The chasm between providers and non-providers in health care may be deeper and wider than anyone can imagine. The differences in priorities, cultures and motivations are astounding.
Take for instance a recent article in the Harvard Business review titled “Making Appointments Fast and Easy Must be Health Care’s Top Priority”. The piece was submitted by Jonathan Bush the CEO of athenahealth, a provider of health care services such as EHRs and billing. In the article Mr Bush asserts that fast and easy appointments should be the focus, or keystone habit, of every health care system in the US. The author begins with a subtle trashing of the “Triple Aim” which originated from the Institute for Health Care Improvement in 2008. The Triple Aim suggested that the focus of health care systems should be to 1) Improve the patient experience, 2) Improve the health of populations and 3) Reduce the per capita cost of care. The Harvard Business Review article even contains a seemingly sarcastic association between the Triple Aim and “motherhood, apple pie and the Stars and Stripes”. The contrast between Mr Bush’s (a non-provider) quick access keystone habit and The Institute for Health Care Improvement’s (providers) goals are striking and revealing. Mr Bush’s push is to get patients into a broken system as quickly as possible. The Institute for Health Care Improvement implies that the focus should be on fixing the system first.
Can there really ever by alignment between providers and non-providers? Probably not. Consider the training, job description and motivations of all involved. Providers are trained to provide health care to patients in need. They are trained to review complex scientific literature and make decisions for patients. Their loyalties are first to their patients. Non-providers, such as those in the health care services industry, are business people who are trained to make money and their entire motivation is a bottom line. Their loyalties are first to the corporate bottom line (See Self Serving Interests). It is not surprising that a health services company would focus on quick access. It’s what they do. They can sell quick access via their services. It is how they improve their bottom line. It also provides non-providers with a metric that they can manage in an era where their cash cow wRVU metric is rumored to be obsolete. Both metrics, quick access and wRVUs, measure and drive utilization – nothing more. Nothing to do with quality or value.
There is no question that access is important. There are certain conditions which require immediate access for better outcomes. On the other hand there are a lot of medical conditions that are emotional emergencies but do not require immediate care. And yes patients have come to expect on-demand care for even the most trivial conditions. However, forcing non-urgent conditions into immediate care helps no one. This expectation of immediate care is better addressed with educational initiatives. As mentioned in a comment following the article most patients, if properly educated, are likely to understand that their care will be better, less rushed and likely more affordable with the appropriate timing.
So the Harvard Business Review article exposes the chasm between providers and non-providers with respect to how to improve the health care system. It’s time to educate patients (i.e. the paying customer) and let them help define the future of health care. Do they simply want the quickest access possible to a dysfunctional system? Or are they smarter than that and willing to wait (when appropriate) for quality?
As one looks for reasons as to why the health care system is so dysfunctional no one is without at least some degree of blame. HCR believes that beginning of the end was accelerated at Harvard in 1985 when William Hsiao and colleagues contrived the resource based value unit or RVU. At that moment the health care system was handed over to corporate interests, strategies and tactics. At that moment there was a metric to manage. However this metric had nothing to do with health care quality. Nothing. At that moment people who know nothing about providing care to human beings were handed the keys. The goal was to control cost. Instead the greed of corporate interests saw the cash cow and simply drove output. Physicians were coerced to see more patients and work faster to maintain what they felt was fair compensation for their services. Physicians became little hamsters on the wheel and the patient-doctor relationship began its death spiral. EPIC FAIL!!!!
And the beat goes on. Health care is currently managed by administrators and insurance executives who thoroughly enjoy data. Of course they do. They have never been in an exam room with a patient. They have never read, nor would they understand, a medical journal. We are on a path that could make it worse instead of better. We are focusing on Big Data instead of Big People and Big Culture.
“We can not solve our problems with the same level of thinking that created them”
– Albert Einstein
Just ask yourself this question. If an electronic medical record or big data can cut the cost of health care (and they certainly may) will that savings be passed along to the patient/consumer Probably not. The same business motivations that managed the RVU debacle will simply siphon the savings off to their pockets. It’s what they are trained to do – make money.
The center of the health care universe will always be the patient-doctor relationship. As mentioned here before it is also the hard target for quality and value initiatives. Decades of corporate driven health care have replaced the patient-doctor relationship with the doctor-patient transaction (Relationships Over Transactions). A quick, impersonal, mostly authoritarian and more recently technology-focused transaction. It’s what administrators and managers do so why did we expect anything else when we handed over the keys?
A healthy relationship, as in patient-doctor relationship, is built upon a foundation of components such as trust, respect, communication, patience and empathy. In a service-based relationship the communication aspect is the most important and communication requires time. None of these components are required for the current doctor-patient transaction. A recent blog post entitled “Is Lack of Time Really Why So Many Physicians Are Poor Communicators?” asserted that poor physician communication is a learned behavior taught in medical school. There was an implication that the authoritarian approach to patient interaction is part of the training. HCR believes this to not be the case. It is true that physicians in training spend a great deal of time learning about the science of the body in health and disease. And it is also true that the individual human aspect of health and disease is often overlooked. The question is: does a focus on science necessarily lead to poor communication? It is probably a safe bet that no where in medical school are students taught an authoritarian approach to patient interaction. It is also a safe bet that no where in medical school are students taught to spend as little time as possible with patients. Rather, HCR believes that the current state of the patient-doctor relationship (transaction) is a direct result of the system and environment in which physicians work and practice.
Physicians, and more importantly current and past physician leaders (A Call-Out to All Physicians In Leadership Positions), are guilty of weakness and complacency. They have slowly and overtime conceded to the business school model of health care where volume trumps quality. And driving volume means less time with each patient. The only way for that to happen if for weakened physicians to completely take over the interaction and transform a relationship into a transaction. The authoritarian nature of the transaction is a coping mechanism rather than a methodology taught in medical school.
HCR believes that most physicians leaving medical school sincerely wish to do the right thing and practice their profession with pride. HCR believes that mid to later career physicians would thoroughly enjoy recapturing their autonomy and practicing medicine without a useless administrator beating them up for their numbers each month. So yes HCR believes that more time will matter (What If Physicians Had More Time?). It will signal a return to a patient-doctor relationship rather than a transaction. With more time greater things are possible. Physicians will have more time to discuss options. More time to discuss risks and benefits. More time to listen. More time to make sure patients understand. How could health care not be better for all? Except the MBA’s.