Wednesday, August 8, 2007

Culture, effect of, Medical Trends - Medical Mindsets -Five Physician Mindsets and Trends

Medical Mindsets -Five Physician Mindsets and Trends

Mindsets work like fixed stars in our heads. Holding on to them, our mind drifting like a ship in an ocean of information, finds orientation. They keep it on course and guide it safely to its destination.

John Naisbitt, Mind Set! Collins, 2006

In what follows, I describe five physician mindsets. Mindsets are sets of beliefs or ways of things that determine how one behaves or acts. Physician mindsets change only slowly, are rooted in the present and past, and reflect bottom-up cultural beliefs. America is an overwhelming bottom-up society. Most physician behavioral changes come from the physician culture below rather than from government above.

Finding Top-Down Trends

It’s easy to find top-down trends, which represent mindset shifts. from such sources as government reports, PriceWaterhouseCooper, The Kaiser Family Foundation, the Center for Studying Health System Change, the Robert Wood Johnson Foundation, Modern Healthcare, JAMA, AMA News, or the New England Journal of Medicine. These are excellent sources, but they may not capture what individual physicians are doing, saying, or thinking.

Discovering What Individual Physicians Are Thinking

It’s hard to discern what doctors are thinking individually. On occasion, you’ll find physician mindset shifts described in the sources noted above. And you can find what physicians think at Sermo. com, a website created by Daniel Palestrant, MD, a Cambridge, Massachusetts general surgeon. On the site, doctors exchange ideas and talk. Wall Street firms support and study the site to track physician trends. The AMA likes Sermo. It recently signed a deal to promote it among its members to see where doctors are trending.

I’ve contributed many “posts” to Sermo, and it’s my impression doctors, though conservative, aren’t necessary ideological. Physicians want the uninsured covered, health care to be affordable, to show compassion, and deploy the tools and technologies of modern medicine. Physicians know doing all these things at once poses cost dilemmas. They’re realistic and recognize change is likely to arise from present adjustments, rather than from some future revolution. They instinctively know changes happen slowly.

Low Physician Morale

Physician morale is low because of decreasing Medicare and health plan revenues, rising malpractice rates, overwork and burnout secondary to physician shortages, unceasing criticism from pundits and managers about inconsistent quality, patient safety, and business inefficiencies.

Doctors tend to suspect commercial ventures intruding on their turf. Retail clinics for convenient non-emergent care and enterprises like LifeLine Screening to screen for potentially fatal vascular lesions in asymptomatic patients are cases in point. They’re also leery of fellow physicians who profit from dispensing drugs from their office or who sell alternative drugs or herbs.

Doctors feel they’re doing the best they can and working as hard as they can, which some equate to treading water. These struggles leave scant time for speculating about trends. The physician culture, and the mindsets it represents, form the basis for the trends I’ve selected..

Physician Mindsets

In assessing mindsets and their evolution into trends, I’ve found it useful to consider John Naisbitt’s thoughts about trends in his new book (Mind Set! Collins, 2006). Naisbitt, as you may recall, was the author of Megatrends 25 years ago. Megatrends accurately forecast where American society was headed.

Here are Naisbitt’s current thoughts on how he analyzes mindsets and trends (bold print). My responses, in italics, follow.

1.While many things change, most things remain constant (No matter what turns reform takes, most things will remain constant .Indeed, maintaining the status quo can be thought of as a trend, In other words, with reform everything is likely to change, but the status quo).

2.The future is embedded in the present (Future changes are likely to evolve out the present and aren’t likely to be a radical departure from present practices).

3.Focus on the score the game (The score of the game will be cost versus outcome metrics. In other words, what will improved health outcomes cost, and what will be the most effective way to increase the score – engaging and educating patients, preventive programs, work site clinics, disease management programs, or inter-operative management systems).

4.Understanding how powerful it is not to have be right
( Create your own bandwagon. Innovate, change, and adjust. If you think having a compute to take each patient’s history will be what it takes to achieve standardization and consistency and productivity, say so; If you think retail clinics will lower quality and discourage patient follow-up, say so).

5.See the future as a picture puzzle (Trends rarely occur in a vacuum; they’re made up of multiple converging trends, of recognizing, for example, that the Internet will change multiple things at once).

6.Don’t get so far ahead of the parade that people don’t know you’re in it (Radical changes are, well, radical. In IT applications to health care, leaders are expected to be ahead of the pack. But in the end, the marketplace and health consumers will decide what works).

7.Resistance to change falls if benefits are real (A good example of this is physician resistance to EMRs. When physicians find EMRs benefit them, or see physicians using EMRs are market leaders due to EMRs, they will change – and fast).

8.Things that we expect to happen always happen more slowly (Changes are always evolutionary rather than revolutionary. The slow migration of physicians into larger integrated groups is a good example).

9.You don’t get results by solving problems but by exploiting opportunities ( The explosion of retail clinics in sites where people shop and fill prescriptions represents seizure of an opportunity – filling a gap in convenience and low cost care).

10.Don’t add unless you subtract (For physicians, one of the purposes of adding information technologies is to subtract staff).

11.Don’t forget the ecology of technology ( When physicians add technology, they should simultaneously ratchet up humanism. Patients seek high tech/high touch, not one over the other).

Blog Lessons

I’ve learned a lot about physician trends through my blog and physician comments on its contents. Over the last nine months, I’ve made 250 entries, largely based on material culled from newspapers medical journals, policy reports, Physician Practice Options (a newsletter I edited for the last 11 years), responses to my recent books, healthleaders news features, and countless phone conversations with authorities and analysts around the country. I’ve used material from some of my own writings in this commentary. As one perceptive writer observed, “How do I know what I’m saying until I’ve read what I’ve written?”

