Trust in Physicians and HealthCare Reform
In a recent perspective article in The New England Journal of Medicine, Blendon and colleagues wrote:[1]
One emerging question is what role the medical profession and its leaders will play in shaping future national health care policies that affect decision making about patient care. Research suggests that for physicians to play a substantial role in such decision making, there has to be a relatively high level of public trust in the profession’s views and leadership. But an examination of U. S. public-opinion data over time…raises a note of caution about physicians’ public role and influence with the U. S. public.
They note that a 2014 Gallup survey found only 23% of the public express a great deal or quite a lot of confidence in the U. S. health care system. A study of relative public trust of the medical profession in 29 industrialized countries, showed U. S. physicians rank near the bottom at 24th. Yet, U. S. physicians ranked 3rd when asked if patients were completely or very satisfied with the care received on their most recent visit with their physician. However, this high degree of satisfaction is most marked in those patients reasonably well off and with insurance coverage. Patients with lower incomes and less complete coverage were less satisfied, although the rank was still 7th. In considering the polling data with its subgroup analyses, the authors conclude:
We believe that the U. S. political process, with its extensive media coverage, tends to make physician advocacy seem more contentious than it seems in many other countries. Moreover, the U. S. medical profession, unlike many of its counterparts, does not share in the management of the health system with government officials, but instead must exert its influence from outside government through various private medical organizations.
Recently, I attended a phone conference of a meeting including senior medical executives from some of the largest and best known groups in the United States. Now I have been attending these phone conferences as representative for my group for several years but have not contributed to the conversation, since I see us as a big fish in a very small pond. Our perspectives are not those held by these large integrated providers. This conference was different, though, because the leaders were expressing dismay that physicians were being excluded from the reform conversations. Even being a big fish in a big pond, and “schooling” with other big fish, is not enough to gain a seat at the table. The group executive, with extensive experience on the Washington scene, observed that unless the group had something to say about the Affordable Care Act, there was zero chance of gaining any traction on the political scene in the next two years.
From previous conversations, I know these physician executives are seriously committed to designing health care systems that improve outcomes for patients and save money in the process. They also know that these systems cannot be designed, much less operated, without active and ongoing physician participation and leadership. Yet, they have found no one willing to do more than listen politely. To date, there have been no serious policy discussions with anyone in government about how reform should proceed. In other words, this group is yet another private medical organization seeking to exert influence from the outside.
Some of my more politically active colleagues would say we have no seat at the table, because doctors are historically stingy with their money and don’t fund their political action committees at the rate of others, say trial lawyers. Others would point out that physicians don’t speak with one voice, and even if they did, there are not enough of them to influence the outcome of an election. While these positions are likely correct, I think they miss the point. What doctors as a group bring is expertise, which is only valuable if there is consensus on the direction we need to go.
While there are many opinions about health care reform, the one point of agreement is that a lot of money is involved. Any attempt by physicians to stake out a position in the present environment will be assumed to represent a personal economic perspective, whether true or not. Our protestations about quality of care are seen as politically expedient cover for our “real” agenda—preserving our current income levels.
If my analysis is correct, what, if anything can physicians do? I suggest we should “keep our powder dry” until the national debate about how we are going to fund health care and at what level has arrived at some consensus. Second, we must continue to develop delivery systems that are focused on providing good patient care, while being flexible about where the money comes from. Lastly, we must continue to argue, whenever and wherever we can, for realistic flexibility in clinical goal setting. What do I mean by this?
In a recent New York Times op-ed piece, Hartzband and Groopman commented:[2]
When we are patients, we want our doctors to make recommendations that are in our best interests as individuals. As physicians, we strive to do the same for our patients. But financial forces, largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions. Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice.
The problem with current practice is not necessarily in poor guidelines, but in the level of analysis. I have been involved with a major insurance company in Tennessee, which was developing very sophisticated performance measures looking at the individual physician. Yet they knew that very few physicians had enough patients with any condition of interest to generate valid statistics. I argued that the unit of analysis needed to be at the group level. This would overcome the small number problem, but it would also promote cooperation and discussion at the local level about the best way to deal with common problems.
As physicians, we must continue to improve the metrics, not resist them, but we must also develop more sophisticated analyses. I have spent hours looking at these sorts of reports, and in most cases, the differences among providers in a single call group could be explained by external factors that had nothing to do with quality or effectiveness of patient care. If we have organized systems of care, we should be able to improve the population’s outcome on the metrics of interest by improving our processes, without having to insist on rigid application of guidelines when either the patient or the physician demurred.
Said another way, clinical outcomes are, at best, statements of statistical probability. If treatment x is delivered, then outcome y will be seen z percentage of the time. Our goal is to improve the percentage of desirable outcomes, but our ability to measure all of the inputs is still quite limited. Unfortunately, the easiest input to measure is still money. Hence our dilemma. Perhaps this is also the origin of the dichotomy between public trust in the profession compared to public trust in one’s own physician. We need to be careful not to squander the latter in the process of trying to improve the former.
24 November 2014
[1] Blendon RJ, Benson JA, Hero JO. Public Trust in Physicians—U. S. Medicine in International Perspective. N Engl J Med 2014;317(17):1570-72.
[2] Hartzband P, Groopman J. How Medical Care is Being Corrupted. The New York Times, 18 November 2014, p. A25. http://www.nytimes.com/2014/11/19/opinion/how-medical-care-is-being-corrupted.
