How Middlemen Undermine Patient-Centered Care
A new study shows that doctors disregard patient-reported outcome measures.
A recent scientific study found that doctors don’t make use of patient feedback in their clinical work. Despite the fact that almost 60% of patients report outcome measures (patient-reported outcome measures, or PROMs), only 1% of doctors pay attention to them when providing care, even when those measures are included in medical records and accessible to providers. Why don’t doctors care about these metrics? Probably because they have nothing to gain from using them. Patients can’t reward or penalize doctors for performance.
Even as they express shock at the 1% figure, the authors of the study indicate that the number they found is probably as good as it gets. The cases they observed all took place within a state – Minnesota – whose medical professionals are particularly committed to measuring care quality and within a department of a major health system that has long been devoted to integrating patient data into work flows. If getting doctors to use PROMs fails in that setting, it would probably fail more dramatically everywhere else.
The high rates of patients reporting outcomes and the technical prowess of including it all in doctors’ electronic systems is a rare feat in an industry known for being fragmented and technologically challenged. It could be that docs don’t trust the data or face logistical challenges and time constraints preventing them from using the PROMs. Those factors probably play a role. Yet, as one journalist put it, “the researchers posited there is still a major, unidentified barrier keeping healthcare providers from using PROMs.” They fell short of an explanation.
There’s a good chance that said “major and unidentified barrier” is the fact that patients aren't technically the customers of the care they receive: The real customer is insurance companies.
Imagine if you had a great meal at a new restaurant and wanted to share a review about your experience. You could do so by tipping well, posting a glowing review on Yelp, and patronizing it again.
And if you had a terrible experience, you could leave a low tip, write a negative review, and vow never to eat there again.
In either case, the restaurant owner would take your experience seriously, because it has an immediate impact on the company's reputation and bottom line.
In healthcare, payment doesn't really vary depending on performance. In fact, doctors can make more money if they go for the more invasive treatment option or if a patient has to come back to the hospital to fix a medical mess. But even if providers aren't paid via fee-for-service, at the end of the day, the patient isn't the customer – insurance companies are. Patient experience doesn't matter nearly as much as insurers being happy.
In our third-party payer healthcare system, the third party isn’t the insurance companies. It’s the patients.
PROMs should matter in clinical decisions. Patients aren’t machines that technicians are fixing up; their own experience of the treatment’s effects is integral to clinical success. Countless non-clinical inputs make a difference in treatment outcomes, including visits from relatives and even a positive attitude. Surely, accounting for the detailed survey answers patients submit would enhance their health. That’s in fact the goal of patient-centered care and why PROMs are collected in the first place.
The modern healthcare industry doesn’t encourage doctors to look at their patients holistically. If it did, then doctors would think twice before prescribing mental health drugs that risk placing depressed patients in bankruptcy. And patients feel that they are at the mercy of a system that treats them like non-player characters.
To achieve true patient-centered care, patients have to gain ownership over their own healthcare decisions, which includes healthcare dollars, and doctors should work in such a way that patient satisfaction is the foremost metric for success.
To that end, patients should be able to stop pouring thousands of dollars into health insurance premiums each year only to start all over again the next year, and instead save that money until they incur a big expense. Then, when they need complex care, they’ll want to shop for a good deal rather than hand that decision over to an insurance company that doesn’t have their best interest at heart. This should be true not only for privately insured patients but also for those on Medicaid and traditional Medicare, government programs whose sheer size and administrative bloat prevents them from offering tailor-made treatments to beneficiaries.
Patients don’t have medical degrees, and that’s why they go to the doctor. But they aren’t clueless either, and they deserve a say in what’s being done to their bodies and minds. Incorporating their insights into the clinical process requires restoring financial agency to them as well.
I'm skeptical of blaming middlemen because middlemen (in our case insurance companies) perform a service for both sellers and buyers: they take on the search costs of connecting would-be buyers and sellers.
Let's say that patients have the ability for shop for their own doctor (IOW sellers). They then have to take the time to research what kind of specialist they need, the doctor's performance record, and the price of hiring that specialist. Searching for the right specialist comes at the cost of the next-highest valued use of the patient's time. In addition, if a doctor wants to stay in business, she'll need to find patients. The costs of the doctor searching for patients (IOW buyers) is the next-highest valued use of her time.
Insurance companies (albeit far from perfect) take on the search costs of finding doctors for patients and vice versa. Of course insurance companies aren't benevolent (in the Smithian sense), but middlemen do not have to be benevolent. They simply have to be alert to entrepreneurial opportunities.
Before we call to "eliminate the middleman," consider the costs of doing so and compare it the alternatives.
This is by no means an endorsement of the status quo. I support regulatory reforms to increase competition in the healthcare market and lower costs for consumers. As mentioned by Liam Sigaud, there are many regulations (especially ones on insurance companies) that contribute to the rising costs of healthcare in the U.S.
Definitely need to lose the middlemen in medicine.