Editor’s note: This post is part of a Health Affairs Blog symposium stemming from “The New Health Care Industry: Integration, Consolidation, Competition in the Wake of the Affordable Care Act,” a conference held recently at Yale Law School’s Solomon Center for Health Law and Policy. Links to all posts in the symposium will be added to Abbe Gluck’s introductory post as they appear, and you can access a full list of symposium pieces here or by clicking on the “Yale Health Care Industry Symposium” tag at the bottom of any symposium post.
Whenever a wave of reform washes through the U.S. health care system, demanding greater coverage or lower cost, the effect on the medical profession is a paramount public concern. Will physicians’ skills be compromised? Or their availability? Or their independence? Or their ethics, usually meaning their loyalty to patients?
As Paul Starr described more than 30 years ago, the American medical profession has repeatedly fought off two potential sources of control—government and industry—and has only partially accepted a third source, patients themselves. Potential corruption of professional values arose in the debate over the Affordable Care Act (ACA) and remains relevant to its implementation. Fear of government compromising medical professionalism was aired most stridently in accusations concerning “death panels,” a politically motivated misrepresentation of a Medicare proposal to pay physicians for counseling patients about end-of-life care (which was very recently implemented). But it is also built into other provisions of the ACA, such as restrictions on using comparative effectiveness research to modify covered benefits, and it continues to drive resistance to launching the Independent Payment Advisory Board (IPAB).
With respect to corporate control, the ACA continues a pattern in federal health legislation of applying general principles of “managed competition” among health plans, but also conferring favored status on specific organizations directed by health care providers rather than insurers. To their supporters, accountable care organizations (ACOs) are presumptively more likely than commercial managed care plans to honor physicians’ professional values. However, nostalgia for physician omniscience and beneficence does not make the health care system more efficient or effective, and may even invite poorly conceived or badly managed organizations to feed at the Medicare trough. For example, some of the policy predecessors of ACOs—such as physician-hospital organizations (PHOs) and provider-sponsored managed care organizations (PSOs)—have not succeeded.
Accounting For Generational Change
In defending medical professionalism, reformers and the public have largely overlooked an important truth about physicians; indeed, about all professions. Professions invite us to imagine archetypes with deep historical roots (and, in policy debate, to assign them fixed political preferences). But as much as we imbue the doctor, the lawyer, the engineer, or the nurse with timeless qualities, professions are merely people. And those people change.
Generational change among the health professions is seldom acknowledged in health policy, in part because the political process relies so heavily on labels. Politicians seek support from groups, weighing one group’s apparent interest and ideology against another’s, while media coverage focuses more on the conflicts between groups than the diversity within groups. Moreover, interest groups typically represent the least innovative of their potential constituents, a bias that professional associations accentuate because leadership positions at the national level are earned only after years or decades of lesser service. As a result, the light they cast on the professional world often resembles that reaching earth from nearby stars: formed in the tumult of an earlier time and showing things as they were, not as they are.
When one accounts for generational change, the integrated, consolidated, industrialized health care system that health reform appears to be fostering becomes markedly less threatening to medical professionalism. Because of who they are, how they are trained, and what they believe about the goals and consequences of the tasks they are undertaking, the challenges of post-ACA medical practice are considerably more tractable and less ethically jarring for younger generations of physicians than for older ones.
Physician Thought Leaders
Over the past two decades, a noteworthy shift has occurred in the framing of health care reform, especially with respect to the quality and efficiency of service delivery. Although individuals with diverse professional and non-professional backgrounds contributed to this rethinking, physician leadership was significant in both forming and disseminating these ideas.
In the 1980s and 1990s, rapid growth in health care expenditures was generally attributed to the development of new medical technologies, for which U.S. health care was frequently touted as the best in the world. The challenge usually articulated for health policy during this period was to reach societal consensus on an acceptable balance among cost, quality, and access to care, which were portrayed as an “iron triangle” of political equipoise.
The late Dr. William Kissick, a Yale-trained physician who participated in the drafting of Medicare and later served as professor of medicine at the University of Pennsylvania, was among those articulating this perspective on health policymaking. His 1994 book titled Medicine’s Dilemmas: Infinite Needs Versus Finite Resources, summarized his view as follows: “No society in the world has ever been—or will ever be—able to afford providing all the health services its population is capable of utilizing.”
Kissick’s policy world was zero-sum, with technological innovation constantly adding to the store of science-based, medically necessary modalities of care. Consequently, access and affordability were possible only by sacrificing quality, or by explicit rationing of high-cost services. As society devoted more and more of its limited resources to health care, moreover, advocates for other causes “medicalized” those problems in pursuit of funding while profiteers tempted the physicians who authorized medical expenditures with “conflicts of interest” — both phenomena to be monitored and discouraged by policymakers. The best solution to these problems given the perils of continued medical inflation was a definitive political settlement similar to those that seemed already to have been reached elsewhere in the developed world.
While many of these issues remain important today, they are no longer the exclusive or even the dominant lens though which national health policy is filtered. Beginning with the small-area variation studies conducted at Dartmouth, and accelerating through the Institute of Medicine’s reports To Err is Human (1999) and Crossing the Quality Chasm (2001), a competing vision emerged that characterized American medicine as less scientific, more dangerous, and in urgent need of improvement. As the IOM concluded in its quality chasm report, U.S. health care was not, but had to become, safe, effective, patient-centered, timely, efficient, and equitable.
