Why are doctors crazy enough to accept health care’s status quo?

We believe integrated will triumph fragmented every time.
-Steve Jobs

Two articles recently got my attention. The first was an interview by Dr. Robert Pearl, CEO of the Permanente Medical Group with my favorite author and thinker Malcolm Gladwell. On Pearl’s blog, he answered Gladwell’s request to tell people what is was like to be a doctor.

The second was a NPR article, “When Facts Are Scarce, ER Doctor Turns Detective To Decide On Care” by Dr. Leana Wen, patient advocate and author.

Both articles reminded me how doctors and patients have different realities simply by where they practice. As a practicing primary care doctor in an integrated health care system, which is partnered with a physician led medical group, these stories were quite foreign to me. These stories were once my reality in residency but no longer the case today.

The real question is will doctors and patients embrace the system I work in or continue with the status quo as outlined by Pearl and Wen?

In Pearl’s interview, Gladwell noted during a recent doctor visit:

… interacting with four support staff: three doing paperwork and only one assisting the physician with medical care. “That’s insane,” [Gladwell] said. ‘The only other industry in America that has a higher ratio of back-office to front-office is financial services, which also is a massively crazy business. It’s just wrong. It’s a misuse of resources.”

Gladwell continued:

“I don’t understand, given the constraints physicians have in doing their job and the paperwork demanded of them, why people want to be physicians. I think we’ve made it very, very difficult for them to perform their job. I think that’s a shame. My principal concern is the amount of time and attention spent worrying about the business side. You don’t train someone for all of those years of medical school and residency, particularly people who want to help others optimize their physical and psychological health, and then have them run a claims-processing operation for insurance companies.”

Why are doctors crazy enough to accept this status quo? One of my colleagues is in a small group practice where she is the human resources person, the IT person, the chief negotiator with health insurance companies, and also the chief financial officer. On top of that she is also a sister, a spouse and a mother with other personal hobbies and interests. Of course, she still needs to be a doctor.

Aside from the byzantine and fragmented nature of the business of health care, there is another obstacle: the lack of patient information in a readily accessible format, real-time, 24/7.  We still use paper charts and paper prescription pads. Unlike our smartphones, tablets, or computers which have much of our personal content of photos, emails, and songs on the cloud, health care has our information stuck in photo albums, letters, and CDs, locked up in someone’s home, attic, or who knows where.

Wen runs into this dilemma when examining a 73-year-old man brought into the emergency room by ambulance. The only information paramedics could provide was a name and address. The patient could only offer the year 1843 and two phone numbers that were not accurate. Wen, a resident physician, and medical student play detective.

The patient tells us his full name and says that the year is 1843. “It’s 2014,” I say, as my medical student looks for his records on a nearby computer. She shakes her head. He’s never been in our hospital. He gives us two phone numbers for his son, but neither works. The patient says his doctor lives in Kansas …

… He wants to go home. He pleads with us, saying he hates hospitals. He promises he’ll be ok. I try his home phone and his son’s numbers again. The resident calls two local hospitals on the chance they’ve seen him before. No luck.

“The year is now 1914,” the patient declares. Everyone sighs. We have to admit him. It’s the last hospital bed we’ve got, and the patients who come after him will have to wait through the night in the ER …

The following day Wen gets a call from the patient’s son and daughter-in-law:

They’re irate. The patient has dementia and frequently falls. That’s why the family has arranged for live-in help 18 hours a day. The man has had anemia and kidney problems for years. His longtime doctor (here in town, not in Kansas) monitors these issues closely. The internist taking care of him say that the man never should have been hospitalized …

… When caring for patients we don’t know and who could have life-threatening illnesses, emergency physicians have to do what is safest and best with the information at hand, sparse as it may be. In this case, I made the choice to admit the patient. He was confused and had several abnormal test results. We couldn’t be sure he’d be safe at home.

As I listen to his family, I also see the other side. I can see how unhappy they are that he was stripped, poked and kept against his wishes. I understand their frustration at our system of sick care: Why don’t we have unified electronic medical records? Why aren’t there better interventions for coordinating care and keeping people out of hospitals?

I tell them that I’m sorry. Knowing what I know now, I would have made a different decision. I gently suggest that it would be helpful to make sure he carries a document in his wallet with updated phone numbers, medical conditions and wishes for his care.

Wen concludes her piece with another patient in the emergency room with a similar situation.

