Chaos and Organization in Health Care

10. Provider Change

10 Provider Change As is probably evident from what we have written thus far, we believe in groupness. We think that the economic challenges and quality issues in health care cannot be addressed effectively unless physicians and other providers are organized into groups that have enough size and effectiveness to adopt tools that improve care. Those tools should help clinicians keep track of data, and make decisions that are safe, efficient, and beneficial for their patients. And these tools should reinforce groupness by helping clinicians work within teams that include patients themselves. Patients are the real focus of health care, of course, and we think they can bring some organization to care, as can employers and health insurance plans. Nevertheless, perhaps because of where we sit in the health care system, we believe that increasing the organization of providers is the single most critical step needed to meet our health care challenges . If physicians are not organized in groups, they cannot sign contracts with incentives to improve quality and efficiency—one of the most important chicken-and-egg dilemmas that stymie health care. If physicians and hospitals cannot become organized enough to become the targets of incentives for meaningful goals, the incentives have little effect. The goodness of groupness goes beyond the ability of groups to respond to market forces and adopt systems like EMRs. Larger organizations have visible and sometimes conspicuous roles in society, so they must confront issues that are easily overlooked by small physician practices—issues like care for the uninsured, conflicts of interest, and identification of physicians whose ability to practice has become impaired by mental or other health problems. Larger provider organizations often offer a more orderly life for physicians, so younger doctors 176 Chapter 10 today tend to seek employment in larger groups rather than small practices. Because of these demographic trends and the desire of patients for the innovations that larger groups can provide (e.g., Internet connectivity to their medical records), we think organized health care will inevitably “win” over fragmented health care. There are, however, some bumps in the road between here and there. They cannot be traversed without changes in the payment system and the overall health care marketplace—topics to be addressed in the two chapters that follow. But in this chapter, we focus on changes among health care providers that we believe are necessary to improve care and control costs. Clarity on the goals and barriers to provider change should inform the development of policies intended to hasten the evolution of health care delivery. We do not believe that the pace of change can be set by demographic trends—that is, we should not just wait for a younger generation of physicians to replace older practitioners. Nor should we expect large numbers of doctors to leap from small physician practices to tightly integrated organizations in which all of the clinicians use the same EMR and work in teams. The disruption to patients and physicians alike would cause unnecessary upheaval. A more realistic expectation is that all health care providers become progressively more organized, making incremental progress down this road regardless of their starting point, adopting tools like EMRs and disease management programs that help them work together along the way. If more organized health care is better, why aren’t physicians and other leaders in medicine moving along this path more quickly? To address these questions, this chapter will describe cultural barriers to change and financial challenges such as the need for capital to fund information systems. We will then turn to a description of some of the skills that health care leaders need to bring greater organization to medicine. Cultural Barriers Physician Autonomy The core of medicine is characterized by altruism, making it a wonderful field in which to work—and a difficult one to change. The goal of health care is to relieve suffering and help people live longer, and the people who are attracted to medicine want to earn their living by doing such work. Physicians in particular train for many years, work long Provider Change 177 hours, and see themselves as fierce advocates for their patients. For generations, the quality of health care has relied on the high personal standards of the individuals who provide it. Many laudable aspects of medicine flow directly from these high personal standards, but an unintended side effect can be resistance...