Many changes in pay­ment, prac­tice are only paving the road to fur­ther physi­cian dis­con­tent

Modern Healthcare - - COMMENT - By Ti­mothy Hoff

We live in chal­leng­ing times for physi­cians, who are re­quired to do things that are wear­ing them out and mak­ing them feel bad about their jobs.

Sur­veys show­ing large per­cent­ages of doc­tors burned out, dis­sat­is­fied with their work or re­gret­ting their ca­reer choice point to some­thing deeply psy­cho­log­i­cal that is hap­pen­ing to many doc­tors—some­thing that should make all of us very con­cerned.

The things hap­pen­ing to them are clear—their work is a daily tread­mill of trun­cated, rapid-fire pa­tient vis­its and cook­book medicine; they have too many ad­min­is­tra­tive and in­fra­struc­ture re­quire­ments placed un­der their re­spon­si­bil­ity; they must col­lect, doc­u­ment and re­port per­for­mance-re­lated minu­tiae; they have been forced to use in­for­ma­tion tech­nol­ogy in heavy-handed ways; they must lead “teams” while at the same time car­ing for in­di­vid­ual pa­tients on a full-time ba­sis; and they work un­der their em­ploy­ers’ as­sump­tion that they have to be watched to know if they are do­ing their job cor­rectly.

All of these dy­nam­ics are mag­ni­fied for the large num­ber of salaried em­ploy­ees work­ing in more-con­trol­ling cor­po­rate work set­tings.

Mak­ing things worse is the move to “value-based pay­ment” schemes, par­tic­u­larly through the re­cent Medi­care Ac­cess and CHIP Reau­tho­riza­tion Act rolled out late last year. If you spend hun­dreds of pages, as the MACRA fi­nal rule does, spell­ing out how some­one is go­ing to get paid, in this case physi­cians, don’t ex­pect that some­one to be­lieve that you have their best in­ter­ests at heart.

You also may want to read up on the sci­ence of hu­man mo­ti­va­tion. That sci­ence, and my own research and ob­ser­va­tions over time, show that most doc­tors are in­deed driven pri­mar­ily by in­trin­sic de­sires, i.e., things such as the per­sonal mean­ing in their work, strong in­ter­per­sonal re­la­tion­ships with pa­tients and the emo­tional re­wards they get from help­ing peo­ple. A sys­tem based on ex­trin­sic mo­ti­va­tors and ex­ter­nal over­sight, in­her­ent in MACRA and other pay-for-per­for­mance pro­grams, fur­ther erodes doc­tors’ abil­ity to pur­sue these in­trin­sic re­wards.

The healthcare sys­tem still can­not ac­knowl­edge that physi­cians are trained to be in­de­pen­dent, self-con­fi­dent de­ci­sion­mak­ers, of­ten asked to act in the midst of high clin­i­cal un­cer­tainty. The pay­ment schemes placed on them now clash with this re­al­ity, mostly by pro­duc­ing the daily work en­vi­ron­ments de­scribed above, as does be­com­ing salaried em­ploy­ees in or­ga­ni­za­tions that dic­tate work­flow and of­ten give physi­cians little col­lec­tive voice.

Mean­while, the mod­ern health qual­ity move­ment—with its non­stop assem­bly line of “in­no­va­tions” such as one-size-fits-all care guide­lines, overuse of “big data” and man­age­ment in­ter­ven­tions such as Lean tech­niques—works un­der the false as­sump­tion that healthcare de­liv­ery is just like build­ing cars on an assem­bly line or op­er­at­ing a ho­tel. It's not.

We are at a tip­ping point in bring­ing doc­tors back to the fold. We must avoid turn­ing wide swaths of pa­tient care into cheap­ened sets of low-level, su­per­fi­cial trans­ac­tions that now de­fine so much of our ev­ery­day world. Of course, we can’t go back to a pure “do more, get more” pay­ment sys­tem. And our sys­tem cer­tainly needs a recom­mit­ment to qual­ity and max­i­mum value for the healthcare dol­lar.

But the dan­ger with pay­ment sys­tems of­fer­ing in­cen­tives that over­sim­plify com­plex clin­i­cal work­flows, while con­vey­ing little sense of trust in doc­tors, is that they turn healthcare set­tings into places no one, in­clud­ing pa­tients, seems to en­joy be­ing in, which for a help­ing in­dus­try is sad. We will re­tire thou­sands of good, experienced doc­tors be­cause they don’t need to put up with things as they are. We will lose a gen­er­a­tion of younger doc­tors who see their work in less-pas­sion­ate ways, go­ing more for the pay­check or for a con­ve­nient life­style rather than for the joy of go­ing the ex­tra mile in their work and see­ing pa­tients ben­e­fit first­hand.

Much is needed to im­prove our healthcare sys­tem. Giv­ing physi­cians a bet­ter ev­ery­day ex­pe­ri­ence and mo­ti­vat­ing them cor­rectly should be moved quickly to­ward the top of that list.

Ti­mothy Hoff is a pro­fes­sor of man­age­ment, healthcare sys­tems and health pol­icy at North­east­ern Univer­sity in Bos­ton and a vis­it­ing as­so­ci­ate fel­low at Ox­ford Univer­sity.

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