Obama wants to tie doctors pay to quality starting next year

[jdh71]

If you were anyone else I'd bait, but because you're you I'll just be up front and say that was some trolling sarcasm.

Obama? More like Obameh, amirite?

Well. Now. That's an alligator roll you just saved me and the group. This should probably be a lesson on how to handle such matters in here.

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[midweststudent1]

Also, the idea of taking only 600 patients is appealing, but the guy who originally started the first concierge practice, MD Squared, has already said that if enough physicians start doing that, we'll lose public opinion and then be subjected to laws requiring quotas or other commu- *cough cough* I mean socialist agendas. (Dr. Howard Maron was quoted in an article on the ethics of concierge medicine recently; I googled but can't find the article again).

I think if doctors start taking only 600 patients, the general public will DEMAND that they're covered that way also. These doctors guarantee 30 minutes minimum for an appointment and at least an hr per yearly appointment. They're available 24 hours a day by phone call, email, FaceTime, anything. They make house calls at no additional fee. Whether it's needing stitches or coming in for a blood pressure screening--it's all covered under their (very reasonable) monthly fee. It's the best way of caring for chronic illnesses because they actually establish a relationship, and it's very effective preventative care, because people can get the attention they need.

And best part? Keep the $$$$ between only the patients and the doctors---none to/from the government or insurance!!

 

[VisionaryTics]

I also think an interesting free market experiment is the Surgery Center of Oklahoma, which is completely physician-owned and lists its prices on the website ahead of time. $200 pre-surgical appointment, nonrefundable. The rest is the doctor fees (surgeon + anesthesiologist) and the facility fee. When you click on the fine print, it does say that any additional labs or imaging will have to be paid for as well by the patient and aren't in the listed price, but their prices look pretty doggone reasonable to me:

http://www.surgerycenterok.com/pricing/

Holy **** some of these prices are crazy.

$1600 for a frenulectomy? $1700 for bilateral ear tubes? $1900 for closed reduction of nasal fracture?

I wonder how much the surgeon makes for each of those.

 

[fancymylotus]

Holy **** some of these prices are crazy.

$1600 for a frenulectomy? $1700 for bilateral ear tubes? $1900 for closed reduction of nasal fracture?

I wonder how much the surgeon makes for each of those.

our oral surgeon does frenulectomies, I should start lurking in his op when he's working and then try doing them myself.


(Totally kidding)

 

[Jabbed]

Other than a emotional inflammatory response, can you provide what metrics constitutes being crappy?

Crappy doctor = not being able to cure malignant hypertension, diabetes, chronic organ failure, or pain syndromes in one office. Also, asking patients to make lifestyle changes is an alternative route to achieving a similar level of crappiness.

 

[RJGOP]

our oral surgeon does frenulectomies, I should start lurking in his op when he's working and then try doing them myself.


(Totally kidding)

Well there have been dentists who performed breast implants and other surgeries, so performing a frenulectomy wouldn't seem so egregious. I say go for it.

(Somewhat kidding)

 

[fancymylotus]

Well there have been dentists who performed breast implants and other surgeries, so performing a frenulectomy wouldn't seem so egregious. I say go for it.

(Somewhat kidding)

I would rather push papers around on my desk and drink my chai while complaining about my life on sdn, instead

 

[RJGOP]

I would rather push papers around on my desk and drink my chai while complaining about my life on sdn, instead

Sounds fun. Earl Gray is better than chai btw, and so is coffee. But I bet you don't drink cofee since you're a dentist. Gotta protect those pearly whites.

 

[fancymylotus]

Sounds fun. Earl Gray is better than chai btw, and so is coffee. But I bet you don't drink cofee since you're a dentist. Gotta protect those pearly whites.

No. I'm brown. Chai all day everyday. And always through a straw. Bc teeth. The few times I get stuck with crappy coffee, I also find a straw. Same for red wine.

 

[WhippleWhileWeWork]

Wonderful news.

Maybe we'll end up with reverse paternalism. Ok sir, you tell me how you would like us to address your medical problems today, sound good? Great, please be sure to give us 10/10 if you're happy with our service.

 

[WhippleWhileWeWork]

Good. Crappy docs not needed.

Yeah, no doubt.

 

[jeffk805dent]

Good thing Medicare doesn't cover dental. **** you Obama.

ditto. I'll be bald getting through all this private dental practice drama.

