What Should Doctors Do?
Don’t do nothing, do something! (David Coombes, Health Care Consultant)
What should doctors do to combat current political and cultural forces working against them?
First, recognize that these forces include:
· Takeover and control of health care by government, managed care organizations, hospitals, and insurance companies,
· The rise of corporate care and management-directed outcomes and physician pay-for-performance using inferential process “data” as the alternative to establishing and maintaining traditional doctor-patient relationships,
· De-humanization of patient care with replacement of clinical judgment and doctor-patient collaboration by proxies for “value” calculated from data derived from population-based health studies,
· Mindsets by current political powers that stress “progressive” (socialistic) ideologies in health care policy rather than supporting traditional (Hippocratic) patient-centric views,
· The new political reality: American culture, education, and vehicles of communication defining “truth” in health care are based on Internet-based information and opinion.
A Discussion with Lee Beecher, MD
Today I had an enlightening discussion with Lee Beecher, MD, a 77 year old psychiatrist, who, in his position as president of the Minnesota Patient-Physician Alliance (MPPA), and tempered by political fights at the national level to preserve and strengthen the lot of cognitive medical specialists, is seeking to articulate conservative views in a book he and Dave Racer, a Minnesota publisher, are writing.
Doctor Beecher says the debate on the future of health care and health care funding in America hinges on four issues.
1) Choice – The degree that US patients and families and physicians have freedom to choose or organize what type of care or practice they desire without stifling government and third party mandates and controls.
2) Continuity – A new focus on continuity and flexibility of care depending on patient need and demand available over time for individual patients including access to trusted doctors, appropriate and flexible levels of care intensity, payment for urgent and hospital treatments, and consumer pressure to provide third party insurance coverage in competitive individual, employer and government health coverage marketplace.
3) Competence – denoting who is competent and responsible to deliver this care involves credentialing those who are qualified to deliver care (professional licensure).
4) (Non) Conflicts of interest – With managed and government care, in today’s world often really the same, how to resolve the ethical question of what is good for the “system” or the corporate entity versus what is good or best for the patient?
These issues are not easily resolvable . Ultimately addressing them will depend on the political will of American voters who in 2016 oppose Obamacare by a margin of 55% to 45%. These issues may be clarified and dealt with given a GOP President or with Obamacare repeal, but these tensions will endure no matter who is elected President in 2016. If ACA repeal occurs in the future, a big issue for an alternative market-based plan will be how to care for the 20 million uninsured who have signed on through the Obamacare exchanges and federally subsidized Medicaid expansion in 25 states.
Doctor Beecher asked me these questions, which I shall try to answer briefly.
– How do recent medical graduate see their roles as physicians going forward? Is this a significant change from doctors in the past? And how do the new physicians view health care payment and entitlement legislation in terms of their careers?
I believe they see their role as adapting to the present realities by pursuing specialties that allow them to lead a balanced life with time for family and personal pursuits and enough income to pay off their educational debts, which average $150,000 to $200,000 at time from medical school or residency programs. The preferred specialties are the so-called ROAD specialties (Radiology, Ophthalmology or Orthopedics, Anesthesiology , Dermatology), and a preferred place of work is as an employee of a large specialty group or integrated health system or hospital.
– What do patients today think about the quality of time spent with physicians?
I think patients prefer to spend time in a personal relationship with a physician rather than with a physician assistant or nurse practitioner. However, patients have good things to say about nurses and others who listen and are available to them. Patients trust physicians more than they do the government. And patients and families are in the process of rejecting Obamacare because of its increasingly unaffordable insurance premiums, mandates, high out-of-pocket deductibles, and its profound narrowing of their choice of doctors. But no matter what patients think about the health care system, they do not know what to do about changing or fixing it and are angry and anxious about their health care costs.
– What should physicians do?
That is the $2 trillion question, because that the likely cost of Obamacare over the next 10 years if the ACA survives in the present form.
