Jack Cochran

“As a PCP, I’ve seen the morale in my area, and I see a major crisis coming if the complaints are ignored.”

“I’ve lived in the hell that is American health care…”

A devoted physician wrote these words in reaction to a recent blog post we wrote. And he is clearly not alone.

In our new book The Doctor Crisis, we report on the widespread unhappiness, frustration, dissatisfaction, and anger of so many American physicians.

We believe this crisis is real and growing; that it is an impediment to providing the care the American people need; that dealing with the doctor crisis is fundamentally patient-centered; and that the crisis has not been recognized for the fundamental threat it poses.

Our recent feature on The Health Care Blog elicited some powerful reaction:

Rob: ”In a certain sense, individual doctors ARE victims of a system that rewards over-consumption, ridiculous documentation, attention to codes over people, and bureaucracy over partnership…”

Jeff: “Can validate what Rob has said. I’ve spent the last three years listening to physicians about the possible alternative futures for their profession, and the overwhelming desire was exactly as Rob said- an overwhelming impulse to flee…”

Some commentators wrote that doctors shouldn’t complain because they earn a lot of money, drive fancy cars and own nice homes. But that theme – accurate in many cases but certainly not all — gets us nowhere.

We think the rubber meets the road with this warning from Dr. Rob, ”…As a PCP, I’ve seen the morale in my area, and I see a major crisis coming if the complaints are ignored.”

Is Dr. Rob overstating it? We don’t think so. In fact, we think he has it exactly right. How can our system function properly if the level of job satisfaction among doctors continues to spiral downward?

Harris Interactive research describes the profession as “a minefield’’ where physicians feel burned out and “under assault on all fronts.’’ Has such extreme language ever been used to characterize the medical profession? Have doctors ever faced a time as turbulent as this?

Doctors are certainly not blameless as both Brian and Rob noted in their comments:

Brian: “…I’m concerned that you have framed your argument as though physicians are victims of the system rather than partial drivers of its characteristics …”

Rob: “…physicians as a group have been complicit in building this system, and so should bear a lot of the blame…”

So what needs to be done?

A crucial first step is for health care stakeholders to recognize and acknowledge the existence of the crisis. Doing so will get the doctor crisis on the national health care agenda. Unfortunately, the matter is  not currently a priority for many, if not most, provider organizations. That needs to change.

When it does, there are some powerful solutions out there. There is no doubt, in fact, that the building blocks for a better future are out there. They are found in many provider organizations that have improved both physician and patient satisfaction while improving care.

Important progress can be seen at many organizations including some we write about in our book: HealthPartners (Minnesota), Atrius Health (Massachusetts), Virginia Mason (Washington), and Kaiser Permanente (nine states).

We draw inspiration from the work of Drs. Christine Sinsky, Tom Bodenheimer and their colleagues who identified 23 high functioning primary care practices. Their findings and recommendations, if spread throughout the country, could help transform primary care in our nation. [Annals of Family Medicine (May/June 2013) In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices.]

We’ll be writing much more about these solutions to the doctor crisis in the weeks and months to come.

What ideas do you have for improving both physician and patient satisfaction?

The evolution of the physician role seems to accelerate daily. In our new book, The Doctor Crisis, we characterize the expanded role for physicians as that of healer-leader-partner.

Many physicians are adapting beautifully to this shift. Others struggle mightily. Some angrily. A number of doctors consider the change fundamentally unfair – a kind of bait and switch. We got into medicine to take care of patients, and now we’re being asked not only to heal but to become effective leaders and partners, as well. It’s too much.

No question – it is a lot to ask. But how can we turn back? Unless doctors step up as healers-leaders-partners, we can’t deliver the kind of care the American people need and deserve.

We defined what we mean by the terms healer and leader in our last two posts, but what do we mean exactly by physician as partner? We write in our book “physician as partner means being a great team member and recognizes that the surest route to sustained quality care is through effective teamwork.”

We’re talking about pulling a team together to do great population health management; working across siloes to team up with nurses, pharmacists, techs, and administrators. Great physician partners are collegial, approachable, and always respectful of other team members.

Some examples include:

  • Partnering with patients on shared decision making.
  • Partnering with nurses in clinical teams and on a larger scale when necessary.
  • An example of the latter is the partnership between the Colorado Permanente Medical Group and Exempla Healthcare to establish an accelerated nursing degree program and skills lab at Metropolitan State University of Denver.
  •  Partnering with physician colleagues by listening – as Dr. Cochran did in his listening tour (detailed in our book) where he sat down to talk with all 500 KP Colorado doctors to fully understand how best to fix a dysfunctional situation.
  • Partnering with clinical pharmacists so that everyone is practicing at the top of their license.

An outstanding example of a physician as partner is Dr. Paul Grundy, the director of health care transformation at IBM. Dr. Grundy and his IBM colleague Dr. Martin Sepulveda partnered with a wide variety of primary care organizations to build the Patient-Centered Primary Care Collaborative – a powerful partnership for the patient-centered medical home.

We quote Dr. Grundy in our new book:

“If you put resources upstream – if you manage aspirin, blood pressure, and cholesterol upstream you have a third less need to do cardiac intervention. If you don’t manage those things, you see more cardiac disease. This isn’t rocket science!”


This is exactly what we do so well at Kaiser Permanente – manage member health upstream. A major factor in our success in this area is our physician as partner culture. Just as Kaiser Permanente embodies physician as partner, so too does the patient centered medical home. Both rely upon physicians as partners with one another as well as with administrators, health plan partners, nurses, medical assistants, clinical pharmacists, behavioral health specialists, schedulers, receptionists and many more – all partnering in the cause of great patient care.

If Kaiser Permanente is in some way a model for the patient-centered medical home that will grow in importance in the future, then Dr. Grundy is in many ways a model for the healer-leader-partner that physicians must aspire to. His portfolio is global, as befits a global company such as IBM. He is as likely to be in Beijing, Zurich or Wellington as he is in Charlotte, Chicago or Los Angeles.

The essence of what Dr. Grundy does – especially his role as a leader and partner to many organizations seeking to improve – shows the pathway forward for other doctors. The geography doesn’t matter. Whether a doctor travels the world or remains in a small clinic in a rural area, the essential ingredients for success in the new age remains the same: Physician as healer-leader-partner.

What does effective partnering look like in your organization?

Jack Cochran, MD, FACS(@JackHCochran) is executive director of The Permanente Federation, headquartered in Oakland, California.

Charles C. Kenney is a former reporter and editor at the Boston Globe and author of several books on healthcare in the United States. 

Cochran and Kenney are authors of The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care. Both write about physician leadership at kp.org/physicianleader, where this post originally appeared.

 

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76 Responses for “Lost in the Health Care System?”

  1. Vuckovich says:

    I am a physician considering working with KP. I’ve heard from friends within the organization that you generally expect 8 hrs clinical time / 2 documentation daily from providers. Add on call time and that’s obviously not nothing. I understand the world is changing and I am willing to change with it. I love my work and consider myself lucky to be highly compensated by comparison to many of my peers, but I am frankly concerned that not enough attention is being paid to the impact of policies like this. As a company, are you studying the impact of your policies on physicians at all? I assume you are. If you are doing such studies, can you tell me what you are finding?

