If patients are now "customers," what does that make physicians?

Physicians find themselves increasingly dissatisfied with medical practice in America.[1] The esteem in which the medical profession is held by American society has fallen, and our health care system is seen as a problem to be fixed rather than as a triumph to be celebrated.[2] Health care reform, whether national, state, or employer-driven, threatens to compromise the role of the individual practitioner in favor of health care delivery organizations and to further erode the status and morale of the medical professional.[3]

This fall from grace has been discouraging. Rather than acting as agents of change, physicians see themselves as victims of forces outside medicine that are shaping health care. Such influences as malpractice liability, cost containment, and payment reform, act on a scale impossible for any one physician to effectively confront.[4]

As hospitals and managed care organizations, especially health maintenance organizations (HMOs), have adopted quality improvement programs, physician discouragement has increased. Clinical practice guidelines adopted as part of many quality improvement efforts challenge the autonomy of the medical professional. "Outcomes measurement" promises a further erosion of this autonomy by evaluating the results of a physician's care and comparing them to those of his or her peers.[5] Early outcomes monitoring efforts have included controversial events, such as publication of individual cardiac surgeons' success and complication rates.[6] These initial attempts have not reassured physicians about further efforts directed at measuring the outcomes of their care.

Patients as Members and Customers

Managed care is another disturbing force causing change. Managed care transforms patients into "members," physicians into "providers," and medical treatment into "health care delivery systems."[7] This seems to strike at the foundation of the physician-patient relationship on which physicians' professional identities and self-esteem have traditionally been based. At best, these changes are confusing and conflict with cherished beliefs about the practice of medicine. At worst, adversarial utilization and reimbursement mechanisms lead to frustration and resentment.[8]

Quality improvement focuses on patients as "customers," which threatens physicians in other ways. Customer "requirements" come to define quality standards, and customer satisfaction is used to evaluate, sometimes to compensate, and even at times to reject individual physicians as providers of care in a health plan. There is an explicit analogy in the theoretical framework of quality improvement that likens medical care to commercial endeavors.[9] This is not a happy comparison for most physicians; being compared to a factory worker or a shopkeeper and having medical care compared to manufacturing or merchandising activities is both disturbing and ominous.

Adapting to the changes inherent in this new medical practice is neither easy nor comfortable and may require altered expectations of both personal income and professional identity. Fundamentally, however, these changes seem consistent with the fundamental bioethical ideals of the medical profession: nonmaleficence, beneficence, and justice.[10] Realizing these ideals and contending with oncoming changes requires understanding of the new roles physicians assume with the advent of quality improvement, managed care, and national health care reform.

The Physician as Agent of Quality

A central feature of the emerging medical practice model is the role of the physician as the principal agent of quality. "Quality" for physicians formerly referred to quality assurance activities such as peer review, activities that are based on a largely passive and retrospective inspection model. This model gained professional acceptance as a familiar activity reminiscent of clinico-pathologic conferences, grand rounds, and the "Morning Report."[11] While the quality assurance approach may be relatively familiar and comfortable, there is considerable question about its effectiveness in improving the quality of health care.[12]

Peer review and related approaches to medical quality are analogous to the "quality control" inspection model in industrial settings. This model has largely been discarded in industry in favor of more prospective quality management approaches, such as continuous quality improvement (CQI).[13] As a similar shift occurs in health care, the physician is recognized as the central agent of producing quality by virtue of being the director of health care. Acting in this new capacity, a physician's obligation is seen as broader than to simply perform medical services for individuals; he or she must actively deliver quality. A physician within a CQI model does not simply treat a patient, but instead acts within a medical delivery system that must be measured and modified on a continuous basis to reduce variation and improve the clinical outcomes of care.[14]

Success in this quality role requires mastery of a new set of skills and a shift in perception. Flow charts, Pareto histograms, and cause-and-effect diagrams become new clinical tools, and practice guidelines and outcome measures become features of the practice of medicine. Embracing this change is challenging, both technically and philosophically, but it is consistent with the medical ethic of offering the best available care for the patient.

