Health care’s Holy Grail: Patient engagement

Consultant Leonard Kish likened the effect of patient engagement to that of a blockbuster drug. He cited a 2009 Kaiser study showing that coordinated cardiac care reduced the risk of dying of a cardiac-related cause by 88 percent within the first three months after a heart attack and overall mortality by 76 percent during the same time period.

“Can you imagine what the headlines would be if a new cardiac drug showed this kind of effectiveness?” he wrote.

Kish pointed out that patient and family engagement, which is part of Meaningful Use’s (MU) Stage 2, may be the hardest MU goal to achieve.

Defining patient engagement is elusive. The National eHealth Collaborative surveyed health-care organization leaders about it. Nearly all said it was important. But they could not agree on what it meant.

The most common description was offering patients resources to help them learn about their condition. Other descriptions involved face-to-face communication between physician and patient.

Patient activation and patient engagement are not synonymous. Patient activation encompasses the knowledge, skills and willingness to manage one’s own health and care. Patient engagement seeks to increase activation and promote healthy behavior.

One study found that patients with the lowest activation scores cost the health-care system 8 percent more in 2010 and 21 percent more in 2011 than patients who had the highest activation levels.

Being a compliant patient would seem to be a relatively easy task. However, a Kaiser Permanente researcher created a chart for a theoretical 67-year-old patient with diabetes, hypertension and high cholesterol and calculated what it would take to heed all medical recommendations. The final tally was more than 3,000 separate behaviors.

Better health outcomes and more years of healthy life require patient engagement. An activated patient consistently does what needs to be done to gain the greatest benefit from available health resources.

How many do this? Patients can be divided into thirds. One-third are engaged. Another third are tentative and inconsistent. The final third are disengaged. People with more education, income and self-confidence are more likely to be in the first group.

People who do not take charge of their health will fare poorly and be a drag on the performance of their health-care providers under accountable care.

Hospitals will be penalized if they do not provide a high level of patient-centered care. That means they must provide a comfortable, emotionally supportive environment. However, it also means patients will be encouraged to be involved in their own care. They will be asked to participate in decisions about their care and follow treatment plans so they are not readmitted needlessly.

Organized systems of care emerging from health reform, such as accountable care organizations (ACOs) and patient-centered medical homes (PCMHs), will be paid based on the health of their patients. That is a shared responsibility. Access to physicians increasingly will become difficult as the number of insured patients increases. Providers may end up “firing” patients if they are not compliant.

High-deductible health plans will be a central feature of the health-insurance exchanges established by the new law. An increasing number of companies will offer them – in some cases exclusively – as a means of controlling costs. These plans assume that engaged consumers will make wiser personal-health choices to minimize their out-of-pocket costs.

Engaged patients are not deterred by the complexity and fragmentation of the health-care system. They practice good health habits. They manage over-the-counter medications, minor wounds and injuries on their own. They collaborate with their providers and participate in making treatment decisions. They successfully navigate the health-care system, paying attention to provider quality and performance. They seek out reliable information on their own.

Ultimately, personal health requires self-care. Consider that physicians spend about two hours annually with their diabetic patients. Otherwise, those patients log an average of 8,758 hours a year managing the condition on their own.

Research consistently shows that engaged consumers have better health, make better choices and avoid medical errors. Engagement leads to better compliance with treatment, lower health-care costs and better-quality care. Patients do not have the power to change the health-care system. However, they do have the power to change their own care.

The disengaged are overwhelmed. They are less likely to have a usual source of care. They forget 40 to 80 percent of what the physician tells them in the exam room. Six out of 10 with employer-based insurance blame their disengagement on not knowing where to go for information. One in 4 Medicare beneficiaries are disengaged, and would “rather have someone else tell me what I need to do.” One in 3 of those who are uninsured are simply “not interested.”

Researcher Judith Hibbard has developed a way to measure this, called the Patient Activation Measure. The measure includes four stages to becoming a fully competent health-care consumer. She believes activation is constantly changing and subject to a range of flash points that encourage or discourage engagement. She suggests that providers start with the easiest behaviors to instill confidence and break those behaviors down into smaller steps.

The payoff is worth it. Hibbard found that highly activated patients have better care experiences and greater satisfaction than those with lower levels of activation—a critical point under MU rules.

