July 4, Health Care Choice and Independence

Costs and Consequences

Choice is the U.S. health system’s wild card. Choice makes the system what it is, not what it ought to be. Choices pose dilemmas – choices between unpleasant options.

Choice is the right, power, and chance to choose. It is freedom. It is also variation – the bane of those who preach “zero variation” in human behavior and services. But this is America, a land where people vary enormously.

Patient Choices

In America, people have the right to choose. Choice lets them choose one doctor – or many doctors. Some say many choices of doctors are bad. They say patients ought to have one doctor directing traffic. Each patient, they say, ought to have one medical home. But this is America, and people have choices of where and from whom to seek care. American people, it seems, want more than one doctor home.

Medicare patients have choice of doctors. Medicare claims show patients average seeing six doctors each year. Sick patients with multiple diseases average 11 patients. Many doctors do not know of the other doctors. This is bad, critics say. There ought to be a common health record for each person so other doctors can know what other doctors are doing, saying, or prescribing. There ought to be one choice, which some consider no choice at all. But every patient, say the pundits, ought to have one record, shared by all doctors with the patient’s permission. But this is America, and some people feel a personal health record showing all your medical history violates privacy and invites job discrimination.

People have the choice of going to one doctor, practicing alone or in a small group, or of going to a large group with dozens, even hundreds of doctors. Critics say big groups are better. Doctors can confer with one another. They can work in teams. They can provide options in one setting, coordinate care, and offer one-stop care. But patients have choices, and 90% still choose to be seen in solo or small groups. It’s a matter of being in the neighborhood, word of mouth, and personal choice. This is America, and people choose to make personal choices.

In America, people can choose to be uninsured or uninsured. Some, of course, have no choice. They lack cash to pay premiums. But two-thirds of those with no coverage choose not be insured. They want to spend their cash on other choices. Some are young and healthy and see no need for insurance. In Massachusetts officials are trying to explain to people having insurance is an obligation, not a choice, but some, given a choice, prefer not to pay. Instead they chance going “bare” and tempting fate.

Another set of choices is emerging. The consumer-driven movement talks of consumers should choose based on quality and price data. One think tank pushing the consumer concept calls itself the Center for Health Care Choices. Advocates say consumers spending their own money in high deductible plans, often linked to health savings accounts, will choose more prudently, just as they do in making other choices in the consumer market. Doctors, optimists say, will compete openly on costs and quality data. “Transparency” is the vogue word of the day. In America, people like to know costs and quality upfront.

Patients have a choice whether to change their habits of diet, stress management, weight control, smoking, drinking, and self-care. They can choose to improve their health status or stave off disease complications. But America is a free country. We are free to choose what habits to cease or change. Government and corporations are trying to change people’s habits by banning smoking in public places and at work, hiring only non-smokers, raising “sin” taxes, forcing food vendors to post nutritional labels on their products, banning foods high in trans-fats, and rewarding employees who stay healthy by participating in preventive and wellness programs. But Americans, if they wish, can choose to continue bad habits. They know other Americans will pay for their habits and their consequences.

Doctor Choices

Doctors have choices, too. They can choose to practice solo or in small groups, be paid fee-for-service, or practice in large groups or in hospitals or other institutions, and be paid hourly or by salaries. Most still choose to be paid piecemeal for what they do, not for what they do or don’t do, although 40% of doctors now work on salaries, often with clauses for productivity.

Doctors can choose to see patients – or not to see them. With declines in Medicare payments of 10% next year, nearly 30% of doctors say they will no longer choose to see new Medicare patients. Many doctors no longer accept Medicaid patients. Doctors say they have no choice because payments from these patients no longer cover overhead costs.

Doctors have a choice whether to invest in EMRs. Many health care gurus say EMRs are the electronic Holy Grail. They say EMRs will improve care, patient safety, and efficiency. Doctors say EMRs cost too much, pose privacy problems, slow productivity, and are for the good of government and health plans – not for doctors and patients. It doesn’t make matter who is right. Doctors have a choice. In spite of nearly 20 years of pushing for doctors to instill EMRs, only 15 to 18% use them, which is why 82% to 85% of doctors choose not to invest in EMRs.

Doctors can choose to follow clinical protocols and quality indicators. There are as many as 400 of protocols and 1000 indicators, depending on your specialty and the organizations offering them. The purpose of these protocols and indicators is to standardize and improve care. Yet doctors have a choice. For various reasons, only about 50% to 55% of doctors choose to meet these indicators and follow these protocols. In America, independent doctors can choose to exercise their independent clinical judgment.

