Wednesday, April 16, 2014

Trust, Money and the Physician’s Role

Should a discussion of healthcare costs ever enter the exam room? Should doctors be rewarded for focusing more on costs when seeing patients?   A recent viewpoint article in the Journal of the American Medical Association (JAMA) entitled “Health Reform and Physician-Led Accountable Care” suggests that primary care physician-led accountable care -- with proper incentives for physicians to focus on lowering unnecessary costs -- may be the answer to the healthcare cost dilemma. I read this article and shared many of my fellow bloggers’ opinions: This is a wonderful advance in our national discussion -- and yet, in other ways, I was also frightened by some of the implications. I cringe somewhat when I think of physicians being responsible for the costs of the care they are recommending for me as a patient. I worry that the imperative to lower costs, and the financial incentive to do so, will subvert the focus that a physician should have on the patient’s well-being – and, in so doing harm the sacred trust that should define the physician- patient relationship.

The authors start out by saying: “Even though most adult primary care physicians may not realize it, they each can be seen as a chief executive officer (CEO) in charge of approximately $10 million of annual revenue.” That alone was enough to scare me. When I walk in to a doctor’s office, I want that doctor to be concerned about my life, my problems, my symptoms, and my concerns --not the running of a 10–million-dollar-a-year business. I want my abdominal pain, my chest pain or my fear of dying to be foremost in his or her mind, and not the desire for a return on investment. I do want my physicians to think of cost when it is important to me, as the patient. If I, for one second, believe that their commitment to help me is being influenced by some other concern, the trust that I must have in them – the trust I need for the therapeutic relationship to work -- is undermined.

And I am not alone. In that same JAMA article, the authors noted that “Physicians see opportunities every day to improve quality and lower costs, but in a recent survey reported that they should not be expected to play a central role in controlling costs.” I understand that attitude. Doctors are in the business of managing the uncertainty of illness, and if they are to work with patients to manage that uncertainty, the patient must trust that physicians’ total focus imperative is on helping them, not on the costs to the system.

Patients feel the same way. In a February 2013 Health Affairs article, researchers from the Rand Corporation ran focus groups asking if cost should enter into medical assessment and treatment. That article, “Focus Groups Highlight That Many Patients Object to Clinicians’ Focusing on Costs,” found that “the majority of participants were unwilling to consider costs when deciding between nearly comparable options and generally resisted the less expensive, marginally inferior option.” The authors identified a number of “barriers” for this unwillingness to discuss costs -- and all of them were related to the need to trust that their physician will do what is best for them, in the context of their lives. From a patient’s point of view, putting their doctor at financial risk to save money can undermine that necessary trust.  Patients want physicians to spend time with them and they fear that an emphasis on cost and efficiency will limit that time. 

At Accolade, we have developed a system that involves health assistants -- who are evaluated and rewarded almost solely on their ability to understand the people in need, and to help them fulfill their needs in the context of their life and their values. The true paradox is that when you focus on what people want and need, and take the time to build trust and address those wants and needs, you save money. As that trust forms, health assistants can help people manage the uncertainty of illness and help educate them to the fact that sometimes higher quality means lower costs.


Physicians know how to save money by making care safer and more personal, but most of the systems that attempt to incent primary care physicians to achieve savings, and make them the “CEO” of the healthcare dollar, have the unintended consequence of potentially eroding trust. Physicians are dedicated, smart, focused individuals who take on a priestly, sacred responsibility for their patients. Anything that may erode that trust is unlikely to improve care, save money and achieve our societal goals.