A Painless Way To Hold Down Health Costs?
Listen (NPR)
"Medicine is different from many services that are marketed in 2 important ways. First, evaluation of quality by the patient is difficult. An implication of this characteristic is that although objective measures of quality may be available, it is possible to overemphasize the elements that patients can evaluate and dismiss those they cannot. For example, physician behavior that is perceived as action-oriented (ordering frequent blood work and diagnostic tests) may be viewed more favorably compared with other elements of the encounter such as counseling about smoking cessation or weight loss. Thus, additional work is necessary to operationalize a full complement of both objective and subjective measures that address quality of care. A second difference from traditional business transactions is that, in medicine, recipients and payers are frequently not the same entities. This is different from the marketing perspective in which evaluations of satisfaction are linked with considerations of cost that are immediately and directly felt by the customer. Traditional marketing situations innately include price and performance trade-offs in the minds of the service recipients. At least to a degree, these trade-offs act as controlling mechanisms with respect to cost. An implication of this critical difference between medicine and other services is that neither patients nor payers make decisions with a holistic view of the trade-offs involved.
If patient satisfaction is accepted as a valid outcome, then it should be held to the same standard as any other intervention or device. Namely, does it objectively and efficiently improve health care outcomes? As of today, patient satisfaction surveys do not have that credibility as supported by the medical literature. Wendell Willkie's statement during the Great Depression that “a good catchphrase obscures analysis for fifty years” seems applicable to patient satisfaction today. Patient satisfaction should be embraced as a desirable goal but it must undergo critical analysis." Kupfer JM, Bond EU. "Patient Satisfaction and Patient-Centered CareNecessary but Not Equal." JAMA. 2012;308(2):139-140 pub online July 11, 2012.
Related: In my opinion, this reference to quality assessment / improvement harkens me, at least, to the work of Jack Wennberg and others. For further information, please search on this website on his name, on "unwarranted variation," or on the topic of "Measurement and Management."
Note: Unfortunately, HCPLive stopped publishing "The Chilling Effect of Cost Containment," [pub. online 6/23/08 [last accessed 7/11/12] and "One Cannot Measure What One Does Not Manage: The Centrality and Inevitability of Measurement and Management," [June 15, 2009] but I believe the following makes the point about unwarranted variation as well:
As an example of unnecessary (which is oftentimes also inappropriate if not the blatant mis- or overuse) is empiric therapy with antibiotics. Take, for example, the knee-jerk choice of antibiotics in a cold/URI conveniently labeled as a case of "sinusitis."
The article, "Acute bacterial rhino-sinusitis in children: Clinical features and diagnosis" by Ellen R. Wald and Editors with table: "Characteristic features of viral versus bacterial rhinosinusitis in children" is compelling about the difference between conditions. It can be accessed on-line, however one must be registered to UpToDate® [an evidence-based, physician-authored clinical decision support resource] to see it. Here's my take on their comparison, which I will call: "URI vs a Real Sinus Infection."
| Clinical feature | Viral rhinosinusitis | Bacterial rhinosinusitis |
| Temperature elevated: |
Usually there is no fever, but when it occurs in the beginning of the illness, it is not a major symptom and it resolves quickly |
When you have this condition, the temperature can be quite high, e.g., 102.2°F (≥39°C ) for more than 3 days or it can reoccur at the end of the first week |
| Nose discharge: | Coryza, green nasal discharge days 3-6 of the illness; then steadily improves | Worsens |
| Cough | Same as the nose, above | Worsening cough |
| Feeling very bad: | Absent | Definitely feeling bad. |
| Headache: | Usually Absent or minor | Severe headache may be preent early or appear as a complication |
| Course: | Initially may slightly worsen but then improves | Symptoms are a real burden, often lasting over a week and a half |
The above speaks to modifying practitioners' behavior; what about the patent's?
For example, what do you do if the patient is test-happy, demanding, insecure and just wants everything done, right now! and more?
"Actively challenging patients' requests for non-beneficial interventions does not subvert properly understood respect for patient autonomy and is consistent with the professional obligation to practice high-quality, cost-effective medicine. Physicians may sometimes disagree among themselves, or with patients and families, on what is beneficial. Indeed, many outcomes from medical interventions are best represented as relative probabilities of benefit and harm, with inherent uncertainty. Nevertheless, professional responsibility involves making reasoned judgments about what is beneficial and appropriate and then practicing accordingly.
In managing requests for nonbeneficial services, physicians should justify their positions, invoke practice guidelines when appropriate, and offer suitable alternatives. The resulting clinical encounter reflects the physician's role as educator and enhances deliberative decision-making in partnership with patients. The successful conduct of such discussions requires that physicians be committed to practicing evidence-based medicine and to lifelong learning. Last, the configuration and financial incentives of contemporary medical practice are antithetical to spending unhurried time with patients. Medical care should be restructured to reward physicians for spending time to address requests for non-beneficial interventions." Brett AS, McCullough LB. JAMA.2012;307:149-150.
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