Saturday, July 4, 2009

Relationships, Incentives, Healthcare

Relationships with doctors, nurses, pharmacists, midwifes, and others are key to effective and efficient healthcare. Most folks, I suspect, would love a more substantive relationship with their doctor, but the realities of insurance reimbursement policies, the threat of malpractice, and the commodification of healthcare all work against this.

In terms of quality of care, nothing can replace having a primary care physician or nurse practitioner who knows your medical history well, who knows what drugs you are taking, who gets the whole picture of your life and health and is able to make informed recommendations and decisions based on such an understanding of your particulars.

I get along well with my doctor, we have some common interests we like to talk about, and I suspect he spends a bit more time with me than with some other patients. But the clock is always ticking—he has to cover his costs--and a long time might be 15 minutes rather than 10. He makes himself accessible by email, and he has even prescribed malaria prophylaxis for me for a trip via email. But he doesn’t get paid for doing that, no compensation from my insurance and he doesn’t charge me. He does it because it is the right thing to do, but the incentive structure is set up to discourage such interactions.

(And, why can’t my pharmacist prescribe something like malaria prophylaxis? There is no danger of abuse, no reason someone would want to take it if they didn’t have to. It would be much more efficient to give pharmacists to power to prescribe such categories of medication. And, with an integrated electronic medical record system, one’s primary doctor could be automatically notified, maintaining the holistic view of one’s health and medications.)

We need to set up incentive structures (partly through a public healthcare insurance plan) to nudge (as Thaler and Sunstein use the term) the promotion of relationships with healthcare providers. The new model of “boutique” medical practices is revealing. For annual fees starting at less than $1500, patients get long (and wait-free) consultations with their physician, cell phone numbers and around the clock access for emergencies or even just pressing questions that don’t warrant an office visit. The fee allows physicians to radically reduce their patient load while insuring that their office overhead expenses will be covered. And they provide the sort of care everyone should be getting. With 300m people in the country, paying doctors $1500 per person to be their primary care physician would cost $450 billion—a lot of money, about 3% of GDP, but we spend upwards of 17% of GDP on healthcare now. We could also up the compensation paid doctors for an annual well-patient visit, so that they have time to uncover hidden problems or just get a better handle on overall health.

(Then, let’s also spend a few billion getting healthy school lunches in cafeterias, and a few more promoting bike riding, walking, and public transportation. Subsidizing public transportation isn’t just about getting people from point A to point B, or cutting down on carbon emissions, but also about having a healthier population, who, if nothing more, walks to and from the bus stops.)

Building better relations can introduce more trust into doctor/patient interactions—and this is could not just for the quality of care the patient will receive but also for the system. Malpractice suits are needed to discourage and punish malfeasance. But malpractice has become such an industry, that it now serves private gain much more than the public good. Research has shown that doctors apologizing for their errors cuts down significantly in malpractice suits. Patients want that apology, and if given and take at the level of human, personal interaction, they are often willing to accept and forgive the fallibility of doctors. But the fear of malpractice and subsequent rules imposed by hospitals discourages this sort of interaction. (At the same time, as my colleague Erin O’Hara of the Vanderbilt Law School points out, apologies can also be used cynically to present warranted sanctions or lawsuits, much as abusive spouses might employ apologies.)

But what is we had a Hippocratic Oath in which the patient could look into the doctor’s soul and see that the doctor would rather die than have the patient die, would rather suffer whatever consequences herself rather than have the patient suffer them? Such a bond of trust between doctor and patient would, like the sincere apology, obviate much of the desire for retribution when something does go wrong.


  1. Thanks for posting your thoughts for us to read. It is vital, if we are going for real reform of the system to look at all aspects of our medical care. Seniors use up the most dollars and we often leave children and pregnant women under insured or uncared for. We need to put our emphasis on preventative care and not on hip replacements and organ transplants.

  2. Similar thoughts on transforming the model: