Doing Better and Feeling Worse: Why Aren't Doctors Feeling Better About the Future?

“ ‘Age and disease will be our next engine of growth,’ says Teresa Ghilarducci, a professor of economics at the New School. ‘That’s the really good news.’

As millions of baby boomers retire, she says, they will segue from their accumulation years into their spend-down years.

‘They’re going to be spending a lot on health care,’ Professor Ghilarducci said, ‘to forestall disease, to make themselves look younger. Low-end services, high-end services. CT scans, face lifts, bionic knees. We all think that health care is a high percent of gross domestic product now, but we ain’t seen nothing yet.’ “

But is it a good idea to nip, tuck and CT scan our way to prosperity? “

David Segal, “Economic Fix-Its,” New York Times, November 28, 2010

Why, if health care will be the next engine of growth and will consume ever more of the GDP, are doctors feeling so glum about the future? If you doubt how they feel, I invite you to read Health Reform and the Decline of Physician Private Practice (Merritt Hawkins. October 2010).

This feeling of dread is not new. In 1977, John Knowles, MD, a Massachusetts General internist who became the President of the Rockefeller Foundation, edited a book Doing Better and Feeling Worse: Health in the United States (W.W. Norton and Company).

The problem then, as now, was the system was doing better in improving health outcomes but doing worse in controlling costs, and many of the bad things, in both the economic and health realms, that happen to people were beyond the reach of medicine. The health system didn’t have all the answers.

To take a leading example, why can’t we contain demand and control health costs?

That, of course, is this year’s $2.7 trillion question.

According to Regina Herzlinger, PhD, a tenured professor at Harvard Business School, the problem is we don’t let consumers, spend their own money. pick their own providers, drive the system.(Who Killed Health Care? America’s $2 Trillion Medical Problem – and the Consumer-Driven Cure (McGraw Hill Companies, 2007).

Dr. Herzlinger identifies the five “killers” of a consumer-driven system as:

1. Health insurers, who insure the death of cost control through their dysfunctional culture.

2. General hospitals, which kill cost-control through their building of centralized. Ever-expanding empires of care.

3. Employers, who doom consumerism because they generally give their employees the “choice” of only one plan.

4. The U.S. Congress, who spur cost growth through lavish entitlement program riddled with fraud, abuse, and overuse.

5. Academics who contribute to the death of consumerism because of their elitist, technocratic, superior attitudes.

“Sadly, “comments Herzlinger, “on the federal government level, representatives from Republicans and Democrats have quaffed deeply form the Beltway Kool-Aid well. Neither believes in the power of innovators and consumers to reshape markets. Neither is in the-small-is-beautiful camp. Both believe the more oversight of health care by the government and academies is the solution. Both believe that big-is-beautiful.”

She goes on, “The federal government has not only specified what should be measured but also the protocols that health care providers must follow. These monopolistic powers are cloaked in the pseudoscientific mantle of ‘evidence-based.” The title implies that the guidelines are shaped by intelligent saints devoid of a shred of self-interest or vanity, guided only by ‘evidence’”

Small wonder doctors are glum. Everyone else, other than themselves and their patients, think they know what is best about the practice of medicine and the health care business. The health reform law effectively squelches health savings accounts which encourage consumers to shop for what they consider to be the best deal and doctors to compete for the consumers’ dollar. Rules and regulations forbid doctors to creatively re-design their practices and repackage their services. Medicare laws prohibit patients and doctors from privately contracting with each other. Prices keeps rising as regulations keep growing.

Medicine, it seems, is too important to be left to doctors and consumers. Trust us, is the mantra. We’re from the government and other large institutions, and only we know what is good for you and yur health.

Care, Cost, Access, and Health Reform

November 27 – This morning my good friend, Brian Klepper, an imminent health care analyst, sent me an email that said, in part,

“Later this week on Wednesday, 12/1, David Kibbe and I will launch a new health care professional forum called Care and Cost, which we hope will aggregate and showcase great HC writers of all persuasions and from all disciplines.

We’ve put some energy into designing the site and its characteristics. Among the things we’ll do:

• Categorize each post into major interest areas, so readers can easily find articles germane to their own work.