Would doctors and patients choose a different health care system if given the choice? Would they choose a system where care was streamlined and coordinated, information available 24/7/365, and doctors and patients could focus only on health by connecting, healing, and getting better?

Would they chose an integrated health care system partnered with a physician led medical group? In my reality, I have access to a common electronic medical record (EMR), which not only allows my colleagues and I to access a patient’s medical information in the outpatient and inpatient settings. We can collaborate on cases real-time. Patients also have access to their medical records electronically. Book appointments online, review labs results, refill medications, and securely email their doctors. We also now have access to other hospitals and health care systems, which share a similar EMR platform. Now I don’t need to repeat a CT scan of the head if a patient paid for one recently. I know exactly now which leg was scanned for a deep blood clot and when it was completed.

In other words, our system enables doctors and patients to worry less and focus more on providing better care.

With health care reform and the drive to make medical care more like any other consumer market with health insurance exchanges (think Expedia), transparency (think Amazon), and ratings (think Consumer Reports, US News and World Report), will a health care system I work in simply be seen as the same as everyone else as doctors and medical care become more like a commodity? Or will it be seen as something else — the future of American health care? Where I work, we are an outlier.  We care for 1 percent of the US population. Will others join us and make a statement that they want something far better?

Time will tell.

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

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  • Dr. Drake Ramoray

    Your article presents a false narrative between the status quo and the idea of a PCMH/ACO and glosses over the negatives of your proposed system. I value my indpenendence as a physician to do what is best more than anything else. I have worked for a corp med hospital, and I have worked for a multi-specialty group and both were sorely lacking for my specialty as outside forces were always controlling my schedule (in the multispecialty group I had no power dismiss patients including one who no showed 9 times for her initial consult), my work flow, or even my ability to provide services that are perfomed by others (radiology I’m looking at you). On one hand fine, I don’t have control of my schedule, on the other management shouldn’t come complaining to me that I’m not busy enough. At both institutions getting time for CME, vacation was a hassle and required extensive notfication in advance and required approval. Frequent meetings for financial targets, meaningless education requiremetns on how to lift patients and other mandated activties that were completely worthless. All of this and the prior authorizations, meaningful use criteria, dictats, and mandates of current medicine practice remained.

    In essence, when I finished medical school and started my post-graduate training I intended to go out into the world hang my shingle and treat patients. I am in a single specialty group now and it is far better than any other model that I have experienced to date. I have control over much of my daily life. I know that I am not alone. In 2012 less than 1:5 Endocrinologists would pick there practice setting again, and most work for multi-specialty groups or hospitals.

    http://www.medscape.com/features/slideshow/compensation/2012/diabetes-endocrinology

    Our view as a specialty is not optimistic with regareds to the ACO/PCMH largely because of the compensation based on outcomes and the inherent negative selection bias that an Endocrinologist will see in the office (especially for diabeters). In addition, those like me in relatively rural parts of the country think ACO’s will be terrible for patient care. One could even make a case in the ACO/PCMH world to be the one in the community without Endocrine services, and then plead rural hardship for bad diabetes outcomes.

    In summary I want to take care of patients with as little third party distractions as possible. The PCMH/ACO does not take any of that away it just shifts it to a large IT department, billing office, and then makes me subject to mandates, dictats, target productivity goals, and worthless meetings to the benefit of yet another third party as I am their employee.

    My solution is to move to a low cost direct pay practice. There is a demand in my area, probably nationwide, for thyroid only services and I figure I can provide ultrasound, nuclear medicine studies and treatments for about 1/4 of the cost of the hospital. It will be me two patient rooms, and ulrasound room, a hot lab, and one person to keep track of my scheduling, billing etc. Eventually in house labs. My napkin math suggests that I will actually probably make less than I do now, but a world of medicine where the patient truly comes first, no prior authorizations (ok excep nuc med alhough not hard when treating hyperthyroidism or cancer), no insurance billing hassles, an affordable price, and most importanly the maintenance of my freedom to control my life and practice medicine.

    There is an alternative to the status quo, and for me at least it isn’t the PCMH/ACO and the beuracrats and dictats that come with it. I trained until my early 30′s to be a physician and treat patients not be some corporate drone clicking boxes for federal dictats.

    .

    • http://www.davisliumd.blogspot.com Davis Liu, MD

      There is no false narrative. The system I work in is far better than an ACO/PCMH, which in theory sounds good, but time will tell. The group I work with also isn’t for every doctor. Your prior experience isn’t my reality. Many of the frustrations you describe simply don’t exist in where I work. My narrative describes a typical day.

