Saturday, October 30, 2010

Nanny State and Nanny Employer

This election season has been saturated with backlash against "government takeover" of health care. Critique of the Patient Protection and Affordable Care Act ranges from thoughtful, fact-based responses to know-nothing paranoia.

The law is imperfect, but it's the best our body politic was capable of in 2010. It represents a substantial step forward. But it has touched a very raw nerve in our political psyche - the depth of our reluctance to acknowledge that health isn't just a matter of individual rights - our community has responsibilities to us as individuals, and we as individuals have responsibilities to our community.

The "Government, keep off my back!" issue is being fought out in federal court over the awkward, but necessary, legal, and ethically entirely justifiable individual mandate (see here, here, and here, for previous posts on the mandate). But the same dynamic is starting to emerge towards the growing tendency for employer-based insurance to include wellness incentives, as set forth especially clearly in this recent letter in the New York Times:
It’s About Time to Check the Fine Print on Your Health Plan” (Patient Money, Oct. 16) says that “your company may be offering cash rewards ... if you complete a health risk assessment or get screened for blood sugar, high cholesterol or high blood pressure,” as if this were an unproblematic perk. But it undermines your privacy when your employer monitors your health and offers incentives for good behavior.

We are familiar with criticism of the nanny state, but isn’t it about time to extend such criticism to the nanny employer, whose power over employees threatens their freedom to make their own health choices about their own lives?
Some workers hate their employers with the same passion the Tea Party expresses towards the government. But even for them, it's potentially easier to understand the social compact that underlies employer-based health insurance than in our highly fragmented national system.

The employer takes money the company earns and puts it towards health insurance, money that otherwise could go into wages or improving the company's competitive position. If I'm hit by a car, my fellow employees and employer are, in effect, subsidizing my care. If that happens, I hope I'll be appropriately grateful. But my fellow employees and employer are entitled to expect me to approach my own health in a responsible manner, because (a) they care about me and (b) they will be paying for the health care I need.

I have a right to smoke, become a couch potato, and toss my medications into the toilet. But I don't have a right to tell my fellow employees and employer - "I have no responsibility for the consequences - it's your role to pay for me...and don't you dare ask any questions or ask me to take any responsibility!"

Incentives (carrots and sticks) can be done well or poorly, fairly or unfairly. Behavioral economics research on how incentives work and ethical reflection on what kinds of incentives are justifiable, is well underway. As an example, here's the mission of the Center for Health Incentives at the University of Pennsylvania, a leading site for behavioral economics research:

Our mission is to facilitate research that makes significant contributions to reducing the disease burden from major public health problems such as tobacco use, obesity, and medication non-adherence for cardiovascular and other diseases through better understanding of how to design and apply incentives and other behavioral economic approaches to improving health. The center has 3 primary missions:

  1. To advance knowledge about incentive design
  2. To develop and test scalable and cost-effective applications
  3. To work with private and public sector entities such as large employers, insurers and health systems to improve health care delivery and the health of the population
I hope we see lots of debate about "Nanny Employers" in the months ahead. It will be hard for us to take glib libertarian positions when those who will be affected by our actions are our comrades at work. It's easy to rail against "government takeover," "socialism" and "Obamacare." It's harder to look into the eyes of our fellow workers and spout the same nonsense!

Sunday, October 24, 2010

Health Care and the Campaign

A New York Times editorial on "Health Care and the Campaign" summarizes nicely the lies, distortions and disinformation about health reform the Republicans are purveying:
  1. Lies. Here's John Raese, Republican candidate for Senator in West Virginia, on health reform: "From here on out under Obamacare, you're going to have a patient-bureaucrat relationship, because the first person that patient has to go to is a bureaucrat. That is called a panel."

