Physicians–grumpy and getting grumpier

As the careful THCB reader may have noted, we like to feature Daniel Palestrant (CEO of Sermo) and Jonathan Bush (CEO of athenahealth) relatively frequently because a) they’re both very entertaining and b) their companies are providing new types of services that aggregate both the opinions and the clinical activities of physicians. Given that physicians are very important in health care, and that I (and my Health 2.0 colleagues) think new clinical and business processes are a must, it’s well worth considering what physicians are thinking.

My impressions from observing what’s happening in Sermo is that physicians are grumpy. Grumpy with insurers, grumpy with the AMA, and grumpy with government. My sense is that about 2/3s of commenters on Sermo wish they can go to some kind of cash-only direct patient pay system, and the rest would want to go to some kind of protected salary system. As reported by Palestrant on THCB, on Friday Sermo released a survey of results of its members done for athenahealth. And the results don’t make for great reading. Most physicians are unhappy about their lot and think that the recent reform will make things worse not better. They’re also extremely unhappy with the way (and amount) they get paid by private insurers, Medicare and Medicaid—there were literally 0% disagreeing with the statement that “Getting paid by Insurers has become increasingly burdensome and complex.”

What was pretty interesting was to dive into the details of the survey

My quick impression is docs who are registered on Sermo (and therefore we assume the surveyed docs) skew a touch younger than the whole population of docs, but not much. And they are slightly more likely to be practicing independently in practices of less than 3 doctors. (The AMA data considers over 3 docs in partnership a “group” and most doctors (well over 60%) have—despite all the changes of the 1990s—stayed outside of groups. The last time I looked seriously at this (over a decade ago in my IFTF days) reports of physicians leaving small practice were being much overstated—in fact many of the large practice groups blew up in the late 1990s and many hospitals divested themselves of the practices they’d bought. However, as the NY Times reports anecdotally, this seems to be changing very very fast.  We’ll have to look at the AMA’s new data, but anecdotally many docs are signing up wit hospitals or bigger groups, and the Sermo docs generally said that they don’t think small practices can survive (only 22% were optimistic).

The only place that there was any optimism (luckily for the survey’s sponsor athenahealth!) was in the arena of EMRs. No quick note here. I think that the data found in this survey either reflects poorly asked questions or a biased sample. Most current data suggests that EMR use is well under 50% among physicians and lower in hospitals. Of course it all depends what you mean by “EMR” but I’ taking the data point that 88% of those surveyed use an EMR either in their office or in a hospital as being pretty unlikely. That 53% say they are “very familiar” with an EMR is probably a better data point.

However, what the respondents report about EMRs is pretty interesting. It can be summarized by saying that EMRs improve the quality of the care they deliver, allow them to bill more, but slow their workflow and increase their practice costs. That fits well with what lots of doctors have anecdotally told me (and many others) over the years. But despite that, over 80% have a favorable or very favorable opinion of EMRs. This makes me a little optimistic, suggesting that the average physician will accept a little of the pain that implementing an EMR provides because it’ll help them improve the quality of care their deliver. Of course anyone who can reduce the pain and cost associated with EMRs is likely to find greater acceptance! And it’s also worth saying that less complex technologies (such as registries like Docsite) can probably get an bigger bang for the buck.

But part of the assumption of most of us expecting that digitizing clinical workflow will improve care is that it’s not enough by itself, and that we have to get away from FFS medicine and replace it with some other payment format. And here the survey is much less optimistic mostly because there’s a distrust in government. I think that Sermo attracts a slightly more libertarian than average crowd, but slightly more than half (54%) disagree that government regulation can lower costs and a similar (though not quite as distrusting) number think that it can improve outcomes. And when asked specifically about pay for performance while most think it might improve care quality, at least 50% think it will hurt their practices profitability. (Statistically that might be likely of course!).

Most worryingly 59% say the quality of medicine will go down in 5 years and only 19% think it will improve—suggesting that whatever changes they are expecting, most doctors don’t think thy will work.

In general it’s hard to expect doctors to be happy. And there are also questions about self-selection on Sermo. But to my mind it’s clear that we need doctors on board with changing how care is delivered both in terms of using electronic tools and changing care delivery organization and incentives. Now that the coverage fight is over (more or less), the next question is how Medicare is going to run pilots to change its incentives, which of course means getting doctors on board. It’s hard to imagine that happening in an atmosphere as pessimistic as the one this survey reveals. A little bit of physician marketing would be a good way to start.

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