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.