  2. Rob says:

    As the doctor who is quoted in this article, let me first say: thank you. This is a problem to be taken seriously, as the burdens of our system are soon to create a crisis much larger than those we currently face (which themselves are daunting). My route was to create a new system that doesn’t have the same pressures of the fee-for-service world. I think that if we, who are blazing other trails, can build an alternative that is attractive enough to PCP’s before the FFS system changes favorably (decreasing inane documentation burdens and other barriers to care), the docs will flee to higher ground and create a major primary care crisis. If alternative systems are able to pick up the slack for the FFS world, then everything is OK and things move to the more sensible system, but if all the PCP’s leave to become concierge docs with 500 patients in their practices, then there will be an enormous problem.

    • Charles Kenney says:

      Rob thanks for your comment. When Jack and I were working on our book THE DOCTOR CRISIS it became clear to me that the challenges docs face — particularly in primary care — are not taken nearly seriously enough by other stakeholders. It’s easy to dismiss physician complaints as whining and that has too often been the response. But these concerns are real, very legitimate, and need to be taken seriously and acted upon. You have had the courage to do something better and that’s commendable. I am convinced a new approach to primary care is emerging slowly but surely. You can see it in the work of Drs. Sinsky and Bodenheimer et al in the Joy in Practice work focused on 23 high performing primary care sites. You can see it in the flow work designed at Virginia Mason and now spreading to other locations.

      I find it difficult to believe we can achieve our overall goals of access, quality, safety, equity and affordability unless we listen carefully to what physicians like you and others are saying. In a way that is the purpose of our book: To define and call attention to the issue and offer suggestions for new pathways forward. And, not incidentally, to spark some debate.

  3. Peter says:

    As a physician in the KP system, I find this article very typical of the Kaiser way of thinking.

    The first commenter is exactly correct – a full day is expected for clinical work with administrative time not factored in. What does this mean? You come early. You work through lunch. And you stay late. While there is nothing technically wrong with this (any academic job or the private sector would work this way too), there is a hypocrisy to the image that is presented of a work schedule that is efficient and leaves you time to get the necessary actions done in the actual 8 hour day.

    This is an apparently patient centric model which is frankly painful for physicians. With this, comes:

    * A million email messages flying between providers that require follow up, answering and checking up. Sounds simple, but turns out to be surprisingly time consuming. I like email too, but not like this.

    * Secure messaging emails and letters which have to be provided to each new patient telling them how happy you are that they are your patients (there are metrics that actually measure initiatives like this). You seriously couldn’t automate this?

    * A whole slew of messages that are generated from this initial email that then require multiple further emails and follow up. While this is often helpful, the provider workflow is not designed to accommodate this.

    * A moving schedule which allows direct booking of patients to a clinic even if the consult is inappropriate. This prevents any ability to plan your day and take less or more time as you may need with a patient because you’re never quite sure if another patient has just been added in.

    * 15min/30min slots are allowed for follow up and new patients which is fairly typical except for the fact that the amount of documentation required with an EPIC EMR (with KP modifications of course) that was never well designed for the outpatient setting either ends up taking more time than you are allotted or you end up short changing the note and putting yourself at risk medico-legally.

    There are undoubtedly strengths and many aspects of care that are done well. But this system is far from the utopia that is often pitched.

  4. Joel Hassman, MD says:

    If I read the title of the book one more time in this thread, i will gag. We get it, the authors wrote a book and think we should all read it, but, how about a little humility and respect for readers in not having to mention it ad nauseum in posts and thread comments?

    And sorry to say, a bit disingenuous at least, dishonest to me more likely to be advising doctors should and alleged ARE being seen as leaders in health care, um, what is the reality of those coming to that conclusion? We are moreso janitors and assembly line workers in this hijacked system of profit mongering. But, keep saying what you have to to make that sales quota for your book.

    God, some stuff at this blog is beyond shameless.

  5. Charles Kenney says:

    Joel thanks for your thoughtful and insightful comment. Advances the discussion beautifully!

    • Joel Hassman, MD says:

      No problem. This empty and vapid discussion without real investment nor concern for change is improving health care by leaps and bounds every day!

  6. Granpappy Yokum says:

    Oh dear, where to begin?

    1. The Sinsky/Bodenheimer article is a total fraud. They present not one shred of evidence that the physicians in the practices they profile (“high performing” seems to mean “high overhead, high expense practices where our friends work”) experience any more joy than their peers. Rather, it appears that they’ve developed coping mechanisms so they can run faster while their administrator masters turn up the speed on the treadmill.

    2. The PCPCC is a front organization designed to buff the image of the large insurers and health corporations. Their modus operandi, as we’ve read here, is to distort “data” that was really lousy to begin with and report enormous savings that never get back to the patients or the physicians.

    3. Dr. Grundy may partner with his fellow execs at IBM, but certainly not with real-life patients or practicing physicians. His contempt and disdain for his peer physicians are notorious and have been quite visibly demonstrated on various discussion boards (personal experience).

    This posting is definitely of the wolf in sheep’s clothing type: under the guise of wanting to help physicians, we hear the true voice of Big Corp Medicine.

  7. Charles Kenney says:

    Granpappy,

    Accusing the Sinsky/Bodenheimer team of “fraud” is crass and unprofessional. The report doesn’t pretend to suggest a delirious level of happiness among the groups they observed. Rather, their report acknowledges the reality: “We set out in search of joy in practice. What we found were pockets of professional satisfaction. Even at the best of practices, physicians are still often caught in what Chesluk has coined the `frantic bubble’… Our observations suggest that these 23 innovative sites are pointing the way toward a better model.” In other words, they found indications of progress and their report details it well.

  8. Vik Khanna says:

    I think the far more interesting question is why doesn’t the Kaiser model work well outside California? The organization’s beachhead in the mid-Atlantic region is modest at best, and I know of no other major geographic region in the US where it has even that presence.

    Part of KP’s ‘success’ in California certainly derives from California consumers growing up within its confines where it has embeded into the healthcare landscape. Thus, they are must becoming comfortable with what it has to offer and how it operates.

    This has clearly not been the reception elsewhere in the nation. And, Reed Abelson’s fawning 2013 fable of KP as the future aside, there are plenty of elements of KP’s operations and finances that raise questions amongst business leaders, consumers, and regulators (of which I was once one). At the end of the day KP is just another health plan, a highly profitable non-profit one at that, that makes abundant claims of excellence just like all its competitors.

    BTW, I found the assertion that physicians are victims to be laughably moronic.

    • allan says:

      Vic, doesn’t Kaiser have a lot of influence over the medical boards, politicians, judges that do arbitration so that many of the cases against them are left sealed and not open to the public? Doesn’t MICRA keep the awards low so that attorney’s don’t find it profitable to look at some of Kaiser’s bad habits?

