Rethinking the Physician-Patient Relationship

In Health and Human Services Secretary Tom Price’s confirmation testimony before the Senate Health, Education, Labor and Pensions Committee (HELP) January 17-18 and in numerous interviews and speeches since, Dr. Price has pledged to restore the centrality of the physician-patient relationship to the American health care system. It’s clear it’s the mantra from which he will oversee the agency’s $1 trillion budget.

Dr. Price is an orthopedic surgeon, having trained at Michigan and Emory. He practiced for 20 years in the Atlanta area before beginning his political career in the Georgia State Senate in 1997 and U.S. House of Representatives in 2005.   And he frequently tells audiences that he is married to a physician—his wife Betty practiced anesthesiology at Grady in Atlanta and the son and grandson of physicians. So the practice of medicine runs deep in his bloodline.

Representative Price was one of 10 Republican clinicians in the “Doctors Caucus” and an active member of the American Association of Physicians and Surgeons, a group opposed to Obamacare, mandatory vaccines and elements of the Medicare program. And now as HHS Secretary, he wields power to determine how the Affordable Care Act will be changed or replaced through the myriad of administrative actions and policies he can initiate impacting meaningful use, alternative payment programs, private inurement and self-referral and much more. Remember: in the Affordable Care Act, “the Secretary shall…” figured prominently in its implementation and is referenced more than 1400 times. Dr. Price’s view of the physician-patient relationship is certain to influence policies he’ll advance as Secretary.

Most weekends, I participate in strategic planning retreats where physician leaders, boards and management of healthcare organizations review their plans, sharpen their focus and adjust their capital and operational priorities accordingly. Invariably, the trends, issues and challenges of their affiliated physicians gets attention. In tandem, there’s also talk about relationships with patients, alternately referenced as consumers or members in some settings. And views about the changing dynamics of physician-patient relationships are shared.

The realities are these:

Most physicians practice medicine for its professional fulfillment that includes handsome compensation and public esteem for the profession. It’s noble, worthwhile work that’s hard. Most are frustrated by the red tape involved in plying their trade and many are burned out. Most think their patients are incapable or unwilling to navigate their health options effectively prompting a paternalistic view toward their patients.  Most think they are not paid well-enough nor respected as much as they deserve. Most would like to turn back the clock on physician-patient relationships to an era when they had adequate time and unchallenged authority to control the care of their patients sans insurer reviews, regulator policing and online report cards about their activities. Most would like to practice independently and with complete clinical autonomy and see employment of physicians by hospitals and insurers as a slippery slope toward medicine’s demise. Most do their jobs well but a handful cross ethical lines to benefit themselves at the expense of their patients. And the majority believe they do a good job managing their physician-patient relationships given the unusual complexities and constraints of the business and expectations of their patients. They acknowledge physician-patient relationships could be better, but largely blame the system for the shortcomings.

Most patients trust their physicians, but it’s eroding. Per Blendon’s study (Harvard School of Public Health), just 34% of U.S. adults polled in 2012 said they had “great confidence in the leaders of the medical profession,” down from 76% in 1966, and a survey of people in 29 countries found the United States ranked 24th in public trust of doctors with just 58% of Americans saying they “strongly agreed” or “agreed” with the statement that “doctors in your country can be trusted,” versus 83% in Switzerland 79% in runner-up Denmark.

Most consumers believe a strong physician-patient relationship is more about the willingness of their physician to listen over technical skills. Most do not study online treatment options for comparative effectiveness, challenge their clinician’s recommendation, or calculate the out of pocket costs that might result. Most think physicians are smart and rich, relatively speaking. Most are reluctant to ask questions lest they appear stupid and most withhold information otherwise useful to a more accurate diagnosis fearing embarrassment. Few have heard of accountable care and bundled payments nor do they care how their physicians are paid. Most want access to their medical records and the ability to communicate with their physician via e-mail. Most accept that physicians today run assembly line operations: move ‘em in, move ‘em out. All recognize that the physician-patient relationship is changing: some (especially Millennials) see it as necessary improvement and others as a step backward. But all recognize it’s changing.

It’s clear the increased complexity of the medical profession coupled with the monumental shifts in the patient marketplace require a new framework for defining and measuring physician-patient relationships. The new normal for both is significantly different than their past:

·       Physicians: Physician performance is now public record: outcomes, errors, compensation, business practices, conflicts of interest and patient experience measures are accessible to all and compensation directly linked to their results. Adherence to evidence based practices and scrutiny about unnecessary tests and procedures are table stakes. The use of electronic medical records and digital health technologies is expected and practices must operate in locations with hours convenient for patients, not the physicians. Little wonder most physicians think the best days of medicine are past and one in three is now an employee of a hospital—a reluctant concession to a new world order in medicine.

