In this show, Powers discusses the different factors that have contributed to a decrease in trust between patients and providers. Issues covered include the power of payers to control clinical care, to the role of consumerism in giving patients options, the failure of physicians to effectively communicate with patients and of course, the differing recommendations of strategies to control Covid-19. Take a listen to hear Powers’s solution to the problem, an idea that can alleviate health inequity and elevate the power of the primary care physician.
- History of medical profession: Op-Med
Read the Transcript
Welcome to The Powers Report Podcast. I am your host, Janis Powers. The show brings you candid, unique and data-driven perspectives on the health care industry. I believe that any solution that is going to positively impact the American health care system has to satisfy two major criteria: financial viability and behavioral incentive alignment. In other words, access to high quality care can only be achieved if we can afford it, and if we behave in ways that optimize our health. Please subscribe to our show on your preferred podcasting platform and connect with us on social media. Again, this is Janis Powers, and welcome to The Powers Report Podcast.
The practice of medicine and specifically, what it means to be a doctor, is at a cross-road. This is a problem because the number of primary care doctors in America is declining, yet Americans are increasingly unhealthy. Who is going to take care of us?
This issue is of particular importance to my company, KnowThyself. KnowThyself has evolved into a direct-to-consumer digital health platform. We predict health outcomes so our customers can better control their health care experience.
Our goal is to get people on a level playing field with everyone who’s supposed to be managing our health, and that includes doctors. It’s sort of a “know before you go” model. We want people to know what diseases and conditions they’re going to develop, know how to prevent them and, if/when they happen, know about all the treatment options. This enables our customers to partner with their doctor to select the care that works for them. Studies show that the more a patient is engaged with their health care, the better their outcomes.
In this show, I will talk about the factors that have paved the way for companies like mine and many others that are changing how we look at health care – and what role doctors will play in them in the future.
To start, I want to draw a parallel to another field that has transformed dramatically over the past couple of generations: architecture.
Although I’ve spent decades in the health care industry, my college major at Yale was architecture. I also have a master’s degree in architecture (and an MBA) from the University of Michigan. I loved studying architecture. You had to have a weird blend of right and left brain power to excel in the field. Architects are creative and artistic, but also analytical and regimented.
Doctors are known to have a “God complex” but we, the controllers of the environments where you work, live, love and die, are “Hero architects.”
Architects used to be the center of the entire building process. They designed and then oversaw everything, from the position of the windows to the placement of light switches to the choice of roofing materials. Not anymore. Today, massive design-build companies run the show. These folks do all the designing in-house and then manage the entire process, from design all the way to construction.
According to the US News and World Report Best Jobs ranking, in 2019 the average hourly wage for an architect was $43.06. Architects are ranked under the category of engineering jobs. They don’t even have their own group. An architect’s pay is less than that of civil, environmental and mechanical engineers. Good news though: Architects out-earn cartographers.
A lot of this fall from grace can be blamed on the Baby Boomers. As families expanded after World War II, housing was needed. In order to meet demand, builder William J. Levitt decided it was a good idea to use the assembly line concept and build the same house over and over. Over the decades, eight “levittowns” were built, the first of which, called Levittown, is on Long Island. It’s a little more than 10 miles from where I grew up. I should have seen the writing on the wall, that the architect’s days were numbered, knowing what Levittown was like.
Anyway, out went customization. Out went the need for the architect to design each house, one by one. All of this was enabled by production line assembly and global trade, which provided raw materials to builders and manufacturers.
Then came the computer. That was the nail in the coffin for the architectural profession as we knew it.
Auto-cad automated the architect’s ever-important skill: drafting. Next thing you know, people are designing their bathrooms in Home Depot. Frank Lloyd Wright is rolling over in his grave at the thought.
So to you doctors who worry that your profession is losing its power and influence, I feel your pain.
I will acknowledge that a good doctor is much more important that a good architect. If I don’t like my house, I can move. If I don’t like my body, well, I’m stuck with it. That means I care a lot about what doctors recommend and what they want to do to it. Trust is paramount.
Unfortunately, our trust in doctors is not what it used to be. Some of this is the fault of the doctors and some of it isn’t. But this lack of trust is undeniable.
