Health care reform: Physician-patient relationship cannot be sacrificed

Issue: August 2012

ByDouglas W. Jackson, MD

The physician-patient relationship is the basis for the practice of medicine and high quality health care. It is the foundation of our professional rapport with patients and upholds their dignity, privacy and assurance. We will do our best for them. The patient-physician relationship involves mutual respect and trust that the decisions made are best for patients. When I talk with hospital administrators, insurance executives and politicians about changes in medicine, they assume the things they do will not interfere with this relationship.

As the Patient Protection and Affordable Care Act (PPACA) is progressively implemented, physicians must be certain its application does not interfere with or change the long-standing traditional relationships between physicians and patients. We need to be careful that new proposed regulations and reimbursements do not make physicians solely measurement and guideline practitioners of medicine.

Beware of changes

The sacred relationship in medicine where patients come to physicians with expectations of their complete attention and efforts to make them better is one reason we became physicians. During the past several years, I have come to believe that while we as physicians are strongly committed to maintaining this relationship, we have succumbed to the changes and new phases to represent quality in health care reform. However, we must represent our patients in all the proposed changes to improve the quality of cost-effective care. Many new changes have already been proposed and even implemented with little attention or discussion about their possible effects on the patient-physician relationship.

Newly introduced incentives will change physician behavior and motivation to comply with the new mandates and directives. During the ongoing debates on health care reform, hospitals, large institutions and pharmaceutical and insurance companies have paid little attention to resulting changes that may challenge the traditional patient-physician relationship. This topic deserves a more significant role as does actual face time in the national debate.

Douglas W. Jackson

In search of speakers

The problem is that no one entity speaks for physicians. Many patients and politicians believe the American Medical Association (AMA) speaks for physicians. But “we” and “they” are not the same. It is difficult to get accurate numbers on physician membership from the AMA. The figures include far more than the due-paying physicians who belong to the AMA. The numbers often include non-due paying medical students, residents, semi-retired and retired physicians, as well as members whose dues are paid by their employers. Of the due-paying, practicing, fully trained physicians and specialists, it appears that less than 20% of private practicing and treating physicians belong to the AMA. The AMA tends to represent primarily primary care physicians and state societies. The elected physician leadership of the AMA usually arises from these groups and works with a large ongoing administrative staff.

The AMA signed on early to the PPACA with little input from the majority of practicing physicians. In speaking at the AMA’s Annual Meeting in June 2009, President Obama said: “No matter how we reform health care, we will keep this promise: If you like your doctor, you will be able to keep your doctor.” Questions remain as to how this statement will hold as the health care reform continues to unfold. With declining reimbursements and increased mandates and recordkeeping responsibilities, many patients will not be able to keep their physicians, and some physician may not be able keep certain patients.

In all the debate, we have to ask who speaks for our patients. Who asks for more data to not only show how patients benefit from proposed regulations, but also how the intrusion of more extensive documentation and coding improves face-to-face patient care? We must challenge the data that support new mandates that claim to improve patient care. Individually, mandates have good motivation and some documentation behind them, but physicians need to stand up and say when “enough is enough.”

Physicians need more conclusive data that new mandates, additional time and increased expenses will benefit patient care. It seems to me that we are on a bullet train headed by the government and supported by third parties, hospitals and big industry who increasingly tell physicians what they can and cannot do, how much to charge and which treatments are covered. Additionally, it is still unclear how physicians will comply with the new Physician Quality Reporting System lodged at the Centers for Medicare & Medicaid Services (CMS). The program provides an incentive payment to practices with eligible professionals who satisfactorily report data on quality measures for covered physician fee schedule services furnished to Medicare Part B fee-for-service.

Have we acquiesced already?

In today’s health care arena, it is not uncommon to see more physicians becoming demoralized as a result of this increasing intrusion into private practice and patient care. Physicians wonder if they have a voice or any input to make a difference. We have already seen increasing number of younger physicians who do not want to struggle with the business aspects of private medicine. They are willing to take less financial risks and often view salaried positions attractive as they can work “shifts” and are not tied to a pager or phone service during their free time. If we look around the world where the trend is toward salaried positions, the physicians eventually become unionized to negotiate for better working conditions and higher salaries. Salaried physicians often work fewer hours per week, have more vacation and holiday time and undisturbed evenings, but the trade-off is lower income and less autonomy.

Even if most physicians become salaried, we still need to peer review the supporting data and documentation used to develop the new incentive systems based on individual physician performances. Are they accurate measures of patient care as applied to non-hospital settings? A good viewpoint on upcoming changes and relevant concerns was recently published in the Journal of the American Medical Association. The authors discuss the complex interactions that contribute to physician behavior – financial rewards and lifestyle considerations, as well as feelings of accomplishment associated with good patient outcomes.

Valid clinical measures

Current validated clinical measures of performance apply to a limited number of patient illnesses and injuries. It is important that we require published results that withstand vigorous peer-review before rapid expansion. It seems to me there is insufficient data to support performance measurements. Yet, the PPACA requires CMS to use consensus measures for payment rewards systems. As we march to increase the science of medicine, we must be careful not to lose the art of medicine simply because we cannot measure it nor have a realistic benchmark for comparison.

The role of a physician may change to that of a health care provider in the new proposed systems after implementation of the PPACA. However, we must be certain the physician-patient relationship is not lost. Physicians and patients must remain at the center of health care. Important parts of being a physician are humanitarianism and the art of medicine. It is hard to quantitate these aspects, and they will be lost if science distances the physician from the patient.

Reference:

Cassel CK, Jain SH. Assessing individual physician performance: Does measurement suppress motivation? JAMA. 2012;307(24):2595-2596.

For more information:

Douglas W. Jackson, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: orthopedics@healio.com.