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Cooperation, Cost Control and Consumer Focus Are Critical Challenges for Health Care. (Leadership).

IN THIS ARTICLE...

As we move into the 21st Century, the U.S. health care system faces tremendous challenges such as care for an aging and increasingly diverse population, escalating costs and limited resources. Government, consumers, hospitals and the insurance industry are positioning themselves for the future. Physicians need to do the same. Physicians must come to the table and assert leadership by working collaboratively with major stakeholders. Examine some steps that need to be taken to help shape the future of medicine.

IN THE PAST 100 YEARS, the health sector in this country experienced considerable growing pains as it evolved from a craft-based profession to a multi-billion dollar industry.

This growth was fueled by substantial government subsidy and encouraged by strong public support. But more recently, concerns about escalating costs led to increasing oversight and regulation by third-party payers.

The United States has one of the most costly health care systems in the world, yet it fails to cover nearly one in six citizens. Perhaps even more troubling is that health outcomes, such as immunization and infant mortality rates, are worse than in most industrialized nations.

How to provide affordable care for our population remains one of the biggest questions. Some argue that the U.S. should adopt a national health system, similar to the United Kingdom's or Canada's.

Critics say such systems offer substandard care characterized by long delays and under funding. Many Americans also oppose the heavy tax burden associated with such plans. They don't have confidence that the government can deliver an efficient single-payer plan. The U.S. health care system will almost certainly remain a market-driven enterprise for the near future.

Even if THE U.S. economy remains strong, the health care industry will face tremendous financial pressures in the coming decade. Third party payers will continue to restrict payments in an effort to control expenses. At the same time, more intensive and complex services will be needed as the population ages and becomes more diverse.

How will health care handle this increased demand?

Major stakeholders must be willing to look beyond individual interests and work together to exert a positive influence over the future. This requires a consensus to resolve the tensions between the needs of the individual patient and those of the population.

* We need to determine what part physicians will play in health care reform.

* We need to realign clinician and provider missions.

* We need to partner with consumers.

For the purposes of this discussion, clinicians are defined as health professionals involved in direct patient care, providers are health care entities such as hospitals, and consumers comprise patients and those representing their interests, such as employers. Physicians are discussed separately from other clinicians because they usually function independently from health providers such as hospitals.

The role of physicians in health care reform

Physicians play a key role in shaping the health care system.

While we continue to direct the efforts of clinical team members in patient care, our culture and training failed to prepare us to lead the entire health care system.

Physicians are increasingly seen as workers responsible for producing work units.

We face unprecedented scrutiny of service utilization and productivity.

In addition, most specialties experienced considerable cuts in income levels.

And worst of all, consumer confidence is shaken by widely publicized rates of medical errors and perceived financial conflicts of interest influencing medical decisions. Despite our best efforts, care often seems fragmented, superficial and inefficient.

Managed care wasn't the magic bullet. Physicians reacted in a variety of ways to health care reform through managed competition.

* Most consolidated practices in order to share rising overhead costs. But shrinking payments led to financial conflicts and bitter competition.

* Some physicians chose to embrace corporate medicine, assuming executive roles in the system.

* Others took salaried positions, hoping to buffer themselves from the administrative burdens. But working conditions for salaried physicians are sometimes so undesirable that they make a push to unionize.

* And some physicians left the practice of medicine altogether.

Physicians must come together as a group if we want to participate in shaping the future of health care. Our patients need our proactive advocacy. To assume leadership, we must be willing to meet new mandates for cost and accountability.

And we must look beyond care of the individual patient, share our knowledge and collaborate with other stakeholders in caring for the population as a whole.

Realigning clinician and provider missions

In the past, clinicians and providers shared a mission of excellence in patient care.

As long as payments were made on a fee-for-service basis, the two groups worked in complementary and mutually beneficial ways.

More recently, financial pressures caused conflicts between clinicians and providers.

In response to market forces, complex partnership and ownership arrangements arose between providers, clinicians and even payers. Disagreements center on cost and efficiency, quality and safety. Third-party payment schemes reinforce this environment of divergent incentives.

