Like many other doctors, patients, and President Obama, I've been thinking about Atul Gawande's brilliant piece in the New Yorker on the root causes of spiraling health care costs in the U.S. One aspect that has not yet been given enough air-time is what role patients should play in this discussion. Gawande describes a thought experiment performed by him and a cardiac surgeon:
A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they're supposed to haggle over the price as if he were selling a rug in a souk? "I'll do three vessels for thirty thousand, but if you take four I'll throw in an extra night in the I.C.U." -- that sort of thing? Dyke shook his head. "Who comes up with this stuff?" he asked. "Any plan that relies on the sheep to negotiate with the wolves is doomed to failure."
I'm not naive enough to think that we will do well if patients negotiate on price for how many of their coronary arteries should get un-clogged. And while few patients are ready to use a microscope to diagnosis their own Crohn's disease, those that do should remind us who has the biggest incentive for sustainable, high quality health care. It is critical that patients be a part of this conversation.
When the best treatment is well understood, and should not vary by the patient's values or preferences, then our traditional paternalistic system works well for many consumers: Doc, tell me what to do, and let's do it. However, in the many cases where the best data says there are two or more equally good options -- e.g., whether to have surgery for low back pain -- then we need more innovation and thought leadership on how to have these conversations effectively. How do patients best understand risks? How can we organize data about effectiveness of treatments for the top 100 conditions so that average doctors can keep up and discuss options with their patients? These are solvable problems.
It is awesome that Peter Orszag himself (Director of OMB) offered a thoughtful and data-rich response to Gawande's article on the official Whitehouse website. Let's also keep front and center the need for the consumer to be part of the conversation, and that doctors and patients alike need better access to basic data about what works and what doesn't. Doctors should increasingly expect patients to ask: "What is the likely outcome if we choose this option?", and patients should expect an answer.
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