This is the third and final installment of Dr. Pearl’s series on the physician experience. The first focused on why this is the best of times to be a physician, the second on why it’s also the hardest. Today’s column highlights the changes needed to enhance the rewards of medical practice and minimize the difficulties for both patients and physicians.
Ask physicians across the country what problems they want solved, and they won’t hesitate to tell you. They worry about the growing health risks they observe in patients based on lifestyle choices, obesity and a variety of social factors which they feel powerless to change. Ask what they would modify if they had a magic wand and they’ll point to the illogical, problematic and increasingly complex reimbursement schemes still favored by public and private payors. Ask about all the wasteful spending in health care and they’ll cite the current medical-legal system. Ask about the frustrations built into day-to-day medical practice and they’ll criticize how difficult it is to use the current computer systems and the growing amount of time they spend each day looking at their computer screens.
The following four proposals are intended to address some of those obstacles. They are offered as a starting point and the beginning of a road map for the days ahead.
1. Invest in public health
Personal health is often a function of education, income and geography – where a person lives, what kind of food they can buy at the local grocery store, and whether adequate community services are available. These types of factors often are referred to as the upstream social determinants of health.
Many of the underlying causes behind the chronic diseases that have become an epidemic in the United States relate to personal choices and lifestyle. Nearly one-third of Americans are significantly overweight, leading to adult-onset of diabetes and associated medical problems, with another third headed in that direction.
Physicians understand that diet, exercise and stress influence people’s health, but often feel powerless to make a difference with any of those factors. Successful public health interventions in our schools and communities could make a hugely positive impact, and could lower health care costs in the future. But such initiatives require communities, schools, and the government to invest in public health education.
Funds will need to be earmarked for issues that go beyond traditional physical and public health. As an example, increasingly physicians are seeing patients with mental health issues that are the consequences of unemployment, financial stress and domestic violence. Although some of these symptoms can be treated with a combination of medication and therapy, physicians are frustrated with their inability to influence the underlying social determinants.
Many physicians don’t understand why approaches that could make a dent in the social and lifestyle drivers of poor health – banning of tobacco use, disincentivizing consumption of sugar-sweetened beverages, elimination of candy in schools, and implementation of a variety of programs aimed at reducing domestic and community violence that is exacerbated by ready access to firearms – are beyond the political will of our governments and leaders.
The roots of most illnesses begin long before the first symptoms appear. Increasing funding for social services, community-based counseling, and employment training would go far toward improving our nation’s health.
Given the magnitude of the current problems, progress will be slow. Given the political process, the power of entrenched special interests and the cutbacks to municipal, state, and national budgets, today’s problems are likely to get worse before they get better. The first step will be to acknowledge the damage being done, and then start to undo it.
2. Shift from fee-for-service to pay-for-value
Everyone agrees it is better – and less expensive – for patients to avoid a heart attack or stroke than to be treated for an acute episode after the fact. But physicians find they don’t have the time to help patients make the improvements needed. Counseling patients on the lifestyle changes — exercise, smoking cessation, diet, and sleep – takes time to engage the person and help them commit to change. And even for specific medical interventions, most insurance companies pay little to physicians for the effort it requires to provide preventive care, compared to how much they reimburse doctors who perform interventional procedures.
With the opportunity to receive $5,000 for a procedure that takes two hours, versus $50 for a half hour of counseling, physicians are likely to skip battling with the patient to stop smoking or adopt a new diet. Little wonder that applicants for cardiology and other specialties where procedures represent the majority of billings dramatically outnumber the number of positions available, while primary care residency positions frequently go unfilled.
Logic suggests that private payors would want to invest in prevention, rather than keep paying for high-cost, after-the-fact interventions. Unfortunately, investments in prevention tend to take five to ten years to have an impact on the health of an individual. As such, for insurers with shareholders tracking profit-and-loss statements quarterly, these types of investments are viewed as having a negative return on investment, given how frequently their members switch carriers.
In contrast, when we look at some of the not-for-profit systems with the lowest rates of turnover, we see prevention rates that are much higher, as reported through the Healthcare Effective Data and Information Set (HEDIS) and the National Committee for Quality Assurance (NCQA).
The creation of Accountable Care Organizations, in both Medicare and the commercial markets, and the expansion of integrated delivery systems capable of sharing risk and working together effectively, are seen as paths to moving payment from fee-for-volume to pay-for-value. Such models have recently achieved some progress, particularly in quality improvement. But the financial results to date are mixed – with the added cost of implementing programs sometimes as high as the savings produced.
And creating a highly effective model is difficult. Successful integration requires having just the right number of physicians in each specialty. That can mean having to decide which doctors in a community to include and which to leave out. It also demands enlisting physicians with enough expertise in both medicine and business to serve as leaders, even though few in medical schools have been trained in business skills. And integration will work only if the partnerships between physicians and hospitals are much stronger than those that exist today.
