Managing Physician Skepticism About the Affordable Care Act

Let’s play a game. Today we are going to pretend you are a Vice President for Medical Affairs, or a Chief of Staff, or a health system CEO about to announce a collaboration with a major health insurer like CMS or a regional Blues Plan. You’ve done your homework, read the journals, listened to the experts, anticipated the future and haven’t applied enough skepticism in reading all those pro-EHR and pro-bundled payment posts on THCB.  You really believe payment reform and the EHR are the way to go.

You’ve called a meeting of your organization’s physician staff – the professionals you are counting on, caring for all those patients – and your job is go to the front of the auditorium and convince them that the success of your new venture relies on lowering health care costs with new payment arrangements that align incentives, in tandem with the launch of a new EHR.

Armed with a 30-slide PowerPoint filled with the latest consultant nostrums, you launch into your presentation.  The physicians listen in respectful silence.  After a few easy questions, there’s always that one doc in the back of the room who uncomfortably points out that the evidence about the ability of payment reforms and the EHR ability to optimize costs is uneven and that organization is making a huge bet.  Many of the docs in the room nod in agreement.  That’s when you realize that the insights of all those economists, policymakers, politicians and bloggers mean nothing if you don’t have the physicians on board.

That’s the real message behind this telling survey that was just published in JAMA.  While the overwhelming majority of physicians agreed that they have responsibility for health care costs, higher percentages felt hospitals, health systems, insurers, pharma, medical device manufacturers and personal injury attorneys had a greater mandate.  In other words, everyone is responsible, but the physicians’ duty is superseded by their ethical obligation to advocate for their patients regardless of cost.  The survey also showed that not all physicians are convinced that the electronic health record (74%) is a cost-reducing panacea, while a minority felt readmission penalties (41%) and bundled payments (35%) were likely to lead to lower costs.

So what do you do? How do you convince physicians to get on board and make this thing work? What can you possibly tell them to convince them that they should set aside their preconceived notions about the grand adventure you are all about to engage on is a worthy one?

Many THCB readers probably believe physicians either don’t understand the merits of health reform or are acting out of economic self-interest.  I don’t believe either are true, but that’s not the point.  After years of operating in their closed information loops, pre-reform pundits, policymakers and politicians have convinced themselves about benefits of information technology and payment reform without bothering to do a reality check with their doctors.  These survey data should act as a note of caution to all those VPs, Chiefs and CEOs who believe that what the “experts” are telling them is really the truth.

Jaan Sidorov, MD, is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Disease Management Care Blog. This piece was adapted from a recent DMCB post.

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27 replies »

  1. Interesting comment. I too have some questions.

    What other industry in a “free” market is tethered to the life support systems of the 3rd party payor for its very survival (the largest of which is far and away the federal government)? Is that not the crux of this entire problem? Concierge is but a well-heeled gnat on the back of the gnarly beast here.

    What are the one and five year failure rates for small business startups generally? (Hint: on the order of 50% and 95% respectively).

    What does AHIP CEO Karen Ignani make per year? (Hint: ~$2 million)

    What was United Health Group CEO Stephen Hemsley paid in 2012? (Hint: $13.89 million)

    Is Robert Downey Jr. worth $75 million per year? (~75 heart transplants)

    In what other industry would arrogant juicer A-Rod get banned from his industry and still be able to collect $60 million from the remainder of his industry contract?

    The things we value as a society are seriously askew, from a moral perspective, are they not? But, hey, that’s a “free” market” “democracy,” is it not?

    Focusing back on “health care” (sportstainment being easy to dismiss), is Stephen Hemsley “worth” eighty times the average family medicine doc’s 2012 compensation ($13.89 miliion / $175k, re: Medscape 2013 physician compensation survey). He’s apparently “worth” it some some stakeholders.

    I too ” just want to provide…for [my clients] and community and earn an income that is consistent with [my] own personal needs, aspirations, expectations.” But I have to make the market value-add case every time, with no 3rd party payors in sight. No one gives a flip about “all the time, effort, financial resources and expenditures that [I] have put forth.”

    I personally wish that competent physicians were paid at LEAST 2-3 times that which they make now, given the breadth and depth of expensive knowledge they must master, and the ongoing assiduous care with which they must subsequently dispense it. How can we get there? In a “free” market” “democracy”?

    (ps- Seeing the words “free market” and “democracy” in the same sentence begs a few more questions, does it not?)

    CODA: From CNN Money, in 2011, “The top 25 hedge fund managers took home an average of $576 million each.” Jeez, Hemsley’s just a Minor Leaguer.

