Friday, September 30, 2011

Too much care?

The US healthcare system is in a state of crisis. At this point, we’re starting to sound like broken records. Increases in healthcare premiums have been outpacing increases in wages for several years now. A National Academy of Sciences slideshow I saw gave projected prices for staple foods had their prices increased at the same rate as healthcare costs – picture paying $134 for a dozen oranges. What is absolutely certain is that this is not going to be an easy fix, and that cutting costs is going to involve trimming in many sectors.

Interest in reducing healthcare costs resulted in a recent survey of primary care physicians, which found that many primary care docs are over-treating their patients because of current factors in health care. At first read, most people would probably react negatively to these findings, for after all, most Americans feel that they’re receiving substandard healthcare and paying increasingly more for it. In my experience, patients feel their visits are too short, and that their doctors just order labs and write prescriptions without spending the time to listen or answer questions. I often joke that I could base my entire practice as a naturopathic physician around explaining to people how to read the labs their other doctors have ordered.

It turns out that patients and doctors agree on this topic. The results of this survey, published in the prestigious Archives of Internal Medicine, indicate that physicians feel they aren’t given enough time with patients, aren’t able to follow up with patients by phone or email as much as they would like, and have to order lab tests and imaging studies more aggressively than they would like. Most primary care physicians surveyed would prefer to treat more conservatively and spend more time with their patients than they do currently.

There are two main messages I think are important to take from the survey. The first is that both doctors and patients agree on what they want from the doctor patient relationship. Patients want to be heard, and doctors want to listen. This sets us a goal for assessing the quality of healthcare delivered.

The second message is this: the doctors surveyed were very clear about the factors they felt interfered with their ability to deliver quality healthcare. One such concern was fear of malpractice litigation, which was causing doctors to over-prescribe and over-diagnose for fear that they would be sued. Also high on the list were concerns over insurance reimbursement. It’s a sad truth that insurance doesn’t reimburse for quality time spent with patients, but rather for referrals to specialists, procedures, prescriptions, and for seeing lots of patients for shorter periods of time. The article concludes that the quality of healthcare could be improved by reforming malpractice liability and modifying financial incentives to reward quality time spent with patients.

Of important note is the fact that the article’s lead author works for the Veteran’s Administration, an organization that currently provides its physicians greater protection from malpractice suit and doesn’t offer the same financial incentives, but which has traditionally performed very high when it comes to patient satisfaction and quality of care.

Go back now to the slideshow I mentioned earlier – the section titled ‘How Much is Waste?’ highlights some ways that healthcare dollars could be saved. Here we see that $210 billion dollars were spent on ‘Unnecessary Services’, due in part to defensive medicine – overly aggressive treatment done to avoid lawsuit or other repurcussions. Similarly, $55 billion dollars were misspent on ‘Missed Prevention Opportunities’, probably because doctors don’t have the time to spend with their patients discussing prevention. I bring this up to point out that the same factors that get in the way of delivering quality care are also driving up healthcare costs.

Doctors and patients want the same thing. They want quality healthcare and they want a system that works. This survey showed that doctors want to give patients the time and care that they deserve, rather than just rushing them out to see a specialist, and it turns out that it would save the country money as well. A few years ago, we missed a real opportunity to make fundamental change in the country’s healthcare system – it looks like the topic is coming around again soon. Let’s see if we can do a better job this time.