Engineering Complexity into Healthcare

Dr. Alan Kurose, president and CEO of Coastal Medical, tells Felice Freyer:

My style was always to be a little bit on the slower side and spend more time with people. Watching others do differently and be rewarded for it was disheartening.

He’s therefore happy to see Coastal’s contract with Blue Cross begin to work in financial incentives for doctors to strive for better outcomes for patients. The insurer will calculate savings that the provider achieves by comparing the cost of its patients with the total pool of Blue Cross members and share them with the doctors.  Problems begin to arise in the complexity of the system:

In its previous contract with Coastal Medical, Blue Cross paid the salaries of nurse care managers and pharmacists to work with complex patients, and helped pay for Saturday office hours. It also offered physicians extra pay if they met 10 measures of such things as how well patients control diabetes and hypertension.

Under the new contract, physicians can still get the extra pay for meeting those same standards. Those who meet 7 of the 10 will also be eligible for a portion of the “shared savings” benefit.

Blue Cross President and CEO Peter Andruszkiewicz describes the evolving contract as gradually undoing decades of dysfunction in the system, but it seems to risk a top down dysfunction of its own.  Doctors will ultimately be responsible for patients’ general lifestyles (if they’re obstinate about quitting smoking, for example), but Blue Cross “will monitor patient panels to make sure that Coastal doctors don’t drop or avoid difficult patients.”

Think of the subjectivity and opportunity for numbers games.

One wonders what’s wrong with pay-for-service consumer choice.  A doctor who has better outcomes will have a better reputation.  He or she can then charge more and/or take compelling clients in a mix that suits his or her own ambitions and morality.  Doctors who want to offer more rapid, more cursory care can charge less, and patients satisfied with that level of service can save money.  Perhaps enterprising practices would develop to blend the two methods such that the faster doctor acts in the manner of “first tier” technical support, with patients who require deeper care moving on to the more meticulous physician.

No system will ever be perfect, and objections about fairness ought to have a hearing.  But we ought to be suspicious of a system that attempts to move more and more decisions and interactions into a sort of algorithm by which the human beings who provide and receive care have to fit themselves.