Physicians

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  In other words, everyone is responsible, but the physicians’ duty is superseded by their ethical obligation to advocate for their patients regardless of cost.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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Bobby Gladdalan t falkoff, md, faafplegacyflyerrichard l. reece, mdm13 Recent comment authors
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alan t falkoff, md, faafp
Guest

Why don’t you ask and LISTEN to the private practice primary care physician? The answer lies and lives with them.

Jaan
Guest

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… Read more »

alan t falkoff, md, faafp
Guest

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… Read more »

Bobby Gladd
Guest

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… Read more »

Jaan
Guest

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… Read more »

legacyflyer
Guest
legacyflyer

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… Read more »

alan t falkoff, md, faafp
Guest

Why don’t you ask and LISTEN to the private practice primary care physician. That’s where the answers are.

richard l. reece, md
Guest

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… Read more »

Jaan
Guest

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… Read more »

m13
Guest

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… Read more »

m13
Guest

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… Read more »

Jaan
Guest

“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.

Dr. Rick Lippin
Guest
Dr. Rick Lippin

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
Southampton,Pa

Jaan
Guest

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… Read more »

Leslie Kernisan, MD MPH
Guest

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… Read more »

Jaan
Guest

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!”

Leslie Kernisan, MD MPH
Guest

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… Read more »

Al
Guest
Al

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… Read more »

J. Severson, Ph.D.
Guest
J. Severson, Ph.D.

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… Read more »

Jaan
Guest

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 –… Read more »