Imagine you're back in college as a young idealist with a goal of working in medicine but only a vague idea about how to make it happen. In front of you, two roads diverge.
One path requires four years of medical school after your undergraduate studies, possibly racking up hundreds of thousands of dollars in debt. After that, you work another three years as a resident for low wages. If your passion is primary care and you don't opt for more training to become a specialist, you can begin chipping away at your medical school debt after seven years of post-graduate training with an average salary of about $170,000.
The second path looks a little easier to traverse in comparison. Instead of going to medical school, you study nursing as an undergraduate. You become a registered nurse and acquire a minimum of one year of acute care nursing experience. In as little as two years after that, you can complete a program to become a certified registered nurse anesthetist. When you're done, the average base salary of your profession will be nearly $190,000.
It's not difficult to see why so few medical students are pursuing primary care these days.
CRNA salaries have been outpacing primary care compensation for a while now, but the trend has become severe enough to even attract CNN's attention recently. I'm not highlighting this to wade into the debate about whether CRNAs should be able to practice without physician supervision (they should), or to suggest that CRNAs are somehow responsible for primary care shortages (they aren't). The wage gap is just a symptom of the larger problem of poor primary care reimbursement.
Most doctors in fact don't choose between becoming a CRNA and a primary care doctor. The paths diverge a little later, when they're deciding between practicing primary care or specialty medicine.
Today is Match Day, when each year medical students find out which residency program they were matched with, which can determine the course of their career.
Like previous years, it's likely that more primary care than specialty slots will go unfilled. Top choices are often anesthesiology, surgery, and other specialties that can pay four times as much as family practice or internal medicine.
Part of the difference is due to market value. A recent survey found that a neurosurgeon on average generates $2.8 million in revenue each year for an affiliated hospital (through referrals, tests, and procedures), whereas a family physician brings in $1.6 million. But the real driver has been the lopsided reimbursement system that rewards procedures over cognitive care.
I've written several times in the last few years about this discrepancy and the problems it creates, as well as a range of possible solutions. CMS is working on redistributing reimbursement slightly from specialists to primary care doctors, and healthcare reform will include additional payment bonuses for PCPs. International medical graduates play a big role in filling the gap and keeping primary care afloat.
But these measures aren't going to reverse the trend overnight. To borrow an analogy, the healthcare system is an ocean liner, not a speedboat. Increasing reimbursement 10% or so is a change in the right direction, but the imbalance took years to build up and will probably take a while to correct.
Improving the system of primary care will require more than additional physicians. We need new models of care and better communication between doctors. New technologies and better use of nonphysicians will help.
A good indicator of progress each year will be the results of Match Day, and how many new physicians find it worthwhile to take the road less traveled.
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After only one year, it is too early to assess the true impact of the Health Information Technology for Economic and Clinical Health Act. The first reimbursement payments to physicians for electronic health record adoption won't go out until 2011, after all. But early signs suggest that the program is pushing more physicians to adopt EHR systems, and that it is well on its way to accomplishing its long-term goals.
For example, in the 2010 HealthLeaders Media Industry Survey, we asked physician leaders about their plans for taking advantage of HITECH funds. More than 40% expect they will meet the meaningful use requirements and be eligible to receive reimbursements for EHR use by next year. Although quite a few respondents said it was still too early to tell if they will be eligible down the road, only less than 10% expected to not be eligible at all.
That's good news for an industry that seemed like it would take decades to get fully onboard with EHR use.
The Bush administration initially set the goal of EHRs for every American by 2014, and with an executive order in 2004, Bush created the new position of the National Coordinator for Health Information Technology to oversee the transition. This was a big first step toward improving national adoption, but the recent success seems to boil down to one factor: Money.
The promise of a financial carrot for adoption—as well as the eventual stick of lower Medicare reimbursements—has gotten physicians' attention.
As my colleague Gienna Shaw pointed out in a recent column, money has always been the biggest concern for doctors when it comes to technology. When I first wrote about the HITECH Act last year, most of the feedback I received from physician readers included concerns about costs, as well.