1. Concentrate on areas where physicians have leverage in seeing or taking on Medicaid , Medicare, and Obamacare exchange patients they can see without losing money and jeopardizing the financial viability of their practices. Once these numbers reach 50% of physician non-acceptance, voters will demand more access and they will criticize the government.
2. Focus on creating collaborative physician organizations that respect and offer consumer convenience and lower costs – outpatient focused, urgent care venues, ambulatory care surgery centers, mental health specialty care continuity, personalized addiction treatments, and other specific disease-related centers. The operative words here are “focused” and patient-centered. Broad philosophical approaches, tirades against progressive policies of high taxation and loss of freedom, etc. are not likely to work. Quality alternatives for patients will.
3. Form and lead physician led organizations which espouse strong doctor-patient relationships and colaborative, patient-centered care, like the Minnesota Physician-Patient Alliance (MPPA) and Association of American Physicians and Surgeons (AAPS).
4. Focus on:
Broadcasting the news to influential opinion-makers that Obamacare is unpopular in the eyes of many physicians, patients and voters. Support these contentions with survey facts from Physicians Foundation national surveys which consistently show both physicians and patients disapprove of Obamacare in significant numbers.
Joining or forming national organizations that show how the deleterious effects of ACA legislation are contributing to widespread physician shortages and decreasing access to health care. One such organization is the Unified Physician and Surgeons Association, which addresses issues like interference in doctor-patient relationships, unrealistic credentialing processes, excessive government regulations driving up physician practice costs, burdensome mandatory and “meaningful use” electronic health records rules, and advantages of thought out tort reforms. And remember: patients pay attention to organized protests more than the litany of individual doctor’s discontents.
Creating new collaborative and creative relationships with hospitals, the 800 pound health care gorilla in most communities. For example, have hospitals support referral to independent physicians for psychiatric services needing continuous care after discharge. Make hospitalists aware of psychiatric and geriatric services outside of the hospital. Alert hospitals to the existence of entities such as Health Leads, a 10 year company that provides referrals to social services, medical transportation services, home visits, housing availability, and job training — making it possible for physicians in hospital clinics to “ prescribe” these services with the help of college volunteers who set up “help desks” on site and seek out and refer patients to these service.
Have concierge and direct cash and direct primary care physicians set up relationships with employers who through HSAs, HRAs, and other means are seeking cheaper, higher quality, employee-pleasing services by bypassing traditional 3rd parties.
Encourage large employers to set up on site offices manned by primary care physicians and nurses (these have a history of saving 20% to 30% on employer health costs).
Thinking through how physicians might use the Internet and Information apps more effectively to make care more useful, more efficient, more convenient, and more personal for patients. These apps which already exists might include such things as Skype consultations, virtual visits, health status evaluation, health promotions, and marketing of dispersed, focused, doctor-run outpatient centers in convenient locations with ample parking.
Two Tectonic Shifts
Keep in mind two tectonic shifts are going on simultaneously , one, consolidation and centralization in hospital settings, and two, decentralization into dispersed centers outside the realm of government and large integrated organizations. Several examples come to mind: the growth of direct cash and concierge medicine with bundled services and the establishing and marketing of ambulatory surgery centers, both of which provide care at a fraction of the cost of hospital surgeries and with a lot less bureaucratic impediments. Finally, explore, promote, and develop cyber-visits, cyber-diagnosis, cyber-workups, cyber-interviews, cyber-consultations and cyber-imaging evaluations with the end game of referral to physicians for face-to-face 2nd opinions.
I’m reminded of the story of husband and wife who were watching their children play on the newly laid concrete sidewalk. The husband is livid. The wife says, “But dear, I thought you loved children.” He replies, “ I do, in the abstract, but not in the concrete. I am suggesting and recommending that we move beyond ideological grousing and reach out to millennials – future physicians, practicing doctors, patients, and all the IT nerds who are the future of American medicine.
Richard L. Reece, MD