Clinician and provider missions must be realigned to put patient care first. This would allow both sides to focus on value, while factoring in both cost and quality. Consider this scenario:

Mrs. Jones is hospitalized for an infected diabetic foot ulcer. Her insurance company pays the same amount of money to the hospital whether she is there for two days or five days. The hospital prefers to discharge her quickly and provide less expensive home health care with appropriate medication and nursing services.

Mrs. Jones' physician, Dr. Smith, is paid a professional fee for each day that he sees her in the hospital. This fee is higher than what he receives from either an office visit or oversight of home health care.

Mrs. Jones' diabetes was so out of control when she was first admitted that an endocrinologist was asked to consult. This specialist feels that Mrs. Jones should stay in the hospital for at least seven days.

Because she lives alone, Mrs. Jones wants to stay in the hospital until the ulcer heals completely. That would take at least a month. Her daughter, who takes care of her mother, would like that, too.

It's easy to see how financial incentives could play a role in Dr. Smith's decisions. On the other hand, it's unfair to accuse Dr. Smith of responding only to the economics of the situation. He must also factor in the patient's own wishes, those of her daughter and the specialist's opinion.

Under managed competition, clinicians must make similar decisions every day, often involving far more complex circumstances. With so many variables to consider; it's no wonder there is little consistency between the medical practices.

Scientific approach

Clinicians and providers must agree on the best ways to deliver value.

An objective, scientifically derived set of standards could allow us to balance cost with quality to achieve value. While such standards exist in evidence-based clinical guidelines, they are difficult to implement.

Advances in biomedical science continue to develop at astonishing rates. The science of managing health lags behind. We continue to rely on inconsistencies that characterize the so-called "art" of medical management rather than objective "science."

In our scenario, the hospital and Dr. Smith could make use of clinical guidelines to determine a reasonable benchmark for Mrs. Jones's length of stay, given her age and other medical conditions.

A care map determines the care she receives while in the hospital and through home health. This care map is accessible to her and everyone involved in her care, so that her progress can be charted and adjusted accordingly.

Mrs. Jones and her daughter might feel the decision making process is more transparent and less arbitrary. They may then be more comfortable transitioning to home care.

The most compelling reason for advancing the science of health management is that it eliminates financial conflicts of interest. Using objective standards, clinicians can be held accountable for costs. Providers are accountable for delivering quality care.

Rigorously prepared and systematically implemented sets of clinical guidelines make it easier for people to do the right thing most the time. Unfortunately, such health management tools are expensive to develop, implement and maintain.

Modern information technology can simplify these tasks, but few can afford to invest a great deal of capital in computer systems during harsh economic times.

Failure to advance the science of health management isn't anything new.

In the 1990s, development of clinical guidelines didn't improve health outcomes for a number of reasons:

* Third-party payers didn't contribute to implementation of guidelines through support systems and staff.

* Individual clinicians were held to performance standards without support, alienating them from the process.

* Perhaps most importantly, independent-minded clinicians rejected standardization as "cookbook" approaches to clinical management.

Clinicians and providers must agree that we can work together in the best interests of patient care. We need find innovative ways to care for a larger and sicker population. It becomes clear that we will need to standardize and simplify. And we must be able to demonstrate this value and communicate it.

Partnership with consumers

In health care, we traditionally organized in ways designed to provide convenience for clinicians and providers.

Little attention was paid to the wants and needs of patients until diminishing resources forced providers to compete for market share.

The culture of medicine is quite resistant to use of the term "customer" when referring to patients. That's because it calls attention to the financial aspect of the patient relationship.

Perhaps another reason is calling patients customers gives more power to the patient. The term suggests that patients may exercise judgment about the quality of care and where to receive it.

In reality, of course, a financial relationship does exist. Health care costs can only be controlled when both patients and clinicians accept responsibility for them.

We learned in the past decade that control and choice are key components of patient satisfaction. Patients do have power, not only as individual customers, but also as health care purchasers for their families and through third-party payers.

Cost accountability will only be achieved by linking service with payment, so clinicians must work with consumers and third-party payers to design a care system that promotes fiscal responsibility.

'Consumer' revolution

A term that serves us better than either patient or customer is "consumer." It describes patients more broadly in terms of health behaviors. It empowers them and gives them responsibility at the same time.

Ultimately, consumers are responsible for their own health and for financing the health care system.

Our experience with managed care taught us that consumers have strong convictions about what they want, but they often don't have adequate information to make appropriate decisions. In addition, when providers and consumers face no immediate financial consequences for medical decisions, appropriateness becomes secondary to service.

* We must partner with consumers and government to provide improved access to validated health information so consumers can make informed choices about their medical care.

* We must also help consumers understand the limits of what is economically achievable by developing quality indicators so that they may more accurately determine value.

* And we must make use of technology such as e-mail and Web-based tools to deliver service more efficiently.

Consumers today are overwhelmed by health information from television, newspapers, magazines and the Internet. Many clinicians fear some of the information may be biased and choosing medical services based on such information might be inappropriate.

Two key elements are missing in the information revolution.

1. Education on how to judge the credibility of the information

2. Education on the cost consequences of choices made

The government is beginning to work with content experts to provide up-to-date and validated health information for the public. Clinicians must also help educate consumers on how to determine the validity of health information.

Most studies examining shared medical decision making demonstrate that people will choose less technology when they are fully informed of their choices. Given enough accurate information on preventive health practices, consumers will also make healthy lifestyle choices.

Performance counts

As consumers, patients must learn how to measure performance.

Product measures and performance reports exist in most other industries and help consumers to determine value while allowing individual choice. Traditional measures of patient satisfaction assumed that consumers were not capable of making judgments on quality of clinical care.

We can partner with consumers to develop more sophisticated, objective indicators of quality care.

The Buyer's Health Care Action Group Consumer Satisfaction Survey in Minnesota is an example of ongoing work in this area. This measurement tool is a product of an employer-owned and-operated purchasing coalition.

It seeks to measure and report on the value of regional health services. It incorporates both clinical quality measures and patient satisfaction data. Although the project is in its infancy, it is already a powerful driver of quality and performance.

Health care lags behind other industries in use of advanced technology. At present, most health care encounters still take place face-to-face, primarily because payment is based on physical encounters such as clinic visits and hospital days.

But it will be increasingly difficult to accommodate the volume of health care needs in the future without more sophisticated communications technology. Modern telecommunications tools such as e-mail and the Web can help us control costs and improve quality, accuracy and timeliness.

Utilization of services can be reduced through use of clinical care algorithms for routine ambulatory health problems and chronic disease management. But in order to bring health care practices into alignment with modern technology, either consumers or third-party payers -- or both -- must first be willing to pay for such encounters.

Then, clinicians and consumers must be willing to set reasonable service standards, agree on clinician liability and documentation requirements and determine confidentiality policies.

The future is now

Futurist literature encourages us not to fear what the future may hold, but to determine what we want it to hold. The challenges facing health care include cooperation, cost control and establishing a consumer focus.

We will be forced to set aside our differences to work on these priorities, and in the process, we will rediscover our shared values. We have within ourselves the means to heal and rebuild our health care system.

It's up to us to choose our future.

RELATED ARTICLE: Additional resources

1 Deyo, R.A. "Tell it like it is: patients as partners in medical decision making." J Gen Intern Med. 2000,15:752-753.

2 Bodenheimer, T.S. and Grumbach, K. Understanding Health Policy: A Clinical Approach, 2nd Ed. Stamford, Appleton and Lange, 1998.

3 Starr, P. The Social Transformation of American Medicine. Basic Books, 1982.

4 McLaughlin, C.P. and Kaluzny A.D. "Building client centered systems of care: choosing a process direction for the next century." Health Care Manage Rev. 2000, 25(1):73-82.

5 Heineccius, L. Health Care Futures: Managing Care, Managing Cost, or Just Managing 'til Sunset? Washington State Hospital Association, 1998.
COPYRIGHT 2001 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Author:Wong, Emily Y.
Publication:Physician Executive
Date:Nov 1, 2001
Words:2461
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