Last time I wrote about the appointment I couldn't get, access to care, and how care is not always paid for in a way that incentivizes access. Since then, I've been thinking about why not and about what would work better. What levers can be pulled to incentivize the health care we actually want?
My best friend also sent me a workbook in the mail so that I could "design my life" alongside her. The workbook asked me to step back and reflect on different parts of my life, as well as my identity, and my values, and look for where things are coherent and aligned and where they are not. It then asked me to observe myself day to day, and see if what I was doing fit who I said I was.
In the past, when I've set personal goals for myself, I've tried to measure things. Want to spend more time outside in nature? I'll track how much time I'm actually spending outside. But then, the thing I'm doing becomes the tracking. Tracking my time outside turns my attention to the clock, and away from the whole reason I'm out there in the first place. I miss the bird in the tree, the way the sun is hitting those rocks, the what-is-that-wildflower wonder.
It turns out some of the things that matter most (my phrasing here is intentionally mirroring that of the 4Ms) in our lives resist measurement entirely. They require human stories to understand and time for reflection to integrate and work with.
When we are thinking about what we want healthcare to look like and accomplish (about what outcomes matter), age makes a big difference. For young people- living longer is a reasonable goal across the board. Mortality is easy to measure. As we approach the limits of what medicine can add in years, the question becomes "what do you want to be able to do with the time you have?" The answers are personal and heterogeneous and very often fall exactly in the category of things that resist measurement. Just the thought of trying to categorize and measure and report those as outcomes is migraine inducing.
I've asked some version of the question "what outcome matters to you" more times than I can count. I have heard all sorts of answers. One patient wants to be able to care for his young grandson, since he is the only male role model in the boy's life. Another wanted simply "to watch my westerns in peace" (that one actually was my late grandfather between his dialysis sessions.) One lit up every dinner table she sat at with stories and lively conversation and wanted to keep "telling stories". Another wanted to get back to church with incontinence and hearing issues managed well enough to sit through a full service. None of those answers are cleanly translated from the rich human story to a data point. The care that accomplishes those goals looks a little different for each person in a way that is genuinely complex.
I knew how to get those patients care that aligned with "what matters" because of my decade of clinical training and experience including fellowship training and board certification in Geriatric Medicine. I was able to ask the question and understand the story of who they were and what mattered to them because I had the time to pay attention to them. Appointment time, like access, is a solvable structural problem. Adding checkboxes to existing burdensome documentation requirements to prove to a payor that the provider is asking the right question, however well intentioned, risks taking that time away and having the opposite of the intended effect. This is something we need to be very careful about with outcome or processed oriented payment systems. It also risks undermining the value of clinical training and expertise and the individualized clinical decision-making process.
There is evidence to support the importance of just having the time beyond my anecdotal experience. A study of primary care visit time found that shorter appointments were associated with a higher rate of prescribing potentially inappropriate medications. California saw mortality drop when they mandated minimum nurse staffing ratios in hospitals.
One concession/aside: I do think there is room for innovation in how we assess, track, and report functional outcomes in healthcare. I genuinely believe function is an important link in bridging the gap between what is meaningful and what is measurable later in life and there is work to be done there that can move the needle for older adults.
Fee-for-service gets a lot of blame, and some of it is fair. It has one thing going for it, though: you can understand it. I would love to see more payment models chase that kind of intuitive simplicity instead of a precision that they cannot actually deliver. I genuinely worry that increasingly complex payment structures will lead to increasing opacity that makes it harder for patients and those actually providing them care to understand the system and advocate for what they need. Pay for structure in a way people can understand. Train for process. Measure the outcomes that are universally meaningful and measurable like mortality (and, eventually, hopefully, function). Use them for quality monitoring and feedback as part of a larger scale Learning Healthcare System, but not necessarily to directly drive payments. And keep the measuring itself simple and automated enough that we are not spending more resources on proving care happened (like me comically tracking my nature time) than we spend on the care itself.
The workbook my friend sent me made me sit down and think about who I am and what I value before I could "design" anything. It then asked me to go live that story, come back to reflect and iterate, then do it again. Outcomes-based payment looks like the fair, hands-off answer: pay for the what, not for how. But in practice it falls apart when the outcome you really want can't be measured (so you settle for proxy outcomes that don't actually have the impact on care you thought they would) and it hands over the bigger job of figuring out which structures actually produce measurable outcomes to individual practices (or health systems) and the administrators running them. How do we expect that to work?
So this learning healthcare system (a 20-year-old yet unrealized idea) is a part of what I have been dreaming of instead. Pay for structure. Train processes. Watch and study what it produces, and let that change what structure is paid for next.
I admit that a geriatrician with a life-design workbook is not the same as a health policy expert. Have I fallen out of touch, or does any of this track?
Have you ever gotten lost trying to measure something immeasurable, in your own life or work? Hit reply and tell me about it. I'd love to hear the story.