Tuesday, August 26, 2014

Playing 3 Dimensional Chess: Saving Money in Health Care the Right Way – Part 2: The Doctor Patient Dance

Costs are generated when a patient, meets a health professional, (usually a doctor but in our modern world, increasingly a nurse-clinician, a physician assistant or a non-MD therapist), and decisions are made which generate claims and bills and ultimately costs.  An old saying in medical management is that the most expensive medical instrument is the pen, because doctors write orders with pens.  While today it may be the keyboard instead of the pen, the saying is still true.   This may appear obvious on its face however when we think and write of health policies driving either savings or increased costs, we must think about what happens between the patient and the doctor.  This joint decision making may be thought of as an intricate dance that if performed well, results in a sacred trust relationship.  I fear that this dance that doctors and patients take part in is changing and not necessarily for the better.

I have a wonderful primary care physician, who is very smart, and very caring and who was taught to be more attuned to the population trends than I was taught to be, even though I have spent the last thirty years of my life focused on just those population needs.  Needless to say he is significantly younger than I am.  More than a week ago, I fell ill.  I am fortunate because I have medical knowledge, and I am married to the smartest physician I know.  The first few days of the illness, I treated myself, with my wife’s advice.  After five days, my wife convinced me to call my PCP with an eye towards getting an exam and some blood tests because we were both  starting to get worried.  I called my physician and he quite rightly told me that I most likely had something that would get better on its own, and that the best action at that time was  to wait.  On that basis, he said, I probably did not need to be seen and did not need blood tests.  Because we have a close relationship, I kept in touch by phone and a few days later he saw me in his office as I was still sick.  On exam he noted abnormal physical findings and blood tests were found to be abnormal. We both saw that while waiting had not hurt me, it was perhaps not the best approach in this instance as it delayed treatment.  It was, however the right way to proceed from a statistical evidence based,  population health point of view.   I have to wonder if someone who did not have as trusting a relationship with his or her doctor, would have stayed in as close touch with the doctor as I did.  If not, they likely would have ended up with a more serious and more costly medical condition.

The fact is, that even with my sophistication or perhaps because of it, I needed that trusted, objective and knowledgable confidant.  I needed my doctor to examine me and really hear my symptoms and my fears.  I was scared and thinking the worst.  No matter what, I felt better that I was being cared for once I saw my doctor and was able to directly see his concern for me and his thoughtfulness about my problem.  He has a concierge type of practice, together with three other physicians (although they all function as solo practitioners with their own nurse) and their practice fits into what is today considered to be a small medical practice. 

In a study just published on line in Health Affairs, Lawrence Casalino and his associates at Cornell Medical College found that, while it is assumed that large practices, often with team based medical homes and quality of care controls in place,  provide better care, smaller practices of fewer than 9 physicians, had 27% fewer preventable hospital admissions with practices of 1 to 3 physicians having 33% fewer preventable admissions.  Physician owned practices also had fewer preventable hospital admissions.  The authors postulated that this was perhaps due to easier access to the doctor who was part of smaller practices.  My theory is that smaller, more personalized medical practices create more trust.  When your doctor tells you to wait, you tend to trust your doctor and wait rather than run to the Emergency Room and end up admitted unnecessarily.  While waiting, a person cared for in a smaller practice will tend to stay in closer touch, knowing that a call will allow one to speak to your trusted doctor or nurse rather than be triaged by the nurse or doctor on call. 

In our impatient society, one of the hidden secrets of medicine is how time-based it is.  Illnesses tend to follow, what is often called in medicine, a natural history, and throughout much of the history of medicine, the role of the physician was to know the natural history in order to predict, for the patient and the family, what was likely to happen as the physician’s ability to impact what was going to happen was limited.  In our medically sophisticated world in which there appears to be a drug and a procedure and a surgery for every ache and pain, that physician’s art of prediction – of knowing the natural history and thus being able to counsel a patient about not only what should be done, but also if and when it should be done, is critical and is based on trust. 

It is this trust that makes one not only a physician but a healer.  I trust my doctor and for me, his judgment and his caring are critical to the decisions I make.  I still make my own decisions, but his advice is necessary for me to make good decisions. Trust is the key to the ability to time care appropriately which saves money and more importantly, helps people avoid the risks of unnecessary care and the risks of necessary care delayed.    

In an unpublished work (privately shared), Drs Saul Weiner and Simon Auster wrote about the need for physicians to have healing relationships with their patients, in order to engender the type of trust needed for medical care to be successful (and in case anyone has not noticed – successful care is less expensive than unsuccessful care unless of course the unsuccessful care results in very quick and efficient death).  They speak of the need for the doctor and the patient to become one social unit, and the requirement that this relationship happen over time with both the doctor and the patient sharing parts of themselves in ways that creates vulnerabilities.  They describe four characteristics of the healing relationship.

  1. It cannot be scripted
  2. It evolves with a relationship over time
  3. The individuality of the physician, like the patient’s, is central to the direction the relationship takes
  4. It depends on trust or, in the initial phases, on the expectation of trust

This of course beings me back to the dance between doctor and patient and the health care cost equation.  The equation, just as a reminder is

Total Population Costs = Volume of Services X Unit Cost of Service

The only way to decrease the volume of services is to build relationships between health professionals and patients that meet the four characteristics outlined by Weiner and Auster.  When I was in medical school, I was taught that my only focus should be the good of the patient whose care was entrusted to me.  The building and maintanence of that  sacred trust relationship was a major part of the education that made me a doctor.  In today’s world, we ask physicians to also think about the health of populations and the reduction of the per capita costs of health care as defined by the triple aim I spoke about in part 1 of this series.  My fear is that in trying to make physicians more aware of the societal needs, we may inadvertently be changing that focus and undermining the trust necessary to save money in health care the right way.
I worry that our desire to refocus physicians toward societal goals, and our push to make them focus on the use of technology  may paradoxically work against the goal of lowering costs. As we try to leverage and even replace doctors and nurses with protocols, apps, and systems, do we end up eroding the trusting relationships that are at the heart of medical care?  While the technology and the systems offer many benefits, our challenge is to use them to foster and strengthen relationships and not to try replace relationships in the name of efficiency