The typical health consumer:

  • is able to perform simpler tasks such as making a list of medications, rather than more complex tasks such as participating in treatment decisions.
  • seeks out information about a provider or health plan but tends not to use it.
  • does not research health information until there is a specific need.
  • is quick to cite barriers to care, such as poor health, insufficient knowledge or lack of external support.
  • uses the Internet to learn about a condition or symptoms, but it is less clear whether the newly gained knowledge changes behavior.

Physicians don’t get paid to counsel patients, with predictable results

Counseling of patients by physicians can have an impact on health behaviors, but it happens infrequently. The average 15-minute doctor-patient encounter does not leave much time for discussion. Doctors also do not think they are very good at it. According to a survey, less than half felt competent prescribing specific diet regimens because they believed they had been inadequately trained.

The lack of reimbursement by insurers for weight-loss counseling and confidence yields predictable results. Only about one-third of obese patients are advised by their doctors to lose weight. That proportion rises to about one-half only if the obesity has created some other medical conditions. Physicians offer to help about 1 out of 4 smokers with tobacco-cessation strategies.

Doctors also lack faith that patients will change their habits. Who could blame them? Barely 1 in 10 diabetics follow dietary guidelines limiting saturated fat. About 18 percent of heart-disease patients continue to smoke, which is not much better than the overall smoking rate.

A doctor’s pep talk at the end of the visit does not accomplish much. Success requires a joint action plan and a commitment to follow up. In one study, physicians counseled inactive patients to exercise and had a staff member call two weeks later to monitor progress. Those patients walked five times more than those who were not counseled and monitored.

The American Heart Association advises physicians to use this sort of approach to lower the risk of heart disease. The organization reviewed a decade of research to determine what works best. Joint goal setting, physician feedback and monitoring topped the list. Self-monitoring, such as food diaries, also helps. However, clinical initiatives are employed infrequently because they are time-consuming and insurance companies generally will not pay for them.

It does not help matters that Americans are in denial about their health. In a poll by The Atlantic, 9 out of 10 Americans said they were in “very good” or “somewhat good” health. Only 1 percent said they were unsure about their health status.

Yet more than 1 out of 3 Americans are obese, and about 1 out of 10 have a chronic condition such as high blood pressure or diabetes.

Baby boomers are in worse health than their parents were at the same age. They are more obese; have more diabetes, high blood pressure and high cholesterol; get less exercise; and are more likely to use a cane or walker.

A 2009 poll of 2,000 Americans by GE Healthcare, the Cleveland Clinic and Ochsner Health System captured the gap between belief and reality. More than half the respondents said the population’s health “was going in the wrong direction,” compared with 17 percent who characterized their own health that way.

Only one-quarter to one-third knew their personal basic health numbers – body-mass index, blood pressure, cholesterol, blood glucose level – yet the majority said keeping those numbers in a good range was important to good health.

About 95 percent said regular physician checkups were important, but 70 percent admitted avoiding their doctors by hoping health problems would go away or asking a friend for medical advice.

Pollsters asked respondents to grade their health behaviors, and asked doctors to do the same for their patients. One out of three gave themselves an “A” for nutrition, exercise and personal health management. More than 90 percent graded patients “C” or worse on these.

High-deductible health plan patients use less health care

Physician visits and prescription drug use dropped among workers who had high-deductible health plans with health savings accounts, according to a Health Affairs study.

The study compared health-care costs for two Midwestern companies between 2006 and 2010. One of the companies converted its workforce to a HDHP with a health savings option in January 2007. The other company did not.

Routine cancer screening among those on the HDHP initially fell, and then rebounded by the third year. However, emergency-department visits rose during the third year. Hospitalizations remained the same.

The decline in preventive care suggests that health insurers must “design plans to incentivize primary care and prevention and educate members about what the plan covers,” the authors said.

Access to care is hindered either by the inability to afford care or the lack of opportunity for timely care. Regardless of the reason, 1 out of 5 Americans had unmet medical needs in 2010, compared with 1 out of 6 in 2000.

 For several years, the Kaiser Family Foundation has been tracking Americans’ health–care utilization. In a 2012 survey, more than 1 out of 3 relied on self-help remedies and over-the-counter drops, and cut back dental care.

People with HDHPs generally use less health care. They usually use self-diagnosis, followed by self-rationing. They generally cut back equally on unnecessary and necessary care. Patients tend to give less weight to future health than to present costs.

A 2011 RAND study showed that most HDHP enrollees cut back on care regardless of their income or health.

People on Medicare are especially sensitive to greater cost-sharing, even to increases of just a few dollars. One study of health plans that raised copayments by less than $10 for physician visits showed a dramatic impact – which ultimately led to more costly care later on. For every 100 people who had to pay more, there were 20 fewer doctor visits, two additional hospitalizations and 13 more days in the hospital the following year. Unlike the younger participants in the 1970s RAND study, Medicare beneficiaries have far more chronic conditions that can flare up without consistent care.

The long-term effects of cutting back are unknown. However, forgone care can lead to greater complications. For example, high cost-sharing causes those with newly diagnosed chronic conditions to delay filling their prescriptions.

Some companies are employing a strategy called value-based insurance design. The format varies the degree of cost-sharing with employees based on the scientific evidence of a drug’s or procedure’s effectiveness. For example, Pitney Bowes reduced the copayments for several medications that treat conditions such as diabetes, high blood pressure and asthma. The company’s higher pharmacy costs were offset by fewer emergency department visits and avoidable hospitalizations.

A 2007 study concluded that the optimal copayment for cholesterol-lowering medication was $0 or even negative – meaning patients should be paid to take the drugs, in order to lower overall costs.

Health-insurance companies have enjoyed record profits, because patients are seeking less care than anticipated as premiums and deductibles have continued to rise. It is hard to know whether this is a temporary lull or the new normal in health-care use.

What is puzzling is that HDHPs also prompt patients to cut back on preventive care, even when it is free. This suggests either they did not understand that their policies paid for the services completely, or they are leery of the health-care system generally.  They also may fear that the doctor will find something wrong that will result in costly treatment.

HDHPs work well for a significant percentage of the population. However, they will do little to hold down national health costs, because a small percentage of consumers account for a large percentage of those costs. The healthiest 50 percent of Americans each spend about $250 a year on health care. Treating the sickest 5 percent costs more than $43,000 a year apiece.  Even an HDHP would not make a dent in costs for these patients. Once the deductible has been met, the incentive to minimize health-care costs often subsidies.

The harsh reality of HDHPs is that 8 out of 10 families earning about $52,000 do not save enough to cover the deductible. More than 40 percent of adults with HDHPs spent 10 percent or more of their income on household medical expenses – a threshold many consider a financial burden on the average family.

Health savings accounts are meant to be an incentive to set aside money to pay for future medical expenses. However, many have difficulty saving for retirement or even vacations – both more pleasant prospects and worthy goals. If people cannot do that, it is unlikely they will save for an unpleasant circumstance such as an unforeseen bout with cancer.

A 2008 consumer survey delivered one of the most depressing commentaries on the American health-care system: People were more concerned about the prospect of paying for the treatment of an illness than about the illness itself.

Cutting Medicare rates to physicians could doom the program

Commercial health plans are difficult to deal with, but at least they represent revenue that is not subject to annual legislated reduction.

The average physician practice relies on Medicare for about 25 percent of its revenue. That revenue source is at risk every year because of the Sustainable Growth Rate (SGR), established in 1997 to keep Medicare from growing faster than the overall economy. The SGR formula factored in the rising number of people on Medicare. However, the per-beneficiary costs charged by providers rose at a faster rate than the economy. When that happens, the federal government is supposed to cut payments across the board to control costs. Every year since 2002, Congress has blocked these cuts. The proposed cumulative rate cut to satisfy the SGR was scheduled to be 24.7 percent in January 2014 if Congress did not step in again.

According to CMS actuaries, that cut would drop Medicare pay rates to 61 percent of what private insurers pay for the same services, and even drop below those of Medicaid. Rates are scheduled to drop further until, in 2050, Medicare falls below 40 percent of what private insurers pay. The actuaries  acknowledge it is unlikely that Congress would allow this scenario to play out. The annual threat of a proposed rate cut will continue until Congress fixes the formula.

Congress has overridden the SGR-mandated cuts a dozen times, substituting either pay freezes or small pay increases. The price tag for freezing physician rates has dropped significantly because of declines in health-care spending growth. According to a 2013 CBO report, the estimated 10-year cost  of repealing the SGR and freezing Medicare payments to physicians would be $116.5 billion, compared with the previous estimate of $244 billion.

