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Do Value-Based Payments Lead to Higher Doctor-Satisfaction Scores?

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By JACK COCHRAN, MD  and CHARLES KENNEY

Jack CochranRecently we wrote a blog post promoting the benefits of shifting from fee-for-service to value-based payments. We praised the recent decision by leaders at the U.S. Department of Health and Human Services (HHS) to accelerate that shift, and we were then and remain convinced this shift paves the way for better, more affordable care.

There were some strong reactions to the post.

Some people think capitated payments have been discredited, others believe the change from fee-for-service will change little. One physician told John Irvine, editor at The Health Care Blog, that he got the impression from our post that we were saying value-based payments would make physicians lives easier. “Really?” Irvine’s doctor friend said. “You’re making my life easier? Prove it.”

How Will the Practice of Medicine Change?

We didn’t actually use the word easier in the post though we did say that “increasingly, physicians seek liberation from the constraints of fee-for-service in order to focus on the overall health of their patients. Value-based payments allow doctors to do exactly that.” So we definitely hear what Irvine’s friend is saying — and we understand his frustration. Has there ever been a time when so many physicians have been worn thin — angry with the direction of our health care system?

Irvine invited us to respond to his friend and we thought we would do so by soliciting the thoughts of Scott Young, MD, executive director of Kaiser Permanente’s Care Management Institute and associate executive director for Clinical Care and Innovation at The Permanente Federation.

“Easier?” said Dr. Young. “No, value-based payments don’t make doctors’ lives easier. But I think it does make the practice of medicine more rewarding and fulfilling.”

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Health IT: Glass Half Empty? Half Full? Shattered?

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By JACK COCHRAN, MD  and CHARLES KENNEY

Jack CochranTechnology occupies an unusual place in health care. Some people say that electronic health records are clumsy barriers between patients and their doctors. Others suggest that technology is a kind of secret sauce.

In many places physicians and other clinicians are stymied by awkward technology. In other organizations — Kaiser Permanente included — electronic health records enable some of the finest individual and population health care ever.

This humorous equation speaks volumes about technology and health care:

NT + OO = COO

New technology + old organization = Costly old organization. In other words, technology doesn’t change an organization. Change is about leadership and culture. It is about thinking in new ways and asking new questions.

For example, rather than ask how many patients can you see, let’s ask how many patients’ problems can you solve?

Instead of asking how can we convince patients to get required prevention, let’s ask how can we create systems that significantly increase the likelihood that patients get required prevention?

Instead of asking how often should a physician see a patient to optimally monitor a condition, let’s ask what is the best way to optimally monitor a condition?

When we begin asking these kinds of questions, we see technology as a tool — not a solution by itself, but as a powerful tool we can use to deliver better individual and population care. Technology, like data, is only useful when it enables clinicians and teams to work effectively to provide the highest quality care for patients.

Hospitals and physician groups throughout the country are installing and working with electronic health records at a rapid pace. Some organizations integrate the systems beautifully, others do not.

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Lost in the Health Care System?

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Jack Cochran

By Jack Cochran & Charles Kenney

“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.

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The Doctor Crisis

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By JACK COCHRAN, MD & CHARLES C. KENNEY

the doctor crisis photoDoctors get blamed a lot these days — blamed for aversion to change, for obstructing innovation, and for being self-centered. This familiar litany asserts that in the nation’s drive to transform health care, physicians are part of the problem.

While it is undeniable that doctors are part of the problem in some places, it is equally undeniable that they are leading innovation in many places and must be part of the solution everywhere.

We may well be in the midst of the most unsettling era in health care and that turbulence is bone-jarring to physicians. We argue that there is a doctor crisis in the United States today – a convergence of complex forces preventing primary care and specialty physicians from doing what they most want to do: Put their patients first at every step in the care process every time.

Barriers include overzealous regulation, bureaucracy, liability burden, reduced reimbursements, and poorly designed care delivery systems.

On the surface the notion of a doctor crisis seems altogether counterintuitive. How could there be a “crisis’’ afflicting such highly educated, well-compensated members of our society?

But the nature of the crisis emerges quite clearly when we listen to doctors. Ask about the environment in which they practice and you hear words such as “chaos,’’ “conflict,’’ and “dysfunction.’’ Based on deep interviews with doctors throughout the country, the research firm Harris Interactive reports that a majority of physicians are pessimistic about their profession; a profession Harris describes as “a minefield’’ where physicians feel burned out and “under assault on all fronts.’’

Have terms this extreme ever been used to characterize the plight of physicians in our nation? Burnout, chaos, conflict, dysfunction, minefield, under assault. How can the nation transform its health care system under such disturbing conditions?

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Health Care Innovations Hiding in Plain Sight

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By Maureen Bisognano and Charles Kenney

While the nation has been focused on the recent Supreme Court ruling on the Affordable Care Act, innovations in hospitals and physician practices far from Capitol Hill have been triggering an historic transformation of our health care system. Propelled by a mix of urgency and vision, innovators at hospitals, physician groups and companies are remaking American health care by demonstrating that more effective and affordable care is achievable quite apart from statutory changes in Washington.

These organizations are working to achieve the Triple Aim: improve the health of the population; enhance the patient experience of care (including quality, access, and reliability); and reduce, or at least control, the per capita cost of care. This approach, developed by the Institute for Healthcare Improvement, is a sharp break with the traditional focus on single encounters with patients within the strict walls of health care delivery, typically addressing only the most immediate problems.
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