When Dr. Mark Cohen trained to be a doctor three decades ago, he learned that it was his job to handle every aspect of his patient’s care. Draw blood. Take blood to lab. Take patient to radiology. Read X-ray. Know latest in medical literature. Make diagnosis. Talk to patient. And if somebody else drops the ball? Your patient, your problem.
"It was a huge amount of responsibility, which was what we all signed up for," said Cohen, a heart specialist who practices at Piedmont Hospital. "I grew up in the 1960s and I watched 'Marcus Welby, M.D.,' and that's who I wanted to be. I wanted to be the doctor."
Paging Dr. Welby: Please report to the relic department. Medicine is now bigger than you are.
“It’s more than anything we ever dreamed it would be around 30 years ago,” said Cohen, whose specialty of cardiac electrophysiology did not even exist when he was in medical school. “The management of this is way beyond what one person can do.”
That truth is forcing a dramatic transformation of what it means to be a doctor and what it’s like to be a patient. Doctors are becoming corporate employees, with salaries, regular performance evaluations and rules about how they practice. Patients will be cared for by a team whose primary concern will not just be reacting to ailments but preventing them from happening.
Also due for radical surgery: the way doctors bill and receive payment. Instead of getting paid more for doing more — the current “fee for service” model — they will get paid more for doing better. Advocates of the new approach say it could save health care in America.
“We can’t go back to the way we practiced 25 years ago unless we want to become Greece or Italy, unless we want to bankrupt our country,” said Dr. Patrick Battey, a vascular surgeon in Atlanta. “We cannot afford it. We have to try to figure out a different way.”
Better quality, lower cost
Two fundamental forces are driving these changes, known in the industry as “integration”: first, health care costs too much, and second, this new approach yields healthier people.
“The glaring headline in this is that improved quality reduces the costs,” said Chris Kane, who heads business strategy for the WellStar Health System, a nonprofit that operates five public hospitals in Cobb, Douglas and Paulding counties.
Every test that is not duplicated, every infection that is prevented, every cancer that is caught early and every diabetic whose condition is kept in check becomes a less costly case. The proponents say that integration can achieve those outcomes and many more, over and over again.
WellStar calculates that the average cost of a hospital stay in its system declined by about $200 during the 2011 fiscal year, compared to 2010. That’s a remarkable result at a time when medical costs continue to spiral upward and an achievement that WellStar attributes to its integrated approach to care.
Slicing just that $200 off of every hospital stay in metro Atlanta for a year would save $85 million, Kane said, noting that the savings would pay health insurance premiums for 5,700 families for a year.
“In an industry of $2.5 trillion per year, even seemingly small improvements in health care can yield a significant impact,” Kane said.
The move toward “integration” worries some doctors, who view their independence as a sacred part of practicing medicine and who wonder whether the “health systems” of tomorrow will be more concerned with profit than patients.
Most doctors are already feeling pressure from the government, insurance companies and hospitals to change. Attempts to control spending in the Medicare program have already prompted some to give up their private practices. But the marketplace is a force in this transformation, too. Every insurance company and every employer who offers health coverage insists that something be done to rein in costs.
‘A whole different world’
The doctor’s change in assignment — from medical god to, say, captain of the team — won’t be easy for many MDs.
“Years ago, physicians really were not team players,” said Dr. Robert Jansen, president of the WellStar Medical Group. “The training was that you were autonomous and you did what you wanted and everybody took orders from you.
“It’s a whole different world now. Medicine is too complex not to do it in a team approach. And that team includes physicians, nurses, pharmacists and other therapists as needed. All of those people need to be participants — and active participants — in the care of that patient.”
Many longtime doctors read the Tom Wolfe book “The Right Stuff ” and identified with the book’s portrayal of Chuck Yeager, the ace test pilot who was the consummate solo performer. He flew alone at speeds few had ever dreamed of and was remarkably adept at turning an inflight emergency into a safe landing.
That was a celebrated personality type among doctors for years. Not so much today.
"If Chuck Yeager were flying a 747 now, it would crash,” said Cohen. “The plane is so complex that the pilots kind of can’t fly it. What the pilots do is monitor the systems that are flying the plane and they are highly trained to intervene when something is going wrong. But even then, they’re following protocols.”
