Wednesday, May 26, 2010

An Under-Recognized Ingredient in the Lingering Battle Over Health Reform, the SGR and Physician Buy-In: Professional Autonomy

Physicians have plenty of reasons to be vexed and lately this is coming up. Commercial insurers and Medicare have always been squeezing payment rates. Now the Obama Administration is failing to hold up its unofficial pledge to fix the repugnant Sustainable Growth Rate formula in exchange for organized physician support for its health reform legislation. Yet, something deeper is going on here and the DMCB couldn't quite put it's finger on it....

Until it read this and viewed this.

First, the "read" of the Archives of Internal Medicine article by Randall Stafford and colleagues, titled "Impact of the ALLHAT/JNC7 Dissemination Project on Thiazide-Type Diuretic Use." Feeling pretty good about the results from a huge international study called "ALLHAT" that showed simple cheap water pills are a best option for the treatment of high blood pressure,the investigators concocted a follow-on study. They figured they'd go out to more than 18,000 physicians' offices and academically teach, persuade, market, convince and ultimately "detail" docs to use water pills among their patients with high blood pressure.

Compared to nationwide trends, the investigators found that the physician outreach was associated with a discernible increase in the prescription of thiazide-type water pills. Unfortunately, the effect was modest, with a bump in prescribing from a baseline of 38% to 47% among persons with high blood pressure. They even tracked the intensity of the teaching as a function of how many physicians per county received the intervention. Counties with relatively low numbers of physicians saw no meaningful increase in thiazide prescribing.

While the authors generously noted that their physician "detailing" had an impact, they also recognized it was blunted. An accompanying editorial suggests that the detailing was watered down (groups of physicians were approached in lieu of one-on-one) and that the data included patients who were on stable doses of medicine, making their physicians less inclined to change things if they were doing well. The DMCB adds that the detailing used by the ALLHAT investigators was "weak" compared to the traditional pharma detailing that is typically linked to considerable financial incentives.

But the DMCB thinks something else was going on.

Which makes this video worth viewing. While authored by a surgeon, the diatribe starting at about 9:40 is does a good job of describing physicians' overall eroding sense of autonomy. It's not a small issue. Loss of professional autonomy correlates highly with overall primary care physician career satisfaction. It can get in the way of pay for performance programs and could impede the successful creation of the Administration's cherished "Accountable Care Organizations" (more on that here). The DMCB also thinks this also may have gotten in the way of the ALLHAT detailing described above.

And it is probably an ingredient among the percent of physicians opposed to Obamacare.

Years ago, the DMCB was the manager of a work force of health professionals. It quickly learned that disgruntlement over "compensation" frequently belied a deeper underlying issue. While those issues often included co-worker conflicts or pressure over job duties, it frequently boiled down to disagreements over what the employer wanted and what the employee was willing to do. That spoke to autonomy, and addressing it often helped smooth things over.

Accordingly, the DMCB worries that organized medical groups like the AMA and the Obama Administration are failing to address a far more important issue than how many shekels docs get from Medicare. That's bad news, because even if the SGR gets fixed somehow, a sizable contingent of docs - who live by more than bread alone - will remain unhappy.

Which brings up a important issue for the population-based care/disease management industry. Learn how to deliver the care interventions to the patients you serve and simultaneously preserve what's left of your physicians' sense of autonomy, and you'll win.

Very difficult? Yes. Extremely important? Very.


Phil 314 said...

Autonomy is one of my two major "sins" that physicians commit that worsens the care system. (the other is passivity)

The high valuation of autonomy leads to low valuation of collaboration and "system thinking". Autonomy often morphs into a sense of entitlement.

I, and only I, get to judge what's important for this patient

I know the analogy to airline pilots is overused but a pilot is autonomous within the cockpit but he relies on the checklists and instruments that others have constructed. He collaborates with air traffic control to safely land the plane.

And finally, when physicians directly consume a quarter of every dollar spent in healthcare and by the power of their pen control a large proportion of the rest, do they really believe the system can change with a significant impact on their "autonomy". In other words:
You had your chance to run the system and we now have a pretty good BUT NOT PERFECT care system that still can't care for 1 in 7 in the country and costs 50% more than the next highest system

PS I'm a physician

Jaan Sidorov said...

This business over the autonomy of physicians has certainly generated a lot of feedback. More to follow......