What is more important -- politics or the patient?
By Miles Varn, M.D.
Chief Medical Officer, PinnacleCare
The debate surrounding healthcare reform is necessary and needed. Cost considerations are important to discuss; the reality is that we have to get a handle on healthcare costs. But, in addressing reform and cost reduction let’s not lose focus on what is most important and quite frankly what is most obvious. What is best for the patient?
Recent data from PricewaterhouseCoopers’ Health Institute recently concluded of the $2.2 trillion we spend annually on healthcare in this country, $1.2 trillion of it is wasteful spending. There were 16 different areas identified but the six categories that total more than $500 billion in spending include too many tests, inefficient claims processing, using the ER as a clinic, medical mistakes, return visits to the hospital due to patients not following instructions after discharge, and infections acquired during hospital stays.
From a physician perspective, what drives up these costs are two simple things: higher risk patients and higher risk procedures. More risk going in means more tests in the ER or in the hospital or in a private office or as part of the anesthesia pre op evaluation, more errors and more complications. From a patient perspective, higher costs derive from two simple overriding factors: lack of information and inadequate support. An uninformed patient with poor support is making choices that increase the risk of medical mistakes, of return hospital visits, of ER visits, of infections and of complications.
Why is this? There is a great deal of medicine being practiced in community settings. Obviously some of this is necessary and some of the care provided it is high quality. However, as many of my surgical colleagues have pointed out and much data have supported, successful surgical procedures demand experience and discipline. If a hospital performs ten total knee replacements each year-no doubt a higher risk procedure-the experience and discipline is less than that of a center of excellence that does hundreds each year. If a surgeon does a few heart valve surgeries each year, his or her skill is likely to be less than that of a surgeon who does nothing but heart valve surgeries on a daily basis. Moreover, the skill and experience of the team that supports the patient- anesthesia, nursing, infection control, physical therapy, social worker, billing- all lack the know-how to deliver care at the highest level. This is not a criticism of these dedicated professionals; they are simply being asked to manage the risk without the proper training or experience.
Yet in the end who suffers? The patient spends more time in the hospital, rehabilitating or recovering from a complication or wound infection, returns to the ER because they received inadequate discharge instructions and ends up with a bill that is exorbitant not only because of the various complications, but because it has been miscoded as well.
The complex cancer patient who is referred to the local oncologist suffers the same fate. Although, there is standardization of treatment for certain cancers, there are unique therapies and delivery systems available at oncology centers of excellence. The patient is given choices and some of these choices may involve a different approach, not available in a community setting; the difference can be life saving. Beyond this, the centers of excellence tend to rely upon evidence based measures of progress and/or success. Patients are not as exposed to unnecessary blood or radiographic testing. The consequence is that the patient is afforded the highest level of expertise and given the best opportunity for a positive outcome. Lower costs are a secondary, but nevertheless, desirable side effect.
So why don’t patients go to centers of excellence for complex, high risk issues? Those who are well connected or who have savvy family members, friends or professional advisors end up there every day; in part because they can afford to travel, but more often because they are educated, active consumers of healthcare. Like other aspects of their lives-legal, financial, education - they do research and they seek expert advice and support. They do so for quality reasons, not to save money for their insurance carrier. But in the end, everyone wins, except perhaps those who, with only the best intentions, are providing costly, substandard care. The business of healthcare has clearly gotten in the way of our referral process; the patient is the one who is suffering the consequences.
Any healthcare reform should promote access to objective and independent resources to help the patient understand all of his or her options to help fight a complex, high risk condition. Reform should include resources to explain options, provide education, clarify insurance benefits and, first and foremost, insure that the patient gets objective guidance. Let’s focus on quality and support for the patient first; not only will the costs go down but the US healthcare system will be less of a “system” and more of a benefit. Americans are smart and savvy and will do what is best if given the proper resources and the right opportunity.