The physician leader most closely associated with this shift in thinking is Donald Berwick. A pediatrician trained at Harvard, Berwick reinvented the field of medical quality assurance while at the Harvard Community Health Plan, and went on to found the Institute for Healthcare Improvement (IHI). IHI is best known for formulating the “Triple Aim,” which is now the mantra for both community health advocates and those hoping to redesign health care delivery. The Triple Aim consists of the following: Improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care.
Unlike Kissick’s iron triangle of cost, access, and quality goals in eternal competition with one another, Berwick’s triad is synergistic and capable of simultaneous realization. This can be possible only if the current health care system, rather than being at the cutting edge of beneficial technology as Kissick imagined, is in fact far off what economists call the “Pareto frontier.” Instead of rationing, Berwick’s policy frame invites a massive reduction in waste and inefficiency by carefully measuring costs and outcomes, and by paying only for value achieved. It also directs physicians’ attention to the vast “upstream” domain in which people are not yet patients, emphasizing community-based prevention and self-help, as well as attacking social determinants of poor health at the population level. Significantly, achieving the Triple Aim does not require a national political consensus, only a policy environment that supports a sustained commitment to incremental improvement from within the health care system.
Innovative Medical Education
Medical education has turned an important corner as well. When I was a medical student in the 1980s, educational leaders mainly bemoaned what seemed to have been lost in physician training as money poured into medicine: spending time with patients, committing to the whole person and not one body part, relying on one’s own skills and senses, refusing unethical profits. But the best prescription these reformers could offer was the ideal of scientific medicine articulated in the Flexner Report, which remained the Bible for medical education nearly a century after its 1910 publication, notwithstanding indisputably massive changes in health care financing and delivery.
Medical education embarked on a new path in the mid-2000s, first changing how physicians learn and, more recently, changing what physicians learn. The causes of this shift in perception and commitment have yet to be fully explained, but they include generational change in educational leadership as physicians of Kissick’s vintage were succeeded by physicians of Berwick’s who recognized the health care system’s failings but did not yearn for a mythic “Golden Age” of physician stewardship. As University of California San Francisco Vice Dean for Education Catherine Lucey has observed, traditional medical education will not produce the physicians that society currently needs.
More concretely, educators were forced to acknowledge that medical knowledge had outgrown curricular resources, necessitating a conceptual overhaul of the four years leading to the MD degree. And the clinical enterprise within academic medical centers, which funds the vast majority of medical education, came under pressure to change in ways that the instructional establishment could not resist even if it had wanted to.
The result has been a burst of educational innovation, first within individual institutions but later with leadership from umbrella groups such as the American Medical Association (AMA) and the Association of American Medical Colleges (AAMC). In an increasing number of medical schools today, students do not spend two years in lecture halls memorizing and regurgitating medical science followed by two years of loose clinical apprenticeship. They learn the basics online, problem-solve in “flipped classrooms”; work in inter-professional teams; build portfolios; use “learning EHRs” for information exchange; demonstrate clinical competencies in both simulated and actual patient care settings; and achieve professional milestones.
Informed by both educational theory and real-world needs, curricular content increasingly includes professional identity formation; communication and teamwork; data analytics; population health management; quality and safety improvement; and health system redesign. Young physicians graduating from these programs are both capable of working toward the Triple Aim and eager to do so.
Speculations about generational change in society as a whole are frequent, difficult to parse, and impossible to verify. One is tempted to paraphrase a famous (and almost certainly apocryphal) exchange between F. Scott Fitzgerald and Ernest Hemingway: Post-millennials are different from you and me. Yes, they are younger.
Still, one can offer a few observations about recent generations of physicians. They are gender-diverse and want careers that offer work-life balance. They regard information, even professional expertise, as abundant and democratically accessible. Technology is a pervasive aspect of their personal and professional lives. Their social networks do not track traditional groups or hierarchies. They not only respect but expect patient autonomy, and they do not find medical consumerism off-putting. They think globally about health.
The new health care industry—integrated, consolidated, corporatized—-has been “challenging” in a negative sense to physicians who entered the medical profession in the 1980s and 1990s, who bought into Kissick’s assumptions about U.S. health care, and who experienced the educational orientation of that time. This generation of physicians was lectured about the virtues of becoming a primary care physician while every incentive pointed them toward specialization. They were taught to fear control by hospitals and managed care organizations, and were cautioned that they might never “have” patients but would “rent” them from others.
They learned to mistrust any ethical reorientation from individual patients to populations as obligating them to ration care at the bedside. They bristled under accusations of financial conflict of interest, fretted over the effects of quality “report cards” on their professional reputations and opportunities, and struggled to computerize their record-keeping. They worried about the economic viability of converting their small private practices from simple cash-flow models to complex payment negotiations that included risk-bearing.
Emerging generations of physicians, by contrast, see many of the same challenges through a different and more positive lens. Informed by the IHI’s Triple Aim and supported by an improved pedagogy, they do not insist on independent practice for its own sake and are comfortable working in large organizations unless and until they decide to pursue specific entrepreneurial opportunities. They are acclimated to inter-professional teamwork, system-based practice, and patient-centered care, and they regard these terms as more than mere buzzwords. They expect to have their performance measured and compared and to be paid for the value they deliver. They do not fear “big data,” and they see the health of populations as part of their clinical and social responsibility.
Evolving the medical profession to meet the expectations of the new health care industry will be neither a quick transition nor a foregone conclusion—any more than the transformation of our $3 trillion health care system to demonstrable value and improved population health is certain of success. But it would be a serious mistake to assume that medical professionalism and the structures and goals of the new system are fundamentally incompatible, despite a few pessimistic, typically older voices. Professions are composed of people, and the people who will practice medicine in the future see the glass as half full.