I recently came across a Huffington blog post by Jeffrey Bland PhD, “The Elephant in the Exam Room: How Insurance Companies Affect the Doctor-Patient Relationship,” that compels me to respond to both physicians–and patients. Dr. Bland’s thoughts ring so true. His premise is that medical insurers are the “elephant in the room” that is eroding the doctor-patient relationship. This in turn can affect patient and physician satisfaction, clinical outcomes and the spiraling cost of health care.
Dr. Bland points out the values that he saw in his physician friend that we all want in our providers: patient centeredness, taking courses to improve one self, going to conferences on leadership and communication skills, and finding the time to be available for patients. Yet these values are of little meaning when the insurance companies seek to create a different “standard of care”. This care includes doctors holding very brief office visits and ordering expensive diagnostic tests, prescriptions and therapeutic procedures, and homogenizing care into standard guidelines to increase throughput and save costs, and which may not apply to all patients. Doctors are being forced to accept these standards in order to be properly reimbursed so they can financially maintain their practice.
“The medicine that third-party payers would like to support is formulaic and prescriptive,” rather than individualistic
As Dr. Bland states, “The medicine that third-party payers would like to support is formulaic and prescriptive” rather than individualistic. In fact, the very values mentioned that enhance physician quality are neither encouraged nor reimbursed by third party payers despite abundant scientific evidence that they improve patient satisfaction, treatment adherence and health outcomes, and can reduce health care costs
In the business of medicine the reality is that the time spent learning these positive attributes of physician quality is not endorsed by payers or properly monetized. Investors are more likely to invest in a smart phone app or a computer software program to improve the electronic medical record than to teach health care providers how to communicate better with their patients. Even the recent effort to evaluate patient satisfaction in the hospitals (HCAHPS) focuses more on the cleanliness and quietness of the facility, the ability of staff to respond to medication requests or to get to the patient to the bathroom than the humanistic features of provider empathy, treatment negotiation, patient centered care, and active listening, all of which have more proven effects on patient satisfaction.
“What is best for the patient,” replaced with, “What will generate more income?”
I was in academic medicine for over 35 years and have seen the detrimental changes in the humanistic education of our young physicians and its impact on patients. Years ago, when working with residents and students the guiding aphorism during times of clinical uncertainty was “What is best for the patient?” This has been replaced by the (perhaps unspoken) statement: “What will generate more income?” Almost 10 years ago I wrote an editorial in the journal Gastroenterology: “Medicine has Become a Business, But What is the Cost,” where I talked about the de-emphasis on good teaching. There has been less time has been allotted for faculty teaching, the elimination of the complete physical examination, reductions in the curriculum for teaching communication skills, and focus on the computerized electronic record where face to face time with the patient is reduced as the health care copies and pastes the previous medical record since there is little time to obtain information directly from the patient. Even our academic leaders have moved from the values of research, student teaching and patient care to that of learning better business practices to achieve a bottom line profit. I regret to say that the predictions in this article have gone beyond expectations.
Is there a solution?
It’s hard to know if solution is possible.There are good physicians out there who need to learn the good practices, but who will pay for that training? We need to reward clinicians and educators for these humanistic skills and this should be supported by third-party payers, maybe even a congressional mandate. Perhaps certifying boards should require courses to teach basic concepts like communication skills and methods to enhance patient centered care for accreditation and licensing. Ultimately increasing health care provider skills in these areas will reduce health care costs and quality of care.
For further information on learning ways to improve patient-centered care please visits Drossman Center or the American Academy on Comunication in Healthcare (AACH). If you are a patient looking to be seen for your GI problems please visit Drossman Gastroenterology.
Douglas A. Drossman, MD