It’s no secret there’s a wide chasm between healthcare and business, and even more so, between clinical medicine and healthcare administration. You’ve likely heard cautionary tales of providers who “went to the dark side” and chose administrative positions over clinical medicine, and there’s certainly no love lost between the two.

We have clinical providers of systems who want to give good patient care, and we have system administrators tasked with developing self-sustaining business that offers a quality product (i.e. healthcare) that consumers want and need.

East is East and West is West, and never the twain shall meet.

Much could be said about the origin of the divide, but essentially it boils down to the false economy developed by fee-for-service and third party payers with deep pockets. This system created extreme wealth but didn’t function like a real-world business. And the lack of normal economic boundaries caused costs to spill over into our population with devastating effects.

The goal here is not to focus on how bad off we are, but to shed some light on how we ended up here and what can be done to bridge the divide and move together toward the Triple Aim. In the following posts of this series, we’ll take a look at what’s needed from providers and administrators to begin the bridge-building process.

Where we are now

Before the ACA, business and the government (as well as the uninsured, in some cases) absorbed the majority of the high costs of healthcare. Now much of the financial dysfunction has shifted to healthcare consumers, making our general population acutely aware of the problem.

This article and other similar stories about life after the ACA further reinforce the gravity of the situation. The issue isn’t just a matter of who pays for healthcare; the problem is that healthcare is simply too expensive for everyone involved in the equation.

Cost creates a huge barrier for healthcare consumers to accessible, quality care, even if they have insurance under the ACA. The ACA made insurance affordable for some, but many still can’t afford healthcare in its current state due to high copays and deductibles.

A brief history lesson

It’s fair to say the dysfunctional relationship between healthcare administrators and providers is a disaster that has been decades in the making. Every system across the U.S. is struggling, but no one really wants to deal with the root of the problem.

Up through the 1980s, virtually no practice was owned by a hospital system. It was so easy to make a living as a doctor in those days that medical schools offered little, if any, business training for practitioners.

When HMOs came on the scene in the early 1990s, private practices became far less viable. Physicians began selling their private practices to hospital systems and became employees of those systems.

The problem is that because doctors weren’t well versed in business, they brought poor habits (and a reluctance to change them) into the more controlled environment of hospital systems. As a result, we started seeing the ramifications of the myths they (and by extension, patients) had come to accept about the care delivery process:

7 Care Delivery Myths

1. If a provider produces quality clinical care, his or her business is guaranteed to survive.

2. The patient’s expectations should control the visit in order for the provider to meet the patient’s needs.

3. Quality care demands a lot of time.

4. A good provider shouldn’t pay attention to time.

5. If it’s not expensive, it’s probably not quality care.

6. Socializing with patients is just as important as clinical effort.

7. If a provider is unable to see a patient, another provider (who doesn’t know the patient) can deliver the same quality of care.

This kind of mentality isolated business and clinical care and put them at odds with each other. It justified providers’ rejection of business norms—like efficiency, competition, and innovation—because they believed this kind of care was what a good provider should provide. But in reality, it came at a tremendous cost to their patients and posed significant problems for administrators.

There’s no such thing as a free lunch

In part to curb this kind of thinking, HMOs and Medicare began trying to establish some kind of connection between the level of clinical care and the cost of care for that level. This was the environment in which the “blank check” payment structure was created. Patients could go to as many providers as many times as they wanted and get any test they wanted—and a third party payer would cover everything. But because of the blank check, the healthcare industry never had much motivation to limit care in order to produce health or fix the lack of normal business parameters.

Fee-for-service and third party payers helped us survive the environment of the chasm for a while. But these factors, along with the continuing poor business practices of many providers, created an economic catastrophe for government, businesses and healthcare consumers. It’s also what ultimately led to our large uninsured and underinsured population.

Bridge construction ahead

There’s more discussion to come on this topic. We’ll look at other aspects of the issue—and practical steps to move us toward resolution—in following posts in the coming weeks.

The important point to realize is that we have to acknowledge the divide between administrators and providers. The problem is evident; now we have to fix it in order to achieve sustainable business and accessible, quality care.

To bridge the gap, we have to protect what’s critical for good clinical care while also protecting what’s critical for business to thrive. And both sides must be involved to bring about a truly successful solution that will bridge their two worlds.

Check out the second post in this series for a look at how providers can help bridge the gap by recognizing the poor business practices we often bring into the exam room.

It may be, but the road leading there has some challenges

As the team-based care model and its focus on care coordination expand throughout the world of primary care, so do the “coordinator” analogies. For example if you like sports, you might view the primary care physician as the quarterback of the team or the coxswain of the racing boat. If your interests run to music the PCP is the conductor of the orchestra. For cinema buffs, he or she is the director of the film.

