Helping Physicians Do What They Got Into Medicine to Do

Sep 25, 2014, 10:02 AM, Posted by Anne Weiss

“Health care was never intended to be the behemoth it's become. It was intended to be the place where people could get help for medical problems so they can return to living a healthy life.”

For me, this statement—from an internist I met last month—is a refreshing take on the value of the health care system in a Culture of Health. It’s an inspiring vision for those of us focused on the usual litany of problems: Our health care system costs too much, and delivers outcomes that lag behind other countries to such a degree that it threatens our economic health and social fabric.

Last year, the Robert Wood Johnson Foundation (RWJF) invested in five markets—Maine, Minnesota, Oregon, Colorado, and the St. Louis region—where there is the will and ability to measure health care costs and quality, and use that information to drive change. In each of these markets, we’re working with multi-stakeholder organizations who are members of the Network for Regional Health Improvement (NHRI). Each organization will produce reports that compare the cost of treating patients in each primary care practice in their market. (You can learn more about this project here.)

At RWJF, we believe working at community level, with many different people and organizations, can help build a Culture of Health. But when it comes to our health care system, physicians are still perhaps the most influential force, in part because they hold the power of the pen to order services. They (along with nurses) also are among the strongest political and moral voices for or against change. Granted, we can't ask our doctors to heal a broken health care system the way they treat a broken bone; on the other hand, I don’t think we can fix the health care system without having physicians on board.

I met that internist quoted above during NHRI’s two-day workshop with 16 primary care physician champions from the five pioneering regions. Our goal was to prepare them to help their physician colleagues back home to use the cost comparison reports to find ways to reduce costs and improve quality—in other words, to deliver high-value care. Some of these physicians had been nominated by community leaders; others were selected by competitive application. Some were veteran health care value champions; some were newbies. All willingly plunged into the complex details of cost measurement.

The physician leaders I met recognize that the current American health care system is financially unsustainable, and that health care is only one component of a Culture of Health.

They understand that our national overinvestment in health care is making it impossible for American industry to be competitive, crowding out investments in things such as education and infrastructure. I didn’t hear anyone say, “That’s not our problem as health care providers to fix.” These physicians know that big changes are coming in the way health care is paid for and delivered, and they seemed anxious for a forum in which they can talk with their peers about how to get ready for those changes. Most of the time was spent helping them think about how cost and quality data will help them lead change in their communities.

One very inspiring session brought together the hard evidence about what we’ve learned from neuroscience and other disciplines about how people use (and don’t use) information to make decisions, with a deeply empathetic framing of how physicians, especially, may respond to reports that compare their performance to their peers. I came away understanding more than ever that when you want people to change, it won’t help—and it may hurt—if you just show people (especially physicians) a pile of data and charts, or just offer to pay them more.

Physicians need to believe that the cost of care comparisons will help them do the work they hoped to do when they entered medical school, and that working with the comparisons “feels” like the right thing to do. It made me think about how I want the doctors who treat my family and me to escape from what was referred to as a “soul-crushing” system.

I also came away understanding much more clearly how the ground is shifting under physicians’ feet; as one participant put it, now that we are better able to measure outcomes, and now that those data are cheap, physicians no longer have infinite power and infinite responsibility.

One of our physician champions challenged us: “Show me something I can change tomorrow.” They all wanted concrete, actionable steps they can take, whether it’s changing their prescribing practices, when they order tests, or where they refer their patients for specialty care. I especially enjoyed a presentation from Sutter Health’s Mike Von Duren, who called himself the “midwife of the ‘aha” moment.” He brings data on variation—in prescribing practices, or diagnostic test ordering, or procedure rates—to community physicians. Mike described the way physicians digest the data, then turn away from the screen and toward each other; they begin to talk to each other and trade best practices—and they have fun doing it!

I was inspired and energized by the 16 physician leaders I met at the workshop, but on the way home, I couldn’t help wondering: Are they enough to change the health care system? Medical education is beginning to incorporate important concepts of health care performance and value but the problems facing us are too urgent to wait for a new generation of leaders. The question is how to extend the efforts of 16 physician leaders in five communities, across the nation. What will it take to get us there? I’d love it if you shared any ideas you might have in the comments section below.

Anne F. Weiss, a director for the Robert Wood Johnson Foundation, leads efforts to achieve the highest possible value from our nation’s investments in improving health and health care. Read her full bio.