A lot of this fall from grace can be blamed on insurance companies. Increasingly, how doctors practice medicine isn’t based on what they think their patients need, but on what insurance companies will pay for. I find it outrageous that a physician may recommend a medication for a patient, but that patient can’t access it because their insurance company won’t pay for it. Anger needs to be directed at the insurance company, but doctors quite often unfairly suffer the brunt of the blame.
Trust is also a problem because patients don’t get a lot of time with their doctors. This is especially true of the primary care doctors who are supposed to be the gateway to all the other specialists in the health care system. This problem has been brewing for centuries.
Back in the day, like in colonial America, doctors were generalists. They did everything and most weren’t formally trained. The first medical school was founded in 1765 and is now part of the University of Pennsylvania. It took decades for organized training and education to get formalized. In 1847, before the Civil War, the American Medical Association, or the AMA, was formed. This was and remains today to be the primary advocacy group for doctors in the U.S.
With the advent of new tools and technology, from the stethoscope to the MRI, doctors have been splintering into different groups or specialties. This splintering was seen as a problem when it started. Generalists were alarmed at the idea that any one element of the body could be treated independently, without consideration for what was going on everywhere else.
Yet being a “specialist” meant that you had certain skills that generalists did not. Think about the myriad ways that doctors can explore different aspects of our bodies from a hands-on approach, to using tools to probe, listen, test, observe and repair.
Specialization takes skill and that special skill warrants more pay and that translates to more power. That’s why in today’s medical community, the specialists who can perform complicated activities for groups with significant need – like cardiovascular surgeons – are the most well-paid.
The generalists, especially the primary care doctors, are not well paid in comparison. If the government is writing the check, especially for Medicaid patients, then primary care doctors are increasingly less interested in taking on patients. You know the drill. These doctors need to make money so they reduce the amount of time they spend with patients so they can see more patients. Not having a doctor spend enough time with patients has been a contributing factor to poor care quality.
Primary care doctors aren’t happy about it. Fewer of them are graduating from medical school. They don’t want to spend years in school only to spend three minutes with a patient. On top of that, they’re oftentimes taking on hundreds of thousands of dollars of debt. They’d be wise to pursue a high paying field, not something like primary care. Sorry.
Scarcity of primary care docs is being exacerbated because lots of them are retiring. The pandemic has exhausted doctors who were exhausted to begin with, and now concerns over their own well-being because of Covid-19 are driving many to just hang up their shingle.
Here’s the thing that blows my mind. Insurance companies make visits to primary care doctors basically free and yet people are loath to go to the doctor. The idea is that the primary care doctor is supposed to coordinate everything. Some insurance plans require patients to get referrals from the primary care doctor in order to see a specialist. Yet, there’s a shortage of primary care doctors. So getting to a specialist via a primary care doctor can take weeks if not months.
While we can trace the root cause of this issue to insurers – meaning the hurdles to access – it’s still the doctor who’s on the front lines, viewed as the problem.
A recent study came out identifying reasons why people don’t like to go to their primary care doctor. Access is a problem. But here’s what’s surprising. Half of the reasons why people don’t like going is because they think the doctor is going to prescribe them medication or recommend a procedure that they don’t need. In other words, some doctors aren’t listening to what patients want.
There are a lot of reasons why this happens. Doctors may not have data access to other providers that would enable them to see tests that have already been done or better understand a patient’s medical history. As discussed, some insurance plans restrict what doctors can do, limiting treatment options, which may result in prescribing things patients don’t necessarily want. And let’s not forget that some doctors are just trying to ring the reimbursement bell as often as possible so they can make more money.
People can bat around excuses ten ways til Sunday, but consider this: if doctors were doing a good job delivering health care, then why are Americans so unhealthy?
Doctors need to take a good look in the mirror and own up to this problem. I’d love to blame Americans’ unhealthiness on health insurance mandates and poor patient behavior, but the failure of the medical community to deliver health care to patients effectively is an issue that no one wants to talk about or admit.
Doctors are, at heart, scientists. They’re supposed to combine facts with their expertise to diagnose patients and come up with treatments. I think doctors are pretty good at figuring out what a lot of the problems are but getting patients to do something about it is a different story altogether.
Think about the value-based care movement. If you’re not a health care industry wonk, you may not know what I’m talking about. Basically, the idea of value-based care is that doctors and other providers (hospitals, etc.) should get rewarded for positive patient outcomes. In theory, this is great. Sure, I’d like to pay my doctor for making me well, not just for ordering tests and medications. And yeah, I’d like them to be penalized if they make mistakes.
