The price tag on healthcare services and medications is soaring, the average American can't afford his deductible, and too many physicians are suffering from burnout. Experts speaking Monday at a University of Chicago symposium on the Affordable Care Act agree the healthcare law is a step toward fixing a broken system by incentivizing physicians to produce better outcomes, but on the road to paying for value instead of volume, the industry has miles to go.
“What you have to do is change the intrinsic structure of healthcare,” Dr. Robbie Pearl, executive director and CEO of the Permanente Medical Group, said during a panel discussion at the symposium in Chicago. “It's going to have to be integrated… It's going to have to be prepaid, whether it's prepaid at the capitated level or a bundled payment in some particular fashion. It's going to require people to come together in a way that they work as one, and it's going to require physician leadership to make it happen.”
The healthcare law is a start. It's putting “pressure in the right direction” by rewarding five-star Medicare Advantage programs, and encouraging physicians to form groups, like accountable care organizations, under the Medicare Access and CHIP Reauthorization Act, Pearl said.
But creating a well-functioning group is disruptive, difficult to do and will take decades. The Kaiser Permanente group, for instance, took more than half a century to get where it is today.
“Between San Jose and San Francisco, there's 10 heart programs. Three of them do fewer than 300 surgeries a year. That means that there's 65 days a year at least that they're doing nothing,” Pearl said. If the three programs join up, while cutting out some of the specialists, they'll perform on a higher volume of patients and as a result, “likely get better physicians, better outcomes, better nurses.”
Health information technology is central to the movement from volume to value, but entering and extracting data to measure outcomes is no easy feat with the technology available today.
“EHRs are great” for some things, but “they don't have the feature of interoperability and liquidity across systems, nor do they have the feature of this ease of data entry and extraction,” said American Medical Association CEO James Madara.
Instead, physicians spend half their time putting data into a computer and less time in front of patients. That leads to burnout and higher risk of medical errors, Madara said. A study by the AMA and Mayo Clinic showed the burnout rate among physicians climbed to 50% from 42% in the last three years, he said.
“We have the most expensive data entry workforce on the planet,” Madara said. “We're completely misusing that workforce across much of our healthcare system.”
At the Permanente group, where services are prepaid, physicians spend less time in front of a computer because they don't bill for claims, Pearl said. As a result, doctors are much more satisfied.
Physician education also needs to evolve to focus on the whole patient for medical outcomes to improve, said Daniel Polsky, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania and a professor of medicine at the university's Perelman School of Medicine.
“Physicians are very much oriented towards their specialty,” he said. “Oftentimes the patient, who has lots of organs, is often forgotten in the treatment of any particular organ. Often that's how the training happens for physicians. And it would be great to move from inputs to outputs and really focus on the whole patient as we think about the next generation of medicine... and the way we train physicians.”
The panelists agreed the trend toward narrow networks to control costs is hampering progress toward paying for value. Narrow networks limit where patients can seek care by making patients pay more of the cost when they go to an out-of-network provider.
These could “lead to fragmentation of care and challenges in the relationship between primary care and specialists,” Polsky said, adding that there's little data of the impact of these networks on quality.
“Narrow networks are the latest trick, and it's always talked about and sold in terms of quality, but it's really in terms of cost,” Madara said.