  2. Good question, Dr. Falkoff. The assumption underlying the dissemination of the EHR and the institution of these bundled/capitated payment arrangements is that large, organized or integrated provider practices are the only way to organize the human and economic capital to increase quality and lower health care costs. The result in the clinical trenches is the perception (warranted or not) of federal hostility toward the small physician-owned practices that still provide the majority of health care in huge swaths of the U.S. geography. That is the specific message.

    That being said, I remain optimistic that the future is still bright for all those thousands of private practices. The survivors are staffed by hustling entrepreneurs who really care about their patients and provide a level of service and cost-effectiveness that can and often do exceed the averages of those large mega-corporate ACO wannabes. I’m not sure just how they’ll succeed (that’s a topic for another post by someone far wiser) or how badly income levels will suffer, but outpatients – despite Washington’s levers – know value when they see it. Those practices that tap into that need will do very well indeed.

  3. I think many would like to know how this complex evolving system of healthcare is going to account for, accommodate,all those thousands of private practices, especially in primary care. Whether those private businesses are just starting out, one year old, 2 or 3, or 5-10-15-20-25 or even longer. What is going to happen to all the time, effort, financial resources and expenditures that these individuals have put forth? What is their short term and long term futures under these new and evolving systems? Many wanted to start, run, stay in businesses of their own. Many just want to provide care for their patients and community and earn an income that is consistent with their own personal needs, aspirations, expectations. What message is being sent to those in practice now, running their own businesses, as well as what is the message to others considering medicine as a career? Will all physicians have to work for the government? A hospital system? Or other large organization? What about those medical students in the pipeline? What other industry in a free market, democratic society does this?

    Please explain in details and not generalities.

  4. Dr. Reece notes change is both inevitable as well as hard. That being said, says he, docs should not despair: if done right, team support and technology will make things better.

    Alas, Dr. Reece – the EHR and its supporting technology has been around for more than a decade. You’d think that if it was going to work, it would have declared itself by now with a value proposition that is self-evident in the clinical trenches. Instead, HIT remains very much a promise that has yet to be fulfilled. While we wait the arrival of efficiencies, time savings, better work flows, quality and lower costs, too many docs – who are trained to be independent thinkers – are concluding that these boxes and funny cash flows are just not quite ready for prime time.

    And then there’s the common final pathway for health reform’s apologists: that this is an “experiment,” chock full of “innovation” waiting to be sampled like some fluffy nougat in a Gumpish box of chocolates. Listen to the White House, CMS and most of the pro-health reform economists, and they are always inclined to say that payment changes and HIT are OBVIOUSLY “the” fix to all that ails health care – that is until the back of the room heckler points out that many inconvenient facts and physician opinion suggests otherwise. That’s when the “experimental,” “pilot,” “demonstration” “trial and error” nostrums come out.

    What else could account for LegacyFlyer’s opinion. Too many docs are in his or her camp and it does not bode well for Plan A.

  5. There is nothing I like better than having my “expectations managed”. Most people prefer to have their “expectations managed” rather than met or exceeded – don’t you?

    Yes if only a well dressed, well spoken shill – oops sorry – physician leader tells me how good things are going to be with the new EMR, well by golly it must be true.

    And how do I know that what they say is true?
    • Never mind my own experience with using the EHR, which has been painful and has cut my productivity.
    • Never mind that there is no proof that EHRs save money.
    • Never mind that there is no evidence that EHRs improve outcomes.
    No, it must be true because as doctors we must believe that EMRs are the key to improving medical care. Because if we don’t believe that well …. maybe we won’t drink the KoolAid.

    Is there a plan B if the EMR doesn’t pan out like its proponents say?

  6. John: If I were addressing a group of skeptical physicians about the changes taking place, I would say it differently. I would say things are going to be different, perhaps better because of organizational support and technological support, and because of coordinated team care, but maybe worse if you are wedded to the concept of personal autonomy for physicians. Technological aid will come in the form of diagnostic support, instant access to historical information, data about drug interactions, and electronic connections to patients and colleagues. The underlying idea behind these changes, advocated by both private sector and government , is to make care better and more cost-effective. But achieving these outcome will not be easy.
    This is an era of experimentation, a search for a better way of doing things. Sometimes experiments fail, like ACO “savings,” EHR “efficiencies,” pay for value,” but they are gropings for better ways of doing things. Sometimes things get worse before they get better.
    Will it be hard? Yes. Change is always hard. Let’s face it. You will have to become skilled and comfortable with entering, absorbing, and interpreting data electronically. Some of you will not like with computer system-driven care. You will find it lessens your personal productivity. It will be awkward to use and to digest. Some of you, particularly older physicians, may drop out, retire, form concierge practices, or join physician-driven groups. But most of you will hang in there, welcome organizational transformation, and understand the need for management systems that promise better, more cost-effective care. We hope you will be leaders in this transition. There is a better world coming. Accept it. Help shape it.