    There's simply no truth whatsoever to Raese's claim. Zero. Nada. But since the lie coincides with the widespread distrust of government that is at the heart of American political culture, it confirms a preconception. Wariness and skepticism about authority are good, but they can be turned into paranoia by Raese's lies and Palin's "death panel" nonsense. (See here for discussion of the paranoid style in American politics.)
  2. Socialism. The Republican play-book calls for high frequency repetition of the "Obamacare is socialism" and "government takeover" mantras. As the Times points out: "What is true is that the law relies heavily on private insurers and employers to provide coverage. It also strengthens regulation of those insurers and provides government subsidies to help low- and middle-income people buy private insurance on the exchanges. Those exchanges will promote greater competition among insurers and a better deal for consumers, which last time we checked was a fundamental of capitalism. "

    Billy Wharton, co-chair of the Socialist Party USA, agrees with the Times: "This is not a healthcare reform bill. It is instead a corporate restructuring of the American healthcare system designed to enhance the profits of private health insurance companies disguised with the language of reform."
  3. Cost increases. The out-of-control cost trend is a key reason we need health reform, and premiums continue to go up well beyond the general rate of inflation. This gives Republicans a rhetorical meatball - "look, Obamacare is already driving costs through the roof the way we warned about!" (See here for a videoclip.) But as we teach medical students in their introductory courses, correlation doesn't establish causation. The primary harm of the Republican distortion is that it contributes to lack of public understanding of the primary drivers of the cost trend: excessive administrative costs, high prices for medical services, and inefficient provision of care.
  4. Medicare scare tactics. Efforts to scare seniors is an election year ritual. When the Democrats were out of power they did just what the Republicans are doing now. Both parties understand that Medicare (a) is a crucial social program, (b) is very popular, but (c) is economically unsustainable as the baby boom ages. Clinicians who care for the elderly, adult children involved with their parents' medical care, and many seniors, recognize that Medicare needs to move away from uncoordinated fee-for-service treatment, through a combination of better integrated care (through medical homes and accountable care organizations) and wiser CMS oversight. This particular piece of Republican rhetoric is part of political silly season. Democrats are just as profligate in their use of Medicare scare tactics.
From Socialists to the Tea Party, no one loves Patient Protection and Affordable Care Act. Given the intensity of political passion, the enormous economic interests at stake, the complexity of health care, and the dismal state of public and political understanding, passing a comprehensive bill was a remarkable achievement. It's a last ditch effort to make a health system governed by market forces viable. The only alternative is some form of single payer system. If the Republicans succeed in tearing down the health reform process they'll be advancing their own nightmare vision!

Friday, October 22, 2010

Octomom and the Physician-Patient Relationship

At a hearing in California to see if his license should be revoked, Dr. Michael Kamrava, the fertility specialist who implanted 12 embryos in Nadya Suleman ("Octomom"), testified that he recommended implanting "only four," but Ms. Suleman was "adamant about using all 12" so he "obeyed her wishes."

Almost 20 years ago, Zeke and Linda Emanuel wrote a now classic article - "Four Models of the Physician-Patient Relationship." Dr. Kamrava's defense exemplifies what the Emanuels called the informative approach to to the physician-patient relationship:
[Under] the informative model, sometimes called the scientific, engineering, or consumer model... the objective of the physician-patient interaction is for the physician to provide the patient with all relevant information, for the patient to select the medical interventions he or she wants, and for the physician to execute the selected interventions. It is the physician's obligation to provide all the available facts, and the patient's values then determine what treatments are to be given. There is no role for the physician's values, the physician's understanding of the patient's values, or his or her judgment of the worth of the patient's values. In the informative model, the physician is a purveyor of technical expertise, providing the patient with the means to exercise control.
I can remember when the values embodied in the "informative model" came into play. It was the late 1960s - 1970s, in the context of the cultural critique of elitism and expertise that manifested itself in medicine as a well-deserved backlash against "paternalism." The profession swung from seeing the patient as a passive obeyer of the "doctor's orders" to seeing the physician as a passive obeyer of the "patient's orders."

The basis for arguing that Dr. Kamrava should lose his medical license is that he so clearly went against the American Society of Reproductive Medicine guidelines on embryo transfer:
For patients under the age of 35 who have a more favorable prognosis, consideration should be given to transferring only a single embryo. All others in this age group should have no more than 2 embryos (cleavage-stage or blastocyst) transferred in the absence of extraordinary circumstances.
But as reckless and ill-advised as his actions were, he was entitled to argue in response that he was following a recognized model of physician-patient interaction, which, in his view, trumped the ASRM guidelines.

