Health Services Research: Trying to Fix a Broken System

Making Sense of It All

When Louise Davies, MD, MS, Assistant Professor at Dartmouth Medical School and Chief of the VA Outcomes Group in White River Junction, VT, sees two patients, one with a T2 and the other with a T4 esophageal cancer, she thinks not only of the clinical picture but of what kind of insurance coverage each one has. Often the T2 patient has wonderful insurance and the T4 patient has none. While many other otolaryngologists and head and neck surgeons might also wonder if the T4 patient is uninsured or underinsured, Dr. Davies, a former Robert Wood Johnson Clinical Scholar, has the tools to see poor clinical outcomes resulting from a broken health care system. The Robert Wood Johnson scholarship allowed her to get a close view of how patients move through the health care system, how they make choices, and how specialists dealing with oncology patients can make that an informed journey (see sidebar).

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.