In the research that yielded our book, Unbalanced—The Evolving Medical Care Crisis, Dr. Youkey and I (Dr. Spence Taylor) discovered multiple examples where the concern for patient well-being was often secondary to the well-being of the various institutions supporting medical care.
In most cases, those institutions were comprised of non-clinicians, and dollars were usually a priority. While we concluded the medical care environment is out of balance, perhaps the more obvious conclusion could have been that non-clinicians have assumed a disproportionate control of medical care. In fact, over the past fifty years, systematic changes to American medical care have been led mostly by administrators, policy makers, businesspeople and politicians. Doctors have been relegated to the role of advancing medical treatment, the scientific discovery of new drugs and procedures. And in that role, our capabilities have expanded exponentially. Yet, with this current assignment of responsibility, patient satisfaction has deteriorated (satisfaction with medical care consistently measures less than 50% in current surveys). Patient well-being is not something we define, measure or preferentially consider. Our current state is one of high technology and low touch, a trade-off where sophisticated medical treatment has seemingly displaced compassion.
If the medical system is out of balance as we suggest, an examination of the number of non-clinicians in medicine may shine a light on why this is the case. A famous graph produced by the Kaiser Foundation in 2012 continues to be circulated at national medical meetings. It shows the growth in the number of non-clinician administrators compared to physicians over the past fifty years (below). The figures are sobering and eliminate any surprise as to why the influence of non-clinicians has been so prominent. Given that most non-clinician administrators do not provide care (but do add expense), it may also explain, as suggested by the graph, why healthcare costs have risen so sharply.
Placing cost and influence of non-clinicians aside, notice how policies implemented by non-clinicians have also negatively impacted the doctor’s well-being, which in turn affects patient well-being. For instance, over the time depicted by the graph above, policy makers (non-clinicians) passed legislation that implemented Diagnostic Related Groups (DRGs) for hospital billing in 1983, the Resource-Based Relative Value Scale (RBRVS) for physician billing in 1992 and the American Recovery and Reinvestment Act of 2009 linking payment by governmental payors to the use of the Electronic Health Record (EHR). These initiatives were well-meaning “solutions” imposed by government to address real concerns such as the rising cost of healthcare and the variability of patient record-keeping. But as conservative scholar Thomas Sowell might say, centrally imposed “solutions” like these rarely solve all the issues. They simply trigger a set of “trade-offs” that seemingly address the central issue, but also create unintended consequences. In this case, the governmental billing system placed the care of patients in the hands of governmental policy makers who determined what care would receive reimbursement, and what would not. It shifted the political and economic upper hand from the doctors (and hospitals) to government and private payors. Governmental policy makers, not doctors, were now empowered to decide what (and to what degree) diagnoses and treatments were to be valued. The EHR, a terrific concept when proposed, slashed patient care productivity by 40% when implemented and triggered a state of physician burn-out from which we have yet to recover. Obviously, these policies were not universal “solutions.” They were measures which produced “trade-offs.” In this case, the “trade-offs” shifted control and responsibility of patient care from the doctor to policy makers and EHR vendors (i.e., non-clinicians). While the merits of the current billing and record-keeping system can be debated, its unintended consequences are undeniable. Doctors have less autonomy (less control and less responsibility) and more burnout.
Sadly, many doctors have seemingly surrendered to this reality. For them, autonomy is no longer a possibility. They have accepted their plight as laborers in a profession that they no longer lead (even to the point of forming labor unions). They have also lost meaning. A recent survey showed that doctors only consider 20%-30% of their work as meaningful (Shanafelt et al. Archives of Int Med, 2009:169 [10]): 990). No wonder they are burned out.
Without autonomous doctors, will we ever be able to rebalance medical care? If the answer to this is “no”, how, then, will we restore doctor autonomy?
The answer may rest with the recent practice trends in family medicine, where autonomy is making a resurgence. That trend is called Direct Primary Care (DPC). In the DPC model, family doctors recruit a panel of patients, charge them a monthly fee and never send a bill for episodic care. In fact, doctors never deal with payors at all—no insurance contracts, no Medicare, no precertification, no EHR (unless the doctor wants it), and no revenue cycle management. Doctors are in total control. The patients have 24 hours/ 7 days a week access to the doctor. Doctors have more time to spend with patients when they visit. Patients and doctors get to know each other and satisfaction for both is sky high (no burnout!). Monthly fees are around $70 a month/ patient and an average patient panel size/ doctor is around 600 patients. According to the American Academy of Family Physicians (AAFP) website (www.aafp.org), there are over 2,000 DPC practices in the US. DPC practices experienced a 400% increase between 2014-2017. Currently the number of DPC practices is growing by 50% a year. The result: doctor autonomy is restored; burnout is reduced, and patient well-being is the priority. Perhaps balancing the medical care environment starts by disinviting the non-clinicians from the table as demonstrated here!
Obviously, we need non-clinicians at the table. But we also need autonomous doctors. Whether it is a model like DPC or some other, doctor autonomy will be the key to solving our medical care crisis. Only then will patient well-being be the priority.
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