How Doctors React to Being "Managed"

Last week I blogged on how a former corporate medical affairs executive thought independent practicing doctors should be managed.

Among other things, he said corporations should,

• regard health care as just another product,

• deal only with doctors who comply with product specifications,

• judge doctors to whom to refer by judging value (cost/quality).

• pay only for evidence-based care.

Doctor readers reacted swiftly. My blog rating dropped sharply by 40%. Negative comments ensued. Being a messenger of bad news bore adverse consequences.

I’m not surprised how doctors reacted. Twenty years ago, I wrote in And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota (Media Medicus) that managed care was doomed to fail. And in a second book, Managed Care Memor: A Physician’s Whistle-Stop Journey, 1983-2003 (Infinity Press, 2003), I elaborated on why managed care was failing. In essence, I said doctors think of themselves as professionals to be trusted, not as providers to be managed, or as cost-generating renegades to be reined in.

For years, I’ve argued with this medical executive that,

• You can’t manage care like other, more tangible products because medical practice is a subjective, complex interactive human activity;

• You can’t force doctors everywhere to comply with product specifications because care varies with local cultures;

• You can’t base payment solely on “evidence-based” care because more thant 50% of doctor visits aren’t evidence-based; visits are human-based, neighborhood-based, relationship-based, and circumstance based. .

• Ultimately, you can’t judge physicians on outcomes depend on how patients behave once they leave the doctor’s office, not on what the doctor does at the point of care.

• If you want to control costs, deal directly with physicians rather than through their human relations departments or through managed care surrogates, and make your case with irrefutable data.

Case closed.

A Major Disruptive Innovation = Doing Away with the Paperwork

“…Disruptive innovations – cheaper, simpler, more convenient…”

Clayton Christensen, Richard Bohmer, and John Kenagy, “Will Disruptive Innovations Cure Heallh Care?’ Harvard Business Review, September-October, 2000

I just attended a conference on strategic innovation. At a pre-proceedings greeting dinner, the group leader asked, “Name the most disruptive innovation that has changed society forever.” Or words to that effect.

The audience included senior executives of a global company and a handful of experts representing various spheres of economic activities affecting society and business. I was the “expert” on health care trends, a title I so richly deserve but so seldom get.

These answers, some profound, some trivial, came back:

“Television.”
“The Personal Computer”
“The Internet”
“Google.”
“E-mails”
“Post-It Notes”
“Bottled water.”
“Cellphones,”
“I-Pods”
“Boneless chicken wings.”

At my table in the rear of the room, a health care guy, I was in a jocular mood. So I threw out “virtual colonoscopy” as a disruptive innovation, or perhaps I should say, a non-disruptive procedure. I was there, after all, to talk of health care trends. One trend I foresaw was minimally invasive procedures.

That Damned Paperwork

Suddenly the mood turned serious among our little subgroup, and we collectively concluded that the single most disruptive innovation that could even happen, was, “Getting rid of that damn paperwork.”

Detailed paperwork – get down the demographics, note past and present diagnoses, record the history, state the chief complaint, list allergies and drugs, identify the person to notify in care of emergency, document the encounter, and above all, confirm who is paying – is the bane of patients and doctors alike.

Perils of Paperwork

Paperwork is, well, so complex, duplicative, time-consuming, and, so frequently irrelevant, to the task at hand. Finding out what’s wrong and what to do about it the case of the patient; practicing what you’re trained to do in a cost effective and timely manner, in the case of the doctor, the waste of everybody’s valuable time, and one of the singularly most inefficient aspects of the health system.

Patients indignantly ask, “How many times do I have to go through this routine?” Or, “Don’t you people ever talk to each other?” Doctors, in their turn, ask,” Why do I have to do this?” “what the hell does this have to do with being a doctor?” “Why hasn’t this been done ahead of time?” Or, “Why can’t I have all this information in front of me when I see the patient?”

The paperwork involved, as everybody with any sense at all, knows, is a giant invoice, rather than a communication document.

And, to compound the problem, EMRs, until now, have been nothing, more or less, than a huge electronic invoice. This may be about to change, and the pressure is coming from multiple commercial enterprises =- WebMD, Google, and Microsoft, and others – who see simplifying the problem as a giant opportunity to streamline the patient-doctor encounter in the form of personal health records, owned by patients, frontloaded with patient data, and designed to be continually updated by patients and their doctors – as the vehicle for transforming health care and making it more efficient.

Not a Sure Thing

Sure, personal health records have privacy, security, and data entry hassles and concerns. Sure, patients and doctors alike may find it complicated at first, as they did personal computers, the Internet, e-mails, and those damn EMRs. But, these records have the potential of dramatically simplifying the patient-doctor encounter and making it more convenient, satisfying , and productive. It may even help get rid of that damn paperwork.

Meanwhile, disruptive innovations have yet to “cure: health care, as I noted in the opening quote.

A Call to the American Public

Operator, connect me to all of the American public,
Yes, all 303 million of them under the USA rubric.

Yes, I know this call is out of the ordinary,
But times call for the highly extraordinary.

Who is calling? Sermo physicians working together.
We want to talk to Americans about making care better.

Pause...

Hello, American health care consumers and patients.
We American doctors want to show our impatience.

With high costs, excess paperwork, and long waits,
And huge malpractice costs for occasional mistakes.

Yes, we’re human and we occasionally do err,
And if we do, we insist you be treated fair.

We prefer to deal with you directly,
Rather than through 3rd parties indirectly.

We want to be your direct partner and guide,
We want you to know we’re on your side.

We believe costs of rules, regulations, and mindless standardization,
May overly restrict freedom, choice, and thoughtful individualization.