Among doctors the change is most controversial for shifting medicine a bit more toward the science and a bit more away from the art. But those in favor of the change say that it no longer makes sense to indulge the “art of medicine” if that results in 100 doctors handling the same case 100 different ways.
"I think we need physicians who are more like John Glenn and less like Yeager,” said Cohen, referring to “The Right Stuff ’s” portrayal of Glenn’s methodical, by-the-numbers approach.
"If you were standing in the cockpit while the plane is landing I don't think you would want to hear the pilot say to the co-pilot, 'I'm going to show you my special way of landing a plane," he said.
"Everybody says they know how to land a plane. And you learn a lot in textbooks. But I'm going to show you my special way. I'm the best expert here and I know how to do this.' That is the Chuck Yeager mentality. That is the Marcus Welby mentality."
Doctors as employees
Some patients — and some doctors — are experiencing the early waves of change.
WellStar has adopted several hallmarks of integration — including hiring doctors as employees instead of simply extending them privileges to practice at its hospitals. The WellStar Medical Group began in 1994 with 51 employed MDs; today it employs 375.
Each uses the WellStar computer system for patients’ records. And WellStar closely tracks every doctor’s performance, whether a primarycare doctor’s ability to control diabetes or a surgeon’s ability to perform infection-free procedures. Patient satisfaction is monitored, too, through follow-up surveys by an outside company.
“It is a transition for physicians who have been in practice a number of years to suddenly have some feedback,” said Jansen, WellStar’s president. “But it isn’t delivered in a negative way. We assume physicians are going to deliver quality care.”
And that’s just one part of the change. When it comes to patients with complex conditions, doctors will find themselves with a lot of company.
For example, when tests suggest that a patient has lung cancer, the system’s STAT Cancer Clinic brings together a thoracic surgeon, pulmonary physician, oncologist and radiation oncologist to evaluate the patient on the same day and then gather in a room to discuss — and sometimes debate — the best options for that person’s care.
The new approach cut the average time from diagnosis to treatment from 64 days to 13.
“It is really about getting the patient to the right place quickly,” Jansen said. “The psychological burden of illness is sometimes as great as the physical burden. So if you can expedite that care, youhave improved care.”
‘A real wake-up call’
Something similar is goingon at Piedmont Healthcare —with an enormous effort towardintegration focused on the heart.
The Piedmont Heart Institute brought together specialists who had been competing against one another — and also competing against the hospital itself for the business of performing tests. The institute today employs 82 cardiologists, cardiac surgeons, thoracic surgeons and vascular surgeons.
The doctors have left the administrative headaches of running a small business behind and joined a team in which they agree, as a group, on the techniques and practices they will use when treating patients — even in cases where 10 doctors might all have their own approach to the same procedure. That kind of discussion is entirely new in Atlanta.
“Medicine has traditionally been a cottage industry where you have had a bunch of individual practitioners who have had a silo that they focused their attention and their efforts on,” said Dr. Battey, a vascular surgeon who is part of the Piedmont Heart Institute staff. “There wasn’t a lot of, ‘Let’s sit down and craft a treatment plan and a goal of therapy.”
The heart institute closely monitors patients — and individual doctors — with detailed statistics tracking results.
And Piedmont says the results support the theory that integration improves quality. The mortality rate for heart bypass surgery, for example, dropped from around 2 percent to 0.5 percent in a year, Cohen said.
“What we think happened was that the surgeons and cardiologists were together under one umbrella and became very comfortable talking to each other in ways they weren’t comfortable before,” Cohen said. “Stop and take a breath and pull the team together and discuss it and then move forward.”
In some cases, this shift means doctors must change the way they have practiced medicine for years. That change might be requiring a simple checklist or ordering a different approach to one part of a procedure. And it means that performance will be measured and that everyone will be held accountable. For years, before any hospital or doctors tracked their results, it was easy to boast about excellence.
