Medical Professionalism: Jousting at Windmills, or Seeking the Holy Grail?

For physicians, this is a “good news/bad news” piece…or more accurately, “good news/word of caution.”

First the good news.

We live in an era of increased anxiety related to our health. Too many people are demanding too many services for too much money resulting in less than optimal outcomes. The good news? Even in the face of substantial challenges and uncertainty, trust of physicians (and healthcare providers in general) remains high. In fact, according to Gallop polling administered over more than three decades, the US public continues to rate the honesty and ethical standards of physicians among the highest of all professions (see chart below, and CLICK HERE FOR LINK). Although physicians rank very highly, the nursing profession deserves credit for their solid lock on first place.

Perhaps more significant than the current high trust ratings, are the trends over the past 30-40 years. During this period, almost every profession has seen an erosion of public trust. Journalists, judges, lawyers, bankers, clergy and politicians all have all experienced major reductions in public confidence. This is perhaps not surprising given the increasing speed and transparency of information flow…familiarity breeds contempt.

Healthcare providers have bucked the overall trend, and are rated as more honest and ethical than they were in the mid-1970’s. In an era of uncertainty and change, it is very good news that the public still has a high degree of confidence in the providers of care.

Now for the word of caution.

The trust place in healthcare providers is not immutable, and cannot be taken for granted. A case in point, bankers enjoyed a stable and relatively high level of trust (41% Very High or High) as recently as 2005. By 2009, this number had plummeted to 19%, following the global economic meltdown.

Jain and Cassel emphasized this point in their 2010 article in JAMA, Societal Perceptions of Physicians: Knights, Knaves and Pawns? (CLICK HERE FOR LINK). Jain and Cassel refer to a 2006 book by economist Julian Le Grand, Motivation, Agency, and Public Policy: Of Knights and Knaves, Pawns and Queens. Le Grand observed the changing public attitudes regarding civil servants in Great Britain. Immediately following World War II, civil servants were held in the highest possible regard. Schoolteachers, physicians, policemen, child welfare workers and others were heroes, part of a concerted national effort that defeated Hitler. What followed, according to Le Grand, was an era of good will and public optimism that lead to an expansion of state services… “a triumph of collectivism”.

Today, the same groups that once were celebrated are viewed as part of a faceless monolith of public services that deliver low quality services for undesirably high tax rates. Part of Le Grand’s hypothesis is that as society’s view of the motivation of a profession changes (e.g., are they Knights, Knaves or Pawns?), there is a direct impact on public policy.

Knights are driven by virtue, and are predisposed to do the right thing. Per Jain and Cassel, physician knights are stewards of the healthcare system. They can be trusted to manage resources effectively. They are life-long learners because they have an inherent love of learning. First and foremost, they are advocates of the patient. If society believes in physician knights, the public policy implication is that minimal regulation is required…knights will do the right thing to protect us…just get out of the way and let them pursue their vocation.

Knaves are driven by self-interest. Money, fame and lifestyle considerations are of primary importance, and the needs of patients are secondary. Knowledge is acquired, or research is performed, out of some expectation of personal gain. If society believes in physician knaves, then public policy must prevent malfeasance. Rules and regulations must be established to guard against greed and monitor potential conflicts of interest that may impact patient care decisions. Think of the financial regulatory environment after the US housing market collapse.

The poor physician pawns blow where the breeze takes them, helpless to act and at the mercy of the environment. They do their required continuing education because they are told to do so. If you need them to order fewer lab tests, they will comply. If next month you want them to do more lab tests, they will comply. They are reeds in the wind. From a public policy perspective, physician pawns are mindless automatons; production units with little judgment, unable to engage in autonomous decision-making. Regulation must therefore be highly prescriptive. Since physicians cannot make decisions, society must carefully create a script for them to follow.

If you accept Le Grand’s premise, then public perception drives policy and regulation. However, I think it is more of a cycle, or more accurately, a spiral. Behavior of the profession drives public perception. Public perception drives regulation. But regulation also influences behavior (which drive perception, then regulation, etc.).

Imagine two good parents have three generally well-behaved and respectful children…a teenager, child and infant. The parents have faith in their children. The children seem inclined to do the right thing. Because of the trust the parents have in the children, they are given a high degree of autonomy. They are child knights. One weekend the teenager is involved in a momentary indiscretion (you may choose your indiscretion). The transgression was not heinous, but showed poor judgment.

Perhaps the parents will continue to regard their eldest as a knight. However, if he slips towards knave status in their eyes, the parents could respond by ramping up the regulation. Curfews might be added, expectations for frequent communication heightened, friends more carefully scrutinized, social media sites monitored, etc. What influence would this heightened level of supervision, and decreased parental trust have on the teenager and middle child? It is not unreasonable to expect the children might become less transparent; they might become less communicative; they might lie about friendships and activities. In other words, the regulation designed to protect the family and children accelerates the journey to knave status. The reactive behaviors influence the parents’ opinion of the child, stimulate more rules and oversight, and drive more knave-like behavior. The cycle continues.

