Theory v. Practice in Health Reform

Two great articles came out last week about the role of physicians in health reform – both as the source of problems and the need for them to lead in implementing solutions. (These articles also made me think back about some of my own positions on physicians engaging in health policy – see the bottom of this post.)

The first article was by Atul Gawande in the New Yorker, where he explores how physicians contribute to some communities having higher healthcare costs than others.  The second article is in the New England Journal of Medicine, and is written by three distinguished health policy thought leaders, (Elliott Fisher, Don Berwick and Karen Davis), who discuss how physicians can help implement positive reforms.

While Drs. Gawande, Fisher, Berwick and Davis all know the same data and studies about the US healthcare system, the NEJM article discusses possible solutions at a theoretical level and advocates macro solutions that each of them have been associated with, e.g. Accountable Care Organziations (Fisher) and Triple Aim (Berwick).  In contrast, Dr. Gawande goes to the practical ground level and explores why one town in Texas has such high healthcare costs.  His conclusions are illuminating, scary, and not surprising to most health policy experts: The high healthcare costs are due to the overuse of medical services, (particularly some high cost tests and services), and this overuse is driven by profit incentives for physicians who have essentially shifted from practicing medicine in the interest of patients to running a business for the benefit of their bank accounts. (What is surprising is that while many of the local physicians understood this, the hospital administrators apparently didn’t recognize this situation.)

The importance of this ground level view for achieving the high performing health system envisioned by Karen Davis and others, should not be underestimated.  With hundreds of thousands of physicians in the US – and most of them still working in small practices – changing clinical behaviors faces high hurdles.  In theory, changing financial incentives to reward quality rather than just quantity of care provided should make significant improvements in cost growth and quality of care.  However, achieving this without very damaging negative consequences will requires two major leaps. First, clinicians who are currently running profit maximizing medical businesses have incentives to oppose any changes.  And second, if incentives are changed to reward quality, then there will need to for extensive information gathering and monitoring to ensure that the same profit maximizing behaviors that currently predominate in certain communities don’t result in patients being denied appropriate or needed care under what would likely be bundled payment systems.  (This is why information gathering and monitoring needs to include both process and actual outcome measures which can be used to evaluate clinical and economic aspects of the healthcare system’s operations for both individuals and entire communities.)

My own belief is that successfully remaking the US healthcare system to perform higher and achieve the Triple Aim – whether it be through Accountable Care Organizations, other forms of integrated delivery systems, or Patient Centered Medical Homes – will require greater input and buy-in from physicians.  And this will require significant local leadership – from both physicians and other community champions for change.  I stated my belief in this last fall when being interviewed for the Massachusetts Medical Law Report’s Rx for Excellence Leader in Quality award. (see below)

My belief that leadership and communications by key individuals are needed for health reform to be successful hasn’t changed since the early 1990s.  For example, I recently came across an EBRI report that quoted me discussing this in a 1992 meeting: “Mike Miller of Rep. Sander Levin’s office swung back to the need for leadership. ‘People want change but there is no agreement beyond this,’ he said. ‘Leadership has to put together the policy and sell it to the people, communicating the benefits and down sides, showing how it is better than what we have now.'”

The bottom line is that because physicians’ decisions determine about 70% of healthcare spending, physicians can and should both play a role as leaders in developing what changes make up “health reform,” and in communicating the value of these changes to both their peers and their local communities.  The alternative is more of the same.  And it is becoming increasingly unclear how sustainable our current system is, so that at some point the money eating system we have built may collapse like General Motors.

4 thoughts on “Theory v. Practice in Health Reform

  1. It is certainly true that physician shortages and lack of affordable care for all Americans are some of the greatest challenges our nation is currently facing and will continue to face in the coming years. Health reform will not happen overnight, but Americans need cost effective and reliable healthcare now.

    To achieve this goal of a “high performing health system” that Dr. Miller comments upon, it is important to realize that doctors are not the only ones who can help to fix the current system. Throughout the country, you’ll find a broad spectrum of healthcare professionals (who are not doctors of medicine or osteopathy) who are well-prepared to meet the growing healthcare needs of Americans. These providers, who range from certified nurse-midwives to natural medicine specialists to psychologists, provide a diverse array of safe, high-quality and affordable services. All providers, MDs and non-MDs, can and should contribute to health reform. And throughout the process, we should protect patients’ rights to see their provider of choice.

    For more information on how to protect patients’ rights, visit the Coalition for Patients’ Rights™ at

    -By The Coalition for Patients’ Rights™

  2. I hear Mr. Langston’s argument and agree with Dr. Miller’s response to it, that doctors at Mayo and elsewhere already figured out ways to deliver excellent care at reasonable prices. It is unfair to paint all physicians with a broad brush just because there are a few unscrupulous or even greedy doctors. It’s also unfair to ask any doctor to work for free, or for less then their skills are worth to a society. There has to be a fair wage, and a commensurate salary for the years of training and deferred gratification that doctors invest for the privilege of providing care to their patients. Most doctors are fair and honest people, and these doctors want a fair system too. Doctors may be part of the problem, but they will be a big part of the solution when one is found.

  3. Christopher – Thanks for your great insights. I didn’t mean to imply that all physicians are operating medical businesses with the goal of profit maximization. Atul’s New Yorker article discusses several excellent examples of communities where physicians have been part of the leadership structure for creating local healthcare systems that operate with very high quality and below average costs. It is this type of physician leadership that is needed as part of an overall process where all stakeholders agree to the desired outcomes and objectives, and then jointly develop and implement plans to achieve those goals….. I hope this clarifies things a bit. Thanks, Mike

  4. Dear Dr. Miller – Thank’s for your interesting observations about the need to influence both health care systems at the macro level and physician practices at the ground level to create change. Also for your concern that the same profit incentives that have undermined the current system, be monitored carefully to be sure that patients are not denied access or other aspects of quality care.

    However, I wanted to raise a concern with your conclusion that because of their role in the problem, physician leaders need to be brought into the plans for reform. I believe the argument is that on the one hand they are potential opponents of change who must be propitiated and on the other they are potential local leaders for the more positive future we wish to have.

    While I don’t oppose this in principle, the argument has the interesting structure that since the poor behavior of these actors has caused much of the problem (“. . . physicians who have essentially shifted from practicing medicine in the interest of patients to running a business for the benefit of their bank accounts.”), therefore they have to be part of the solution.

    It doesn’t seem nessecerily “right” that those who have contributed to the problem be given great sway in determining its solution – this is certainly not an argument given much weight in other areas. Nor is it necessarily as practical as you are suggesting – what if the people who have benefited from the current system are essentially unwilling to change? Why give a veto to one particular group in the discussion?

    While it is challenging to many fundamental American assumptions, I think that much of the difficulty stems from the fact that physicians continue as individual piece-worker practitioners subject to the same incentives as any small business person, where take home pay is the difference between practice revenues and practice costs. Should teachers or police officers also be able to practice their craft under the same basis? We have fundamentally overestimated the protections to society of “professionalism” as the only real restraint on physicians. Wouldn’t it be just as reasonable that physicians be employed professionals?

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