I am way prettier than a pair of scissors. But I'll take the somewhat Aladdin av

can I please be the Genie?

There's a lesbian joke in here somewhere.

when I read this, I thought of the South Park episode with Mr. Garrison and Xerxes.

 

[Roxas]

Wonderful news.

Maybe we'll end up with reverse paternalism. Ok sir, you tell me how you would like us to address your medical problems today, sound good? Great, please be sure to give us 10/10 if you're happy with our service.

Sadly, that's not too far of a leap

 

[loris]

No. I'm brown. Chai all day everyday. And always through a straw. Bc teeth. The few times I get stuck with crappy coffee, I also find a straw. Same for red wine.

Ohhhh...
This thing makes sense now. Backpacking dentists.

 

[sazerac]

Wonderful news.

Maybe we'll end up with reverse paternalism. Ok sir, you tell me how you would like us to address your medical problems today, sound good? Great, please be sure to give us 10/10 if you're happy with our service.

Or give the patients a cut of the action... "If you rate us 10/10, that's $10 off your next visit!"

 

[fastlane]

This is great. Lets stick a rod in the ass of the primary care doctors who are already spread thin.
All this is, is another way to further cut doctors pay.
Thanks, Obama!

 

[NickNaylor]

Also, the idea of taking only 600 patients is appealing, but the guy who originally started the first concierge practice, MD Squared, has already said that if enough physicians start doing that, we'll lose public opinion and then be subjected to laws requiring quotas or other commu- *cough cough* I mean socialist agendas. (Dr. Howard Maron was quoted in an article on the ethics of concierge medicine recently; I googled but can't find the article again).

Exactly, this model is great for the small subset of the population, but having any significant portion of the population receiving healthcare in this way is just asking for government intervention.

 

[Mad Jack]

I really hope more physicians stop taking insurance entirely as the cuts continue to get worse. This is getting ridiculous.

 

[Mad Jack]

Also, the idea of taking only 600 patients is appealing, but the guy who originally started the first concierge practice, MD Squared, has already said that if enough physicians start doing that, we'll lose public opinion and then be subjected to laws requiring quotas or other commu- *cough cough* I mean socialist agendas. (Dr. Howard Maron was quoted in an article on the ethics of concierge medicine recently; I googled but can't find the article again).

I would leave medicine entirely before being forced to see a set number of patients or to accept any sort of insurance.

 

[Awesome Sauceome]

I really hope more physicians stop taking insurance entirely as the cuts continue to get worse. This is getting ridiculous.

I agree, but you hafta be careful, if too many doctors go against the system then they will make it so that receiving your licensing is based upon compliance to see medicare and medicaid patients.

Use the rod instead of the carrot.

People will argue "but its against the constitution," but really... how many things going on as of lately have sort of side stepped certain portions of it...

 

[doapplicant2015]

Ah yes, blatantly incorrect and misleading comments

 

[fancymylotus]

I really hope more physicians stop taking insurance entirely as the cuts continue to get worse. This is getting ridiculous.

You wouldnt believe the number of "whaaaaaaaaaaaaat? I thought obamacare would cover my implants/cosmetic dental procedures!!!!!!" calls we get

lol

 

[Awesome Sauceome]

Exactly, this model is great for the small subset of the population, but having any significant portion of the population receiving healthcare in this way is just asking for government intervention.

How? AtlasMD is charging what $50 a month for adults and $10 for kids? The government is spending WAYYYY more than that per month on medicare. I see it as working for the general population if enough docs get on board. If enough dont though then it would be horrible because there wouldnt be enough docs for all of the patients - making a doctor shortage a legit thing (and not just geographically specific like it is now).

 

[Mad Jack]

I agree, but you hafta be careful, if too many doctors go against the system then they will make it so that receiving your licensing is based upon compliance to see medicare and medicaid patients.

Use the rod instead of the carrot.

People will argue "but its against the constitution," but really... how many things going on as of lately have sort of side stepped certain portions of it...

I'd rather leave medicine entirely than be a slave to some government system that I don't even have a choice whether or not to be a part of. Screw that.