But there are other worries. According to a new survey from the Medical Group Management Association, a majority of practices fear that meaningful use criteria are too complex and will decrease provider productivity. There were two specific requirements that had providers worried:
The proposed requirement that 80% of all patient requests for an electronic copy of their health information be fulfilled within 48 hours
The proposed requirement that 10% of all patients be given electronic access to their health information within 96 hours of the information being available
While maintaining productivity is a concern, it is primarily a transitional issue, not a problem that should completely prevent adoption. No one said the transition would be completely painless, but with most of the costs taken care of, practices are in a much better position to solve the operational challenges before 2011.
Interestingly, despite concerns about its implementation, the HITECH Act is one of the most popular components of the Obama administration's efforts to reform healthcare. More than 54% of respondents to the HealthLeaders Media survey have a positive view of it, which is considerably higher than anything else under the reform umbrella.
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All eyes in Washington and the medical community were on Senator Jim Bunning (R-KY) this week as he single-handedly held up an unemployment benefits bill that included a provision to delay the 21% reduction in Medicare reimbursements to doctors, which was scheduled to take effect March 1.
Technically, it did go into effect. But CMS asked contractors to hold claims for 10 business days in order to buy time for the Senate to talk Bunning down off his ledge.
The Senator's objections were valid enough—he was concerned about adding to the deficit and wanted Congress to stick to the pay-go requirements it had passed a few weeks earlier. The problem had more to do with procedure. A single Senator representing one state gummed up the works for every physician in the country, not to mention the unemployed Americans counting on benefits.
Bunning ultimately dropped his objection, and the Senate voted overwhelmingly to postpone the Medicare reimbursement cut until the end of March.
But so what?
This was barely a victory at all for physicians. The alternative—a 21% drop in payments—would have certainly been worse, but all that was gained is another delay in a long series of delays that have done little to fix the underlying problem with the sustainable growth rate formula (SGR).
If Congress couldn't come up with a permanent solution by the end of 2009, when the cut was originally scheduled to kick in, and if they couldn't put together a bill by the March 1 deadline, it's hard to believe that another 30 days is going to make much of a difference.
The problem goes back to Bunning's concern about the deficit. He was getting obstinate about a bill with a relatively small price tag, but to permanently repeal the SGR would cost nearly $250 billion over 10 years. That's why a bill that would have done just that failed in the Senate last fall after passing in the House.
The cost will only grow if Congress kicks the can down the road another few years, but unfortunately politicians prefer hypothetical future pain over guaranteed immediate pain, especially during an election year.
At this point, a permanent fix in the next few months seems unlikely. The Senate is currently debating another bill that includes a provision to freeze payments until September 30 of this year. By the end of March, Congress will probably pass that to buy more time.
The SGR boondoggle actually makes a pretty compelling case for moving forward with the proposed Independent Medicare Payment Advisory Board that many physicians (particularly in select specialties) seem to oppose.
Some doctors fear that the board would significantly redistribute reimbursement from specialists to primary care doctors, or that it would enact unpopular payment changes that physician lobbies would be powerless to stop.
That is a possibility, of course. But it would also have the authority to follow through with proposals for moving away from the SGR formula and even change the underlying structure of the physician reimbursement system. It could take action, for a change.
American Medical Association physicians are in Washington this week to personally encourage Senators to pass the legislation that stalled last fall. Maybe it will work and Washington can redeem itself.
But Congress has pushed the SGR problem down the road for so long that it's hard to believe that it is actually capable of solving it anymore.
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After remaining steady for nearly 30 years, the number of hours that an average physician works each week dropped sharply in the last decade. Understanding why is particularly important at a time when Congress is struggling at the last minute to prevent a 21% cut in Medicare payments.
Between 1977 and 1997, non-resident physicians worked an average of about 55 hours per week, according to a new study in this week's Journal of the American Medical Association. From 1998-2008, however, that dropped to about 51 hours per week.
That's still a pretty busy workweek, and physicians certainly deserve a little reprieve. But the drop in hours means patient access is a little more limited (it's the equivalent of losing 36,000 doctors from the workforce), and it adds to challenges of meeting patient demand when provider shortages are predicted for the near future.
What happened in the late 1990s to cause the sudden change in work habits?
If you've been following physician workforce trends you might guess that it is simple demographics. Female physicians tend to work fewer hours and have been entering practice in greater numbers. Younger Generation X physicians in general tend to have a different philosophy about medicine and place more emphasis on work-life balance than their predecessors.
