Vascular Experts Need to Embrace Health Advocacy as a New Discipline of Medicine
Guest blog post by Ibrahim G. Eid. MD, FACS
It is time for vascular surgeons, interventional cardiologists, interventional radiologists, and cardiovascular surgeons to embrace health advocacy as a new discipline of medicine. It is a fact that when patients seek second opinions in cases of major issues like cancer or major surgery, the second recommendation is likely to differ from the original one in around 30% of the cases. In numerous studies about decision aid support, patients given a brochure to read about their choices tend to opt out of surgeries at least 20% of the time. These studies were conducted in centers of excellence, where abuse and overutilization are assumed to be absent and the margin in a real-life deployment could be higher. Given third-party credible education, patients often steer their care from the direction chosen by their treating physician.
It is naïve to think that financial gains are the only influence on a physician’s recommendation. “High volume” physicians gain respect in the medical community and get direct and indirect power and other leadership roles in hospitals and medical groups. In addition, and for surgical specialties, the “easy” cases which tend to produce good outcomes and happy patients are necessary for the statistics of the surgeon, as they provide the denominator over which complications are counted. It is these easy and safe cases that often may not be necessary to the care of the uninformed patient and that add to the inflated national health care bill.
One would assume that health care reform with pay for performance and the return of “capitation” from the back door could protect consumers and patients from non-necessary care but this does not undo the incentives mentioned above, and the opposite may be happening in some cases. Hospital chains are buying physician practices at unprecedented rates and physicians are now incentivized to “feed” patients to the expensive hospital programs and “cost centers.” In pure capitation models, patients may suffer from underutilization as the system is now incentivized to reduce expenditure. In addition, health care systems are becoming contractual closed systems and patients may never be informed about care options that may suit them better and that are outside of the network. The need for health advocacy has never been more acute.
It is disappointing that the medical profession has failed to recognize what businesses and industry have, because it is the profession society trusts to provide every citizen with the care that is best for him. Health advocacy is a billion-dollar industry serving employers, consumers, and insurance companies alike, and has been populated by nurses, social workers, and now computer software, but rarely physicians. It lives in a parallel universe to the medical one and this has consistently eroded its value. Many studies support what we all know: When patients are facing major health decisions, the most powerful source of information for decision making remains the physician, followed by friends and family. None less than a credible specialist will empower a patient to question his treating physician.
It is the physician who should advocate for the patient by providing the knowledge to make decisions, both on the medical level and the consumer level as well. The patient should understand that not all physicians and hospitals are created the same, and should be empowered to ask questions about medical choices, but also about surgeons or hospital’s volume, outcomes, cost, participation in outcome registries, and board certification and accreditation status.
Until health advocacy shapes up as a discipline of medicine, where a physician can dedicate time to learn the skills necessary to provide information support and gets reimbursed separately to perform that important function, matching the right treatment to the right patient and the right setting of care will remain as accurate as a roll of a dice.
The above is a challenge and an opportunity for vascular specialists. Vascular conditions are ideal "preference sensitive" conditions, defined as conditions where multiple options are available for treatment and where physicians often are not sure or disagree about the best treatment plan for an individual patient. In these cases, it is unfortunately the specialist who picks the treatment for the patient, often blinding him to other possible treatments or to the fact that no treatment is an option like in the case of claudication, abdominal aneurysms, or carotid disease. It is in dealing with these decisions where the patient needs to be empowered with knowledge that is free of self interest or bias and reflective of transparency about clinicians background and level of training and experience. Vascular specialists should be leaders in "shared decision making" where patients are placed in the decision driver's seat and in transparency relating to other options or skill sets, and this can be achieved by creating a network for third-party education provided by specialists who are engaging patients as educators and advocates and not as providers of treatment or second opinions.
Editor's note: Ibrahim G. Eid, MD, FACS, is chief of the Prima CARE Center for Vascular Diseases, Fall River, MA, and chairman of the department of surgery at Saint Anne’s Hospital, Fall River, MA. Dr. Eid is the President and CEO of Expert Medical Navigation.
