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

Are Some Physicians Stockholm Syndrome Victims?

A hostage sides with her
captors in a bank hold-up

Years ago, when the Population Health Blog was the staff physician supervising an overworked inpatient consult service, its team of residents was asked by a surgeon to evaluate abnormal kidney function tests on one of her patients. After quickly surmising that the cause was a simple case of easily-corrected dehydration, the residents complained that the surgeon should have spotted the diagnosis. As a result, they said, this was a waste of their time.

"Not so!" said the PHB. It pointed out that the resident's medical knowledge was so advanced that they could glance at some lab numbers and spot the diagnosis. It's not that the surgeon was dumb or lazy, but that they were extremely smart.

The PHB also challenged them to snap out of it. Their low self-esteem was allowing them to be held hostage by narrative that not only devalued their expertise, but put their professional well-being at risk.

Fast forward to today when it's not about troubled kidney function, but a troubled healthcare system.

As we look for solutions, physicians are being buffeted by a widespread narrative that they're largely responsible for low quality, high costs and poor patient experience.

For example, there's literature that physicians order too many or (too few) tests, that misdiagnosis is common and that their treatments warrant scrutiny.  Or, thanks to their "power of the pen," misaligned physician incentives have led to the United States' outlier status on life expectancy vs. per capita costs.

How much is truly under the physicians' control is up to debate. What's more, physicians bring tremendous value to the table of health reform.  But, public perception says otherwise, and that's likely playing a role in the declining public trust in physicians and drops in their prestige. That, in turn, is contributing to widespread professional dissatisfaction and burn-out with significant implications for patient care.

Which makes the PHB wonder if it's witnessing the consult service scenario described above, but on a national scale.  It's one thing for its physician colleagues to emotionally struggle with the tectonic challenges of health reform (and there are ways, like this and this, to deal with it), but it's entirely another thing for them to agree that their professional value has been diminished.

Which leads the PHB's to speculate about its biggest fear. In addition to the hassles of physician-owned practice, the intellectual and emotional buy-in of a narrative of incompetence may be leading many docs to willingly outsource national policy as well as local practice decisions about quality and costs to the corporation.

For some docs, this could be a professional version of the Stockholm Syndrome.

As so elegantly described by Paul Levy in his blog, the Stockholm Syndrome occurs when hostages misinterpret the near-term lack of abuse by their captors to the point of emotionally bonding with them. While he was writing about the relationship of healthcare institutions to electronic record vendors, the PHB wonders if the same could be said about the relationship of physicians to their administrators, policy makers, elected representatives, regulators and the other clerisy.

Their reward for any role they've played in marginalizing physicians is greater authority, and some docs may not only going along with it, but embracing it.

The PHB looked for physician surveys or other data to support this, and can't find it. It suspects no one has asked the question.

Until now.