Two Podcasts

In reference to "why the doctor needs a boss."

I agree that some sort of patient advocate is needed, someone who has a holistic, or project management approach to patient care, particularly in cases where the care needed is complex. I'm just not sure who that should be. As I see it, there are 3 main parties involved in the healthcare decision process as it stands. This would be the payer (usually the insurance company or medicare), the doctor, and the patient. You could possibly add a 4th, the patient's family, but their incentives are bascially in line with those of the patient, so I would lump them together with the patient.

You had suggested the possibility of corporations such as Kaiser Permanente. My problem with that is that I don't see how the incentives line up for them. They are a business, so their main incentive is profit. More specifically, for any one patient under treatment, it's cost containment. I don't think this makes them a good candidate for patient advocate. Perhaps you mean a separate corporation, one not involved in paying for the care?

Doctors like to say they are patient advocates and are not concerned about cost. I'm sure they care about patients, but they also have incentives that may not line up with those of the patients. They also have to turn a profit, and one aspect of that might be avoiding lawsuits. This means that to at least some degree, care might be guided by lawsuit avoidance. Also, it seems many doctors now have a business relationship (i.e. they profit) from certain of the testing and outpatient centers they are sending patients to. Lastly, doctors simply need to process enough patients through the system to turn a profit, so there is incentive to increase throughput. Whatever you may think of doctors as people, we all know incentives matter, and I don't see them as in the best alignment with patients.

That leaves the patient, or patient's family. Obviously, this group has the most clearcut incentive to want exactly the care required for the patient. Problem is, this group is the least equipped to make informed medical decisions, and is legally and/or financially barred from ordering treatment even if they feel it's correct. They can only deny treatment, unless it's over-the-counter, or resort to "alternative" medicine. As a result, this group is almost completely at the mercy of the other 2 groups.

So, how do we create an advocate for the patient whose incentives line up in such a way as to deliver a superior overall healthcare experience and one who has the power and knowledge to actually influence choices for the patient, but at the same time, doesn't break the bank? And, is adding yet another stakeholder to the process going to actually make things better and/or cheaper?

Most of the goods and services I buy come from firms trying to make a profit. I don't need an "advocate" to get them to provide quality products or services. Market competition works. It doesn't work that way in health care, because the consumer does not pay the bills.

I think I'm leaning towards a model where the unit of care comes from a hospital, not a doctor. Due to economies of scale, this would probably need to employ at least 100 doctors, maybe even 500 or 1000. People pay a flat annual fee to be a member, or the government does. The hospital is for-profit or non-profit; it doesn't matter. All these doctors don't need to be in the same building, as it would be valuable to have small simple offices scattered around.

Care is managed, and people can call a nurse 24/7 to discuss an issue without worrying about the bill. No procedures or tests are done without either some evidence they will improve patient health, or in order to gather that evidence. In some cases the hospital does things proactively, like operating a flu-shot van that

Then give it a few guiding principles:
1. Everyone dies.
2. Small things first.
3. Just because you can doesn't mean you should.

Dan Weber,

That's also known as Kaiser Permanente.

They deserve credit for being very proactive about preventive care in order to reduce overall cost. It's not a bad business model, but they've had problems with the quality of care they provide because they use a profit-sharing mechanism that discourages doctors from prescribing expensive procedures patients would benefit from whether or not the patient will benefit from less expensive alternatives.

I knew a woman with lupis, a patient of Kaiser, who went through years of cheaper and ineffective treatment before they would formally diagnose the disease and treat it appropriately. IMHO, that's not good health care. There has to be greater acceptance of chronic illnesses and a willingness to step up to the plate to manage them appropriately when they are not or cannot be prevented. As you say, everyone dies, so health care is about both quality and length of life. They failed with respect to both criteria in her case.

Arnold,

Great podcasts. Thank you.