      Isn’t the partner physician group incentivized to restrict care? Don’t the physician partners control the other physicians and split the profits 50/50 with the hospital? (Thus though many think the whole thing is non profit…it wouldn’t be if that is the case.) That is a pretty big incentive to deny needed care and could cause problems in other states where Kaiser isn’t as powerful.

      Does Kaiser live up to the standards of medical care? I don’t know. I have heard Kaiser creates its own guidelines for certain diseases and thus can help control their costs. For example I have heard heard they don’t follow the ADA guidelines for diabetes, but created a less stringent one for themselves. For all I know their guideline is a better one, but I heard it helps save them money so if the 50/50 split exists, as I have been told, isn’t there is an incentive to save money by denying needed care?

      Is Kaiser the medical group that lost the pill splitting case? Does Kaiser have its own hospice? If it does that could create bad incentives.

      I ask these questions because I don’t have firm answers to them and you state that you were one of the regulators so perhaps you have more knowledge that is solid and correct any mistakes I might have made.

      • Vik Khanna says:

        KP is no more or less sleazy than any of its peers. It has a carefully burnished patina of credibility because of its (wink, wink) not for profit status and because it claims great clinical excellence.

        The article notes that KP has a presence in 9 of the 50 states. I’d be much more interested in knowing: its market share and trend line in those states (I am guessing small outside of the areas I noted) and the frequency with which KP members files complaints against it with their insurance commission or attorney general’s office.

      • Vik Khanna says:

        I have been out of the regulatory sphere for many years, but the issues you raise about denial of care by KP and the secrecy that shrouds much of its operations has truth to it.

        Some of the first and most compelling cases I handled for the Maryland Attorney General’s Office were serious coverage and reimbursement disputes between KP and consumers. And, in legislative wrangling in the General Assembly at the time, I cannot a recall a single time when KP’s hired guns sides with Maryland consumers.

        • allan says:

          “KP is no more or less sleazy than any of its peers.”

          Thanks Vik for your great summary of all my concerns in one easy sentence. The statement doesn’t say much for KP since from what I know personally about some of its peers sleaze is an excellent word. Early on in the days of the HMO one HMO unbelievably had as its motto ‘Delay in treatment means profit’. At least they were honest.

          I have heard even worse things about KP, but I just wanted to touch on a few things I had reason to believe were true. Others can search the Internet for the horror stories involving all the HMO’s and KP by name and determine for themselves what is or is not true. There is one site of interest that I saw years ago and apparently has been kept up. Take a look at Harp.org It has a google search engine on it to take one to a whole bunch of things about Kaiser. Not too pretty.

    • Joel Hassman, MD says:

      Kaiser is no shining example for how it manages psychiatric care, and that is from those in the front lines. Sad how so many buy into the managed care/business model without hesitation.

      Lies become truth, and sold here onwards voraciously. And with this last sentence, I bid those who care and are genuinely committed to honest and defendable standards of care good luck at this blog. Just remember the statistical standard of random chance, 1 of 20 might actually be true and well intended. That standard fits here, in my opinion.

      Be safe, be well.

      Joel Hassman, MD
      Board Certified Psychiatrist

      • Charles Kenney says:

        Joel,

        Why the relentless negativity? And what in the real world does it mean when you write “lies become truth, and sold here onwards voraciously.”? This whole discussion started because Jack and I wrote a post about what we contend is a serious problem in health care in the United States today. We believe that all stakeholders need to get involved to preserve and enhance careers for physicians. Not to coddle but to create practice conditions that enable them to provide quality care while at the same time preventing burnout. We need to do better by docs if we are to achieve our national goals of improved access, quality, equity and affordability. That’s where this whole thing began. Your contribution has been so snarl. Just so you know, Joel, it doesn’t help even a little.

        • Joel Hassman, MD says:

          You are right, because I read your posts and comment rebuttals to sell an agenda, not principles that are foundations to what health care should be as instinct.

          Frankly, as long as profit motives rule conversation and policy in provider offices, everyone is screwed, except those who get a paycheck often for absolutely nothing that goes on between the patient and provider.

          You want to have real frank and brutally candid discussions among those who are the “front line grunts” to health care? Start with this simple question: “when did you first become concerned about health care interventions being interfered with that directly compromised your ability to provide the best care trained to offer?”

          At the risk of the comment being censored or just stricken from view, it would be answered almost word for word by those who took the Hippocratic Oath seriously at graduation: “when managed care assholes only out to siphon, if not floridly steal any and all monies from the health care system, got the validation to do so from not only bureaucratic controls, but from the timid and cowardly reactions from colleagues who looked at their wallets and purses first, then just glanced cursory at their patients.”

          People who write most posts here don’t really want to fix health care and restore it to what it SHOULD be, but just maintain a status quo and maximize a business agenda that never will fit the boundaries of what is an appropriate health care agenda.

          Do you say that at all in your book “The Doctor Crisis”? If you honestly and clearly do, then I just echo those points. If you don’t, then isn’t that a sizeable lapse in judgment in omitting?

          I am done at this thread and this blog, sorry for the hypocrisy in this further comment, but, do you really respect honest dissent, or just want a choir shrieking your “message”?

          Talk amongst yourselves if this comment is worth digesting.

          And, your title could have been better, how about “Doctors facing extermination”, certainly a more grabbing headline!

          Sheesh, does anyone here remember “Network” and the scene of “mad as hell and not going to take it anymore”? Or, are your gonads gone and intestines stapled?!

          • Charles Kenney says:

            Wow. “Gonads,” Joel? I am sorry to are so deeply angry that you resort to this sort of thing.

  9. Joe Flower says:

    “Fraud”? “Laughably moronic”?

    I’ve been arguing in Internet forums since the days when we had to chip our own bits out of wood and carry them in oaken buckets. There are many types of posts and posters. There are some who elucidate a problem, add to the discussion, make clear arguments, and even influence others’ points of view. There are others who use inflammatory language. There are none who do both.

    People who use inflammatory, accusing language do change my opinion — but it’s my opinion of them, not of what they are writing about.

    • Charles Kenney says:

      Joe really well said

    • Vik Khanna says:

      Medical school applications and admissions at all time highs.

      According to the Bureau of Labor Statistics, after athletes and celebrities, physicians are the highest paid professionals in the US, far higher than the lawyers and business leaders they love to complain about.

      I don’t dispute that some physicians have great difficulty with the way the healthcare system has evolved. But, they and their professional organizations and lobbyists have been complicit at every step of the process.

      So, remind me…how are they victims? I guess I am unfamiliar with fields of endeavor that end in victimhood yet attract thousands of people. Yeah, docs are real victims, you mean like the 440,000 people who die in the US annually from medical errors? Or the >500 people in Nebraska told by their state’s wellness program that they had cancer when they didn’t? Or the patients of the radiologist who bragged openly in a column about the $330K he made each year referring people for xrays to a facility he owned? Which victims do docs resemble? The “oh I have so much paperwork to do” victims?

