Providers of medical care in the United States are consolidating. Hospitals are merging into “systems” and physicians are joining large physician groups, many of which are part of “vertically integrated” delivery networks that include hospitals.
Many forces are driving this consolidation, including the high capital requirements technologically advanced care, the challenge of meeting government regulations, the “arms race” consolidation of the commercial insurance industry, and the drive toward accountable care, in which providers take on some or all of the financial risk associated with the health outcomes of a population, and therefore need to work closely together to manage care delivery.
A recent paper in Health Affairs points out that structural integration does not necessarily translate into functional integration from the perspective of those who ought to matter the most – patients.
Continue reading Structure and Function
While Washington now seems consumed with the mess swirling around the White House that was triggered by the abrupt firing of the FBI director, I want to get back to the mess swirling around the latest effort to “repeal and replace” the Affordable Care Act.
Although the President stated that “nobody knew that health care could be so complicated,” his apparent surprise is surely based on his own profound, willful ignorance. Anyone who has paid even the most cursory attention to American health care delivery and financing knows that our “system” is uniquely complicated (actually, it is complex). The complexity has been driven by many forces including, among others, the historical accident of employer-based health insurance, a mythic belief in “the market” to improve everything it touches, a corresponding skepticism that government can do anything effectively, and a lack of national consensus about what we, as citizens, owe each other to “promote the general welfare.”
The net result has been well documented. Health care in America is characterized by huge disparities in access to care, major failures of quality and safety, and unsustainable costs. It is, of course, also characterized by amazing life-saving and life-sustaining technology and millions of dedicated, compassionate people who struggle daily to overcome the dysfunction to deliver great care. So how to fix the bad without destroying the good?
Continue reading Back to Health Care
The Association of American Medical Colleges (AAMC) recently released a new report detailing their predictions for the physician workforce of the future. The accompanying press release highlighted the key finding of the report: by 2030, the US “physician shortage” will be between 40,000 and roughly 105,000 physicians. The projection is based on a few assumptions, including that the 2015 physician workforce was “in balance” (enough doctors to meet demand); the aging of the population; retirement trends among physicians; and improvements in access to care for traditionally underserved populations.
Mostly the report made me think of horse manure. Specifically, it reminded me of frequently quoted predictions, made in the late 19th century, that cities such as New York and London would, by the early 20th century, be buried in mountains of it. This has been dubbed “The Great Horse Manure Crisis of 1894” which, of course, never came to pass.
In retrospect, it is easy to see that the 19th-century alarmists missed the technological revolution that was about to replace horses with vehicles powered by internal combustion engines, which averted the “crisis.”
Continue reading Workforce Predictions and Horse Manure
Everybody knows the old saw about how the legislative process resembles a sausage factory: even if you like the product, it may turn your stomach to see how it is made. I have been thinking about that metaphor a lot lately as I have watched the Republican caucus in the US House of Representatives slap together their plan to “repeal and replace Obamacare.”
As the House lurches toward a critical vote today, I offer a few personal observations:
- The Republicans have long complained bitterly about how the Democrats “rammed through” the ACA in 2009. This, despite the fact that there were months of negotiations and the bill incorporated many previously mainstream Republican principles (including the individual mandate, which now seems anathema), and the Republicans deliberately walked away as part of their obstructionist strategy to deny President Obama a legislative victory of any sort. It is therefore particularly disturbing to see them scramble to bring this dog of a bill to a vote on some arbitrary self-imposed deadline. What is the rush?
- Speaking of a dog of a bill (with apologies to dogs everywhere), the only “principle” or “goal” that it advances is checking a box that says “repeal Obamacare.” The challenges facing our health care system are pretty easy to categorize. We need to assure access to care, we need to improve care, and we need to control costs. This bill does none of those things and stands to reverse the progress made by the ACA in providing coverage for millions of Americans.
- Don’t be fooled by claims of “lower costs.” The only thing this bill would lower is coverage, mostly by throwing millions off of Medicaid, and by stripping covered services from ACA plans. Any accrued “savings” are achieved by just providing less care for those who are in need.
- The targeting of Planned Parenthood and of reproductive health services, in general, is a shameful demonstration of the deep hypocrisy in the Republican party that has stood for individual choice and limited government (well, at least back when the party stood for anything at all) until it comes to dictating women’s health choices.
- The proposal is demonstrably, clearly, unambiguously and completely at odds with the President’s stated goal of “repealing Obamacare and replacing it with something beautiful” that “covers everybody.”
- Mostly, I am saddened by this rush to do harm, driven by political expediency, facilitated by ignorance, and leavened by a callous disregard for the health and wellbeing of our fellow citizens
What do you think?
Measuring the quality of care and improving it over time is a fundamental obligation of healthcare providers. Increasingly, quality is also tied to reimbursement and is reported publicly. While I strongly agree with both trends, three recent articles point out some of the challenges ahead.
The common theme among them is that “risk-adjustment” is a hard thing to do. A brief diversion to provide some context.
There are two main ways to measure and compare quality. One is to assess processes of care, such as adherence to established best practices and evidence-based treatment guidelines. This is relatively easy to do, but is by definition highly reductionist. Clinicians understand that “good care” is more than the sum of a handful of isolated activities. Does anyone really think that good diabetes care is equivalent to measuring the HgbA1c level annually and making sure that everyone is screened for diabetic retinopathy? The other way to me is to assess patient outcomes, or how patients actually fare at the hands of different providers. This allows for comparison of endpoints that providers and patients find important, and frees providers to innovate. The challenge is that it is very difficult to separate the relative impacts of patients’ baseline characteristics from the care received in determining the outcomes.
