Value based- Patient Centric Healthcare

Everyone has heard the one about what happens when you ask 10 doctors the same question; you get 15 different opinions. The most fascinating part about that joke is that it is true. Some have gone so far as to say that converging doctors is much like herding cats. No argument there, either.

The healthcare system reform debate hasn’t done much to harmonize the diverse and often disagreeable doctor community. Everyone and every organization claims to have “the” solution. Most answers, however, are directed towards an opportunity to fortify assets, protect turf, or build a legacy.

But, among practicing physicians, the patient-doctor relationship is sacrosanct and that remains the one commandment and guiding principle. The reform that would shadow that one revered ethic must be that patient care should be focused on patient need. That is why the concept of Pay for Performance (P4P) is illogical if not irresponsible. That said, it is illustrative of so much of what is wrong with our healthcare system today.

Fortunately, we have seen signs that “the truth” is rising in the Eastern sky. Recent studies driven by the P4P ideology fail to demonstrate that patients’ outcomes are improved. No surprise. Editorials have warned that high-risk patients may have a hard time finding a physician.

The discussion laid out about P4P in the media would appear righteous: the government and the health plans want to pay physicians and hospitals that perform better. That might work if 1) the doctor were working for the government or the health plan 2) the work performed had proven value and 3) the payment was value based. But, we work for our patients and our work product should be driven by our patient’s specific individual needs, not by an unproven statistical analysis.

Population based health care (what is good for one, is good for all) has never been proven to be cost effective or quality driven. Moreover, the point could be made that it might be dangerous for those patients receiving unnecessary services. Pay for performance and other financially driven health care reform models will only lead America down the road of industrialized health care, a hazardous choice; rather peculiar in a market where everyone wants their own personalized website and IPod.

It is hard to rationalize doing mammograms in a 90 year old women, only to receive a bonus payment and it is wasteful to ask a hospital to repeat an echocardiogram just for documentation purposes because a patient has a history of congestive heart failure that is 20 years old and stable. But, that represents P4P. Really, it is not Pay for Performance. It is more like Perform for Payment. Talk about an “old” profession.

As physicians, our time should be spent individualizing the care of every person who puts their life in our hands. Our expertise should be employed to make our patients’ lives better. Every surgical procedure ought to be specifically designed to suit the surgery necessary and every medication protocol should be developed around the patient’s specific lifestyle, medical needs, and life goals.

By centering care on patient need, costs will be trimmed. As it is, millions of health care dollars are lost in a system that is more about maintaining an administrative infrastructure than about evidence based methods to further patient health. The idea that the government or a health plan can define our patients’ health is preposterous if not arrogant. The philosophy of treating to “normal” rather than optimal cheats our patients of their ultimate potential.

P4P is an administrative quagmire built on the premise that physicians are so demoralized that we would rather fill in the blanks than hold our patients’ hand when they are in pain. Indeed P4P could be adequately achieved without a physician ever talking to the patient. Envision Lucy and the Chocolate Factory: P4P motivated health care reform is an assembly line of prescriptions, lab tests, and procedures running independent of patient need. It loses its humor when it is about your mother, or child.

The American doctor was not trained to be an indolent pawn. We were trained to lead, to inspire and to protect. Our professional tools are a valuable asset and should be used to better our patients’ day. Doctors are not a commodity available for trade on the open market. And our patients are not the collateral they will become if P4P continues to deliver a “report” that mirrors “teaching to the test”.

“Conventional wisdom”, “usual and customary” were never part of the vernacular until we lost our way and allowed the health care delivery system to be financially driven. Standards in healthcare were originally established as minimums but the current system has perpetuated the concept of standardization as a means of payment. So it is with P4P.

Healthcare system reform needs rehab. America must relieve itself of its addiction to government or health plan run health delivery systems that only serve to industrialize the personal health needs of our patients. Studies show P4P doesn’t work. We knew that, now everyone knows that.

Pavlov was about dogs and should not define a health care delivery system. Our patients deserve the respect of a health care system driven by the patient-doctor relationship. As physicians, we are determined to maintain our focus on the best, individualized, patient centric care and the opportunity to optimize our patients’ day.