If the "Octomom" situation was a single lapse on Dr. Kamrava's part, I would not favor having him lose his license. He would deserve to be publicly chastised and required to practice under the close supervision, paid for at his own expense, of an experienced IVF specialist. (If it was part of a pattern of reckless practice I would support loss of license.)

The paternalistic model and the informative model should both be tossed out the physician-patient window as default orientations. There's often a need for firm guidance - but when it's calibrated to the details of the patient's needs it's not paternalism. Likewise, there's often a need for saying (in effect) to the patient - "now that I understand your values I'll get right to work" - but when that response is calibrated to thoughtful, evidence-based care it's good medical practice, not slavish consumerism.

(See here for a previous post on the "Octomom" case.)

Wednesday, October 20, 2010

Medical Group Growth and Expansion

I recently met with a physician leader in a group that is expanding through merger with another group. He was interested in my direct experience with growth and expansion during my years with Harvard Vanguard Medical Associates (formerly Harvard Community Health Plan). Because the movement towards Accountable Care Organizations will result in a lot of growth and expansion, I thought these observations about what can occur might be useful to others:

  1. Pride. Being joined by new physicians or another group may be experienced as an affirmation that the practice is respected, admired, and an excellent place to be.

  2. Security. The external environment is full of threats. Members of the group may feel that there is greater strength and security in greater numbers. More leverage in dealing with insurers drives up overall costs and contributes to the national cost spiral, but from within the group it looks like a good thing.

  3. Alienation. Many physicians join group practices hoping to be able to practice medicine without having to fret over the business elements of the profession. What interests them is seeing patients. What turns them off is their leaders' preoccupation with growth and excitement about it. They may feel like the older sibling when a new baby comes along - "have you stopped caring about me?"

  4. Fear. Especially when a small group becomes larger, it may feel like the loss of a golden age. This is a common phenomenon in organizational development and not distinctive to medicine. The feeling is - "why can't we stay as we are - things are great right now?"

  5. Opportunity. Sometimes growth creates new professional opportunities for members of the group. I experienced this in 1975. I was practicing contentedly at Harvard Community Health Plan when the group developed a new practice site in the town where I lived. I was asked if I was interested in leading the new site. My first answer was "no." But when I thought about the challenge of building a practice that would directly serve my own community I changed my mind.

  6. Learning. Growth is a significant change for organizations, and change creates the potential for learning. In the 1970s at Harvard Community Health Plan we argued about whether we needed to grow. For many of us, myself included, these discussions increased our "economic literacy" about what the U.S. commitment to a "competitive medical marketplace" meant. And developing a new practice site led us to make visits to each other to refine our understanding of local "best practices."

In ethical medicine, the guiding principle is to learn from each other and disseminate best practices. In competitive capitalism, the guiding principle is to hoard our good ideas to gain market strength. In the era of insurance company-led managed care, insurers followed the second path. Criteria for defining "medical necessity" were treated as proprietary business secrets. This was standard business practice, but a gross violation of health care ethics. It contributed to the backlash against managed care.

If ACOs take that route they won't deliver on their promise and the public won't - and shouldn't - trust them. The right ethical configuration for healthcare is as a "learning healthcare system," with free and open communication among clinicians and between clinicians and patients. It would be a tragedy for the ACO movement not to reach its potential.

Monday, October 18, 2010

Chilean Miners, Informed Consent, and Medical Ethics

I've never met Chris MacDonald, but I admire his superb Business Ethics Blog. Chris teaches philosophy and business ethics at Saint Mary's University in Halifax, Canada.

This post is triggered by what Chris wrote yesterday about the recently rescued Chilean miners, but a paragraph from his post today explains what I like so much about his way of approaching ethics. I highlighted the key sentence:
A bit of economics can go a long ways in helping understand a range of issues in business ethics. I’m not an economist myself, but I’ve read a fair bit of economics here & there. And I want to read more. In order to arrive at sound ethical conclusions, you need more than just ethical beliefs: you need some understanding of how the world works. For many issues in business ethics, economics provides relevant facts.
Chris hits the nail on the head. In medical ethics, as in business ethics, to "arrive at sound ethical conclusions" requires ability to reason well and even a bit of theory, but also practical knowledge "of how the world works."