  7. Hey m13! It’s great sport to be that back-of-the-room heckler and for any physician-reader who hasn’t given that role a test drive, you really should. Armed with the right kind of anecdote and a selective quote from the medical literature, no administrator is immune. Ironically, I’ve also been on the front end of that unpleasant experience, so I know of what I speak.

    Yes, much ultimately depends on that younger generation of physician-millennials who, if generalities are correct, are even less likely to care about the EHR or how their salaries get funded. On the other hand, in the course of my conversations with students and residents, I’ve been pleasantly surprised by how well-informed they are. I have reason to hope.

    I’m not too sure that the financial aspect of healthcare in the U.S. is as bad as everyone says. Health care cost trends have been tolerable in the last few years and is right now it’s lower than many other developed nations. The integrated model has much going for it, but it’s not – despite how much we think of ACOs – generalizable to much of the U.S. I agree that big data is an important part of the solution, which is something that is remarkably absent from the blunt force capabilities that surround currently available EHRs (a billing and documentation tool) or payment reform. The mathematics dealing with measures of central tendency or comparators around fairly setting bundled payments have lots of problems and CMS doesn’t quite seem up to the task… but that’s a topic for another post.

    Last but not least, you’ve hit the nail on the head: if we docs are going to take a personal hit, come out and tell us. Stop with the BS, please!

  8. Alright, I’ve taken a breath. What I said before stands in that a big issue right now is that reality has changed and the expectations that were in place before are no longer reasonable.

    #1 The financial aspect of healthcare in the US is not tenable. #2 There are many benefits from the integrated model and using processes to guide some of our work. #3 Data can be a surprising motivator in understanding and making explicit the actions we take, our reasoning, and the different results from our actions.

    If we as physicians can accept these basic tenets, we can start to work with them. The truth is that we all want the system to be better for the greater good. What we have to accept is that in that process, we may take a personal hit.

  9. I think the issue is one of paradigm. I too am an MD. I too have an MBA. I chose not to enter the world of finance or business (some people get the additional education for reasons other than to make money), but to continue to work on different aspects of healthcare, including clinical medicine.

    I think the problem is that there was an implicit contract for many physicians in the last few generations. Doctors from the early 1900’s didn’t expect to get rich, but they did expect to be respected members of community, to have autonomy and to not struggle for their livelihood. Since the 1970s, there has been perhaps a greater (too great?) a focus on monetary gains, but the old expectations from the field was still reasonable – you could make good money, be fairly well respected, have autonomy, AND do good for people. All without having to take on huge risk. Yes, you had to incur expense in training and defer gratification, but all in all, it was a worthwhile trade off.

    Now, the field has shifted and that’s the problem. In other countries, physicians don’t necessarily make a lot of money, but they’re fairly comfortable, respected, not constantly worrying about liability, don’t have huge expenses coming out of school and are fairly happy with their service to others. Their situation is in alignment with their expectations, and their expectations are in synch with the investment they have made.

    It will be interesting to see how the younger generation responds. Will they be well behaved checklist following, decision support guided, leave at 12n after call because they follow work hour regulations, well healed hospital employed, non-independent practitioners that follow the rules, but really love their stable hours and integrated healthcare system providers? Just read posts by some of the up and coming writers in medicine. They tow the line perfectly and criticize all the old ways and practitioners biases, just like the policy makers, emr vendors, and pundits.

    I have consulted in hospitals trying to move physicians and I have been the heckler in the back of the room. The sad truth (from my cynical self) is that I don’t think it matters that physicians aren’t on board. If we don’t tow the line, we will be replaced – by younger generations and ancillary providers who will be given broader scope of practice, because after all, ‘we really don’t need doctors for the vast majority of care given’.

  10. LKernisan says: “busy docs tend to take the path of least resistance. ”

    I’d say since time is limited and Docs pick their battles. It is government involvement that removes the patient from any responsibility so that the patients can overload physicians with unlimited requests. Being put in-between the two is not comforting.

    “Follow the data closely. See what’s driving them crazy.”

    We already have the answer. Too much government involvement. Doctors don’t go into primary care when they want to avoid the patient. Pathology would be much better at avoiding such contact.
    Jaan, Obamacare is a disease perhaps a mental one at that. The diagnostic feature of the disease in medical terms is that the thinking process is screwed up.

