Stakeholders? I Don't Think So.

Stakeholder Relationships

I don't know when I first heard the term.  My guess is that it was about 15-20 years ago.  I am sure that it came up during a meeting about "productivity expectations" and contract negotiations.  In case you missed it productivity is a grand concept courtesy of the US Government and managed care industry.  It was designed to get doctors to work a lot more for lot less.  Increased regulatory leverage against physicians was an added bonus.  If you happen to be a psychiatrist the reimbursement as indicated in some of my early posts can be trivial.  That is all before a managed care company or the government steps in and makes a totally subjective determination based on documentation that enough bullet points may not have been covered to justify a particular billing code.  In that case the penalties range from incarceration in federal prison (yes I was in a seminar where that was the message) to a managed care company deciding that you need to pay them back by adjusting your codes to lower levels and demanding reimbursement.  Say what you want about physicians, the natural question is how a group of fairly bright people end up in such a hapless position?  I have had lawyers confide in me that they would never accept the kind of harassment and financial manipulations that have been forced on physicians.  I suppose arguments have been made by politicians that it should be an accepted condition by physicians, especially those who sign on for government programs for the most needy.  Practicing medicine is after all a privilege right?

A lot of it comes down to boundaries.  I tried to illustrate these boundaries in the diagrams at the top of this post.  In the diagram at the top, the boundaries are fairly porous.  Looking back at how the important medical organizations sold some of these concepts to their members and continue to sell them today, it usually involves somebody hitting the panic button and someone suggesting that the solution is the next great idea from a business consultant or politician.  History illustrates that we have followed a long road of nonsolutions for the past 30 years.  The reason for that has been obvious to me.  Professional organizations frequently allow the government and the industry and their ideas direct access to the highest levels of governance in our organizations and the solutions from these special interest groups follow.  The special interests are often in the form of a person or persons who happen to be true believers and may coincidentally have some employment arrangement or guru role with business or government.   The entire scheme of rationing medical and psychiatric services to improve the bottom line of insurance companies is the best case in point.  After all, what comes out of the intersection of the three spheres in the top diagram?  The "cost effective" rhetoric for one.  Every President of the American Psychiatric Association (APA) or the American Medical Association (AMA) at some point utters these words and these words are included in documents of most APA District Branches.   We are living in a time when we have the worst infrastructure and systems of treatment for psychiatric and substance use problems in the last 30 years.  People are no longer adequately treated in psychiatric hospitals.  State hospital systems are in shambles.  County jails and state prisons have become places to house people with severe mental illnesses.  Outpatient clinics are placing more people than ever on generic antidepressants based on a rating scale score.  Medications are both over and under prescribed based on the lack of expertise and the lack of infrastructure necessary for detoxification, social interventions and psychological treatments.  The term cost effective should no longer be used by any psychiatrist or professional organization.  We should have started spending more money on treating severe mental illnesses about 20 years ago.

What happens if we remove the term cost-effective from the top diagram of muddled boundaries where the administrators in all organizations essentially say the same thing?  In the lower diagram we can actually hear the people in each sphere saying different things.  It is possible for physicians to say for example that across the board cost cutting is the tool of incompetent administrators.  It is possible for psychiatrists to say that over time various incentives seem to have been in place that favored all specialties over time except psychiatry.  It is possible for physicians to say that there is a huge gap between the care that governments are funding and what professional standards really are.   It is possible for psychiatrists to say that the way state hospitals are managed by government bureaucrats is hideous and that somebody with knowledge of staff dynamics and patient safety needs to be administering these places - not somebody with no training.  All of these things are possible if there is an actual boundary between the professional organization and the government and their friends in the business community.

I know that there are plenty of skeptics out there in the physician community.  I am not even interested in what the business people or politicians/regulators have to say because of conflict of interest considerations.   I also left out the professional boards including the American Board of Medical Specialities (ABMS) and the American Board of Psychiatry and Neurology for the same reasons - no boundaries and plenty of conflicts of interest.  The skeptics out there who I would like to address are the physicians just like me.  We go to work every day and know it is a hard job made a lot harder by all of the other so-called stakeholders.