• Incorporate an area called “Urgent Science” that will run peer-reviewed, highly documented scientific review articles, aimed at giving practicing clinicians the basis for using new approaches.

• Run daily charts that say something interesting about what’s going on in health care.

• Provide occasional image galleries, by topic, suitable for presentations.”

David Kibbe, MD. MBA, and Brian Klepper, PhD, are long-time, trenchant commentators on health reform, innovation, new practice models, and medical homes. Their major concern. as I see it, is how to rationalize the system to bring costs into line while maintaining quality. They would like to do this before costs bring the system to its knees, and chaos ensues.

I do not always agree with their point of view – that practicing doctors, especially specialists, are the major drivers of cost, loose cannons that need to be reined in and that strict adherence to “best practices” will bring costs down dramatically – but I understand their logic.

I recommend readers visit their C&C site for their insights.

The big things that concern me about health reform are the cost implications of reform for physician supply, demand, and patient access. Reform will immediately add 16 million more people to Medicaid rolls (now 47 million or 19% of U.S. citizens) and potentially millions more as employers drop coverage, premiums escalate for existing plans, and word gets around that a massive new entitlement program is there to be had.

To me, the biggest question is: what will be the effect of reform on Medicare/Medicaid access? No one knows for sure. But a 2008 survey by The Physicians Foundation of 300,000 primary care physicians may hold some clues.
Here is how primary care physicians responded to three key survey questions.

1) Which, if any, of the following payers provide reimbursement that is less than your cost of providing care?

• Medicaid 65%
• Some HMO/PPO 43%
• Medicare 36%
• CHAMPUS 21%
• Some indemnity plans 14%
• SCHIP14%

2) Have cost/reimbursement or time issues in your practice compelled you to close your practice to any category of patient?

• Yes, 47%
• No, 53%

3) If yes, which types?

• Medicaid patients 34%
• Some HMO/managed care patients 30%
• Certain managed care companies 26%
• Indigent patients 16%
• Medicare patients 12%
• New patients 5%
• Other 4%
• Self pay patients, 4%

These figures were before the health reform bill passed in March 2010. In a 2010 Physician Foundation survey of 2600 randomly selected physicians of all specialties, 51% said they would close their practices to new Medicaid patients, and 30% indicated they would not accept new Medicare patients.

Low government reimbursements for Medicare and Medicaid do not bode well for expanded access, the primary purpose of health reform. Instead, limited access may be an unintended and paradoxical consequence of the health reform law.

Black Dog Thoughts on Black Friday

Today is Black Friday, the day after Thanksgiving.

For me it is a day of black thoughts on health reform, perhaps because I’ve been reading about Winston Churchill as seen through the eyes of his physician, Lord Moran. Churchill was subject to attacks of the Black Dog, bouts of depression. One black dog came in 1945, after Clement Attlee and the Socialists defeated him and the Tories. Churchill could not believe the English people turned him out after he had led England to victory after World War II.

Churchill did not believe in socialism - government policies dictating takeovers of private industries, wealth redistribution, and standardization, homogeneity, and uniformity of health care for all with equal benefits for all.

Socialism is utopianism, but it has flaws. So does capitalism. As Churchill so famously said, “The inherent vice of capitalism is the unequal sharing of blessings, the inherent vice of socialism is the equal sharing of miseries.”

This quote got me to thinking about problems of how one can standardize, homogenize, and make uniform the behavior of physicians, a notoriously independent lot who believe their clinical judgments surpass that of government or any clinical algorithm, protocol, or guideline. Perhaps one can erase regional and personal differences in care, but I am dubious.

The first problem is that government officials are not present at the site of the doctor-patient encounter. Remote bureaucrats, no matter how smart, cannot construct protocols covering every possible permutation and combination of clinical encounters subject to the whims of human behavior.

A second problem is that doctors, like patients, are infinitely variable. As a health care Pied Piper might say, doctors come in all varieties. There are big doctors, small doctors, lean doctors, brawny doctors, fat doctors, male doctors, female doctors, brown doctors, black doctors, white doctors, grave old plodders, gay young friskers, aggressive doctors, passive doctors, compulsive doctors, intuitive doctors, procedural doctors, cognitive doctors, entrepreneurial doctors, health system doctors, doctors that practice in bewilderingly different settings, each requiring different mindsets and skills.