      You and I simply have different points of view. Is it a small single specialty practice or a large multispecialty group practice? Neither solution is the cure all for our problem in health care. It is simply a difference between cowboys and pit crews – http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html. It is a question of whether integrated care done at a large scale
      and done well can be a solution for health care – for both doctors and
      patients –
      http://www.kevinmd.com/blog/2011/04/future-primary-care-accountable-care-organizations.html – and whether doctors and patients see a difference or not. If they do, they will join. If not, they will leave.

      • Thomas D Guastavino

        Fair enough. If I am reading you correctly your ideal health care system would run something like this: All healthcare would come under one coordinated system with one common records system that can be accessed anytime, anywhere, assuming the IT does not run like healthcare.gov. Healthcare decisions would now be made by committee consisting of both medical, run mostly by primary care, and business people.( The integrated health system that physicians are partnered with). Providers income will now depend on how well they meet certain quality guidelines and how well they follow the decisions of the committee, assuming of course they are not fighting other providers over a shrinking pie.
        Does this sound about right?

      • Lisa

        Thanks for the link to the New Yorker article.

      • Dr. Drake Ramoray

        False narrative may be incorrect, although false choice between PCMH/ACO certainly seems to apply. Your original article leaves out any of the vexing things about healthcare today and suggest that if I would just inegrate into a system that it will all be rainbows and sunshine.

        I am fine with 24/7/365 access (our patients have access to us at any time as we rotate call). I also don’t necessarily have issues with e-mail (my opinion on this subject has changed some although my partners are very much against it). I only wish EMR’s talked to each other and we could have access to oher records. I may not actually be so much against them if it was required for them to have an interface for which they could all talk to each other before I was mandated to have one in the first place. My current practice would save a lot of time on faxes and record requests, I don’t dispuste that but they are just additional work thrust on physicians, who are now part data entry clerk, with the ultimate goal of reducing reimbursement.

        I am for many of the things that your piece suggests, which is why I think you are missing the point. My issues is that the current system plans to tie reimbursement to outcomes, data entered into the EMR (by physicians of course), and is so cumbersome that nearly makes it mandatory for me to work for a “system” that doesn’t always have my or the patien’s best interest in mind. I support a lot of what you say, just not the method which this country currently plans on acheiving it.

        • http://www.davisliumd.blogspot.com Davis Liu, MD

          I believe we agree more than disagree. Integration alone will not have rainbows, sunshine, and unicorns. The ability to access other health care systems EMR has been helpful.

          • Dr. Drake Ramoray

            We agree that access to other EMR’s is helpful. With all due respect we agree on little else. While that may not be obvoius to the casual reader on this thread, the stark differences are pretty well represented in my responses to you for this article.

            http://www.kevinmd.com/blog/2014/03/measure-takes-good-doctor.html#comment-1313700643

            I would leave the country and practice in a single payer system if my only alternative was to work for Kaiser or some other corp med entity.

  • Thomas D Guastavino

    There once was a man who bought a table but noticed that it was unbalanced because one of the legs was to long. Because he was in hurry and inexperienced, he decided to cut the leg without taking the time to properly measure. Once again the table was unbalanced. Not realizing that he had to take the time to think through what he was doing, and consider the negative consequences of such, the man continued to blindly cut the legs. Soon he had a table with no legs sitting on the floor.
    Moral: Just because you have a problem it does not justify blindly stumbling around without thinking the problem through and considering the consequences of your actions.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Dr. Liu, the way I see it is that what differentiates your system from the usual large hospital system is the “prepaid” nature of it. I would assume that when the insurer and the service provider are one and the same, much of the insane games being played between the two are eliminated.
    To me that is indicative that perhaps similar quality can be achieved by eliminating the insanity from the rest of the system. Perhaps your friend who is in private practice, and the one anecdote Mr. Gladwell uses as a basis for his overarching conclusions, would be able to function much differently if we change how we pay for medical care without necessarily changing how care is delivered. It would at the very least warrant some experimentation, I would think.
    In addition, the amounts we pay for care do not seem to be beneficially affected by the completely integrated model. If I am not mistaken the premiums for these “prepaid” entities are the same (or higher) than the traditional insurance mediated models. If there was a significant financial difference, I would suspect that by now, the model would have spread like wildfire. It didn’t.
    What I am most interested in is singling out the true critical factors that affect both quality and cost, and figuring out a way to scale those. I am not sure that the entire integrated package is absolutely necessary, and I am not certain that all its parts are optimal, and I suspect that there are features in other models of care that may be equally important to retain in a good system. I don’t think we are doing the research we should be doing.