ACOs depend on a different reimbursement model from the current fee for service – one that rewards physicians for prevention of serious illness and care coordination for patients with chronic conditions. And inevitably this leads to a narrowing of the gap between highly compensated specialists like cardiologists, who treat problems after the fact, and primary care physicians, whose expertise is in preventing them in the first place.
But changing what people earn always is contentious and those succeeding under the current rules are hardly eager to move to a different reimbursement environment and accept the consequences.
Efforts by the Federal government to move to pay for value are underway and private carriers and other payors are likely to follow. But make no mistake: the road will be uphill, and very bumpy. And we need to watch carefully whether the recent consolidation of the insurance industry into only three large national companies, each with huge market size and control, will promote the type of trust these new models require or drive physicians and hospitals to consolidate in order to protect their interests.
3. Reform our medical malpractice system
The current adversarial medical malpractice system is broken. It primarily benefits lawyers rather than patients and wastes health care resources when doctors are forced to practice “defensive medicine” — ordering excessive testing out of fear of being sued should something go wrong.
And this additional testing often leads to worse, not better outcomes, when there are complications from the procedures involved are included in the analysis. Most medical mistakes are the result of system errors, not individual physician mistakes or incompetence, according to the Institute for Healthcare Improvement (IHI). And though the aggregate expense from professional liability awards may be a small percentage of total health care spending, the costs that the practice of defensive medicine incurs are large.
Naturally, if a patient is harmed, he should be compensated for the losses experienced. But today’s system gives as much as 40% of the dollars awarded to the attorney, and fails to invest in added patient safety.
Trial lawyers are among the most powerful lobbying groups in the country, and so moving to an approach that maximizes patient safety rather than maximizing awards will be a challenge.
Ideally, as people come to understand how much more they are personally paying in health care costs to support this broken system, change will begin to happen.
4. Unlock access to patient information
Electronic health records (EHRs) have dramatically improved medical treatment in many ways. For those practicing in integrated delivery systems, an EHR allows complete visibility into the treatment plans of all physicians caring for a patient. This means safer care without unnecessary duplication of services or wasted effort. It also means the ability to deploy technology-driven, population-based approaches focused on prevention, early detection and proactive management of chronic conditions. The result is better clinical outcomes, plus more effective use of health care resources.
But two major problems limit the potential of EHRs to improve quality and efficiency.
The first is usability. Today’s EHR systems are difficult to use. Data entry takes longer than with a paper record, voice recognition requires editing, access to information involves multiple clicks, and navigation is anything but intuitive. As a result, physician workflow is slowed and inefficient compared to the past. And as a consequence, the physician in the exam room is often focused more on the computer screen than the patient — a growing source of frustration to both.
Every day in our personal lives, we use dozens of technological devices and mobile applications without running into such issues. Manufacturers of our EHR systems need to make this health care technology just as user-friendly.
The second issue is interoperability. Although many physicians have installed computer systems in their personal offices, a minority share data with each other. So when a patient sees her community cardiologist, her primary care physician can’t access information about that visit. As a result, clinical decisions are made based on incomplete records, data must be exchanged through antiquated systems (the fax or copy machine) and care is delayed and redundant.
ATMs rapidly exchange sensitive financial information across competing banks and around the globe. And we can directly log into online newspaper subscriptions via our Facebook accounts. Interoperability of EHRs should be no different.
If you assume the only reason is technical, guess again. Rather, part of the problem results from the underlying business models of the major EHR manufacturers. They refuse to allow third-party developers to access the applications in their systems. As a result, the types of interfaces that could solve this challenge are not being built. Just as you can now access the Instagram photos you posted with an Apple phone through an Android device, so the doctor treating you should be able to access your medical information regardless of the EHR through which it was entered. But to the frustration of patient and physicians, in most cases, you can’t.
Without some type of outside encouragement, this problem won’t get solved. And every day we wait, patient care suffers.
Ironically, physicians find great joy in volunteering around the globe in needy locales, or on weekends at a local community clinic, but increasingly they report diminished satisfaction in their day-to-day clinical practice. Physicians have always worked hard, and doctors today are no different. But too often physicians today feel as though they are being asked to provide health care with one hand tied behind their backs. That is a relatively new phenomenon.
The four recommendations above are intended to bring greater satisfaction to patients and fulfillment to physicians. Each will be met with resistance and prove difficult to implement.
And even these changes won’t be enough. Entire system redesign and expansion of current technology will be necessary in the future. But accomplishing these four would be a good starting point.
And when we do so, the beneficiaries will not only be the next generation of physicians, but also our families, our communities and our nation.
This is the 3d and last article in the series. It appeared on AUG 20, 2015 @ 10:00 AM, Forbes.com
- The first article in the series, Why This is the Best of Times to be a Physician in America, appeared in Forbes on July 23, 2015.
- The second article in the series, Why This is the Hardest of Times to be a Physician in America, appeared in Forbes on August 6, 2015.