The Quality Improvement Process

One way to understand the changes brought about by adopting a quality improvement perspective is to view traditional medical treatment from the standpoint of continuous quality improvement. Figure 1, below, illustrates a customer-supplier chain for inpatient medical services. Similar diagrams are used in nonmedical settings to analyze the production of goods and services and to determine performance standards,[15] and are derived from analytical tools used in economics for value-chain analyses.[16] The "customer" for inpatient medical treatment is a hospital patient. The proximate supplier is a physician, who orders, directs, and delivers the individual components of care, which together compose a course of therapy, sometimes as part of a team of health professionals. These components of care include both diagnostic and therapeutic events, such as serum chemistry determinations or operative procedures. A patient's "requirements" are the clinical determinants of appropriate medical treatment and outcome and might include relief of pain and return to well-being.

Within this framework a physician also represents a secondary customer. In order to deliver high-quality inpatient care, a physician requires that the hospital arrange for appropriate medical goods and services. These might include nursing care, antibiotics, or a cardiac catheterization laboratory. The physician thus becomes a customer for the hospital while remaining a supplier to the patient. In much the same way that the patient as customer has requirements of the physician as supplier, the physician as a customer has requirements of the hospital as supplier. These requirements are dictated by the need to provide high-quality physician inpatient services.

Similarly, a hospital needs vendors of medical equipment, food services, pharmaceuticals, and other goods and services to meet physicians' needs and is therefore a customer of these suppliers, which strive to meet the hospital's requirements. Vendors also represent customers to yet another generation of suppliers, and so on.

How well the requirements of each successive customer are met determines the quality of the final service. Each generation of customers is therefore motivated to demand a higher level of performance from its suppliers in order to be most competitive and successful in delivering its goods and services to its customers. Quality within this framework emerges as the critical feature of each level of customer/supplier transaction and drives the health care delivery system toward better inpatient outcomes for patients.[17]

This analysis may be challenged on the basis that, in traditional inpatient medical care, the ultimate customer has not been the patient. Rather, the quality of medical treatment has been judged by physicians, according to this argument, and not by patients.[18] The medical education setting shows physicians in training to be strongly motivated to satisfy the requirements of chief residents and attending staff, which supports this viewpoint. A similar customer/supplier analysis can be performed using professional colleagues as the ultimate customer in place of patients. Such an analysis reveals similar customer/supplier relationships and determinants of quality. In either case, the nature of customer-supplier relationships has a clear role in defining the quality of medical treatment.

The emphasis on quality in this analysis is also consistent with commonly accepted medical values. "Treatment of choice," "standards of excellence," and "optimal results" are all familiar terms and support fundamental physician values consistent with a quality improvement framework: patient advocacy, personal responsibility, and scientific method. The challenges implicit in quality improvement initiatives are primarily those of internalizing new perspectives and conceptual frameworks, while building on familiar professional perspectives. Adapting to the challenges presented by the managed health care environment requires a similar mastery of new perspectives and abilities.

The Physician as Agent of Medical

Care Management

Another key feature of the emerging medical practice model is the role of the physician in managing the delivery of health care resources to patients.[19] "Utilization management" explicitly involves weighing the costs of a medical procedure against its expected benefits. This activity has most often been performed as an adversarial procedure between providers of care and payers, with the physician defending a request for treatment against a utilization control agent challenging the benefit of that treatment. This model emerged as a mechanism to control the cost of medical treatment in a predominantly fee-for-service environment, but it is being replaced by other utilization mechanisms as the American health care system evolves to include a greater proportion of prepaid medical care.[20]

In a capitated setting, an individual or group of physicians is responsible for both the cost and the medical outcomes of the care rendered to patients. The locus of control in utilization decisions shifts to the physician, and more accurately to the "gate-keeper," most often a primary care physician who provides the bulk of the patient's medical care. This physician also assumes the role of agent for medical care management decisions. This new role demands new knowledge, skills, and perspectives.[21]

The management of medical utilization embraces clinical guidelines and outcomes measurement much as the management of medical quality does. It is possible to measure the technical, financial, and subjective outcomes of alternative courses of therapy for a given symptom or diagnosis, with the result that a preferred approach to clinical care based on these findings can be outlined.[22] These steps define cost-effective medical care. They can also decrease the variation in clinical practice patterns. At this level of medical care management, distinctions between quality and utilization begin to blur and disappear. Deviation from a clinical practice guideline may represent both an inappropriate utilization of medical resources and an incident of substandard medical quality.

The adoption of this role by a physician can be explored by considering the customer-supplier chain of health care coverage depicted in figure 2, below. Health care coverage represents a complex structure combining the financing, delivery, and management of health care and is obtained as a package by purchasers on behalf of defined beneficiaries, most commonly by an employer purchasing health benefits for employees. In a prepaid model, this coverage is obtained through entities such as HMOs, which in turn arrange for the delivery of medical services consistent with the contracted benefits. A physician will have responsibility for the care of the beneficiary on behalf of the HMO and will individually or in a group be held liable for the cost of medical treatments rendered.[23]

The purchase of health care coverage by employers is primarily a cost-driven activity. Careful attention is paid in purchasing health care coverage to "benefit design," the trade-off between what health care services are to be covered at what beneficiary contribution level on the one hand, and the cost of those benefits on the other.[24] There is competition between potential suppliers of these benefits, including HMOs, preferred provider organizations (PPOs), and traditional indemnity insurers, whether self-funded by the employer or fully insured. This competition translates into a keen awareness on the part of the organization supplying health care coverage of the requirements of the purchaser.[25] Meeting those requirements means satisfying the purchasers' expectations in such areas as cost-effectiveness, administrative ease, and beneficiary satisfaction.

In a managed care environment, there must be a balancing of clinical and cost considerations, regardless of whether it is done in staff, group, or IPA settings. These are utilization decisions, and the HMO's vulnerability to the physician's decision making is shared with the clinician through mechanisms as varied as prior authorization requirements and financial risk-sharing arrangements.[26] Such risk-related arrangements are the hallmark of HMO operations, but they are only one aspect of how the purchasing customer's health benefits requirements dictate the activities that an HMO must ask of its physician-suppliers.

An HMO must have information on the treatment of beneficiaries and on the cost of care delivered to demonstrate value to the purchaser. Treatment plans must accommodate the specific arrangements an HMO may have with other health care providers, such as mental and behavioral health, pharmacy, and home health organizations. These needs in turn dictate that the physician's office staff supply various services to the physician to enable him or her to provide the information and flexibility the HMO requires on behalf of the purchaser.[27]

Coping with the role of agent for medical care management clearly imposes novel demands on the physician. To master the language, tools, and perspectives of medical care management, physicians must not only understand utilization protocols and procedures, but also effectively participate in financial risk-sharing, either individually or in groups. Information systems, eligibility and benefit management, formulary administration, and utilization profiles must be negotiated.[28]

Physicians as HMO Partners

Perhaps the greatest leap for physicians in becoming agents of managing health care is to partnership with the HMO. Whether this is a legal partnership through contractual or salary arrangements or a functional partnership dictated by common interest, making this transition requires physicians to abandon hostility toward HMOs. This is a difficult challenge, particularly in the current adversarial environment created by heavy-handed utilization control mechanisms. It is nevertheless essential if the physician is to succeed in playing an effective role in obtaining cost-effective care for the patient, satisfying both the needs of the physician to care for his or her patients and the needs of the HMO to meet its obligations to health benefits purchasers.[29]

The need for this transition also highlights a change in the social basis of medical care. Many of medicine's traditions and patient care perspectives are based on a model of the patient as purchaser and sole beneficiary of medical care.[30] Changes dictated by the cost, financing, and organization of medical practice have led to an increased role of legal, regulatory, employment, and third-party intermediaries in delivering health services. These changes have not been fully reflected in the nature of the physician's relation to the patient, which currently tends to downplay the significance of these factors.

The Physician as Agent of Service

A third major role for physicians in the emerging health care model is that of agent of service. Although this role is linked to those of quality and care management, it has distinct implications for physicians in practice. It also epitomizes some of the discomfort physicians feel in looking at a patient as a "customer."

Previously, physicians emphasized their role as experts, a fraternity of cognoscenti. This translated into a preoccupation with the strictly medical aspects of patient care and a disregard for the service features of medical practice. Patients came to regard waiting several hours in a physician's office for a scheduled appointment as commonplace, and even as an indicator of a good physician. These attitudes have been documented elsewhere as a source of patient dissatisfaction with traditional medical care.[31]

This disregard for service is changing. As individual physicians organize into groups and these groups compete for patients as part of a health care delivery system, satisfying the nonmedical needs of patients assumes a higher priority. Issues such as access, availability, and member satisfaction emerge as important aspects of health care systems.[32] This is translated by the health care system into activities such physician profiling, reimbursement incentives, and provider contracting, activities that measure the nonmedical features of a physician's practice.[33] In this manner, the physician is assessed as an agent of service on behalf of the HMO.

