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Patients Don't Want To (and Can't) Reform Healthcare System

Posted Sep 03 2009 11:26am
Don't misinterpret the heading of this entry. It's not that patients don't want healthcare reform. It's that patients don't want to be the responsibility of reforming the healthcare system.

And who could blame them.

Although it appears that the federal government is working to reform the healthcare system, one will periodically hear experts talk about consumer driven healthcare. That is, give patients more financial responsibility for their health through higher deductibles and copays and health savings accounts. Seeing this increased financial burden, they will consequently make better choices about their health, shop around for the best care, and make more rational decisions about when to seek medical care much the same way they do for other services and goods.

Please.

Note how the the person in a story in the Economist managed to spend a lot of money for a strained muscle.


I would note that giving the public more responsibility for reforming a benefit program occurred decades ago with retirement planning. Employers stressed by the increasing obligations from pension plans opted many years ago to move from defined benefit plans to defined contribution plans. Pension plan now becomes a 401k plan. The burden of having enough assets to comfortably retire moved from employer to employee. Theory was individuals now would take charge and do better.

Right.

We now know that this was a disaster for nearly everyone, except for the financial services industry it created. Individuals didn't save money or invest in the right financial products. Many were in cash, which generally doesn't keep up with inflation. As a result, employers are becoming more involved requiring people to opt out of a 401k rather than opting in, choosing a target date mutual fund account as a default rather than cash, and spending resources on educating their workers more about financial planning.

So the problem with healthcare? Patients don't have the expertise and don't wish to grasp the nuances of medical diagnosis and treatment. They falsely believe that the answers to their problems and ailments come from the high-tech MRIs and CT scans, blood work, and other tools at our disposal as doctors. It could be due to television shows like ER or House or doctors doing extensive work-ups with little thought on costs or relevance. Nevertheless, with increasing co-pays, patients feel that to solve their problem, forgo the doctor visit and simply order a test.

Unfortunately, these tests are merely tools and can help provide doctors clues into what is happening, but don't provide the universal truth. In other cases, we don't need the test because it is quite clear what the problem is. However, Dr. Scott Haig notes in a recent Time article that it is practically impossible to convince patients otherwise. They want the tests even though it is obvious what is happening.

I see it in my office plenty of times.
  • How do you know what the skin rash is without doing a biopsy? (Answer - do you know what acne looks like? You don't need biopsy that do you? The reason we go to medical school and residency programs for a minimum of seven years isn't to figure out what tests to order, but how to correctly diagnosis and treat illness and get you better).
  • I'm having chest pain and I want at CT scan (which is the 64 slicer CT scan which rules out an pulmonary embolus - blood clot in the lungs, a dissecting aortic aneurysm, or a heart attack - acute coronary syndrome) as well as the medication PLAVIX to thin the blood. (Answer - After spending quite a bit of time asking questions about the symptoms and what made it better or worse, it was clear the symptoms were due to irritation of the esophagous due to increase alcohol usage. Had those tests been ordered, it would have cost the patient more as he would need to pay for the procedures, discovered that the tests were all normal, and at the end NOT solve anything. CT scans don't diagnose esophageal reflux. So this patient would have returned for a second office visit and say I'm still hurting and undoubtedly demand more tests. Is he better off healthwise or financially?).
  • I'm having a migraine headache and I want an MRI. How do you know it's a migraine? (Answer - From your classic history of your mother having a migraine, when she was diagnosed MRI technology didn't exist and doctors got it right, your symptoms of a throbbing unilateral headache which worsens with physical activity, at times can cause nausea, vomiting, sensitivity to sounds and light, and typically better with quiet dark rooms, and a total episode time of 24 to 48 hours. Incidentially, when the MRI of the head comes back as normal, does that mean you don't have a migraine? If you still have pain does that mean the MRI was wrong? Did the MRI add any value to your visit?)
Why do patients behave this way? The reimbursement structure of our healthcare system provided incentives to do more. Doctors are paid piecemeal. Do a procedure, get paid. We get paid for quantity and volume not quality. As a result, patients fall into a trap thinking that getting more is better care when in fact research shows Americans get more spent on healthcare per capita than any industrialized country in the world and yet we rank dead last on health outcomes.

Finding a smart doctor who knows how to diagnose you by asking the right questions and thinking is truly a blessing. If you find one that sits down, talks to you, and tries hard to understand your symptoms so it is clear in her mind what your problem is, never give her up. Anyone can order tests and xrays. Only a few can figure out when it is needed and when it is not.

I don't blame doctors who occassionally cave-in to patient demands. I do worry about those who do most of the time to placate a patient. Patients see us to get better and unfortunately they wrongly believe that requires extensive testing. If we continue to perpetuate the lie and if consumer driven healthcare advocates have their way, we'll see more healthcare costs and worse outcomes, not better.

What do patients really want? They want doctors to listen and order tests, imaging studies, and medications that are necessary to get them better or keep them well. They want healthcare to be affordable and accessible.

What they don't want is the responsibility of reforming the system. They don't have the expertise to do so.

I don't blame them.
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