But that isn't what the researchers found. Work hours declined across demographic groups—for both male and female physicians, younger and older physicians, and regardless of whether the doctors were employed or independent practitioners.
Decreases in hours were larger for younger physicians, so the lifestyle preferences may have been one of many drivers of the change. But the study authors found a different correlate to the drop in hours: Reimbursement rates.
Inflation-adjusted physician fees dropped by 25% between 1996 and 2006, and the hours worked by physicians strongly correlated with the fee index from the prior year. Researchers went a step further and found that physician hours worked were lowest (49 per week) in the metropolitan areas with the lowest fees.
Correlation doesn't imply causation, of course, and there are many possible explanations for the overlap. Physicians have become much more productive in recent years, for example. Although fees decreased 19% and hours worked dropped 5% between 1995 and 2003, inflation-adjusted physician income declined only 7%, suggesting physicians are able to earn more in less time these days.
However, the authors of the study think the reimbursement decline is a big reason for the drop. "When fees decrease, a physician earns less for working an additional hour, all else equal, and may have less incentive to work long hours," they write.
They go on to conclude that, "Further reductions in fees and increased market pressure on physicians may, therefore, contribute to continued decreases in physician work hours in the future."
Which brings me back to the looming Medicare payment cut. Congress has until next Monday to permanently fix the SGR formula or delay the scheduled 21% cut.
The American Medical Association and other physician groups obviously want the former, and they have boldly campaigned against short-term fixes in favor of real solutions. But that is risky considering a bill that would have fixed the SGR-driven problems failed to pass in the Senate last fall.
Congress has become dysfunctional, and government spending has become such a hot-button political issue that it is difficult to muster support for things worthy of our dollars. As of this writing, it looks like the best Washington can offer for now is delaying the cut until March 28.
But if policy makers don't get their act together and the cut goes into effect, or if they only put another Band-Aid on this growing gash in the healthcare system, the research about physician work hours may be telling of what's to come.
Theoretically, if reimbursement fell by 21%, a lot of physicians would work 21% longer in order to maintain current incomes. But that's not going to happen. It just isn't worth the extra stress, effort, and resources for a lot of doctors.
Instead, they're just going to work less, and patient access will ultimately suffer.
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Some Americans receive worse healthcare than others. Some of us are more likely to be uninsured; some of us have poorer outcomes; some have lower health literacy and other obstacles to access. Most would agree that eliminating these care gaps for our fellow citizens should be a top priority.
But add a few details about these disparities and many people start to get uncomfortable. Race and ethnicity are often strong determinants of healthcare quality. Immigrants tend to struggle in the system. Poverty also plays a role and often overlaps with demographics.
It's not that providers, politicians, and the rest of us don't care about these factors. It's that Americans still don't talk about race and ethnic issues very well, or maturely. Our shameful history of segregation, civil rights struggles, and even slavery isn't that far behind us and still taints our discussions, so we often avoid them altogether or treat them as a spectacle.
In all of the debate about reforming healthcare in the last year, very little has been said about the importance of reducing racial and ethnic care disparities. Yet, these disparities persist, and in some cases they are growing more severe.
For example:
The 2008 National Healthcare Disparities Report found that for minorities and poor people, at least 60% of the quality measures it tracks were either staying the same or getting worse.
Minorities, particularly Hispanics, are still less likely to have health insurance Although the gap has been closing between white and black Americans, that is largely because now fewer whites have insurance.
Minority patients are less likely to have surgeries at high-volume hospitals and by high-volume surgeons, according to a new study.
Minorities are less likely to receive certain regular preventive measures, such as colorectal cancer screenings. New AIDS diagnoses are three times higher for Hispanics as for non-Hispanic whites; for black Americans the rate is more than nine times higher.
Physician adoption of recommended practices to improve care for minority patients—such as training in minority health issues, providing interpreter services, and following reports about demographic information and care quality—remain “modest and uneven,” according to the Center for Studying Health System Change.
There are numerous other studies that highlight factors ranging from provider discrimination to wellness to genetic differences as possible causes of racial and ethnic disparities. But eliminating these gaps isn't simply a matter of finding a single problem and fixing it. These are complex structural issues for which there aren't always easy solutions.
