Can We All Get Along?

On March 3, 1991, an infamous event was caught on videotape in Los Angeles. Rodney King, a parolee and construction worker, was beaten brutally by Los Angeles police officers following a high-speed chase. After the video went viral the police officers were arrested and charged with assault and excessive force. Following the acquittal of three of the four officers on April 29, 1992, there were riots in Los Angeles, with 53 people killed and thousands injured. It was during the riots that Rodney King, the lightning rod for these events, asked, “Can we all get along?”

I lived in Los Angeles during these difficult times and I was reminded of them when I read a recent article in The New York Times: “A Hospital War Reflects a Bind for Doctors in the U.S.” (http://www.nytimes.com/2012/12/01/business/a-hospital-war -reflects-a-tightening-bind-for-doctors-nationwide.html). The story is about the battle between two dominant hospitals in Boise, Idaho, that are in deep competition and together employ nearly half of the doctors in that part of the state. Physicians are bitterly complaining about the ongoing competitiveness, citing disruption of referral patterns, care driven by system financial-performance metrics and loss of autonomy for doctors. The real losers are the patients, whose access to choice in care has diminished and whose costs of care have risen. “First do no harm” is nowhere to be seen.

Although the hospitals involved deny any unintended consequences of the consolidated environment and acquisition of physician practices, the article drew a number of concerned letters in a subsequent issue of the Times (http://www.nytimes.com/2012/12/10/opinion/when-hospitals-buy -doctor-practices.html?_r=0). The president of the American Hospital Association weighed in, as did the president of the American Medical Association and several doctors and patients. The comments made one thing clear: getting along without losing sight of the ultimate goal—greater value in healthcare, better quality at a lower cost—is extremely difficult. Former senator Bill Frist, a heart-transplant surgeon, clearly articulated the direction in which I believe we need to go: “A more activist professionalism among doctors must openly counter the unspoken and unacceptable incentives that too often define doctor-hospital ‘productivity’ more in terms of financial gain than patient outcome.… In health care today, we are going through a tumultuous transition, with the new federal health reform law, escalating cost of health care, large mandatory cuts for doctors occurring in January, and certain reduction in Medicare financing in the fiscal-cliff negotiations. To get it right, all incentives…must realign solely around value to the patient.”

As general integrated care–management programs get formed, three entities are trying to do the organizing: hospitals, insurance companies and physician groups. The misalignment of incentives for hospitals is clear—when integrated care management has as a primary goal keeping patients healthy (that is, out of the hospital), this creates significant problems for hospitals. Insurers are better positioned since they are familiar with taking risks, but they often have to focus on utilization management to contain costs.

Physicians should be in the driver’s seat in this emerging world. Physicians can evaluate the best current medical evidence and do the appropriate testing and treating based on it. Whether you call this the application of comparative effectiveness knowledge or common sense, it is doctors who are best positioned to drive better clinical quality while controlling costs. Unfortunately, however, our track record of delivering on such promises has not been good except in a small number of physician groups. HealthCare Partners® is one such group, which is why we are so excited about DaVita HealthCare PartnersSM. The HealthCare Partners credo is that when you do what is best for the patient, you will be doing what is best for the organization.

So that brings us back to the beginning. In order for there to be truly integrated care, we all need to get along. That is the only way to achieve the triple aim articulated by Donald M. Berwick, MD, former CMS chief: better outcomes for the population; better health for the individual; lower costs to the system. Doctors, hospitals, payers and patients need to have aligned incentives and to be committed to holistic, patient-centric care. If we can do this, we can transform healthcare in America.

As Atul Gawande, the guru of the checklist in medicine said,

“[In medicine,] we have trained, hired and rewarded people to be cowboys, but it’s pit crews that we need.… Having great components is not enough, and yet we’ve been obsessed in medicine with components. We want the best drugs, the best technologies, the best specialists, but we don’t think too much about how it all comes together.”

Striving to bring quality to life,
Allen R. Nissenson, MD

Follow me on twitter @DrNissenson

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