ClickCare Café

New Pay Structures May Make It Harder to Care for Poor Patients

Posted by Lawrence Kerr on Thu, Jul 19, 2018 @ 07:00 AM

matt-collamer-555626-unsplashCaring for everyone has always been a core part of our practice of medicine.

Whether or not you can pay, and the complexity of your condition (medical or social) has never been a factor in whether we are willing to treat you, or in the quality of care you receive. 

In both of our community medical practices — Cheryl as a pediatrician and Larry as a reconstructive surgeon — this is just how we’ve done medicine, and it’s been a core part of what we did from the beginning. It’s not that we make money during our regular practice and then volunteer for the “disadvantaged” a few weeks per year — rather, we know that no one gets truly great care if a doctor is picking and choosing who to care for. The slope of that line of thinking is simply too slippery.

The truth, though, is that caring for people in this way used to be easier.

It’s certainly not impossible now. But taking payment from a patient in the form of chicken eggs (if that’s what they had to pay with) is almost impossible given the insurance and regulatory context we’re currently in. And that used to be somewhat frequent in my practice. Furthermore, the tools and workflow structures that orchestrate our day generally work against thoughtful, deep, individualized work with patients — driving us towards testing and diffusion of responsibility and fast, solo decisions.

So I do think that an article that came out in the New York Times recently is an important one.

Overall, the author, Dr. Dhruv Khullar, makes the point that “Doctors who care for disadvantaged populations need more resources to produce comparable health outcomes, but they’re less likely to have them.”  Further, that the current drive toward a fee-for-performance system is going to deeply dis-incentivize care of patients who have especially complex social, emotional, or economic needs. In a fee-for-service system, there are many inappropriate incentives — but at least doctors are compensated fairly for patients who have external circumstances demanding more time.

I think this perspective, in which we consider how new structures will affect all of our patients, is important. It’s not discussed enough, though. That said, I also worry that the framework of the discussion has some flaws. First, the framing of some patients as "poor / disadvantaged / complex" and others as "wealthy / straight forward" neglects to acknowledge that on any given day, even the wealthiest among us may experience complex social or economic constraints that make them the complex patient. Further, the truth is that the richness of our healthcare practice comes from treating all patients to a single standard  not to dividing up and choosing our standard of care (or who we treat) in any way.

Second, I believe that medical providers should view the imperatives of good medicine as outside of  and above  any fluctuations in payment or even workflow tools. We are each responsible for the hippocratic oath we took; we are each responsible to the human being sitting in front of us. It is up to us to find or create the tools and structures we need to do medicine in the ways that our conscience demands. 

That's why we believe so strongly in our work with iClickCare. The healthcare providers who use iClickCare to do healthcare collaboration, to improve medicine, to make their workday more satisfying do so because it's important to them  and they need wait for no one to start using it. It's affordable enough, and the ROI is so extreme, that it is a choice we can each make, on behalf of our patients  without anything else structural changing at all. 

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Tags: good medicine, healthcare collaboration

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