The Gap Between Rank and File Physicians and Their Leaders

Awaiting our orders

Talk about a study in contrasts.

According to this Commonwealth Fund and Kaiser Family Foundation survey, only a minority of "front-line" primary care providers (including a sample of non-physicians) believe that the major linchpins of health reform such as value-based payments, Accountable Care Organizations (ACOs) and medical homes are having a "positive impact on medical care."

The survey relied on a representative national sample of 1,624 primary care docs and 525 nurse practitioners and physician assistants who were working in primary care practices.  64% and 87%, respectively, were compensated with a mix of salary and/or capitation and 55% of the docs' had incentives that were based on quality, patient surveys or cost. Just under 30% were participating in some sort of ACO arrangement.

Only 33% of the physicians and 40% of the non-physicians believed medical homes are beneficial. 

26% of the physicians also viewed ACOs negatively.  Among the physicians who were in an ACO, "three of 10 said ACOs are having a positive impact, one-quarter said their impact is negative, and 20 percent said they have no impact."

What's more, 50% and 40% of physicians and non-physicians believe quality incentives are having a "negative" impact on the quality of care.

And how bad is it? 47% and 27% of physician and non-physicians are considering retirement "earlier than they thought they would."

And then there is this separate report by the "American Association for Physician Leadership."  According to partner "Navigant Center for Healthcare Research and Policy Analysis," this survey of 2,398 of the Association's members shows that "55%" believe the Affordable Care Act has "more good than bad," that "69%" felt that physicians should be held "accountable for costs of care" and that 57% agreed that ACOs will "be a permanent model for risk sharing."

And just was is the AAPL?  The Population Health Blog didn't know this, but it's the rebranded American College of Physician Executives (ACPE).  Being a member of AAPL doesn't necessary mean that a doc occupies a position of leadership in a hospital or clinic, but the credential suggests a strong interest in that career path.

Why the disconnect between physician leaders and rank and file primary care physicians? 

It could be argued that their vantage point enables the leaders to be better aware of the realities of health reform and that those realities have yet to be communicated or accepted by primary care physicians.  Cue the narrative about education, aligning incentives, letting the malcontents quit and questioning whether physicians should even be in charge.

But the PHB isn't sure that quite explains everything.

The recent controversy over maintenance of certification (MOC) is a telling example of how easy it is for otherwise smart and respected physician leaders who are advancing quality and value to get it really wrong.  Thanks to all the publications, webinars, meetings, PowerPoints in the closed-information loops of health reform, it's too easy for well-meaning leaders to recycle Washington DC's value-based nostrums.  The PHB is running into many of them, and the group-think is getting both boring and alarming.

In other words, just because "leaders" are championing change doesn't mean the rank and file "get it."  There is also no guarantee that there won't be inconvenient raising of ethical concerns, a reprise of the anti-managed care backlash, a strike threat or even acts of civil disobedience.

Based on the input of physicians who are at the front lines and are seeing the impact first hand, health reform remains very much a work in progress.  And maybe it's the physician leaders that don't get it.

Stay tuned.

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The Remarkable Consensus Over the Next Steps for Health Reform, Including the Role of Population Health Management

Let's fix it!

While noisy media leprechauns dispense blame and declare winners in the government shutdown imbroglio, the Disease Management Care Blog remains focused on the next steps for meaningful health reform. So are JAMA authors Jack Lewin, Lawrence Atkins and Larry McNeely who, other than one lapse in their editorial, get it mostly right.

Their important insight is that the Bipartisan Policy Center, Brookings Institution, Commonwealth Fund, Kaiser Family Foundation, the National Coalition on Health Care, Partnership for Sustainable Health Care and Urban Institute all have a remarkable degree of overlap in their recommendations for the next phases of health reform. 

Most of these expert organizations agree on the merits of value-based payment as well as insurance reform (pay for quality), information technology, competition, tort reform, evidence-based benefit design (paying when there's evidence that it works), workforce changes (greater efficiency), reforming Medicare, changing tax policy (the exemption for health insurance) and instituting regional or local caps (stick to a budget or there's consequences).

The DMCB wholeheartedly agrees and hopes that the bipartisan consensus evident among these think-tank institutions leads Congress (if not this one, the next) and the President (if not this one....) to use these ingredients to build on the successes and correct the many deficiencies of the Affordable Care Act.

And the lapse? 

Jack Lewin et al were missing one thing. The DMCB looked in each of these organizations' web sites and found that there was also considerable support for population health management.

To wit:

The Bipartisan Policy Center - while the emphasis of this report is on health information technology, the real dividends are pretty clear when it mentions "population health" 14 times:

This plan should address the development and adoption of policies and standards needed for the delivery of care, the empowerment of individuals, and improvements in population health based on national health and health care priorities.

The Commonwealth Fund:

 Effective population health management requires fundamental change in care delivery that must be supported by changes in payment.

National Coalition

Real reform means engaging consumers in their own health and health care choices. In both Medicare and too many private plans today, benefit design neither supports self-management of chronic disease nor distinguishes between care that is effective and care that is not.

Partnership for Sustainable Health Care - see page 22:

Federal nurse education funding should be refocused to equip registered nurses to assume the roles of case manager and population health coordinator.

The Urban Institute - see page 17 on the topic of Medicaid reform:

States can start in select geographic areas or specific population groups (adults and children or specific chronic conditions), and then incrementally expand them after learning from experience and making program improvements and adjustments. Broader efforts typically mean additional stakeholders, increased collaboration and communication.