Monday, September 15, 2014

Playing 3 Dimensional Chess: Saving Money in Health Care the Right Way – Part 3: Physician Incentives

As patients, we all want our doctors to be smart and caring, and to focus all of their attentions on helping us as we struggle with illness.  We want our primary care doctors to take their time with us, allowing us to tell our stories and to fulfill their role as our trusted advisor and advocate as we traverse the health care system.  We want them to be clinically aware of all the implications of what we say, to be able to assess us with their skilled physical examination and to be able to choose the right tests and therapies to treat us.  We want them to help us access the right specialty expertise when that is warranted. 

We want our specialists to have in depth knowledge and skills so that if we put our lives in their hands, we will be confident that we will come out of our interaction with them better and healthier than when we started.  We want their technical expertise to be excellent and their judgment to be impeccable when our lives are on the line.  We want our surgeons to have gifted hands and gifted minds to go with those hands.  We want our cardiologists, our endocrinologists, our pulmonologists and our gastroenterologists to be able to assess and treat our illnesses when those illnesses fall into their areas of expertise and we want them to have the wisdom to know when our problems are not in their areas. 

We as patients want our clinicians to follow the advice of Dr. Daniel Sulmasy who states  in his book, “The Rebirth of the Clinic” that our clinicians should “concentrate on the basics, becoming again who we always have known we should be – physician, surgeons, nurses and others who are full of care; humble, sincere, compassionate, and competent.”  

But it must be acknowledged that the costs involved are real and impact other family needs from housing costs, to food, to the ability to care for families.  So costs cannot be ignored.  As I stated in part 2 of this series on saving money in health care, costs are generated when a patient meets a health professional and decisions are made which generate claims and bills and ultimately costs.  The smallest part of the costs generated by a visit to a doctor are the fees that are charged for seeing the physician.  The testing, the therapies, the surgeries, the imaging and the facility charges make up the bulk of the services that costs all of us so much.  Payors need to better understand that dynamic and try to pay physicians and other health care professionals in ways that foster what patients want, which is for clinicians to use their knowledge and skills to help make decisions that best help the patient.  Does the reality of our payment and incentive system actually match our desired outcome when a patient sees a physician? 

Many years ago, I used to speak on the topic of how to pay and incent physicians.  With my tongue firmly in my cheek, I would always say that there are three ways to pay a physician.  One is to do less, one is to do more, and one is to leave at 5 PM.  When you pay a doctor a fixed fee per patient, whether the patient is seen or not, often called “capitation”, you are paying them to do less.  When you pay them a fee per service, and allow individual services, such as ECG reading, blood drawing, and physical exam to be separate services and therefore billed separately, then you are paying them to do more.  When you pay them a salary you are paying them to leave at 5 PM.  The point I was attempting to make when I would say this was that doctors are people and we need to acknowledge that they work towards incentives just as all people do. 

At the same time, patients (and we are all patients at times) often don’t want doctors and health professionals to be ordinary people.  We, as patients want them to be more.  We want them to fulfill a calling and to understand their standing in our society as occupying a position of trust that is a both a privilege and a responsibility.  It may be a bit overwhelming to try and think of developing an incentive system that recognizes and encourages that sense of professionalism that leads to the calling being fulfilled; however we must try.  Our current incentives do not succeed at fostering this sense of professionalism. 

The language used to describe clinicians has changed and incentives are driven by the language.  They are no longer doctors and nurses caring for those in need.  They are no longer clinicians but “providers” and patients are not patients but “consumers”.  The language of caring and healing has gone by the wayside to be replaced by the language of economics.  Society has allowed the MBAs (and I say that as a physician with an MBA who takes great pride in that degree) and the economists to suck the professionalism out of health care professionals by allowing the financial people to claim the language. 

By lumping all clinicians into the bucket of “providers”, the payers first tell them that their training, knowledge, education and expertise is merely a set of information “content” that can be replicated, at a much lower cost, by advanced computer systems, by lower level personnel using expert systems, and by technical advances that make their professionalism primitive and even quaint.  The clinicians are told that they must precertify their decisions as the payers don’t really trust how they are applying their knowledge, and must assume that they will be doing the wrong thing for the patient and for society.   The actions of payers and regulators, are based on the assumption that clinicians are likely to make mistakes and to overcharge.  That is hardly a way to incent what we, as patients, appear to want.  Our payment system is now geared towards the false efficiency of having doctors see more patients in less time, and in having more work leveraged to other personnel who are lower cost.  This may actually work against us.  For nurses it is no different.  The skilled nurse of the past, who had a patient who she (and it was usually a “she” in the past) felt personally responsible for has been replaced with the nurse manager who triages the work to the lower cost nurse’s aide and other support personnel.  The interest in knowing the person behind the patient has come to be seen as just too expensive.
 
