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We want patient-friendly care
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On a recent Saturday afternoon, I had an experience that made me appreciate and marvel at the delivery of patient-friendly care. There was no 4-hour to 6-hour wait in an emergency room. No authorizations were needed. We had a minimal waiting time to see a qualified specialist, and all the appropriate tests and surgery were done in an efficient manner.
The care was delivered in a physician-owned private office. The tests and imaging were performed at the physician-owned specialty hospital. The care was delivered by an experienced surgeon working in his physician-owned operating room (OR) with carefully selected assistants and equipment. This was the type of care we would like to have for our families and patients.
However, it was in a 100% fee-for-service setting in a physician-owned facility — one that policymakers have identified as needing to be changed and limited in the United States.
Let me explain in more detail how this patient-friendly care occurred. On that Saturday morning, my daughter called me at 8:00 a.m. to tell me her dog was having trouble walking and was falling because of weakness in his hind legs. She brought her dog over for me to observe and examine. My working diagnosis was an acute disc herniation with neurological finding in both hind legs. My daughter made a 10:30 a.m. appointment with her local veterinarian. He confirmed a neurologic problem and made an immediate referral to an experienced surgeon specializing in neurologic disorders in dogs.
Douglas W. Jackson
We presented for a 1:30 p.m. appointment at a veterinarian specialty hospital, which was owned by a group of specialists. After a history and examination, the surgeon confirmed it was most likely an extruded disc and suggested an MRI. He offered an option of steroids and a period of observation, but we elected to move to the MRI after a detailed discussion. He called in his team and the dog underwent anesthesia to have the MRI. It was completed by 4 p.m. and after discussion of the findings and under the same anesthesia, the dog was taken to the OR and successful surgery was performed.
The dog was in the recovery room by 6:30 p.m. In less than 11 hours from the time my daughter called me in the morning, we had access to a primary care veterinarian and a referral to a specialized surgeon. The MRI and surgery were performed that same Saturday afternoon. I was impressed with the sensitivity and friendliness of the staff, attention to detail, quality of care and compassion shown to my daughter and her dog.
Fee-for-service model
Because of increasing costs and overutilization, this type of medical care is no longer available to everyone. Future cost containment efforts are scheduled to change the more traditional fee-for-service, which offers incentives for doing procedures and tests. The new health care policies and coverage are programmed to change the incentives for providing care.
Delivering patient-friendly care in a fee-for-service setting is something I have been able to do my whole career. I have seen the current fee-for-service system become a fragmented payment process that often shields consumers from the actual costs. However, the fee-for-service we received that day resulted in high-quality care and all the decisions were between the surgeon and my family with no third party involved. There were no authorizations, second opinions, or insurance issues for the facility or surgeon. No excessive paperwork or regulatory staff was involved.
While most people agree that things need to be improved to make health care delivery more efficient, they want the necessary changes “without diminishing” the quality of care. However, there is no agreement on how it can best be done in the United States even though a major reform is unfolding until 2014. Many of the same issues trying to control overall health care costs will remain as health care continues to operate under price controls and market distortions. While the type of fee-for-service my family experienced that Saturday will not work for everyone’s health care in the United States, it is apparent that future health care will require more authorizations, will be delivered within cost-efficient scheduling and staffing considerations and with some rationing. Future patient-friendly care will involve answering to accountants and auditors — not necessarily just the patients.
Limited in economic decisions
More regulations will limit physicians in making economic decisions as there will be increased layers of bureaucracy, thereby separating patients from their physicians. This health care bureaucracy has been incrementally increasing from the time health insurance became an employer-provided benefit. This began as the result of market distortions involving wage freezes imposed by the federal government during World War II. Employers gave more health care benefits instead of salary increases. At the same time, there was an accompanying growing bureaucracy related to the administration of Medicare and Medicaid.
As health care costs continued to increase, we saw additional price controls and attempts to control costs with the introduction of HMOs and PPOs. This is now being followed with ACOs and the new “review panel” superimposed on the system. We now are entering a period of an unproven “market-friendly health care alternative.”
Ezekiel J. Emanuel, MD, PhD, Neera Tanden, JD, and Donald M. Berwick, MD, have written on the basis of the new approach. They conclude that “sustainable cost control lies in encouraging physicians and hospitals to focus on quality rather than quantity, and value rather than volume. This is based on the premise that a change in payment and reimbursements will have as the incentive to keep patients healthy.”
As part of this new proposed patient-friendly system, payments to hospitals will in part be based on a 27-question government survey administered to patients as well as their benchmarking their outcomes. Hospitals with high scores will get bonus payments that basically are the sum of their outcomes and patient surveys. Payments will be taken from hospitals with low pay-for-performance scores and given to hospitals with higher ratings. Many federal officials believe this scoring system is a reliable indicator of whether hospitals give good care.
There are a few examples where these types of objectives have been achieved. Under the Kaiser Permanente system, a group of represented salaried, primary care physicians and specialists have kept costs within a fixed budget. According to the 2010 Healthcare Quality Report Card from the California Office of the Patient Advocate, these physicians deliver care with patient satisfaction equal to or better than similar populations.
Cost-efficiency, customer satisfaction
The irony is that the government agencies overseeing the whole process would do well to meet a similar standard on cost-efficiency and customer satisfaction themselves. Economist Milton Friedman, PhD, frequently wrote that the free market was an efficient self-correcting system, as well as the dangers of oversight and regulations from powerful federal agencies and their inefficiencies.
We are faced with an ever-expanding federal government changing the rules that supposedly will encourage providers to be more cost-efficient and promote the well being of patients. My real concern is that this is the same type of potential bureaucratic controls that have led to the efficiencies in Fannie and Freddie, the U.S. Postal Service, Amtrak, Medicare and Social Security. All of these are close to or are threatened by running out of funds.
I am convinced physicians will give patient-friendly care in the future, but it seems it was easier in the past.