Health care’s new paternalism?

Is the patient’s blood pressure at 120 over 80 or below and controlled with one or more medications if necessary? Check.

Normal body mass index? Check.

Recommended screenings carried out according to the recommended schedule? Check, check, check.

But here’s the real question: Are all of these goals important to the patient, or does he/she see them as frustrating, burdensome and perhaps impossible to achieve?

The push toward better health care has organizations and clinicians focusing a tremendous amount of energy these days on patient outcomes. Few policymakers seem to have asked, however, where patients fit into this and how they feel about having their health goals – appropriate weight, appropriate blood pressure, glucose and cholesterol levels, appropriate prescription medications and so on – essentially dictated to them.

Is it going too far to call it a new form of health care paternalism?

If you listen closely, you can hear the beginnings of some pushback from people like Dr. Victor Montori of the Mayo Clinic, who last week talked to the Star Tribune of Minneapolis about hitting the pause button on all the checklists and having a heart-to-heart conversation with patients about what they really want.

An excerpt from the newspaper’s interview with Dr. Montori:

He argues that doctors must take into account the patients’ “values and preferences.” If one drug can bring their blood sugar down a notch, but doesn’t make them feel better, is it worth taking? “It’s making sure we don’t make any decisions about them without them,” he said. It’s a strategy that stops demanding perfection from patients and focuses on the treatments that are most important to them. “So they only get what they need and what they want.”

This is squarely at odds with the current approach of setting goals and measures and expecting all the players to reach these targets in order to achieve quality care.

There’s much at stake. By fiscal year 2015, fully 30 percent of Medicare payments to hospitals will be based on outcomes. Medical practices are dealing with similar pressure to reach specific goals in patient care.

This isn’t to say health care shouldn’t be held accountable for results. Outcomes do matter. But when an organization’s fiscal health and people’s livelihoods are on the line, it’s not hard to see why there would be a rising tide of all-around frustration when patients can’t – or won’t – meet the prescribed goals.

Meetings of the Rice Memorial Hospital board here in Willmar are normally rather subdued, but one of the most animated discussions I’ve seen in months erupted this week over the issue of patient adherence.

The doctors in the room spoke of the challenge of persuading their patients to adhere to the standard, and the frustration of being penalized when they don’t.

The hospital leaders in the room spoke of the unenviable task of being asked to meet goals that may hinge on patient decisions and behaviors beyond the hospital’s control.

The implications go deeper than this, though. What about hospitals who care for high numbers of elderly, frail and medically complex patients who may not have outcomes as favorable as that of a younger, healthy population? What about the 90-year-old who has been living with congestive heart failure for a decade and has decided it’s time to stop with aggressive management of the condition?

Should hospitals and medical practices become more selective about the patients they’re willing to take and start turning away those deemed to be too sick or too complicated or less likely to be compliant? Most Americans would agree it’s unethical (or at least unfair) to cherry-pick the “best” patients, but there’s no denying this looms as one of the unintended consequences of outcome-based payment. Left unanswered in all of this is who, exactly, will care for the sickest and most vulnerable when the reimbursement model is rigged against them.

Finally, there’s the issue of patient autonomy. The patient’s right to make his or her own medical decisions is one of the core tenets in American health care. This basic value seems to mesh uneasily, however, with performance-based payment. What happens to patients who don’t want to take a particular medication because the regimen is too burdensome or the side effects are intolerable? What about the patient who simply wants to feel better and function better rather than meeting specific target numbers?

To make things even more complicated, all of this is taking place simultaneously with a growing emphasis on patient-centered health care and shared decisionmaking.

It’s far from clear how this is supposed to fit together, or the extent to which the average consumer is aware of the push-pull between giving patients more say in their care, while at the same time deciding on their behalf what the measure of their health should be.

Don’t look for this to be resolved anytime soon. No one ever said health care was simple.

2 thoughts on “Health care’s new paternalism?

  1. Last Visit my dr spent at least 30 minutes looking at a computer screen and maybe 5 looking at me. I left feeling very frustrated and unheard. There was no discussion at all about my own health goals and regimens which, as an older human being, are becoming a major part of my daily thinking and action. I thought it was just my dr’s problem, but now I see it is a result of the whole medical establishment. Yuck!

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