I admit to being a lover of irony and paradox.  Thus I have spent much of my career designing and building programs that encourage more time to be spent with patients by the people most knowledgeable and proving that the irony rests in the fact that the more expensive, more highly trained people, spending more time, not less, with patients, actually saves money.  Many years ago, I was involved in a program to try and lower the costs of mental health care.  We set up a program, for people who were in a psychiatric crisis.  They were usually in an Emergency Room or in a local police station and we would send a PhD level Clinical Psychologist to the patient, wherever they were, to assess and stay with the patient for however long they needed to.  Patients and psychologists often spent 3 or 4 hours together and then saw each other daily for the next few days.  With this approach, paying the psychologist for their time generously, we saved huge sums of money by avoiding unnecessary mental health hospitalizations, and we saved society from the costs of incarcerating people who were acting out because of their mental health crisis.  We theorized that the time these skilled professionals spent with people in need would easily pay for itself and we proved that.  In follow up studies, we also found that the care rendered was far superior to the usual care as measured by recurrence rates which were a fraction of the usual recurrence rates for this type of population. 

Currently, at Accolade, we have built a system which trains a new type of professional, one we call a Health Assistant, who telephonically stays with people in need, for however long they need: someone who forms relationships in ways that are considered too costly in today’s world.  Yet using that relationship as the backbone of a person’s use of the health care system, improves care and saves money.  The paradox that spending more time supporting, educating, and helping people through the trauma of illness and difficulty saves money is real. 

What does my Accolade experience and my experience with the psychiatric crisis intervention program teach me about incentives for physicians?  It says to me that incentive systems should first respect clinicians and not attempt to get in the way of active patient care.  Programs that require pre-review and pre-approval of treatment are demeaning and ultimately counterproductive.  That includes pre-certification, step therapy, and pre-approval of imaging exams and lab tests.  I do not believe that the decisions by clinicians are always correct, only that the programs that try to ensure that they are always correct are bound to get in the way of the trust between doctor and patient and not encourage the type of joint decision making that is needed.  These “mother may I” programs can have the perverse effect of making access to care more difficult.  We should review a doctor’s patterns and records and pay him or her based on the quality of the care as evidenced in those retrospective reviews as long as the reviews include the clinicians ability to form trust relationships with the patient, and to understand the context of the patient’s life. 

Physicians should be reimbursed in ways that encourage them to spend time getting to know patients, and in ways that encourage a direct deep relationship between the doctor and the patient.  For that reason, in primary care, I look on the movement towards direct contract primary care as a good step towards doctor and patient working together with the doctor being paid to be the trusted advisor.  I also believe the open notes movement (the movement towards a medical record which is truly shared by the patient and the doctor) further encourages the type of trust that this relationship requires and incenting office practices to embrace open notes is likely to have a positive effect.  

My desire to incent proper relationships between doctors and patients makes me a bit nervous about the bundled payment movement as I fear it creates a new administrative barrier to the relationship between a doctor, a nurse and a patient.  The service “bundler” tends to be the health system and they have the most to lose financially when clinicians and patients think carefully about all options and how those options will affect a person’s overall life.

I want the incentives for surgeons and other specialists to include payment for talking to patients, with lower payments gong to those surgeons who see themselves purely as technical experts, doing the procedure and then never seeing the patient again, allowing all follow up care to be done by the physician extender.  I wonder if, for both primary care clinicians, and for specialty physicians, an hourly charge system could ultimately result in more thoughtful consultations and more effective joint decision making and a resultant lowering of costs. 


I expect that we will always need multiple payment and incentive systems that understand the variety of people and cultures in our society.  For some doctors and patients, an integrated system that salaries physicians may be best and for others, a more direct financial relationship between doctor and patient may be best.  Whatever the system, it must properly reward what, Warfield T. Longcope, Professor of Medicine at the Johns Hopkins University School of Medicine once wrote when he stated, “even though a clinician has science, art, and craftsmanship, unless he is intensely interested in human beings, he is not likely to be a good doctor.”  All solutions for paying and incenting physicians must encourage and not discourage the professionalism that leads them to ever increasing interest in the human beings they help on a daily basis.