When saying yes means saying no

The US is in the next chapter of how build and finance our sick care system. It is a game of trade offs, with one side willing to trade off access while the other side is willing to trade off cost. In the meantime, quality is getting lip service.

In their book, Getting to Yes, Fisher and Ury stress that you define your interest and be flexible in your position. If our interest is in creating sick care system that optimizes access, quality and cost, then all stakeholders will have to learn to say no to get to yes:

Payers will have to say no to paying for ineffective interventions

Product developers will have to say no to price gouging and me-too products

Policy makers will have to say no to getting re-elected instead of doing the right thing

Patients will have to say no to insisting that their doctors do certain things

Providers will have to say no to prescribing things that are harmful or ineffective

There are many overt and covert ways doctors "ration" care:

1. They refuse to see patients who can't pay.

2. They ration by inconvenience, making it so hard to access their services that you give up trying. In the case of the VA, long waiting lines get public attention. Private waiting lines and lack of access, not so much.

3. They do things, knowingly or not, to a certain subset of their patients, based on gender, race, ethnicity or level of obesity that they would not do for others, contributing to health disparities.

4. They don't learn how to use new technologies that are more cost-effective.

5. They knowingly or unknowingly prescribe drugs that the patient can't afford.

6. Surgeons schedule surgery only on days that are convenient to them (mostly on Tuesday) but inconvenient for the patient. The result are no-shows

7. They open practices in favorable geographic areas rather than underserved or rural areas.

8. They go into specialties that generate the most revenue rather than serving a community with the most need for generalists.

9. They use inefficient practice management systems that discourage consulting them.

10. They self-deal or have conflcts of interest that create a motivation to ration a particular resource or they are part of a system that pays them for "value" that is often a smokescreen for cutting spending.

Here are some tips on how to say no.

The central, intractable obstacle to long-term cost containment, some contend here, is the near impossibility of saying “no” to ever-more-expensive care that yields small marginal benefits. Public and private payers have made myriad unsuccessful attempts to surmount this barrier. The authors propose, instead, to circumvent it—through redirection of cost-control policy away from efforts to limit use of existing, low-benefit technologies and toward strategies for influencing the emergence of new technology. To this end, they urge: redesigning value-based payment to emphasize future rewards for tests and treatments that haven’t yet emerged, and varying the duration of intellectual-property protection so as to tie its rewards to therapeutic effectiveness.

There is power in a positive no. The sooner we all learn it, the better.

Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs