What Business Are We In?
What business are we in? A simple answer for physicians is that we are in the business of providing medical care to individual patients. A better answer might be that we are in the business of providing medical care to a community of persons in a variety of settings. The difference between the first and second answer is that we realize that we need to consider the group of persons who need our help, not just the person who happens to be in front of us at any given time, and second, it acknowledges that the setting in which we provide that care shapes our behaviors and expectations in important ways.
Do changes in financing and public expectations change our definitions? If we use the simple version the answer if probably not. We will do what we have always done, just get paid less for it than we used to be. If we use the broader definition, then the answer is yes, there will be major changes. Like what? Perhaps the biggest change is a deliberate decision to shift away from hospital centered care. Since a lot of physicians have already done this in their practices, this does not seem very radical. However, 40% of the money has been spent on hospital care, and those charged with maintaining the hospital’s financial status have significant difficulty dealing with this. I will come back to this point.
The second change is not really a policy decision, but a recognition that much medical care these days deals with chronic disease management. Policymakers now expect “care coordination” to take place in such a way as to maximize delivery of timely care to the patient before he/she gets sick enough to need hospitalization. The question, then, is who is to do “care coordination?” Primary care physicians used to fulfill this role, but there are insufficient numbers and payment mechanisms such as medical homes, etc., are insufficiently developed to induce those available to fulfill this role. Insurance companies certainly see a role for themselves as care managers, even if they are simply serving as intermediaries for government paid health insurance. I don’t see that as a desirable solution. Instead, I think we need organized groups of local physicians to define Level C evidence for the common problems we treat and build the decision support systems into our computer systems. That way we can collectively manage the process with intruding unnecessarily into the doctor-patient relationship.
The third change is one that we as physicians will have to make. My broad definition says we are responsible for the care of a population of patients. In other words, we have to move beyond “a” or “my” patient to include those who are not currently in our care system, but probably should be. Presently, we limit our practices through contracts. If demand exceeds our capacity, so be it—not our problem. Except it becomes our problem when we are tasked with the burden of unassigned call through the hospital. Would it not be better to imagine cost-effective ways to provide at least some care to the uninsured/underinsured patients and reduce exposure both for us and for the hospital? Could we not visualize partnerships with the health department and community service agencies to reach out?
Many of the people I “hang out with” in the national medical community argue that “the delivery system matters.”[i] There is a body of evidence showing that when physicians work together, care coordination improves and unexplained variations in care decreases. There is also evidence that when the hospital is part of the delivery system lead by physicians, the cost of care goes down and patient satisfaction goes up. I hope it is clear that these are the “desired” outcomes from the government’s perspective, and where our business is headed, whether we like it or not. I have talked about this previously as an “integrated delivery system.”
In the first conversations about such a system everyone got interested in the business aspects, so we got bogged down and lost our way. I want to argue that our first priority needs to be setting up a system focused on the patient’s/population’s health issues. If we can figure out a functional way to cooperate and coordinate care across the spectrum of the delivery system, including the rural health clinic, the office practice, The Jackson Clinic, and General Hospital, as well as coordinating with agencies such as the YMCA, the new Wellness Center, and our version of the Church Health Center, then we can sort out the business issues later. If we have become accustomed to working together, merging some or all of the business aspects, should that seem desirable, become easier. On the other hand, it may be that we can all prosper from “clinical” integration without necessarily striving for business integration. Such a strategy would certainly finesse the anti-trust issues that inevitably arise and in current law seems to be the basis for defending an entity against government action.
I can hear the skeptics now—sounds great, but how do we start, who funds it, who runs it, and how do we measure success. The last question is easy—if we improve our scores on the mandated scorecards, we are doing something worthwhile, even if it only keeps us even financially. The others are more challenging. Any plan that evolves must be broad enough to include many different perspectives. However, I do believe that the guiding principles behind any plan must include the patient-centered principles I have articulated here and embody the attributes of the Institute of Medicine’s quality system. Can you think of others items that need to be included as foundational principles?
[i] A thoughtful current consideration of these issues and an up to date bibliography, much of it online, is presented in Tollen, Laura, et. al. Delivery System Reform Tracking: A Framework for Understanding Change. Commonwealth Fund Publication 1510, copy provided by the author.
Written 28 July 2011, revised 4 May 2014.
Trust in Physicians and Healthcare Reform
Public trust in physicians as a group is quite low, despite the high regard patients have for their personal doctor. The implications for the physician's role in the health care reform debate are considered.
Restoring the Commons
A consideration of the interactions of patient preferences, evidence-based medicine and peer review.
The Public Looks at Healthcare Reform
The Tragedy of the Commons
Recognizing the Commons is critical for success in an era of rapid change.
What Do I Owe?
A discussion of unexamined assumptions about what physicians owe their hospitals.