Monday, July 25, 2016

"Patient Accountability"...really?

Exploring the latest buzzwords to permeate health care discussion.

When I was a medical student and resident, the discussions about health care - that is, the ones that didn't strictly address money - seemed to be all about integration. If only the system were more integrated, if only there were fewer silos, health care would waste less, cost less, and bring about better care. Then prevention and interdisciplinary care came along. We don't have a "health care" system, we have an "illness care" system. Let's focus on lifestyle and other causes of poor health, and work in teams. After that, sustainability and modernization. We need to leverage information technology, reform our 20th century system for 21st century needs, blah, blah, blah. Many continued to cry for patient-centered care, another evident chimera for health care.

Now, in the era of endless government scandals, health care is suddenly about value for money and accountability. This is fine when discussing practices that have little-to-no evidence behind them. And equally fine when discussing excessive bureaucracy, waste, and mismanagement. But when we start talking about user fees, means tested or otherwise, or higher insurance premiums based on "lifestyle" factors, or worse still, user fees or penalties for system "abusers", we engage in a different discussion altogether. It's a discussion often at odds with statistical and anecdotal evidence, and - if coming from doctors or other health professionals - bears the whiff of hubris and contempt for the sick.

With regards to means-testing the cost of health insurance, this is already in effect through progressive income taxes and estate taxes. Ontario takes things a step further with its much-maligned Ontario health premium, which is nothing more than a progressive tax by another name.

With regards to "lifestyle factors", that's another thing built in to our current taxation system. Cigarettes and alcohol are taxed to the moon. Junk food, soda, and prepared foods are all subject to sales tax, while ordinary groceries are not. And obesity has myriad causes, most of them beyond an individual's control.

As to "system abusers", these patients are almost certainly fewer in number than we think, given the natural negativity bias in coloring how big we perceive the problem to be. Let's face it, some of these folks are frustrating to deal with. Then again, people that bounce from one doctor to another, demanding tests and treatment for ailment after ailment might very well have an undiagnosed mental illness such as PTSD - in this case, the so-called "system abuse" is really a symptom of underlying disease, a prompt to make a referral for something apart from another test.

But what about sustainability? If we don't do anything to limit first-dollar coverage for health care (setting aside the Canada Health Act making it essentially illegal), how will we control things when we're hit by the "grey tsunami"? How do we get costs down? Why can't we try user fees to deter system misuse?

I'm sure Canadian provinces could have tried user fees if it weren't perceived to be so politically hazardous. The opportunity would have been wide open while the Harper Conservatives were in power federally. After all, the funding was already locked in from the 2004 accord, and Stephen Harper never cared much for matters of provincial jurisdiction.

There are two pieces of evidence to suggest that, in Canada, user fees will be of limited value, either as a deterrent against frivolous use or as a means of making up revenue shortfalls. In so far as their limited use as a deterrent, we already have evidence that user fees don't seem to make much of a dent - we happen to call that user fee parking.

Just exploring the Ontario Wait Times database, looking at waits for random procedures/tests (I chose hysterectomy, outpatient CTs, and gallbladder surgery) doesn't seem to show an obvious trend, except perhaps longer waits in the larger cities. That there are longer waits in big cities - where parking can be exorbitant - suggests that system usage probably depends much more on capacity than a fee to get in the door.

The greater evidence, and this time there's a whole body of it, to show that user fees are not the panacea they are made out to be, relates to the determinants of health - income, employment, education - and a look at who the greatest users of the system actually are.

Here's an inescapably dramatic statistic: 5% of patients account for 2/3 of the cost of the health care system. One in twenty people consume two of every three dollars spent on health care. That's a staggering sum of money on a relatively small number of people. These heavy system users are by and large poor, elderly, disabled, suffering from multiple chronic conditions, or any and all of the above. Those with poor socioeconomic status are much more likely to undergo hospital admission, and have more trouble accessing specialists.

In other words, it's not the person who's a pest in their family doctor's eyes or showing up repeatedly at walk-in clinics with frivolous complaints that's straining the sustainability of the health care system. Rather it's someone who is poor, sick, disabled, or struggling with mental illness. That these sad souls will be in a position to reduce their own health care needs is an idea somewhere between wishful thinking and cruelty. Moreover, the notion that charging user fees to the other 95% of the population that doesn't use the system very much is going to save a whole lot of money is simply not credible.

So what is behind a call for "patient accountability"? I'm not entirely sure. It could be, as noted above, a reflection of frustration with patients that create headaches for health care providers. It could reflect generalized frustration among health professionals in a system that's always stretched past its capacity. It could also just be a veiled demand by providers for more pay, or sour grapes from the public around generous union settlements.

There is another possibility, however, and it's one that's not at all flattering to health system professionals. The demand for accountability might be part of a growing resistance to treat patients the system doesn't really like. That's predominantly smokers and fat people, but might also include people that create paperwork for health care workers, namely people on social assistance.

No code of ethics I'm aware of permits doctors or nurses to determine who merits service on the basis of anything apart from need and a reasonable chance of benefit. To lay claim to some sort of "moral authority" over who deserves help, in particular when the system is funded and administered through the public purse, goes well beyond the bounds of "good medicine" and into the realm of hubris. It is simply a bridge too far.

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