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.

Image from Wikipedia

Physician Skepticism About the Basic Doctrines of Health Care Reform: We're In This Together and, by the way, More Believe In Care Management Than the EHR

Taking a survey...

Read these headlines assembled by Kaiser Health News and it's easy to get the impression that America's physicians believe everyone else is to blame for health care costs.  A cursory read of the underlying original research suggests otherwise.  Regardless of the interpretation, the results should give pause to anyone who thinks health care reform is a slam dunk.

The Disease Management Care Blog explains.

3900 practicing physicians were randomly selected from the AMA Physician Masterfile. Three physicians were outside the U.S., leaving 3897 docs who were mailed an 8-page survey. $20 was used to increase the response rate. Non-respondents were mailed a second and then a third follow-up. The ultimate response rate was 65% and, aside from a one year age difference, the respondents were quite similar to the original 3897. The survey that was used can be found here.

The results are nicely summarized in Table 3 (go to this link, click the "Tables" tab).

99%, 97%, 94% and 86% of the respondents felt hospitals/health systems, health insurers, pharma and trial lawyers had "potential" major or some responsibility, respectively, to lower health care costs.  95% and 98% also felt the same was true for physicians and patients, respectively.

The DMCB take: None of the answers were mutually exclusive. The physician-respondents thought everyone was responsible.  That being said, if you look at Table 3, you'll see a spread of "major" vs. "some" responsibility.  Physicians were less likely to assign "major" responsibility to themselves (prompting the headlines above) but that's because docs believe their job is to advocate for their patients regardless of cost.

Similarly high percentages of respondents generally felt that continuity of care (98%), chronic disease care coordination (98%) and reducing fraud (93%) were important means of reducing costs. What was interesting that fewer felt the same about the electronic health records (74%), penalizing docs for readmissions (41%) or bundling payments (35%). They were also less sanguine about increasing patient "skin in the game" with higher co-pays (61%) or high deductibles (58%).

The DMCB take: More physicians believed in the cost-reducing potential of disease management/care coordination than the EHR.  While part of the respondents' skepticism about the economic incentives that underlie much of health care reform is arguably motivated by self-interest, the DMCB suspects physicians also genuinely believe patient needs trump economic penalties. Regardless of the underlying thinking, the results should give pause to policymakers and politicians who believe that readmission penalties and bundled payments are a no-brainer and that docs have bought-in.

The DMCB will close with the following scenario:

Pretend you are a Vice President for Medical Affairs, or a Chief of Staff, or a health system CEO about to announce a major collaboration with a major health insurer like CMS or a Blues Plan. You've done your homework, read the journals, listened to the experts and anticipated the future. You haven't been a regular reader of the DMCB.

You've called a meeting of the physician staff - the professionals you are counting on, caring for all those patients - and your job is go to the front of the auditorium and convince them that the success of your new venture relies on lowering health care costs with new payment arrangements that align incentives, in tandem with the launch of an electronic health record.

If the survey outlined above is even partially true, would you want to be that VP, Chief or CEO?