The U.S. healthcare system is shifting dramatically, and for hospital executives and physician leaders, there are not many certainties they can hang their coats on.
How should bundled payments work? Who should be reporting to whom? Is evidence-based medicine the best way to reduce variation? Will EHRs limit physician decision-making? On occasion, this could lead to tension-producing arguments and unwanted conflicts.
However, there is one "given" within this evolving system with which many would agree: Professional relationships need to be renegotiated. Hospitals and physicians can no longer consider themselves to be completely autonomous beings — they both need each other to coordinate care and, eventually, handle reimbursements.
Barry Dorn, MD, associate director of the Program on Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health, and Eric McNulty, senior editorial associate of the same program, are co-authors of the book, Renegotiating Health Care: Resolving Conflict to Build Collaboration, along with their colleague, Leonard Marcus, PhD. They explain there are two areas, among many, within hospitals and health systems where significant conflicts are arising — new business models and the elevated use of analytics — but hospital leaders can resolve those conflicts through the right collaborative approaches and strategies with physicians.
Bundled payments and shared savings strategies are starting to turn from theory to practice, especially within accountable care organizations. Dr. Dorn says decades ago, practicing medicine was more about the Hippocratic Oath — the promise to practice medicine ethically and to keep patients' best interests in mind. Now, physicians have to think about how much their care is costing, and that's a fundamentally different mindset.
"I started in medicine in 1967," Dr. Dorn says. "In that time, and for many years, the model was a one-on-one relationship between physician and patient. A patient would come into the office, and physicians would evaluate and do everything to diagnose and treat [them]. I wouldn't think about what the costs were. Now, when patients present themselves to physicians, physicians have to think of a greater population. What resources I am willing to expend versus what resources do I have to treat entire population?"
Many physicians may not want to switch to that kind of mindset, which leads to internal conflicts. In addition, some hospital leaders have to deal with balancing relationships between physicians and physician extenders. While many physicians are happy physician extenders are able to help out, which allows them to focus on more severe cases, others may not be used to the different roles and the values associated with them. "Part of what is happening is this shift of work from physicians to [physician assistants] or to nurses," Mr. McNulty says. "But now it's a matter of who gets paid for what. That is causing more tension as hospitals are trying to align the value of work with the cost of the person doing it."
So what needs to happen in this new business model? First, according to Dr. Dorn, physicians have to be willing to sit down and decide how new payment models will appropriately apportion the money. There are several compensation options for ACO physicians — including straight salary, productivity-based compensation and capitation — but both sides have to have an active conversation of who is getting what slice of the pie. There can't be many gray areas.
Second, Mr. McNulty says that a fundamental shift in business should also result in a fundamental shift in philosophy. That is, hospitals and physicians have to finally get onboard with focusing on preventive healthcare, keeping patients out of the hospital and incentivizing the primary care physicians to lead the charge. "As a system, we've gotten really good a putting hips in people, but we've not gotten very good at avoiding putting new hips in people," Mr. McNulty says. "The best thing is to not need to replace joints. But it's lucrative for those who do it."
Dr. Dorn points to a commonly cited health system that has already evolved into a working example for others: Oakland, Calif.-based Kaiser Permanente. Kaiser's model promotes collaboration and allows for access to information across the organization, which leads to a healthier population. That's the end goal, he says, and it stems from the fact that all stakeholders are willing to renegotiate their former positions within the broader system.
"I think hospital administrators are going to have to work much more closely with medical staffs," Dr. Dorn says. "What does the community need? What can [the hospital] deliver efficiently? Unfortunately, there is going to be tremendous conflict that you can't avoid. If you can work together efficiently — senior healthcare leaders and physicians — and if systems can learn to function together, they can be extremely efficient."
In an effort to reduce clinical variation, improve patient safety and maintain government reimbursement levels, hospitals are looking toward health IT and analytics for clinical and nonclinical decision-making. Automation, electronic health records, evidence-based medicine, clinical decision support — these are all components of today's health IT push, but they also interfere with a clinician's autonomy. For example, some physicians may view CDS within EHRs as a "physician substitute" even though its main goal is only to assist physicians in their diagnoses and analysis of patient data.
"The increasing role of technology has changed the relationship between doctor and patient," Dr. Dorn says. "The EHR could be a great boon and salvation to prevent many problems, errors and misdiagnoses, but it also is very hard for physicians to work with and institute it. There's also a big cost initially."
As hospital executives peddle the increase of health IT, physicians could be reluctant to a hospital's brash implementation strategies. The resulting dispute could hinder a health system's progress toward meaningful use or general modernity, but there is a source who could assuage this systemic conflict: the patient. Consumer-driven ratings and satisfaction scores are looked at as gospel for hospital leaders and physicians alike today, and patients hold the potential to ramp up technology implementation even more.
"In the long run, [EHRs] are cost-efficient," Dr. Dorn adds. "And as more and more performance data becomes public information, consumers should have a greater say as to what they do. The increasing role of technology as a potential source of conflict could also be a source to solve a lot of problems."
How should bundled payments work? Who should be reporting to whom? Is evidence-based medicine the best way to reduce variation? Will EHRs limit physician decision-making? On occasion, this could lead to tension-producing arguments and unwanted conflicts.