  11. “Ouch!” I have a MHSA, so I hope I make the cut. But Dr. Lippin correctly notes that just because there’s an “M.D.” after the name, it doesn’t mean that that that person is immune to the toxic vapors that pervade the adminosphere.

  12. Of course Docs should not be forced fed rotton top-down toxic pablum from those who know nothing about the actual practice of Medicine-especially from the greed driven EMR/HIT vendors or “expert” administrators.

    Conversely the trend in the 80’s and 90’s of Docs obtaining MBA degrees is also perverse. If Docs want to make lots of money in business my best wishes to them-but leave medical practice. If they want to trade in their MBAs for MPH degrees they could stay in the profession of Medicine- or should I say “former” profession of Medicine?

    Dr. Rick Lippin

  13. If Obamacare is the disease, you offer quite the diagnostic armamentarium. Intravenous nanosensors? OK…. but you first!

    Former CMS Administrator and MA Gubernatorial candidate Don Berwick would say the answer is “yes!”

  14. hi Jaan, appreciate your interest in my unique ideas!
    Actually, I wasn’t thinking so much of fixing all the little things that bug doctors (although fixing some might be nice).

    I was thinking more of adapting some of the trendy ideas in digital health: obsessively following biometrics in order to guide diagnosis and management. What if provider stress-status was a health-system indicator that might be taken seriously and followed in real-time?

    Now that sensors are cheap and everyone has a smartphone, we docs could be walking around with our vitals continuously being recorded. Heck, if Topol is right, we could get nanosensors put in our bloodstream so that the admin and policy people can watch our cortisol levels trend. And the Google Glasses could record how much time we spend with patients versus either futzing with technology or paperwork.

    Analytics is needed so that instead of placating little spikes, one focuses on major trends and prioritizes where to intervene.

    anyway…did stuffing mouths with gold work??

  15. J Severson makes a good point: even though health care cost trends are moderating, health reform is ultimately inevitable. The problem, however, is that the assumptions underpinning the current versions of reform – no matter how promising they are to experts – are viewed with a deep level of skepticism by the very foot soldiers that are supposed to make it all work. We ignore their likewise informed opinion at our peril. It may be underway, but that doesn’t mean it will be smooth sailing. Finally, whether calls for ‘sacrifice’ is the secret sauce to overcome the disengagement remains to be seen. I personally doubt it.

    Leslie, as usual, comes at the problem with a unique and savvy solution: assess and fix the countless small things that irritate docs and hamper a user-friendly clinical environment while simultaneously addressing their professional/personal needs with interventions that enhance well being. This treat-the-symptoms-and-the-underlying-disease-will-get-better approach may have some merit, but I caution that a not-dissimilar approach was used by the Brits’ Nye Bevan when physicians opposed the NHS: he “stuffed their mouths with gold.”

  16. Jaan, thxs for this post & for prompting this conversation.

    Not to sound cynical, but I’m not sure I’d say that docs advocate for patients, regardless of cost. Rather, I think busy docs tend to take the path of least resistance. This often, but not always, means giving the patient what they want: antibiotics for URI, MRI for back pain, specialist referral when maybe it’s not really needed, etc.

    Regarding how to help doctors adapt to change, and maybe even support it, I propose a big data & analytics approach. Use the fancy new technologies available to equip all front-line clinicians with stress and aggravation monitoring. Follow the data closely. See what’s driving them crazy. Make sure they get enough of what they need to recharge & get some satisfaction in their work. Notice if many of them are in a burn-out/red zone. Do something about it. (There is a body of literature out there about worker motivation and response to stress. Exhorting doctors to think of society’s needs is not enough.)

    I’m not sure how it will work out for the proceduralists and surgeons, but I’m quite sure that unhappy & super stressed primary care docs will provide worse care, esp when it comes to anything that requires engagement and connection with patients (i.e. shared decision making). I think some stress and discomfort with ongoing changes is inevitable, but we should make sure it’s not excessive. Because if it is, patient care will suffer.