To complicate matters further, there are solo and two practice doctors (47%), doctors in groups of 3-5 (15%), groups of 6-50 (32%), doctors in hospitals (13%), doctors in medical schools (7%). Doctors in groups of more than 50 (6%), doctors who work in HMOs (4%), and doctors who slave in community health clinics (3%)- each with different mindsets and views of the world. It becomes almost impossible to design an information system that fits them all, pleases them all, and ties them altogether.

It would make socialistic and managerial sense to herd all doctors into large groups or institutional settings that are "integrated" and "coordinated". That way you could put those free-thinking doctors on salary and make them follow rules of the organization and/or government mandates. It would make sense, too, I suppose, to stop all fee-for-service payments, the mode of reimbursement for most other professionals that invites over-use and rests of trust.

A third problem, and it's a whopper, is that America is a center-right individualist. freedom-loving nation that does not believe in centralized, collectivized government. Give me freedom, choice, and opportunity are our rallying cries.

A fourth problem, another whopper, is constructing a giant fail-safe bureaucracy with rules, regulations, protocols, and guidelines to cover every clinical eventualities and different physicians and patients personality types.

To do so, you would have to make myriads of payment, insurance, government changes, experimental demonstration programs to test your changes, and different government agencies to make sure the changes worked in real world. Given the infinite variety of human beings and their needs and vagaries, this new health system might look like this.

>YOUR NEW HEALTH CARE SYSTEM

PRESIDENT

INTERNAL REVENUE SERVICE

CONGRESS

SECRETARY OF HEALTH AND HUMAN SERVICES

ADMINISTRATOR OF CENTER OF MEDICARE AND MEDICAID SERVICES

NATIONAL COORDINATOR OF INFORMATION TECHNOLOGIES

NEW INSURANCE PROVISIONS, ADMINISTERED BY GOVERNMENT EXPERTS

NEW MEDICARE /PAYMENT PROVISIONS, ADVANCED BY ANOTHER SET OF TECHNOCRATS

NEW DEMONSTRATION/PILOT PROJECTS AND ADDITIONAL PROVISIONS, TOO NUMEROUS TO MENTION

NEW AGENCIES

• CENTERS OF MEDICARE AND MEDICAID INNOVATION

• INDEPENDENT MEDICAL ADVISORY BOARD

• PATIENT-CENTERED OUTCOME RESEARCH INSTITUTE


Patients - Doctors


Please note: Patients and doctors are in small print at the bottom of the bureaucratic pile. Wedged and buffered between them are, at last count, 159 different government agencies, boards, and panels. And that doesn’t count tens of thousands of government employees and 13,500 IRS agents required to implement and enforce the whole bundle and caboodle. Regulatory interpretations are piling up, along with regulatory burdens. Since ObamaCare and the Reconciliation Act were signed into law in March, there have been no fewer than twelve sets of additional regulations, guidelines, or notices that have been issued to lend clarification and at the same time add additional regulatory requirements.

Physician Foundation Grassroots Report

I would like to bring to your attention a remarkable document. It is a 110 page white paper Health Reform and the Decline of Physician Private Practice.

It is a grassroots report conducted on behalf of The Physicians Foundation by Merritt Hawkins, the nation’s largest physician recruiting firm. The Foundation is a nonpartisan, grant-making organization representing independent practicing physicians in state medical societies.

Why do I say the document is remarkable? Because it puts health reform in perspective. Amidst all the sound and fury about the health reform law, it tells what’s happening to physicians on the ground and where they are on that ground.

Where Doctors Practice

The document notes, for example, where doctors actually practice. To hear health reform critics talk, you would think most doctors do their work in large integrated groups or medical centers. Not so. Most of them hang out in solo or small to medium-sized groups.

• Solo, two physician practices, 32%

• Group practice, 3-5 doctors, 15%

• Group practices, 6-10 doctors, 19%

• Hospital-based, 13%

• Medical schools/university, 7%

• Group practice, 51+ doctors , 6%

• Group/Staff HMO, 4%

• Community health centers, 3%

What’s Happening at the Grassroots

The document observes that “informal reform,” socioeconomic trends and pressures on the ground, are just as important, perhaps even more so, than policies being dictated from Washington as embodied in the new health care law.

