Unintended Consequences

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Joe is a guy that never really cared about his health. He is overweight, according to any objective standard, and always attributes this to “bigger muscles” (it isn’t). He dutifully comes in once a year, but admittedly only because of his wife’s insistence. She worries about his lack of exercise, his growing abdominal midsection (“muscle”) and the fact that all he does on weekends is sleep. There is a strong history of heart disease in his family—his father was only a few years older than Joe, when he collapsed at the dinner table and died. Joe always turns down repeated offers for the flu vaccine with the response, “I never get sick,” and shows little interest in his lab results, even though his blood sugar and office blood pressure are always high (“I get nervous at the doctor’s office”) and his “bad” cholesterol has never been even close to normal.

At his last appointment, Joe forcefully slapped a stack of papers on the exam table and seemed agitated. “We had a health screening at work last week,” he explained, “My numbers are out of whack and I need your help.” I wasn’t surprised at the numbers, but his seemingly new interest in his own health had me intrigued until he explained. “I get $50.00 off my health premiums, if my blood pressures are normal and $150.00 for having a physical,” he said. Mystery solved—money supplied by his employer was motivating Joe to get healthy.

Not that I’m complaining. Anything that motivates patients to make a positive change and take charge of their health is always welcome. I’m always hoping it’s not a health scare that brings that change. What worries me is the future of healthcare for guys like Joe. Outside business forces now pressure primary care physicians to show quality outcomes. A movement has been afoot to ‘certify’ those physicians that demonstrate quality care: Making sure the patient’s average blood sugar, blood pressure and cholesterol levels are normal and that he receives all the preventive care recommended by health experts. This certification may ultimately affect the physician’s reimbursement and potentially even future employment. But what happens when the patient is simply not interested? Or when the patient shows interest, but can’t afford the many medications required for his many health issues?

Joe becomes a liability. Physicians may feel that guys like Joe need to find a different “medical home.” Joe becomes high risk and physicians will be unwilling to negatively affect their personal certification profiles by having him in their practice. And since all health data is now available electronically, other physicians will turn down his requests to join their practice. Clearly, this is not what the health system intended, as it tries to radically engineer how the provision of care to patients. It becomes an unintended consequence.

Even patients who try their best, but unfortunately stay in poor health, can get caught in this quagmire. Before we embark on “treatment by numbers,” we need to understand that providing adequate health care has always been a partnership between the physician, patient and insurers. We all need to do our best to address what is under our control, while recognizing that optimal health care will never be perfect. We should never let practice by numbers affect access to heath care to those that need it most. After all, that access is the result that physicians intended when they took their sacred oath and that’s the only certification we should depend on.

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