It has to start, however, with greater acknowledgement of the problem. The national healthcare reform debate was an ideal opportunity for that, which has for the most part been squandered.
As the nation grows even more diverse in the coming decades, issues like cultural competency, care for immigrants, and personalized medicine will become more important to everyday practice. To their credit, physicians and other providers are better than most, particularly politicians, at recognizing disparities and working to correct them, even while facing many other healthcare challenges (including a lack of resources for addressing disparities).
But this isn't a problem physicians can address on their own. If we as a country are truly interested in building a better healthcare system, then we have to start by acknowledging that the system fails certain segments of society in predictable and shameful ways.
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In an ideal world, the only factors that would go into a physician's decisions would be his or her years of clinical training and an assessment of what's best for the patient.
Unfortunately, healthcare isn't that simple. A physician may be worried about a crippling lawsuit if he or she misses a diagnosis. Or the patient may be convinced that a particular drug will do the trick and is asking for it by name. Maybe the hospital has been marketing a new piece of equipment and hinting at referrals. And who even knows if the patient's insurance will reimburse for every treatment option?
Physician decision-making has been a central focus of the reform discussions about rising healthcare costs. While most doctors make clinically-sound decisions for nearly all patients, there are external pressures that can influence and increase the tests and procedures doctors order at the margins. An occasional unnecessary test times thousands of physicians and millions of patient encounters can quickly equal billions in unnecessary healthcare spending.
To get a better idea of which pressures influence physician decisions the most, we asked physician leaders about them as part of the 2010 HealthLeaders Media Industry Survey. The question focused on four external influences:
Patients: 27.5% major influence, 54.6% minor influence, 17.9% no influence
Pressure from patients doesn't receive as much public attention as other factors in the controlling healthcare costs debate. But nearly every day physicians encounter a patient who demands a drug he saw advertised on television or asks for an extra test "just to be safe."
Physicians can try to educate patients about unnecessary treatments, but ultimately the patient is a customer, and a lot of physicians give in to demands to avoid losing them to a competitor. A few months ago, we saw how passionate patients can become about treatments when there was an outcry about recommendations to scale back mammograms. And ultimately, if the patient doesn't bear the direct costs of extra tests and procedures, there is no real incentive for holding back.
Fear of lawsuits: 33.3% major influence, 48.1% minor influence, 18.6% no influence
One-third of physician leaders said fear of lawsuits and defensive medicine is a major influence on their decision-making—more than any other category. Other studies have suggested that not only do physicians order more tests to protect themselves from malpractice lawsuits, but they also work fewer hours and change practice habits in other ways when malpractice risk increases.
As I wrote last week, it's a shame the healthcare reform debate hasn't produced more meaningful progress on reforming the malpractice system. Healthcare reform without an overhaul of the medical malpractice system is not complete reform.
Reimbursement and revenue considerations: 30.2% major influence, 38.1% minor influence, 31.7% no influence
It is clear that how physicians are paid matters—more than 68% of doctors said reimbursement and revenue considerations have at least some influence on decisions to order tests and procedures. That's why pay for performance and reforming the reimbursement system have gotten so much attention in recent years. The key to controlling healthcare costs is through physician decisions, and a lot of people think that financial carrots and sticks are the way to change them.
But J. James Rohack, MD, president of the American Medical Association, says the survey results may also reflect the complexity of the reimbursement system and the hoops physicians have to jump through to ensure that they will be reimbursed for their work. "If I'm going to provide a service and I'm not going to get paid for it then I have to communicate that with the patient ahead of time, because otherwise, that may be a non-covered benefit and I'm going to have to deal with it," he says. (Check out my full interview with Dr. Rohack online).
Pressures from administrators and other third parties: 11.2%major influence, 34.0% minor influence, 54.8% no influence
I honestly expected to see more physicians attributing pressure to hospital administration, but more than half said there was no influence at all. Perhaps this reflects the greater emphasis placed on physician-hospital alignment in recent years, and the growing number of physicians who are employed by hospitals and health systems.