Chris discusses two fascinating questions about the miners. First, what law are they under? He cites a law review paper from 1949 that imagines trapped miners who agree to shoot dice to see which one of them will be killed and eaten by the others. Without cannibalism, all will starve to death. When rescued, the survivors are tried for murder. Four judges find them guilty. The fifth acquits them. He argues that while trapped, they formed a mini-society, cut off from the system of government above them, and appropriately created their own form of civil society. Happily, no situation of "earthly crime" occurred in Chile, but the question of how it would have been handled after rescue is not simple.

The second question is relevant for medical ethics. While trapped, the miners drew up a contract agreeing to share equally any profits from telling their story (see here). But Chris asks - in the situation of entrapment, was true informed consent possible? He speculates that the largely positive force of strong group pressure for cooperation might be seen as creating "undue influence" and "duress."

Many years ago, my primary care physician referred me for a cardiac stress test. I arrived at the site, was ushered to the treadmill, and given several pages to read to get my "consent." The technician was standing by, in effect twiddling his thumbs. It wasn't a situation for leisurely perusal and reflection on risks and benefits! I knew enough about the test so that I could sign without reading the mini-tome, but in a minor way, the setting embodied the kind of "undue influence" and "duress" that Chris imagines in the Chilean mine.

In medical ethics class we teach all about the difference between explanation, persuasion, manipulation and coercion in seeking informed consent. Unfortunately, those lessons are often undone when students get to their clinical rotations and are sent off with a clipboard to "consent the patient" before a procedure is done.

Another factor, closer to my own field of psychiatry, involves all the discussion of the miners' supposed need for psychological treatment. The teams working with them while they were trapped were very sophisticated in their psychological thinking, as by not sending down games likely to provoke competition. 2300 feet underground it would be too easy for disputes to get out of hand.

The Chilean government will make six months of counseling available to the men. But some columnists have written that the men will surely suffer psychological disorders on their return. In their view, counseling is inevitably required. In actuality, some probably will need that kind of help, but others probably wont. In our mental health oriented, sometimes psychobabble dominated, culture, we can do inadvertent harm by our assumptions about how the psyche "must" work.

Years ago I did that myself while supervising a psychiatric resident in treating a mildly retarded man who had been incarcerated in a state facility as a teen for exposing himself in public. He had spent the next 50 years in the facility until the deinstitutionalization movement led to his being transferred to a community residence. He seemed happy. I said to the resident - "that can't be all there is to it. After all, he's lost his home of 50 years."

The resident probed and probed. We concluded that I was wrong. Remarkably, the man expressed no resentment for his incarceration. He was a simple soul, and took pure pleasure in being able to go to the neighborhood store when he wanted. In my supervision I'd imposed an assumption on him rather than letting him speak for himself.

With veterans returning from Iraq and Afghanistan, we're doing the right thing by emphasizing that "warriors" who are depressed are strong, not weak, when they ask for help. But in my practice I saw many people who were so persuaded that there was only one way to experience grief that if they didn't cry their unshed tears would create the equivalent of a poisonous toxin inside. Societal receptiveness to sadness and tears turned into a command for them.

In medicine, a core component of the "understanding of how the world works" required for ethical practice comes from listening to our patients without imposing stereotypes and preconceptions.

Wednesday, October 13, 2010

The War Between QALYs and Death Panels

The current issue of the New England Journal of Medicine has an excellent "Perspective" piece by Peter Neumann and Milton Weinstein - "Legislating Against Use of Cost-Effectiveness Informantion." The authors discuss the fact that the health reform bill calls for a Patient Centered Outcomes Research Institute, but specifically forbids it from considering cost per QALY in its work. Here's the gist of their argument:
The antagonism toward costper-QALY comparisons also suggests a bit of magical thinking — the notion that the country can avoid the difficult trade-offs that cost-utility analysis helps to illuminate. It pretends that we can avert our eyes from such choices, and it kicks the can of cost-consciousness farther down the road. It represents another example of our country’s avoidance of unpleasant truths about our resource constraints. Although opportunities undoubtedly exist to eliminate health care waste, the best way to improve health and save money at the same time is often to redirect patient care resources from interventions with a high cost per QALY to those with a lower cost per QALY. At a time when health care costs loom as the greatest challenge facing our country’s fiscal well-being, legislating against the use of the standard metric in the field of cost-effectiveness analysis is regrettable.
The contrast between the relatively grown up approach to health policy in the U.K. and the immature head-in-the-sand approach in the U.S. couldn't be more stark. The National Institute for Clinical Excellence makes explicit use of QALYs - value for human beings per dollar spent. We forbid it.

