How much of the responsibility for our health belongs to doctors, and how much falls on our own shoulders? There’s an interesting discussion about this subject at Notes From An Anesthesioboist, in an article about patient responsibility. If you check it out, make sure you read through the comments too, as there are lots of opinions expressed, and lots of good points made. My own opinion is that each of us has nearly all of the responsibility for our own health, and that we can keep ourselves fairly healthy by eating well, exercising, not smoking, minimizing stress, etc. But what about people who need extensive medical care, despite maintaining a healthy lifestyle? How does the responsibility cookie crumble in those cases?
Some ailments come out of the blue – like my father’s rare autoimmune disease that caused kidney failure and makes him highly dependent on medical care and dialysis (and health insurance) to stay alive. I’m no stranger to the acute need for health care that some people face. But even a situation like my father’s involves a huge amount of patient responsibility. True, he can’t heal his kidneys no matter what he does. But he and my mother are diligent about his diet (the renal diet is extremely restrictive, and they follow it to the letter), his meds (he has to take a phosphate-binder at every meal since dialysis doesn’t remove phosphate), and his dialysis (every night he spends three hours hooked to the dialysis machine). He has to limit his fluid intake, and avoid foods that are high in potassium and phosphate. Life in general is a lot tougher for him than it was before all of this. But the alternative isn’t very appealing, so he works to keep himself as healthy as possible.
Over the years, my parents have met lots of other dialysis patients. Some are smokers. Some drink five times as much liquid as they are supposed to, and rely on dialysis to remove the extra fluid. Some aren’t compliant with their meds at all, and their labs are all over the board. Some have other conditions that exacerbate their kidney failure, and aren’t compliant with their care for either ailment.
That’s not to say that the entire responsibility should be the patient’s. People with serious medical conditions have to place a certain amount of trust in their doctors, and over the years my parents have come across numerous medical errors pertaining to my father’s care. Doctors make mistakes, and some doctors are just plain bad (isn’t that the case in any profession?). For the most part, the doctors my dad works with have provided good care. But they aren’t – and can’t be – babysitters. They can’t be there to say that perhaps it would be better to not have that cigarette or bottle of soda. They can’t force their patients to take meds or avoid certain foods. My parents make the trip to the University of Colorado Hospital once a month to see the doctor. He gives my dad the tools he needs to be as healthy as possible, but it’s up to my dad to put those tools to use.
The concern I have with physician reimbursement based on patient outcome centers around patients like my dad. Nothing he does is going to bring back his kidneys. He’s dependent on medical care indefinitely, despite all of his efforts to be as healthy as possible, and no matter what his doctor does. Would an outcome-based payment system mean that doctors who treat chronically ill patients wouldn’t be reimbursed as well as doctors who treat people who can expect to fully recover from whatever illness they have? Would doctors be less likely to take on chronically ill patients? Yes, we should all eat kale, exercise every day, and take responsibility for our own health. But what if we get sick anyway? Doctors and patients are both responsible for patient outcomes, and any reimbursement reform should focus on both of those aspects.
I found the article about patient/doctor responsibility in Grand Rounds, hosted by Doc Gurley. Check it out – it will remind you of childhood games of clue…