By Evan Falchuk
Welcome to the See First blog. You can read about us here. With this inaugural post, we wanted to share our reasons for joining the online healthcare conversation. We feel that we have a unique perspective on healthcare due to Best Doctors experience helping thousands of people see their way through the complicated and often times, frustrating healthcare system. Finally, we can and will share stories and perspectives from the front lines of healthcare that you won’t hear elsewhere.
While there are a slew of topics to begin this blog with, we wanted to dive into one of the most important topics of all: quality. As important as it is, it is not something well understood in healthcare. What follows is a list of questions often discussed and debated in healthcare circles:
1. How would you define healthcare quality as it relates to employers and employees?
Evan Falchuk: In this country we tend to look at healthcare in terms of “employers” and “employees” and “providers.” They’re technical terms that almost seem to hide what we’re really talking about, which are sick people—moms, dads, kids—who are trying to get better. We need to think about quality in terms of whether our system helps people get better or puts obstacles in their way. So, I define quality very simply: did the patient get the right diagnosis and treatment?
Fritz Hofheinz, MD: As a doctor, I often struggle with trying to figure out what is going on with a patient in the ten of fifteen minutes typically allowed. You need to spend time and listen to the patient to formulate a good judgment of what is going on. The financial pressures in the system make it difficult. Many doctors know the experience of being told that to keep their practice going they have to see 20 or 30 patients in a day. If you only spend 10 or 15 minutes with a patient, it is very difficult to deliver consistently good quality care. So while I agree with Evan on the definition of quality, I think we also need to realize that our healthcare system seems set up to make it hard to deliver it.
EF: Fritz is right about that. There are literally dozens of different “quality” initiatives out there, all with their own definitions of quality. Hospitals and the government routinely measure “quality” in terms of patient “safety”—meaning that they made sure they did the right procedure on the right patient, for example. Others measure it in terms of how many surgeries of a certain kind they have done, or whether they give certain medicines in certain medical situations. It’s very difficult, as a consumer, to make much sense of this. I mean, if I’ve been told I have cancer and am not sure what to do and where to get treated, there is really no useful data out there I can turn to that will help me make a decision about my care.
FH: It is tough to pick the right metrics for this purpose, and it’s clear that the medical community is struggling to figure this out. I’ve seen some strange examples of how this works, where following a rigid quality definition can actually harm patients. Medicine is an art, grounded in science, but we must never lose sight of how much of an art it really is. I am convinced as we physicians become more involved in defining and measuring quality, we will start seeing quality metrics that make sense across the spectrum of care. We are a long way from that I think.
2. What is your opinion on the current state of quality as it relates to employers and employees?
EF: In a word, confused. I’ve been to numerous conferences that talk about healthcare quality and I think there is zero consensus on what “quality” means. Almost everyone is well-meaning on the subject, but they’re casting around trying to find an answer and coming up with complicated and sometimes contradictory approaches. I think the right people to ask are the patients—if you’re sick, what do you consider to be good quality care? Patients will tell you good quality care means they had time with their doctor, that their doctor correctly diagnosed them, and that they got the right treatment. Even if a bad outcome can’t be avoided, patients who feel like they were treated right are grateful towards their doctors and consider themselves to have gotten high-quality care. This should be the starting point of how we define quality, but it is often not part of the discussion.
FH: There may be something of a shift happening. I have seen progressive employers coming to terms with this, certainly the ones who have implemented Best Doctors. If you talk to people who run benefits departments of these companies, they know all about situations where employees have faced difficult medical decisions and haven’t known where to turn, or situations where they found out – too late – that there was additional testing they should have done, or other treatments they should have pursued. Hopefully we can share those experiences through the medium of this blog.
3. How can physicians, patients and employers work together to improve healthcare quality?
EF: We need to focus on that relationship between doctor and patient as the foundation of any discussion of healthcare quality. Doctors need to be able to spend time with their patients, listen to them, think about their problems, and help them get well. Employers can help by encouraging employees to live healthier lifestyles and also by giving employees tools to help them see their way through the healthcare system and make the right medical decisions.
FH: I also think that we need to think about the extent to which some of the managed care programs present obstacles to good quality care. Sometimes these programs are useful, but for many doctors they are seen as an annoyance and become the reason not to do that additional test that would make you sure of the patient’s diagnosis.
EF: It’s a question of cost, also. We talk all the time in this country about needing to contain healthcare costs. But Americans place a high value on healthcare. We think everyone should have the best care, and we get very uncomfortable when we hear of someone being denied something because of cost. We have tried two decades of managed care and costs have still gone up while quality has gone down. Maybe there is something we are doing through the process of managed care that is driving costs, instead of containing them, and hurting quality, rather then helping it.
4. How do you see the term healthcare quality evolving under the Obama administration?
EF: Whatever gets done will be called “reform,” no matter what it is, so I can confidently say we will have that. The most promising quality initiative is the promise to push electronic medical records. Done right, we could have a national standard, which would make it much easier for doctors to share and consolidate information, and better diagnose their patients. But this is an enormously complicated problem.
FH: It is, and the difficulty is that there are so many different types of records already in use so integrating this mess will be a herculean task. Also not well reported is the fact that many physicians think that their EMR actually slows their productivity and interrupts their patient-doctor interactions.
EF: In the meantime, the trends in the market are going to continue to evolve, regardless of government action. Patients are increasingly engaged in their care, and employers are increasingly putting financial responsibility on their employees for their healthcare. This will continue to have important and unpredictable effects.
FH: Patients often show up with print-outs of things they have found on the internet about their condition (PDF), and challenge their doctors to explain the things they have found. I think this is generally a good trend – particularly if we can engage patients in a dialog of what information sources are the reputable ones. As more information becomes available on the web, especially through things like social-networking, I would expect this trend to intensify. What we haven’t seen much of yet is doctors taking advantage of this web 2.0-type stuff to create what I might call an “MD2.0 practice.” For example, a truly wired doc might engage in real-time twitter or email dialogs with their patients throughout the course of a day. Right now, for the most part docs don’t do this even though if they did they might provide higher-quality, more cost-effective care.
EF: We may see more of these concierge-style practices, where patients pay a monthly fee for this kind of access to their doctor—but not just for the affluent. If we really want to reinvigorate primary care, we may need to rethink the way that primary care doctors are paid, and the central role it has to play in our healthcare system.
5. What advice would you give to employers and employees to ensure that they are maximizing healthcare quality?
FH: For employees, live a healthy lifestyle; go see your doctor regularly. If you’re sick, get help researching your condition and ask lots of focused questions of your physician. Recognize that a good patient-physician relationship is truly a partnership. Don’t be afraid to ask for a second opinion. For employers, help your employees be healthy, and encourage them to seek out the best medical care they can get. Seek opinions of physician leaders in your community as to what they believe constitutes “high quality” care and constantly strive to provide quality care for your employees.
EF: I couldn’t say it better than that. If we can think of quality in terms of getting the right diagnosis and treatment, the answers on what to do become much easier to reach.