    • buzzkillerjsmith

      You got it. Dr. L’s argument, in a nutshell, is that private practice is so abusive that doctors would be better off working for Kaiser, which is slightly less abusive but, as I know from long experience, abusive nonetheless. No mention of any other attempt to improve the system. No mention that Kaiser kosts a lot too. Just come to Kaiser. We’ll take care of you, doctor.

      That is of course kingpin-kaiserdoc Pearl’s argument as well. And they have opened something in DC called the Institute for Total Health or something. Should have added Control to the end of it.

      They’re makin’ their play, striking while the iron is hot.

      • http://www.davisliumd.blogspot.com Davis Liu, MD

        Your past history and long experience no longer exists. Where we are and where you have been is like night and day.

        • buzzkillerjsmith

          Spoken like a true kaiserkadre.

        • Patient Kit

          There’s something about this statement that sends chills down my spine — and not in a good way.

          • http://www.davisliumd.blogspot.com Davis Liu, MD

            For the seventh consecutive year, Kaiser Permanente has been given the highest ranking for customer satisfaction in California, ahead of all other health plans in the state, according to the J.D. Power 2014 U.S. Member Health Plan StudySM released this week.

            Kaiser Permanente out-performed seven other health plans in California, scoring 756 on a 1,000-point scale, 76 points higher than the average health plan score in the state. The organization performed particularly well in four key areas: customer service, provider choice, coverage and benefits, and information and communication.

            “Meeting the needs of our members is our constant focus,” said Wade J. Overgaard, Kaiser Permanente’s senior vice president, California Health Plan Operations. “We believe that our ability to make it easy for members to access high-quality care when and how they want it has enabled Kaiser Permanente to rank highest in customer satisfaction in the J.D. Power study of health plans in California for the last seven years.”
            - See more at: http://share.kaiserpermanente.org/article/kaiser-permanente-california-ranks-highest-in-j-d-power-member-satisfaction-study/#sthash.NOxFiOiw.dpuf
            http://share.kaiserpermanente.org/article/kaiser-permanente-california-ranks-highest-in-j-d-power-member-satisfaction-study/

    • http://www.davisliumd.blogspot.com Davis Liu, MD

      What is increasingly apparent is perhaps integrated health care systems offer better value (higher quality, better service – email access to doctors, online booking, streamlined care) as opposed to being less expensive than other traditional insurance mediated models.

      This may be because that integrated and non-integrated systems still have the same societal challenges and issues. Gladwell talks about this http://www.forbes.com/sites/robertpearl/2014/03/06/malcolm-gladwell-on-american-health-care-an-interview/ and an article from the Boston Globe – “Why the US spends so much on medical care – revised” – “Bradley’s research over the past several years examines spending on social services as well as spending on health care services in the equation…..we spend the absolute least (Mexico and Korea are our runners up) on non-health social services. When you put both [health care and social services] together, we’re not number one in spending, we’re number ten. http://bo.st/1cDe45R.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Those are very disturbing and yet enlightening numbers. I can’t be certain about causality, because some more efficient countries are indeed spending more, but a few others are even worse than us. I’m sure there is a significant contribution though and that we are doing a poor job with public health.

        Going back to the integrated systems, Dr. Liu, let’s assume for a moment that these systems do provide better quality care, and then observing that the costs are not budging, should we conclude that better care for individuals, better health for populations at lower per capita costs is not really possible? Should we conclude that the triple aim is not a realistic aim at all (barring scientific breakthroughs), in spite of the daily barrage from industry experts, government and media?

        • Dr. Drake Ramoray

          Very little will change in this country in terms of life expectancy and healthcare as long as there is a Second amendment, automobiles as the major form of transportation, ubiquitous access to empty calories, the penchant for overeating, sedentary lifestyles, and the unwillingness of many patients to change. Many other countries even have some element of private insurance. All of the current going on in medicine is just insurance companies getting tired of holding the bag of financial responsibility after it had been handed to them from the patient thanks in part to the government. Medicare too can’t control costs.

          Many paients don’t want the financial responsibility or to change their lifestyle or habits, the insurance companies don’t want the financial responsibility anymore either, so now it’s being placed on the doctors. Add pharm companies who charge way more for stuff over here and you have a toxic mess to be a physician or a patient.

          Direct pay, research, retire, teach, or leave the country. Those will soon be the only viable options in my book as a physician. Seeing as I will be a chronic patient someday, sometimes I think I should get out now while other countries will still take me while I’m relatively young, healthy, and have a skill. (You know that whole closed borders thing in other countries).

          It’s gonna get worse before it gets better in the US, and without a change in the culture I’m not sure it will get better. It’s all about dividing up the pie, limiting the people or diagnoses that are seen now, or seeing more patients for less money with lots of different level providers and then giving it a pretty name like “Patient Centered Medical Home.”

          • ninguem

            After basic public health matters are addressed, population life expectancy is determined by GENETICS, not the healthcare system.

            Look at Scandinavian lifespan statistics, then go to an Upper Midwest community of the same ethnic group, you get the same lifespan statistics.

        • http://www.davisliumd.blogspot.com Davis Liu, MD

          It is my personal opinion that the triple aim (better quality, better service / access, at decreased costs) is an admirable and aspirational goal. I am unaware that anyone has achieved it…. yet.

          It is likely to be achieved with scientific breakthroughs, if we think different about health care delivery (http://www.forbes.com/sites/robertpearl/2014/03/27/offshoring-american-health-care-higher-quality-at-lower-costs/ and analytics via IBM Watson – more accurate diagnoses), and societal changes (more focus on physical activity, increased popularity / interest in plant based diets, healthier eating, etc). that triple aim goal is possible. Those in Silicon Valley who also think different may also nudge health care better – http://www.davisliumd.com/future-of-health-care-crystal-ball-via-rock-health-inspiring-stories-much-potential-more-questions/

          Improving the health of the country and its citizens is far more complex than fixing health care.

      • JR

        Wow, thank you for that health spending article. It makes complete sense that “medical health spending” isn’t the only thing to take into consideration.

    • ninguem

      What country has this great unified system being praised here?

      The Canadians? The Aussies? The Germans? The French? The British? The Israelis?

      None of them as far as I know.

      The Brits tried a unified EHR, it was horribly expensive and a complete failure. It was scrapped after spending billions of pounds on it.

      All the countries held up as our “betters” still have independent practices and may or may not use EHR’s. They are no more interconnected than we are.

      Is Kaiser so much better? In my state, they’re still cleaning up the mess from the Patel incident at Portland Kaiser. I know, one of his misadventures was done on a lady who does Mrs. Ninguem’s hair. I hear the problems regularly.

      But…..they looked real nice on their performance measures.

      It was revealed with the Patel mess, Kaiser Permanente arranged to legally exempt themselves from the malpractice reporting requirements that apply to the rest of us.

      So they quietly settled their cases and hid their dirty laundry.

      In view of the problems widely reported in the Oregon media, pardon me if I say that I have zero respect for any quality claims by Kaiser Permanente.

    • disqus_McUkQK6a8K

      Margalit nails it, as usual. As a non physician she has ability to speak without having been in myopic “they abused me /they are great for me position of most of PCPs.
      Integrated information is necessary but in a capitalist country political force is needed to force interoperability without PCPs supporting one more vendor. We do not all have to WORK for one employer . I suggest we stop getting lost on form vs function and measure outcomes. I understand that Kaiser has fabulous statistics and I also know alot of docs who despise working there. Hence someone needs to let all docs working alone or with 400 others, in Montana or midtown NYC ,see a a patient’s records.Dr Liu cannot by force of his own experience convince someone else to do what he does ,this is naive and irritating, and unhelpful

      Kaiser indeed takes out of the equation the payer vs doctor problem This is huge Unfortunately docs and most citizens meet this with great resistance Lets advocate for SUSTAINABLE primary care- which improves outcomes and lowers costs – and reform payment for all of us. There is too much hard feeling among docs about how places like hospitals and Kaisers etc treat them for this to be a universal solution anytime soon and a happy dr Liu is not going to persuade anyone .Enabling PCPs to be supported to do their work is what is important. Dr Liu has tools. We all need support and tools to do our work no matter where we do it- by buying unit doses of things we need, by reducing administrative hassles ,by equalizing and simplifying payments and metric measurements — these are the real things to go after yes? Arguing about whether you should work for KAiser or in integrated system just focuses on too narrow a picture and wastes time

  • southerndoc1

    “We believe integrated will triumph fragmented every time.
    -Steve Jobs”

    Wasn’t he referring to corporate profits here?