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No more “partialty” care in healthcare: Fighting fragmentation at the clinical level

We are rerunning this post as more and more news events are drawing the attention to healthcare costs. Let us know what you think.

The current healthcare system is inherently fragmented with all the various pieces vying for attention.

The attention of you.

You see,  it is well established that we as individuals do not present with just one problem – we are not just our depression or our diabetes, but rather we are wholes. But yet we often enter into healthcare expecting that there is one person to take care of this health condition and one person there to take care of that condition.

And so we, those of us in healthcare, often draw attention to how important it is that pieces of you are taken care of. We make you know that there are experts to take care of the pieces.

No matter what your ailment – have no fear, there is a healthcare professional for that.

But we know that humans are not as fragmented as our healthcare system. Consider a recent study published on the relationship between diabetes and depression.

“Tackling depression and diabetes together in primary care is more likely to get both under control than approaching them separately, researchers found. An intervention for integrated care in primary care practices got 60.9% of patients with both conditions to the hemoglobin A1c goal compared with just 35.7% of those in usual care (P<0.001).”

We do better when all aspects of us are addressed simultaneously. In the face of studies like these (and there are many more studies to support addressing mental health and medical conditions), the question that continues to come into my mind is why are we not expecting more comprehensive care? Have we become so used to accepting pieces of us being addressed that we forgot that it is our “whole” that really needs attention?

While an extreme example, the video below begins to point out the ridiculousness of “partialty” care in healthcare (you will see an underlying financial theme here too).

Those of you who have routinely viewed this website know that this parody is also taking a direct shot at hospitals and their underlying business model. We know that the current business model is in need of disruption. However, it is this model that support the ongoing fragmentation in healthcare. It is this model that supports “partialist” care rather than whole person care. Healthcare costs are often based on who does what, how quickly and where on you. To have a better sense of why healthcare is in the situation it is in, one needs look no further than an economist named William Hsiao.

“William Hsiao developed a scale to measure the relative value of every single one of the thousands of services provided by doctors, a job later compared to measuring ‘the exact amount of anger in the world.’ For example, Hsiao’s team deemed that a hysterectomy required 3.8 times more mental effort and 4.47 times more technical skill than a psychotherapy session. In 1992, Medicare formally adopted Hsiao’s concept; private insurers followed suit. Today, this relative value-based system sets the prices—and therefore drives the priorities of American medicine.”

You see, Hsiao’s scale began to relegate certain providers into categories according to their Relative Value Unit  (RVU) status. The problem of “partialty” care in healthcare was born.

Essentially when we talk about volume vs. value in healthcare we inevitably bring up the issue of RVUs.

From an excellent Kevin MD article on the subject:

“Boston Globe columnist Sam Allis talks about the issue, and interviews a few select Harvard physicians about its (RVUs) flaws. Physician-author Jerome Groopman, of How Doctors Think fame, rightly notes that the system does not value some of the truly important things that doctors do: ‘There are no RVUs for spending an hour with a grieving family, or a colleague who wants you to lend him your brain on a case. There are no RVUs for sitting with a confused third-year medical student. There are no RVUs for the humanistic core of medicine that drew me into this profession in the first place.’”

And again we are back to partials. How can a healthcare system be expected to take care of the whole person and all their needs when that system is judged and paid according to units of service and things like relative value units? Changing this mindset, this approach will be a significant challenge for healthcare for years to come.

Because who really wants “partialty” care?