mention discussing the options with patients, or mention their patients having any role whatsoever in critical care involving their hearts! There are benefits and risks associated with each option, the personal value of which only a patient can decide.
Debating government (as an insurer) versus insurers (as a governing payment system) misses a critical point.
When doctors OR politicians argue about who will make “health decisions,” they SAY they don’t want government or insurance getting in the way of a decision made by a “patient and his doctor.” Yet, as we know, patients are not included in informed decision-making as often as we’re being led to think.
What doctors are really arguing about is who will govern the purse strings, i.e., who will make “payment decisions.” The party in control of the dollars will inevitably decide which medical practices get reimbursed, and for what price. And, the procedure that gets paid through reimbursements is the procedure most doctors will choose.
While each side argues which payment system will do better job of protecting the all-important physician-patient relationship, one can only wonder whether the typical relationship is one that deserves protecting. Despite the terminology, neither the private, nor the public option mentions a guarantee of patient inclusion, beyond signing an “informed consent,” which is really just a permission slip approving what has already been decided.
Sadly, one of the only patient-decision-making provisions (optional counseling about end-of-life choices) mentioned by either side has now been removed after it was misconstrued by opponents and in the media.
What should patients be fighting for? Control of both dollars and decisions.
What if we did create health accounts and send patients dollars or vouchers to pay for treatments?
I know—I can already anticipate the objections about patients not being capable:
1) Patients don’t know enough to make good decisions.
2) Patients will be misled by providers when they are vulnerable.
But let’s ask ourselves, are patients better off now in a system where they have almost no control over payments and leave decisions up to others? Are patients given the right amount of information now during times when they are vulnerable?
True reform would come from the bottom up, rather than swapping out big payers.
When we spend our own money, we tend to become more informed and make choices more carefully. In a patient-controlled system, independent, trusted services will evolve (like consumer reports) that help people navigate the system.
In a market where consumers have dollars, we would likely see a revolution of lower-cost health treatments taking the place of today’s outrageously-priced technologies. When the consumer (spending dollars) is choosing rather than a doctor (earning dollars), the incentives would create an opening for brand new approaches to care. Today, doctors protect their right to do high-cost interventions (like stents) instead of prescribing lower-cost medications…while someone else pays.
Despite the insistence of the doctors in the interview above, never doubt that medicine is a business, regardless of who pays. Years ago, the director of a prominent cardiology group approached me about trying to justify higher fees for a safer, lower-cost treatment option.
Asking for anonymity, he confessed that while his team was aware that the new option was probably less traumatic for patients, they decided to continue the traditional approach because revenues were so much higher. He insisted that if only employers would pay additional money for the more efficient option, patients could get better care. Sadly for him, I could think of no method for justifying an over-priced fee for a better option that should be saving everyone money.*
In that unfortunate case, patients were not paying and were not asking about less expensive treatments. And the treatment center didn’t advertise the cheaper alternative. If patients were interested in great outcomes for less money, smart developers and providers would fill the void.
Why this matters: Patients can and should be active decision makers in their healthcare treatments. Any third-party payer, regardless of who it is, retains control by virtue of approving or denying payment for care. If we really want something different, we can make that happen. Placing financial control in the hands of patients would change the dynamic of the doctor-patient relationship in ways that would encourage collaboration, efficiency and accountability.
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*Note: This example certainly highlights the type of provider who does not promote active decision making by patients, and is not intended to represent all providers. We acknowledge and commend the many providers who do facilitate shared decision making, yet believe this practice is not nearly as common as it should be.
References
1. Joffe-Walt C. Doctors Disagree About Effectiveness, Cost of Stents. August 26, 2009; Accessed September 13, 2009.
When given the choice, it seems people will take the Fix me/Heal me now approach.
ReplyDeleteA recent study from the 2009 European Congress of Cardilogy showed that 12 months of exercise training was just as effective as stents in managing stable angina; and better than stents in preventing CV events. When the enthusiastic researchers tried to extend the study: 1) they lacked motivated volunteers because the exercise training was perceived to be "too long and too much work"; and 2)hospitals chose not to be involved because encouraging exercise was "financially less appealing".
This study was posted thru Medscape at http://www.medscape.com/viewarticle/708588.
Sigh!