My mother, a registered nurse, worked for years for our small town doctor. She would drive around the countryside, going to check on elderly folks or those who didn’t drive. We had a number of people who came to our house regularly for things like allergy shots. She kept their vials of medication, rubbing alcohol, cotton balls and syringes in our kitchen cupboard. The doctor (who was the sort to exchange his services for things like eggs and fresh meat) gave me my kindergarten physical in his living room.
While this might seem like Norman Rockwell, misty-eyed nostalgia, there’s one thing for sure: this doctor and my mom knew their patients really well. They knew their concerns, their histories: not just medical, but in all aspects of their life. Given a choice, isn’t this the kind of medical care most of us would choose for ourselves and our families?
Pamela Hartzband and Jerome Groopman are here to tell you that not only is this type of medicine no longer an option, today’s doctors are stuck in a medical marketplace.
Financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.
As insurance companies become more and more involved in patient care, physicians are being pushed to “meet metrics” rather than choosing what’s right for an individual patient. As with any type of statistics, there are a lot of people who fall outside the norm. Unfortunately for them, that doesn’t matter much when it comes to health care.
For example, doctors are rewarded for keeping their patients’ cholesterol and blood pressure below certain target levels. For some patients, this is good medicine, but for others the benefits may not outweigh the risks. Treatment with drugs such as statins can cause significant side effects, including muscle pain and increased risk of diabetes. Blood-pressure therapy to meet an imposed target may lead to increased falls and fractures in older patients.
Physicians who meet their designated targets are not only rewarded with a bonus from the insurer but are also given high ratings on insurer websites. Physicians who deviate from such metrics are financially penalized through lower payments and are publicly shamed, listed on insurer websites in a lower tier. Further, their patients may be required to pay higher co-payments.
Hartzband and Groopman are calling this coercion. It’s hard to argue with that. And, they point out, this type of “medical management” will likely create rock-and-a-hard-place decisions for doctors:
When a patient asks “Is this treatment right for me?” the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.
We really don’t want medicine to be treated like any other marketplace commodity – push what sells, remove items from the shelves if most people don’t need them, what works for most consumers is fine. We want a doctor who knows us well enough to visit us in our own home, even if he never actually does. We don’t have to go back to that small town doctor I knew, but we can do better than medicine management from number-crunchers.