MD 2.0: Physician Leadership for the Information Age. Grace Emerson Terrell MD

perverse financial incentives present across the spectrum of fee-for-service, capitation, and pay-for-performance reimbursement models, translate into moral hazard that impacts the physician-patient relationship directly.14 The inherent moral hazard of supplier-induced demand15 has given rise to the importance of pay-for-performance reimbursement systems and other value-based purchasing programs. Shared decision-making may mitigate the risks of supplier-induced demand, but it will not control the moral hazard of overutilization by insured patients without some market-dependent cost-shifting to patients from third-party payers, or provider-based global payment systems such as ACOs in which providers take on the risk of overutilization and underutilization.

      Reduction in monopolistic power. The monopolistic power once held by physicians has been eliminated by their need for access to capital to provide technology-based care, and the lack of ability on the part of independent physicians to take on substantial business risk. As the holders of capital and risk respectively, large health systems and insurance companies operate in an environment of scrutiny by the Department of Justice and the Federal Trade Commission, which monitor the pro-competitive and anti-competitive effects of mergers and acquisitions of physicians’ practices. In addition over the past ten years the rise of the information technology era has brought to the market an increased consumer awareness of the quality and cost of services provided by physicians. Combined, these issues have resulted in a decrease in the monopolistic power once held by the physician profession. Insured patients understand that they have more choices and therefore can work in partnership with physicians to make better economical decisions about the management of their care. The changes coming through federal and state health reforms will affect the competitive landscape for medical services throughout every region of the country.

      Changes in labor market for physicians and nurses. In the late 1990s enrollments for certain physician specialties in medical schools started on a decline. General surgery, general internal medicine, and family practice have seen dramatic declines. The increase in both status and life-long income for procedure-based specialists over generalists along with the high cost of financing a medical education created a precipitous drop-off in the primary care workforce. Simultaneously there are significant shortages forecasted to occur nationally in the nursing workforce.16 In light of this projection, in 2009 the American Recovery and Reinvestment Act (ARRA) identified a number of programs to increase educational funding to support growth of both junior and advanced nursing degrees.17

      These workforce trends have caused changes in strategy for how best to deliver optimal patient care services throughout regions of the country where the workforce shortages have had the most dramatic impacts. From the perspective of physician leaders, the shifts in power and autonomy in both clinical decision-making and administrative matters have been impacted more from the standpoint of necessity brought on by changes in the labor force than any other phenomena.

      Reflection Points

      As new innovations in delivery models and reimbursement models emerge, the health care industry will experience further shifts in the social power structures, levels of autonomy and control that affect the way health care services are delivered in the United States. The power held by physicians today has changed from that of the past, but their role is critical to ensuring improvement in quality, access, and cost of care. No longer will leadership derive from a position of autonomous authority. Rather, physician leadership will be dependent upon their power, knowledge, and skills to influence patient care at both the micro and macro levels. The rigors of didactic training and experiential learning positions physicians well for the role of ensuring quality of care for the patients and populations they serve. As clinicians, physicians are uniquely suited to leverage their skills to bolster their position as subject matter expert in clinical shared decision-making with patients and in health system operations.

      The physician’s unique professional identity can only be maintained by self-redesign of the profession. This professional redesign will require an introspective understanding of training curricula and how the physician culture should be shaped in the future to improve abilities to lead in patient-centric operations complex health care organizations, and at the national social policy level. The transformation will require continued review of the social and environmental forces that are stressing the physician community and the health care system. Regularly examining the current situation from the perspective of various strategic lenses (e.g., health-centric, economic, political, and social) can uncover changing trends in this complex adaptive system and the changes in communication and relationships that affect the effectiveness of higher quality care and improve patient outcomes in the future. Passive avoidance as a cultural strategy merely worsens strain on the system, and contributes to victimization and dysfunctional physician behavior. The transformation from the hero to the leadership role creates a new professionalism, a new way to serve in our communities, and to provide optimal care to those in need. This is duyukdv.

      References

      1. Starr P. The Social Transformation of American Medicine, p. 359.

      2. Starr P. The Social Transformation of American Medicine, p. 15.

      3. Magee, M. The Evolving Patient-Physician Relationship, Health Politics: Power, Populism and Health. Bronxville, NY: Spencer Books; 2005, p.36.

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      6. Starr P. The Social Transformation of American Medicine, p. 16.

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      8. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. pp. 221-225.

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      11. Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 2008 Jul-Aug;15(4):408-23.

      12. CMS-1345-P, Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations. Proposed Rule. II(B)3. Leadership and Management Structure. March 31, 2011.

      13. Medicare Payment Advisory Commission. (March 2011). Report to Congress: Medicare Payment Policy. Introduction and Chapter 1.

      14. Jacobs P, Rapoport J. Additional topics in the demand for health and medical care. In: The Economics of Health and Medical Care. 5th ed. Subury, MA: Jones and Bartlett Publishers; 2004. p. 86.

      15. Jacobs P. The Economics of Health and Medical Care. 5th ed. pp. 87-88.

      16. Institute of Medicine. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. Current Estimates of Primary Care Providers and Nurses. In: The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011. pp. 257-266.

      17. H.R. 3590, Patient Protection and Affordable Care Act, §5202. Nursing student loan program; §5308. Advanced nursing education grants; §5309. Nurse education, practice and retention grants (2010).

      Chapter 2 Summary

      Leadership Implications and Health Policy Considerations

      Leadership Implications:

      1. Recognize the primary importance of the physician-patient relationship and encourage practicing physicians to embrace and cultivate it as a partnership. Reflect upon the physician-patient relationship as critical to the legitimation of professional authority.

      2. Foster the development of collaborative relationships with nursing leaders and others from clinical disciplinary backgrounds.

      Health Policy Considerations: