Who Is the Most Important Stakeholder in Health Care?

PUBLISHED ON  June 17, 2009

WRITTEN BY  Roni Zeiger

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Like many other doctors, patients, and President Obama, I’ve been thinking about Atul Gawande’s brilliant piece in the New Yorker on the root causes of spiraling health care costs in the U.S. One aspect that has not yet been given enough air-time is what role patients should play in this discussion. Gawande describes a thought experiment performed by him and a cardiac surgeon:

A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.” — that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”

I’m not naive enough to think that we will do well if patients negotiate on price for how many of their coronary arteries should get un-clogged. And while few patients are ready to use a microscope to diagnosis their own Crohn’s disease, those that do should remind us who has the biggest incentive for sustainable, high quality health care. It is critical that patients be a part of this conversation.

When the best treatment is well understood, and should not vary by the patient’s values or preferences, then our traditional paternalistic system works well for many consumers: Doc, tell me what to do, and let’s do it. However, in the many cases where the best data says there are two or more equally good options — e.g., whether to have surgery for low back pain — then we need more innovation and thought leadership on how to have these conversations effectively. How do patients best understand risks? How can we organize data about effectiveness of treatments for the top 100 conditions so that average doctors can keep up and discuss options with their patients? These are solvable problems.

It is awesome that Peter Orszag himself (Director of OMB) offered a thoughtful and data-rich response to Gawande’s article on the official Whitehouse website. Let’s also keep front and center the need for the consumer to be part of the conversation, and that doctors and patients alike need better access to basic data about what works and what doesn’t. Doctors should increasingly expect patients to ask: “What is the likely outcome if we choose this option?”, and patients should expect an answer.

Risks vs. Benefits: Get the Evidence or Fire Your Doctor

PUBLISHED ON  April 14, 2009

WRITTEN BY  Roni Zeiger

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Gone are the days where you should believe what your doctor tells you simply because he or she is a doctor. Medicine can be complicated, and it changes all the time: new drugs, new resistant bugs, and new scientific studies that teach us that sometimes what we once thought was good is in fact killing people. Your job as an informed consumer of healthcare is to make sure that the benefits outweigh the risks. The stakes are too high for you to assume that your doctor knows this.

Risks vs. Benefits: Get the Evidence or Fire Your Doctor
We love talking about benefits — that’s the part of the commercial with smiling lovers and chirping birds. But talking about risks is scary, so we avoid it or mention them really fast when the credits are rolling. When is the last time YOU asked about the risks of a treatment or a test?

Case 1: The doctor says: “You should have a colonoscopy.” How can you decide if this makes sense for you if she doesn’t also tell you that there is a 1 in 14,000 chance you will die from complications of the colonoscopy? This doesn’t mean you shouldn’t do it. It means there had better be a greater than 1 in 14,000 chance that it will save your life or make you healthier. (And your doctor should tell you that for colon cancer screening, the benefits indeed outweigh the risks for adults between 50 and 75 years old.)

Case 2: “There’s a spot on your chest x-ray. It’s probably nothing, but let’s get a CT scan to make sure.” Wow, what a caring doctor. What will you say to him? That’s right, you should ask: “What are the benefits and risks?” If he explains them, including the fact that repeated CT scans increase your risk for cancer — great. If she says, “I don’t know, but let’s find out” — great. If he just wants you to go ahead with the treatment based only on his experience, fire him.

For doctors, it’s quite difficult to find out the actual risks and benefits of the tests and treatments we recommend. You might expect that there is a regularly updated database of the top 100 treatments and invasive tests, which quantifies the risks and benefits for each of them. It doesn’t exist! Most of the data needed to create such a database does exist, but it’s scattered across many research articles and textbooks. I’m willing to bet that if more of you demand this information from your doctors, that database will soon exist. And I know it will help me practice better medicine.

Demand the facts and make informed decisions. Your life depends on it.

The Last Mile Problem in Health

PUBLISHED ON  March 24, 2009

WRITTEN BY  Roni Zeiger

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We have a critical last-mile problem in the healthcare industry: getting from a doctor’s prescription to a patient regularly taking her medication. The “last-mile problem” usually refers to the challenge of laying the final stretch of wire or cable to each individual home when providing telephone or internet service. Healthcare has its own last-mile problem that is approximately the distance from the medicine cabinet to the patient’s mouth. And the fundamental cause is inadequate patient-physician communication.

This doesn’t seem like a complex problem, but the numbers are astounding: about 50% of medications are taken as prescribed. That’s right: the simple, sad math is that about half of patients don’t succeed in taking their medications as prescribed. Given that medications are generally key treatments for our deadliest conditions such as diabetes, heart disease, and asthma; and given that half the time the medication is not making it from the prescription pad to the patient’s mouth, you would expect that we would be working very hard to solve this problem. To suggest otherwise would imply an unconscionable amount of waste, missed opportunity, and needless lives lost.

It turns out that in 2008, there were more studies published just about acid reflux disease (GERD) than there were about medication compliance. Why such a disconnect? Let’s reflect on my medical training. In my seven years of medical school and residency — that’s about 20,000 hours of training — I spent approximately one hour learning about medication compliance, and about 45 minutes of that was talking about all the complications caused by those non-compliant, non-adherent, patients who failed to follow through on doctors’ orders. This is not a failure on the part of the patient, it is a failure of patient-physician communication.

We doctors need to accept our share of responsibility for successfully taken medicines. The fatal flaw is thinking that our responsibility as health care providers ends when we hand the correct prescription to the patient. A corollary is that the vast majority of our research investment is targeted only at getting drugs from discovery to the point of prescription. Here are just a few points downstream from there where we can fail:
– the patient doesn’t understand why he should take the medicine, so he doesn’t
– she is experiencing a side effect, or is afraid of experiencing one
– he can’t afford the medicine, and is embarrassed to tell the physician
– she doesn’t think the medication is helping, so she stops taking it

To be sure, there are other points of failure, but the ones above are common and they have something in common: they all result from inadequate patient-physician communication. Especially among the tens of millions in the U.S. taking multiple medications, many don’t even know why they are taking a given medication. Personally, I think I have failed if one of my patients doesn’t know the purpose of each of her medications. In fact, I try to include the reason for taking the medication as part of the prescription, e.g., “Atenolol 50 mg tablets, take one by mouth every day for high blood pressure.” But the explanation “for high blood pressure” is rarely included in a prescription. In my experience, over 99% of prescriptions handed to patients and printed on the medication bottle fail to include this basic guidance on what the medication is supposed to treat. Why? Because we think our job is done when we figure out what drug to prescribe. Because we are too busy or too lazy. Because the reason for taking the drug is not a required part of the prescription! Now that seems like low-hanging fruit in health care reform.

And let’s not forget to talk to each other. At every doctor visit, the patient and doctor should review the patients’ current medication list (this actually is explicitly recommended by the leading hospital certification organization). Doctors: let’s make sure this discussion includes the patients’ understanding of what each medicine is for, and an invitation to share any questions, doubts, or concerns. It’s amazing what we learn if we simply ask. Patients: this is YOUR health. Don’t leave the doctors’ office until your questions are answered and you understand the plan. Lawmakers: we should require prescriptions to include the reason for taking the medicine, and we should give doctors financial incentives not just when they prescribe the right medicines, but when their patients actually take them. And finally, innovators: as we create novel treatments, let’s not forget the millions of lives and billions of dollars we can save by innovating on the process of getting those prescriptions taken as prescribed.

** Disclaimer: The views expressed here are mine alone and not those of my employer. **