Posts from 2017-09-11

The Folly of “Population Medicine”

“Take care of the patient,” directed my chief resident. “In the ER—he needs you.” My fifth admission for that 36 hour call cycle, and I was tired. Yet those words are as clear to me now as they were 3 decades ago in that post-call afternoon at Detroit Receiving Hospital. “Take care of the patient” is still my care-style and professional reputation, one patient at a time.

Vexingly, in this week’s version of our overseers’ mandates, they direct us, “Take care of the population.” What exactly does that mean? I think it means that once we all work for large employers, who aggregate our little-guy data, we might get paid if our data looks good enough? Big medicine pays little-guy PCPs in their little medical homes based upon “quality measures.” We should collect our “quality measures,” and are expected to change patients’ bad behaviors and habits, and become accountable for their actions and inactions. Is this what we want to do for a living?

Fortunately, in concierge medicine we work for patients (as opposed to third party payers) and can practice the right kind of medicine for each patient. From a business standpoint, insurance pocket change isn’t worth playing the population game. Realizing the folly of population-care, I sleep fine at night when a patient ignores my advice. He is responsible for his own life. My income does not derive from his decisions. If he makes bad choices and generates bad data I’ll do my best to help, but the real change needs to come from his side of the equation. At a recent EHR-sponsored happy hour, one population-incentivized PCP said it nicely, “Noncompliant patients—I just get rid of them. They (noncompliant patients) can eat what they want to eat and do what they want to do, but I want to get paid—so I get rid of them.” Concierge medicine is a better solution.

Payers have pushed physicians into the “you are responsible for your patients’ actions” trap. In today’s iteration of “best care,” doctors are expected to identify and allocate time and money to identify “at risk patients,” all to improve medical practice outcome data. Make no mistake, insurance work is a fixed-sum game, and individual doctors will ultimately pay to pay this game.

In Concierge Medicine we take care of the patient. In my practice, many of those were cast-off by population-treating doctors and their staff. Once in my practice, do the noncompliant suddenly comply? Usually not, but they appreciate the respect they receive, improve their life’s quality, while receiving much better, individualized care. Some smoke too much, drink too much, and-or eat too much. I don’t take on their life’s burdens and expect their numbers to improve. I do my best for them. In my concierge internal medicine practice, if the outliers’ numbers don’t improve, I will still be paid just as much, as I should. It is a lesson in futility for PCP’s to assume their patients’ risk. Collecting data, checking boxes, and groveling for a better performance bonus—who needs it?

Individual doctors cannot generate a generalizable data set. The n-size is simply too small. Bonus payments based upon doctors generating individual data that betters aggregated data will encourage doctors to lie about the data, cherry-pick patients (an insurance company favorite), and to throw out the outliers, AKA get rid of “bad patients.” As I learned in my research fellowship, “garbage in, garbage out.” Population data can only be as good as its weakest link—and there are plenty weak links! If population data looks valid, it won’t be.

The population health story is yet another Emperor’s New Clothes fable (1). The population idea has gained traction such that we all are expected to believe this idea; Like the emperor’s clothes, we should see how wonderful the nonexistent clothes/worthless ideas are—or we are fools! The concepts and PCP busy-work looks pretty to leadership, just as the emperor’s clothes looked pretty to his admirers and to him. In truth, there really isn’t anything to see. It will take decades for payers to realize individual patients generally cause their own poor outcomes, and that micromanaging doctors will not change patient behavior in the long run. PCP burnout and PCP shortages will be the collateral damage for our leaders’ misguidance.

In Concierge Medicine we take care of each patient, in times of sickness and health, and in times of good data and bad data. In Concierge, we guide our patients, and we let them make their own decisions. We respect our patients for who they are, along with their strengths and weaknesses. At days’ end, we take care of real people, not data sets. Keep up the good work!

1. Andersen, Hans Christian; Tatar, Maria (Ed. and transl.); Allen, Julie K. (Transl.) (2008). The Annotated Hans Christian Andersen. New York and London: W. W. Norton & Company, Inc. ISBN 978-0-393-06081-2.

John T. Kihm, MD, FACP

Director, ACPP

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