The May issue of Health Affairs focuses on Reinventing Primary Care - a topic that has been part of health policy discussions for at least 20 years. A few things have changed in that time: now there is better evidence about the importance of primary care providers in coordinating care to improve quality and reduce costs; the structural concept of this care coordination has been codified under the new term the “Patient Centered Medical Home,” (which has also been given precise parameters by NCQA); the complexity of medical care has increased so that the need for care coordination is greater; and electronic information storage, analysis, and communications technologies have been developed which - in theory - should make care coordination and the resultant quality improvement and cost control easier and more practical.
Health Affairs held a briefing on Tuesday about their May issue at the National Press Club. Keynoting the meeting was HHS Secretary Sebelius. She rightly pointed out that healthcare delivery in the US is a “truly broken system.” Her remarks touched on the various parts of the new health reform law that would help fix what’s broken, but the reality is that the Patient Protection and Affordable Care Act (PPACA) is very heavily weighted toward health insurance/financing reform, with comparatively little addressing delivery system reform. Similarly, the Health Affairs articles are very heavy on the situation with primary care, the problems with our delivery system, and what a reformed (or transformed) delivery system should look like, but aside from reimbursement reforms, the articles have very little about how to achieve this transformation.
No “How” to go along with the “Who,” “What,” “When,” and “Why”
Like a good news story, a successful reform initiative needs to address the basic concepts of Who, What, Why, When, and How. Unfortunately, the “How” part is frequently missing or minimal in most health policy discussions and proposals - aside from financial rearrangements. This heavy emphasis on financial incentives is because government programs like Medicare and Medicaid are significantly limited in what they can change outside their payment amounts and methodologies. And in the private sector, changing financial incentives is also the easiest thing to do. In other words, changing reimbursements and other financial incentives, (such as pay-for-performance or bonus payments), is the lever most often used because it is the one that policy leaders are most familiar with, and it is the easiest for them to pull or push.
Challenges of Reorganizing the Unmotivated
Even though transforming healthcare delivery is based upon reorganizing the structure of healthcare delivery there has been very little focus on how to actually get physicians to participate in this reorganization. While economists and others keep pointing to the economic incentives lever, it is pretty clear that physicians are not interested in reorganizing for the sake of improving their incomes. David Rotherman’s review of Timothy Hoff’s book about primary care physicians’ practices at the back of the Health Affairs May issue discusses how physicians like the current situation and their incomes. In this review he notes that it doesn’t appear that “primary care physicians have substantial dissatisfaction with the current system or levels of pay,” and that, “They seem comfortable as pieceworkers, not professionals.”
Thus, while policy researchers and payers correctly describe the great need for and value in delivery system reform, those actually delivering care seem to like many parts of the system - particularly their steady income stream and ability to run their own operations. And while delivery system integration could solve many things clinicians don’t like - such as insurance and paperwork hassles - convincing them that working in a larger organization will significantly improve their lives is a difficult concept to sell. The challenge here is to overcome the inertia of change and getting them to consider the value of shifting from the “devil that they know.”
Private Medical Practices are Small Businesses
Another way to look at this is to see primary care physicians as small businesspeople. As Boedneheim and Pham illustrate in their Health Affairs article, “Primary Care: Current Problems and Proposed Solutions,” 88% of primary care physicians are in practices with 5 or fewer physicians: 32% in solo practice, 14% in two person practices, and 32% in groups with 3-5 physicians.
What distinguishes these small businesses from non-medical enterprises is that because reimbursement systems using fee schedules create fee-for-service volume incentives, these physicians have very few business incentives to change. Since their businesses are generally making a profit, and most physicians’ training and skills are not in running an efficient business, they few reasons to change their businesses operations. While classic economic theory would disagree with that statement, and posit that their incentive should be to improve efficiency to increase profits, the reality is that people don’t like change - and they generally need to believe there there will be a 2:1 return for their financial or psychological investment before they are willing to undertake changes. And small business practicing physicians don’t want to make those changes because they are concerned that no matter what the policy rhetoric states, they believe that any changes will decrease their income.
In addition, physicians generally believe that proposed health delivery transformation changes will reduce their autonomy - something they may value as high, or higher, than their income since it may be one of the reasons they became physicians, it may be why they are practicing in a small group or solo practice, and autonomy of clinical decisions is part of how physicians are trained.
Conclusions - How to Go About Achieving Health Transformation
Transforming healthcare delivery in the US will not be as simple as paying more for primary care services, and/or training more primary care clinicians, and/or training all physicians to work in team-based environments rather than as autonomous clinicians. While all those are good things that certainly should be done, reforming how clinicians are trained will take 20-30 years to produce significant changes in the makeup of the US clinician workforce - and maybe even longer to change the ratio of primary care to specialty practitioners.
Therefore, what is needed is more emphasis on non-financial levers that can be used to alter physicians’ attitudes and actions around improving healthcare delivery - including their immediate practice situations, and how they relate to other providers and their patients. Changing financial incentives can certainly support this, but it is very unlikely to successfully produce these changes in isolation.
Rather, some of the general principles involving the adoption of innovations should be applied to bring physicians - and other community care leaders - to be more receptive and participatory in making delivery transformation both a reality and a success. These principles, (as described by researchers in the 70s and 80s), have been applied to improving the quality of hospital care by organizations like the Institute for Healthcare Improvement, and include providing information about how simple the proposed changes are and how comparable they are to the clinicians existing day-to-day actions, and making it possible for clinicians to observe and/or try out these changes before they have to adopt them.
One of the major catalysts for using these principles to successfully implement reforms is to use change agents to communicate the value and reality of the proposed practice changes, and to simultaneously diffuse misconceptions and fears about them. Since the old adage about physicians is that you can tell them, but you can’t tell them much, the best change agents for leading physicians through this transformation are other physicians who have participated in and/or observed, and/or analyzed other practices that have gone through similar changes. There are also two caveats about these change agent leaders. First, they need to be seen as independent and not biased or conflicted for financial or other reasons. And second, they must be able to culturally and geographically connect to the clinicians they are trying to educate and lead. For example, information about practice transformations in Vermont aren’t going to have much traction with physicians in Texas, nor are the experiences of Philadelphia practices going to carry much weight with physicians in rural Illinois.
Afterward: “Making Health Reform Work” Book Project
These concepts and messages about care delivery transformation using the principles of innovation adoption and stakeholder engagement are at the core of what I’ve been trying to construct into a book containing logical and understandable prose and graphics. The working title for the book is “Making Health Reform Work.” However, the passage of health reform and its impending implementation have overtaken my ability to finish it. Therefore, I wanted to put forward some of these ideas here to stimulate more discussion about these issues and concepts because I strongly believe that without a broad based and balanced approach to health delivery transformation, significant efforts and money will produce suboptimal results and leave a bad precedent for future transformation and quality improvement efforts.
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