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The US healthcare system and reimbursement is undergoing a rapid evolution driven by the desire to cut cost and to quantify card delivery and improve "quality". Meanwhile, Physicians are suffering a rapid increase in burn-out, which many attribute to the loss of autonomy and ability to function as physicians without undue pressure from payer sources and employers.
The few physicians who are involved with government decision makers and insurers in devising the latest healthcare delivery system are buying into the notion that healthcare has to be centralized and controlled in order to achieve desired results. There is a disconnect between that and what physicians in the front lines really need to do their jobs and preserve what little autonomy they have left.
Even the phrase "physician autonomy" is now taboo in many circles as it may upset physician employers and those in power that advocate for more centralized approach to medicine.
Physicians have so many grips with the rapid healthcare system evolution, but as soon as we start tallying the many difficulties we face, our statements sounds like a rant and we are dismissed as outliers.
We are divided by political ideologies with some physicians still speak in term of free market vs single payer socialist approach. We forget that neither option truly exists in the United States. The single payer/healthcare as a human right is unlikely to happen during our life time, and with the advent of ACOs the concept of free market and broad patient choice is already history. On the HMO side, the tighter networks and the PA requirement for physician visits are now extended to inpatient setting where an insurer approves the hospitalization but not all physician visits ( WSJ Article in the subject) that are needed during the inpatient stay, and patients are saddled with bill.
The recent addition of MACRA has meant that primary care bonuses by CMS are gone and the quality measures based reimbursement is in effect. Not all quality measures are linked to physicians and the government is not using all the data it has to apply to physicians, instead it is relying solely on the meaningful use data which is still spotty and doesn't cover all physicians in a meaningful way.
Organizations representing physicians could play an important role in creating a nonpartisan cheat sheets or white papers to use to advocate for physician interests in state and federal levels with decision makers. Such documents can focus on shortcomings in the healthcare system (private and government based) that effect the work of physicians negatively and causing an unprecedented burn out and helplessness among physicians.
Actionable items--not a rant
Both left and right leaning physicians want more autonomy. One side from the government programs increasing centralized controlled and the other wants freedom from the overbearing PA requirements by HMOs and other private entities. This area can be a common cause if we focus on what physicians want and not get into a theoretical argument about which system is better.
Other actionable Items:
-As the healthcare system evolved the physician organization can push decision makers to trust physician based systems over criteria based system which is potentially more subject to abuse and has no ethical underpinning. A physician based system is also more in line with patient centered care.
-we can agree that data and collecting data in healthcare is a great modern development and is very useful, but this data needs to be used by physicians rather than regulators to force physicians to do what is "expected of them" by private or government payer sources. Government programs are more problematic in this area, as once a criteria or a quality measure is put in place it is extremely hard to modify it as our knowledge expands and our understanding of that quality measure evolves. A perfect example here is the pain quality measure which is still in place and is based solely on patient reporting, even as there is an evolution in the understanding of chronic pain management and need to reduce opiate use. The government and private insurance can collect the data and share it with physicians and the public, but we should ask that them not to set it in stone and use it to bribe or blackmail physicians to comply in order to get paid for the work they do.
information technology/EHR is a great addition to healthcare, but IT designers have been to quick to assume that they know what physicians need to do their job. The reality is that EHRs are designed more to force physicians to complete what's required of them with no regard to whether or not the EHR system is allowing them to do their jobs effectively and without decrease in productivity. We can encourage regulators and employers to out in resources to redesign flexible EHRs to meet individual physician needs to do their jobs.
Physicians should be allowed to compete on equal footing with their peers regardless of their employment status. This is becoming harder with recent changes in healthcare system as patients and patient referrals are becoming a commodity in healthcare, subject to be used to creat monopolies and semi-monopolies. The stark laws need to be updated to reflect this change in healthcare systems. There is no longer a fear of hospitals or nursing homes paying the physicians to send their own patients to the hospital or nursing homes. The greater fear is that non-physician referral power can exclude providers who are not willing to take certain reciprocal steps that benefit the referral source.
-Direct marketing to patients has now evolved to completely bypass physicians all together when it comes to Medicare approved equipments. The only time a physician gets involved with any sort of equipment requests by patients is to sign the paperwork prepared by the companies selling the products after they marketed the products directly to patients. This is an area where abuse potential is inherent. An example of that is diabetic shoes. Very little publicized fact is that CMS rules apply to every diabetic patient regardless of their functional status. As a result, wheelchair bound patients in nursing homes can get a new diabetic shoes on a yearly basis even if they never use them. Sellers set up clinics on an annual basis in facilities across the country and their point of contact is not the physicians, except to sign the forms that are prepared for them en mass. Some of us see this as an example of criteria based medicine gone mad.
What is wrong with physicians making requests for equipments for their patients as they need them? Why does CMS think they should replace that system with a criteria based system? The same system that easily gives millions of dollars annually for diabetic shoes that are rarely used, would balk at the notion of a physician filling out a request for diabetic shoes for non diabetics who may qualify for other clinical reasons. The result: frustrated physicians who feel that they have no voice and no say in their practice of medicine.
-"The customer is always right" notion should not be applied to medicine and physicians should not be punished for doing their job by anonymous online reviews that they can't respond to, and by a payment system that requires them to tell patients what they want to hear in order to get paid.
In short, advocates for physicians, such as physician organizations, can be very successful and achieve actual results if they focus on categories like the one mentioned above and advance the cause of physician rather that getting drawn into a partisan utopian discussion about the best model for healthcare. That is not to say that physicians can not say that they support whatever system that improves coverage and choice for their patients, but that's hardly a short term actionable item for physicians when our very ability to do our day to day work is threatened.
I am sure my colleagues would fill in many gaps in the statements in this document-It is not designed to be comprehensive, but rather a conversation starter.