Continue reading Adjusting the Adjustment
We held a retreat last week for the Board of Governors of Northwell Health Physician Partners. Because we have matured as an organization, the agenda was different from recent years. Instead of asking “big questions” about what the group is and should be, we focused on providing information to the Board, and on addressing ways in which we could reduce physician burnout.
Given the imminent inauguration of the new president, and his party’s pledge to repeal the Affordable Care Act, one of the informational sessions was devoted to how the changeover in Washington may affect health care policy. We heard from Northwell Health’s head of government affairs, and from a former senate staffer who now works for a firm that provides our organization with insight into what is going on inside the beltway.
The speakers were knowledgeable and engaging, and I am confident that their description of the incoming administration and of the plans being laid by the new congress was accurate and insightful. It is no criticism of them to also say that I found their description appalling, frightening, and depressing.
Here are a few “highlights”:
Continue reading Repeal and… Then What?
Every clinician knows that “framing” – how we present information to patients – has a big impact on decisions they make about their care. Even something as simple and apparently transparent as talking about “survival” versus “mortality” is important, with “a 90% chance of living” sounding a lot better than “a 10% chance of dying” even if both phrases convey the same estimate of risk.
Things get even more dicey when doctors start talking to patients about more subtle concepts like risk-reduction or number needed to treat. The clinical impact of a big relative risk reduction operating on a low absolute risk can be hard for doctors to explain and patients to understand.
The impact of that complexity was the subject of a recent editorial in Circulation. In it, Diprose and Verster speculate that doing a better job of explaining these things to patients, which certainly seems like a good idea, may paradoxically lead to worse population health outcomes. Here’s how it could happen.
Continue reading Prevention Paradox
A recent story in Crain’s New York Business cited the difficulty small independent medical practices face coping “with declining reimbursement rates from insurers, rising overhead costs and a torrent of new regulations that have come into play in recent years.” According to the article, only 26% of NY State physicians now own their own practice, compared with national rates of physician ownership of 76% thirty years ago. Honestly, I was not surprised by the numbers. Consolidation of independent medical practices into larger organizations is old news, and it is no secret that the drivers include those mentioned.
I was, however, struck by the subsequent letter to the editor by Malcolm Reid, the president of the Medical Society of the State of New York. In it, Dr. Reid states: “Physicians should have a fair choice of practice setting to deliver care to patients, whether that is in a large health system, large medical group or within a smaller medical practice,” and goes on to say that “Many physicians enjoy independent practice because of the personal attention that can be directed to their patients without external interference.”
I am sure they do, but honestly, why should we expect the government or the public to assure that physicians have a “fair” choice? To put it bluntly, Reid (and the rest of us) should get over the idea that the organization of care should revolve around what’s good for doctors. He makes it quite clear that he is not advocating that “fair choice of practice setting” is about patients, since he concedes that effective patient-physician relationships can be maintained in a variety of practice and employment arrangements. Rather, he is saying that doctors should have the right to practice in independent practices because, well, that’s how they like to practice.
To be clear – and before the pitchforks come out – I am NOT saying that independent practice is bad, and I am NOT saying that I don’t care about how physicians feel about their practice arrangements. What I am saying is that if an independent practice is worth preserving, then the case for it has to be made on the basis of what it provides to the patients we serve, and not on the basis of what it provides to the doctors who care for them.
What do you think? Continue reading Is this about Doctors or Patients?
Physician burnout has received a lot of well-deserved attention lately. Characterized by emotional exhaustion and professional frustration, it has been tied to array of bad outcomes, from physician suicide to poor patient outcomes. Organizations are waking up to the need to measure its prevalence and ameliorate its impact.
There seem to be two broad schools of thought about the causes – and by extension, the fixes – of physician burnout.
The first is focused on the inner life of the physician. Yes, the demands of medical practice are high, but if doctors were a little more “zen” about things, then life would be better for them and the people around them, including their patients. There is now a substantial cottage industry peddling retreats, wellness classes, yoga and more to help physicians find inner peace in our tumultuous times.
The second school of thought focuses on the externalities of physician practice. Increasing demands for productivity, economic stress, loss of control over scheduling, and higher “hassle-factors” associated with EMRs and regulations have made medical practice harder and less rewarding. Burnout is just the natural reaction of sane, well-adjusted, intelligent people put into an insane environment.
Continue reading Burnout
In my prior post, I made the case that physicians in leadership roles should maintain a clinical practice. Doing so informs their administrative actions, affords them greater credibility with their peers and strengthens a vital link between the bedside and organizational activities. All of those benefits would accrue to nursing leaders who did the same.
In many organizations, as soon as a nurse takes on a defined managerial role (beyond being the “charge” for a shift) he or she leaves the bedside, never to return. They start to dress differently, with the whites or scrubs replaced with business attire and (often) a white coat. In fact, when I was a resident, we referred to the managerial, non-clinical nursing leaders collectively as “plain clothed nurses.” More importantly, I believe they also start to think and act differently.
Some of that difference is important and appropriate. As they advance organizationally, all leaders – not just nurses — must adjust to new responsibilities, acquire and develop new skills and broaden their perspective. Unfortunately, it also often seems as though clinical leaders lose an important attachment to patient care and to their staff when they are no longer “in the trenches” with them. In fact, it seems that much of what nursing leaders are now asked to do by “rounding” on their staff or regularly visiting nursing units is an attempt to replace what they have lost by leaving the bedside – credibility, first-hand knowledge of organizational effectiveness, and connection to purpose.
I think it would be better if they worked a shift now and again instead.
What do you think?