If a clearer example is needed,  allow me to direct you to what appears to be a cooperative effort between the professional organizations and Medicare involving their pay-for-performance initiative (see paragraphs 6 and 7).   That initiative is based on Physician Quality reporting System (PQRS) that requires physicians to report on a number of measure beginning in 2015 in order to avoid penalties. The reporting is for the obvious convenience of fulfilling the political promise of being able to "compare" physicians on a series of unvalidated measures. This page on the APA web site is off-putting enough for anyone who has actually read it. The APA has deactivated a link that would bring the reader to a 50+ page document written by psychiatrists on quality markers for major depression. The links to that document are currently gone and a comprehensive list of the 2015 PQRS individual measures are not yet available. The APA and AMA have clearly been cooperative with these efforts. The message to individual clinicians is the same - we will waste as much of your time on unreimbursed paperwork to satisfy our collective political arrogance as we want.  These measures are an insult to any working person.  Instead of paying physicians to generate this data, the government's approach is to penalize physicians if the data is not collected and that penalty increases from 1.5% this year to 2% next year on the worst reimbursement source for physicians. It should not be surprising that psychiatrists are rapidly shifting to different methods of reimbursement.

When I got home tonight, I was greeted by a letter from the AMA notifying me that my membership had expired.  It proceeded to tell me what I was missing if I did not renew:

"Full access to online toolkits for working with Physician Transparency Reports (Sunshine Act) and managing HIPPA requirements for your practice.

Our detailed guides to help you navigate employment contract negotiations with hospitals and groups ($149 each, free to members)"

There are probably no better reasons to not renew the membership.  In all three cases, the boundary-less relationships with the federal government and the managed care industry have created these unnecessary burdens.   Like most organizations without boundaries the AMA has found a way to cash in on the new regulatory landscape that they failed to protect their members from in the first place.  Their expired membership notification is an insult to any dedicated member of the profession.

It is time to rewrite the relationship between medical professional organizations and the other so-called stakeholders.  Nobody should have a stake in a profession except those who have paid their dues in time, energy, personal sacrifice and finances and the people who seek their services.  It is time to realize that there are no benefits to a "place at the table" especially when political fees paid by physicians are basically mocked in Washington compared with the businesses who continue to exploit us.



George Dawson, MD, DFAPA

Survey-Centric Versus Customer-Centric Versus Patient-Centric

Over the past decades of managed care we have evolved from a medical model that mandated specific behaviors toward the patient to a business model that is supposedly based on customer satisfaction.  After all, the business theory is basically that satisfied customers are more likely to come back and do additional business. As any customer knows that model does break down in a number of ways.  My recent post illustrates a marked difference in the level of customer assistance available through many Internet companies over the past 15-20 years.  And yet, large managed care companies and other health care companies continue to adopt the customer satisfaction approach even when it can be demonstrated that this approach can result in increased mortality and morbidity for the satisfied patients.

It recently came to my attention that there is another variable in play that would have never been an issue in the days of patient centric care.  The best way to point it out is with the example.   Two separate people recently talked with me about their experience buying new cars.  I am going to maintain their anonymity because it could be traced back to the salesperson and have repercussions as you will see in a few lines.  New cars are high tech vehicles with an impressive array of electronics.  All of these electronics require more than a manual or a DVD.  The salesperson generally gives you an orientation to the vehicle and helps you with the preliminary setup.   In both cases that occurred taking about an hour each time.  At the end of the hour the salesperson approached with the customer satisfaction survey and said something like this:

"This is the customer satisfaction survey.  It is rated on a scale of 1 to 10.  1 is the worst and 10 is the best.  I have  to tell you that if you liked my service I would really appreciate it if you could rate me a 10.  If you rate me a 9 or lower I am out of here!  They will replace me in a month."

