Supported by her RWJ scholarship, Dr. Davies collaborated with a medical anthropologist and a pediatrician, following 25 oncology-head and neck surgery patients in-depth, trying to determine how they made decisions about their care. I found that there wasn’t a lot of decision-making going on, she notes. Most patients decide to have something done, then they move in a linear process through the system. I didn’t see much informed consent. The exception was an extreme prognosis, either very good or very bad, leading doctors and patients to make more definitive decisions.
The implications of Dr. Davies’ research are profound for all specialists dealing with oncology patients. Physicians need time to talk to these patients, and they need to be reimbursed for counseling them through truly informed consent. Practically, that would mean changes in CPT coding, a closer look at RVUs, more clinical trials to get a fix on cost and outcomes, and even reevaluating screening for some conditions such as thyroid cancer, which leads to a lot of false positives and consumption of precious resources-patient and physician time and money. Paradoxically, Dr. Davies says that HSR’s broad-brush approach to policy ultimately will improve the stuff we deal with every day. It will help us with obstacles to access, payment and care coordination. Eventually, it will lead to uniformity in care, pay for performance, and getting rid of everything that makes it hard for us to be the good doctors we were trained to be, she concludes.
Despite the private and public funding of health services research, and the brainpower focused on aligning health policy decisions, provider behavior, budgets, and information technology, there are substantial obstacles to system change. While HSR proponents want to be in the vanguard of either bolstering or killing proposals about system change, they face stiff opposition to a more structured health care system. Some of the challenges that the HSR change masters are up against are multiple competing bureaucracies, provider support for the status quo, greater rewards for specialist over primary care, inadequate IT, duplicate and costly regulatory oversight, and too much provider autonomy at the expense of accountability.