Doctors have choices what and where to practice. More than three-quarters of medical students are choosing to practice in specialties other than primary care. This is not surprising. Specialists, rather than primary care physicians, teach medical students, and many medical schools look down on family practice programs. Medical students are aware specialists command more prestige and income. A 2006 Merritt, Hawkins, & Associates survey indicates the average base salary/guarantees offered were $370,000 or orthopedic surgeons, $340,000 for cardiologists versus $162,000 for internists and $145,000 for family practice. As for where newly minted doctors want to practice, another Merritt and Hawkins survey of final year medical residents indicates only 4.0% want to practice in communities of 25.000 to 50,000, <1% in towns of 10,000 to 25,000, and none in towns of less than 10,000. Doctors have choices, and 81% choose to practice in cities of 100,000 or more. American doctors, like other citizens, can choose what they want to earn and where they want to live.

Doctors have choices of what drugs they prescribe. With drug formularies, and government and health plans efforts to police utilization and identify “outliers,” these choices are narrowing. Patients are starting to have a say, too, by asking their doctors to prescribe cheaper generic drugs. Everybody, it seems is looking for more bang for their buck, an inevitable trend in an inflationary health cost environment and in America itself, whose people are always seeking bargains.

Doctors are told they are part of the “health industry.” Doctors do not think of themselves are being part of an industry. They regard themselves as autonomous professionals. To rub the industry notion in, critics keep saying doctors are part and parcel of a “cottage industry,” meaning doctors vary in their practice patterns, resist uniform standards, prefer to practice individually, and use their clinical judgment. Government and health plans, doctors counter, have no business “practicing medicine” -telling them how to practice, what to prescribe, and what procedures to perform, and what tests to do.

Hospital Choices

American hospitals consume about 50% of all health care dollars. They are the dominant institutions in American medicine. This fact shows American health care focuses on treating rather than treating disease. Hospitals have choices – the status quo, bringing business to centralized institutions vs. decentralizing to serve convenience-seeking consumers; employing doctors vs.partnering with them; catering to consumers with patient-friendly bills, patronizing consumers with marketing with jargon proclaiming technological superiority vs. engaging them with straightforward communication telling them what to expect and avoid in hospital care. It is a tough balancing act. Increasingly consumers will have public information documenting hospital outcomes, and consumers will demand more and will be willing to travel beyond the neighborhood hospital to hospitals with better data. My sense is that hospitals will employ more doctors, sonsolidate multispecialty groups, and seek brand-name recognition as the best regional treatment center. Americans have choices, and they will migrate to regional institutions with the best images.

Employer and Government Choices

Employers have choices. The most obvious ones are to drop coverage, narrow benefits, or switch to health savings accounts and high deductible plans. But there is another choice as well – worksite clinics conducted by salaried physicians. There are already more than 250 of these clinics. Benefits for employers are reduced costs, onsite prevention and wellness programs, tangible convenience for employees, and control of referral networks.

Government Choices

Government has a choice. It can choose to regulate, monitor, make it hard for physicians and hospitals to collaborate and innovate, and punish pharmaceutical companies and health plans. Or it can choose to change conditions so public-private partnerships can flourish and to drop barriers that prevent cooperation and private investment. This is America, and tensions always will exist between champions of government and the market. Government protects the people; the market provides the jobs and funds the government.

Choice Dilemmas

The freedom of Americans and their doctors to make choices creates dilemmas for payers, patients, and physicians. These dilemmas produce consequences – higher costs, inconsistent quality, poor care coordination, sketchy follow-up, impaired patient safety, and freedom of patients and doctors to choose. But this is America, a country built on the freedom to choose what one wants to do, even if in the eyes of critics, those choices may compromise the common good. As a consequence, American health care is imperfect, but it is damn good although it could be better. Bettering the system will probably come from bottom-up choices rather than top-down mandates.

The End Choice

In the end, the American people have a choice,

•Universal government-run coverage with fewer medical bankruptcies, less financial anxieties, higher taxes, less access to high end technologies, longer waiting lines, fewer amenities, and less choices

•Public-private coverage of 85% of the population with higher costs but with universal access to emergency room care and speedy access to the best care their doctors and they choose and the world can offer, and choices only a free market can offer.

In America, where most people want quick but universal access to care, at lower or no cost at the point of care, but with a wealth of choices, this is not an easy choice.