Confusing Populations with Individuals in Health Care

The doctor patient relationship is a sacred one that is ultimately driven by a person in need, putting their trust and even their life in the hands of a health professional.  The bond between a doctor and a patient is formed with the expectation that it will be met by total dedication to the patient’s well-being by the health professional.  However, in recent years, physicians, nurses and others in the caring professions have been challenged to take a broader societal, or population view of those they serve, especially when it comes to cost. Our current high cost of health care can limit needed access to care with the burden often falling on portions of our population who are the most at risk for health problems.  Who better to address this than the health professionals who care for people, so the argument goes.  The theory is that the population view, especially when taken by individual health care providers, will provide more equity in health care and better treat all those in need.  The physician and the health care team then becomes the steward of the health care dollar for our society as well as the caring agent focused on the patient.  But is this an appropriate role for the physician?  Do these newer efforts towards placing societal costs in the equation of “best medical care” for an individual risk creating a system in which physicians have more responsibility to their particular system or to the total society than to the actual people in their care?  

The American College of Cardiology and the American Heart Association (ACC/AHA) have just published a joint statement on cost/value methodology in clinical practice guidelines and performance measures.  They have tried to thread that needle of societal needs for cost control and individual patient care.   The result is a properly nuanced approach that acknowledges the difficulty of the task as well as the current reality that the challenge cannot be ignored.    They note, in their executive summary that “from a societal policy perspective, a critical healthcare goal should be to achieve the best possible health outcomes with finite healthcare resources.”  They further note that “individuals bear the burden of adverse health outcomes, yet costs typically are shared by society (e.g., by families, employers, government, premium payers, fellow employees, taxpayers).”

All true.  Yet what should the role of the physician be?  And how should guidelines from esteemed organizations such as ACC and AHA address these issues when they set standards for individual care?  Should the physician follow a guideline that directs the care they render to be influenced by the fact that the treatment may not be of high value to the payer even if the doctor and patient believe it to be high value in that particular case for that particular patient?  Perhaps a bigger question to ask is whether the patient should trust a doctor if the doctor is being driven by a societal equation instead of an individual patient equation.  Ultimately, this is a question of whose interests – society’s or the patient’s – are paramount when the medical decisions are being made.  I believe that in all cases the physician should focus on the individual patient’s interests for that is the essence of medical care.    While societal costs are extremely important and must be taken into account when setting health policies for a nation, there is something different that is going on when a patient is in an exam room with a doctor, a nurse, or another health professional.  That difference is the sacred trust when one person opens themselves to another in the hope of being cared for when in a time of need. 

But there is often less conflict here than may be apparent.  When the patient’s values and goals are paramount, cost often enters into the equation – it just isn’t the societal cost but the individual cost.  Physicians today are not very good at assessing their patient’s goals, needs and values when they are outside of the purely clinical.  When those individual goals enter the realm of finances, competing priorities (such as taking care of people they love), or the patient’s spiritual needs and beliefs, as evidenced by research done on context by Saul Weiner and Alan Schwartz of the University of Illinois over the past fifteen years the physicians’ ability to recognize, assess and address those needs is poor at best.   We know that patients assess the treatments recommended by physicians based on their own internal equations and cost is often a component of those individual decisions.  The good physician, who forms a true trust bond with the patient, must take that all into account.  When that happens, total societal costs are more easily controlled, as has been previously suggested in a study done by Weiner and Schwartz in assessing the costs of “contextual” errors in health care.  We see that at Accolade as we help patients address their life needs, find their voice and communicate their goals to their doctors, nurse and therapists and see total costs go down. 

It is clear therefore that, as the ACC/AHA statement suggests, that “the need for greater transparency and utility in addressing resource issues has become acute enough that the time has come to include cost-effectiveness/value assessment and recommendations in practice guidelines and performance measures” but the inclusion of “performance measures” does worry me.  If doctors are judged by their ability to meet societal standards of cost effectiveness will that change the doctor/patient relationships and the agency that the doctor now has for the individual in their care?  We clearly need more transparency and we must be able, as health professionals to translate that cost information into useful knowledge to help patients with their decision making however our performance measures should be based on how well we address those individual health care cost needs and the value for that individual.  That is different than being measured by how well we meet the societal goal of lowering health care costs.

The ACC/AHA statement does address how these guidelines are to be used and makes the statement that “the value category should be only one of several considerations in medical decision making and resource allocation.”  But resource allocation for one patient is an entirely different issue and must be based on the patient’s values, not the values of the physician or society.  In the published article, the ACC/AHA committee rightly states that “Care is of high value if it enhances outcomes, safety, and patient satisfaction at a reasonable cost.  Care is of low value if it contributes little to outcomes, safety, and satisfaction or incurs an inappropriately high cost.”  I would add the words “from the patient’s perspective” to those words.  Ultimately, we must understand that as physicians – as health professionals – we are servants to and advocates for those in need and we must define outcomes, safety, satisfaction and even costs from the patient’s point of view.  Until we develop guidelines and performance measures that understand and acknowledge that fundamental agency of the health professional for the individual patient, we will neither save money nor improve care but will only erode the trust that is the cornerstone of health care.