David A. Asch, MD, MBA
Executive director of the Penn Medicine Center for Innovation at the Perelman School of Medicine and the Wharton School of the University of Pennsylvania, Dr. Asch is an expert on physician incentives.
The next frontier in health care is engaging people outside hospitals and outpatient visits. This is because so many important determinants of health occur outside of these encounters. Even patients with chronic illnesses may spend only a few hours a year in front of a doctor or a nurse; however, they spend about 5,000 waking hours a year doing just about everything else. Those hours are typically ignored by the U.S. health care system. But with the increased emphasis on patient outcomes, hospitals are now financially on the hook, at least partly, for what happens to patients between visits, because what happens to patients in those 5,000 hours is often what most affects the health hospitals are trying to achieve.
How this shift toward outcome accountability affects the world of ophthalmology is hard to determine. The more central question is: If ophthalmologists were more accountable for the outcomes of the care they provide, what would they do differently? Most ophthalmologists, like most physicians, almost certainly think of themselves as being accountable for the care they deliver. But what would it mean if ophthalmologists were much more accountable for outcomes? Today, some patients with glaucoma lose vision because they don’t adhere to their medications. I suspect all ophthalmologists would mourn that vision loss. But many might conclude that, in the end, they did what they could and it is up to patients themselves to take their medications and show up for appointments.
Suppose that instead of glaucoma, the patients had congestive heart failure. Today, if a patient is discharged after a hospitalization for heart failure and is readmitted soon thereafter, the hospital might not get paid for the second hospitalization or might get financially penalized in other ways. But why did that patient’s heart failure get worse? In most cases, heart failure worsens for one of three reasons: a new cardiac event, too much sodium in the diet or poor adherence to medication.
The internist of yesterday might have said, “But those things aren’t my fault; how could I prevent new heart attacks, prevent my patients from eating salty foods or make sure they take their medications?” But if you are accountable for care, then you have to find a way to do exactly that. Maybe some of the efforts we direct toward innovation in surgical or medical therapy — innovations we deliver in office visits and hospitalizations — might be redirected toward approaches that make it easier for patients to take their medications at home. And if that happens — say, through the development of glaucoma drop bottles that are easier to use or paired with systems that remind you to use them — maybe it won’t seem so impossible for physicians to accept accountability for the very outcomes their patients seek.
These thoughts aren’t meant to be preachy or sanctimonious. Because so many things affect health, it can seem unfair to suggest that physicians be accountable for all of them. But some of the important health-improving activities physicians feel are out of reach might actually come within reach if we set our minds to them and if we faced incentives that made us accountable for them. That is indeed a new frontier. And it is an exciting one.
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