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.