This value-based model took hold during the Obama administration. It was supposed to be an innovative way to control skyrocketing health care costs. All kinds of models were devised by policy makers and doctors and even worse, by doctors with MBAs. People looked at the data to figure out what to prescribe and how to determine what a good outcome was and all of that was compared to reimbursement rates from Medicare blah blah blah.
Did anyone bother to talk to patients? Yeah. The patient satisfaction metrics incorporated in the value-based reimbursement calculus include important clinical indicators like how quickly a nurse shows up after a patient rings the call button. I’m not joking.
Useful value-based care metrics would have asked the patient what they expected to get out of the experience before surgery or before a course of treatment. That doesn’t happen with the rigor it should. Instead, everyone, with all their different potential outcomes expectations, are lumped together. Meanwhile, the so-called patient satisfaction issues bear almost an inconsequential relevance to outcomes. I mean, if a doctor was able to make me walk again, but the nurse took forever to bring me my pain meds…well…I still think that’s a damned good outcome. Apparently not, in some value-based care models.
Good people are still trying to work out the kinks. Some good work has been done. Interestingly, value-based care advocates are also primary care advocates. They understand that someone’s got to coordinate care for the patient, and they are right.
But these models only work when cost savings are generated for a few very, very sick people in a value-based cluster of enrollees. If you impact a few very sick people, then on average, it looks like value was created for everyone.
The real issue with value-based care is that patients need to be more involved. And from a preventive care perspective, whatever the medical community is doing now to try to impact wellness isn’t working either. Employers have implemented all kinds of wellness programs. They’re ineffective. Why? Because just giving a patient information doesn’t mean they’re going to act on it. If you’re overweight, you probably know it. You don’t need a fancy wellness coach paid by your employer to tell you. And to think that this wellness guru is going to change your behavior by what – putting a gym on-site or giving you a $25 VISA card for eating at the cafeteria salad bar every day – like these empty gestures are going to work?
So we’ve got a medical establishment that can’t effectively motivate its patients, and then … a pandemic hits.
Covid-19 hasn’t helped build the public’s trust with the medical community. The sad irony is that so many doctors did absolutely heroic work fighting a brand new viral foe. Doctors relentlessly innovated, researched, tested, studied and cooperated. Despite the hundreds of thousands of deaths in America, countless other lives were saved by the efforts of our health care practitioners.
Yet the hubris of many physician leaders has been undeniable. Dictums came down about locking down, wearing masks, cleaning food, going out and staying in. The public has been very patient, because we all knew that we were operating blind at the outset of the pandemic. Most of us went along with things at the beginning because no one had any good data.
Now we have data. And there is considerable disagreement about what works to combat the spread of the virus and what’s necessary. Doctors are advocating on both sides of the argument and each constituent is using “science” to bolster their recommendations.
Well, the thing about facts is that they’re not up for debate. So when doctors speak out or advise policy makers and politicians who are trying to lead, using their interpretation of the facts, then they lose their impartiality. That fosters mistrust.
The global community is exhausted from the constant behavioral modifications that have been recommended to try to control the virus. People want their freedom. I suspect this will have a spill-over effect on multiple areas of society. I imagine that that as people interact with the American health care system, they are going to be even more frustrated with its care control mechanisms and restrictions.
One thing I have learned as I’ve tested market strategies for KnowThyself is that there is a significant patient consumer appetite for goods and services offered outside the traditional health care system. People want to make their own choices. Policy makers, employers and insurers need to take note.
There is a prevailing expectation that because people are paying so much for health insurance that they’re not going to use any of their disposable income for stuff outside the system. This is simply not true.
Employers and insurers have pushed more and more costs to the consumer. First, they jacked up insurance premiums. Once that plateaued, they started making deductibles higher. That means that not only were people paying high premiums every month, but they also have to pay out of pocket to access anything other than basic primary care services. So what are patients doing?
They’re spending money on stuff that they find value in. And much of it isn’t covered by insurance. Like:
23andMe. Or Ancestry.com. People do genetic tests because they’re curious. Sometimes they share the data with their doctor, sometimes they don’t.
