By
Talk to the chief executives of American’s prominent health –care institutions, and you might be surprised what you hear:
When it comes to medical care, the United States isn’t getting its money’s worth…A high-performance 21st century health system, they say, must revolve around the central goal of paying for results. That will entail managing chronic diseases better, adopting electronic medical records, coordinating care, researching what treatments work, realigning financial incentives to reward success, encouraging prevention strategies, and, most daunting but perhaps most important, saying no to expensive, unproven therapies. — Ceci Connolly, “U.S. ‘Not Getting What We Pay For.’”
As we approach the Obama administration’s dawn, health care institutional leaders, think tank experts, and politicians recently gathered in Washington, D.C. to pronounce what needs to done to fix the system. The Washington Post reported that leaders from Mayo, Kaiser, Virginia Mason Medical Center, the UnitedHealth Group, and other leading health care organizations were there.
No Complaint
I have no complaint about the executives’ conclusions or opinions issued therein. I note, however, that leaders representing independent physicians were not there to give their point of view. Practitioners presumably were too swamped taking care of patients and trying to meet the bottom line. They rarely have the time or money to spend attending august gatherings.
One Quibble
My only quibble is that those who go to reform meetings rarely represent clinicians in the trenches – those who deliver over 80% of the care. Instead those who go represent the “adminisphere” of institutions, those managing the affairs of large organizations. Not represented are the practicing physicians outside those institutions, who are less well-organized and who speak with multiple voices.
Modest Proposal
I have a modest proposal – that we strive to place practicing physicians at the reform table. As everybody knows, the Clintons’ 1994 reform effort ignominiously collapsed for want of input from those who delivered the care. In retrospect, one reason for that effort’s failure was the absence of practicing physicians and practicing hospital administrators in the Clinton task force of more than 1,000 contributors, composed mostly of Congressional staff, academics, and policy wonks.
The Clinton effort proposed a universal managed competition system that few understood, that was so complex, so unrealistic, and so fraught with managed care jargon that Harry and Louise had an easy time shooting it down. Ira Magiziner, the senior health care advisor to the Clinton task force, unlike Mafia dons, was said to offer a favor that nobody understood.
This Time Around
This time around, we are told, things will be different. “The reform stars,” says the Post, “will be aligned,” Among physicians, insurers, academics, and corporate executives from across the ideological spectrum, “there is remarkably broad consensus on what ought to be done.”
A Spoilsport Speaks
I don’t want to be a spoilsport, but I’m not so sure. Health plans, private Medicare plans, device manufacturers, pharmaceutical firms, and others in the supply chain who profit from the status quo will have lobbyists willing and ready to challenge reform assumptions and will not be taken by surprise. Independent physicians, weary of harassments and low reimbursements from Medicare and Medicaid and private plan followers, are leery of government efforts that infringe upon their autonomy and sovereignty.
Escalating Physician Shortage
Let us not forget the looming physician shortage at the primary care entry level of patients into the system. Universal coverage without primary is access is meaningless. Just ask Massachusetts citizens. And if Congress follows its formula for cutting Medicare by 21% in June 2009, we will have a political donnybrook of unimaginable dimensions on our hands. If that cut occurs, it is likely 1/3 of physicians will no longer accept new Medicare or Medicaid patients. The outcry from the disenfranchised but entitlement-minded populace will be thunderous.
No Single Organization Represents Independent Clinicians
As things now stand, no single organization speaks for independent practicing physicians.
- Not the AMA, which now has only 1/5 of physicians as members, which is perceived to be on side of specialists in its coding system, and which has failed in such things as broad20malpractice reform, the bête noir of most doctors.
- Not the MGMA, whose 2800 members are made up mostly of practice managers of groups.
- Not the Medical Group Association, which is comprised of the multispecialty megaclinics of America, who care for about 10% of Americans.
- Not the Association of American Medical Colleges, representing teaching hospitals, academic medical centers, and whose mission is serve and lead the academic medical community.
- Not the New England Journal of Medicine, a liberal publication – the voice of academic medical community and advocates of government mandated universal coverage.
- And certainly not America’s Health Insurance Plans (AHIP), 1,300 strong, which serves as a surrogate for American business, covering 150 million Americans, and whose policies are not necessarily in the best interests of independent physicians.
It is largely practicing physicians’ own fault that no unified voice represents their work on the front lines. Doctors are fragmented into more than 100 different specialties, each with its own ax to grind. This overspecialization has clouded and diluted the common interests and has produced doctor disarray across the practitioner spectrum. And because most doctors function in democratic autonomous small groups in which each participant has veto power, they are not as well organized or purposeful as hospitals, payers, suppliers or drug firms.
