Healthcare Reform, Burnout and Physician Leadership

Paul B. Convery, M.D., M.M.M.

The news media has been full of opinions about healthcare reform over the past several months. Specifically, the news is about the effort to repeal all or parts of the Affordable Care Act, and to implement various Republican alternatives.

The clinical literature over the past several years has been raising the “red flag” about the increasing rate of physician burnout. It is over 50% in some surveys and there is an alarming increase in physicians leaving their practices.

Jessica Dudley, the Chief Medical Officer for the Brigham and Women’s Physicians Organization, discusses the connection between developing physician leadership, inspiring innovation and responding to physician burnout in an interview in a recent NEJM Catalyst post (November 7, 2017), and I think that she is on to something very important to the future of American healthcare.

Now let us first look at the drivers of healthcare reform. Unlike the drivers in the sixties (many uninsured in the over 65 age group and those living in poverty,) which resulted in Medicaid, Medicare and expanded employee sponsored health insurance, and the drivers in the eighties (rapid rise in healthcare cost) which resulted in managed care, pre-certifications and HMO’s, the drivers today are both of these and they are now at a “tipping point”.   Healthcare costs are unsustainable, and this time really unsustainable. According to the Milliman Medical Index, fully loaded annual healthcare costs, including insurance, copays, and deductibles for the average family of four is $26,000 in 2016, and that is unaffordable for most American families (the median income was $56,000 in 2015.)  The families depend on benefits or subsidies from either their employer or from the federal government. Employers are backing off and shifting more costs to the employees and the federal government now has 28% of the federal budget allocated to healthcare ($1.1 trillion) and that is pretty close to the limit unless we raise taxes dramatically (unlikely) or the national debt (undesirable.)

The other driver of healthcare reform today is lack of access, both to affordable insurance and to care, outside of going to the emergency department (which drives up costs.)  The Affordable Care Act addressed part of the insurance problem for some of the people, but still left millions uninsured, and more with increasing insurance costs. It did not fully address the lack of access to physicians in many parts of the country for patients on Medicaid and sometimes on Medicare.

The two political parties are addressing each side of the issue. The Republicans have proposals (block grant Medicaid, vouchers for Medicare, and repeal of Obama Care) which will potentially hold down cost at the expense of increased access issues (both to insurance and to care.)  The Democrats’ Medicare for all proposal would potentially increase access, but not have a clear way of addressing costs.

So our physicians are stuck in the middle, trying to make the best of a Fee for Service (FFS) system in which fees are capped or decreased, and their only solution is working harder and doing more (increasing the volume side of the “Volume X Price = FFS” equation) and that is leading to overwork, frustration and burnout.

The alternative to FFS (and the future, we are told) is Value Based Reimbursement, but that formula (Quality/Cost) seems obscure and foreign to most practicing physicians. If healthcare costs are too high and access to both care and insurance to pay for care is more and more limited, we must design new and innovative ways of caring for patients in this challenging environment without destroying the morale of our care givers. This is where care delivery innovations come in and these innovations should be designed in whole or in part by physician leaders. One must recall that the three patient care innovations that are featured in the Affordable Care Act, Patient Centered Medical Homes, the Accountable Care Organization, and Bundles of Care, were not invented by the Federal Government, but by physicians, physician groups and health systems dealing with and responding to their changing environment.

The physicians that participated in the development of these innovations were leaders. Not necessarily CEO’s or CMO’s, although some were, but physicians behaving as leaders who understood systems, complexity, resiliency, process improvement, adaptive change and their own role in forging the future. These leadership skills and behaviors can be developed in physicians and leading healthcare organizations are doing that. However, to develop these skills organizations must be strategic and intentional. It will not just happen. Once healthcare organizations have significant numbers of practicing physicians that have mastered these skills and are open to designing new ways of caring for patients (innovations,) the frustration and lack of input that leads to burnout will be diminished. Physicians want to have autonomy, not the Marcus Welby type of autonomy, but they want to be involved in the future and to be at the decision-making table. Physicians want recognition, not a flower on Doctor’s Day, but acknowledgement for their ideas and contributions. Physicians want a sense of professional accomplishment that will come from their participation in the design of the care model of the future.

There is a caution to healthcare systems and organizations that encourage and assist physicians in developing these leadership skills, but then fail to offer opportunities for their input, participation and inclusion in the discussions about the future. Physician leadership is not just a program but a philosophy and a strategy for the future. Offering a leadership program without meaningful participation and inclusion will only add to the cynicism.

Healthcare delivery of the future will look different than that of the 20th century. That much is almost a certainty. The question is will it be designed by the government and politicians or by the care givers. When physicians across the country begin to think and behave as leaders in a complex changing system, real innovations and improved models of delivering healthcare will result. Physicians must own and participate in this redesign. Physicians must learn to think and behave as leaders in these complex systems in order to own and to participate in this. This way of thinking and behaving is not intuitive to most physicians but can be developed. The time to start is now.