Still, creation of the Outcomes Institute is a step forward. The legislation caved in to the death panel crowd, but simply establishing and funding an outcomes process is a positive step. As Churchill said, "You can always count on Americans to do the right thing - after they have tried everything else."

We're not fast learners here in the US!

Tuesday, October 12, 2010

Psychoanalysis in China

A headline in yesterday's Washington Post caught my eye - "Freud coming into fashion in China." Until I saw the article, I'd never used "China" and "Freud" as part of the same sentence!

Through the article I learned about the China American Psychoanalytic Alliance (CAPA). Nine years ago, Dr. Elise Snyder, in her late 60s at the time, gave a paper about psychoanalysis in Beijing. She was startled at how interested young psychiatrists, psychologists and social workers were in learning about psychoanalysis. On returning home she formed CAPA, which has developed a remarkable training program for mental health clinicians in China.

In 1986, on my only trip to China, the psychiatrists I met were organically-minded, and showed little interest in psychoanalysis. It was only their politeness that kept them from describing it as a symptom of western decadence. But with the enormous social changes associated with rapid economic growth, internal migration, and a growing middle class, the anxiety and depression previously seen as western decadence have become part of Chinese life, and interest in the psychological aspects of human function has burgeoned. Incidents of suicides among workers in the economic zone and kindergarten killings have led the government to take more interest in developing access to mental health treatment.

CAPA has established a two year psychotherapy training program in which teachers in the U.S. treat the training participants via Skype and conduct supervision the same way. Faculty members travel to China for face-to-face meetings with the students and their patients. The first class will graduate in Beijing on October 24.

The CAPA program will give a window onto complex ethical questions. Freudian psychology is highly individualistic. Therapy centers on the patient's fears and desires. Societal expectations are seen through the lens of the individual psyche. Despite the extraordinary changes since Mao's death in 1976, however, China is still an authoritarian society. Challenging the state is not welcome. If psychotherapy led to intense questioning of the political structure it could create significant danger to the individual, and could lead to discrediting of the Freudian venture itself.

At a CAPA gathering in New York in January the topic of the main panel will be "Ethical Problems in Teaching and Treating in China," presented by two students in the China program. I hope it will be the start of an extensive piece of intercultural ethical inquiry. There would be much to learn from a dialogue between Freud and Mao!

Monday, October 11, 2010

ACOs, Rationing, and Medical Ethics

Magic bullets come and go in the world of health policy, but the accountable care organization (ACO) is likely to be a durable reform. Except for group practices like Geisinger, Harvard Vanguard, and Kaiser Permanente, systems like the VA, and local communities in which independent practitioners have established cooperative collaborations, health care has been grotesquely uncoordinated in the U.S. ACOs speak to that structural lesion.

Title III of the Patient Protection and Affordable Care Act puts ACOs forward as an innovation to promote the quality and efficiency of health care. "Efficiency" isn't controversial. Doing a second MRI because the results from the first one aren't available is pure waste. But not doing an MRI when a plain film, or a careful physical examination and history, could be "adequate," is more complex. Some would call that "efficiency" or "evidence based practice." Others would call it "rationing." But there's no uncertainty about how to label not offering an effective, and desired, service - that's definitely rationing.

In the October 6 issue of JAMA, Dr. Robert Brook of RAND has an important brief article - "What if Physicians Actually Had to Control Medical Costs?" As a thought experiment, Brook imagines that enough money is available for a physician to treat 100 patients with condition A or condition B. Treating each patient costs $1000, and only $100,000 is available. Epidemiological data predicts that the physician will see 100 patients with A and 100 patients with B. The benefit of treating A is four times the benefit of treating B. What should the physician do?