Out of this miasma of sources and my own writing have raised five physician mindsets.

Five Mindsets

Physician Mindset Number One - Physicians on the ground prefer incremental changes through expanding coverage through tax incentives and market-driven changes rather than through a single-payer system.

Forty years of experience with inadequate payments and burdensome regulations by Medicare and Medicaid has soured doctors on government solutions. One exception to this may be SCHIP (State Children’s Health Insurance Program) legislation, It aims to spend $50 billion or more for 3.2 million children from low-income families too well off for Medicaid not wealthy enough to afford private insurance. The AMA, most medical societies, and most physicians support this legislation, which is likely to survive a presidential veto. The AMA is on the cusp of launching a national campaign stressing universal coverage through tax credits and other measures. But the real AMA hot bottom issues are tort and payment reform. Individual physicians like the idea of a system based on market principles with more choice, but remain leery about negotiating with patients about price, engaging patients in extended “partnership” discussions, rushing to embrace high deductible plans with HSAs, and even being paid at the point of care with credit or HSA cards. Most practicing physicians don’t favor single-payer, although there are exceptions, such as the 14,000 doctors who belong to Physicians for a National Health Program.

Physician Mindset Number Two
– Physicians are adapting to downward pressure on their incomes and harassing rules and regulations by becoming hospital employees.

The evolution of this mindset can’t be disputed. Increasing numbers of primary care physicians and specialists alike are approaching hospitals to become employees. This is a twist from the past. Seven or eight years ago, hospitals were hell-bent on acquiring primary care practices. This turned out to be an economic disaster for many hospitals. But now the tide has turned. The reasons are many. Physicians feel overworked with too many patients and too little time. Practice expenses are mounting while incomes are dropping. Establishing individual and small practices carries too much risk for doctors, and loans from banks and other sources of capital are hard to come by. Many doctors feel they can’t afford to invest in EMRs, and the return of investment doesn’t justify the expenditure. The malpractice specter looms large, and young doctors in particular simply want a more balanced life style with the fringe benefits of hospital employment. Merritt, Hawkins, and Associates reports that 23% of its search assignments in 2006 were from hospitals, up from 19% in 2004/2005m and 11% in 2003/2004. Another unexpected development is multispecialty groups approaching hospitals asking to be absorbed, merged, or acquired so groups can recruit physicians, retain the ones they have, fund retirement programs, and gain access to sufficient capital to invest in EMRs and other improvements.

Physician Mindset Number Three – Physicians regard consumer-driven care with skepticism and tend to be reactive rather than proactive in adapting to change.

Proponents of consumer-driven care call it the “silent revolution,” which poses a problem. It is too silent. although membership in consumer-directed high deductible plans (CDHP) with HSAs now exceeds 4 million, and may grow to 40 million in the next five years, consumer-directed care isn’t getting a big play among pundits, the media, and the reform crowd. Among some liberal critics, CDHPs draw a collective yawn because it’s said they fail to address the problems of the uninsured and costs of disease management. Some hard-pressed employers are switching from HMOs and PPOs to CDHP with HSAs. But employees, given a choice, are reluctant to change because of the uncertainties and unknowns of CDHPs. Perhaps a third of employees are uninsured and signing up because they can now afford premiums. Inducements, such as free preventive care, are attracting a few employees but not many. And there is still a great deal of caution out there whether these new plans are good for employees with chronic disease. Among most doctors, CDHP are still too small to have much of an impact, and the idea of dealing with consumers armed with data still frightens some.

Physician Mindset Number Four
- Physicians do not look upon EMRs, physician websites, or Internet outsourcing as the Holy Grail but are slowly adapting.

Among the physicians to whom I talk, the idea that the computer will change everything – make health care better in every way, render health care pricing and quality more transparent, separate high performers from low ones, help doctors become more productive, increase accuracy of diagnosis, empower consumers, facilitate and streamline billing processes, enhance patient safety, eliminate duplicated histories, drugs, and tests; and somehow transform and rationalize health care just as it has the retail, financial, and service industries -- is met with reluctance and resistance to change. A big part of the problem is organizational structure; physicians don’t have the group size - economies of scale, managerial expertise, and access to capital – to make the changes. Another aspect are a series of fears – radical adjustments in practice styles, outdating of what one learned in medical school and residency programs, dark suspicions of how data will be used, apprehensions about being reduced to a mere technicians behind a computer screen, and the disbelief that you can judge quality on data alone or on insufficient numbers of patients in any given disease category. Some doctors say that over-zealous data-mongers are suffering from hardening of the categories.

Physician Mindset Number Five - Physicians are beginning to recognize economies of scale and organizational structure are important if physicians are to retain control of their destinies.

As I speak to practicing physicians, I sense the idea is dawning they need size, critical mass, and performance data to compete. Some clinics and health systems are adopting Mayo-clinic type arrangements to become more efficient and competitive and to leverage their inherent power and closeness to patients. Those that don’t feel they can compete on these terms are forming concierge practices, going solo, retiring, practicing on a cash only basis, joining hospitals as employees, switching careers, or sticking to their existing practices, hoping to ride out current poor reimbursement and praying Medicare and health plans will increase reimbursement and the doctor shortage will force political change. Roughly 20% of doctors are installing EMRs in hopes of increasing productivity, pleasing consumers and payers, and anticipating EMRs will be needed to participate in consumer-driven markets; meet standards for P4P bonuses, meeting quality indicator, and metrics requirements. Other doctors are aggregating into larger virtual groups, using their wits to make process changes to increase work flow and productivity, adopting efficiency models like the Toyota lean business model, and collaborating or being acquired by hospitals in order to have access to capital, capture more of the health care dollar, and pay for the infrastructure needed to compete. As one practice management expert said, either one “competes or retreats.”

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