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BlogRX - Taking the Pulse of the Healthcare Industry

Who will Lead the Reform of Healthcare?

Paul Convery, MD, MMM

The healthcare industry is on the verge of major reform, driven by unsustainable cost growth and increasingly restricted access to care and affordable insurance.  A fundamental concern is who will assume the leadership role in this reform effort.

Healthcare costs have grown faster than national income virtually every year for the past five decades, and have finally reached a tipping point.  The Milliman Medical Index shows that in 2017 the total cost of healthcare for a family of four covered by the average employer-sponsored PPO was almost $27,000, equal to approximately 46% of median family income.  Faced with rising healthcare costs, employers are shifting more of the costs to employees, restraining real wage growth and squeezing disposable income.  With almost 30% of the entire Federal budget already consumed by healthcare, there is little or no room for the Government to provide additional subsidies. 

The second driver of healthcare reform is lack of access, both to affordable insurance and to care outside of the emergency department.  The 2010 Affordable Care Act  addressed part of the insurance problem for some of the population, but still left millions uninsured, and more with increasing premium costs.  It completely failed to address the growing lack of access to physicians in many parts of the country for patients on Medicaid and Medicare.

The two political parties purport to address reform from opposite sides of the issue.  The Republicans propose repeal of Obamacare, Medicaid block grants and Medicare vouchers, all of which would potentially hold down cost at the expense of access. The Democrats’ trial balloon of Medicare-for-all would potentially improve access, but with no clear way of controlling costs. 

The unfortunate result is that physicians are stuck in the middle, trying to make the best of a fee-for-service system in which fees are capped or decreased, and where the only recourse is to work harder and increase the volume of services.  The result has been overwork, frustration and increasing burnout, with an alarming number of physicians reporting that they are planning to leave their practice. 

Given these challenging circumstances, it’s clear we must design new and innovative ways of caring for patients without destroying the morale of care givers.  This is where care delivery innovation come in.  Moreover, this innovation should be designed and led by physician leaders.  It’s important to recall that the three patient care innovations featured in the Affordable Care Act—the patient centered medical home, the accountable care organization and bundles of care—were not invented by the Federal Government, but by physician groups and health systems dealing with and responding to their changing environment. 

The leaders in the development of these innovations were physicians.  Not necessarily CEO’s or CMO’s, although some were, but physicians behaving as leaders who understood systems complexity, process improvement, adaptive change and their own role in forging the future.  These leadership skills and behaviors can be developed in the medical staff, and some leading healthcare organizations are doing just that.  However, the effort must be strategic and intentional; it will not happen on its own. 

Once healthcare organizations have sufficient numbers of practicing physicians who have mastered these leadership skills and are open to designing new, innovative ways of caring for patients, the frustration and lack of input that lead to burnout will be diminished.  Physicians want influence, to be acknowledged for their ideas and at the table when decisions are made.  Physicians want the sense of professional accomplishment that will come from their participation in the design of the care model of the future. 

A cautionary note to organizations that invest in developing physician leadership but then fail to offer opportunities for their participation in discussions about the future.  Physician leadership is not just a program but a strategy and a philosophy.  Offering a leadership program without subsequent meaningful physician inclusion will only add to cynicism.

Healthcare delivery of the future will look very different than that of the twentieth century.  That much is a certainty.  The question is whether it will be designed by politicians or by care givers.   When physicians begin to think of themselves as leaders in a complex changing system, real innovation and improved models of delivering care will result.  This way of thinking and behaving is not instinctual to most physicians, but it can be developed.  The time to start is now.