The first time I heard that, I thought "Incredible - this is just like the scripting that occurs at major hospitals and clinics."  Scripting is basically an exit interview set up to capture the elements of the customer satisfaction survey and inflate the scores.  The best way to get a high rating on a question about whether or not your nurse provided you with information on how to take your medication, is to have that nurse go through a standardized protocol about that right before he or she hands you the satisfaction survey.  What can you do at that point?  It just happened and it matches the survey question.  In compiling that kind of information, it should not surprise anyone when you find that all of the facilities in your area are in the 90th percentile.

I had a second thought.  I remembered the times that a patient was clearly satisfied with my work and said so right during the appointment.  Having been "scripted" about the importance of customer satisfaction at a recent staff meeting I had the thought: "Well if you really feel that way, it would greatly help me if you said that on the survey that they will send out to you on your satisfaction with my care."  I admit to thinking about it, but never said it.   I would never say it because I consider it to be a boundary violation.  Since when is it proper to suggest to a patient that they do something to advance your interests?  To my way of thinking (and the thinking of psychiatrists who preceded me) - never.  It is such a natural thought that it would not surprise me if it happens.  I think it is more likely to happen with clinicians schooled in business model of medicine.  If it was ever disclosed I can imagine that there are any number of administrators waiting to jump on it.  I can recall a physician telling me that his administrator insisted that he tell all patients coming in to see him that they need to bring in their insurance card.  He was actually reprimanded for not doing it a few times.  It only took a couple of complaints about that physician being too focused on the insurance card to get him fired by the same administrator who insisted that he should ask about it in the first place.

It is internally consistent that the MBAs who currently run America's healthcare system with seemingly little input from physicians would force the customer satisfaction issue.   They consider it a tool even though I would question its validity these days.  It seems like customer service is just common sense - why shouldn't it be rated?  There are a number of reasons.  Many ratings appear to have an unusual level of complexity.  Does it really take 10 or 20 different Likert scales or is a simple "yes" or "no" global rating better?  Clinical trials technology would suggest that there is an important role for both.  What about the manner in which the data was collected?  Should a rating that was coached by the subject who is being rating have the same validity as the rating that was not coached?  I would say no - again based on clinical trials technology.  Data needs to be collected in the same way to be comparable.  Either everybody uses scripting or nobody uses it.  There could also be a correction factor for ratings where scripting occurs.  It may result in a more realistic look at health care resources in local communities.  We also know that the way health care companies are managed has nothing to do with customer satisfaction.  One of the leading texts in how MBAs are taught shows very clearly that profitability counts and mental health services are considered the "dog" quadrant.   Are you really going to pay much attention to ratings of providers in the "dog" quadrant?  Only if you need it for leverage with those providers.  And finally does everything have to be rated?  If I am desperately searching for a way to fix my computer so that I can complete a document for a deadline, are pop-ups asking me to rate whether or not suggested fixes that did not work were helpful?  Probably not.   On the clinic or hospital rating from those questions focus on services that are peripheral to the provision of care.  How does the lack of parking or an ATM machine affect a patient's attitude toward their doctor when it comes to those ratings?

The most important consideration that nobody seems interested at all in - what is lost when we apply business ratings to physicians.  It allows us to consider that physicians are just like any other group of hucksters bound only by their ability to separate you from your money.  Caveat emptor right?  It neglects an entire system of checks and balances that have evolved over centuries from the professional relationship between patients and their physicians.  It also neglects a massive bureaucratic structure that regulates physicians and demands certain behaviors and concessions when they engage in certain types of business transactions.  Rating physicians, even with multiple Likert scales seems to put them on the same plane as the pizza delivery guy.

With the current business emphasis in medicine,  it may be that some day physicians will have the same level of responsibility as the pizza delivery guy especially if governments and business interests succeed in their efforts to erode professionalism.  Until then, I think it pays to remember that your physician is obligated to treat you in a certain way - irrespective of any rating systems.

That includes not requesting a certain rating.  



George Dawson, MD, DFAPA


Supplementary 1:  No offense to pizza delivery guys everywhere and I hope you don't have to hand out customer satisfaction surveys with the pizza.