Open Letter To My Physician Colleagues
By Tim Bartholow
Much has changed since the ABIM 2002 professionalism statement, but valuing efficacy, safety, and affordability has not:
Physicians must be dedicated to continuous improvement in the quality of health care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, increase patient safety, minimize overuse of healthcare resources, and optimize the outcomes of care.
Today, you witness with me, many more patients cannot follow our advice because their deductible is $3,000, $6,000, $10,000. This is a consequence of healthcare costs that have risen faster than businesses can raise the prices on goods and services (and faster than employee wages increase). Private and public businesses have had the employee/patient pick up some/much of the extra cost, hoping that they can be a “better consumer” of their health care.
At the same time, many of us do not know the real price of what we recommended — we just have not built our system to do this. We have said this is unsustainable for 30 years. It may now have reached this point.
In our state, employers need us to be aware of RAND 3.0, an employer effort to assure that there is transparency about the state-to-state and facility-to-facility variation in pricing. Also watch the conversation about the GNS study of WHIO data by the Business Health Care Group — far too much defensive press has been issued about the method of analysis, and not about how we together are committing to reduce the crushing costs of health care for families.
We were approached by the Appleton Area School District (AASD) with a harsh, if expected, reality that AASD could do two but not all three of:
- Provide employee cost-of-living increases (only 5% over the whole of the last four years)
- Preserve student programs
- Preserve the current trend in healthcare increases at an unsustainable 6% or more
They cannot do all three. So, which one do you think AASD should not do?
Why do we not see a flash in the sky to signal when this “unsustainable moment” has arrived?
Well, in a slowly incremental process, teachers, bus drivers, administrative staff, and food-service workers have an incrementally higher deductible, a few programs are silently reduced, and employees do not get a full cost-of-living increase. We are busy, it is complicated, and we have not drawn a line of understanding between cost of care made by our choices and our patient’s denied cost-of-living increase — but this is exactly what is happening.
So, we have not noticed that deductibles have risen by 111% over the past decade, whereas workers’ earnings have only risen by 27%.
The patient is in a sacred covenant with us as clinicians, whether we remember this promise every minute of care or not. They think we are acting in their best interest — to achieve the best outcome and not waste their money. The patient wants the care we recommend and trusts that when two equal quality choices exist, we choose the one that will not cost them needlessly, now or in the future.
Some will say this money is coming mostly “from insurers” (or employers or taxpayers). But there is no money tree, and if we act like there is, we are unwittingly raising the cost of insurance and decreasing the money available for our patient’s salary.
So, what can our part in this be?
AASD is working with clinics and Health Tradition to inform employee/patients that we will recommend high-quality, affordable solutions. For the top three most expensive things we do or order, by unit price or by high volume, we clinicians need to know which choices are the most cost-effective. And when we become more aware of the first three, go to the next three.
You will not have all the data you need, but examine what you have, ask a trusted insurer to help identify what is more costly, or ask your system partner (who owes us transparency) about what the cost to the patient is. I once asked for the prices of items on the hospital obstetric delivery table so that I could make these choices and was denied — not OK.
I believe that AASD is only the tip of a proverbial iceberg of employers seeking improving care (and health) with concrete affordability.
This is an opening in this conversation, and the stakes are possibly higher than any of us have seen in our careers. If we end up making choices based on a new understanding of costs or cost-worthiness, it fulfills the agreement with our patient. The other members of the care team will know that this is a new requirement in care.
Those that achieve improving outcomes with improving affordability can expect businesses and insurers to steer employees/patients toward those practices. This may be hard for some doctors, but it is only children’s programming at schools or AASD salaries that are in the balance.
As physicians, let us lead in this moment and help make answers.