Patient Care and Population Health

Patient Care and Population Health: Goals, Roles and Costs –  free full-text /PMC4207028/ – Aug 2014

We should welcome efforts that encourage clinicians to avoid tests and treatments that do not improve health and thereby waste valuable resources

But we should critically evaluate proposals that assign clinicians the direct double responsibility of

  1. meeting the medical needs of patients while
  2. simultaneously meeting the economic needs of populations.

Why should we be sceptical? For two reasons.   

  • First, shared decision making between a clinician and patient is a unique process between two human beings who come to the clinical encounter with their individual beliefs, values, and expectations

Clinical decision making is therefore always an individualized process based on specific patient and clinician characteristics.

It is not a standardized process, which means it is all the more susceptible to variation for clinical and non-clinical reasons.

  • Second, if clinicians are expected to control costs for populations, they should be expected to do so justly, without favouring or disfavouring care on the basis of anything but a valid medical reason, ethical imperative, or patient preference.

We ought to support systems of care that encourage clinicians to practice quality-driven, evidence-based, patient-centred, and cost-effective medicine.

But we ought to do so without placing on clinicians’ shoulders a responsibility for controlling health care costs in ways that may decrease their advocacy for individual patients as they increase their advocacy for the greater good of populations

A division of labour allows individual patients to have advocates in physicians, and populations to have advocates in administrators and legislators.

And the need for cost control should not by itself be seen as a justification for a role-expansion that would make clinicians directly responsible for controlling costs through resource allocation at the level of individual patients.

If society imposes on clinicians the expectation of the dual responsibility to serve simultaneously as advocates of patient care and overall cost control, we should watch for an attitudinal shift.

In terms of ethics, this shift would represent a movement

  • from the principle of beneficence (focused on the benefit of the patient)
  • to the principle of utility (focused on the maximization of benefits across a population).

In terms of goals, this shift would assimilate the economic goal of cost-containment into the set of clinical goals of care that have traditionally guided clinicians’ decision making.

We should think carefully about the possible unintended consequences that can come with such a shift in attitudes and goals, realizing that what might be measurable as an economic gain could be accompanied by a far-reaching professional loss.

I’ve never seen any opioid policy created while “thinking carefully about the possible unintended consequences” and that has been our biggest problem.

Politicians don’t care about what happens later, only what is happening right now and how it affects their constituents or, more importantly, how constituents *believe* it affects them.

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