Replacing efficient doctors with effective ones

Everyone wants to be efficient.  We want others to be efficient as well.  Efficiency is always a good thing.  Right?  ...not so fast.  In reality, the very last thing you want is an efficient physician.

Efficiency means producing the most or best output using the least input or resources to do it.  "Output" refers to either goods, such as cars, apples, or sweaters, or services, such as dry cleaning, legal support, or medical care.  "Least resources" refers to time, money, and materials.

A worker who makes four sweaters in an hour is more efficient that someone who makes two in the same time.  The automobile manufacturer who spends $10,000 to make a car is less efficient than one who spends only $8,000 to produce the same car.  The dry cleaner who launders the most garments in an hour is the most efficient. 

The one who pays for the goods or services defines efficiency.  In all commercial activities, except health care, the payer is also the buyer or consumer.  Thus, everywhere but health care, the consumer/buyer/payer determines what is efficient and what is not.

In health care, and only health care, the payer is a third party, not the buyer or consumer.  The third-party payer — federal government directly or private insurance — defines efficiency.  What is "efficient" for Washington or for Cigna may not be "efficient" for consumers, also known as patients.

In fact, when Washington is efficient in health care, Americans die standing in line waiting for care.  This is called death by queueing.

"Efficient" spending by Washington produces their desired outcome: power.  That is why every federal "fix" for health care has expanded the bureaucracy and extended government's reach.  Extension of federal control and expansion of its bureaucracy costs money, literally trillions of dollars.  Those are "health care" dollars taken away from patient care.  In other words, what is efficient for government as payer for health care is inefficient for delivery of patient care.

The same disconnect — between what is good for patients and what is good for the payer — is true of insurance companies.  For them, efficiency is making profit.  They do this by not spending money, which results in the "3D strategy": Delay, Defer, Deny payment for care.  That way, insurance companies keep more of the money paid to them as premiums.  So, just like Washington, insurance efficiency reduces patients' access to care.

What is an efficient interaction between patients and physicians?  Typically, hospitals and health plans keep scorecards of individual doctors' efficiency.  The more patients an M.D. sees in a day, the better efficiency score is recorded.  The physician who sees the most patients spends the least time with each patient and therefore is the most efficient M.D.!

As a pediatric cardiologist, my efficiency benchmark was seeing 4.2 established patients per hour.  That's 14 minutes per patient.  Fourteen minutes to take a history, do a physical exam, review records and tests, think about the patient, make a diagnosis, explain the diagnosis and treatment plan, and write out prescriptions.  It takes me 14 minutes just to befriend a young patient enough so the child will allow a physical exam.  Needless to say, I was a very inefficient pediatric cardiologist.

My own personal physician has more than 900 individuals on her patient roster.  She is very efficient.  Of course, it takes 4–6 months to get an appointment, and then you have only 15 minutes with her, most of which she spends filling out forms on the computer.

"Beauty is in the eye of the beholder," wrote Margaret Hungerford in the 1878 book Molly Bawn, paraphrasing Plato's On Aesthetics.  

Efficiency is in the eye of the payer.  As long as a third party and not the patient is the payer for health care, efficiency will benefit the third party and hurt the patient.  

What patients need are effective physicians, not efficient ones.  Patients want doctors who will produce the effect they want: timely, accurate diagnosis, and prompt corrective treatment.

To fix health care, start by focusing on effectiveness and eschew efficiency.

Deane Waldman, M.D., MBA is Professor Emeritus of Pediatrics, Pathology, and Decision Science; former director of the Center for Healthcare Policy at the Texas Public Policy Foundation; and author of the multi-award-winning book Curing the Cancer in U.S. HealthcareStatesCare and Market-Based Medicine. 

Image: Luke Fildes.


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