Regular readers of this blog know about my opposition to the now entrenched third party payor process of even routine health care costs in the U.S. health care finance system.

Removing the consumer from controlling the complex decisions that go into paying or attempting to avoid such costs has had far-reaching consequences, not only on the cost of health care, but also on the way in which consumers view their responsibility in regard to maintaining their own health.

I was reminded of those implications recently when I came across this Pauline Chen/NY Times article on the vagaries of third party payors compensating doctors based on patient performance, and this Happy Hospitalist post on the difficulty of telling a patient who is expecting a cure regardless of the cost that the doctor really doesn’t know what’s wrong with with the patient.

These items prompted a friend of mine – first-rate hospitalist and internist – to pass along his experience on the unrealistic expectations of many patients:

Here is an insight into what the practice of medicine has evolved into.

Because hospitals and other corporate organizations are so focused on "customer satisfaction" these days (with Press-Gainey satisfaction survey scores and the like), the opinions of persons like the one the Happy Hospitalist describes get far more purchase than they have in the past.

Often times, I see drug-seeking persons like this get all the testing and all the Dilaudid they want (bad medical practice on multiple levels) because a doctor may not want to set himself up to get "dinged" on a patient survey – some places tie physician bonuses to patient satisfaction scores – some docs even get fired for bad scores.

And, unfortunately, patients like this are not a rare occurrence.  I see at least one or two every week I work in the hospital. 

I had a patient tell me, "Screw you" last month when I suggested that she might have a bit more money for medicines if she were to stop smoking two packs of cigarettes per day. This is after I had admitted her for treatment of accelerated hypertension and uncontrolled diabetes, found her previously undiagnosed high cholesterol, and got those all under control with medications she could get through the WalMart $4 program. There was no "thank you", and certainly no payment to me or to the hospital for our expertise.

It’s really disappointing to see how frequently the patient-physician interaction has deteriorated into something like this.  I guess that other professions are subject to similar abuse, but I don’t see any other examples as severe as what I am seeing in medicine.

I’ve always thought that the best approach is to do what’s right for the patient, even if it is not necessarily what the patient wants.  In this current climate, this has at times put me at odds with hospital administration.

What do you think Walt [my late father] would do if faced with this deterioration of patient-physician interaction?

I think my father’s reaction would be the following:

1. When you remove from the patient the responsibility to pay – or at least contributing to pay — for their health care, patients tend not only to become more irresponsible regarding how they spend money for their health care, but also less interested in understanding how to avoid those costs.

2. Doctors share a big part of the blame for the foregoing problem because they encouraged (and previously got rich by) over-billing of third party payors who insulated the consumer from the cost of health care. Now those chickens are coming home to roost.

I continue to believe that the solution to these problems is not by adding complexity to the health care finance system. Rather, take away insulation of routine health care costs and require consumers to pay those costs, allow insurers to provide true insurance for catastrophic illness or injury and use government as a reinsurer of true health insurance and an insurer of last resort for folks who cannot afford health care or private insurance. Allow such a system to develop over a generation or two and we might bring some semblance of consumer education and price stability through market forces back to the health care finance system.

But I’m not counting on it.