 

[Mad Jack]

You think that Medicare spends $600 per beneficiary per year on primary care services? (Ie annual H&Ps and routine visits)

The visits cover more than just H&Ps- you get EKGs, cryosurgery, spirometry, lac closure, house calls, etc (basically any service a PCP can perform) all included in the price. Plus most of their diagnostic tests have been contracted out at rates 1/10th of what Medicare charges, so it is often cheaper to just get your diagnostic imaging, bloodwork, etc done through Atlas than it is to pay an insurance copay. With the smaller patient panel, they cam take the time to do the tasks that have largely been bumped off to specialists due to their being too time intensive for PCPs to manage in the traditional insurance environment.

I don't think it is a perfect model, but I think it is a viable one. It is certainly a higher level of both service and primary care than most patients currently receive.

 

[Mad Jack]

I do think it's an interesting model. But I also think it relies on a lot of low utilizes (Ie their patient population is not the medicare population).

Most concierge practices rely on a golds gym or a planet fitness model where most members pay the subscription fee and then maybe call once or twice a year about cold and flu symptoms.

If you're paying $600-1200 a year for something and there is no cost per visit, you'll probably use it. Or so health economists claimed when discussing Obamacare and how to structure incentives.

On an unrelated note, Obamacare autocorrects to panacea on my phone, it's a conspiracy!

 

[Mad Jack]

I don't think that's necessarily the case though. The people who can afford it are paying for security. They like the thought that they can call their doctor anytime, or get a same day appointment if they get sick. But how much they actually use that service? Not nearly that often

I understand the appeal of a concierge model for both providers and patients, but I doubt it is a conceivable model to replace primary care overall.

http://thehill.com/blogs/pundits-bl...mary-care-part-of-the-solution-or-part-of-the

A decent article on the topic. Concierge practices aren't a viable solution for anything, IMO, but DPC practices with wraparound coverage that takes care of everything the PCP doesn't offer seem like a great alternative system, and one that is allowed in place of traditional insurance under the ACA:

"Interestingly, the ACA allows DPC practices to offer coverage in the health insurance exchanges when combined with a wraparound catastrophic insurance policy provided by a qualified health plan (QHP). The QHP is used for hospitalization, specialty care and other more costly services. To date, there are no DPC practices operating in the federally facilitated exchanges, but the first DPC offering paired with a QHP will be available in the Washington state exchange in January 2015."

 

[link2swim06]

I agree, but you hafta be careful, if too many doctors go against the system then they will make it so that receiving your licensing is based upon compliance to see medicare and medicaid patients.

Use the rod instead of the carrot.

People will argue "but its against the constitution," but really... how many things going on as of lately have sort of side stepped certain portions of it...

I highly doubt it will ever be required to see a subset of patients. Even ERs aren't required to treat all patients under EMTALA unless they accept medicare/medicaid payments or funding.

However, the government can do plenty of financial things with reimbursements, fees, and taxes to accomplish what they want.

 

[Mad Jack]

http://www.surgerycenterok.com/pricing/

This is another interesting model of care- direct pay surgery. Costs cover everything- facility fees, the surgeon's fee, anesthesia, and meds used during the procedure. Sure, they're probably cherry picking the healthiest patients, but their costs are quite reasonable.

 

[Awesome Sauceome]

I do think it's an interesting model. But I also think it relies on a lot of low utilizes (Ie their patient population is not the medicare population).

Most concierge practices rely on a golds gym or a planet fitness model where most members pay the subscription fee and then maybe call once or twice a year about cold and flu symptoms.

I mean essentially thats what the ACA does anyways? It relies on young people to pull the cost down (since they visit less). DPC does essentially the same thing - you would be relying on say 100/600 of your patients to only visit once a year, as most of your time would be spent on the other 500/600 elderly and/or people with more complex diseases. Its just another way to skin a cat, but I think it is A) cheaper - as Madjack pointed out most testing is contracted out at 1/10 the cost (not pay per service). B) It saves people (or say if the government did this) money. and C) allows physicians to practice autonomously instead of at the whims of a larger corporation of insurance company.

I should add that this probably would not work for a lot of specialties, basically just primary care. I should also reinforce my original statement, that on a large scale it would only work if enough docs switch over to that system. The few docs that are doing it seem to be doing well, but if it was to be official strategy or policy it would require a lot of docs to buy into that idea, otherwise I think it would actually make things worse off because even LESS patients would have access to care.

