That’s the message built-in to most contemporary policy, initiatives, and programs, and the source of much professional atrophy and distress among caregivers. No matter the end goal – increase EHR adoption, shift to quality metrics from volume, record sharing and interoperability, improve safety and patient outcomes, reduce national healthcare expenditures – the fulcrum of policy is on the backs of the provider, most typically physicians.
Physicians are, in a sense, the target for incentives, pressure, supervision, and a generous amount of scapegoating. In corporate terms, doctors handle production; administrative and financial matters all ultimately rely on the admin team. Changing outcomes, culture, organization, and all else begins (and ends) with their participation.
Conspicuous by their absence from this change equation: patients. In any healthcare transaction, patients are in many ways the most important stakeholder. Yet they have escaped accountability for driving change through a combination of ignorance, dependence, and commoditization. The fee-for-service Health 1.0 model made patients numbers rather than partners in healthcare transactions. Health 2.0 is struggling to integrate patients into a quality model, because it hasn’t really created the necessary context for patients to assert their interests or needs in a meaningful way, nor are they more broadly empowered to understand the system itself.
A lack of, or low, health literacy is part of the problem. Even as Obamacare/ACA rely on “market forces” to drive change vis-a-vis higher deductibles and greater patient financial obligations, patients have been less inclined to shop smarter than to avoid healthcare spending. Basically, patients are supposed to strategically change their behavior under the new system, but not enough understand the system, and their options within it well enough to behave as intended.
Author and occasional Health Standards blogger Dan Munro discussed healthcare’s designed confusion principle in this episode of HITcast:
People know when they lose money to healthcare expenses, and they fear debt; they don’t really know how to shop around before they have an acute need for medical services. That is at least part of the reason why there is a similar refrain coming from those working with doctors:
“Ours is a technologically proficient but emotionally deficient and inconsistent medical system that is best at treating acute, not chronic, problems,”
And politicians working with policy: “…so often what we label as a health care system is actually more of a disease-care system in which the patient is passive.”
Quality metrics that incorporate the patient experience as a measure of provider/institutional performance are doomed, in part, because patients are ill-equipped to judge their experiences in terms of medical merit. So they will reference the only other set of experiences they have for providing feedback: customer service.
For all the clamor among administrators about improving the system by implementing evidence-based best practices, those practices have not incorporated the experiences of virtually every other customer-facing industry. Whether or not patients should see themselves as customers doesn’t matter: that is how they are conditioned to provide feedback. And patients, as customers, are not impressed with American healthcare.
According to Harry Greenspun, managing director of Deloitte’s Center for Health Solutions:
“Consumers’ expectations of a service are formed based upon their experience in every other industry: how they shop, how they travel, how they’re able to get information about anything else, and how they interact with providers. When they come to a hospital or go to a doctor’s office, and they can’t make their own appointments; they can’t understand what their bill is going to be; they can’t get the information they want; they can’t change things easily; and they can’t communicate in the way they want to communicate, they begin to see that as lesser service quality.”
So compensation is tied to patient attitudes, but not outcomes, despite patients being poor overall judges of the net value and quality of their experience, because they would rather not be patients in the first place. Collective economic patient misbehavior, combined with health illiteracy and a focus on customer service over outcomes, means that those working within the health system just have to press that much harder on doctors to effect change, incremental or otherwise.
Relieving the provider burden depends heavily on physicians distributing accountability to patients. That only happens when patients have more information and direct engagement to act on and learn from. That takes a different sort of buy-in from the healthcare community than simply beating physicians with carrots and sticks.
Doctors need some help making it all work, but patients historically have received no real training on how to be partners in their own care. Providers, rather, are on the hook for their own patients’ participation and engagement as well as their care. We need patients to be engaged, accountable, and informed, but we aren’t really regulating, promoting, or offering any real direction on how they should use the tools available to them.
Technological literacy has managed to become almost as critical to navigating the modern world as traditional literacy itself. Everything is “smart,” from cars and phones to refrigerators and clothing. If health literacy is the aim, and Health 2.0 is the new paradigm, then patient portals seem like a critical node for patient education. Providers can’t make this leap on their own. Getting patients engaged, educated, and health literate might require making portals their hub for all things medical, despite the current poor reviews of portal users throughout the industry.
Part of the obligation can be distributed to schools as well. Teaching students how to approach healthcare outside of “to get better” might support a conversation about what population health should look like. Personal health maintenance as a component of citizenship could be as elemental as voting and paying taxes. These are all cultural touch points that current policy demands from physicians, when, in reality, it has to originate with patients.
Surely, with all the preoccupation with financial incentives to drive behavior, there is room for insurers to implement more robust point systems, which discount patients for completing health literacy milestones, engaging with free informational resources, and exhibiting proactive behaviors that support preventative care. Rather than patients holding physicians hostage with experience ratings, suppose physicians had to sign-off on patient efforts to stay healthy between visits. There are any number of models that give patients both power and responsibility for improving healthcare.
In a system designed around acute care and disaster recovery, physicians are not the most capable educators or innovators in health matters. It is time to stop putting them at the center of every program and conversation, and start making room for patients to own their role. Until this is achieved, we will continue limping along and driving providers away from their passion and profession.