Thursday, March 01, 2012

The Fetish of Choice 
Unrestricted choice of physician is a fetish we have to get over. 

The February 24 issue of the New York Times has a story about the growing number of PACE programs, under which Medicare pays providers a lump sum per month to take care of frail seniors.  The focus of the story was how PACE programs keep these seniors in their homes as long as possible – something preferred by many patients and believed to be less expensive than nursing home care. 

It was mentioned in the middle of the story that some patients “spurn” the program because they refuse to change physicians.  Care under PACE is provided by a tightly organized, pre-selected, carefully managed team that includes doctors, nurses, social workers, therapists, etc.  That means that in order to participate, a patient has to change doctors, unless his or her doctor happens already to be member of a PACE team.  

As a culture, we cling to the idea that free choice of physician is something to be highly valued – almost a right.  When AARP advertises its Medicare supplement health insurance policy, it emphasizes that subscribers choose their own physicians.  

At the same time, we are increasingly alarmed about the high and rising cost of care, not recognizing that the two things are related. 

One obvious way to control the cost of care is to manage it and the PACE program is an attempt to do just that.  But in order to manage any activity you have to organize it and do it systematically.  In the case of health care, that becomes impossible if each patient has the right independently to pick his or her physician – arguably the most important person in the care team. 

In practice, physician choice is actually not as big a deal as we make it out to be.  People move from one town to another.  Physicians retire or die.  In both cases, patients have to change doctors.  Patients who go to the emergency room get their care from whatever physician happens to be on duty at the time.  With increasing frequency, a hospital inpatient is treated by the hospitalist physician who happens to be assigned to the case.  Nobody complains in these cases.  However, if the insurance company wants us to change physician, we act as though our persons have been violated. 

We need to be weaned off that.  One approach we are likely to see is the health care insurance policy that offers the option of a lower premium if you use a physician who is a member of the insurance company’s network or panel.   Wife Marilyn and I have a primary care physician we love dearly, but if we could each save $50 a month by changing, we’d think about it.

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