Lost in the Health Care System?

Lost in the Health Care System?

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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 Comments on "Lost in the Health Care System?"


Guest
Vuckovich
Jun 4, 2014

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?

Guest
Jun 4, 2014

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.

Guest
Charles Kenney
Jun 5, 2014

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.

Guest
Jun 4, 2014

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.

Guest
LeoHolmMD
Jun 5, 2014

Sounds like they are perfecting burnout.

Guest
Joel Hassman, MD
Jun 5, 2014

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.

Guest
Charles Kenney
Jun 5, 2014

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

Guest
Joel Hassman, MD
Jun 5, 2014

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

Guest
Granpappy Yokum
Jun 5, 2014

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.

Guest
Charles Kenney
Jun 5, 2014

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.

Guest
Jun 5, 2014

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.

Guest
allan
Jun 5, 2014

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.

Guest
Vik Khanna
Jun 5, 2014

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.

Guest
Vik Khanna
Jun 5, 2014

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.

Guest
allan
Jun 5, 2014

“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.

Guest
Joel Hassman, MD
Jun 6, 2014

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

Guest
Charles Kenney
Jun 6, 2014

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.

Guest
Joel Hassman, MD
Jun 6, 2014

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?!

Guest
Charles Kenney
Jun 6, 2014

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

Guest
Jun 5, 2014

“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.

Guest
Charles Kenney
Jun 5, 2014

Joe really well said

Guest
Vik Khanna
Jun 5, 2014

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?

Guest
Charles Kenney
Jun 5, 2014

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.

Guest
Vik Khanna
Jun 5, 2014

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.

Guest
Charles Kenney
Jun 5, 2014

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?

Guest
Jun 5, 2014

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.

Guest
allan
Jun 5, 2014

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.

Guest
Vik Khanna
Jun 5, 2014

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.

Guest
allan
Jun 5, 2014

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?

Guest
Jun 5, 2014

Amen, Joe. Very well-said.

Guest
Jun 5, 2014

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.

Guest
allan
Jun 5, 2014

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.

Guest
Jun 5, 2014

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.

Guest
allan
Jun 5, 2014

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.

Guest
Jun 6, 2014

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.

Guest
Granpappy Yokum
Jun 6, 2014

“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.

Guest
allan
Jun 6, 2014

“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?

Guest
Granpappy Yokum
Jun 5, 2014

“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.

Guest
Jun 5, 2014

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.

Guest
Charles Kenney
Jun 5, 2014

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

Guest
allan
Jun 5, 2014

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.”

Guest
Barry Carol
Jun 5, 2014

”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.

Guest
Barry Carol
Jun 5, 2014

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.