      • Charles Kenney says:

        Vik,

        It’s is difficult to take you seriously Who said doctors were victims? Jack and I never said that. I think you should check your facts re: your assertion that “440,000 people” die “in the US annually from medical errors.” And you suggest that the Bureau of Labor Statistics suggests that MDs are paid more than anyone except athletes a celebrities? Is there such a category at BLS as celebrities? So people on Wall Street earn less than docs?

        I don’t mind arguing about the issue of the doctor crisis with someone who makes a cogent argument but your assertions don’t carry much substance.

        You are angry at MDs for some reason. The reality is that physicians today — especially primary care docs — work under difficult circumstances. The pressure is relentless from government regulations, insurance companies, etc. There is are elements of a better pathway forward for primary care docs and we will be blogging about those encouraging signs soon. In the meantime, Vic, how about more reason and less rage? This debate deserves no less.

        • Vik Khanna says:

          Medical errors: http://www.scientificamerican.com/article/how-many-die-from-medical-mistakes-in-us-hospitals/

          You might read your article again: Rob: ”In a certain sense, individual doctors ARE victims of a system that rewards over-consumption, ridiculous documentation, attention to codes over people, and bureaucracy over partnership…” You and your coauthor: Is Dr. Rob overstating it? We don’t think so. In fact, we think he has it exactly right.

          BLS data on annual mean wages across all tracked occupations, which includes performers of all kinds: http://www.bls.gov/oes/current/oes_nat.htm#00-0000

          No, actually, I don’t think American healthcare consumers are enraged enough at a system that is meant primarily to satisfy its own needs and continue expanding inexorably. We seem to always be just another $100Bn and 10 more years away from medical nirvana, but we never quite get there.

          • Charles Kenney says:

            Vic,

            Your unwillingness to recognize the pressures on primary care physicians is vexing. When Jack and I listen to primary care docs we hear about the challenges – -they are immense. Yet you dismiss with a “oh I have so much paperwork to do” victims?” This is too bad. These docs deserve better. They worked very hard to get where they are and far too often their work-life balance is less than it should be. When Jack took over leadership of KP Colorado he went out and met face-to-face with 500 docs. He heard their concerns and concluded that as a leader he needed to work to preserve and enhance physician careers. 500 physicians in person is a pretty good sample. No?

      • Joe Flower says:

        Vik, you may find someone reading this discussion who is eager to debate with you just what is the best inflammatory term to use, and precisely what level of sarcasm and vitriol to heap on anyone who uses a different term. But that someone will not be me.

      • allan says:

        Vic, I believe the IOM study you were referring to was 44,000 to 98,000, but recognize that many of the bad results had nothing to do with malpractice. In fact these numbers were flawed as the sample used for the extrapolation was too small and the locations very limited. This report is unfortunate as the idea behind the initial study was to find things in common that could be changed not to blame anyone since the initial study wasn’t created to do that.

        • Vik Khanna says:

          The author of the paper himself acknowledges that there are limitations to his study (http://safepatientproject.org/posts/4802-hospital-harm-new-estimate-of-patient-deaths-due-to-hospital-care-shockingly-high). But, even if his extrapolation is completely off base, it still leaves medical errors as around the sixth leading cause of death in the US, which is both appalling and inexcusable.

          Who knows the real number is? How would we find that out? In 1981, a surgical resident bragged to me that no matter even if a patient died on his watch, he was so deft at writing operative notes that he’d be able to convince any reader that the patient got up off the table and killed himself.

          It’s a standard operating theory in the world of consumer protection law that for every consumer who complains about a commercial transaction with a major player in the marketplace, there are probably ten to twenty people who either don’t know how to complain or just won’t. In six years of work in that space, I found that it held quite true and many times understated the breadth of a problem. It would not surprise me to learn going forward to that are vastly underestimating medical harm because there is so much money and power invested in avoiding disclosure of the problem.

          • allan says:

            Vic thank you for site. I will read it later, but not all error is malpractice and I believe he made that clear in interviews. I don’t like to minimize the errors committed in hospitals or by doctors, but we have to remember that many of these people that died and many more would have died without treatment. The complexities in medicine are tremendous and all too frequently some of the most important decisions have to be made on the spot. The best physicians with the best intentions doing the best they can can and will occasionally screw up.

            Can we do better? Of course and that is what we must strive to do, but that is dependent upon society as a whole not just the hospital or the medical profession.

            Are you looking for the perfect physician? Are you looking to blame physicians? What are your objectives?

    • Rob says:

      Amen, Joe. Very well-said.

  10. Joe Flower says:

    I am not a doctor, but I talk to a lot of doctors all across the country all the time. Just yesterday I lectured and led a discussion at the Cleveland Clinics. I also talk to a lot of people who are trying to work with doctors, people who lead medical groups, heads of medical systems and such. There are some things about “the doctor problem” that I feel are pretty inarguable.

    o That there is a problem
    o That getting to a better and cheaper healthcare system greatly depends on physicians not merely cooperating or “buying in,” but leading the way forward with thoughtful passion, commitment, and a willingness to try different methods
    o That any vision of better and cheaper healthcare will require doctors to practice differently in different business models with different relationships to each other. There is no way to get there that relies on “business as usual”.
    o That whether “victim” is the right word, doctors overwhelmingly report that their job is more difficult, stressful and time-consuming than it used to be. Most of the innovations (such as EMRs) that were meant to simplify their workflow and make it more efficient have in many if not most contexts added complexity and time instead, as Peter eloquently laid out in his post.
    o That all this varies enormously from one doctor to another, one context to another. Though there is no physician nirvana out there, and certainly no one model that could fit all, there are definitely better and worse places and ways to work, some organizations that have much better physician satisfaction than others, some that have better outcomes, some that have better financial models for the new era of “population health” — which suggests we might learn something from them. If you feel Sinsky and Bodenheimer did not pick the right ones to emulate, please suggest some of your own, write your own paper, help other doctors find some models for better ways forward.

    • allan says:

      Joe, you provide a lot of potential system reforms, but what you forget is that it is the physicians job to treat the patient at the bedside not to treat society’s ills.

      We got to where we are today due to too much intervention, not too little. We have a third party payer system where the future patient frequently has little to do with the purchase of his insurance. We have to get rid of third party payer caused by the tax code.

      When you want a physician to lead, you wish him to do that not with his M.D. degree that he uses at the bedside rather with his own policy beliefs created through experience. Physicians are not necessarily the best businessmen so many times the policies they present can be superficial. They do, however, know where the problems lie even if their description of the problem is at first poorly stated.

      The problems with many of the new things available in healthcare such as EMR’s are not that physicians don’t want them or that they will never work, rather things have to develop organically and not be mandated. Remember, physicians are used to change more than most any other group of people and they deal with hi tech and high tech change all the time.

      Physicians have a lot to complain about and so do the insurers, governments, taxpayers, nurses, etc., but the whole reason for the system is to take care of the patient and very seldom is the patient really included in the discussion.

      • Joe Flower says:

        Allan, when you are referring to what I advocate, I cannot match what you are saying to anything I actually advocate. It doesn’t sound like anything I am familiar with.