Taken alone, each of these four influences would be enough to steer the occasional decision. But these pressures are felt simultaneously nearly every day. Figuring out how to alleviate pressures to order more care and creating incentives for quality may be one of the more elusive keys to reforming healthcare.
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After months of public debate about healthcare reform, one thing is now clear: Barring last-minute changes, the current medical malpractice system will remain intact, no matter what happens to the bill. Not only has there been little progress in addressing the problems related to medical liability reform, but serious and honest discussions about malpractice and defensive medicine have been largely absent from the larger reform debate.
The lack of dialogue has been disappointing because this issue is as tainted by politics and veiled in misconceptions as any other issue related to healthcare reform. Both sides of the tort reform debate have gotten used to retreating to their respective corners and rehashing the same old talking points from a safe distance.
On the one hand, Democrats and others on the forefront of current reform efforts have done physicians and the healthcare system in general a disservice by ignoring the flaws of the medical malpractice system, including the costs of defensive medicine. Revamping the tort system could save $55 billion over 10 years, according to a 2002 report from the Congressional Budget Office.
And a new study in the Journal of Law and Economics illustrates yet another way malpractice risk is impacting healthcare: When expected medical liability risk increases by just 10%, physicians end up working 1.7 fewer hours per week, researchers found. That is the equivalent to "one in 35 physicians leaving a workforce entirely, or about 21,000 physicians" at a time when the industry is facing provider shortages.
President Obama promised physicians throughout 2009 that medical liability reform would be on the table, but the most he could muster was a $25 million grant program for states to test pilot programs. While exploring different solutions to reforming medical malpractice is the right approach, the size and intent of the program was far from bold.
But fault doesn't only lie with tort reform opponents. Many supporters also need a new perspective on the debate. In the same 2002 report mentioned earlier, the CBO said that malpractice costs represent only about 2% of total healthcare spending and that savings from tort reform "would not have a significant impact on total healthcare costs."
Yet to listen to some opponents of the current reform approach, you'd think that tort reform was the be-all and end-all of healthcare reform. Last week, I argued that Congress should pass the current reform bill because it is better than maintaining the status quo for several years. I received many responses from readers who disagree, and almost without fail, tort reform was the first solution (and often the only substantial suggestion) most offered as an alternative to the current approach.
While I agree that the medical malpractice system needs reform, it is only a small part of real healthcare reform.
President Obama suggested as much last Friday when he took questions from Republicans at their annual issues conference: "If I'm told, for example, that the solution to dealing with healthcare costs is tort reform, something that I've said I am willing to work with you on, but the CBO or other experts say to me, at best, this could reduce healthcare costs relative to where they're growing by a couple of percentage points, or save $5 billion a year, that's what we can score it at, and it will not bend the cost curve long term or reduce premiums significantly—then you can't make the claim that that's the only thing that we have to do."
The exchange between the president and Congressional Republicans last week was a refreshing display of genuine and substantive political debate, which has been missing from most of the reform process. It would be nice to see more of these exchanges, particularly about medical malpractice reform.
Last September, I wrote a column suggesting that a compromise on medical liability reform could be the path to a truly bipartisan healthcare reform package. I still believe it's true, but it will require a serious acknowledgment of the problem from Democrats. And from Republicans, it will take a willingness to look for solutions beyond damage caps, which are one of the most ineffective ways of reforming malpractice.
To really bring down medical liability premiums while ensuring patient safety and fair compensation for patients who genuinely deserve it, we need to be more innovative than our politics has recently allowed. We need special health courts; we need medical screening panels; we need apology statutes; and we need a combination of different reform approaches.
But first, we need to set aside politics and have an honest and productive discussion about the true nature of the problem and its solutions.
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While the healthcare reform process is far from over, the election of Republican Scott Brown to the U.S. Senate last week undoubtedly changed the process and made the passage of the current legislation less certain.
That's why American Medical Association President J. James Rohack, MD, sent a letter Tuesday to President Obama and members of Congress to encourage them to "continue efforts to enact meaningful health system reform this year." Many supporters, including several senators and representatives, have been getting cold feet about finishing the job that began so many months ago. Rohack's letter made it clear that, although the AMA still doesn't support every provision in the legislation, now is not the time to give up.
As President Obama put it during his first State of the Union address last night: "Do not walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people."