Nevertheless, four former Medicare administrators told a Senate committee hearing in May 2012 that the SGR must be replaced.

The American Medical Association (AMA) and more than 100 state and specialty medical societies issued a set of principles in October 2012 that they said could support a transition from the SGR to “a higher-performing Medicare program.” They urged a plan that would allow physicians to choose their own payment models, eschewed penalties and allowed physicians to demonstrate that they are taking accountability for quality and cost control.

In October 2013, the Medicare Payment Advisory Commission (MedPAC) recommended eliminating the SGR formula by cutting fees for some specialists and imposing a 10-year freeze on rates for primary-care physicians. Predictably, the proposal was strongly opposed by health industry groups and the AMA.

Reps. Allyson Schwartz, D-Pa., and Joe Heck, R-Nev., an osteopathic physician, reintroduced legislation in February 2013 to repeal the SGR, increase payments to physicians for four years and test new payment and delivery models.

Alternatively, House Republican leaders have urged an SGR repeal plan that would freeze physician payment rates for the next decade, with future increases based on physicians’ quality and efficiency of care.

Health-care industry groups urged Congress to use projected Iraqi and Afghanistan war savings to repeal the SGR.

In its 2013 annual report, MedPAC said, “The SGR formula may have resulted in lower (reimbursement updates, but it has failed to restrain volume growth; in fact, for some specialties the formula may have exacerbated growth. In addition, the temporary increases, or ‘fixes,’ to override the SGR formula are undermining the credibility of Medicare by engendering uncertainty and frustration among providers, which may be causing anxiety among beneficiaries.”

Nearly all lawmakers want to repeal the SGR, but no one is willing to add to the federal deficit to accomplish that. The result is zombie public policy that annually creates anxiety in the provider community and offers another opportunity to heap scorn on Congress for burying its head in the sand.

The indecisiveness over the SGR has cost physicians dearly. Over the past decade, the cost of providing care has increased five times faster than Medicare reimbursement. Medicare patients require far more complex and time-consuming care for about 60 percent less reimbursement, compared with commercial insurance rates.

Forty-five percent of physicians say they would stop seeing Medicare patients if Congress enacts the Medicare physician rate cuts.

Despite current challenges, 82 percent of respondents said they would be willing to explore new payment and delivery models if a level of stability were restored to the Medicare physician-payment system, according to a Medical Group Management Association (MGMA) survey.

About 60 percent said they have delayed buying new facilities and equipment in the past decade because of the annual SGR uncertainty.

The uncertainty over that looming SGR rate cut was the No. 1 concern for physician practice managers, according to an MGMA survey.

Each time SGR cuts are scheduled for a congressional vote, the nation’s physicians become nervous and threaten to pull out of the program. According to the Texas Medical Association (TMA) website: “This decade-long and continued uncertainty is forcing some physicians to make a difficult decision to either opt out of Medicare, limit the number of patients they treat, or retire early. A TMA survey (from August 2011) indicates 50 percent of Texas physicians are considering opting out of the Medicare program altogether.”

So far, only about 1 percent of the nation’s physicians have opted out of Medicare, according to a Department of Health and Human Services Office of Inspector General (OIG) report. The OIG said it could not determine why these physicians are leaving the program and urged CMS to strengthen its data requirements to track opt-outs.


Patients seeing physicians less often

Census data bear out what physicians already know: Patients were visiting them less frequently than 10 years ago. In 2010, adults age 18 to 64 made an average of 3.9 visits per person, compared with 4.8 visits in 2001. The U.S. uninsured rate rose during that period, from 17 percent to nearly 22 percent. Only 1 out of 4 uninsured people went to the doctor in 2010, compared with nearly 3 out of 4 of the general population of working adults.

However, physician visits rose 4.8 percent in the second quarter of 2012 compared with the same quarter in 2011, which reversed a two-year decline. Nearly every health insurer reported lower earnings during that quarter. Humana said in its quarterly report that more of its members were seeking care—and more of it—because they had put off going to the doctor during the economic downturn. It said wellness visits were up 200 percent over the previous year, and routine physician visits were up by 22 percent. The first-dollar coverage of preventive care also was a fueling factor.

Rising insurance premium costs for 2014 because of the ACA’s ban on pre-existing condition underwriting and more comprehensive policies—combined with rapidly growing high-deductible insurance plans—may short-circuit the rebound in physician visits.

Even so, any rebound is welcome. Physician-office visits had declined 4.7 percent in 2011 and 4.2 percent in 2010, and had declined in four of the previous five years.

A Stanford University analysis for the Kaiser Family Foundation found a 17 percent decline in office visits between 2009 and 2011. Office visits had risen from 140 million to 160 million between 2000 and 2005 and held at that rate until the start of the recession in late 2007.  The rate dropped below 130 million visits in the second quarter of 2011.

More than 9 million people lost health insurance coverage during the recession. Fewer than half of unemployed adults had health insurance, compared with more than 81 percent of employed adults. Unemployed adults have poorer mental and physical health, yet they are less likely to receive needed medical care, because of cost.

Even people with private insurance have been cutting back on routine care. Rising deductibles and copayments make people more reluctant to seek care, even if they have chronic conditions. Employees with high-deductible health plans are 3 to 4 times more likely to delay or forgo care, compared with those in more traditional plans.

The share of employees with an annual deductible of at least $1,000 grew from 18 percent in 2008 to 31 percent to 2011.

Fewer office visits also helped slow prescription drug spending. The number of prescriptions filled grew only 1.2 percent in 2012.

Employers held health-benefit cost growth to 4.1 percent in 2012, which was the lowest in 15 years. They have stepped up cost management in anticipation of added cost pressures from health reform. Many health-reform opponents expected more businesses to stop offering  health insurance. According to business consultant Mercer, that number actually rose slightly in 2012.

Experts say there are too little data to determine whether the slower increase in health-care spending is permanent or a temporary function of the weak economy.

Harvard economist David Cutler told The New York Times, “The recession just doesn’t account for the numbers we’re seeing. I think there’s much more going on.”

Economist Gail Wilensky, who headed the CMS under President George W. Bush, said, “If there’s something else going on, we don’t know what it is yet. The most honest thing to say is that, one, the reduction in use is greater than the recession predicts; two, we don’t understand why yet; and three,  you’d be foolhardy to say that we can understand it.”


Younger physicians prefer to ‘have a life’

Baby boomer physicians often deride the fact that newly minted doctors want lives that are more balanced. Many older physicians still work Welby-style 70-to-80-hour weeks. White men dominated the profession in the 1970s. Fewer than 8 percent of physicians were women. Women now make up about half of incoming medical school classes. Research shows that they work fewer hours, largely because of family obligations.

Ripley Hollister, Colorado family physician and Physicians Foundation board member, said: “The older ones are being pushed out (of the system). Many are pissed off and leaving. They have a different view of medicine than the new ones. Being a doctor defined who they were. It was their purpose in life. Younger doctors work maybe 40 hours a week. They see it more as employment than a profession. They have a different view about quality of life. They won’t be quite the workforce (in quantity of hours).”

Darrell Kirch, president of the Association of American Medical Colleges, believes that new physicians have a more expansive view of medicine and life, and considers that a positive development.

“I see no evidence that indicates that their ethical commitment is any weaker, that they care any less for patients,” he told the Associated Press.

New Hampshire physician and Dartmouth Medical School professor Robert Wortmann wrote: “It’s a bit unfair to consider Generation X physicians to be unprofessional. Times change and so does our profession. Marcus Welby did not have a working wife, a computer, a preauthorization clerk in his office, or a utilization review committee in his hospital. When he started practice, there were only two nonsteroidal anti-inflammatory drugs available, and hypertension was not treated until it became symptomatic. Few hospitals had coronary-care units. Compared with today’s environment, he had so few tools to work with that his most valuable patient care resource was his time.”

In some ways, Welby was the predecessor of a concierge physician. He was available 24/7 and would spend as much time as the patient needed. Welby, of course, did not get a monthly retainer fee. In fact, he was quick to provide uncompensated care.

The spirit of Marcus Welby lives in today’s physicians. However, his business model is swiftly disappearing from the American landscape. Welby’s practice style could not survive financially in today’s medical culture: having to see one patient every 15 minutes to keep the practice open; seeking insurance preauthorization for treatment; and being office-bound.


How would Marcus Welby, M.D., fare today?

A 30-ish public-relations executive representing a large, modern physician practice was shaking her head in puzzlement.

Her physician client liked to talk about how his practice was not “a Marcus Welby shop,” meaning that its approach and technology reflected the best the 21st century had to offer.