Brook believes, and I agree, that even when we have wrung all efficiency savings out of health care, there will still be beneficial interventions physicians want to provide, and patients want to receive, that our society will not be prepared to pay for. He argues, and I agree, that the medical profession is unprepared for engaging with this eventuality:
Policy makers discuss controlling medical costs, and academics publish articles analyzing cost-control approaches. But physicians seem oblivious to the possibility that, sooner or later, care will need to be explicitly rationed. Physicians who actually order the health-related diagnostics or treatment for which taxpayers pay must decide how they will cope with explicit rationing. Will there be a physician plan or health professional plan to deal with the eventuality of explicit rationing? Should planning begin now instead of waiting until the decision is imminent?
There's no way that the need for rationing could have been part of the federal health reform process. We're not yet mature enough as a body politic to deal with that piece of reality without going ballistic about "death panels." But wishful thinking and political immaturity don't change the fact that rationing happens now, will have to be acknowledged in the future, and is an ethical requirement, not an abomination. Brook concludes, and I again agree: explicit plan for rationing needs to be developed. But who will do it, and how?
Physicians (and other health professionals), patients and the wider public should be the "who?" And with regard to "how?," the experience of the Didcot practice in the U.K. provides a model of deliberative process. With help from two ethicists, the general practice group created guidelines for the practice, reviewed them with members of the practice, and made them public.

No one wants to go first in discussing rationing. To do so would invite savage, know-nothing political attack. But it's important for public deliberation about how to ration in a clinically guided, ethically justifiable and potentially socially acceptable manner to get underway. Accountable Care Organizations are an ideal setting for physicians and patients to join together in this kind of what if scenario planning.

Thursday, October 7, 2010

General Practice Leadership in the NHS

A few days ago I wrote about the split in U.S. health policy between concepts of physician-led reform and market-driven/consumer-led reform.

In England, the new Conservative-Liberal Democrat coalition has opted for a degree of physician-leadership that couldn't be imagined in the U.S. It envisions reorganizing the National Health Service around GP consortia that will "commission" (in U.S. lingo, "purchase") secondary health care services for populations of 100,000 to 750,000. Here's what the new government's White Paper says about GP commissioning:
This change will build on the pivotal and trusted role that primary care professionals already play in coordinating patient care...Primary care professionals coordinate all the services that patients receive, helping them to navigate the system and ensure they get the best care (of course, they do not deliver all the care themselves). For this reason they are best placed to coordinate the commissioning of care for their patients...
In the U.K. approximately 50% of the physician workforce is in primary care, and the numbers are holding steady. In the U.S., we've had a 50% drop in the number of medical students going into primary care in the last ten years. I know from interviewing residency applicants that many would prefer to make a career in primary care, but a combination of the monstrous debts they graduate with, the poor compensation of PCPs relative to specialists, and the increasingly harried worklife of the PCP, drive them away.

We in U.S. talk out of both sides of our mouths with regard to primary care. We construct elegant conceptual models for how primary care would ideally function, but we systematically devalue the field through the way we govern our health system.

Given the declining number of primary care physicians, the concept of consumer/patients who coordinate their own care and shop for a package of services to meet their self-perceived needs, is filling a vacuum. Without consciously intending it, we've been putting patients into the position of "disintermediating" primary care physicians as unnecessary middlemen in the care system. The Conservative-Liberal Democrat White Paper dramatizes just how much we've marginalized general practice here in the U.S.

Not every member of our population wants to have a PCP as care coordinator. Millennials have imbibed the internet along with mother's milk, and many take readily to the consumer model of patient care. But Millenial PCPs, along with Millennially-minded older PCPs, know how to partner with activist patients and thrive in that kind of partnership.

Activist patients partnering with primary care physicians is where our health system needs to go.

(To learn more about GP-led commissioning in the National Health Service see this recent New England Journal article, the full government White Paper, or this analysis from the British Medical Association.)

Tuesday, October 5, 2010

Activist Patients, Cancer, and Medical Care

Two days ago I wrote about the polarized world of health policy, in which "physician-led reform" and "consumer-led reform" fall into opposing policy camps. This either/or dichotomy is destructive foolishness. The only sensible position is that we need both.

Real reform won't happen without robust patient-physician partnerships. I've recently seen an example of what this means in the way my friend Jessie Gruman handled a health emergency.