·       Patients: The patient marketplace is likewise dynamic: cost sensitivities, social media, demands for alternative therapies, preferences for treatment options, insurance terms and conditions, narrow networks, ubiquitous media coverage about physician misdeeds and growing market use of technology-enabled self-care tools are disintermediating physician-patient relationships and chipping away at physician pedestals. Half of adults under 35 do not have physician relationships, and 4 in 5 that do say their physician wouldn’t recognize them anyway. That’s why urgent care and retail clinics, alternative remedies and probiotics and online care communities are flourishing. For patients, the physician-patient relationship is much more than being able to see a doctor.

So how might the physician-patient relationship change in coming years?

The dimensions and complexity of physician-patient relationships expand exponentially:

Focus

Yesterday: 

• Individual physician “management” of patients focused on a medical problem with primary care in the front seat

Today: 

• Individual physician coordination of care for populations; adherence to guidelines set by the medical group, hospital & insurer; measurement of effective and efficient care with primary care in the back seat

Tomorrow:

• Customization & coordination of care for individuals & populations by multi-disciplinary teams with clinical navigators acting as the patient’s advocate with a balance of traditional & alternative preventive, chronic, acute & post-acute services appropriated thru total cost of care models.

Key Performance Characteristics

Yesterday:

• ‘Reputation’ (affability, accessibility) of the individual clinician 
• Word of mouth comments from patients
• Hospital affiliation insurance coverage (acceptance)    

Today:

• ‘Reputation’ (affability, accessibility, social media profile) of the individual clinician & the medical group with which he/she is affiliated
• Patient experience report cards based on perceived and actual effectiveness of care measures
• Health system affiliation (website, self-care tools, public report cards terms of coverage by Insurance & out of pocket costs to individuals    

Tomorrow: 

• ‘Reputation’ (user experiences, outcomes, estimated costs, efficacy & effectiveness of treatments) of the individual clinician & the system of health affiliation
• User experiences measurement based on effectiveness and efficiency (costs) of services provided across the entire continuum of care
• Availability of expanded scale & scope of services including insurance and delivery, guided self-care tools, information technologies, retail health et al
• Accessible, comprehensive primary care “front door” relationship with physical & behavioral health, dentistry, eyecare, pharmacy, nutrition & health coaching
• Insurance coverage that makes clear out of pocket costs and financial risks to individuals
• Guarantees for results: physicians assume responsibility for outcomes they control
   

The future for physician-patient relationships is not likely a repeat of the past. That’s a mixed bag. Customizing care based on individual genotypes and preferences is a plus, but that takes capital and coordination. Organizing care around continuous relationships with a care team is a plus, but it’s hard to implement in cultures where individualism is rewarded over team performance. Assuming total responsibility for both financing and delivering care is uncharted turf for most. And recognizing that reputations will be based on actual outcomes, costs and firsthand patient (consumer) experiences requires sober preparation. Each of these alters how physician-patient relationships are built and sustained.

Hopefully, Dr. Price is looking to the future of physician-patient relationships in framing his aspirations as HHS head. Modernizing our thinking about physician-patient relationships is necessary to our system’s future but more complicated than usually recognized.

Paul

PS: The breaking news of the week: Anthem Inc. on Friday lost its bid to overturn a decision that blocked it from proceeding with its $54 billion merger with Cigna Corp., after a split D.C. Circuit panel was not convinced by the insurer’s argument that the transaction should go through because it would generate savings for consumers. That means Anthem will be forced to pay a break-up fee of $1.85 billion to Cigna. Expect Anthem to negotiate with providers for steeper cuts, be more cautious about its participation in the exchange markets and attempt to pass thru premium increases to its customers to offset the legal setback….The House and Senate approved a temporary extension of federal discretionary spending until May 5 to avoid a government shutdown and the latest Kaiser tracking poll showed the majority (74% including 53% who support the Trump administration) want to see Congress focus on fixing the Affordable Care Act versus replacing it. At the top of the public’s concerns: lowering premiums in the individual insurance market and drug prices. 
 
For Additional Reading:

-Neil Wagner Questioning the Doctor, Challenging a God The Atlantic Daily July 12, 2012.
-Anne Harding Americans’ Trust in Doctors Is Falling Live Science October 22, 2014.
-Zikmund-Fisher BJ, Couper MP, Singer E, Ubel PA, Ziniel S, Fowler,FJ Jr., et al. Deficits and variations in patients’ experience with making 9 common medical decisions: the DECISIONS Survey. Medical Decision Making. 2010;30(5):85S–95S.
-Katz J. The silent world of doctor and patient. Baltimore (MD): Johns Hopkins University Press; 2002.
-Cullati S, Courvoisier DS, Charvet- Bérard AI, Perneger TV. Desire for autonomy in health care decisions: a general population survey. Patient Education Counselor. 2011;83(1):134–8.