In a recent perspective article in The New England Journal of Medicine, Blendon and colleagues wrote:[1]
One emerging question is what role the medical profession and its leaders will play in shaping future national health care policies that affect decision making about patient care. Research suggests that for physicians to play a substantial role in such decision making, there has to be a relatively high level of public trust in the profession’s views and leadership. But an examination of U. S. public-opinion data over time…raises a note of caution about physicians’ public role and influence with the U. S. public.
They note that a 2014 Gallup survey found only 23% of the public express a great deal or quite a lot of confidence in the U. S. health care system. A study of relative public trust of the medical profession in 29 industrialized countries, showed U. S. physicians rank near the bottom at 24th. Yet, U. S. physicians ranked 3rd when asked if patients were completely or very satisfied with the care received on their most recent visit with their physician. However, this high degree of satisfaction is most marked in those patients reasonably well off and with insurance coverage. Patients with lower incomes and less complete coverage were less satisfied, although the rank was still 7th. In considering the polling data with its subgroup analyses, the authors conclude:
We believe that the U. S. political process, with its extensive media coverage, tends to make physician advocacy seem more contentious than it seems in many other countries. Moreover, the U. S. medical profession, unlike many of its counterparts, does not share in the management of the health system with government officials, but instead must exert its influence from outside government through various private medical organizations.
Recently, I attended a phone conference of a meeting including senior medical executives from some of the largest and best known groups in the United States. Now I have been attending these phone conferences as representative for my group for several years but have not contributed to the conversation, since I see us as a big fish in a very small pond. Our perspectives are not those held by these large integrated providers. This conference was different, though, because the leaders were expressing dismay that physicians were being excluded from the reform conversations. Even being a big fish in a big pond, and “schooling” with other big fish, is not enough to gain a seat at the table. The group executive, with extensive experience on the Washington scene, observed that unless the group had something to say about the Affordable Care Act, there was zero chance of gaining any traction on the political scene in the next two years.
From previous conversations, I know these physician executives are seriously committed to designing health care systems that improve outcomes for patients and save money in the process. They also know that these systems cannot be designed, much less operated, without active and ongoing physician participation and leadership. Yet, they have found no one willing to do more than listen politely. To date, there have been no serious policy discussions with anyone in government about how reform should proceed. In other words, this group is yet another private medical organization seeking to exert influence from the outside.
Some of my more politically active colleagues would say we have no seat at the table, because doctors are historically stingy with their money and don’t fund their political action committees at the rate of others, say trial lawyers. Others would point out that physicians don’t speak with one voice, and even if they did, there are not enough of them to influence the outcome of an election. While these positions are likely correct, I think they miss the point. What doctors as a group bring is expertise, which is only valuable if there is consensus on the direction we need to go.
While there are many opinions about health care reform, the one point of agreement is that a lot of money is involved. Any attempt by physicians to stake out a position in the present environment will be assumed to represent a personal economic perspective, whether true or not. Our protestations about quality of care are seen as politically expedient cover for our “real” agenda—preserving our current income levels.
If my analysis is correct, what, if anything can physicians do? I suggest we should “keep our powder dry” until the national debate about how we are going to fund health care and at what level has arrived at some consensus. Second, we must continue to develop delivery systems that are focused on providing good patient care, while being flexible about where the money comes from. Lastly, we must continue to argue, whenever and wherever we can, for realistic flexibility in clinical goal setting. What do I mean by this?
In a recent New York Times op-ed piece, Hartzband and Groopman commented:[2]
When we are patients, we want our doctors to make recommendations that are in our best interests as individuals. As physicians, we strive to do the same for our patients. But financial forces, largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions. Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice.
The problem with current practice is not necessarily in poor guidelines, but in the level of analysis. I have been involved with a major insurance company in Tennessee, which was developing very sophisticated performance measures looking at the individual physician. Yet they knew that very few physicians had enough patients with any condition of interest to generate valid statistics. I argued that the unit of analysis needed to be at the group level. This would overcome the small number problem, but it would also promote cooperation and discussion at the local level about the best way to deal with common problems.
As physicians, we must continue to improve the metrics, not resist them, but we must also develop more sophisticated analyses. I have spent hours looking at these sorts of reports, and in most cases, the differences among providers in a single call group could be explained by external factors that had nothing to do with quality or effectiveness of patient care. If we have organized systems of care, we should be able to improve the population’s outcome on the metrics of interest by improving our processes, without having to insist on rigid application of guidelines when either the patient or the physician demurred.
Said another way, clinical outcomes are, at best, statements of statistical probability. If treatment x is delivered, then outcome y will be seen z percentage of the time. Our goal is to improve the percentage of desirable outcomes, but our ability to measure all of the inputs is still quite limited. Unfortunately, the easiest input to measure is still money. Hence our dilemma. Perhaps this is also the origin of the dichotomy between public trust in the profession compared to public trust in one’s own physician. We need to be careful not to squander the latter in the process of trying to improve the former.
24 November 2014
[1] Blendon RJ, Benson JA, Hero JO. Public Trust in Physicians—U. S. Medicine in International Perspective. N Engl J Med 2014;317(17):1570-72.
[2] Hartzband P, Groopman J. How Medical Care is Being Corrupted. The New York Times, 18 November 2014, p. A25. http://www.nytimes.com/2014/11/19/opinion/how-medical-care-is-being-corrupted.