Physicians Feel Reform's Tight Scrutiny

Thanks to healthcare reform, there are now more eyes on how doctors treat their patients and more opinions on how they should be treating them. But one physician leader says the pressure doesn't necessarily mean that doctors have to be on the defensive.

All working professionals, from writers to physicians, have a preference for the way their work gets done, but a doctor's penchant for how he or she cares for a patient is increasingly coming under scrutiny.

First, there are cost and quality pressures from hospitals, health systems, and payers as a result of the value-based healthcare transition that affects how physicians practice, not to mention public pressure on how much physicians get paid with the recent release of Medicare payment data.

Then there are the efforts to standardize patient care among providers in hospitals, group practices, and health systems in an effort to improve quality.

All of it leads to more eyes (and opinions) on how doctors care for patients, which can be uncomfortable.

Kevin Wheelan, MD, chief of staff and co-medical director of cardiology for Baylor Heart and Vascular Hospital, a joint venture hospital within Dallas-based Baylor Scott & White Health, says the pressure doesn't necessarily mean that doctors have to be on the defensive, or have an adversarial relationship with leaders.

Rather, Wheelan looks at the issue through a different lens. Without uniformity of care, quality can suffer, and patients leave confused. "Ten different sets of discharge instructions sets up [the hospital] for inconsistency," he says. "If the patient doesn't leave the hospital with a well-articulated game plan, that could lead to an unscheduled visit to the ER."

That's code for readmissions and possible penalties. Reducing both requires better communication with the patient, which Wheelan says has improved at BHVH with better and easier-to-understand discharge instructions.

"The tools have improved in terms of more detailed collateral materials as a resource for patients to refer back to," says Wheelan.

In addition, Wheelan says BHVH has also enhanced medication reconciliation by having both a nurse and a physician review what medicine a patient is taking at home that could interfere with medication prescribed upon release.

The post-discharge appointment is also a more focused discussion, says Wheelan.

"Instead of telling a patient, 'See you within 30 days,' for example, the goal is to have a follow up appointment scheduled, so it's not a nebulous concept of when they're returning."

Follow-up phone calls also help reduce readmissions and anxiety from patients. The phone calls are also a data mining exercise that shows variance among physicians. It's not intended to be an exercise in checking up on physicians, but it has helped standardize care and reinforce a culture of teamwork.

"We keep track of all of these phone calls," says Wheelan. "We have a document typed up, blinded to the patients' names, and those results are provided back to the physician leader and the physician practices for an opportunity for improvement issue."

Using data to show a variance can take some of the sting out of a difficult conversation with a physician. It helps, says Wheelan, that physicians see exactly what a patient is saying.

"It gives [physicians] a different insight," he says. "The doctors get to see types of concerns the patients have."

Wheelan says BHVH's system isn't not perfect. There are still difficulties with weekend discharges, but he says setting a specific follow-up appointment time is the biggest change since BHVH opened in 2002. But it didn't happen easily because of physician preference.

"It's an issue of compromise," says Wheelan. "You have a group of physicians who say, 'I need to see a patient two days post-op,' and another group who says they need five days. So we have to come to an agreement that we will see the patient within 2–5 days."

Getting standardization among physicians is difficult, admits Wheelan, but it's also an opportunity for physician leaders to emerge because "someone has to be a champion," willing to track down the other physicians and get buy in for clinical protocols.

Using data to accompany a potentially hard conversation about performance is an approach that is also used at Southwest General Health Center, a 354-bed hospital in Middleburg Heights, OH.

"Physicians tend to be logical, numbers-driven people," says Jill Barber, director of managed care operations and revenue integrity for Southwest General. "When hospital administrators meet with doctors, we talk in great platitudes, and it's easy for physicians to say, 'Well, my patients are sicker.' Data takes out the emotion. It can be a moment of shock."

Also like BHVH, Southwest General uses verbatim comments from patients to give physicians insight into patient satisfaction. "By sharing with them the actual comments, it brings it home," says Barber.

They key to delivering information unemotionally is using a physician leader as the messenger. It's what BHVH and Southwest General rely on because it is peer-to-peer, and more "collegial" rather than punitive, says Barber.

Physicians also have to think differently in a value-based era of healthcare, explains Wheelan.

"The important mental transition that has to occur within physicians is, 'This is about a team concept and approach to care. It's not just about me and why I think is best for my patient.' That's a problem some physicians have."

It's a problem they'll likely have to grow out of, too, in order to withstand the pressure, opinions, and eyes that are watching.