Some implications of this change are evident in an examination of the service aspects of an office visit, which is depicted in figure 3, above. The ultimate customer is still the patient, but the patient is also a member of a health plan. As an integrated system, the health plan arranges for and will be held accountable for all aspects of the member's care, including the actions of the physician.

In this service relationship, a health plan member has requirements beyond medical care. In addition to effective treatment, the member has expectations such as respect, attention, accommodation, and timeliness. The physician is the proximate agent of satisfying these service requirements and is held responsible for them by the health plan. It is widely recognized that members judge an HMO predominantly by the nature of their interactions with the organization's physicians.[34] It is therefore critical to an HMO that physicians meet members' service needs.

To satisfy the member's service expectations, the physician sets customer requirement standards for the medical office staff. A nurse must greet the member, gather information, and perform activities that prepare for the physician encounter. If this is not done effectively, the physician will be unable to diagnose, treat, and educate in a manner consistent with the member's service expectations. Similarly, appointments must be scheduled, charts prepared, and medical data made available by receptionists and other office staff to meet the nurse's customer requirements.

These individuals in turn require telephone lines, office supplies, and information transmission to deliver their services effectively. When each of these successive suppliers performs in a manner consistent with customers' requirements, the physician is able to meet the member's service expectations.

The physician will be judged by the member on the basis of the service expectations that the member brings to the visit. This highlights another aspect of the emerging health care system. In the indemnity insurance-based, fee-for-service health system, the physician has been individually accountable for meeting the beneficiary's service expectations. Failure to meet these expectations was a reflection on the physician, not on the insurance carrier. As a consequence of incorporation into an HMO, however, the physician becomes a part of a larger health care system, and failure to meet the member's expectations reflects adversely on the HMO. That organization will therefore concern itself with the non-medical aspects of the member's care, tracking these through member surveys, response cards, and complaint phone lines. An HMO may also hold the physician accountable for the results of these performance assessments.[35]

Physicians must accept this new relationship with an HMO in order to function effectively in a managed care environment. A de facto partnership must be created that extends beyond financial reimbursement for medical services to include representing the HMO as its agent and allowing the HMO to represent the physician to its members and purchasers. It includes tacit agreement on the shared goals of cost-effective medical care and respect for each party's interests. At its best, this partnership enables the physician to practice medicine in a manner consistent with both professional ideals and personal goals.[36]

The Physician as Agent of Change

As service and cost concerns reshape patient care, as quality improvement and managed care initiatives remodel medical practice, and as national reform and the rise of health care delivery systems redefine the place of medicine in American life, physicians are being inundated by change. This change is stressful, particularly because it confronts personal, social, and professional values that are important to physicians in caring for patients, values that include autonomy, esteem, and professionalism. This change can be overwhelming, given the speed and magnitude of the forces reshaping health care, making it seem that there is little hope and only a grim future.[37]

It may be difficult to discern, but these changes respect the fundamental tenets of health care. Continuous quality improvement's intent is to improve the health of the patient.[38] Managed care strives to get each member the best outcome for a given level of resource expenditures.[39] Health care reform is driven by the need to bring the benefits of medical care to every American.[40] All of these efforts embrace beliefs that health is a compelling social value and that physicians are performing an essential public service. Recognizing these beliefs supports physicians collectively in shaping the outcome of the current changes. These beliefs also support physicians individually as they understand, cope with, and master the forces that are changing their daily practice.

The challenge facing physicians and the medical profession is not only to change, to adopt new roles, skills, and perspectives, but, in doing so, to rediscover the ideals that have sustained medicine as a fundamental human endeavor. Health competes as a social good in a marketplace of alternatives, and much of the current debate serves to emphasize the importance of medicine and its ideals in American life. These ideals have inspired art and literature and have captured the imagination of generations, and they endure through the current debates and changes. The setting may change and the funding may be different, but the promise that medicine represents continues for the public and the profession alike.

References

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