But what of the infant child in the family? Raised in an environment of rules, restrictions and guardrails, the child develops without the opportunity to test boundaries, make mistakes and be rewarded for making good decisions. The infant potentially grows into a child who needs regulation to survive, incapable of working through difficult problems independently. The child pawn requires more and more detailed rules, as he appears incapable of developing independent moral thought.

So by way of analogy, physicians who act like knaves will drive public perception, which in turn drives regulation, which impacts behavior and the spiral continues. One concrete example: Medicare billing guidelines are very tightly linked to documentation of the history and physical examination (because physicians are viewed as knaves by Medicare, prescriptive documentation guidelines are enforced to prevent overbilling). One of the areas of documentation is the “review of systems” (ROS). The physician asks questions about symptoms attributable to a specific organ system – cardiovascular, respiratory, gastrointestinal, genitourinary, etc. Medicare defines four levels of charges, ascending in complexity and payment. For the lowest level, no ROS is required at all. The next level up, the ROS is “problem pertinent”, and can be limited to the system directly involved with the illness under evaluation. The next highest level requires documentation the physician asked the patient about 2 to 9 systems. The highest level requires the physician ask about 10 or more organ systems. Especially in the era of electronic medical records, where much documentation is driven by checkboxes, it is not unreasonable to assume that some of the 900,000 physicians in the country will over-document their review of systems – a very small number deliberately, a much larger number innocently. Healthcare systems and practices invest in audit systems to try and catch and correct these errors in documentation. Medicare ramps up investigations to try and catch those acting badly. More regulations are spawned, and the spiral continues.

So are physicians knights, knaves or pawns? An environment that is moving towards increased guardrails and regulation runs the risk of demoralizing the knights, and creating knaves and pawns. Recognizing this risk, physicians and healthcare providers must work to interrupt the cycle by committing to fundamental principles of professionalism. Individual physicians, and the advocacy and accrediting bodies representing them, must hold sacrosanct one principle: first and always, the duty of a professional is the protection and promotion of a patient’s health. All other forms of self-interest must be unequivocally secondary. Once commitment to professionalism starts to erode, we are headed down a path where the primary protector of a patient’s well being are the rules and regulations governing the physician-patient interaction – not the physician.

Pay-For-Performance and Unintended Consequences: The International Language

Pay-For-Performance (or P4P) is an important tool in our effort to improve the quality of the nation’s health care, and control cost.  It may prove to be a critical and effective tool. However, we need to tread cautiously; P4P is no panacea.

Central to all health care reform proposals, across the political spectrum, is the observation that part of our problem is perverse economics.  The economics are warped in (at least) two ways.  First, since the post-World War II growth of employee provided insurance, and the 1965 introduction of Medicare, consumers have largely been removed from any direct financial impact of the provision of medical services.  With no consequence to consumption, demand grows without restraint.  This long-standing dynamic is starting to be reversed as employers are steadily shifting more of the financial cost of insurance to employees.

The second dynamic is equally pernicious.  In any city in the United States we have physicians who deliver excellent, evidence-based care; who are great communicators with outstanding bedside manner; who achieve outcomes beyond those of their peers.  We also have doctors in the same city (or same practice) who are insensitive, abrupt, below average clinicians with below average outcomes.   I believe, thankfully, the former category substantially outnumbers the latter.  However, here is where the economics are twisted:  the good, kind and efficient doctor will see the same sort of patient and perform the same types of procedure as the gruff doctor with poorer outcomes.  Both doctors will submit a bill for a unit of service to Medicare, Medicaid or private insurance, and both doctors are paid exactly the same thing.  A consequence of the payment system in America is the only way for a physician (or hospital) to do better financially, is to do a greater volume, pure and simple.  The sole incentive is to do more, not to do better.

Some studies show family physicians spend only 7-8 minutes with a patient in a typical visit.  It is not by their choice.  I know dozens, perhaps hundreds of family physicians.  As a group, they are wired to take time, engage in meaningful dialog, dig into complex interpersonal dynamics and try to understand how an illness impacts a patient as a human being.  This is why they chose their field.  Left to their own devices, most would happily linger with a patient for an hour or longer. 

The unfortunate economic dynamic prohibits this sort of interaction.   Family physicians are already among the poorest paid of physicians, earning less than half, or even a third of their specialist colleagues.  To pay office staff, cover overhead, keep the lights on and take home a reasonable wage, the typical doctor must see at least 30 patients a day.  I will do the math for you…over an 8-hour day, that works out to 16 minutes per patient.  Take from that time for documentation, phone calls, and sicker patients who demand more time, and you quickly get to 8 minutes per patient.