Who Speaks for Independent Practitioners
As I see it, three organizations are rising to represent the voice of frustrated independent practicing physicians who want a voice at the health reform table and who seek to change the shape of American medicine.
Sermo – This social networking website formed two years ago. It is open only to physicians and has about 100.000 participating doctors. Its purpose is to let doctors openly present cases to each other, learn from each other, give early evidence of adverse drug reactions or positive drug effects, voice their complaints, suggestions, and observations about the current health system, and to unite on issues relating to reform. Sermo physicians are not happy with with system, tend to favor consumer-driven care, harbor a deep angst against health plans, and do not believe EMRs represent the Holy Grail that will lead the system onto higher ground. Sermo’s participants are in the late stages of issuing an Open Letter to the American Public signed by 10,000 physicians about their grievances.
The Patient-Centered Primary Care Collaborative (PCPCC)– Paul Grundy, MD, an IBM physician executive, deserved credit for being the moving force behind this collaborative. As a buyer of care worldwide for IBM, he had observed that countries with a broad primary care base have higher satisfaction, higher quality, and better outcomes than the U.S.
The organization, now about two years old, is coalition of primary care organizations (America Academy of Family Physicians, American College of Physicians, American Academy of Pediatricians, and American Osteopathic Association), major employers, consumer groups, quality organizations, and health plans. Its main purpose is to advance primary care and increase its numbers to improve care, sustain the system, and change the mode of compensating physicians. Irrefutable evidence shows a broad primary care base cuts costs, improves care, and enhances outcomes. Though multiple initiatives at the state and federal levels, the PCPCC is pushing the concept of the Medical Home, led by primary care physicians and their teams, to offer coordinated comprehensive care at one location. These initiatives are running into political resistance from some quarters and are at the lift-off stage. Given the tyranny of the status quo and profitability of entrenched special interests, progress may be fitful and slow, but is nevertheless underway.
The Physicians’ Foundation – Created in 2003 with assets of $98 million as the result of a successful claims action suit against major insurers, the Foundation represents state and local medical societies, which have a much larger membership than the AMA, perhaps because they are closer to the ground and know intimately the concerns of their members.
The Foundation seeks to improve care delivered by its members through grants and through surveys highlighting their problems. It has issued grants worth $22 million to 41 member organizations, often relating to EMRs, but found members were ill-equipped to implement these systems and to use them in a productive way with adequate return on investment or improvement in practice quality. On November 18, the Foundation released results of a national survey mailed to 270,000 primary care physicians and 50,000 specialists.
The survey, released to national news media, received wide exposure. It indicated a deep loss of morale among primary care physicians, with 78% of respondents saying a shortage of physicians existed, 49% saying in the next three years they planned to reduce the number of patient seen or to retire, and 60% indicating they would not recommend medicine as a career to young people. More and more physicians are seeking a way out. Growing numbers are seeking hospital employment and non-clinical positions. Through this survey and other efforts, the Foundation hopes to persuade policymakers that something has to be done to address the concerns of primary care doctors and to ward off an impending and escalating physician shortage.
Such a shortage no doubt will create a political crisis. The Foundation believes compensation methods for rewarding primary care doctor’s needs to be overhauled, and the 21% cut in Medicare fees, scheduled for June 21, 2009, must be averted.
Conclusions
Unhappy doctors are groping to find a unified voice, expressing their frustrations with the existing health system. Certain organizations – Sermo, Patient-Centered Primary Care Collaborative, and The Physicians’ Foundation – are emerging as vehicles to influence policymakers, to express physician unhappiness, to warn pervasive loss of morale will produce further physician shortages, and to predict these shortages may lead to an access and a political crisis.
Political reforms that expand coverage are certain to exacerbate the physician shortage and magnify defects of the system. The solutions may lie in more equitable payment reforms, more formal and larger physician organizations, in more hierarchical organizational structures and in salaried employment. Primary care physicians and specialists will need to find common ground to end doctor disarray and to serve patients better in a more coordinated and comprehensive fashion, or the greater physician community will continued to whipsawed between more organized entities seeking a larger part of the health care pie.
Richard L. Reece MD is a retired pathologist who believes in the abilities of practicing doctors and their patients to control and improve their health destinies through innovation. He is author of ten books. The latest is Innovation-Driven Health Care: 34 Key Concepts for Transformation.
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I bought this because I just needed something to help me open up a 5th Generation iPod Video.