However, there is one "given" within this evolving system with which many would agree: Professional relationships need to be renegotiated. Hospitals and physicians can no longer consider themselves to be completely autonomous beings — they both need each other to coordinate care and, eventually, handle reimbursements.
Barry Dorn, MD, associate director of the Program on Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health, and Eric McNulty, senior editorial associate of the same program, are co-authors of the book, Renegotiating Health Care: Resolving Conflict to Build Collaboration, along with their colleague, Leonard Marcus, PhD. They explain there are two areas, among many, within hospitals and health systems where significant conflicts are arising — new business models and the elevated use of analytics — but hospital leaders can resolve those conflicts through the right collaborative approaches and strategies with physicians.
Shifting business models
One of the biggest shifts in today's healthcare environment is the changing business model — in other words, how are hospitals, physicians and other healthcare players going to be reimbursed in the future?Bundled payments and shared savings strategies are starting to turn from theory to practice, especially within accountable care organizations. Dr. Dorn says decades ago, practicing medicine was more about the Hippocratic Oath — the promise to practice medicine ethically and to keep patients' best interests in mind. Now, physicians have to think about how much their care is costing, and that's a fundamentally different mindset.
"I started in medicine in 1967," Dr. Dorn says. "In that time, and for many years, the model was a one-on-one relationship between physician and patient. A patient would come into the office, and physicians would evaluate and do everything to diagnose and treat [them]. I wouldn't think about what the costs were. Now, when patients present themselves to physicians, physicians have to think of a greater population. What resources I am willing to expend versus what resources do I have to treat entire population?"
Many physicians may not want to switch to that kind of mindset, which leads to internal conflicts. In addition, some hospital leaders have to deal with balancing relationships between physicians and physician extenders. While many physicians are happy physician extenders are able to help out, which allows them to focus on more severe cases, others may not be used to the different roles and the values associated with them. "Part of what is happening is this shift of work from physicians to [physician assistants] or to nurses," Mr. McNulty says. "But now it's a matter of who gets paid for what. That is causing more tension as hospitals are trying to align the value of work with the cost of the person doing it."
So what needs to happen in this new business model? First, according to Dr. Dorn, physicians have to be willing to sit down and decide how new payment models will appropriately apportion the money. There are several compensation options for ACO physicians — including straight salary, productivity-based compensation and capitation — but both sides have to have an active conversation of who is getting what slice of the pie. There can't be many gray areas.
Second, Mr. McNulty says that a fundamental shift in business should also result in a fundamental shift in philosophy. That is, hospitals and physicians have to finally get onboard with focusing on preventive healthcare, keeping patients out of the hospital and incentivizing the primary care physicians to lead the charge. "As a system, we've gotten really good a putting hips in people, but we've not gotten very good at avoiding putting new hips in people," Mr. McNulty says. "The best thing is to not need to replace joints. But it's lucrative for those who do it."
Dr. Dorn points to a commonly cited health system that has already evolved into a working example for others: Oakland, Calif.-based Kaiser Permanente. Kaiser's model promotes collaboration and allows for access to information across the organization, which leads to a healthier population. That's the end goal, he says, and it stems from the fact that all stakeholders are willing to renegotiate their former positions within the broader system.
"I think hospital administrators are going to have to work much more closely with medical staffs," Dr. Dorn says. "What does the community need? What can [the hospital] deliver efficiently? Unfortunately, there is going to be tremendous conflict that you can't avoid. If you can work together efficiently — senior healthcare leaders and physicians — and if systems can learn to function together, they can be extremely efficient."
Analytics for clinical and nonclinical decision-making
The shifting business model in healthcare is the biggest area where conflict is arising between hospitals and physicians, but information technology is also an area that could cause rifts.In an effort to reduce clinical variation, improve patient safety and maintain government reimbursement levels, hospitals are looking toward health IT and analytics for clinical and nonclinical decision-making. Automation, electronic health records, evidence-based medicine, clinical decision support — these are all components of today's health IT push, but they also interfere with a clinician's autonomy. For example, some physicians may view CDS within EHRs as a "physician substitute" even though its main goal is only to assist physicians in their diagnoses and analysis of patient data.
"The increasing role of technology has changed the relationship between doctor and patient," Dr. Dorn says. "The EHR could be a great boon and salvation to prevent many problems, errors and misdiagnoses, but it also is very hard for physicians to work with and institute it. There's also a big cost initially."
As hospital executives peddle the increase of health IT, physicians could be reluctant to a hospital's brash implementation strategies. The resulting dispute could hinder a health system's progress toward meaningful use or general modernity, but there is a source who could assuage this systemic conflict: the patient. Consumer-driven ratings and satisfaction scores are looked at as gospel for hospital leaders and physicians alike today, and patients hold the potential to ramp up technology implementation even more.
"In the long run, [EHRs] are cost-efficient," Dr. Dorn adds. "And as more and more performance data becomes public information, consumers should have a greater say as to what they do. The increasing role of technology as a potential source of conflict could also be a source to solve a lot of problems."
More Articles on Hospital Leadership:
Advancing Accountable Care: 5 Hospital ACO Leaders Share Insight
Leading in the Lone Star State: Q&A With Joe Freudenberger, CEO of OakBend Medical Center
Resolving 3 Common Areas of Conflict Between Hospitals and Anesthesia Providers