Enter P4P.  The concept is seductive in its simplicity.  Let’s stop paying doctors based on volume, and start paying them based on quality of patient outcomes and patient satisfaction.  On a purely intuitive level, this idea has almost universal appeal.  However, because something makes intuitive sense, does not necessarily mean it will work, especially when rolled out on a very large scale across a complex system.

I recently read two studies related to physician compensation as a tool to modify behavior.  Both studies had excellent and worthy goals.  Both implemented well-designed and rational compensation changes.  Otherwise, the two studies could not have been any more different, except for one other significant similarity… neither worked as expected.

The first study comes from an unexpected source:  a rural delivery system in a poor province of China.¹  The physicians in that community had two sources of income.  They billed for services in a traditional fee for service model – more volume, more income – and they were permitted to sell drugs at a substantial mark up.  The health care planners in the province were concerned that this payment mechanism was encouraging unnecessary service and over-prescription of medications.  The fix was to revise the compensation system.

The payment scheme was revised so that rural providers would now have three sources of revenue: 1) a base salary ($15/month); 2) a volume bonus ($0.06/outpatient); and 3) a quality bonus, based on defined metrics ($12.50/month).  The economic incentive to sell medications was eliminated.  Move the decimal point about three places to the right, and this payment system looks much like many US compensation models. 

Rational, thoughtful, well designed.  So what were the results?

The designers had a number of expectations. Spending would decrease on the village level.  Unnecessary care would be reduced, particularly to the young and healthy.  There would be a reduction in prescription of unnecessary drugs.  In fact, all these results were achieved, but with one significant unexpected consequence.  Sicker patients were more costly for the rural doctors to treat, and negatively impacted their quality metrics (and pay).  As a result, there was a sharp increase in the referral of the sicker patients to more expensive city clinics.  The net result after 5 years? No cost savings to the healthcare system.

From a small study in China to a massive study in the United States.²  Starting in 2005, ten physician practices were voluntarily enrolled in the Medicare Physician Group Practice Demonstration (PGPD).  These groups joined what was considered to be a precursor of Accountable Care Organizations (ACO).  Quality metrics were introduced, and cost saving monitored in the demonstration groups.  Any savings realized from more efficient, more effective care, would in part return to the physician practice.

From 2005 through 2009 there were 990,177 patients enrolled in PGPD practices.  In a quasi-experimental design, this group was compared to patients in non-PGPD practices, both during the trial, and for the four years preceding the trial.  Keep in mind, the practices that enrolled in this demonstration were best of class.  They would not have enrolled if they were not confident they had the ability to succeed. 

Like the Chinese study: good and noble goals, rational design.  The results?  Although not a total failure, the positive impact was limited to a relatively small subset of patients (see figure below, taken from the JAMA article in the footnotes).

For Medicare patients, over a five-year period, there were no statistically significant savings.  In fact, the statistical confidence interval was such it was possible the care was actually more expensive.

The group that did seem to benefit was the Medicare “dually eligible”, that is, those patients with Medicare, who were also eligible for some portion of Medicaid benefits.  This group is primarily comprised of the disabled, and the elderly poor.  The dually eligibles also tend to suffer from multiple chronic illnesses, and have a disproportionately high rate of mental health issues, so it is not necessarily surprising they benefited from the enhanced case management typically part of an ACO, “medical home” model.

Two studies, different sides of the world, different cultures, aligning incentives in a rational manner…both with disappointing results.

This is admittedly a very limited and selective review of the literature.  Although at the time health care reform was passed there was a dearth of evidence to prove P4P actually works, there has been subsequent demonstration of efficacy, at least in select populations. 

What lessons can we take away from this? I think there are three:

• Often we see the need to improve care, and the need to engage physicians and other providers in supporting change. This usually leads to a conversation around “aligned incentives”. The groupthink sometimes seems to be, “if we could design the perfect compensation system, solutions to all these problems will fall into place.” It is clear; compensation design is not a magic bullet. 

• General solutions, widely applied over a large population, are not likely to be effective for all patients. A team-based, case management intensive model may work exceptionally well for an elderly disabled patient with multiple medical conditions. It may not be the right model for a healthy young adult. 

• More important than a payment system of accountability, we need to develop a medical culture of accountability. Compensation may be a tool in shifting culture, but it is only a single tool. 

¹ Wang H, Zhang L, Yip W, Hsiao W. An experiment in payment reform for doctors in rural China reduced some unnecessary care but did not lower total costs. Health Affairs. 2011; 30(12): 2427-36.

² Colla C, Wennberg D, Meara E, et al. Spending Differences Associated With the Medicare Physician Group Practice Demonstration. JAMA. 2012; 308(10): 1015-1023.  Click for link to article

AAMC April Blog Carnival

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