And he's right. I've pointed out some of the flaws in both the debate's substance and process, but I've been consistently convinced that reform legislation should pass. That's because as long as I've been writing about healthcare, I have been hearing from physicians about the problems with the current system and the dire need for changes.
The reimbursement system is flawed. Quality is poor. Costs are out of control. The insurance system is impossible to navigate, and many Americans only have access to care through hospital emergency departments.
The Senate bill (which will likely be passed on its own instead of merged with the House version) isn't perfect. But even after months of debate most of us don't understand the nuts and bolts of the legislation. That is partially because of the misleading talking points coming out of Washington, but also because the focus has primarily been on small portions of the reform bills that legislators disagree about.
There are many good components of legislation that don't make the nightly news because they aren't controversial, but they will be lost if the reform efforts fall to poisonous politics. Here are a few:
Primary care reimbursements. For years, physicians have been telling me that one of the major flaws in medicine is that there are no longer financial incentives for doctors to practice primary care, and as a result we're looking at a severe provider shortage. The Senate bill doesn't fix the problem, but it does raise Medicare reimbursement for primary care physicians by 10% over four years, which helps.
Administrative simplifications. This was one of the key goals of the Medical Group Management Association, and current legislation could help cut out billions being wasted on medical practice administration. Machine-readable patient ID cards, electronic claims attachments, standardized insurance operating rules, real-time processing, and other improvements could make it a little easier to practice medicine.
Expanded coverage. Reducing the number of uninsured has obviously been the central goal of reform, and many providers are skeptical about whether the system will be able to handle an influx of patients. But many physicians have also for years been concerned about uninsured patients relying on the ED for care, not to mention the moral implications of a system that doesn't provide access to all members of society. With all the focus on the shortcomings in the areas of quality improvement and cost reduction, some are forgetting that expanding access was also one of the big three challenges of reform, and we're closer than ever to making that happen.
Pilot projects. Sure, the legislation won't begin rewarding providers for quality over quantity, and it doesn't get at the heart of our cost problems, but the answers may lie in its many pilot projects that test new reimbursement systems, medical liability models, and other potential long-term changes. If you don't believe me, Atul Gawande makes a much more compelling case.
(Eventual) payment system reform. Most physician groups aren't too keen on the idea of an independent Medicare payment commission that will have control over Medicare payment policies. That's because they've had success in lobbying Congress to prevent proposed cuts to reimbursement, and they don't want to lose that influence. But Congress' fickleness has been part of the problem. I think permanent payment reform—including a transition away from fee for service—will ultimately come from this new independent Medicare commission.
I could have easily found five flaws with the Senate bill and written about those instead, and there was a time for that. The healthcare industry was right to poke holes in the legislation and fight for an ideal bill as it was being developed.
But that stage has passed. Despite a year of smothering cynicism, this bill is better than it gets credit for and more bipartisan than politicians will admit (in substance it is more conservative than what Presidents Bill Clinton or Richard Nixon proposed in the past). It should be viewed as a first step, rather than a final solution to the healthcare system's problems.
Now we're left with a choice between an imperfect bill and the status quo, for possibly several years. The last time reform failed it was more than a decade before it again became a priority, and it could be that long or longer if history repeats itself. Unfortunately, that's how politics works these days.
Despite the missed opportunities and flaws in the process, the healthcare reform debate at this point boils down to one question: Are we better off with the current system for the next three, eight, or 16 years?
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When presented with pay-for-performance metrics, clinical benchmarks, and other statistics about the care they provide, physicians typically react one of two ways.
Some bristle at the notion of being measured and quantified to such extremes. It feels bureaucratic and impersonal. It overlooks the compassion, energy, and knowledge that they pour into each patient encounter and represents the care they provide as a cheap set of numbers. These doctors see it as a hinderance, rather than a way to improve healthcare.
Other doctors, however, jump at the chance to find out how they measure up to their peers. The competitive instincts that got them into and out of medical school and residencies kick in, and they try to improve areas where they may be lagging behind the norms. They reach out to the top performers to learn from their successes.
Dean Health System in central Wisconsin hopes its physicians have the second reaction as it attempts to cut clinical wastes by benchmarking "any clinical indicator for which an evidence-based guideline or external comparison [is] available," says Craig E. Samitt, MD, MBA, Dean's president and CEO.
