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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Response to "Who Paid" and "Disturbing Preconceptions"
Who Paid?
Disturbing Preconceptions
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David E. Hildebrandt, Grand Junction, CO USA Psychologist/ University of Colorado, Westfall, JM; Smith, PC
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Thanks to our readers for their responses and to the Annals for a chance to respond. We agree with Mr. Savage that a patient’s insurer might be associated with whether they call frequently or use more health services. Unfortunately, for several reasons (e.g. frequent turnover of insurers) we were unable to accurately determine insurer during the study period. We appreciate Mr. Bilcher’s concerns. Medical care can be impersonal, and we understand how patients can sometimes feel like commodities. However, we disagree with some of the misconceptions he inferred from our study. Our paper had three objectives: 1. to describe patients who call frequently after-hours 2. to categorize their medical problems, and 3. to determine how their utilization of health services differs from those of patients who don’t call frequently. We did not intend to study, conclude, or imply why patients call frequently, or whether any such reasons are the “property of the patient.” We agree that many of these patients’ needs may not be well-served by traditional, reactive, office-based practice, which is why we offered numerous alternatives in the discussion that may serve them better. We intended these alternatives as ways to improve care while reducing costs and improving safety, analogous to the newer models of care for diabetes mentioned at the beginning of the discussion. We suspect that “excess demand” reflects dissatisfaction for patients, providers, and payers alike. We vehemently deny that patients are “commodities.” However, although we may not like it, medical services are commodities, which are both limited and expensive. Finding simpler ways to identify patients who are not well served by traditional modes of care despite consuming limited and expensive resources is an important goal for all concerned parties, including patients. We recommend the IOM’s report Crossing the Quality Chasm as a good introduction to complex relationships between non-optimal service delivery, quality, and safety.1 Finally, we’re sorry if any reader inferred from our study that our goal was to lighten the practices’ workload by shifting patients to other settings or excluding them from the practice altogether. Nothing could be further from the truth. In a prior study of after-hours call management2, we concluded that rather than using non-provider personnel to triage after -hours calls, practices should forward all calls to the on-call physician, thereby improving patient safety by avoiding potential delays in care. Indeed, anyone who has attempted to “intervene with targeted education, proactive treatment, and intensive case management” recognizes that these are likely to represent more rather than less work. We hope this clarifies our position and underlying assumptions. 1. Committee on Health Care in America, Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press. 2. Hildebrandt DE, Westfall JM, Smith PC. After-hours phone calls to physicians: barriers that may impact patient safety. Journal of Family Practice 2003;52:222-6. Competing interests: None declared |
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Terence E Savage, Chicago, IL USA Underwriter/Owner Consulting Firm
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One item missing from the study that may have significance in determining frequency of utilization, is the patients insurance. Of the high utilization group, was there any difference in use between those insured with Medicare, Medicaid, HMO, PPO or uninsured? Competing interests: None declared |
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A. Peter Blicher, vacaville, usa consultant
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Although I find the objective findings of this article quite interesting, I'm disturbed by the subjective content of the article. The fundamental preconception is that the reason for frequent calls rests in some property of the patient. That's one reasonable hypothesis. Another reasonable hypothesis is that certain types of problems or patients are not well-served by the usual hours or methods of delivering family health care. As just the first example that comes to mind, many ailments tend to have symptoms that peak at night or near bedtime. Some depend on diurnal rhythms of things like cortisol, which is psychogenically modulated. Poor quality treatment might inappropriately involve a primarily psychiatric diagnosis. In addition, the overall tone of the paper seems to be that it is desirable to somehow avoid the frequent callers, either by sending them somewhere else, or (not stated) identifying them before accepting them as patients. For example, the phrasing "Targeted interventions for these patients may decrease the excess demand" makes the subjective judgment that the "demand" is excessive. Maybe the demand is exactly right in view of the patient's needs, which perhaps are not being met. It is also disturbing that the very phrase "excess demand" is economics jargon. This belies the article's bias toward the commoditization of patients, rather than individualization to discover the specific treatment needs. Unfortunately, it is exceedingly difficult to conduct a study which examines all these factors in a quantitative way. Nevertheless, the presumptions I mention should be avoided without data or an explicit statement that the goal of the study was say to find ways to decrease work load. Competing interests: None declared |
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