During the 90’s I worked for the PA Health Care Cost Containment Council (PHC4), one of the first and still leading state agencies to report on the outcomes of hospital and physician care.
As we traveled around the state of Pennsylvania explaining the concept, there was always someone in the audience or the group who asked the question, “Do you mean that we should use this information to challenge our doctor?” (Read, my doctor walks on water)
Our group health plan is trying to promote disease management and wellness within our population. Yet we here from many members, “Don’t butt into my business. My doctor tells me everything I need to know.” (Read, my doctor walks on water)
Early in my career, I had to explain to someone very much my senior, that the bone density test for his wife was not a covered service under his health plan. At that time, this particular bone density test was still considered experimental. Every health plan excludes payment for services that are not part of “generally accepted medical practice”. Naturally the man asked why the insurance company questioned the judgment of his physician that the tests were medically necessary. (Read, my doctor walks on water)
Few doctors would publicly assert their infallibility. Since I started work for the PHC4, there has been a remarkable transformation in the widespread acceptance of the concepts underlying evidenced based medicine and outcomes measurement both among the provider community and the larger public. Still, no doctor wants to hear that their medical judgment is outside any norms.
The character of this space between the norms of evidenced based medicine and the judgment of individual physicians will shape the outcome of any health reform. What latitude will the individual physician have to deviate from the accepted practice guidelines? Who will be at risk? How will practice guidelines be enforced? What exactly is or should be a non-covered service?
Here are two unacceptable scenarios.
The plan pays for non-standard care
The current fee for service paradigm permits – some say encourages – physicians to prescribe unnecessary services. Who holds docs accountable? Who even knows? Medical care can be a bit like home work excuses. What can be justified on an individual case does not hold up when it becomes a pattern.
Not all docs are part of a large group practice that measures practice patterns. Insurance companies have physician data but can only capture data on the patients they cover.
The plan does not pay for standard care.
The baffling array of benefit designs in the market place today make it nearly impossible for a physician to know whether even standard care is covered in any given circumstance. They can almost be excused for their lack of concern about who pays.
That’s why this space between what is good medical practice and what is covered under any plan will be the defining battleground. It won’t be put in those terms. The questions will be around who should make medical decisions and who should be financially accountable.
On one extreme will be the docs-walk-on-water camp who think the rest of us should pay for libertine practice patterns. The other extreme is the hold-docs-accountable camp, who thinks the care giver community should deliver care within a strict budget. Interestingly, it seems that Physicians for a National Health Care advocate global budgeting for hospitals but not for physicians.
About fifteen years ago, as managed care was just gaining some traction, I attended a conference at Dartmouth. One of the sessions featured four medical directors, two from hospitals and two from health care plans. They discussed a changing paradigm for physicians. No longer could a physician assume unlimited resources to treat the patient in front of them. Now they had to take a population perspective to health and ask whether this patient’s needs are greater than those of the next patient who might come through the door.
That paradigm never took hold.
I recognize that care givers across the board should not be unnecessarily constrained by rules. Physicians need space to bend or extend guidelines, but those decisions should not leave patients paying the financial price. A system needs to be in place that clearly delineates patient financial responsibility.
There are some who think that patients should have no financial responsibility. I am not one of those.
But I am not from the docs walk-on-water camp, either. I think we all walk on a very slippery floor.