So keep an American Eagle eye out for our Open Letter,
With your help together we will make health care better.

Thousands of us want to shout what needs to be done,
to make our precious health care system better run.

Right now I can’t tell all.
But we plan to stand tall.

What these united doctors want to reveal
is now in An Open Letter still under seal.

Straight Talk with a Corporate Medical VP

Recently I ran across this statistic: 60% of health coverage is employer-based and 30% is government-based. This struck me. I felt government was on the verge of taking over, mostly because employers can’t keep up with health cost inflation, which has been 4.4 X of health inflation vs. general inflation. Yet I know employers are reluctant to accept government-regulated cae.

So I called a lifelong friend, formerly the VP for medical affairs of a major multinational corporation. He prefers to remain anonymous. He’s an internist who wrestled with health inflation demons for 13 years during his corporate life.

I asked him, how can Corporate America subdue the inflation beast?

Here are his answers, none of which are easy to do.

1) Overcome the entitlement mindset. He claims Health Resources departments think of themselves as dispensers of health care entitlements rather guardians of cost.

2) Manage care rather than finance it. Too often, he says, corporations simply pay for efficient use of unnecessary care.

3) Treat health care as simply another product: deal only with providers who comply with product specifications. Quality first saves money.

4) For major illnesses, contract with major institutions with known outcomes. Again quality first saves money.

5) Institute wellness and prevention programs. Focus on screening and controlling those things – BP, glucose, and weight – known to have adverse outcomes.

6) Pay only for evidence-based care, based on evidence generated from the medical literature and from specialty societies: reduce excessive care.

7) Be aware of consumer-driven care and shared consumer-cost responsibility but do not rely on them. Employers will be wary of intrusions into their financial and lifestyle worlds and are difficult to inform and educate about proper care.

8) Have the CFO, who is responsible for the corporate bottom-line, engage directly in conversations with local and national physician organizations to set standards to see what else can be done rather than going through the current chain of health care command -- HR departments, HMOs and PPOs, and health care consultants.

A Call to Aesculapius

Operator, please connect me to Greece
Who’s calling? My name is Dr. Reece.

What city? It’s a place called Mount Olympus
Who am I calling? His name is Aesculapius.

No, I confess I don’t know his first name.
With his fame, you don’t need a first name.

What’s my reason for calling?
Tell him the medical sky’s falling.

I desperately need his advice,
That reason should suffice.

Pause……

Hello, Aesculapius?

I’m delighted to speak to you
I want to get your point of view.

Down here the operative words are “hope” and “change,”
Which aren’t so good if you view them at close range.

Take the simple common matter of clinical priority,
Doctors now turn to technology as the first authority.

Instead of looking at the patient and taking a history
They turn first to scans and tests to solve the mystery.

Reflexive, senseless technologies drive up costs,
Tests become the boss and have an automatic gloss.

Did you order a CT and MRI scan, asks loudly the instructor?
Of course, says the intern proudly to the rounds conductor.

As if it’s not what you observe on the outside,
But what counts is what is seen on the inside.

Forget subjectivity,
Focus on objectivity.

At medical school, doctors learn practice management,
Rather than the ins and outs of disease management.

By the way, how is the doctor’s first advisor, Hippocrates?
Tell him his famous oath is now swinging in the breeze.

Doctors are now swearing different kinds of oaths,
At rules, regulations, and bureaucratic over-growths.

And at malpractice lawyers on the offensive,
Which makes doctors practice on the defensive.

If you happen to run across Sir William Osler,
Tell him the Art of Medicine has taken a detour.

Today we talk of medicine as being data-driven,
As if numbers, not humanity, were the only given.

Please forgive me, Aesculapius.
If my bias is overtly obvious.

This is simply my own rendition,
Of medicine’s current condition.

As I complete these bad-time, bed-side medical rounds,
I think of Mark Twain’s comment on Richard Wagner’s music, “It’s not as bad as it sounds.”

Of Doctors, Debt, and Time

I see by today’s May 15 Wall Street Journal that the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University will award full scholarships to all entering medical students to cover the $43,500 tuition but not the estimated $21,800 for living expenses, fees, equipment, and books.

The school is starting a five-year program to train physician investigators for academic careers. Medical student interest in academic careers has been flat for a decade, hovering around 15%, but dropped to 9.4% in 2007.

The program also addresses the problem of the high cost of medical education, which is $140,000 on average. Other medical schools – the University of South Florida and Yale – are also moving to address the problem of education debt.

Buried in the WSJ report is this statement, “Academic careers are very demanding in terms of time. Some students feel those kinds of demands would be difficult for them to meet while also trying to obtain some sense of work-life balance.”

I find this comment interesting because doctor critics too often ignore the whole concept of time spent becoming a functioning doctor – 11 to 16 years depending on specialty. time expended in seeing this 25 patients answering those 50 phone calls, and filling out those endless forms in the course of day.
Maybe those young doctors flocking to hospital employment and those 8 hour days and 40 hour weeks have it right – time is fleeting, life is short, and family relationships are sweet.

In any event, the words of Peter F. Drucker (1909-2006) come to mind.

“Time is a unique resource. Of the other major resources, money is actually quite plentiful. We long ago should have learned that is the demand for capital, rather the supply thereof that sets the limits of economic growth. People – the third limiting resources – one cannot hire, through one can rarely hire enough good people. But one cannot rent, hire, buy, or otherwise obtain more time.

The supply of time is totally inelast6ic. No matter how high the demand, the supply will never go up. There are no prices for it, and no marginal utility curve for it. Moreover, time is totally perishable and cannot be stored. Yesterday’s time is gone forever and will never come back. Time, therefore is in exceedingly short supply.

Time is totally irreplaceable. Everything requires time.