By assessing physicians using quality of care indicators, the payers have succeeded in changing physician behaviour using methods ranging from simple feedback and peer pressure, to the use of financial incentives. 6 The payers look for indicators that are easy to measure such as laboratory data, and not necessarily what is important to measure, such as time spent with each patient. In the name of economic utility the payers, who might be health maintenance organisations or health ministries, have adopted a ‘one suit fits all’ solution based on epidemiological data. In order to satisfy their stakeholders, the payers together with our professional organisations have developed quality of care indicators that are now driving medical care in the community at the expense of individually tailored medical care. Ethically we should be listening and be guided by the patients’ agenda but in daily practice this is unfortunately not necessarily the case. 5 We physicians see the tears and hear the patients in their daily struggle. 4 The statement that ‘Health statistics represent people with the tears wiped off’ has been attributed to one of the fathers of epidemiology, Sir Austin Bradford Hill. This change together with the sets of biometric data that are being collected by the payers on all the patients are an unprecedented change of the doctor–patient relationship and constitute a paradigm shift. The payers make decisions on health policy based on epidemiological data and can’t take into consideration the specific needs of each patient. The payers’ interest is not necessarily the same as that of the patient sitting in the physician’s clinic. The increasing costs of new technologies 3 and the ageing population have made the promises of full universal health care very challenging as the payers collect data in their effort to try to keep the costs under control. In most people’s minds health was simply the absence of illness. There was no mention or thought given to quality of care provided, the assumption being that the physicians would do their best. 2 However, this did not much matter because modern medicine was in its infancy, the populations were younger, and medical technologies relatively cheap. The benefits of universal health coverage for the citizens were explicit and defined in the Bismarck model 1 they were vague and implicit in the Beveridge model. In the brave new world after the Second World War many countries developed models of universal health coverage. The payer may be the government through a mixture of taxes, employer contributions, and national insurance, or they may be an insurance company or a health maintenance organisation. In the past, the payer used to be the patient and the relationship was clear now we pay indirectly. I don’t want to idealise that situation but there is no doubt that the relationship was a private interaction based on trust. Before the Second World War most individuals had a physician who was responsible for their health from cradle to grave.
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