        • allan says:

          Joe, I reread what you said and I guess what you said could be taken in more than one way because there was no significant detail in what you said. I might be influenced by what you said in an earlier posting, but I cannot be sure without looking it up which is not important at this juncture.

          If you have reasonable agreement with what I said above then that would be good enough for me. If not I am sure you will post again and I will point out the specifics of where I feel you are wrong and where we differ.

          I will, however, expand on one of your thoughts; “but leading the way forward with thoughtful passion, commitment, and a willingness to try different methods”

          Do you believe physicians are unwilling to take untried paths? They do that all the time when practicing medicine. A physician that goes out alone and sets up a practice is not what I would call one that is afraid of starting something new from scratch. Are you looking for their leadership in an organic fashion or are you suggesting that instead of doing it the way they find best you want to push them to do it another way suggested by one with an ideology or a business plan?

          Change by itself does not mean a betterment of a condition as we have learned over the past almost 6 years.

          • Joe Flower says:

            Thanks for the thoughtful reply, Allan.

            Let me sketch out a bit more about what I meant by “trying different methods.” I am not demanding that physicians fix society’s ills. Rather, solutions are arising that can fix healthcare, but sone of these solutions depend on doctor shifting the ways they practice, the ways they collaborate, as well as the business models they work in.

            There are numerous examples of waste in the system, things that we would be better off without, that cost tens of billions of dollars every year, from colonoscopies for mass screening, to computer-assisted mammograms, to unnecessary stents to complex back fusion surgery for simple back pain. Doctors do them because they get paid on volume. Most organizations that don’t get paid on volume (e.g. Kaiser) don’t do most of them, or do them much less.

            Population health management is definitely a medical issue, one which requires a much tighter relationship between the doctor and the patient, and between the primary and the rest of the medical establishment. Doctors have not typically done this because they don’t get paid to do it. Patient-centered medical homes are a method of paying them to do this.

            Many of the other emerging methods of payment require doctors or hospitals to take on risk, that is, they can lose money if they manage it poorly and gain if they manage it well (which is what we expect from any other industry). To manage it well, they need to establish new work routines, new methods of dealing with patients, and new relationships between the doctors, often under some new risk-bearing business model.

            Physicians have not been wildly experimental in these new methods, understandably, because they are experimental, and they are trying to make a living, have a career. Like anyone else, most of them tend to do what is tried and true when it comes to making a living. Now most doctors are clear that we really are moving into a new era, and what was tried and true — volume-based fee-for-service — may not work so well in the future. So increasingly they are trying these new ways. Many of them will not do so well, because we don’t have a lot of collective experience in how to manage these new structures. But we have to try, because we have to find the way forward to healthcare that is both much better and much cheaper.

          • Granpappy Yokum says:

            “There are numerous examples of waste in the system, things that we would be better off without, that cost tens of billions of dollars every year, from colonoscopies for mass screening, to computer-assisted mammograms, to unnecessary stents to complex back fusion surgery for simple back pain.”

            And the waste is there because doing these procedures is so lucrative. Wouldn’t a more direct method of solving the problem be to pay dramatically less for these procedures and dramatically more for cognitive work? We PCPs feel that the PCMH and other innovations are at root an attempt to blame us for a problem we neither caused nor profited from, and telling us it’s our responsibility to fix it.

          • allan says:

            “Rather, solutions are arising that can fix healthcare”

            Joe, like a magician the government and its abettors force the healthcare solution they desire for political and personal economic reasons. Why else leave the patient out of the equation? From that direction high in the clouds we hear a whole slew of solutions that are born from the same branch of the tree. None of these things are innovative. They are all trying to mimic market solutions that grow organically not from the top down.

            Are you looking for an imposed solution mandated on the American population? If so you will never get the free support and innovation of American physicians and businesses. If you wish to buy their support you will get their passive support, but not their true innovative support except for the few that innovate for their personal profit while gaming the system.

            If you truly are looking 360 degrees and don’t have tunnel vision you will recognize that we need organic change coming from physicians and private individuals all over the nation and letting these smaller organic changes consolidate and break down as things progress. You will not be looking for a top down solution which only offers the innovation of the very few elites that have learned their craft from the same book.

            “There are numerous examples of waste”

            I see you have fallen into the waste trap where the cause of our problems are blamed at least in part on waste (and fraud). That’s what you get when you don’t have a market place to tell you how much a dollar is worth.

            “Population health management is definitely a medical issue”

            Define population health management and pin down what that term really means. In China 100,000 pigs were slaughtered because of an epidemic in the pig population. That is population management. Keep the herd of deer at a certain level and kill the rest. That is population management as well. I await your definition for without it any comments you make cannot be of great vaue.

            Patient centered homes and disease management are what Internists do. But they weren’t paid to do that. Who do you think started such nonsense? The same ones that wrote the book and mandated the solutions.

            We need to stop trying to control the results which have only led to higher costs, less satisfaction and a poor distribution of health dollars. That is top down thinking. Is that the type of thinking you want to see? After over 50 years of third party payer don’t you think it is time to give back control to the patient and let the patient call the shots outside of the contrived systems that we have all become too familiar with?

  11. Granpappy Yokum says:

    “If you feel Sinsky and Bodenheimer did not pick the right ones to emulate”

    But that’s what many people feel is exactly the problem: the authors just picked practices and told us that the doctors there experience more joy/satisfaction without any evidence to support that claim.

    As they state:

    “Our observations suggest that a shift from a physician-centric model of work distribution and responsibility to a shared-care model, with a higher level of clinical support staff per physician and frequent forums for communication, can result in high-functioning teams, improved professional satisfaction, and greater joy in practice”

    But we’re given no evidence that the observed physicians actually are more joyful and satisfied than their peers, and no evidence that the management techniques described are the cause of any joy and satisfaction that these physicians do experience. They start with their conclusion and then claim that the anecdotes they share prove it.

    I think that fits the “an act of deceiving or misrepresenting” definition of the F word. If the monitors here disagree, I have no objection to my post being deleted.

  12. Rob says:

    Vic:
    As the person who used the “v-word” I would like to point out the whole of what I said. I was not saying we were poor defenseless victims that others should pity. I was saying that docs have become increasingly emasculated in a system that values us (read: pays us) for note and code generation more than for giving care to patients. I fought this for 18 years, trying to maintain patient-centered care in a system that was forcing me to use patients as commodities whose main purpose was data-generation. I fought it from the inside, and now am doing so from the outside. Patients, of course, get the worst of this arrangement, as at least we docs were paid to ignore our patients and focus on the data; patients are now simply raw-materials for CPT codes.

    But to deny the crisis atmosphere in primary care seems like someone with an agenda who wants to ignore a hard truth. Our system is encouraging docs to medical errors, and docs who go along with our system — one that discourages taking time with patients and practicing responsible care — are viewed as weak and selfish for giving in. Docs like me, who leave the system to build something better, are portrayed as sell-outs who aren’t doing our patriotic duty to accept insulting reimbursements for bad care offered by CMS.

    Please listen to the discontent of the PCP’s. We are the backbone of any system of health care and the system is doing its best to break our backs under a pile of data.

