Saturday, March 4, 2017

Managed for Mediocrity - Corporate Medicine in the 21st Century

I had in interesting conversation with a colleague the other day.  The focus was on the concept of population based medicine.  It has been a buzzword in managed care and HMOs for the past 20 years.  I have seen many physicians who were promoted to administrators in these organizations who had to start talking the population based medicine hype as part of their role as administrators.  Looking at Medline references the definition goes back to 1995, but I heard it long before that.  If you Google the term you will find a definition that is attributed to the American Medical Association:

An approach that allows one to assess the health status and health needs of a target population, implement and evaluate interventions that are designed to improve the health of that population, and efficiently and effectively provide care for members of that population in a way that is consistent with the community’s cultural, policy, and health resource values.

In trying to confirm that definition for the past three days through AMA staff and their web site - I have been unable to locate the specific document.  The problem with this definition should be apparent to any physician.  Physicians are trained to assess and treat individuals.  They are trained to treat people with diseases and illnesses.  They spend the majority of their time doing this.  The idea that this kind of approach is going to be implemented by a physician or even a group of physicians is overreaching and absurd.  It is very convenient for managed care companies, pharmaceutical benefit managers, and governments who want to ration resources across communities and intentionally discriminate against others.  What could be a better rationale for having fewer and fewer people being seen by physicians and more people taking inexpensive screenings or just being told that there are no resources.  It is also useful to mass market very expensive pharmaceuticals to people who will get minimal to no benefit from them.  Corporate management removes physicians from those decisions, but in some cases makes it seem like the physicians approve.  The best example is a corporation limiting choices and then making it seem like the physician is approving the course of action.

The business and government led movement to homogenize medicine has additional fall out that I am sure few people outside of medicine know very much about.  Physicians are managed to see a number of billing codes per day and those codes are typically optimized to collect the maximum billing per encounter.  They need to be because the payers are already gaming the system to pay the lowest possible amount per billing code.  That tension between the non-medical forces on three sides: payers, coding specialists, and physician managers creates a pathological assembly line of brief expensive visits where not much happens.  Have you ever been told by a physician or nurse that you can be seen for only one problem at a time and if you have a second or third problem you will need to set up new appointments? This is the pathological assembly line approach taken to its absurd conclusion.  Any slight glitch in appointment times or a patient suddenly requiring more intense treatment than anticipated throws a wrench into the works.  Some patients in the waiting areas can be backed up for hours.

Homogenization has another intended consequence - it makes it seem like all of the physicians in the clinic are the same.  That is always true to some extent, but there are always major unappreciated differences.  Some physicians gravitate toward specialty areas based on their interest and experience.  Some physicians have a natural talent to deal with certain problems and procedures.  Other physicians know that they should avoid certain areas of medical practice and for that reason stay out of specialty areas.  On this blog, I have posted that many physicians have told me over the years that they really like psychiatry but that they could never tolerate treating a certain type of personality or trying to determine the level of suicide risk when seeing patient with that problem.  There are differences within the same specialty.  Some psychiatrists are better at handling the medical aspects of psychiatry.  Others do a better job with psychotherapy.  Prior to homogenization, those differences were allowed to exist and they were developed across the entire professional lifespan of physicians.  When that happens in any group of specialists, these skills are recognized and patients with those problems are directed to the physician with those skills.   Today billing codes, patient visits, and electronic health record templates  preclude any differences between physicians and have them all producing the same rapid low quality product.

Physician evaluations are often set up to not recognize the unique contribution of the physician to the department and to insist instead on some kind of meaningless corporatized individual improvement plan.  The maintenance of certification (MOC) and maintenance of licensure (MOL) in some states is way to send the message that individual physicians don't have any particular expertise and in fact have to pass an arbitrary general exam in order to maintain certification - even if they have specialized in the area for 20 years, are recognized for their expertise, and know more about it than the physicians who designed the exam.

Physicians themselves know that I am speaking the truth about specialization because in many cases they still have this inside information.  They try to get at this information and use it to recommend care to family members and other patients.  If my spouse needs surgery, you can bet I am going to find the surgeon who does the most procedures and the one recommended by his or her colleagues.  Non-physicians do the same thing to some extent by talking to relatives and neighbors who have had surgery and asking them if they would recommend that surgeon.

There is probably no better term for this corporate tactic than suppression.  Current health care management actively suppresses physicians at multiple levels.  That is obvious in the initial interview in any health care organizational if the physician is savvy enough to ask directly about the expectations of the corporation.  They may discover unrealistic productivity and call expectations.  They may find out that although they were hired for some administrative, research or teaching position that there will also be at least a half time productivity expectation that involves seeing a lot of patients.  The associated administrative time cuts into their other role.  They will find that there is no time for the necessary phone calls for pharmacy and insurance hassles, documentation, or even meetings with an administrative agenda that are of no benefit to the physician.  Annual reviews are another place to observe corporate suppression in action.  One of the greatest tools ever created to suppress physicians and give them the message that they need active guidance by the less accountable is the 360 degree evaluation.  Today that typically involves soliciting anonymous negative comments from fellow employees and including that in the physician's review.  Many solid performing physicians many find it disquieting to put in a solid performance both in terms of productivity and other functions like teaching and presentations and leave their annual evaluation feeling like they have just been slandered.  In some cases, administrators may go as far as suggesting a performance improvement plan based on the fiction in the anonymous comments.

All of that is a far cry from the professionalism that used to exist among physicians practicing in groups and hospitals.  The current tactics certainly create more than enough leverage against physicians to keep the businessmen and politicians firmly in control.  The price is clearly a less vibrant, creative, and enthusiastic physician workforce.  The burnout syndrome has been written about extensively in the past several years and the single-most important cause of that burnout is bad management.

There is of course an asymmetry to the management tactics.  They are never applied to the managers themselves.  How would you manage the productivity of managers - the number of bad ideas they can come up with in a month?  Some of them make mistakes that approach a legendary scope in terms of losing money by restructuring employee schedules or signing licensing agreements with electronic health record companies.  They can make decisions that lose millions of dollars and shrug it off like nothing happened.  They can solicit employee complaints because it is currently the corporate ethos to do so and solve none of the problems.  There is no shortage of health care companies that hemorrhage professional employees because of their cookie cutter bad management approach.  It is probably logical from management's perspective because they see physicians and other professionals as production workers who could not survive without active guidance.  They fail to recognize that all of this active interference removes the best minds for treating the problem and relegates them to a secondary role.  In some cases, it appears that the administrators are practicing medicine.
These days bad management is about the only management that is out there.                      

George Dawson, MD, DFAPA


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  1. Any psychiatrist who signs on to the groveling clerk role in collabo-care for the illusion of security instead of the freedom and dignity of a craftsman deserves neither security nor freedom. There is no security in the former because he/she will eventually be replaced by an algorithm. I am so sick of colleagues who are just cowardly sellouts, refusing to take the long view, and being tactically idiotic because psychiatry is in demand. If so-called experts in human behavior don't understand any of this, I'd say they really don't understand human behavior at all. So maybe it all works out in a karmic sense.

    1. I think the problem is twofold:

      1. The way it is hyped and sold - first off which collabo-care model is it anyway? There are at least three as far as I can tell - with varying degrees of psychiatric contact with patients from little to none.

      2. The fact that it is "evidence based" - trainees being exposed to it will see the same research that cropped up in the 1990s to show that managed care was "superior" or "no different" from treatment as usual. Nobody looked at the conflict of interest in those studies and as anyone should know - you can "prove" just about anything with your research.

      Today it should be very easy to show that collabo-care is better then anything else because everything else is managed care rationed minimal to no treatment.

  2. Everything works out beautifully in PowerPoint, including Rube Goldberg machines made of papier-mache.

    The truth is that the only models that really work in psychiatry long-term involve taking insurance out of the picture.

    Academics love O-Care and keep trying to squeeze craftsmen in private practice into the assembly line model. Knowing of course, that the consequences don't affect them. Consequences be damned, they meant well, and that's all that matters in the tower.