Changing Physician Behavior
In the article on financing healthcare that I posted last month, I observed “What has changed, it seems to me, is that in 1970, the “profit” went to the providers. Now the profit goes to the businesses and everyone is trying to manipulate the providers to behave in a way that looks out for their interests.”
As you might expect, I read an opinion piece published by Gail Wilensky, PhD, entitled “Changing Physician Behavior Is Harder Than We Thought” with great interest. She focused her comments on two reports: the midterm assessment of the Comprehensive Primary Care Initiative and the recently announced Comprehensive Primary Care Plus (CPC+) plans. She noted the midterm assessment showed:
“…despite having paid the participating practices a median of $115,000 per clinician in care-management fees over two years, the midterm assessment found that practices have not demonstrated any net savings after taking the incentive payments into consideration. This is not surprising. Other pilot projects (including the Medicare Group Practice Demonstration and the CMMI’s Pioneer Accountable Care Organization have shown that it is challenging even for large, seasoned group practices to produce savings. More surprising was the finding that the practices participating in the Comprehensive Primary Care Initiative have not shown many appreciable quality improvements to date.”
I did not find these results surprising and many of the topics discussed previously illuminate various issues that impact the results. What did surprise me was that a major “player” in the policy scene was surprised. This is what I want to think about in this article. Dr. Wilensky is trained as an economist, so it is possible she assumes that the “economic man” model explains behavior. This model assumes that over the long run people will make decisions in their economic best interest. I used to have long discussions with my clinic administrator about the uses and abuses of this concept. We never really resolved the issue.
Perhaps part of the problem is that physicians do not make their decisions entirely on an economic basis. This is not to say that physicians are not self-interested. When I was actively involved in leading my medical group I used to say there were only two things that divided us: money and night call. I am suggesting, though, that physician training does not start from an economic viewpoint. Instead, we are trained to look for the “best” decision. The fact that the best decision is conditional and depends heavily on the patient’s perspective, and is therefore not totally predictable, means that the “cost” of care will vary not only from doctor to doctor, but from patient to patient.
However, let us consider the problem in the terms outlined—we spent a lot of money in the project, but don’t have much to show for it. There were several assumptions underlying the project that were likely never articulated. First, “care management will save money” is based on the notion that we can prevent expensive complications of disease from occurring. Unfortunately, it would be more honest if we stated the hypothesis as “Care management may be able to defer complications until later.”
A second assumption is that improved quality can be measured. As it stands now, we have surrogates, mostly process measurements, available. I would suggest using care management fees to make sure patients got more medications to meet more process measurements would cost more money than “usual care,” but it would be difficult to see any delay in expensive care such as hospitalizations in just two years. We really do believe “more is better” when it comes to healthcare, despite a lack of compelling evidence that it is true.
The third assumption is that changing payments would change behaviors. But physicians did not necessarily recognize the connection between the care management payments and the desired behavioral changes. Certainly my group is using its care management fees to hire ancillary staff to make sure patients keep follow up appointments and get recommended tests and examinations. In the meantime, the doctors are seeing the patients and doing what they always did.
Perhaps the real issue, as always, comes back to money. Dr. Wilensky has spent much of her career dealing with aspects of financing health care and I am sure she know more about the policy implications of various changes than I do. However, I do have a short list of items that would save money.
The most immediate is to reduce hospitalizations—not just length of stay, but admissions per patient per year. Hospitals, of course, don’t like this, and one side effect of current CMS efforts to change physician behavior is that many have opted to sign on with large hospital systems. Hospital systems will certainly try to ameliorate efforts by CMS to change hospitalization behavior. This means, of course, that we will need to invest in a care delivery system that maintains constant availability—the office is always open—and that has the resources to deliver home care of the sort previously done by extended family (most of whom now don’t live anywhere nearby.)
Second, we need to develop operational definitions of frailty predictive of patients who will not respond well to aggressive interventions. When the frail patient does not respond to conservative management, we need to move toward palliative care approaches. This is not “rationing,” in that the motive is not reduce expenditures, but it is a medical effort to recognize the limits of what we can do. In my grandfather’s day, there were only a few things they could do, so as a physician, he spent a lot of time watching. Now we have many things we can do, but we have not developed the collective wisdom to do these things wisely from the patient’s perspective. In the old days, the patient and his/her personal physician made these decisions, usually in an implicit, informal way. Since Marcus Welby, M. D., died years ago, though, we need a replacement process that does not depend on a personal physician who knows what we want and whom we trust to get us what we need.
Lastly, and perhaps most challenging, we need to develop effective treatments for those who abuse drugs and alcohol, including tobacco. There is a lot of lip-service about treatment, but the fact is we currently do not understand the biological basis of addiction and so don’t have reasonably effective treatments that can be widely applied. Yes, there are some programs that deliver results, but the patient population has to be tailored for the program. We don’t have something a family doctor can do as easily as he can treat hypertension.
Maybe the issue isn’t so much changing physician behaviors as changing the structures in which physicians practice. Much of what we are doing in care management these days may be of value to patients. I don’t know from personal experience and I have not seen any data. But it is possible that patients will appreciate the extra attention and service provided in these programs. Perhaps, but only perhaps, it will reduce costs in the “out-years” as the policy folks say, but I don’t know how you measure money not spent and costs not incurred in a meaningful way. By the same token, how do you measure the care I did not provide when I talked for a long time to a patient and family and we decided to stop dialysis? How do you measure the quality of that? All I know is the family almost always says “Thank you for being honest and helping us.” I guess that will have to do.
20 July 2016
 Wilensky G. Changing Physician Behavior Is Harder Than We Thought. JAMA 2016;316(1):21-22. doi:10.1001/jama.2016.8019. Accessed 14 July 2016 at http://jama.jamanetwork.com/article.aspx?articleid=2531993.
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