As she walked a visitor toward the office-building exit, she confided, “He keeps talking about this Marcus Welby. I think it’s someone he went to business school with.”

Marcus Welby, the iconic primary care physician who treated patients with inexhaustible kindness and compassion, was at or near the top of the television network ratings and a staple of ABC’s lineup from 1969 to 1976. Marcus Welby, M.D., rose to No. 1 in the Nielsen ratings in its second season, viewed regularly in about 1 out of 4 American homes. Stars Robert Young (Welby) and James Brolin, who played partner Steven Kiley, won Emmy Awards in 1971, and Young won a Golden Globe in 1972.

Predictably, most diseases could be cured within the show’s hourlong time slot. If not, Welby would at least ease the patient’s emotional burden. Young received thousands of letters from fans asking for advice on medical or personal problems.

There was some debate at the time about whether Welby’s image was good for U.S. physicians. Welby could not have been a more positive face for American medicine. However, some doctors were concerned that his tireless customer service and patient bedside manner would lead to unrealistic expectations from patients. Some even believed that Welby contributed to the rise in malpractice lawsuits.

Dr. Don McCanne, a senior health policy fellow at Physicians for a National Health Program, wrote a 2011 blog post titled, “How would Marcus Welby, M.D., fare in an ACO?”

The broader question is whether Welby would be able to function effectively under today’s government regulation and insurance bureaucracy. Welby and Kiley had one nurse/receptionist. It is no wonder that they could spend so much time with the patients. The pair comprised the ultimate patient-centered medical home—no need for National Committee for Quality Assurance certification.

During the show’s run in the late 1960s and early 1970s, physician payment from Medicare was based on a system of customary, prevailing and reasonable charges. From the mid-1970s through the mid-1980s, government implemented a series of cost controls. Nearly half of medical bills were paid out of pocket by commercially insured patients, compared with less than 10 percent today.

The appeal of primary care as a career seemed endless at the time. During the show’s final season in 1976, a Department of Health, Education and Welfare advisory committee predicted a surplus of 145,000 primary-care physicians by 2000.

 It did not work out that way. In a 2005 survey of U.S. med school seniors, half considered limits on income and lifestyle as serious obstacles to entering a primary care practice. However, the No. 1 deterrent, respondents said, was the lack of positive role models or mentors. There were no more Marcus Welbys. Instead, about 3 out of 4 physicians between age 50 and 65 said medicine was increasingly unsatisfying, according to a 2004 survey.

Physician recruiter Merritt Hawkins CEO Mark Smith testified before a U.S. House subcommittee in July 2012 on the decline of solo physician practices.

“Virtually no one wants to be Marcus Welby anymore,” Smith said. He said small physician practices face five major barriers: flat or declining reimbursement; increasing regulatory and administrative paperwork; increasing malpractice insurance costs; health information-technology mandates; and the effects of health-delivery reform. A 2011 survey of final-year medical residents found that only 1 percent wanted to work as solo practitioners like Welby. Only 2 percent of Merritt Hawkins job searches involved recruitment of solo practitioners in 2011, down from 17 percent five years previously.

Said Phillip Miller, Merritt Hawkins vice president of communications, of solo practitioners: “No one is looking for one. No one wants to be one.”

In 1973, only 15 percent of physicians voiced regret about their career choice—and Welby certainly embodied that sense of certainty. By 2002, more than half of physicians over 50 years old said they would not choose medicine as a career again.

Welby always seemed suspicious of specialists, so it is questionable how skilled he would have been at care coordination. However, even he moved his practice to a hospital toward the end of the show’s run.


Obamacare may be the last exit before universal health care

Declaring a full-scale revamping of health-care quality and population health while lowering costs is a daunting task. That tension is highlighted by what Yale University professor William Kissick calls “the iron triangle” of health care: quality, cost and access. Each component competes for resources at the expense of the others. Costs can be cut but, if that is done unwisely, quality and access suffer. Access can be broadened, but it inevitably will cost more and may harm quality. Improving quality also likely will cost more and may restrict access.

 Put differently, it is a version of the project management triangle: cheap, good, fast …pick two.

There is a growing sense that, regardless of the implementation of the ACA, the U.S. is running out of time to deal with the pernicious nature of health-care costs. They are approaching 20 percent of the U.S. economy—crowding out other government priorities, diminishing workers’ wages, businesses’ profits and household savings.