To extend the analogy, it’s clear these particular coordinators would have a problem if, respectively, the offensive tackle decided not to block, the sweep refused to row, the first violin didn’t want to tune up and the star wouldn’t memorize her lines. You get the idea. Team-based coordinated care only works if everyone involved is open to being coordinated. When it comes to primary care medicine, the coordinated team includes the patient who, if we’re doing it right, is at the center of the whole process. And that’s exactly where we’re starting to see a growing concern.

As individuals and families covered through employee health plans or other forms of public or private insurance are becoming exposed to higher out-of-pocket costs for their health care, we can expect a corresponding increase in non-compliance based on financial pressures. It’s a simple equation. Less comprehensive plans and the higher co-payments and deductibles that go with them mean more and more people will make the decision to forego needed therapies, medications and procedures because they don’t think they can afford their share of the cost.

Given this scenario, what role can physicians play to improve treatment plan adherence in the face of healthcare sticker shock? To start with, we’re not financial advisors so a direct assault on the underlying economic concerns is not going to be part of our repertoire. What can be highly effective, however, is a more open approach to talking about costs before going forward with potentially expensive diagnostic procedures or ordering medications in those instances where it may not be affordable in either the short or long term.

In an excellent article on this subject in the New England Journal of Medicine the authors contend that having this kind of discussion is as important as sharing information on the potential side effects of treatment – with the belief that the anxiety created by financial concerns is a type of negative side effect in its own right. The article goes on to suggest a number of important reasons why a greater degree of transparency and open communication in the exam room has important benefits to patient outcomes, to the patient-physician relationship and to the healthcare system as a whole.

Care coordination is an essential element in the Patient-Centered Medical Home. Likewise, it’s a critical part of the way ACOs are going to work and the foundation of our ability to provide the right care at the right time in the right place.  But without the buy-in, literally and figuratively, of the patient and often the family, without the compliance of the person who’s at the center of all the coordination resources and efforts, the full promise of care coordination won’t be realized.

Talking directly about the cost of care isn’t something we train for and is generally not the easiest kind of conversation to have with patients. Beyond the possibility that they might range from mildly awkward to downright difficult, however, these discussions are becoming part of the way we should orient our view of the whole patient. And if we believe care coordination is the future of primary care medicine, or at the very least, a big part of it, conversations related to potential out-of-pocket costs are something we need to have. There’s that much at stake.

Chances are an Improvement Will Work as Well as a Re-invention

If you’ve followed previous blogs it won’t come as a surprise that I put a lot of emphasis on the exam room not only as a key element in an individual practice, but also as a critical step in strengthening primary care medicine itself. As the path to healthcare reform becomes increasingly difficult to clearly follow, it’s a safe bet that I’ll focus on the exam room even more as one of the aspects of the medical world over which we can actually exert control.

Of course, whenever we make changes in any part of the way we have practiced in the past there’s always going to be someone who tells us, “Don’t re-invent the wheel.” If you’ve been given that familiar advice lately, roll this over in your mind:

The research and engineering team that helped develop steel belted radial tires certainly didn’t re-invent the wheel. They didn’t even re-invent the tires that go on the wheel. But they certainly improved them. In the process countless lives were saved over the years from blowout-related accidents. And a lot of people never had to endure the stress of getting a flat tire on a dark and lonely highway.

There’s a pretty direct analogy with the exam room. What we’ve been doing has kept things moving along, but “road conditions” are getting more difficult. This is due to the increase in individuals with health insurance, the expanding population of older adults with multiple health issues and the increased demands of documentation. Let’s face it, the EMR has not been the panacea we hoped for with regard to improving either patient care or workplace conditions. All of these factors have melded into an increasingly difficult scenario.

There’s also that inconvenient shortage of PCPs that we read so much about. It probably stems from a combination of burnout and earlier than expected retirement as well as a growing lack of enthusiasm for Primary Care, a field that’s high on work load and comparatively shorter on reimbursement.

That’s why I keep talking about the exam room and the benefits of a coordinated team approach to care based on deep protocols, a physician willing to make changes and a well-trained and empowered staff that serves as a data gathering and information resource. A staff specifically trained to function inside the exam room to let you focus on patients, not computers. It’s not only a place to start, it’s a place where we can truly make a difference in a relatively short amount of time – especially when compared to the wholesale reconstruction of a broken healthcare system.

Clinicians tend to be intelligent and highly capable people. Most of us, however, are not inventors. But we can all be improvers. The good news is that you can be a highly successful physician on both a professional and personal level without re-inventing the wheel … as long as you keep making it better.