  13. Charles Kenney says:

    Thx Rob for being a voice of insight and reason as usual

  14. allan says:

    The following letter to the editor was written by Uwe Reinhardt in 2007

    Though it deals with compensation I think it can be expanded to other areas of physician concern in this discussion of victimhood which is a very poor choice of words. Would Dr. Reinhardt’s words be better “demoralized medical profession”?

    “In ”Sending Back the Doctor’s Bill” (Week in Review, July 29), you compare the incomes of American physicians with those earned by doctors in other countries and suggest that American doctors seem overpaid. A more relevant benchmark, however, would seem to be the earnings of the American talent pool from which American doctors must be recruited.

    Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.

    Besides, cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.

    This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.

    Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere.”

    • Barry Carol says:

      ”Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere.”

      I think Dr. Reinhardt is absolutely right about this. The unwarranted health spending elsewhere presumably includes inappropriate and unnecessary care including futile and marginally useful care at the end of life. Any care that the doc wouldn’t want for himself or a family member if he were paying the bill out of his own pocket shouldn’t be ordered for a patient either. Sensible tort reform combined with moving away from the fee for service payment model could eliminate a significant percentage of this systemic waste, in my opinion.

  15. Barry Carol says:

    If a large health system like Kaiser can attract and hold competent physicians and the docs know up front what is expected in terms of both workload and work environment, I don’t see what the problem is. As payment models move away from fee for service in favor of bundled payments and capitation where appropriate, the incentives that drive how doctors practice medicine will presumably change. As a patient, I don’t have a problem with incentives to withhold care as long as the care that’s withheld is unnecessary and inappropriate but sometimes would have been provided before if hospitals and doctors knew they would be paid for it.

    Large provider organizations need collaboration among their employees to be successful and they need to hire doctors who are personally comfortable with working in a collegial, team oriented, collaborative environment. Many doctors who grew up practicing in solo or small group practices with nobody looking over their shoulder are either unable or unwilling to make such a cultural transition. I suspect they are among those who feel most burdened by increased payer demands for documentation. The larger groups, at least in theory, can provide more administrative support to handle much of that work. While that adds to costs at the primary care practice level, good primary care should be able to avoid a lot of more expensive care down the road. The economics won’t work under a fee for service payment model but can and should work under capitation and bundling. Of course, the big provider systems need to learn how to take on actuarial risk if they don’t already know how to. Perhaps buying an existing insurance company could provide them with the necessary expertise in that area.

    The bottom line is that the healthcare world is changing along with incentives and payment models. Not everyone is able or willing to adapt to those secular changes. For those who are old enough to retire or will be soon, there is light at the end of the tunnel for them. The rest of the profession will probably have to adapt one way or another.

  16. allan says:

    Barry, how do you know whether or not the care being withheld is necessary care or unnecessary care. Many times even the experts aren’t sure.

    One thing, however, is sure. In FFS a work up will include many people and a thick trail of paperwork. The HMO need not have but one person involved and no paper work to withhold necessary care.

    Example: A patient passes out on the ladder and that person has a murmur. The potential diagnosis is Aortic Stenosis which without treatment leads to a high mortality in a short time frame. With a workup under FFS there is loads of documentation and people involved. Under capitation the doctor could simply say that the patient felt dry and passed out due to dehydration. When the patient dies if he is elderly it will be considered a normal death. The amount of savings is tremendous. I have seen this type of problem in real life.

    Please note I am not ascribing this to any HMO in particular rather trying to demonstrate the difficulty in discovering when an HMO is not treating necessary conditions and why they can be so dangerous.

    One of the best studies on this subject was by Ware (a non physician) comparing FFS to HMO. The conclusion: During the study period, elderly and poor chronically ill patients had worse physical health outcomes in HMOs than in FFS systems” (FFS = fee for service or a PPO (part of managed care, but far closer to FFS than HMO’s); HMO’s are capitated plans.

    In a capitated model one doesn’t have to deny care always. Just a comparatively few well placed denials can lead to millions of dollars in profit. That is an incentive hard to resist and many are unable to.

    Check out Harp.org

    • Barry Carol says:

      allan,

      I guess my bottom line on this is that either you trust the system or you don’t. How many people are over treated due to excessive testing, false positives and follow-up treatment and are harmed as a result? How many never get an accurate diagnosis despite an extensive workup? Also, how do we define outcomes for the elderly and poor people you referred to being treated by HMO’s.

      My personal view in an end of life situation, especially if I’ve already lived a normal lifespan, is that if I would not be willing to spend my own money for treatment even if I could easily afford to, I don’t think I should spend taxpayer or insurer money either. If some longshot cancer treatment might buy me an extra couple of months of low quality of life if it works at a cost of $200K, I would rather use that money to fund my grandchild’s college education. If I have advanced Alzheimer’s or dementia, I don’t want doctors to try too hard to keep me alive. Common sense should dictate when enough is enough unless people want to use their own money for marginally useful treatment.

      Resources are finite. We can only spend a given dollar one time and there are plenty of worthwhile competing priorities both public and private for the available funds. If there is more risk of potentially harmful under treatment with a capitated payment model vs. fee for service, that’s a risk I’m willing to accept.

      • allan says:

        “I guess my bottom line on this is that either you trust the system or you don’t.”

        Barry, what do you do flip a coin, or do you look at the incentives to determine potential outcomes?

        Dealing in general: A marginal extra test that makes a physician earn more money might help a rare patient, but in general doesn’t hurt the patient. If it does and it was unnecessary the suit will be lost. A denial of an important finding or symptom where the medical record is written up to protect from suit (HMO) is a case that loses in court.

        Thus in the end from the do no harm FFS/PPO is less harmful and suits are easier to win. In the HMO model (capitated) a denial can be life threatening and no proof may exist.

        End of life situation: You should control your own destiny. Should you involuntarily pay for another by being forced to take a specific plan? No.

        You are right, we spend too much and do too much, but I am solely looking at this from the patient perspective and where his risks are highest. Go to that study I suggested earlier and read it. It’s on the Harp.org site. Google Ware and go to the 4 year study. Old, but as good today as it was then because the incentives haven’t changed.

  17. sr says:

    Not to throw any further flame on this discussion, but nothing irritates me more than the scope of practice question and the implication that NP’s and PA’s are equal or even close to physicians in their abilities and qualifications. It is an extension of the undervaluing of physicians and their training, and this extends not only to primary care but the surgical fields as well.

    I think one of the most interesting take-aways from Vik’s comments is the view it provides into the enmity, disregard and condescension that is present towards physicians.

    • Perry says:

      sr,

      Good points about NPs and PAs. I would readily agree that they have a place in modern medical care, as I have used both in practice. There is currently a hot debate now because if we are saying that these mid-levels may be able to practice without supervision, what is the point of doctors spending time and money on MOC and the recertification testing?

