Saturday, December 21, 2013

Why changing physician behavior to fix the healthcare system is not likely to work

The healthcare system is broken . This is as true in India as it is in the US . While the healthcare ecosystem is complex, there are two key targets whom  we can work on – doctors and patients . In order to fix the problem , we need to change their behavior . It’s much easier to work on trying to change the behavior of the physician , because there are much fewer physicians as compared to doctors; and they are all trained professionals, who are more likely to listen to reason.

This is why physicians are often the primary targets when we try to reform healthcare. Because they are gatekeepers for medical care , we believe that they are the ones who hold the key to success, because they are extremely influential. They control what tests are ordered ; what treatment is advised; and most patients will pretty much do whatever their doctor tells them to.

If doctors learn to diagnose correctly and prescribe sensibly, a lot of money can be saved . Today, we are seeing an epidemic of overdiagnosis and overtreatment, as a result of which healthcare costs are going through the roof.  If we can improve physician behaviour, we will be able to achieve the goals of improving patient satisfaction ; increasing quality of care ; and reducing medical costs . This is why so much money is being spent on trying to incentivize doctors to do what is right for patients; and pay for performance is the fashionable mantra today.

While it’s true that it’s easier to target physician behavior, it’s also equally true that doctors are independent professionals who don’t like being told what to do. They are quite intelligent and find it quite easy to game the system . Every doctor feels they are competent and they don’t like being monitored and controlled. They have high self-esteem and each doctor believes he is doing the best he can for his patients. They do not think they are not likely to benefit from someone else’s advise – especially when the source is a meddlesome government bureaucracy; or a highhanded health insurance company who wants to call the shots just because they are footing the bill.

The problem is that good physicians are ethical professionals who don’t need monitoring – and that bad ones will never improve, no matter what anyone tells them. It’s very hard to change physician behavior, especially when they have invested 10 years of the prime of their life in being professionalized and indoctrinated.  While well-meaning bureaucrats will continue fiddling with incentives and penalties to try to get doctors to play nice, I feel that on a long-term basis , the only durable way of fixing the problem is by helping patients change their behavior !

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