Healthcare Control Using Fear

Command-ControlGiven enough fear, people welcome control.

Sickness and trauma scare us. Patients need to hear, “It’s okay. Don’t worry. You’re going to be all right.”

Fear begs action.

Scared people want someone in control. In the past, doctors and nurses calmed fears.  Patients just focused on recovery.

Medicine got better.  Worry about sickness decreased, and worry about hospital bills increased. Losing homes became as much a concern as losing health.

Media sells on fear, especially in the USA:

Desperate Times Call for Drastic Measures

Extremis malis extrema remedia

Pundits leverage people’s dread of sickness. Panic about rare, high-cost medical catastrophes justifies command and control over delivery of everything else.

People don’t panic over high blood pressure or diabetes.  But most healthcare dollars go to chronic disease and risky behaviour in the USA and in Canada.

Paradoxically, central planners back off a little in the provision of high profile, newsworthy medical care. Trauma care works best when doctors set up systems guided by outcomes.   Bureaucrats let medical experts design delivery and just pay the bill; it’s a much smaller portion of healthcare spending anyways.

But fear about medical bankruptcy justifies more and more micromanagement of everything else.

Healthcare Control

Service, quality and efficiency needs empowered front line providers.  Patients suffer when physicians are bound by rigid guidelines, shackled by fear of lawsuits and motivated by perverse incentives. Patients benefit when providers are incentivized to meet patient needs, not system rules.

Command and control does not work in business (Command and Control Leadership Doesn’t Cut it Any More – Globe and Mail).  It will never work in healthcare.  But fear continues to justify military-style leadership leaving patients on the sidelines as costs.

Most of us support a safety net for rare, catastrophic illness.  It’s dishonest to use legitimate fear about medical catastrophe to allow central healthcare control that harms patient access, service and quality.  For the bulk of healthcare spending, we should empower patients and providers and let them drive service, quality and efficiency.  We should stop supporting central command and control.

What do you think?  Do we need more centralized, bureaucratic healthcare control or less?

 Photo credit: engageforsuccess.org.  Check out their post on Command and Control.

Are Healthcare Economists Healthcare Experts?

mula-toy-hammering-block__0252853_PE399518_S4Healthcare economists see numbers and money not patients and care.

Professional economists study markets and policy.  They do not lead businesses, serve customers or develop product.  Sure, some CEOs take economics in undergrad but need MBAs and experience before leading big companies.

Take Michael Decter for example.  He’s a Harvard trained economist, previous Deputy Minister of Health and seems to be kind and sincere.  If you ever hear him talk about healthcare, ask yourself, “Who does he think leads and understands healthcare?” (see ‘Does Money Buy Change‘).

Decter wrote a piece recently called Saving Medicare. He talks about using paramedics, community nurses, pharmacists and palliative care to save Medicare.

He interprets symptoms of Medicare malaise, pronounces a diagnosis and prescribes treatment.

A Panacea

To a child with a hammer everything’s a nail.

Economists whack at provincial spending and fiscal policy.  And so they should.

But like chubby toddlers with hammers, they look around for other things to hit.  They pummel clinics and hospitals.  They batter doctor patient relationships redefining them as costs and waste.  They wrap pudgy fingers about their favourite hammers and reshape access to care and who provides it.  Then the government, like a good parent, lines up new shiny targets for economists to attack: utilization rates, collective bargaining, policy reform…

Experts at What?

  • Do economists run businesses?
  • Do they lead hospitals?
  • Do they build clinics or care for patients?

Then why do economists talk like experts on healthcare?

Economists rule in publicly funded medicine.  They’ve mutated medical care into discussions about money, legislation, policy and politics.

Economists train to observe and critique.  They expertly identify patterns and problems.  Even if we grant (generously) that economists correctly diagnose healthcare problems, that does not mean economists can accurately prescribe treatment.  Furthermore, there is no proof economists could operationalize their solutions without command-and-control legislation.

Top Down

Economists think high level and see patients as numbers, care as cost.  They generalize and offer idealized solutions necessarily top-down.  They invert healthcare.  Instead of starting with a patient and her doctor, Medicare economists start with governments and tax dollars.

They should use their expert skills to measure, model and predict.  Then they should be quiet.

Why, for heaven’s sake, do governments think they can run a $50 billion industry with leadership made of mostly economists, researchers and policy experts?

Medicine Redefined

Pundits see medical care as economic transactions instead relationships based on one party devoting themselves to meeting another’s need.  Politicians cannot imagine patients being cared for by anyone other than purely self-interested providers.  Bureaucrats cannot understand therapeutic relationships.

Doctors and patients need to take back medicine.   It requires continual effort to keep healthcare about patients and providers instead of policies and budgets.  On behalf of patients everywhere, physicians need to challenge economists’ diagnoses and treatments.  We need to challenge economists’ definition of healthcare.  Healthcare is about therapeutic relationships not anonymous economic policy.

Healthcare economists are not healthcare experts.  What do you think?

Photo credit: Ikea.com

Provider Guilt and Healthcare Waste

doc asleep“But your patients expect to see you,” she said.  “It doesn’t matter if it’s 8 o-clock at night… When I need my doctor, I expect him to answer.”

My mother’s words still echo 25 years later.  She nursed 2 floors of Alzheimer’s patients by herself. She’s practical and tough with medical concerns.  She managed most things without any support, largely alone, at night, with very sick patients.

When she finally calls a doc, she expects an answer.

Physicians used to be available 24-7.  They slept in hospitals as much as home.  It grew out of guilt, duty, greed, social expectations, escape from personal relationships…a complicated list.

24-7 created some odd physicians.

People now realize that healthy providers give better care.  Patients benefit with doctors fully engaged, fully aware.

Guilt

“There’s a patient who needs…[some great need]…up near [some place 40 minutes away].”

The one, lost sheep…

Often lost sheep have many people who could help and might even do a better job of helping.  But physicians feel a ‘proper’ doctor would go and attend.

Driving 30-40 minutes, one way, to see one healthy patient while making 8-10 other patients wait or rebook appointments is not model behavior.  It is not altruistic.  It is profligate, wasteful.

Healthcare Waste

Payers and auditors obsess over unnecessary tests and visits.  They care less about efficient use of physician time.

Patients benefit when physicians spend time with them.

No matter what else planners dream up, the system should always maximize physician efficiency to keep maximum time available for patients.  Regulations, bureaucracy, forms, record keeping for 3rd parties, audits, and quality improvement projects must be measured by the time they steal from patients with their doctors.

Guilt & Waste

Provider guilt works like another layer of wasteful bureaucracy.  It often makes physicians steal time from dozens of patients by pretending to model sacrificial behavior for one.  Guilt often blends with pride; providers like people to know about our sacrifice and hardships.  Often our stories of sacrifice are examples of time stolen from other patients who needed us more.

Efficiency is…

Everything we do means something else cannot be done.  Thankfully, patients now expect their physicians to maintain their personal and family life.

We need the system – and all the providers in it – to insist physicians stay maximally efficient.  Before all else, healthcare efficiency should start with measuring how much time physicians could be spending with patients if they didn’t waste it somewhere else.

Photo credit: nytimes.com