38. Systems will be designed so patients can stay healthy and take as few drugs, have as few procedures, and avoid the system as much as possible.

Rob Lamberts, MD, Owner Dr. Rob Lamberts, LLC

This is part of a series of essays on the Health Rosetta’s Principles.

This thesis seems, on first glance, to have an inherent irony: build a system that discourages the use of or need for that system. What business would aggressively advocate a situation in which customers would need the services of the business less over time? In essence, it advocates that the medical industry should do whatever it can to work itself out of a job. Does that make sense?

But consider the current state of health care from the physician’s business perspective. The most profitable situation is one where:
• The patients are very sick and/or complex, requiring frequent visits
• The physician can perform multiple procedures on the patient (each a billable item)
• The physician and staff spend as little time with each patient, allowing a higher volume.

These business goals are exactly the opposite of what each person wants in their own care, which leads to the sad, but not surprising conclusion: the system gives physician incentive to give patients exactly what they do not want. Conversely, the system penalizes physicians who meet the desires of their patients (to be healthy and to have as little interaction with the healthcare system as possible).

Not only is this system counter to anything healthcare consumers want, it also comes at a high cost to society. You get what you pay for, and we are paying for busy doctors, full waiting rooms, sick people, and many unnecessary procedures. Any attempt at fixing our system must start with this problem, as it is at the core of our uncontrolled costs. Access to good insurance did not happen on its own; it happened because the cost of care was driven up by this incentive for more procedures, sicker people, and increased consumption in the healthcare space (in fact, it is easier to conclude that increased access to insurance will accelerate the crisis rather than solve it).

So what can be done to reverse this perverse incentive to increase consumption and make a system that rewards what is both best for the system and best for health care consumers? Clearly any system set up in such a way would be inherently "patient-centered," as the end goal of that system would be identical to that of the patient: to create healthy people who don't need doctors, drugs or procedures.

The most rational way to set up this kind of system is to create an ally within the system who is rewarded for achieving the goals of the patient. At the present time, the closest thing to an ally in this regard is the payor, who has obvious motivation to reduce cost, but is generally not trusted by either patients or healthcare providers.

The best candidate for such an ally is the primary care physician, as the vast majority of care coordination happens through the office of the PCP. Patients generally only get access to medications, procedures, and specialists through their PCP (a fact that the insurance companies have used to reduce cost through the use of "authorizations" for medications, procedures, and consults).

The cost of care can be lowered by simply increasing access to primary care physicians (the cost of care has been shown to be inversely proportional to number of PCP's in a community). The presumed reason for this is that early access to care will reduce the severity of problems and hence the cost of care.

But most primary care physicians are still not dedicated to reducing cost of care and preventing problems, as the system still rewards them for the opposite. The ideal ally for the patient would be a PCP that shared the motivation of the patient and was rewarded for it.

I've lived in such a relationship with my patients for the past 2 1/2 years, having previously worked in a standard fee-for-service setting for 18 years. The difference is dramatic, both in the nature of the care I give and my relationships with my patients.

I am paid a flat fee (between $30 and $60) per month by my patients in exchange for access to me and my services. I am paid just as much for sick patients as I am for healthy ones, and so have no motivation to have a sicker population. Instead, I am motivated to give them easy access to me via phone, office visit, or electronic communication, catching problems early and keeping them small.

I am also motivated by the fact that my patients pay me directly, and so am, in essence, employed by them. If they don't feel I am their ally in care, they stop paying for my service. So our office is constantly finding ways to save patients money and avoid unnecessary care, as doing so justifies the monthly payment.

The end result of this is care that is much more personal, patient-centered, cost-conscious, and preventive in its nature. Ironically, my push to reduce cost also benefits the insurance companies, as I help many of my patients to keep from spending their deductibles.

Whether care is given in my model (a growing type of practice labeled "direct primary care") or other models, the contrast between my former and my current practices is remarkable. Here are some of the factors I think lead to my success, and hence should be part of any patient-centered care model:

1. Cost must be transparent - My patients know what they must pay to be my patient, and any additional goods or services are specified in advance. I discuss cost of medications and procedures with people as well.
2. There must be cost-accountability - I am accountable to my patients if their care is unnecessarily expensive (they can leave my practice). This causes a dedication of me and my staff to reducing cost. My patients, many of which have either no insurance or high-deductibles, are also accountable to the cost. The value of each medication and procedure (the amount of benefit per cost) is frequently discussed.
3. There must be a financial reward for achieving health, preventing illness, and reducing unnecessary cost. My reward is that I retain patients, continue to collect their monthly payment, and can grow my panel size. The pernicious practice of penalizing providers for good care must stop.
4. The center of this must be a strong relationship with a primary care physician. This model doesn't work well with most specialists (especially ones who rely on procedures). But much of the specialty care can be avoided or simplified with strategic testing and treatment, and thoughtful care given by a PCP.

Who stands in the way of such change? Obviously, those who profit off of the perverse incentives and careless spending in our system. Preventing ER visits, unnecessary procedures, preventable specialty care, and hospitalizations will hurt each of those parties. A healthy patient is bad for business for those companies that rely on sickness for profit.

But hopefully most can see how maintaining our system as it stands is untenable, and will inevitably lead to crisis, financial loss, and patient suffering if not addressed. After all, even doctors, hospital administrators, and people employed by the pharmaceutical industry want what the rest of us want: to be healthy, to catch problems early, to be on as few medications as possible, and to keep the cost of their own care down.

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