'Medicare for All' doesn't address necessary doctor incentives

'Medicare for All' doesn't address necessary doctor incentives
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As House Democrats, led by Rep. Pramila JayapalPramila JayapalCentrist Democrats raise concerns over minimum wage push Centrist Democrats raise concerns over minimum wage push Overnight Health Care: Democratic bill would require insurance to cover OTC birth control | House Dems vote to overturn ban on fetal tissue research | New rule aims to expand health choices for small businesses MORE (D-Wash..), co-chair of the Congressional Progressive Caucus, prepare a proposal for “Medicare for All,” there’s another big problem in American health care that needs fixing.

Insurers, payers and administrators must re-incentivize physicians to listen patiently and attentively to the stories patients have to tell. To tell one’s story and have the doctor hear, acknowledge and use that story as the basis for diagnosis and treatment of whatever is causing suffering is the point of going to the doctor, after all. But these days, doctors are shackled to electronic medical record (EMR) checklists that demand their attention to the laptop screen and distract from attentive communication with the patient.

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In my practice as a neurologist, I translate patient stories to symptoms and discern whether they represent a life-threatening condition or something else. But in the limited time I have, I am now tasked with electronically documenting symptoms and physical examination findings on checkbox lists and data-entry prompts used only for coding and billing purposes.

The quality of my data entry determines how I am reimbursed in a system that can also produce inefficiencies, overuse of testing and medical errors. For example, two patients may have very similar checkbox lists: generalized weakness, weight loss, anxiousness, poor sleep, mild tremor of the hands.

But the diagnosis might be vastly different and only findable by talking at length to explore the nature, timing, effect and disability of the condition. Prior traumas, workplace exposures decades ago, emotional symptoms, family dynamics, detailed genetic history and other evidence may hold the keys to discovery. In order to mine for this type of data, a physician needs the flexibility, time and support structures to build trust, explore uncomfortable topics and hear the patient’s narrative. But it is this cognitive effort that is actively disincentivized in our current health-care system.

Research I conducted in my neuro-oncology clinic showed that patients had significant existential and medical needs that were not shared during their consultations. They were overwhelmed, fearful, distrusting of the physicians, distracted by concerns about loss of autonomy, increasing disability and burden on their families. They needed a lot more exploration than a 45-minute visit could provide.

Yet I was reimbursed only for the quality of my checkbox data entry and not for the quality of my exploration of patient and caregiver needs. The nursing, social work and counseling work provided was not sufficient to compensate for my need to move to the next patient. In a system where more and more patients are put in schedules with increasingly shorter time slots, I cannot provide what I know patients need.

Perverse physician incentives are now well-recognized, perhaps most clearly demonstrated by the effects on emergency physicians for refusing to prescribe narcotic pain medication. A pillar of modern health care, evidence-based medicine shows that most pain in an ER is not best managed with narcotics.

A refusal for narcotics by an ER physician, however, frequently leads to a negative patient satisfaction score, which then has adverse financial consequences for the physician. In the throes of an opioid addiction crisis, there is thus a clear disincentive to the ER doctor to perform evidence-based medicine.

While patient satisfaction with the overall experience of health care is incredibly important at an administrative level, the Press Ganey approach to measurement adopted by hospitals and regulatory agencies holds physicians responsible for aspects of care beyond their control. Fear of negative Press Ganey scores has been shown to alter decision making in the ED which further damages the patient/physician relationship.

Physicians are feeling this gaping hole in a current system designed to provide impersonal “quality” health care. Narrative medicine, a discipline to redevelop deep listening skills, is increasingly taught in medical schools and residency training programs and has emerged as an antidote to the depersonalization and cynicism our system has wrought.

A grass-roots tribe of narrative medicine practitioners are influencing how health-care providers better receive patients’ jumbled stories and recently have turned their eye to questions of how to encourage patients to frame and organize their stories to improve communication.

Narrative medicine has had its critics. Listening intently is time consuming. Accurate medical coding to prevent fraud and adhere to quality and safety reporting needs are absolutely important. Patient narratives may veer into emotional or psychosocial landscapes that distract attention from objective biomedical data that doctors need. Alternatively, a published review of studies using written or oral patient storytelling as an adjunct to typical medical care showed improved health outcomes in diseases ranging from cancer to diabetes, mental illness to fertility problems and end-of-life care.

A report this month in "Medical Humanities" demonstrated that recent studies examining incorporation of patient and physician written narratives into regular interactions found that patients identified the fundamental importance of having a physician who acknowledges their humanity.

Future physicians enter medical school to follow a desire to help their fellow humans, not enter data. The current system has created fundamental burdens that are directly responsible for the exploding crisis of physician burnout as the sources of meaning they have historically found in the profession are being stripped away.

Patients and doctors want the same things from American health care: a system that works more efficiently to deliver better health outcomes. In the next iteration, innovative insurance and payer arrangements must incentivize physicians and provide the administrative supports to allow personalized and comprehensive care.

Perhaps scribes powered by AI will free doctors to listen and examine patients, rather than enter data. Perhaps new conceptualization on delivery of patient narratives to increasingly time-pressured physicians, flexible scheduling models and time/complexity paired reimbursements can be introduced. Medicare for All is a worthy goal, but whatever system we choose must better incentivize doctors to listen to their patients or it won’t be a system worth having.

Lara Ronan, M.D. is an associate professor of neurology and medicine at Geisel School of Medicine Dartmouth College and vice-chair for education in the Department of Neurology Dartmouth-Hitchcock. She is a 2019 Public Voices fellow of the OpEd Project.