“I love the feeling of putting on my white coat and walking into the hospital and walking into the office and being the doctor. That is pretty heady stuff,” Cohen said. “But what we have to realize is we don’t actually do as good a job as we think we do. In my role as chief quality officer for the heart institute, I try to pull out areas where you thought you were doing a great job and here’s the data. And oftentimes it’s a real wake-up call for the doctors.”
‘One size doesn’t fit all’
In his day, Marcus Welby could fit most of the tools available to doctors in his black bag. Today, those tools fill entire hospitals and more medical journals than Welby could read in a lifetime.
That explosion in medical knowledge and technology has happened over time, and has gradually increased what its costs to be a patient in America. The rising costs have caused the nation to ponder a new way over the years. Hillary Clinton and her husband made an unsuccessful stab at dramatic reform.
HMOs, once viewed as a possible savior, never managed to gain the confidence of a majority of patients after criticism that they were more focused on reducing medical spending than providing topnotch care.
Dr. Tom Bat doesn’t question that the nation’s approach to health care needs to change. But he’s wondering whether we’re headed in the right direction.
Bat isn’t trying to cling to the old days of solo practice and paper records. He manages a 15-doctor group that has been paperless for 15 years and developed its own software to track patients.
The practice has already adopted what many health care systems are just now trying to create — a team approachto primary care that includes physicians, physician assistants and nurses working together. Patient care coordinators are also on staff. The practice offers urgent care, Saturday hours and same-day appointments to try to keep patients out of the emergency room. They see as many as 500 people a day.
“We have created a model here that the hospital administrators tell me, ‘We’re trying to do that everywhere,’” Bat said.
But he worries about the pressures his team would face if it followed the trends and became part of one of Atlanta’s growing health care systems. He’s especially concerned about the way a system might interfere with the doctor-patient relationship.
“We know that diabetics that exercise or lose weight and eat right do better,” Dr. Bat said. “That’s easy."
But he envisions a time when government or health system rules would dictate that he complete a checklist every time he sees a diabetic patient: five minutes on a foot check, 10 minutes on diet, 15 minutes on exercise.
“I sit there and I say wow, I have spent 20-30 minutes on a patient that I really needed to be talking to about something else,” Bat said. “I have worked on that patient on diet and weight and smoking for years and years and years and the government is looking over our shoulder and saying you’ve got to do it this way. I think that is the doctor’s concern over evidence driven medicine. One size doesn’t fit all. The cookbook doesn’t apply.”
Concierge practices
The loss of independence isn’t troubling to many young physicians. Today, most medical students are taught to adopt a team approach.
“We were constantly told to incorporate multiple views — not to just figure it out on our own,” said Dr. Carolina Hsu, 31, a pediatrician at WellStar. “That is what is going to provide the best care for the patient.”
For some older doctors, the changes feel like a loss at a time when many are already struggling to keep their private practices solid financially. Medicare is threatening to slash already meager payments while also demanding that every doctor’s office make an expensive conversion to electronic records.
“I have been in practice for 25 years and I have seen a number of physicians who have retired, who said, ‘I sure am glad I’m getting out now,’” Battey said.
Many doctors today have already stopped taking new Medicare patients. Many others are thinking about it. Meanwhile, other doctors have set up “concierge” practices that require a monthly payment to get access to a doctor who has a limited number of patients and promises enhanced service.
Proponents of integration say that doctors who accept a loss of total control can reap great benefits. They can stop trying to practice medicine while also worrying about whether patients are paying bills, whether the computers are working and whether Medicare will hit them with yet another cut next month. And they can be part of a system that offers patients something better.
“If this is going to result in the triple credo of ‘Don’t hurt me, make me better and treat me well,’ how can you argue against that?” Battey said.
But sitting at the conference room table in his Alpharetta office, Bat isn’t convinced that medicine has found its holy grail.
“The health care system is going to change, you would be dumb not to know that,” he said. “The days of the one and two-man practices are probably over. We’re going to have some form of integrated delivery system, but the question I ask myself is — will we create a system that is to the benefit of the patient, the doctor, the nurse who works her butt off 24 hours a day?
“Or are we going to create a clinically integrated system that benefits the payers, the Wall Street players and the big administrators of the health care delivery system? If that is the purpose, if that is what happens, I think we as a country have lost.”
