MDs! Customize care … for “selected patients”
In a recent issue of the Journal of the American Medical Association, we learn that physicians generally blame other groups for the runaway train that is American health care costs: lawyers and patients, for instance. Ezekiel Emanuel, in an accompanying editorial, bemoans this buck-passing, and identifies several domains which must be changed to remake health care, with the physician in the lead. “There is no magic solution,” he says – rather, a combined approach is needed to control health care costs.
He lists the following ways in which health care delivery must be transformed:
More cost consciousness in decision making
Increased emphasis on keeping patients healthy rather than treating exacerbations of chronic illness
A move toward team-based care delivery and away from individual practitioners
More organized and coordinated systems
More process standardization with customization for selected patients
Greater price and quality transparency
Do you notice what I notice about this list? It’s centered on the provider, or the team, and not on the patient. Patients in general aren’t cost conscious; it’s not clear whether preventive health, rather than treating exacerbations, will actually lower costs; who knows how patients will react, in general, to the team-based care promised by medical homes; price and quality transparency doesn’t improve outcomes, at least according to a review we published this year.
My favorite point, however, is the “process standardization with customization for selected patients.” Which processes can be standardized with only “selected customization” – that’s my question. Is cardiac catheterization *ever* done exactly the same way in two patients? What about treatment for pneumonia? Blood pressure control? Depression treatment?
I’m not being flip, or at least – I’m trying not to be. The article, in its population-based naivete, points up the gap between cost-saving measures and patient-centered care – while failing to recognize it at all. Selected customization, indeed!