These trends and pressures include:

• The replacement of traditional independent practice by consolidated entities – hospital-doctor alliances, larger groups, and emerging models, such as accountable care organizations, medical homes, concierge practices, and community health centers.

• Legal and government pressures fostering and forcing an environment to “comply” with outside authorities and statutes and “improvement” and “compliance” measures.

• Increased demand for physician services in the face of growing physician shortages, especially of primary care doctors and general surgeons, with no relief in sight because of time required to mint new physicians.

• The “imperative to care for more patients, to provide higher perceived quality, at less costs, with increased reporting and tracking demands, in an environment of high potential liability and problematic reimbursement," Many physicians regard these imperatives as "mission improbable," or to use a word that runs through the report, as "problematic."


• The reluctance of Congress to include a “fix” for reasonable doctor Medicare pay, as embodied in the SGR formula, which indicates to physicians that Congress is not on the side of doctors, that health care is too important in the minds of politicians to be left to doctors, and that the viewpoint of doctors in likely to be ignored, further disengaging doctors from the profession and making access to them more difficult.

• Changes induced by reform, both “informal” and “formal” are inevitable and sometimes necessary, but do not bode well for increased coverage, quality, access, and private independent practice survival, which now and in the future, will be required for a high quality accessible health system.

Doctors, conveniently available on the ground and using individual clinical judgment rather than just marching to government mandates, are important, especially when you are sick and need their help.

A Physician Survey Shows Private Practice Decline and Disapproval of Health Reform

Today a booklet crossed my desk entitled Health Reform and the Decline of Physician Private Practice: A White Papers Examining the Effects of The Patient Protection and Affordable Care Act on Physician Practices in the United States. It contains a survey 0f 2600 randomly selected private physicians of various specialties from a cross-section of physicians across the country.

The survey makes for depressing reading.

Here are a few of the selected findings.

1) Are you in an independent, physician-owned practice or are you employed by a hospital, health system, or other entity?

Physician-owned practice 59%
Employed by hospital or other entity 41%

2) What was your initial reaction to passage of the 2010 Patient Protection and Affordable Care?

Very positive 12%
Somewhat positive 15%
Neutral 6%
Somewhat negative 15%
Very negative 52%

3) How do you now feel about health reform?

I am more positive than I was initially 10%
My feelings have not changed 51%
I am more negative than I was initially 39%

4) Do you believe the viewpoint of physicians was adequately represented in policy matters and the public during the run-up to passage of health reform?

Yes 14%
No 86%

5) How do you think reform will affect patient volume at your practice?

Patient volume will increase 54%
Patient volume will remain the same 35%
Patient volume will decrease 11%

6) Do you now have the time and resources to see additional patients in your practice while still maintaining quality of care?

Yes 31%
No 69%

7) How do you believe reform will affect the quality of care you are able to provide to your patients?

Improve 10%
No effect 19%
Diminish 56%
Unsure 15%

8) How do you believe health reform will affect the amount of time you are able to spend per patients?

I will be able to spend more time per patients 5%
There will be change in the amount of time I can spend per patient 24%
I will have less time per patients 59%
Unsure 24%

9) What effect do you believe reform will have on the financial viability of your practice?

Enhance 10%
No effect 9%
Diminish 68%
Unsure 13%

10) Health reform provides pilot projects to test “bundled (capitates) payments” for patients for episodic care. What is your view of bundled payments?

A generally good idea 11%
A generally bad idea 68%
Unsure 21%

11) Which is likely to have the greatest impact on your practice – health reform or a “fix” of Medicare’s Sustainable Growth Rare (SGR) formula?

Health reform 34%
SGR 36%
Unsure 30%

12) Do you believe reform will compel you to close or significantly restrict your practice to any category of patient?

Yes 60%
No 40%

What categories?

Close Significantly Restrict
Medicaid 51% 42%
Medicare 30% 57%
Indigent 43% 38%
Patients covered through exchanges 24% 44%
HMO 17% 42%
All new patients 5% 37%
Self-pay 10% 24%
Privately insured 5% 18%
Other 6% 9%

12) Consider your practice plans over the next three years as reform is phasing in. What do you plan to do?

