Physicians and Care
Medicine, or Doctors Controlling Their Own Destiny?
Nearly 7 out of
10 physicians consider themselves "anti-managed care", according
to a recent study.
Physicians tend to equate the old model of managed care (managing
costs rather than managing patient care) with overpaid MBAs who tell
them how to practice medicine, squeeze them for discounts, and
randomly throw them out of provider networks.
How do physicians feel about new approaches of care management?
Shouldn't they be wildly supportive? Studies are mounting that
disease management, medical management, demand management, and case
management improve patient outcomes, reduce hospitalizations, reduce
emergency room visits, and increase patient satisfaction. Care
management approaches fit well with most physicians' self-image of
"doctor as scientist" - "Show me the data, and I'll change the way I
The reality is that today doctors are mostly indifferent and often
hostile to care management initiatives.
What's going on here? Let's back up a step and examine two
aspects of health care conventional wisdom:
Conventional Wisdom #1: Today, physicians direct over 70% of
medical costs. When we make presentations to audiences, Tom often
asks the question "What is the SINGLE most expensive medical
instrument?" While some in the audience mull over whether they
think the answer is an MRI or a CAT scanner, he blares out that the
answer is "THIS PEN (holding up a pen) IN THE HANDS OF A DOCTOR."
The logic here is that 70%+ of medical costs must be prescribed,
i.e., authorized, by a physician. This includes hospital
admissions, lab tests, imaging tests, drugs, etc. (The 70%+ of
costs DIRECTED by physicians should not be confused with the 20% of
total medical costs that go TO physicians for their services. HCFA,
1998) In short, today physicians are the quarterbacks of the
medical team - they call the plays.
Conventional Wisdom #2: Tomorrow's evolving vision of the
health care system is "a seamless, integrated system of patient
care" in which patients flow to the right provider, at the right
time, for the right treatment, in the right setting, for the right
price. This vision of seamless care management is enabled by data
and technologies -- information systems, medical call centers,
the Internet, WebTVs, hand held devices to capture patient
So .consider these two aspects of conventional wisdom in tandem:
(1) Today's power of the doctor's pen, and (2) Tomorrow's seamless,
integrated system of care. How well do they fit together from
the doctor's point of view? NOT AT ALL! Physicians are
at risk of being disintermediated, or in plain old English (POE)
they stand to lose their role as quarterback of the team! We
shouldn't be surprised that they don't want that to happen.
We want to introduce the concept of a moment of truth in the
doctor/patient relationship. The moment of truth for care management
initiatives (and many other programs) often occurs in the privacy of
the doctor's exam room. Here's a common scenario:
"Doctor Jones, I've been offered an opportunity to participate in a
diabetes disease management program through my ______(employer, HMO,
pharmaceutical company, hospital). They say they do a great
job. What do you think?"
This is the moment of truth. This is the moment at which many
offerings will either sprout and thrive, or die unnoticed.
Will the doctor say "Great program, go for it," or will she say
"Terrible idea, forget it." Despite patients' mistrust of
doctors in general, trust levels for "my doctor" remain very high.
In our experience, few care management programs have planned for
this milestone moment.
There are 4 key motivational elements to getting doctors enthused
about care management approaches. These elements are:
(1) Improved patient care. "Will my patient get better
care?" (This is necessary, but NOT SUFFICIENT to motivate most
(2) Aligned financial incentives. "Will this program
help or hurt my pocketbook?"
(3) Convenience. "How will this new program or system
affect my day. Will it save or cost me time?"
(4) Control. "Can I continue to control my destiny? Will
I retain autonomy? Is all this another MBA telling me how to
Doctors could look at care management as an opportunity to guarantee
their role in the next generation of health care. Will
physicians seize the day? We are aware of a few physician
organizations that are developing this mindset!
That's your food for thought for now. In coming months we will
devote an occasional issue to each of these four elements and share
examples of organizations that have done a great job at one or more.
Can you guess which one just about everybody gets right? .the one
that hardly anybody is paying attention to?
We have been working with a private investor funded company that has
developed software to coordinate care for the highest cost patients.
In a typical health plan, 1% of patients account for 30% of health
care costs. The software links case managers, physicians, and
patients/families, thereby saving 8-15% of medical costs.
HOT OFF THE
Wired for Health and Well-Being: The Emergence of Interactive Health
Communication. U.S. Government Printing Office, April 1999.
SciPICH. While this 180 page report is oriented toward public
policy issues, it contains a wealth of valuable information.
E-CareManagement News is an
e-newsletter that tracks a major change in health care and managed
care—the paradigm shift from “managing cost” to “managing care”.
This e-newsletter is brought to you by Better Health Technologies,
LLC (http://www.bhtinfo.com) . BHT provides consulting and
business development services relating to disease management, demand
management, and patient health information technologies.