Tell me specialists will not find a way to keep their income. Canada found that supply of doctors did not affect health costs, each new doctor created was a profit center and needed to produce income one way or the other, irregardless of supply. Limiting docs was the only way to control costs as even an over supply did not lower costs with reduced prices or billings. My own wife’s hospital is seeing a reduction in usage due to the economy but they’re not announcing any health sales yet, like two knee surgeries for the price of one. Anyway, this is a moot point as America is not going to change lifestyle anytime soon.
Peter – That’s a pretty difficult statement to make. I agree that the powers of supply and demand, which are very strong in most markets, are not as strong in the healthcare market. However, you are suggesting that a drop in demand will INCREASE price. Even though the healthcare market is in disarray right now, I just don’t see an opposite supply/demand effect happening. At some point, consumers have to make value based decisions to allow the competitive forces to take hold. It’s not happening too well right now, but I think it would kick in before the scenario you described can materialize.
If you look north to Canada, their diet, stress, exercise, and exposure to environmental toxins is about the same as the U.S., at least in and around the urban centers, yet their healthcare spending is about 1/2. Poverty support is better but there are still food banks and homeless. So the health system does matter greatly. I think if people in the U.S. did all they could to stay healthy and reduced utilization, the for profit system would turn those savings into higher healthcare costs to support the same number of providers.
twa – You raise an important point that could be explored further. I would counter that American lifestyles do play a major role in our difference in spending compared to other developed countries. Our obesity rates are higher. Same with hypertension and chronic conditions in general, teen pregnancy, gun violence, and many other key measures that drive up costs.
I’m not saying it’s the biggest reason for the higher spending compared to France, Germany, etc, but it’s a bigger factor than many realize.
twa, I cannot agree more that no one person is perfect, but a team can be, and getting integation in care is the best way to get the best care. Maybe I misinterpreted your post. That’s why I said, PCPs have “potential value”. I’m not advocating they maintain their “shoe repair” model, but I think institutions tend to get impersonal because of the assembly line attitudes that develope. There’s no reason we can’t have PCPs who have the right mindset and are trained and reimbursed for co-ordinated care. Maybe you said if its all under one roof it has easier access and communication. Maybe Dr. Reece can comment on his practice and how he attempts to co-ordinate care and different caregivers.
Peter – It is not a choice between independent docs and “institutions”. The fundamental interaction is ultimately the doctor and patient, whether it is a solo doc or an “institutional” doc (besides the fact that we should be moving to more team-based collaborative care). Why would I want care for me or my family from a solo doc with limited support systems, no back up, no ready access to colleagues for advice, no coverage after hours, no ability to easily share my medical records with other providers, incentives to over-treat, limited resources for keeping up to date on training (a problem you point out yourself) … need I go on?
This isn’t about “institutionalized PCP’s”. That’s so 1980’s. Even Kaiser isn’t that Kaiser anymore. This is about moving into the 21st century. Look at where health care is going – it is about systems and structures that can support reimbursement that better aligns interests around providing coordinated, connected, and comprehensive care. If you really look at the issues driving cost and poor quality, the Dartmouth data, employer trends, transparency efforts, efforts at measurement and outcomes, population health, the triple aim, on and on – all are better addressed through integrated care – not solo practitioners operating in the same business model as the guy that fixes my shoes.
Yes our personal behavior is a large influence. But I just can’t believe that American’s behavior accounts for the exponential difference in cost/outcomes that we experience relative to other countries.
“The solo/small/independent practioner is an out-dated business model that we should no longer accept (the exception being rural healthcare).”
I disagree with this statement because it fails to recognize that healthcare IS a people business, not an institution business. Independant docs like Dr. Reese may be unwilling to adapt or change, but they still have tremendous potential value in healthcare because they ARE NOT instituions and can know their patient’s conditions intimately. I personally have not had good diagnostic experiences with PCPs, but so far have determined that it equates to out of date medical training and poor reimbursement incentives. And tell me why the solo practitioner is so good for rural healhcare and not urban, and if that would include city clinics serving the poor because institutions will not have them?
“The poor healthcare outcomes across the population tell us that the individual practitioners providing fragmented care without information systems and proper infrastructure and support are not delivering value for the money spent.”
NO, poor healthcare outcomes are because we eat crap, breath crap, drink crap, are stressed to keep up with the Joneses or just get by, and we sit in front of TVs and computer screens more than we use our feet. Tell me how institutionalized PCPs will change this?
