Good Medicine Needs Good Business

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Earlier this spring, the Centers for Medicare and Medicaid Services rolled out new parameters for the latest “doc fix” of the Affordable Care Act (ACA), called the Medicare Access and CHIP Reauthorization Act, or MACRA. MACRA is complex, but the main objective is to ease the transition to quality-based care standards required by ACA. Health Affairs summarizes:

MACRA creates a payment system for physicians that will accelerate Medicare’s transition from fee-for-service to payment based on performance metrics, patient experience, and patient outcomes.

Legislation like this creates a new business of medicine within which all physicians are undeniably tangled. The pressure to drive down costs while increasing quality of care requires an understanding that is beyond the scope of traditional medical school curriculum. Nearly half of U.S. medical schools offer a combined MBA program to their students. However, this adds significantly more work and costs to students who are already bleeding for time and money.

NEJM Catalyst discusses the need for medical schools to incorporate business school skills in an article re-released today. Its authors provide the concept of an interdisciplinary clinical rotation as a possible solution:

In our view, the best learning experiences would be project-based, combining components of didactic teaching sessions and hands-on experience. The goal of the four-week course would be for the student to identify and solve real problems facing the school’s hospitals and clinics. By the end, students would have developed the business skills needed to lead multi-disciplinary teams, serve as contributing team members, and apply data analytics to improve clinical practice.

Let’s take a look at each of these initiatives.

First, physicians are called on to be both team leaders and team contributors. Health care delivery from solo practice is disappearing in the United States. On the rise are larger hospital groups or small groups in an office setting with physicians leading mid-level providers. Thus, physicians must utilize team leadership strategies to survive. A group lives or dies by the physician leader’s ability to gain and keep patients, motivate and engage a team, understand its strengths and weaknesses, develop a culture of constructive feedback, and ultimately find financial success. These are just some of the skills that a business-orientated rotation could help teach medical students.

But a good leader isn’t the only important element of a team. Physicians should learn how to be a contributing team member:

Many business schools use simulated environments to teach team dynamics and help participants learn how to develop team culture, set clear expectations, and communicate effectively. These abilities require emotional intelligence and deep understanding of interpersonal dynamics — concepts and skills that are essential to maximizing quality, increasing patient safety, and improving clinical performance.

Transitioning from fee-for-service to value-based care in physician reimbursement also puts pressure on doctors to be better self-advocates. They can no longer expect a strong salary simply by providing a baseline of services or tests. Addressing salary and negotiating a contract with metrics, expectations, and incentives can take new doctors by surprise. Knowledge of business would help physicians transition better from medical training to the real world, where making money requires more than just clinical skill.

Finally, physicians must become experts in data, or operational analytics. Electronic medical records have allowed us to create warehouses of quality and performance data. It is now much easier to connect doctors to their performance in real-time. This is really the meat and potatoes of approaching value-based care. In order to improve quality and cut costs, physicians must first ask the right questions:

As reimbursements drop, physicians in the future will need to identify opportunities to improve performance by decreasing bottlenecks in their offices, reducing patient wait-times for the operating room, modeling alternative treatments to determine the most cost-effective option for a particular patient, and performing statistical analysis to identify trends in patient quality outcomes.

Providing care is expensive. Despite being the number one spender of health care in the world, millions of Americans struggle to get the care that they need. But when physicians are called on for solutions, they should be adequately prepared to answer. Luckily, the AMA and other groups provide resources on the business side of medicine.

Medical school teaches future physicians how to make the right decisions for their patients, but this isn’t enough. Combining clinical and financial decision-making into a student’s curriculum could be a first step in the right direction.

Four weeks would be similar in length to the majority of other rotations, and an adequate amount of time to identify and examine a real-world problem. Students working in groups could conclude how best to increase the rates of screening for cancer or how they might streamline the hospital discharge process. This program would not be a complete business and leadership education. Like other fourth-year elective rotations, it would develop the foundation for lifelong learning in this area.

Better financial decisions for health care are made when physicians are at the table, so let’s give them the confidence and ability to pull up a chair.

Image: Physician’s Weekly

Why The New Restriction on Resident Hours is Bad and Good (or Actually May Not Make a Difference)

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On March 10, 2017, the Accreditation Council for Graduate Medical Education (ACGME) increased the limit on continuous resident hour shifts from 16 to 24 hours. Especially in the context of increasing rates of physician burnout, reactionary opposition began to spill into editorials, headlines, and podcasts. But before we break out the pitchforks, let me say that there is more than one way to view this situation.

Why It’s Bad

In 2003, the ACGME imposed shift restrictions after the premature passing of Libby Zion, an 18-year-old college student. Her death was attributed to the resident’s continuous 36-hour shift (although you can probably also argue for lack of supervision, according to the The Washington Post). In the wake of the 2017 reform, many physicians voiced their concerns about why sleep-deprived residents are a danger to both themselves and their patients. 

Why It’s Good or Might Not Matter

To support the new regulations, advocates have been frequently citing the conclusion of a study from the New England Journal of Medicine on surgical residents:

In surgical settings, most studies have shown no difference or a worsening in patient postoperative outcomes and resident education after duty-hour reforms. However, many studies have suggested that duty-hour reforms resulted in improved well-being and less fatigue among surgical residents.

This finding is controversial, because we also have to weigh the scale between the health of the patient and of the resident. The study also begs the question of whether we should have shift restrictions at all. Additionally, Johns Hopkins researchers argue that shorter shift times lead to an increased number of handoffs, which jeopardizes patient safety.

Of course, we still need to consider other factors. For example: specialty, location of practice, hospital/clinic bureaucracy, and individual expectations (e.g. I need time for naps daily…emphasis on “need”). These all chip at the balance between physician competence and patient safety. More studies and other means of evidence-based input are needed to better gauge the repercussions of instituting the reform (or removing it completely) on residents of different fields, their colleagues – including nurses, PAs, and others – and patients.

Image: RSNA