Wednesday, 9 May 2012

Increasing Efficiency of Health-care Delivery: Introduction for the Resident Physician

How would you as a physician improve the quality and cost of care delivered to your patient in the American health care system? This is an important question each physician should ask himself. This article is for physicians, residents, junior doctors, health care related personnel, or just about any one who has interest in health care policy. During residency/ fellowship interview or even during physician job interview, this is a fair question to ask the potential applicant. This helps to gauge depth of understanding of the problems and to ascertain if the applicant has some insight regarding improvement in efficiency of patient care.

Although this is a great interview question it is also useful to look informed when talking to your peers or faculty. Let the program and physician faculty know they are dealing with a critical, well read, intellectual rather than just another medical graduate wanting to do residency in US
Fig 1: The triad of health care efficiency determinants

The annual cost of health care in US is exorbitant. For example, a simple doctors visit can cost a person (without insurance) anywhere from 40 to 100 dollars excluding the cost of test, medication, other ancillary services with the median expense being 64$ [1]. With insurance, the acute costs are reduced but over a long term, the expense still persists. This insurance-based practice structure is not ideal but had become a reality of many practicing physicians and the patients. Though resident reimbursement has never a problem, physician reimbursement remains a contentious issue. As seen in the figure, the patient, physician and the health system (hospital or clinic) form the triad upon which efficient health care can be addressed.

The following are patient related factors, which affect the efficiency of health care delivery

  1. The Exacting patient: This kind of patient feels that the more you do to them the better it is. Patient demands one test after another leading to a drain on resources. Identification of such patient is important because rational explanation and education will often counter the patient’s demands for unnecessary intervention.
  2. Brand preference: Imagine day after day, on TV and radio you hear the pharmaceutical companies advertising the drugs for the common ailments. Patient learns to recognize the names and achieve a sense of familiarity with the drug. The effect is clear, which would you rather take? A drug, which sound very unfamiliar to you or something that you have heard about all the time? Brand medications have their place in the pharmacopoeia but generic medications will certainly bring down the cost of health care [2].  Education of patients regarding efficacy of generics will help mitigate costs.
  3. Disease awareness: Patient must be educated about the disease they have. They should be encouraged to seek information regarding their disease state. Awareness of the illness, the evolution of their disease, the complications to expect and general knowledge about the illness will help keep costs down by early and timely intervention.
  4. Preventative health: Encouraging patients to see their doctor on a timely fashion will help reduce the risk of late complications. This is a huge cost cutting factor because, late complications end up costing several hundred time more than early interventions.

There are also physician related factors that affect the efficiency of patient care. 

  1. Uncoordinated care: This increases the costs by duplication of efforts to take care of the same disease state. The patients internist or primary care provider should assume the role of the coordinator when multiple specialists are involved in taking care of the patient.
  2. Unnecessary referrals and test: Just as sometimes, patient feel that more tests is better, there is also a tendency for physicians to be frivolous with their armamentarium of investigations. Developing a good clinical acumen can often tone down the need for over zealous testing. The tune is slowly shifting from “don’t just stand there, do something” to “don’t just do something, stand there”.
  3. Defensive medicine: US is a litigious society, this has instilled a streak of fear among physicians and they tend to practice defensive medicine. It is the practice of diagnostic or therapeutic measures conducted primarily not to ensure the health of the patient, but as a safeguard against possible malpractice liability. [3]
  4. Incentivisation: is the practice of building incentives into an arrangement or system in order to motivate participants within it. Incentives to order more tests, bonuses to do more procedures etc are all onerous activities that encumber the health care system.
  5. Physician education: medicine is an ever-changing science. The guidelines for appropriate care of patients in disease states change every 5-10 years and this is often reflected in the specialties board exams like ABIM or ABFM. Doing a new thing, which is correct is more cost effective than doing the old thing, which is now incorrect. Keeping informed is going to help take the right decisions and reduce costs.

Health system based factors affecting efficiency of health care

  1. Ease of access to care: this important fact helps beat costs by providing medical care in a well-timed fashion.
  2. Availability of services: A health provider system should try and acquire all services related to the care of their patient under one aegis. Many practices are adopting this model thus reducing the costs of transfer of care to another facility. It is not surprising to see a X ray machine in a primary care physicians office or a basic laboratory attached to a group practice.
  3. Evidence based Medicine core measures:  The heatlh systems should allow for institution of check-points which build into practice the core measures for other disease states. There has been very successful implementation of core measures for pneumonia, acute myocardial infraction and congestive heart failure in the inpatient setting in many hospitals across the US. Such measures, are the minimum essential measures of care that have shown to make tremendous impact on patient mortality and morbidity.
  4. Integration of EMR: Electronic medical records or EMR is now the sine qua non in many health care systems across the US both hospital and clinic based. Cross platform integration of differing medical records will allow for seamless transfer for care and prevent duplication of expensive testing.
  5. Decision support system: Expanding the use of decision support system in the electronic medical records will aid the physician in making correct a judgment. At the present time, almost all EMRs provide some level of decision support like checking for drug-drug interactions or drug-allergy checking.

Fig 2: Determinants of health care efficiency

The points discussed above are not exhaustive but are intended as a seed idea for an physician to critically appraise their role in the health care machinery. Finally figure 2, summarizes the gist of factors discussed above. If you have any suggestions or comment please join me on facebook or follow on twitter!

  3. Anderson RE (November 1999). "Billions for defense: the pervasive nature of defensive medicine". Arch. Intern. Med. 159 (20): 2399–402. PMID 10665887

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