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.
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