They’ll do consumer-based over-the-counter lab tests like EverlyWell, or they’ll stop into a retail location like AnyLabTestNow. They may do this, even if their insurance might cover the lab work, because they’re concerned about privacy or speed or convenience. You can even send your fecal matter to numerous companies for a custom poop analysis. You can get your gut analyzed, your glucose levels modulated, your heart rate tracked, all via products available direct-to-consumer.
Where do patients find this stuff? The internet. And that’s where Dr. Google lives. Right out there, at every patient’s fingertips, is a wealth of information that patients sometimes use to try to self-diagnose. Real doctors hate it. Oh well. Google isn’t going anywhere.
A lot of these retail products bleed right into traditional medicine. The company Hims offers telemedicine to diagnose male issues, like erectile dysfunction. I’m not a guy and I am not a urologist, but that sounds like an automated Viagra dispensary to me. Well, if I were a guy, maybe I’d want an automated Viagra dispensary. Heck, you can get all kinds of medications on the internet that used to require a doctor to prescribe them. Again, it’s about privacy and convenience.
And then there’s Amazon, the company that has taken logistics to insane levels of customer satisfaction. Most folks are aware of their push into pharmaceuticals with their purchase of PillPack. It makes sense, because 90% of prescriptions are generics and Amazon can source this stuff and deliver it to patients better than anyone.
But they are also challenging the need for a primary care doctor’s office. Yes. Their initiative Amazon Care makes you wonder if you’ll ever have to go to a primary care doctor ever again. Why? Because he or she will come to you.
With Amazon Care, you type your symptoms into a chatbot and that routes you to telemedicine or dispatches someone to your home. You can imagine the logistical and legal challenges of having a stranger show up at your front door with a needle ready to draw your blood, but if anyone has enough money to throw at the problem, it’s Amazon. Anyway, the home visitor/nurse practitioner/doctor/phlebotomist does their thing, lab work is analyzed almost instantaneously and then you get your pills within the hour.
If you’re a doctor right now, how do you manage all of this? How do you balance treating patients with what their insurance will pay for versus what they can buy or access on their own?
Well, I think the best thing for the future of the medical profession is to untether itself from the payment system. Stop contracting with insurers so you can serve the people you want to serve, the patient.
Some doctors already do this. Concierge medicine and even direct primary care operate outside the health care system. Even some specialists have opted for a direct-pay model only. That’s great, but you’ve got to have the disposable income to access this sort of care. Not everyone does.
It would be much more beneficial for all patients if the AMA advocated for a two-system approach: one for Medicare patients, and one for everyone else.
The Medicare system serves the elderly. That payment system is well-established and it’s not going anywhere. The elderly have more acute health care needs and they’re the ones filling up hospitals. The patient group and the sites of care delivery are complex and it’s worth considering how to separate them from the rest of the system.
If you take Medicare patients out of the mix, you’re left with the privately insured, those on Medicaid, the uninsured and some other programs like veteran’s care. I think it would be great if the employer and the government gave patients an allowance to spend on health care. That allowance would have stipulations and I suspect working with a physician or recognized third party would help to ensure that patients got medical that was legitimate.
Assuming a liberal interpretation of the word “legitimate”, this approach would open up payment for almost any treatment out there –– not just the stuff that insurance companies or the government wants to cover. I think this would actually amplify the role of the doctor, especially the primary care doctor. Doctors could develop their practice based on the approaches they think work best and patients would partner with physicians who were aligned with the kind of care they want to receive.
This approach also helps address inequities in the health care system. Medicaid patients could access the same doctors as everyone else, because the doctors would set the rates, not the government. There would need to be some regulation on doctor rates so they don’t become astronomical. However, I definitely believe there should be some market-based variability in pricing. Good doctors deserve to be paid more if they feel it’s justified.
Of course just unilaterally cutting out health insurers is an unlikely scenario – at least in the immediate future. Nonetheless, the medical community needs to speak up. They need to take a more proactive role in structuring how health care should be delivered. Critically, they need to start listening to the patient consumer. Patients – never discount the value of a good doctor, because at some point, we’re all going to need one. Let’s just hope we can find one who’s aligned with our health care choices so we can be as healthy as we can be.
This is The Powers Report Podcast. I invite you to subscribe to our show. Check us out at powersreportpodcast.com. You can access over two years of podcasts on the website and communicate through the Contact page. I look forward to hearing from you. Thanks so much for listening!