 

[Successful BM]

I agree, but you hafta be careful, if too many doctors go against the system then they will make it so that receiving your licensing is based upon compliance to see medicare and medicaid patients.

I would leave medicine. Not exaggerating. That's not even ~universal healthcare~. That's socialism bordering on serfdom. If you consider that most of us sacrifice our entire young professional lives to become physicians and that it's all we know, serfdom isn't such a stretch when you take away our choice of who we choose to treat.

 

[Awesome Sauceome]

I highly doubt it will ever be required to see a subset of patients. Even ERs aren't required to treat all patients under EMTALA unless they accept medicare/medicaid payments or funding.

However, the government can do plenty of financial things with reimbursements, fees, and taxes to accomplish what they want.

Very true... Even if they dont necessarily say you HAVE to see certain patients, there are ways to sort of twist your arm. Either way, you are essentially doing something that you might not feel called to do or that may hurt your practice.

 

[Mad Jack]

Not all the prices are reasonable as VT posted above.

If your only option to get tubes for your kids ears was to pay 2K out of pocket...how many parents would be skimping on having this done when its indicated?

I'm not saying it's a great option for everyone, hell no. I'm just saying- if you go into a hospital and have one of those procedures done without insurance because you are uninsured, your bill will be much, much higher. Here's just the hospital charges for a knee replacement (cost $19,000 at Surgery Center of Oklahoma) at various different locations around the country:

Without insurance, there's only one lower priced place you could go in the entire United States to have a knee replacement.

 

[Awesome Sauceome]

I should add that I really respect your wisdom on the subject @SouthernSurgeon . You have had a lot more experience in the medical field than I have... Just adding some food for thought, just an alternative opinion. Realistically do I see a major switch over to DPC? Nah, unfortunately not. And realistically it could be a lot more complicated than I am imagining it to be. But call it wishful thinking I suppose haha. Like I said earlier in the thread, if I had the chance to practice in a set up similar to Atlas', I know personally that I would be significantly more willing to go into primary care.

Its not just about the money, its about the autonomy and seeing many of my primary care physician mentors just being slowly crushed by the system - it doesnt seem like it has to be this way for them.

 

[PL198]

Not all the prices are reasonable as VT posted above.

If your only option to get tubes for your kids ears was to pay 2K out of pocket...how many parents would be skimping on having this done when its indicated?

it baffles me how you refuse to change your frame of mind when dealing with concepts like this.

you look at the issue like 2k is a lot of money right now, while paying premiums, yet it wouldn't be so significant if people weren't and everything was cash only.

 

[Awesome Sauceome]

@Mad Jack

What I think is interesting about the cash only system is something you alluded to: that in some cases, with no (or just crappy) insurance, you would end up paying more at a hospital than in the cash only system anyways. Lets say you need that surgery but your insurance company only covers a low percentage of it. You may end up paying more for the surgery + anesthesia + your regular insurance rates monthly than you would in the cash only system. You might have just been better off saving up that $2K and going with the cash only surgical center. I definitely think in certain situations it could end up saving you money. And like you mentioned in the DPC post - these surgical centers are able to contract out some of the costs or just do EVERYTHING themselves which is how they can offer some of the surgeries for so cheap. But just like concierge/DPC there is this weird stigma about it in the public eye. People are so used to insurance at this point (and heck want their healthcare for FREE) that the thought of paying cash for a medical procedure just seems absurd to them, nevermind the fact that they would be happy to offer the same or more money to an insurance company.

 

[NickNaylor]

it baffles me how you refuse to change your frame of mind when dealing with concepts like this.

you look at the issue like 2k is a lot of money right now, while paying premiums, yet it wouldn't be so significant if people weren't and everything was cash only.

The problem is that the average person is ******ed and has no ability to manage money. Say we nix insurance altogether and somehow manage to construct a cash-based system that is affordable to most. How many people do you think will actually say, "wow, I should probably set aside those thousands I just gained in my income for health expenditures I might have in the future?" My bet is very, very few. Now the libertarian in me says, "**** it, you get what's coming to you personalresponsibility.jpg." But even I have a problem with flat out refusing care to people that can't pay for it. I think that's fundamentally wrong - and I think the overwhelming majority of Americans share that view. And now we find ourself back at step 1: a large, third party payer - likely the government - attempting to manage costs and make ever growing promises to the public that are simply unsustainable.

