Restoring the trusted patient-physician relationship.
Human nature and history provides ample solutions for successful motivation and action. In Fixing the primary care system after the COVID-19 pandemic, Medical Economics, July 2022, pp 24-25, Timothy Hoff, Ph.D. made some excellent observations, good points and opened a critical dialog for bettering medical care. In this article, I take his strategic blueprint for fixing primary care to a more detailed level to achieve our mutual goals, elaborating using quotes from recent writings on these issues by myself and other experts.
The main goal of this plan is the pride of ownership for both the patient and the physician.
1. Patients must own their health. Individuals have an intrinsic right to own themselves and their bodily autonomy. Individuals must be responsible to themselves for their state of health and health outcomes. They must choose and pay. First dollar costs must be their responsibility from the outset. In this way, patients learn through natural consequences to do routine body, mind and spirit maintenance and be attentive to issues as they crop up. This is the pride of ownership. “People spending more of their own money on routine health care would make the system more competitive and transparent and restore the confidence between patients and the doctors without government rationing,” states Benjamin Carson, Jr, MD, retired pediatric neurosurgeon. Patients must choose physicians and services with their own individual unique value systems and, “buy-in,” literally and figuratively, for them to be motivated to take appropriate action
2. Patients must have informed consent to review, accept or deny ANY service, treatment or medication. In the recent past, experimental interventions have been forced by government, employers and schools on both individuals and the public at large. There was no informed consent acceptance of risks, benefits and understanding of alternatives. “In other words, patient-centered medical ethics demand that you have the right to understand and choose each unique intervention separately based on its own merits and risks.” (Craig M. Wax, DO, Physician Outlook, August 7, 2021.)
3. Physicians must own their practice businesses. They must be responsible to themselves and patients for ethical, efficient and effective practice. This too, is the pride of ownership. This would restore the patient-physician therapeutic relationship. Both parties dealing directly with service and payment, eliminating pirating middlemen, and extraneous noise. “Solo and small physician practices were increasingly put out of business, and hospitals hired physicians to serve the mighty electronic data masters —government and third-party payers.” (Craig M. Wax, DO, KevinMD, November 7, 2019.) “Give payment control to the primary care physician and the patient,” says Timothy Huff, Ph.D. Incentives for patient and physicians align when patients choose and pay, and physicians own their own practice business. Both parties are responsible to each other for the service and the outcome in direct care.
4. Cut out the middlemen. Eliminate unnecessary layers that are costly, bloated and divert the focus on the individual patient. Third parties, like managed care insurance, pharmacy benefits managers (PBM), and government programs, must steer clear of interfering in medical decision making and violating patient and physician privacy. PBMs, for instance extort drug manufacturers for kickbacks, disguised as “rebates,” which are rendered legal by the federal government for decades. For details on these schemes see, “America, its pharma middlemen, and legalhievery,” by Marion Mass, MD, Courier Times, May 5, 2021. True insurance is urgent but managed care is insurgent and divergent. “True insurance is an inexpensive tool to curb catastrophic financial loss. But government regulations prevent its sale, and we are left with junk plans with narrow networks that are more expensive than ever. There should be as many health insurance options as the industry can dream and patients will support.” (Craig M. Wax, DO, in Eliminating the 6 degrees of patient-physician relationship, Medical Economics, August 22, 2016.) Especially in primary care, when patients pay directly in fee for service or direct primary care, the care is inexpensive in cost but worth its weight in gold for prevention and treatment.
5. The free market offers the most simple solution to the issues that challenge our entire healthcare system.” (Craig M. Wax, DO, Free market: The answer to health system woes, Medical Economics, June 25, 2012). “Free market, posted prices can prevent sticker shock.”(Craig M. Wax, DO, Medical Economics, June 10, 2012.) Competition brings quality up and prices down by the nature of the economics of capitalism and consumerism.
6. Physicians, their groups and affiliated businesses should be able to own hospitals. Laws and Medicare regulations enacted over the last fifty plus years prevent physicians from owning and running hospitals. The so-called “Affordable Care Act,” of 2010, Section 6001, added new regulatory restrictions and requirements for physician-owned hospitals. See 42 U.S.C. § 1395nn(i). Currently, both giant for-profit and non-profit companies own hospitals. What makes huge monopolies and oligopolies in a service area more responsible, efficient and economical than an invested physician owned medical center? Physicians have significant professional, and personal interest in patient medical care, and significant liability as well. They would be the best to share a financial interest as well, given their investment and liability.
We must all recognize that government and third-party entities have intruded on the patient-physician relationship, wreaking havoc and exponentially raising costs over the last half century. Profiteers like the American Hospital Association (AHA), American Medical Association (AMA, owners of CPT coding system), Pharmaceutical Manufacturers of America (PhRMA), Blue Cross/Blue Shield Association Insurance and the American Association of Retired Persons (AARP) are among the top spenders for congressional lobbying in recent years. Conflicts of interest abound. They write the laws and pay the politicians to execute them on all sides. It has been asked, for instance, “why do PBMs exist?” The answer is, “because political campaigns are expensive.”
“When I became a physician, I made an implicit commitment to deliver quality care to all of my patients. I will never be able to deliver on that promise until the middlemen are cut out and physicians’ voices are leading our health care system,” explain Gary Price, MD, and Timothy Norbeck, PBMs Driving Up Costs and Lowering Quality Care in America, Forbes, August 22, 2019.
In summary, it is long past time to restore the patient-physician relationship by the pride of ownership:
As a proper health investment advisor, a physician should have a fiduciary relationship directly with the patient to assure moral, ethical and effective care recommendations are rendered in an efficient, cost effective and timely way. This is true shared decision making at its finest. Third parties and government entities destroy the privacy, responsibility and benefits to both parties. (The Patient-Physician Relationship is a First Degree Interaction, Physicians Outlook, October 1, 2020)
Craig M. Wax, DO, is a family physician, health policy expert and media host. He served on the Medical Economics Editorial Board from 2009-2016, and wrote editorials for the journal since 2002. Dr. Wax served on the National Physicians Council on Health Care Policy (NCPHCP) in Washington DC from 2015-2018 at the request of Congressman Pete Sessions of TX. Dr. Wax was the host of Your Health Matters, a health interview show, on 89.7 WGLS-FM for twenty years. He created HealthIsNumberOne.com in 1999 to share good health information with the public. Follow him on Instagram, Truth Social and GETTR @DrCraigWax, and on Twitter at @HealthIs1.