Musings on How We Pay for Health Care
"U .S. Ties Hospital Payments to Making Patients Happy," said the headline of a recent article in The Wall Street Journal.
The article reported that nearly a billion dollars of government payments to hospitals would be based partly on how patients responded to a satisfaction survey. High scores would receive a bonus. Lower scores would receive less money.
Medical service payments linked to making patients happy illustrates how difficult it is in medical care delivery to align payments appropriately with quality, cost-effective care.
Sure, we want the physician/patient encounter to be as pleasant, polite and effective as possible. In many situations, honest, evidence-based care will not make the patient happy, no matter how well all of the environmental factors are managed. The patient and the physician simply have a different idea about what is needed.
The patient's and the physician's understanding of the clinical situation are different because they are operating from different knowledge bases - not necessarily right or wrong, just different.
Let me illustrate with some personal medical practice history.
In 1966, Bill Clarke and I came to Southern Pines to practice pediatrics. We were both just out of our two years of military service, having completed residencies at university hospitals - Bill at UNC and I at the Johns Hopkins.
Antibiotics came into widespread use during the latter part of World War II. In the 1950s, we were just beginning to understand the problems of overuse of these new antibiotics. In pediatrics, infections are one of the most frequent reasons a child is brought in to see a doctor.
In general medical practice the 1960s, many infections received a course of antibiotics even though most of the infections were caused by organisms, generally viruses, that were not responsive to antibiotics. Penicillin and other "miracle drugs" had made such a dramatic impression on physicians and the general public that it was common practice to treat most all infections with these "wonder drugs." Some infections that had been life-threatening were interrupted overnight.
Bill and I, just out of training, were determined to treat bacterial infections with antibiotics. I used to think that if I didn't disappoint five mothers by lunchtime, I wasn't doing my job. At first, some of them would return to their local physician for an antibiotic prescription.
"Dave, just give them some penicillin," said one of these physicians, whom I liked and respected. "It won't hurt them, and it might help!" But overuse of penicillin soon led to the development of resistant organisms.
Patient satisfaction score would be the wrong way to value these office visits. Many mothers soon learned the drill. They would bring their child with a sore throat in for a throat culture and avoid the cost of an office visit. Now there are instant tests for a streptococcal infection. Most physicians today are careful not to overuse antibiotics.
Science and Medicine
This bit of personal history illustrates something of how science functions in the retail practice of medicine. Science researchers and academics come to understand current scientific "facts" before the general public. If we are to practice evidence-based medicine, then there will often be an information gap that could lead to some dissatisfaction in the patient/physician encounter.
Because of the transient nature of "scientific facts," there are added pressures in the practice of evidence-based medicine. Another anecdote in my history can help me illustrate this concept.
One of my best teachers was Dr. Charles Hooker, chairman of the anatomy department at UNC School of Medicine. I got to know Dr. Hooker well because I worked in the department in the summers. I helped care for the mice and had a small research grant. Dr. Hooker and I shared an interest in Civil War history. We often had wide-ranging conversations.
One day he said to me, "David, my job in the medical school is to teach future physicians to understand and practice medicine by the concept: 'I don't know.'" Good physicians understand the limits of evidence-based medical care.
In America, we have a major problem of abuse of prescription drugs - especially with pain medications and psychotropic drugs. The N.C. Medical Board receives hundreds of complaints every year from drug seekers who didn't receive the quantity of drugs they sought for pain relief. Diversion is never mentioned as a reason for their drug-seeking.
A Problem on the Streets
Law enforcement officials tell us that diversion of prescription drugs is a problem on the streets as difficult as heroin or cocaine. Prescription drug diversion and drug-seeking doctor-shopping are felony criminal offenses. Before we go too far in linking medical care payments to patient satisfaction, we need to understand how that might play into the prescribing of drugs that may become overused or diverted.
A final consideration in this problem of incentive payments for health care is how often tests or procedures are performed to satisfy the patient.
We know that "defensive medicine" in the medical liability arena has been well-
documented. Unfortunately, this practice has largely become the regular practice of medicine, and not just to "doctor the record," as it once was when medical liability first became a significant factor in the practice of medicine.
Thirty years serving on the board of directors of a medical liability insurance company has taught me that the interpersonal relationships of the physician with the patient and the family lead to medical malpractice suit much more often than errors in medical practice.
Our liability risk management efforts in recent years have become much more focused on transparency, honesty and full disclosure in the physician/patient relationship. Again, the distortion of the clinical practice of medicine is much more important than the costs of medical liability insurance.
Please understand: I do not mean to imply that "patient satisfaction" is not a valid measure to base incentive payments on in medical care services. It is just one of many "outcome" measures that we must learn to use. I am trying to illustrate the complexity we face in health care reform.
It Takes a Community
We must learn how to measure and relate to medical practice outcomes, not just inputs. I'm talking about individual and population-based outcomes such as infant mortality, chronic disease, life expectancy, rational behavior and obesity, to list a few. Now we base payment on inputs like the number of office visits, procedures and images.
This kind of change in our medical payments structure will require a massive cultural change for physicians and their patients. It is a move from a business/
market-based system toward a social/caring system. Most physicians entered medical school wanting to learn how to care for people. Most care for their patients without regard for payment. We will need incentive payments to get the work done. Correct alignment will be the tough part.
I was privileged to receive my medical doctor degree in June 1961. This half-
century has taught me at least one thing for certain about the science and practice of medicine: At least half of what I am currently certain about will not be true in the future. This may be another reason we need to do a better job teaching how to think about science and health literacy in our public schools.
I hope the reader will join the community of people trying to learn how to finance health care in a way that is sustainable and provides universal, high-quality, patient-
centered care. Payment for health care is too important to be left to the providers of health care. It takes a community to raise all the right questions.
H. David Bruton, M.D., is a retired pediatrician. A former member of the Moore County Board of Education, he served during the 1970s as chairman of the N.C. State Board of Education. From 1997 to 2001, he was secretary of the N.C. Department of Health and Human Services. He is the founding chairman and board member of the Moore Free Care Clinic.
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