 

[Mad Jack]

But the issue is "lower priced" to whom?

My hospital might charge medicare 60K for a knee replacement (they don't), but that isn't the price to the patient.

My concern is that if you shift too much cost to the patient, you run the risk of decreasing utilization of discretionary services. E.g. I'm not going to get my hernia fixed because it would cost 5K and it doesn't hurt THAT much...

If you decrease the utilization of discretionary services, then over time you increase the use of emergency services, which are pretty much always drastically more expensive.

I totally agree that it's not a good option to just go to a cash-only system for major procedures like surgery. I'm just saying that sometimes the costs are often comparable to, or in many cases far better than what is charged in hospitals. For someone that lacks insurance, a cash-only surgical center might be a great idea, but it's more of a last resort than a first one.

 

[Psai]

Not all the prices are reasonable as VT posted above.

If your only option to get tubes for your kids ears was to pay 2K out of pocket...how many parents would be skimping on having this done when its indicated?

If you didn't have insurance costs taken out of your paycheck before you got your wages, you would have more money to play with. I'm guessing that this extra money wouldn't be going to healthcare though

 

[Mad Jack]

The problem is that the average person is ******ed and has no ability to manage money. Say we nix insurance altogether and somehow manage to construct a cash-based system that is affordable to most. How many people do you think will actually say, "wow, I should probably set aside those thousands I just gained in my income for health expenditures I might have in the future?" My bet is very, very few. Now the libertarian in me says, "**** it, you get what's coming to you personalresponsibility.jpg." But even I have a problem with flat out refusing care to people that can't pay for it. I think that's fundamentally wrong - and I think the overwhelming majority of Americans share that view. And now we find ourself back at step 1: a large, third party payer - likely the government - attempting to manage costs and make ever growing promises to the public that are simply unsustainable.

If we put the $5,384 employers spend on insurance annually into HSAs that didn't expire and could be invested similar to a 401k in a limited pool of investment options, by the time a major health expense came up, the employee would have more than enough money to cover it. At an 8% return over a 40 year working career that money would be worth $1,507,460.27, more than enough to cover every single health expense a person will encounter in their lifetime. Sure, deductions would happen now and again, but so long as a person is working and they get money dropped in that account that grows yearly, by the time they start making regular hits to their HSA they should have more than enough to cover nearly any medical expense.

 

[Awesome Sauceome]

.

 

[NickNaylor]

If we put the $5,384 employers spend on insurance annually into HSAs that didn't expire and could be invested similar to a 401k in a limited pool of investment options, by the time a major health expense came up, the employee would have more than enough money to cover it. At an 8% return over a 40 year working career that money would be worth $1,507,460.27, more than enough to cover every single health expense a person will encounter in their lifetime. Sure, deductions would happen now and again, but so long as a person is working and they get money dropped in that account that grows yearly, by the time they start making regular hits to their HSA they should have more than enough to cover nearly any medical expense.

Great idea, but again, you're assuming that people will actually do this. I think that's where I get divorced from the idea - what should happen in theory vs. what will happen in reality. Unless you're going to force people to divert x% of their income to an HSA invested in some kind of secure fixed income security a la ACA redux (lel, good luck), I just don't see this working in the real world.

 

[Mad Jack]

Great idea, but again, you're assuming that people will actually do this. I think that's where I get divorced from the idea - what should happen in theory vs. what will happen in reality. Unless you're going to force people to divert x% of their income to an HSA invested in some kind of secure fixed income investment a la ACA redux (lel, good luck), I just don't see this working in the real world.

That's what I'm actually proposing. Instead of health care plans and Medicare/Medicaid, have employers divert to tax-sheltered HSAs that employees cannot withdraw from. It has the same effect as what they've got right now (money they can't touch, such as health insurance plans they don't pick and Medicare deductions that are automatically removed from their check), except that the money grows over time, and overall health care costs can be substantially cut thanks to no longer having to deal with insurance companies (no need for coders, medical billers (software and a high school graduate can handle simple billing that doesn't involve codes), no more insurance companies taking a slice of every health care dollar that comes their way in profit.

