Today is the Healthcare Summit in Washington. There will be a great deal of discussion about efficiency, effectiveness and holding down the cost of health care. Money and time spent were also the topic of a JAMA article this week focused on declining physician work hours in concert with declining physician reimbursement over the past decade.(1) The key facts: 1. Average non-resident practicing physician’s work hours dropped from about 51 to 55 hours per week from 1996 to 2008. 2. The overall decrease in hours coincided with a 25 percent decline in pay for doctors’ services, adjusted for inflation.
Simplistic conclusion: Doctors are working less because they are not paid enough. That bias seeped through most reporting this week, with occasional challenges like this one from from Dr. Robert Perlmutter of Chicago, “”It’s not so much the fees as the hassle factor… There’s so much oversight for what we do, so many people we have to answer to and so little of it improves care, it’s just driving us all crazy.” (2,3,4,5)
So is money the root of this evil, or just along for the ride? If we were to increase physician reimbursement (averaging now $175,000 per year for a Primary Care physician and moving on up from there), would we get more and better access to doctors.(3) And what exactly does throwing more doctors or nurses or hospitals or tests into this antiquated broken system really buy us? More fix-us when we’re broken? More save-us from ourselves? More geographic variability and bias?
How should we advantage this study of physician work hour decline? Let’s start with a premise: Health professionals work is increasingly monetarized, routine, bureaucratic, unstimulating, depersonalized and gamed to prevent further erosion of base salaries. It has lost a great deal of its social context, much of its positioning in the community, and its relationship rich reward system. The work is delivered within a framework that both caring professionals and patients agree is antiquated and in many ways beyond repair.(6,7,8) It utilizes technology to cure, to save, to mend – but not to connect. It’s largely a one way street (in contrast to my boyhood years) – come to me and I’ll care for you, but I am incapable of coming to your home to return the favor.
Based on this premise, is the question how do we financially incentivize our caregivers to expand their hours of dissatisfaction, or how do we create a system for health care teams and patients filled with joy and pride and hope? If it is the later, based on clear signals of distress from this latest study, here are 10 actions I would like to see surface in today’s Presidential Summit that would transform our system:
1. Hospitals and specialty services should be right-sized based on volume and outcomes to eliminate excess capacity. Low volume, poor quality hospitals and specialty services should be eliminated . New rational and innovative community services should be provided based on defined need. Regionalization of in-patient services would require some patient travel but access to excellence would be facilitated, not impeded.
2. Healthcare should be redefined on both an individual and system wide basis as a strategic planning exercise.
3. Health consumers should be rewarded financially (through tax incentives or lower health premiums) for achieving health.
4. Our nation should move radically toward integrated health care team models and away from solo-practitioning with team leadership assumed by those with interest and training. Virtual information linkages should help bridge geographic barriers, giving all the capacity to join a team approach.
5. All current health care workers job descriptions, including physicians – both primary and specialty care should be redefined. Health professional workforce plans and training curricula should then be critically reexamined and adjusted as required. Standardized compensation, with team and individual rewards for keeping people well should become the norm. Debates about physician versus nurse, primary versus specialty should no longer be relevant. Skill set, interest, and capabilities should define one’s role on the team. All team members should be equally valued.
6. National health information standards should be mandated immediately to assure information compatibility, portability and privacy.
7. Health professional credentialing and licensing should be nationalized. Medical liability should be reformed and conform to national standards.
8. Universal coverage should be provided. In return, the roles and responsibilities of individuals, family, community and society should be clearly defined and financial incentives would be aligned to reward success.
9. The concept of the Electronic Medical Record (EMR) should immediately be supplanted by the Lifespan Planning Record (LPR), a 120 year, forward facing, consumer controlled online application designed to support personal, prospective, predictive and preventive health planning. Google, Microsoft, Apple, Intel, and other information innovators should be empowered and incentivized by the Federal Government to develop within one year this “killer application” and launch Version 1.0 as an open source free of charge offering downloadable online and embedded in all new computers. A specific accelerated timeline for national adoption should be put in place.
10. Recognizing that health is the ability to reach ones full human potential, the national goals and objectives of the health, energy, environmental, housing, transportation, education and military sectors should be full integrated in the pursuit of a healthy America.
Bottom line: An empowered and sensible vision like this would be fun to build out, and would be a great system within which health professional teams and patients could actively collaborate. At the end of the day, Mr. President and Members of Congress, it’s not about money or hours. It’s about a life well spent, making a difference, and caring for others who care about you.
For Health Commentary, I’m Mike Magee.
1. Douglas O. Staiger, PhD; David I. Auerbach, PhD; Peter I. Buerhaus, PhD, RN, Trends in the Work Hours of Physicians in the United States. JAMA. 2010;303(8):747-753 http://jama.ama-assn.org/cgi/content/abstract/303/8/747
2. Johnson CK. Washington Post/AP. Docs cut work hours as primary care shortage looms. Tuesday, February 23, 2010; http://www.washingtonpost.com/wp-dyn/content/article/2010/02/23/AR2010022303513.html
3. Wechsler P. Bloomberg Mobile. Hours Fall for a Decade, Adding to a U.S. Shortage. http://www.bloomberg.com/apps/news?pid=newsarchive&sid=a1tbL9.eTmrk
4. Roan S. The doctor is in – but not for long. LA Times. February 23, 2010. http://latimesblogs.latimes.com/booster_shots/2010/02/doctors-hours.html
5. Robeznieks A. Docs working fewer hours, study finds. ModernHealthcare.com. February 23, 2010. http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100223/NEWS/302239959/-1
6. Berwick DM. Escape Fire. December 9, 1999. 11th Annual National Forum on Quality Improvement in Health Care. Commonwealth Foundation. http://www.commonwealthfund.org/usr_doc/berwick_escapefire_563.pdf
7. Snyderman R. Yoedionno Z. Prospective Care: A personalized, preventive approach to care. Pharmacogenomics 7: 2006, (19) http://www.proventys.com/~/media/Proventys/Files/Publications/Prospective_Care-A_Personalized_Preventative_Approach_To_Medicine.ashx
8. Iglehart JK. Interview: Addressing Both Health And Health Care: An Interview With Steven A. Schroeder.2002. http://content.healthaffairs.org/cgi/content/full/21/6/244