Most parents would agree at least verbally, if not in action, that giving in to their child’s every wish and desire may turn out to be counterproductive.  They would say they try to do what is best, and needed, and not necessarily what the child wants.  The downside is the child may be upset or dissatisfied with the decision made regarding their request or perceived need.  But they can’t go across town and choose a different parent.

PCP (Primary Care Physician) to Therapist (T):

PCP: “The kid’s mother told me she was upset that you didn’t have her son come back for more therapy after the initial visit, so I sent them over to the local hospital to get some”.

T: “But Dr. I twisted, and poked and prodded him in every which way and couldn’t reproduce any pain or symptoms, nor could I find even any flexibility deficits.  There is nothing wrong with that 16 y/o kids back”.

PCP: “I know that, it’s just business that’s all.  The parents think he needs it so I ordered it, and he will go to the hospital a couple times a week, for a few weeks, and they will be happy then”.*

            The current healthcare system routinely equates patient satisfaction with quality, i.e. doing what is necessary or in the best interest of helping the patient.  Dr. Nortin Hadler calls this “Type II Malpractice” – doing the unnecessary superbly.  Staff training frequently revolves around patient interactions designed to illicit reports of satisfaction.

             Patients may request tests or procedures based on hearsay or recommendations from a friend or family, or more so today, from something they read or saw in the media, such as magazines, television advertisements, or internet sites.  Patients have perceived needs also. Barring any significant risk (known by that provider) of adverse outcome, the healthcare provider is often under pressure from the administration and often inclined to recommend or order such requests, particularly if a dissatisfied patient has ready access to, or can readily choose another provider.  No matter that it is what is best for the patient or necessary.  Unfortunately, most systems not only condone such behavior but encourage it by rewarding it.  Often performance reviews hinge on patient satisfaction reports, and productivity, i.e. units of service provided and billed for.  Rarely, if ever, is the provision of evidenced-based care a criterion for review.  Where it is a criterion for performance, the transfer of wealth is adversely affected – doing less, but what’s necessary, may mean less revenue. 

            Unfortunately, there is irrefutable evidence that the costs of healthcare have been escalating out of control over the last twenty (20) years.  In the case of back and neck pain, the American Medical Association reported in February 2008 that despite a 65% increase in the cost of care, and a 171% increase in the costs of pharmaceuticals for spine care between 1997 and 2005, proportions of the population with spine impairments has increased.  Cutting reimbursements have failed to curtail the spiraling upward cost of care, obviously.  When less is paid, more is done.  Any wonder costs are escalating?  Healthcare system administrators and managers can be regularly heard declaring that healthcare reform must include “access to more services and providers”.  The aforementioned spine patients had access, spent more on care, and got worse results.

Despite the dilemma of ‘do less and get less’ a handful of progressive and forward-thinking organizations are pursuing this option, and seeking to get reimbursed for doing less, but what is necessary, effective, and has meaningful value – true health care reform that will likely lower costs to all of us.

Ed Scott PT, OCS
October 2, 2009