There is no shortage of proposed solutions to this mess. Physician Harvey Fineberg, IOM president, compiled an outstanding laundry list in a 2011 lecture at the Massachusetts Medical Society: “single-payer system, an all-payer system, increased competition, reduced fragmentation, a change in physician payments, technology assessment, information technology, increased oversight, decreased regulation, malpractice reform, consumer choice, patient-centered care, systems to ensure patient safety and increase quality, lean design principles of production, systems engineering, managed care, educational reform and a new professionalism.”

Most practitioners and policy wonks have heard each of these ideas proffered at one time or another as silver-bullet answers to health care’s inefficiency or ineffectiveness.

Bruce Vladeck, former administrator under President Clinton for what is now the Centers for Medicare and Medicaid Services, wrote about the false hope of managed care in the 1990s. He said the myopia that surrounds a transcendent idea begins when a “modestly successful innovation is hyped as the unique and unitary solution to some complex, persistent problem.”

Urban Institute fellow Dr. Robert Berenson and colleagues, attempting to dampen what they considered unrealistic expectations about the immediate potential of patient-centered medical homes, said, “It would not be the first time a promising policy idea was judged a failure because of premature promotion.”

Yale Professor Emeritus Theodore Marmor and University of North Carolina Professor Jonathan Oberlander are even blunter about these seemingly simple solutions: “The United States has been singularly unsuccessful at controlling health-care spending. During the past four decades, American policymakers and analysts have embraced an ever-changing array of panaceas to control costs, including managed care, consumer-directed health care, and most recently, delivery system reform and value-based purchasing.

“Past panaceas have gone through a cycle of excessive hope followed by disappointment at their failure to rein in medical-care spending… [A]ccountable care organizations, medical homes, and similar ideas in vogue today could repeat this pattern… [T]he United States persistently pursues health policy fads—despite their poor record—and the promotion of panaceas obscures critical debate about controlling health-care costs. Americans spend too much time on the quest for the ‘holy grail’—a reform that will decisively curtail spending while simultaneously improving quality of care—and too little time learning from the experiences of others. Reliable cost control does not, contrary to conventional wisdom, require fundamental delivery system reform or an end to fee-for-service payment. It does require the U.S. to emulate the lessons of other nations that have been more successful at limiting spending through budgeting, system-wide fee schedules, and concentrated purchasing.”

They conclude that “the American quest for cost-control fads hasn’t worked—which helps explain why the U.S. keeps searching for more panaceas.”

Physicians burning out at an alarming rate

Physicians have to fight for every dollar. Plumbers and attorneys do not have to call a third party to verify that they will be paid when they fix leaky faucets or draw up wills. Primary-care physicians’ share of the U.S. health-care dollar is only 7 cents. If payers cut reimbursement for physician services by 25 percent, the average annual rate of medical inflation would only decrease to 5.7 percent from 6.2 percent. However, primary-care doctors control 80 cents of the health-care dollar by sending their patients to hospitals, referring them to specialists and handing out prescriptions.

 This outsize influence extends to patient perceptions. Nurses, pharmacists and physicians annually occupy the top three spots in the annual Gallup survey of how Americans gauge honesty and ethics among professions. Gallup has polled on public trust in professionals since 1976. In its 2012 survey, nurses scored the highest, at 85 percent on “honesty and ethical standards,” followed by pharmacists at 80 percent and physicians at 70 percent.

More than 3 out of 4 Americans say their physicians put patients’ interests ahead of their own, according to a Kaiser Family Foundation poll.

About 4 out of 10 Americans say they are confident in the U.S. health-care system, but more than 8 out of 10 say the health care they receive personally is good or excellent. Physicians are seen as heroes who help people when they are sick, not as cogs in an impersonal economic sector.


Cardiologist Rick Snyder, former president of the Dallas County Medical Society, says physicians do not advocate on their own behalf and fail to use their considerable influence.

“By being an advocate you can treat a whole state or country, not just one patient,” Snyder said. “What are the most credible professions? Nurses and doctors. (Republican pollster) Frank Luntz once said, ‘You doctors are God and the law.’ “

Stanford University professors Victor Fuchs and Arnold Milstein agree. They wrote in the New England Journal of Medicine, “…Physicians are the most influential element in health care. The public’s trust in them makes physicians the only plausible catalyst of policies to accelerate diffusion of cost-effective care. Are U.S. physicians sufficiently visionary, public-minded and well led to respond to this national fiscal and ethical imperative?”