Continue proctors as I am 26%
Cut back on hours 19%
Restore 16%
Switch to cash or concierge prate 16%
Relocate to another computer 14%
Work locum tenens 14%
Cut back on patents seen 12%
Seek a non-clinical job in health care 12%
Seek a job/business unrelated to health care 12%
Seek employment within a hospital 11%
Work 20 hours or less 8%
Close my practice to new patients 6%
Other 4%

13) How do you believe reform will affect the independent private practice?

Will enhance the viability of private practice 34%
Will have little or one affect on private practiced 36%
Will erode private practice 30%

14) Which best describes your view of independent, private practice?

It is a dinosaur soon to go extinct 28%
Is on shaky ground 58%
Is relatively robust and viable? 14%

Summary

Four of five physicians surveyed (2400 in all) believe that one of the consequences of health re4form will be the erosion of traditional independent private practice. 24% will continue to practice as is, but 74% will seek other forms of practice or employment or will retire. 65% of doctors have a somewhat negative or very negative attitude towards reform.

Conclusions

1) The majority of physicians responded unfavorably to passage of health reform.

2) The majority of physicians believe health reform will increase their patient loads while decreasing the financial viability of their practices.

3) The majority of physician plan to alter their practice patterns in ways they will reduce patient access to care, by retiring, working part-time or taking other steps.

4) Physician practice styles will be increasing less homogenous. The full-time, independent practitioners accepting third party payment will largely be supplanted by employed, part-time, locum tene4nes, and concierge practitioners.

For additional information about this survey, contact Phillip Miller of Merritt Hawkins and AMN Healthcare at 469-524-1400 or phil.miller@amnhealthcare.com

A Physician's Gratitude List

The USA remains mankind's last, best hope. Or, as former Secretary of State Madeleine Albright called it, America is "the indispensable nation."

Try to imagine the world without the United States. Who would nurture the universal longing for liberty? Who would guarantee the security of democracies and minorities around the globe? Who would sacrifice their own sons and daughters to liberate others?

Albright got it right: Our nation is indeed indispensable.

Michael Goodwin, “Giving Thanks to Our Nation, “ New York Post, November 24, 2010

This morning I awoke, depressed and gnarly.

My son, an aspiring Episcopalian priest, sensed my mood. He said, “Dad, make a gratitude list. It will make you feel better, and it will put things in perspective.”

Sure enough, it did. Here’s my list.

I am grateful I live in a country where,

• People can disagree disagreeably about the health reform law, but without riots, strikes, or violence.

• Voters can feel free to express their opinions about the health reform law - 48% favored repeal, 47% want it strengthened or left as it.

• The latest Gallup poll indicates 82% of people are satisfied with their health care. That's not 100%, but it is impressive.

• Few citizens choose to go abroad to seek better care.

• Every citizen who goes to an emergency room will be treated no matter what his or her financial circumstances.

• No matter where you live in the U.S., most citizens have quick or immediate access to the best medicine and technologies has to offer without government oversight, second guessing, or rationing. This is not true in most other countries.

• We provide such exceptional care that kings and potentates come here for treatment (The King of Saudia Arabia is now at Cornell to get a herniated disc fixed), and doctors come here from around the world to learn, to train, to practice, and to benefit from our research.

• We listen to the voices of the people when the majority protest a sweeping health reform law they fear will cost them their current coverage and access to doctors.

• We cover 110 million of our 310 million citizens through costly Medicare and Medicaid programs and pay for ½ of all health care costs, an expense per capita above that of other nations.

• Our political system allows us to engage in a lengthy, sometimes acrimonious debate, on what is the right thing to do in the long run to provide the best care for most of the people most of the time.

• As a country, we believe in individualism and choice, in government care as well as private care, in the independence of physicians to choose their specialty, where they want to live, and to provide care they think is best for patients based on individual human judgment rather than bureaucratic rules .

• We are a society that prides itself in our generosity to help others around the world , in our innovations that make us the Internet crossroads of health information of the world, the fountainhead of many advanced medical technologies- in genomics, cancer therapy, life-saving and life-style restoring procedures, our imaging technologies; and in vibrant entrepreneurialism in multiple health care spheres, a spin-off of free markets in a capitalistic society.

I am proud to be an American physician, living in America.