      As far as medical errors, let’s be realistic here. Doctors do not cause all medical errors, many are the result of a combination of problems. By the same token, doctors that are nonchalant about it are unethical in my opinion. Classifying all doctors as such is the same as firing or disciplining all the employees of the VA instead of the ones responsible for the inappropriate behavior.
      I refuse to be a victim or classify myself as such. If doctors don’t want to play by these rules, get out or do something different in the system. We have spent so much time sniping at each other and in territory disputes, outside parties have taken over medicine.

  18. Charles Kenney says:

    Vik the example you site of a wretched doctor from 33 years ago seems not even remotely representative of the vast majority of physicians. Most docs are devoted to their patients and work very hard. Most went into the profession to heal and comfort. Your anti-MD view is so extreme it is difficult to take you seriously.

  19. William Palmer MD says:

    We are being driven by too many fads and ideas and rules arising outside of medicine…this is why we are unhappy. Further, many of these are bad ideas that take many years to prove wrong…up with which we are fed.

    Doctors did not dream of tax-deducting medical care if employers-employees paid but not allowing this if a private citizen paid. This was startling and unfair and has moved health care from a private individual affair with small doctor-patient units towards giant profit-seeking mega corporations selling health care to huge businesses. And it has caused frictional unemployment up the gazoo.

    Physicians did not decide Darling v Charleston Community Memorial Hospital in 1965 which changed hospitals from a physician’s tool into an entity that had to insure and deliver quality care and had to accumulate power to do this…..power that often exceeding that of the medical staff. This resulted in the physicians’ tool, the hospital hotel, feeling that it directed the show.

    Further, physicians did not allow U.S. Patents to be issued for drugs before they were proved useful which we thought completed the necessary triad of “novel, unintuitive and useful” in granting U.S. patents. This, of course, allowed early marketing and required users, providers and hospitals to fund more expensive post-marketing studies untill utility was finally decided. See Xigris.

    Just a few ideas from a host…

  20. Leslie Kernisan, MD says:

    I’m one of those docs who burned out of FFS primary care, in part because it’s especially hard if you want to focus on medically complex older patients.

    I’m very very glad to see Cochran & Kenney bringing attention to the working conditions of primary care doctors. It’s a very important job and it’s far too hard to do well. Modeling myself on Joe’s approach, here are the truths I think we will need to work with:

    - Most PCPs want to do the right thing for their patients. But, they still often are doing the wrong thing. This is partly due to time pressure & stress, partly due to cognitive biases and fast thinking, partly due to (for some) not being in the habit of listening to patients and partnering with them, partly due to not being in the habit of collaborating effectively w other healthcare providers, etc.

    - Many PCPs don’t agree with the above. (Reminds me of back when I was in med school and docs would vociferously object to the idea that they are influenced by pharmaceutical advertising; it took a lot of education and some pressure to change the tide on that one.)

    - Finding a reasonable way to manage PCP motivation will be hard. (Mike Painter had a good THCB post re motivation and physician incentives.) Docs & others respond to autonomy and things that cultivate internal motivation. How to get PCPs to change what they are doing without crippling this? Most of us have disliked being peppered with quality metrics – I was told my elderly patients BP was too high, grr – and performance measures…takes the joy out of the work:(

    - The current stress and pressure of the job makes it very hard to adapt to changes — whether they be new tech, new teamwork, better parterning w patients — and improve one’s approach.

    - I believe a PCP’s job should be to act as healer-partner to individual patients. But, it often takes more emotional and cognitive energy to practice this way.

    - Working with a professional team is hard work. Requires a well-set up team & training (which leadership usually skimps on), and even then it is work. I once had a doc tell me she left a well-established geriatric team practice, because “It was a pain to practice by committee.” Ok maybe she is a bad team player, but just as admin duties and email are not negligible, neither is the effort of working w a team.

    - Many non-doctors have bad feelings about doctors. And as a group, doctors (via AMA and others) have certainly oft acted to protect their priviledges and power. So it will take an effort to get the public to have interest and compassion for the working conditions of PCPs.

    Thanks for bringing everyone’s attention to this imp issue.

    • Granpappy Yokum says:

      Great post, Dr. Kernisan.

      It IS good that the problem is being discussed. I think why some of us are seeing red is that the solutions proposed by the original post, by the “Joy in Practice” crowd, by the PCPCC are very much in the quality metric/performance measures/team care/MOC/PCMH/population management vein: we see what they are proposing as further isolating us from our patients and only making things much worse.

      • Charles Kenney says:

        Granpappy

        It’s actually the opposite of what you suggest. I think if you read the Sinsky-Bodenheimer Joy in Practice report you will readily see that. It is an excellent and very important piece of work.

        • Granpappy Yokum says:

          As my previous posts make clear, I’ve read the report several times. And each time my reaction is “What did I miss?” The authors present absolutely NO EVIDENCE that the doctors in the practices they profile are more satisfied, less burnt-out, more joyful than their peers. I actually am familiar with several of the practices they profile, and I assure you that there are plenty of miserable, stressed out doctors working there (in two of them, significantly more than average, in my opinion). It would be very easy for me to write an article claiming that the practice innovations described cause “misery in practice,” but it would have as little intellectual validity than what S&B have written.

          This one article wouldn’t matter much, except that it’s being referenced by people who should know better as an “excellent and very important piece of work,” that it proves that this expensive, high overhead style of practice results in happy doctors. It proves nothing, it just gives us the opions and whims of the authors. This is exactly the anti-science, evidence free style of thinking (“I think it’s a good idea, so lets make it a policy”) that has given us lousy EMRs, crippling MU, worthless MOC, and everything else that is destroying the morale of practicing physicians. Articles like this are part of the problem, not the solution.

        • LeoHolmMD says:

          I think a lot of the anger you are witnessing has to do with how wrong the thought leader crowd has been in regards to almost everything promised in addition to never getting around to actually putting their money where their mouth is. So when you start singing the same song, it’s just another verse in the ongoing broken promises from quality talkers. The trenches are growing weary of listening to people who ride a desk for a living telling us how to do a better job with less money, more overhead and more regulation. When you see the big systems working from the inside, you see how they are part of the problem with runaway costs.

  21. Paul Gryundy says:

    Wow As I read the tread I see so much anger from a few and so much hope from other. I think change does that. I just visited 17 practices in the middle of transformation to PCMH level care (proactive primary care) in CT, NC and VA none the doc in Ct showed me what they are doing in this short video. http://www.cipci.org/future primary care office of the future.

    Patient Centered Primary Care is an effort to address the high cost/low value situation we find ourselves in as large employer buyers of care. Study after countless study shows that when a patient has a primary care physician that cares about them has and uses the tools to practice comprehensive care centered on the patient needs they get the care they need at a price we can afford. Let’s call that a Proactive Patient Centered Primary Care (PCPC) or Patient Centered Medical Home (PCMH).

