Friday, August 7, 2015

Survey Says

Two new physician surveys -- one of physician leaders and one of primary care physicians -- are out, with some interesting findings.  For example, 69% of physician leaders agree that physicians should be held accountable for the costs of care, as well as for the quality.

This, my friends, is what is considered progress in health care.

The physician leadership survey, conducted by the American Association for Physician Leadership (formerly ACPE) and Navigant, suggests that physician leaders may be ahead of other physicians on the issue of costs.  When I last wrote on the topic, a broader 2013 survey of physicians found that only 36% -- no, that's not a typo, it really was only 36% -- felt that physicians bore a major responsibility for costs, seeing trial lawyers, insurers, pharma/device manufacturers, even patients, as being more to blame.

Perhaps this kind of difference of opinion is why the physician leaders are the leaders.  The question is, is anyone following?

Meanwhile, The Commonwealth Fund surveyed primary care providers -- including not just physicians but also nurse practitioners and physician assistants -- and found that half of primary care physicians feel that use of quality metrics to assess and reward performance has a negative impact on quality.  It is not clear whether they object to being measured at all or if they simply don't like the current generation of measures.

The physician leaders, on the other hand, are more bullish on transparency about quality: 92% think it is important, with more than half saying it was very important.  Of course, only 29% have any confidence that non-physicians can manage the issue, whereas 70% of them think they can.

I wonder what confidence they would have in primary care physicians coming up with solutions.

I don't have much sympathy when physicians or other providers complain about being measured ("giving doctors grades").  Yes, possibly the measurements can be gamed or lead to cherry-picking healthier patients, but that just suggests we should come up with better measures (for example, 360 reviews for surgeons).  In the 21st century, neither patients nor payors should just assume that health care providers are all doing a good job, especially when it is demonstrably true that some are not.

As Ronald Reagan famously said, "trust but verify."

We shouldn't expect that quality measures will necessarily look like what we're used to -- e.g., Hospital Compare, Healthgrades, or even some of the new sites to compare surgeons.  In the absence of easy-to-understand measures, consumers may fall back to consumer reviews, like those already offered for health care providers by Angie's List, Zagat, or Yelp.  Yelp is even teaming up with ProPublica to beef up its consumer ratings and to add some objective data.

Physicians like to think they can't be evaluated like a plumber or a restaurant, and perhaps they are right, but that doesn't mean consumers won't opt to do so.

On the brighter side, despite all the furor about shortcomings in EHRs, 50% of primary care physicians feel that health information technology is having a positive impact on their ability to provide quality care to their patients.  This is an issue upon which physicians and their leaders seem to agree: 88% of the physician leaders think that implementing clinical HIT is important.

The primary care physicians' support for HIT is slightly at odds with other physician surveys.  The Koreo Physicians Practice 2015 Technology Survey found that two-thirds did not believe they have gotten a return on their EHR investment, perhaps because 37% report that their EHR has caused them to see fewer patients, as opposed to 12% seeing more.

Let's just hope that the focus on HIT is in improving (and measuring impact on) quality/value, not simply trying to increase productivity.

Some other highlights from the AAPL and Commonwealth surveys:

  • The primary care physicians believe that penalties for unnecessary admissions/readmissions -- one example of "value-based purchasing" -- have a negative impact on care (52%), whereas 63% physician leaders disagree that moving to value-based arrangements will hurt the quality of care.
  • A surprising 64% of primary care physicians report being paid capitation or salary for some or all of their patients.  Fifty percent currently have quality incentives as part of their compensation, 43% have incentives based on efficiency, with 55% receiving one or both kinds of incentives.
  • The primary care providers are not fans of either PCMHs or ACOs.  More believe those models have had positive impacts on quality than had negative ones, but most thought there has been no impact or weren't sure.  Their opinion was somewhat more favorable if they actually were in one of the models (which less than a third are). They may want to get used to them: a majority of the physician leaders see at least ACOs as a permanent model for risk sharing arrangements in the coming years.
  • Almost all (89%) of the physician leaders are worried about the supposed primary care physician shortage, but only 29% of the primary care physicians see increased reliance on NPs or PAs to deliver primary care is having a positive impact on the quality of that care (versus 88% of the NPs/PAs).  Evidently, traditional turf issues remain.
  • Seventy-four percent of the leaders think that medical training is "archaic" and needs to be updated, something I completely agree with.
One thing that the physician leaders and the primary care physicians seem to agree on is that the medical profession is in some trouble.  Sixty-nine percent of the leaders think that the medical profession is a less attractive career now than when they started, while 47% of primary care physicians say they are considering retiring earlier than expected due to the current environment.

To paraphrase Shakespeare, methinks they doth protest too much.

Certainly the practice of medicine is changing.  Probably their authority is not as unquestioned as it once was.  Perhaps there are more demands on them.  It may be troubling that more medical school graduates are opting to not pursue residencies, some going straight into businesses like digital health start-ups.

All that may be true.  But medical school enrollment is higher than ever, so I wouldn't get too worried just yet.  Survey says, we're still going to need physicians...just maybe not in quite the same ways.

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