  17. Thanks to everyone for replying–as someone in healthcare policy and administration all of the comments have been helpful to read. For that CEO, I would say that it is important to remember that this work is already underway, at least on the CMS side of things, through hefty state innovation grants by local governments (under the ACA budget that has so far survived GOP defunding attacks). Keeping up–or protecting one’s slice of the pie, as one commenter put it–is indeed necessary within this environment. And recognizing clinicians’ professional stake in this change–and the sacrifice evolution of this magnitude necessarily requires–is also critical. You want to provide a great work environment for your docs, and the EHR / payment reform just won’t fly without their support, or at least an appreciation for the need for change. Which brings me to my last point. I think it is essential for us all to remember that reform is needed–for patients (who are going broke–the vast majority of them even with health insurance) and the system (we are all familiar with the GDP stats, hospitals running in the red, etc.). I’m optimistic that, as painful as such sweeping changes can be in the short term, reforms such as EHR and bundled payments offer promise if implemented smartly.

  18. Roger P makes a good point: the political wrangling, no matter who is at “fault” breed cynicism down in the trenches of patient care. My thinking is that that is a chronic governance disease that cannot be cured, only managed. Successful management does NOT include repeating D.C.’s concoctions

    Adrian is pretending he’s in front of all those docs, patiently explaining that bundled payments are ultimately rational, laced with jargon like “cost-centers,” “downsizing,” “arrangements” and “corporate management.” That being said, he makes a good point: docs advocate for patients, regardless of cost. That – not EHRs and not payment rearrangements – is a key to their buy-in.

  19. The framing of your presentation is paradoxical. Instead of bundling payment reform with EHR, why not start with the physician’s ethical obligation to advocate for their patient – period?

    Bundled payment does not have to present a conflict to the physician. Bundled payment simply says that overall health care costs must be reduced. It may well be that spending more money on physicians and less on other cost centers of the organization or downsizing the organization as physicians seek other work arrangements would all result in overall cost reductions without posing an ethical challenge to either the medical profession or individual physicians.

    Framing this problem from the corporate perspective focuses attention on EHRs and other corporate management issues rather than the patient that should be the center of both our technology and our attention.

  20. That’s when you realize that the insights of all those economists, policymakers, politicians and bloggers mean nothing if you don’t have the physicians on board.”

    Absolutely true that engagement and ownership are critical to success, however, the first step should have been the ownership at the political level.

    With ownership of the bill by the Dems and the Repubs working against it, why is that any different than the docs rejecting ACA and now worrying about how to bring them on board?

    I believe the real issue is how to bring the politicians on board because once control changes in politics we can expect the Republicans to defund ACA. You can’t force this level of change, ultimately the naysayers will have their day.

  21. If Al and 40YrOld are any indication of the skepticism in that back row of that auditorium, health reform’s assumptions are in deeper trouble than the JAMA article portrayed.

  22. ” it is going to hurt a lot. However, by the time we’re done, we’re going to have a better system and most of the problems we’re facing will have gone away. Ten years from now, the things we’re talking about now will sound laughable to you.”

    That’s the exact bullshit they fed us ten years ago.

    How about something along the lines of:

    “We’re not doing this to benefit either doctors or patients; we’re doing it because we’re trying desperately to hold on to our share of the pie in this new world of BigCorpMedicine. We don’t care if you don’t like it. Meeting over. Get to work.”

  23. John I: “by the time we’re done, we’re going to have a better system and most of the problems we’re facing will have gone away.”

    …And what do you say when another voice from the back of the room already knowledgeable about the failures of the ACA, EHR’s, HMO’s/ACO’s, etc. asks you how?

  24. Well said, John. Docs have been served too much of this top-down pabulum, when the real solution is to access the innovations at hand and apply them to the workflows that best suit patients. Will MU ever catch up with emerging technologies? Will regulations ever make patient communication truly user friendly? Will our CEOs, VPs and CMOs look out over the audience and see the solution is there, not in their PowerPoints?

  25. Great question. Here’s what I wouldn’t do. I wouldn’t sit those physicians down in front of me and say “we’re doing this with you or without you. you can come along for the ride or not. we don’t really care which” which when you get right down to it is the approach a lot of large organizations are using.

    I wouldn’t insult their intelligence with canned management talking points about quality and efficiency and evidence. They’ve heard them before. I wouldn’t wave my hands in the air and talk about the “magical things that EMR is going to do for us.” These are smart people. They’ve turned on their EMRs. They get it. But talking about technology like we’ve just discovered the Internet and entered the Golden Age of Happiness and Joy isn’t going to do it ..

    I’d talk to them like human beings. And I’d show some degree of empathy. I’d say, look – this is going to hurt. Actually, it is going to hurt a lot. However, by the time we’re done, we’re going to have a better system and most of the problems we’re facing will have gone away. Ten years from now, the things we’re talking about now will sound laughable to you. You’ll forget there was a time when you couldn’t email a patient – or get an instant lab result – or call in a specialist at a major academic medical center using Google Glass …