    But we the buyers have been part of the problem (as Pogo said so long ago I see the enemy it is us) in not demanding systems of payment and practice organization that encourage and enable the comprehensive, patient-focused primary care we desire. There is no money paid for the necessary investments in teams and health information systems so essential to the delivery of comprehensive, cost-effective, patient-centered care. Current payment methods richly reward medical procedures and discourage spending time with patients in such essential activities as history taking, physical examination, diagnosis, planning treatment, counseling, coordination, and prevention. This must change. ,

    When one compares the U.S. health care system with those of other industrialized countries, one is led to the more specific conclusion that the two major problems in U.S. health care are the way we 1) fail to deliver comprehensive primary care and 2) the way primary care is financed. Our premise is that primary care is the only natural locus of control of health care quality and costs. It is the only entity that is charged with the longitudinal care of the patient. It is the only entity whose job it is to consider the whole patient, the health of the whole person, including mental and physical.

    As large employers our national focus on disease management programs is a good example of the failure of primary care and the failure of our efforts to improve care as a work around of the core problem and not face the real issue head on. If stand-alone disease management programs are considered necessary today, it is because primary care is not doing its job. From a primary care perspective, the treatment of chronic conditions, such as diabetes, congestive heart failure, and asthma, with the right tools is basic and straightforward. The care of these conditions is simply not that difficult. However, the quality failures in the treatment of these conditions are well documented. Stand-alone disease management programs which are not delivered at the point of care present a Band-Aid approach to problem solving. These kinds of work a rounds instead of addressing those problems directly, have in fact created additional, expensive, fragmented responses to the primary problem.

    For some reason, the healthcare industry and we as the buyer have demonstrated an inability to develop a sharp focus on solving core problems. We seem much more willing to create complicated responses to our problems than we are to fix the core problems of our delivery system. Again, disease management is a perfect example. If primary care is not delivering high quality care for those with chronic conditions, we can either find a way to work around primary care or we can find a way to fix it. Our willingness as large employers to “pay any price” for that episodic care which for example provides for a Diabetic amputation of a limb but our unwillingness to open our eyes and understand that the reason for the amputation was our failure to be willing to pay for the prevention and primary care.

    Although we tend to focus on the problems we face, there are reasons for a great deal of optimism-optimism due to the opportunities we have to improve and redesign care. Medical practice redesign is happening today. It is taking hold and has become a movement that is gaining momentum. We the large employers for the first time are at the table with the national health benefit companies and primary care professional societies. Let’s seize this opportunity and make the fundamental changes we have been asking for as large employers.

    While I would not argue that primary care should be all things to all
    people, it should be designed to achieve much higher performance than it achieves currently. Such a redesign of primary care is possible today. However, if primary care is not successful in its core tasks of prevention, wellness, and the care of common conditions including many chronic conditions, it will not be possible to control either quality or cost of care in the United States. Again, hospital care and Part-ecialty (specialty) care are crucial to health care, but their use is all too often the failure of upstream care. And look we have to start somewhere lets get really focused and address this lack of a foundation in are primary are delivery system and build onto a PCMH the better hospital and Part-ecialty we also need.

    For the first time in history, we have both the knowledge and the capabilities (if we work hand in hand with our primary care providers) to force together substantial change. We are at a unique time in the history. In five or ten years, we might well look back with amazement at the pace of the changes that are currently taking place. The route is clear: We know what to do. We know how to make the system better. The crucial question is whether we have the courage to take on this difficult solution. But are strength lies in the fact that the primary care physicians want to help us take this on a wholesale transformation at the Micro primary care practice level in exchange for payment reform at the Macro level.

    So how do we as large employers join the ranks of other systems like the VA and Denmark that have driven as much as 60% of the inefficiencies out of the system?

    In step lock with our partners, the primary care providers, lets make it clear to the healthcare benefit companies that we deal with that as an employer buyer it is no longer business as usual. Let also be counted on as employers to send the same message to the other large healthcare buyers Health and Human Services, CMS, Medicaid, Federal Employees, DOD TRICARE, the White House, Congress, State and local government and others.

    Demand of ourselves and our Healthcare benefit companies:

    Comprehensive, continuous, patient centered, personal and holistic primary care which is based on strong relationships between patients and their physician — this is foundational to good health. Practice and payment reform are the prescriptions for achieving it.

    • allan says:

      “Study after countless study shows that when a patient has a primary care physician that cares about them has and uses the tools to practice comprehensive care centered on the patient needs they get the care they need at a price we can afford.”

      This sounds like a bunch of contrived studies with a lot of selection problems and probably definitional problems as well.

      “uses the tools to practice comprehensive care”

      Please define the above.

      “There is no money paid for the necessary investments in teams and health information systems ”

      Really, no money?

      “When one compares the U.S. health care system with those of other industrialized countries”

      If the US were the same as those other countries they would be speaking German today.

      “The care of these conditions is simply not that difficult. ”

      The care can be extremely difficult because no two patients are identical and frequently they have more than one disease.

      “For some reason, the healthcare industry and we as the buyer have demonstrated an inability to develop a sharp focus on solving core problems.”

      That is very much caused by our predominantly third party payer system along with excessive governmental intervention. Employers should not have been given the exclusive right to the tax exemption for health care.

      “So how do we as large employers join ”

      Good managers of companies know their companies inside and out and develop good relationships with their employees, suppliers and their customers. As a rule they know very little about healthcare and insurance.

  22. Granpappy Yokum says:

    The VA has hundreds of empty primary care physician slots that it can’t fill because of low pay and difficult working conditions. It is interesting to see the VA promoted as a model of practice management we should emulate, particularly in a thread dealing with low physician morale.

  23. Paul Grundy says:

    the Whole Country has thousands of empty primary care physician slots not just limited to the VA for sure. We have under invested in primary care. We have over 20,000 die because they can not access car,. The Vets seem to bother us when they need to to lack of access and it should but what about the rest of our citizen what are they just part of the 47%.

  24. Wannabe Doc says:

    The world of healthcare is changing. If you are not ready to change, thousands of us toiling in med schools are willing (since we may not know how it was 20 years ago).

    I don’t see this any different than any other industry. “This is how we used to work twenty years ago” doesn’t work in other industries as well.

    For those who complain about it, take a look at “Who Moved My Cheese” book.

    • allan says:

      The world of healthcare is changing, but one wants the change in the right direction. Top down control is not the way to go. So far top down control has increased bureaucracies, increased the number of businesses feeding off the healthcare dollars, increased total healthcare costs, reduced access and is negatively affecting quality.

      I hope future medical students learn how to evaluate problems and not just rely upon committees to tell them how to think and act.

    • Granpappy Yokum says:

      So young, so wet behind the ears, so smug, so wrong.

      As you’ll learn one day, practicing physicians eat a big bowl of change for breakfast every morning. That’s how wesurvive.

      What we object to is change that is not based on evidence, but that is intended solely to deliver physicians and the health of their patients into the control of corporate greed. if you want to be part of that process, be my guest.

      • allan says:

        Granp…, don’t forget the young have to pay for the change they vote for and right now the total bill is nearing the $100Trillion level. Of course much of that has to do with the actuarial cost of entitlements and things like Obamacare, so they will be left with the problem of financing an impossible debt or getting rid of the programs. The greed of incurring debts hoping they may never have to be repaid eventually catches up.

        You won’t be around to remind them of their early smugness and lack of common sense.

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