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Saturday, June 25, 2011

Allocation of the scarcest resource of all...time

I am a fan of Robert Centor's blog, DB's Medical Rants. I think the title is somewhat misleading since I view a rant as the product of simply blowing off steam. Dr. Centor's "rants" are almost always more thoughtful and provocative than the term rant would imply. In a recent piece, he makes a link between time and cognition:
A recurrent theme here is time.  One must take enough time to take a history, do a physical exam, and consider the problem.  Cognition does take time.  Cognition can save money.  If we paid cognitive only physicians for their time, perhaps we would need less tests.

If the health care system is to be efficient and provide value, it should provide incentives to optimally convert time expended to value to patients. In this realm, it fails miserably. Dr. Centor's astute observation is just part of the puzzle.

Let us think about other scarce resources and how mechanisms in place drive us to wise use of them. The reality is for most scarce resources scarcity is local. That is why market allocation mechanisms work better than all other approaches. Markets can react to local conditions to place value on specific items. Take water for example. There is little premium paid for fresh water in Minnesota but a marked premium which may be required in Death Valley. If water prices were set administratively as prices are set in much of health care, there would be no way to appropriately price water in both contexts. Undervalue water and it simply would cease to be available in the desert. Overvalue and people would overpay where there is no scarcity. 

How can this be applied to time and in particular time within health care interactions? How is time valued within health care? It depends upon whose time we are considering. From a physician's perspective, the return on his or her time investment depends upon a payment system which is divorced from the value actually actually delivered to specific patients. For me, I almost invariably see time committed to thinking about what I am doing translating to lower rates of financial return. Think more, lower your income.

As Dr. Centor notes, cognition is associated with saving money but the issue is who benefits from this? The sad reality is given the present payment scheme it is not the physician. For the most part the more I reflect upon what I do, the less I will test and intervene. My own practice experiences may provide evidence in only a narrow clinical realm but I suspect this conflict of interest permeates throughout the entirety of practice. The more one uses one's brain, the more these fundamental conflicts become apparent. Granted a specific patients may fulfill data driven (or more consensus driven) criteria for a particular intervention, but does this patient really benefit from colonscopy, angiography, stents, MRI, breast biopsy, prostate biopsy, skin biopsy, chemotherapy, CAT scan, ultrasound, PSA, or whatever? More specifically, is it worth my time as a physician to invest the time to even raise these questions? From a financial sense the answer is unquestionably no. Going farther I will venture to say that too much cognition in this realm is financial suicide.

Thinking may deliver value to patients but use of cognitive tools will be an increasingly rare event if deployment of these tools rarely rewards (or event punishes) those who use them. One would think that a payment system which creates a scarcity of cognition would also allow for some sort of escape mechanism. Unfortunately, patients are generally not in the position to deploy their own resources to reward cognitive work. Until recently, physicians simply could not accept additional monies outside of the conventional payment system unless they withdraw entirely. Retainer medicine has provided an alternative model. For most physicians, it is simply easier to focus on narrow high margin medical interventions and cultivate the strategic incompetence which allows them to avoid substantial cognitive work. Oddly enough, it is the innovators who have struggled to maintain the importance of cognitive approaches  through retainer medicine who have been criticized for not living to up to their obligations to society. How ironic to be victimized both my the payment system and for their attempts to deliver what delivers real value to the public.

For time to be valued, it has to be valued by those who derive value from it (patients) in a way where the value of specific time blocks is context specific. One size will not fit all. The IPAB will get it wrong more often than it gets it right, much as the RUC before it. Rational and imperfect people will respond to incentives built in and the behavior of the few physicians who most successfully game the system as it relates to investment of time will quickly spread to become the norm, well before any command and control system can respond.

In an ideal world patients with problems best addressed by with action will be able to find physicians of action and patients needing a more cognitive approach will have access as well. The value of the respective approaches is dependent upon the context. The question is how do we get there?  Markets are the best tools now available to respond to the value question in a context specific manner. Until the market deniers in health recognize this, time as well as all other scarce resources in health care will be squandered.

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