Jessie is the founder and president of the Washington-based Center for Advancing Health, an organization whose efforts "are aimed at increasing patient engagement in the belief that people will not benefit from the health care available to them unless they participate fully and competently in it." (Disclosure - I was on the board of the Center from 1998-2004.) Jessie has a PhD in social psychology and all kinds of work experience, but she also has more personal experience of medical care than anyone should have to go through, including, until recently, three different cancers, starting with Hodgkins Disease in her late teens.

Here's how Jessie writes about her most recent experience:
This is my fourth different cancer-related diagnosis. My stomach cancer was discovered due to the vigilance of my primary care doctor who treats adult survivors of childhood cancer and who leaves no symptom – regardless of how minor – unexplored. I had dismissed my insignificant symptom once it disappeared after a few days. However, my doctor didn’t, and it turned out to be a small gastric tumor, probably a result of the high doses of radiation that were the standard of treatment for my stage of Hodgkin’s disease in the early 1970s...Breaking through [the turmoil I felt] are bright flashes of gratitude: for the amazing luck of finding the cancer while it is small; for my access to smart doctors who take me seriously and who will do their best for me...
Jessie's narrative shows us what "patient-physician partnership" means. Jessie is the quintessential "informed," "consumer-minded" patient. But she's not making impersonal purchases of medical commodities - she's working in close partnership with physicians she trusts.

Jessie took the advice of her trusted primary care physician to investigate the gastric symptoms. But in relation to medical care she's a leader as well as a follower. As an example, two years ago Jessie wrote a wonderful succinct guide for what to do when someone close to us has cancer (see here). But being an activist patient doesn't require a PhD, as exemplified by a former patient of mine who gave me an insightful performance review (see here).

Patient-Physician Partnership means activism by both parties. "Consumer" and "provider" are unfortunate metaphors, with their associations to window shopping at the mall ("consumer") and hawking of goods and services("provider"). Throughout my practice years I was grateful for the guidance and teaching I received from my patients, and I believe many of them were grateful for my care. That's what "partnership" means.

Jessie's post that I quoted above was written on September 27, the day she went in for surgery. I'm happy to report that all went well and she's at home now. I'm sure that after she rests up Jessie will again be teaching us about what patient activism and patient-physician partnership mean!

Sunday, October 3, 2010

Medical Homes, Patient Empowerment, or Both

There are two main beliefs in U.S. policy circles about how to improve health care quality and contain costs - strengthening the role of primary care physicians as "coordinators" or "integrators" of care, and empowering patients to "drive the health care market" by becoming value-oriented consumers.

The two approaches keep different company in policy-land. Strengthening primary care, as by establishing medical homes and accountable care organizations, tends to appeal to public health oriented, liberal folks. Empowering patients to take on the consumer role, as by transparency about quality and cost and "skin in the game" through financial risk, tends to appeal to market oriented, conservative folks.

Looked at from 30,000 feet the two approaches appear to reflect very different value orientations. Advocates for physician-led reform largely trust physicians to be motivated by professional ideals. Their aim is to enable physicians to carry out these ideals in their practices. Advocates for market-driven reform see physicians as Homo economicus, motivated in accord with Adam Smith's teachings:
"It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own interest."
By giving patients who have significant financial responsibility for their care reliable information about quality and cost, they will "shop" for care and shape medical care the same way that consumerism shapes the performance of other markets.

In our increasingly polarized political culture, physician-led reform and market-driven reform tend to be treated as either/or alternatives. Those who favor physician-led reform believe "the other side" just doesn't understand professionalism and our wish, when sick, to be cared for, not to shop. Those who favor market-driven reform believe "the other side" is naive about physician motivation and paternalistic towards patients.

This polarization is destructive. We won't get anywhere in the reform process without primary care leadership and activist patients. If the health system disbelieves in professional altruism, altruism will disappear. But wise physicians understand how much we need our patients to guide and monitor us, just as they need us to guide and monitor them. And prudent consumer-patients want compassionate caretakers, not just responsive Homo economicus.

"Physician-patient partnership" is a current buzz word. But properly understood it's the key to meaningful health reform. In the next few weeks I'll be writing more on what "physician-patient partnership" means.