Doing The Right Thing for Patients
Research shows significant variation in care around the world. How does a doctor decide what tests or procedures should be done for the patient in front of her? And how do we as a society afford to pay the costs that are rising faster than our incomes?
There appears to be an answer that aligns what we need to do for patients and getting ourselves health care that is more affordable. For our health system right now, this is critical. In the current payment system, the road to financial success can be paved with overutilization. To get more money to the bottom line we have to do more — more tests, more procedures, more hospital beds occupied.
The evidence that doing more may cause harm (and doing less is usually better) comes from the Dartmouth Atlas, a more than 20-year series of studies and compilation of data that shows areas of the US with lower utilization and cost tend to have better outcomes and higher patient satisfaction. They have higher concentrations of primary care doctors, fewer specialist visits, and fewer days in the hospital in the last sx months of life. This variation in hospitalization for patients with chronic illness at the end of life varies from 6.1 days to 21.9 days and doctor visits vary from 15 to 60. There is a list of reports available at www.dartmouthatlas.org/atlases.shtm
The data show that doctors do tend to do the right thing for patients when the evidence is good, at the same rates in high expense and low expese areas. Even those rates are too low as the science of performance improvement has only slowly penetrated medical care to improve reliability of applying the science. However, when there is not much evidence to guide doctors, the variation is much greater. And the consistent finding of the research is that ‘local culture’ seems to be the dominant feature influencing whether doctors order lots of tests or not.
A recent article by Atul Guwande in the New Yorker nicely summarizes this conundrum.
Gawande also points out that changing ‘who’ pays for care will not change these dynamics. He draws an analogy to building a house — if, instead of paying a contractor to coordinate the whole thing you paid each ‘specialist’ — plumber, electrician, cabinetmaker — a fee for each item they recommend you’d get ‘a house with a thousand outlets, faucets and cabinets at a price three times what you expected.' Would changing ‘who’ pays for care make a difference? No, it’s the coordination of the care under a system that is accountable for the outcome.
We have learned from the Dartmouth Atlas research that “the lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. “ It a story of integration of the medical staff and the health system like Mayo.
Our health system is poised to make important decisions. The ‘clinic model’ task force of doctors, management, and Board will be recommending a more integrated system. The policy makers in Washington and Vermont are poised to change payment in a model of shared savings that would require us to behave like a system. Our health system needs to be leaner and more effective in using our resources.
These various conditions have come together at a time when we face big challenges. The good news is that we know the status quo is intolerable, and if we do the right thing for patients we will also be cost effective and ready for success under inevitable change in health care payment. So the decisions will be guided by what we do — patient centered care. Doing the right thing will be best for patients and best for us. That will make it easier to find our way.
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