So what happens to all that money when you die? Simple- It gets taxed, and the remainder (if any) is given to your loved ones like any other asset. The tax money goes into a pool to pay for those whose accounts run completely dry and are under duress (disabled and the like, cancer patients, dialysis patients, etc). I mean, this is clearly some out-of-the-box, never going to happen sort of system. I'm just trying to point out that there are other ways we could do things that wouldn't involve the government being heavily involved or insurance dictating what we do. It's more a thought exercise than anything, but who knows, maybe if we all brainstorm enough one day somebody will come up with a great idea that is viable and can change healthcare.

 

[Awesome Sauceome]

That's what I'm actually proposing. Instead of health care plans and Medicare/Medicaid, have employers divert to tax-sheltered HSAs that employees cannot withdraw from. It has the same effect as what they've got right now (money they can't touch, such as health insurance plans they don't pick and Medicare deductions that are automatically removed from their check), except that the money grows over time, and overall health care costs can be substantially cut thanks to no longer having to deal with insurance companies (no need for coders, medical billers (software and a high school graduate can handle simple billing that doesn't involve codes), no more insurance companies taking a slice of every health care dollar that comes their way in profit.

So what happens to all that money when you die? Simple- It gets taxed, and the remainder (if any) is given to your loved ones like any other asset. The tax money goes into a pool to pay for those whose accounts run completely dry and are under duress (disabled and the like, cancer patients, dialysis patients, etc). I mean, this is clearly some out-of-the-box, never going to happen sort of system. I'm just trying to point out that there are other ways we could do things that wouldn't involve the government being heavily involved or insurance dictating what we do. It's more a thought exercise than anything, but who knows, maybe if we all brainstorm enough one day somebody will come up with a great idea that is viable and can change healthcare.

What happens for people that cant/wont work?

I do agree with most of what you are saying though, particularly to cut cost by cutting out the middle men insurance company/billers etc.

 

[1lifeleft28]

Obama should link his pay to quality - probably a bad idea for him bc he would be paying the people to be president.

 

[Awesome Sauceome]

To some degree they promised us that's what EHRs would do. A big part of the ACA was the magical billions of dollars we'd save by implementing EHRs - supposedly by cutting down on inefficiencies like billing.

Do you think that over time (when people get more used to it) it legitimately COULD save money? Like do you think we are just in a growing phase where its actually more inefficient because no one knows how to use it well/properly? Or is it just awful, and like many things with the government, naturally deficient by design.

 

[Awesome Sauceome]

I think in theory it could, but the current EHRs are pretty awful, even the best ones. Ours actually shifted work off of the MAs/coders and onto the physicians which is kind of hilarious.

I suspect that EHRs by the time I am mid to late career will look vastly different and I hope and pray they will be able to seamlessly "talk to" each other and allow full record exchange. But it's going to be a long-time.

I have heard that this has happened a lot, which seems to be counter-intuitive to saving money...

 

[pandahunter]

I love our President, but the way he has handled healthcare policy from the beginning of his tenure has been abhorrent.

 

[charmiedermie]

You can't have real class warfare between 99 out of 100 people and the 1 that remains. It's kind of a BS term, as democracies are ruled by majority vote, so asking the 99 to do what benefits them rather than what benefits the 1 person outside their group isn't warfare, it is common sense and self interest.

For the record, I think many of his policies are terrible, but anyone that says "class warfare" has a serious disconnect with how democracy functions, and has gobbled up laughable talking points.

Except we're not a direct democracy, we're a constitutional republic. Also class warfare isn't a BS term as u call it. Other terms are class conflict or class struggle.

Obama's entire playbook is stoking class resentment which he played during healthcare reform and the 2012 campaign. And I'm someone who plans on voting for Hillary Clinton.

 

[link2swim06]

I think in theory it could, but the current EHRs are pretty awful, even the best ones. Ours actually shifted work off of the MAs/coders and onto the physicians which is kind of hilarious.

I suspect that EHRs by the time I am mid to late career will look vastly different and I hope and pray they will be able to seamlessly "talk to" each other and allow full record exchange. But it's going to be a long-time.

Yep. It is kinda funny how dumb the hospital admins are on some of these things.

It's pretty comical that SDN and my gmail account are easier to navigate and about 10 times faster than my hospital EMR. Tons of money is lost in lower productivity with them without a doubt.

Not to mention the more stuff you make me click on the EMR means less time with the patient. Is clicking a dozen warnings about irrelevant allergies and hospital policies worth spending 10% less time with the patient?