I spoke to Sammitt for this month's HealthLeaders magazine cover story about five remaining growth areas for the healthcare industry. Dean has already nearly exhausted the opportunities for cost savings in Lean-like administrative improvements, so now the organization is looking where many hospitals and practices will be looking to reduce costs in the future: clinical processes.
Whether healthcare reform passes or not, the long debate about how to curb escalating healthcare costs has shed light on just how important physician decisions—and the clinical process from start to finish—are to overall cost control. While reformers are trying to figure out how to bend the cost curve from the top down, Samitt says Dean is bending it at a local level by simply providing physicians with data and letting them adjust on their own.
Dean saved about $9 million in 2009 by benchmarking "admission rates for specific conditions, frequency of surgical intervention, length of stay for specific procedures, appropriateness of inpatient versus outpatient treatment, indications for imaging and lab testing, generic versus brand drug prescription, and so on."
And Dean did it despite the health system's compensation plan. Everyone seems to be singing the praises of physician employment these days, suggesting that it is perhaps the only way to align closely enough with physicians to cut deeply into clinical costs. But Dean has managed to cut clinical costs with roughly 98% of physician compensation based on productivity.
"We've found that when you benchmark information, when you produce and identify best practices and share information with doctors, in many areas the physicians want to do the right thing," Samitt says. "When you show the data, the performance changes."
This is not a new concept. And Dean Health isn't the first healthcare organization to save money by benchmarking clinical processes. But most healthcare organizations are only at the beginning stages of learning how to execute it. As more providers set up digital records and begin sharing information, the quality of data will only improve.
The key going forward will be to balance the concerns of the two types of doctors I mentioned earlier. It will take a lot of willing and eager physicians to systematically improve care and reduce the waste in the system. But the skeptics are also important. The more numbers added to the healthcare system, the closer it gets to medicine-by-the-numbers.
These types of programs will only be successful if they are designed to improve the physician-patient relationship, not replace it.
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It seems to be difficult—perhaps more difficult than it should be—to get an accurate estimate of how many physician offices are actually using electronic health record systems. The go-to survey during the last year or so, when the HITECH Act and healthcare reform were being drafted, has been a Harvard Medical School study from 2008, which reported that only 17% of office-based physicians were using EHRs.
But a recent National Ambulatory Care Survey, conducted by the National Center for Health Statistics, suggests that number was much higher in 2008—above 38%. Preliminary data for 2009 puts the overall adoption rate at 44%.
The discrepancy between the two estimates is pretty startling. The NACS reports that most of the decade's growth happened in 2007-2008, when usage of EHRs jumped 19%. Perhaps the data in the Harvard study lagged a bit and just missed a major shift in adoption.
As the industry is learning from the process of developing meaningful use standards for the HITECH Act, so much depends on how you measure and define an EHR system. Adoption rates will vary significantly depending on whether we're talking about a full-fledged system or a bare-bones electronic health record. Even in the NACS survey, only 4.4% of doctors reported having a "fully-functional" system.
So the overall adoption rate is somewhere between 4.4% and 44%, depending on how optimistic you want to be and which survey you use.
But the real takeaway from the latest survey isn't just the absolute adoption rate. It's the progress that has been made. In the last decade, using the NACS estimates, physician adoption has climbed from 19% to 44%. That's pretty impressive and contradicts a lot of the conventional wisdom about physicians' struggles.
There have been challenges. Electronic health record systems are expensive. Reimbursement has been stagnant or falling. Installing the systems can be disruptive, and some physicians still aren't convinced that they are worth it.
But despite all of that, physician practices are finding ways to move forward and prepare for the future of healthcare, and they are now in a position to receive $44,000 for their efforts.
Suddenly the HITECH Act's ambitious goal of near-widespread adoption by 2014 seems more achievable, even if the industry is still likely to fall short. There is certainly less ground to cover.
Many challenges remain, particularly for small and rural physician practices. But I'm convinced, particularly after these latest numbers, that physicians can overcome them. Roughly 44% of physicians have already started paving the way.
Even for those pessimistic about EHR adoption, the glass is nearly half full.
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