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

Audit Contractor program, adoption of the Correct Coding Initiative in CMS programs, and intensifying the bundling of codes for previously separately reimbursed services.

      • State of Mental Health Services — In light of the prevalence of mental illnesses across all segments of the population and the interconnectedness with physical health, there is great interest in integrating mental health services with primary care services and especially with evolving efforts to expand adoption of the patient-centered medical home model across the nation.22 In 2006 the IOM’s Committee on Crossing the Quality Chasm addressed mental/ substance use (M/SU) issues identifying four critical problems with the quality of M/SU care, which included:

      — Failure to provide care consistent with existing scientific evidence,

      — Variations in care that occur when clear evidence on effective care is lacking,

      — Failure to provide any treatment for an M/SU illness or to address the risk factors associated with the development of these illnesses, and

      — Unsafe care.23

      In addition to intensifying human suffering, the failure to provide an adequate safety net and infrastructure to treat M/SU issues experienced by certain patients has resulted in increased overall health care costs to payers, both private and governmental.

      For those seeking care for mental illness, limited access and insurance coverage for services, stigma and discrimination is embedded in the overall infrastructure on a national level.24 In order to improve outcomes from those in the current fragmented system, physician leaders must drive strategic agendas forward to mitigate risks associated with the current bifurcated system, and continue to develop and implement integrated care models that equally meet patient population needs for both general health and M/SU care programs as recommended by the IOM.

      • Emerging Models and Innovations — A number of changes regarding new models of care and innovation are addressed throughout this book. The most pressing initiatives involve new models for care delivery along with innovative changes in medical education and the accelerated pace of technological advancements. Some of the care delivery model initiatives include patient- centered medical homes, accountable care organizations, and clinical integration programs. Payment reforms will transition the industry away from volume-driven are delivery to a pay-for-performance and value-driven model such as bundled and global payment structures.

      These paradigm-shifting areas and others will have tremendous impact on the strategic initiatives and patient care activities for physicians. Many interconnected health reform initiatives will have long-term effects on the U.S. health care system, and failure of the physician community to responsibly lead and champion health care reform and make effective decisions on how best to address these paradigm shifts will result in the de-professionalism of physicians. Physicians must support patient-centric advocacy efforts by maintaining an awareness of changes regarding privacy laws, patient rights, reporting requirements for increased transparency in quality of services delivered, along with reforms such as new regulations for accountable care organizations and the CMS Meaningful Use of Electronic Health Records (EHR). Without maintaining a strategic leadership presence physicians will lose their centuries-old high social status that is based upon a powerful relationship with patients as their advocates and healers along with a level of societal authority that has grown to transcend the boundaries of health care and move into economic and political domains.25

      Continued physician professional sovereignty will require a renewed focus on national policy initiatives as they pertain to patient care. The countless analyses published on the problems with the current health care system with various proposed remedies contributed to the language of the federal health care legislation of 2009 and 2010. However, the call of the IOM in Crossing the Quality Chasm in 2001 for the development of a 21st Century health care system was one that asserted a new system can improve, not just alter, health care by refocusing on the patient. The IOM declared that our health care system should aim to be safe, timely, efficient, effective, equitable, and patient-centered.26 These six aims have served as the underpinning foundation for many care delivery reform initiatives, research programs, and other transformational initiatives that have occurred or are under way across the country over the past decade. Sadly, the majority of physicians in American have read neither Crossing the Quality Chasm nor the IOM’s 1999 report To Err Is Human that focused on improving patient safety. The 2011 IOM report calling for leadership in nursing in the new health system ironically challenges physicians to intensify their leadership role in order to appropriately remain relevant in the national agenda.27

      The proposed agenda from the IOM Committee on Quality of Health Care in America calls on health care leaders to:

      • Design and implement more effective organizational support processes;

      • Create a national environment that fosters and rewards improvement;

      • Commit to a national statement of purpose and the six aims for improvement;

      • Adopt principles to guide design of care processes; and

      • Identify priority conditions to provide resources to stimulate innovation.

      The key tenets of this agenda have influenced much of the policy decisions of private and governmental payers over the past decade, and are radically changing the culture of American medicine.28

      As it was proposed a decade ago, this agenda led to the commitment to a national statement of purpose that is apparent through the multi-year effort that brought about the Affordable Care Act in 2010 and prioritized the conditions to be focused upon in national health care redesign. The IOM’s generation of a national dialogue endorsing an environment that rewards improvement, has catalyzed the move away from a volume-driven reimbursement system to one that is driven by and pays for performance and delivery of value-added services. A decade after the IOM publication, the health care community is still working to implement initiatives to meet the IOM’s goals. What will it take for physician leaders to achieve these objectives fully in the 21st Century?

      Setting the Stage

      Many people believe the nation’s physicians are ill equipped to manage the tsunami of change engulfing the health care system. Physicians must be prepared to collaboratively lead the multitude of health care reform initiatives, or succumb to becoming its victims. America will be worse off if physicians fail to take on the real leadership role required to improve health care delivery. The high position of respect and honor will be lost if others take up this important challenge in their place. Physicians face challenges that range from the individual practice level to the national landscape and by their very nature cannot be adequately addressed within the context of the traditional authoritarian, paternalistic role. Twenty-first Century health care should be physician-led, but patient-centered. In the paradigm shift, effective leadership will be collaborative rather than authoritarian and proactive rather than reactive.

      The original title of our book was From Hero to Duyukdv. The Cherokee language defines duyukdv (pronounced du-yu-(yo)-dv) as a way of living a healthy life by balancing the proper role of the individual with obligations to the good of the whole community. Duyukdv is a way of living within a culture with truth and dignity. As physicians struggle with the changes in power and authority in their current cultural role, duyukdv offers an alternative concept to the traditional heroic model of medical professionalism. The Cherokee believe that health is achieved by living a life of balance within society, in which one fulfills one’s social roles in a manner that is respectful of the meaning of that role for others, while taking care of one’s personal spiritual health as well. We believe duyukdv is an appropriate metaphor for what medical professionalism must embody in a healthy 21st Century health care delivery system. In Western literature, the traditional story of a hero is one of a journey. The 18th-Century bildungsroman specifically tells the story of a hero’s journey to his proper adult role. In our book, we use the duyukdv concept as an alternative metaphor in which the journey to professional maturity is a different path. Having personal freedom (within the role of physician) only through the context of responsibility to patients and others has always been part of professional obligation. However, in this new era of professionalism, the old traditional