Interesting points Tom. However, the key thing you said was “with the data we have at hand”. I’m not sure we can truly prove the worth of primary by analyzing what we have now. We don’t need incremental change. We need significant change in terms of a focus on prevention and coordination. Most people wait to see their doctor when they’re very sick. Others go for very minor issues that don’t require a physician’s time, expertise, and cost. We can’t look at the current state in a vacuum. It has to be looked at with a broader lens to also include patient behavior, as well as the value of using midlevels for services not requiring a physician.
Dr. Reece says “Irrefutable evidence shows a broad primary care base cuts costs, improves care, and enhances outcomes.” He then cites a summary of work by Barbara Starfield of work that draws strong conclusions from relatively weak, ecological associations. That work needs to be replicated and assessed objectively. When it is subject to scrutiny, it doesn’t hold up very well. See:
Ricketts TC, Holmes GM. (2007) Mortality and physician supply, does region hold the key to the paradox. Health Services Research, Volume 42 No. 5. 2233-2250.
That study doesn’t completely negate the conclusions of Starfield and colleagues, but does strongly suggest that it needs careful re-analysis and continued attention.
I am convinced that the voice of the independent physician is missing from the debate to some degree, and I also believe that and enhanced contribution of primary care is necessary to create an effective and efficient health care delivery system. I am also convinced that we have not yet “proven” the values of primary care led system with the data we have at hand. Primary care is partly valuable because it deals with failures and negative outcomes. The association of supply with negative outcomes is not a terrible thing given that that is what medicine is all about. The costs measurements are a slightly different thing and we are still a very long way with appropriately assigning costs to medical inputs
Good post and point well made. One thing which continually disturbs in the discussion of health care reform is that the largest stakeholder is absent from the table. The patient.
Many patients are aware of the issues in health care delivery and health policy. There are patients who want to have a voice at the table, but too often the attitude is that patients are just consumers who need to be marketed to. Some of that marketing includes what we are told we need, whether it’s a particular drug, an insurance/payment scheme (ie. CDHC), expensive interventions, specialist care, or a medical home.
Admittedly, I have read patients grumble about the increased copays for specialty meds they will be required to pay in the coming year. For instance, a drug copay which is now $50 will be $150 next year. But for a drug which costs over $2100 per month, that’s still not too bad, especially since most Medicare Part D plans and some private insurance plans require a 33% copay which is $700 per month.
My opinion is that representatives from the patient trenches need to be sitting at that health reform table. Why should patients care how the health care system is run if they have no say in how it is structured? If reformers want patients/consumers to have “more skin in the game”, they need to let patients have more say, not simply demand that they spend more money directly from their personal checking accounts. JMHO
“The Foundation … has issued grants worth $22 million to 41 member organizations, often relating to EMRs, but found members were ill-equipped to implement these systems and to use them in a productive way with adequate return on investment or improvement in practice quality.”
The solo/small/independent practioner is an out-dated business model that we should no longer accept (the exception being rural healthcare). Every other segment of our society has progressed to systems and structures that effectively leverage capital, create innovation, and drive down costs. Why do we accept far less in healthcare when it is increasingly clear that the elements that create better care – comprehensive and coordinated care across settings and over time – are best delivered by larger, more integrated groups and systems. The poor healthcare outcomes across the population tell us that the individual practitioners providing fragmented care without information systems and proper infrastructure and support are not delivering value for the money spent.
Yes independent physicians need to be involved – they need to step up, acknowledge that the business model that they cling so tenaciously to is out-dated, and they need to be part of defining how they can work in systems and structures that lead to better outcomes.
We can only hope that our new president will follow through on his promises of healthcare reform and help us save some money. As a webmaster for a group healthcare and financial products broker in Dade and Broward counties in South Florida, I see just how much the costs of care have risen here due to the heavy population of retirees and their needs for prescription drugs and just plain general health pictures. I am approaching retirement myself and have no desire to have to spend my hard earned annuities or IRA and 401K that I have saved as part of my retirement planning on healthcare insurance! Car pooling can help save a little, but healthcare reform would save me a whole lot more.
Jean Drogus
http://www.securefloridian.com
Sorry doc but your own line says it all; “It is largely practicing physicians’ own fault that no unified voice represents their work on the front lines.”
The reality of life is that those who organize get their point of view across. Unions figured this out a long time ago as did industry associations. No easy solution except to go about doing it.
post more related to this…. it is useful
That’s the best post I’ve read in quite some time! Thanks for the thoughtful insight. I agree with nearly everything you said. One small correction: Independent practices are well represented in MGMA, including yours truly. However, I haven’t seen MGMA organize any kind of effort that will achieve anything, despite my call to them to do so.