Unfortunately, the annual battle to avoid reimbursement cuts because of Medicare’s sustainable growth rate has absorbed physicians’ attention in the political arena. All other issues pale by comparison.

Only 15 percent of U.S. primary-care physicians believe the nation’s health-care system works well. More than half are frustrated by the difficulty many of their patients face in paying for care.

Burnout is pervasive

According to a large study in 2012, nearly half of U.S. physicians struggle with job burnout. They said they either were emotionally exhausted or felt a high degree of cynicism or “depersonalization” toward their patients.

The researchers used a questionnaire called the Maslach Burnout Inventory, considered the best measure of job burnout. Burnout was especially prevalent among physicians on the front lines of medicine, such as those who staff emergency rooms or family practices.

On average, physicians worked about 10 hours a week more than other professionals—50 hours vs. the standard 40—and more than 1 out of 3 worked more than 60 hours a week. More than 4 out of 10 expressed dissatisfaction with their work-life balance, almost double the rate of non-physicians.

The study’s authors struck this disheartening note: “Unfortunately, little evidence exists about how to address this problem. Policymakers and health-care organizations must address the problem of burnout for the sake of physicians and their patients.”

A separate survey found that 86 percent of physicians are moderately to severely stressed. Respondents said their top four stress factors were the economy, health-care reform, Medicare and Medicaid policies, and patients without the means to pay for their care.

Physicians have the highest suicide rate of any profession, for distinctive reasons. Non-physicians are more likely to have had a specific traumatic event, such as a personal crisis or death of a loved one. Physicians are more likely to have on-the-job stress or a specific professional problem. They also are less likely to undergo mental-health treatment.

A study of surgeons with work-home conflicts found they were more likely to fall prey to alcohol abuse and depression because of poor work-life balance. The average surgeon works 60 hours a week, spends 16 of those hours in the operating room and is on call two nights a week. About half who reported work-life conflicts showed signs of depression while more than 1 out of 6 of those showed signs of alcohol abuse or dependency.

Physician burnout starts early. Nearly half of medical students become burned out during their training. Students are overworked, fearful of making mistakes and encouraged to tamp down emotions such as grief and self-doubt.

It is troubling that the nation’s health is in the hands of a profession that displays such pervasive signs of disaffection, disenfranchisement and hopelessness.

Even young physicians exhibit a high degree of pessimism. An April 2012  Physicians Foundation survey of physicians under 40 found that more than half were pessimistic about the future of the U.S. health-care system, while 22 percent were optimistic.

Those physicians who are satisfied with their profession tend to display an evangelist’s zeal for practicing medicine, and enjoy addressing conditions such as obesity and nicotine or alcohol dependence. Their empathy also translates into better patient outcomes. Academic Medicine researchers used a Jefferson Scale of Empathy (JSE), designed in 2001 to measure empathy in a medical setting. They found a direct association between a positive physician JSE score and better control of patients’ hemoglobin A1c and cholesterol levels.

Pure and simple, physician satisfaction translates into better patient health.


A survey of hospital executives and practice managers by physician recruiting firm Merritt Hawkins underscores the sharp contrast in the outlook of health-care executives compared with that of physicians. Merritt Hawkins surveyed U.S. physicians for the Physicians Foundation in 2012.

  • More than 9 out of 10 executives say they feel positive about being in health-care management, compared with 1 out of 3 physicians who say they feel positive about being in medicine.
  • Nearly 9 out of 10 executives say their morale is positive and they would recommend health-care management as a career, compared with about 4 out of 10 physicians who would make such a recommendation.

Travis Singleton, a Merritt Hawkins’ senior vice president, said in a statement, “For health-care facility managers, the glass appears to be half full. For physicians, it appears to be half empty.”


According to a survey by locum tenens staffing firm Staff Care, virtually all nurse practitioners said they had positive feelings about being an N.P., and 98 percent said they were optimistic about the future of their profession. In the Physicians Foundation survey, only 13 percent of physicians felt optimistic about the future of medicine.

Marcus Welby took joy in his work.  But he also did not face the obstacles and pressures today’s physicians must endure.