Physician, get with it thyself

Physician, get with it thyself

The emerging consumer-centric health care models are in stark contrast to what’s being left behind, and perhaps nobody understands that more than Ken Kleinberg.

Kleinberg, managing director of research and insights for The Advisory Board Co.

The title of Kleinberg’s presentation, “Goodbye Marcus Welby, Hello Retail Clinics and Empowered Consumers,” provided a clue of what the future holds. Kleinberg says the changes we’re about to witness ultimately will cause attitude adjustments among physicians who now complain that retail health clinics are not staffed by doctors, or that drugs actually are being sold where they are prescribed.

“It’s like a dinosaur complaining that the mammals are taking over,” Kleinberg stated.

As disruptive models develop over the next decade, providers had better respect the myriad of care choices that are becoming available to consumers. That comes with the territory as more Americans move into high-deductible health plans, a trend that is helping to usher in an era of health consumerism where patients bear more of the cost, and become more discerning buyers.

The resulting disruptive business models will replace the “we-will-bill-you” mentality with a “we-will-serve-you” ethic. Large retailers like Walgreens and Walmart are taking the lead with retail health clinics that have begun to deliver digitally connected, low-cost services.

No room for old-school

In his current position, Kleinberg specializes in helping healthcare stakeholders with IT strategy, including electronic health records, health information exchange, and mobile computing. This has given him a unique perspective into the disruption that’s now underway, especially the pockets of physician resistance that eventually will bow to the new consumer-driven reality.

“It’s really valuable to start thinking about where this industry can go if certain types of disruptions occur,” Kleinberg says. “Particular examples would be what patients can do by themselves with monitoring equipment and their iPhones and apps, and how might that mesh with what’s coming down from hospitals and providers in the applications and devices and approaches that they are taking.”

Kleinberg hopes these two worlds meet in the middle, but he says that will require “a little bit of acceptance from clinicians that the data and the interest that patients have in their own health could actually help them do a better job.” In an ACA world where the medical profession is more focused on outcomes, he thinks that acceptance will eventually come.

It’s not that physicians don’t understand that we’re heading into a patient-centric world, it’s that their experience with the doctor-patient relationship conditions them to distrust it. “I think what happens is that when patients go in and meet with their physicians, they are nervous, they are not feeling well, they are rushed, and they are in unfamiliar territory,” Kleinberg explained. “They don’t understand their bodies or chemistry and so forth to enough of a degree, and the jargon and terminology are, of course, very complicated.

“So when the physician is talking to them, they often get confused about their medical history — they get it wrong — and when physicians ask what drugs they are taking, they get it mixed up. I think over time, physicians believe that patients really aren’t in a very good position to manage their own health because that’s really the view they see, with patients not being particularly well educated or knowledgeable about those conditions.”

On the flip side, Kleinberg believes it would be a mistake to underestimate patients, especially when the emerging models give them more skin in the game, and therefore create financial incentives to become more astute. “If you give people clear education, if you give them the resources and the tools, most of them, over time — and this is the trend I think we’ll see — will pay more attention and do a better job.”

The physicians that are more willing to consider what patients have to say are the ones that consumers will migrate toward, Kleinberg asserted. The physicians who remain dismissive will force consumers to “vote with their dollars and their feet and go somewhere else,” he added. “At a certain point, a physician starts to think, `If I want patients, I’m going to have to be a little bit more accepting and give them a little bit more credit than I have in the past.’

“That’s not to say that patients won’t come in with absolute nonsense that they’ve read about somewhere because many sources are not particularly well founded, but we’ve got to strike a little bit better balance.”

Artificial intelligence gathering

Most people have no idea what’s coming in terms of medical knowledge modules and artificial intelligence in medicine, “especially the doctors,” Kleinberg said. He noted recent news accounts that a computer finally passed the Turing Test, which was invented to judge the capabilities as computers. The idea was to determine whether computers were discernable from humans, and recently a group of people could not discern between a 13-year-old youth and a computer.

The situation reminds Kleinberg, a licensed pilot, of the distrust pilots initially had with autopilot equipment. Now that autopilot has proven itself, flyers won’t go without it, and Kleinberg predicts physicians will have the same experience with AI and healthcare information technology. They will be using both as part of evidence-based medical systems, where care protocols for various conditions increasingly are embedded in computer programs that are right at their fingertips in the care setting.

“We’ve been stingy about applying AI to these systems, which could eventually cause a lot of disruption,” he predicted.

Value-less proposition

Kleinberg cited surveys that indicate consumers care less about quality and more about cost and convenience, which is well aligned with the consumer-driven model that retailers are beginning to exploit. “If you think that consumers care about the credentials and quality of their doctor for most of their routine and urgent care, forget it,” he stated. “They care about convenience and cost, and they view doctors as commodities.”

Kleinberg, who is considered an expert in medical management strategies, contends that providers will have to adjust because “we’re moving from a world where mobility is separate and optional to one where it is integrated and mandatory.” Noting that with his influential book, The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care, Eric Topol has taken a baseball bat to the clinicians of the world, and he’s hitting them over the head in a way that produces epiphanies. “Bam! You can’t expect patients to always come to you! Bam, patients have a right to see their own lab results!”

In many ways, the retailers they feel threatened by are taking advantage of a health care IT foundation that will enable the new age of consumerism. “We’ve finally gotten to the stage where most every provider has an electronic medical record, and so an increasing number of them are getting connected to each other,” Kleinberg noted. “We’ve got the trains and the train tracks, and now it’s time to figure out how to get patients to their proper destinations, safely and on time.”

Offering a physician’s perspective, Dr. Barry Chaiken, who served as chairman of the Digital Healthcare Conference, said the degree of physician acceptance depends largely on how they are paid. “If somebody is paid via fee-for-service, they are going to be resistant to somebody coming in and taking a piece of their market share. If they are not paid by fee-for-service, and they are paid on a salary, then they would be less concerned about somebody coming in and taking their market share. They are just going to do the work that they need to do.

“You very much saw that when they started to do payment reform around specialists and primary-care docs,” Chaiken added. “Primary care doctors were not as upset about it as specialists were because the reality is, it wasn’t going to impact the primary care doctor that much. In some instances, it would actually increase their reimbursement. For the specialists, who are highly paid by procedure, if reform was going to decrease what they were paid for procedures, they are obviously concerned with how it would impact their pocketbook.”

This is one of the reasons some observers believe specialists will be compensated less over time, but it’s not the primary reason people are concerned about a doctor shortage. Chaiken, chief medical information officer for Infor, cited the expense of medical school, where prospective physicians can rack up as much as $400,000 in debt, and he believes government needs to consider an investment in the future of medicine.

“If I was able to have a magic wand and say what to do, it would be to provide medical school to people for free so that they can choose what kind of specialties they are interested in, instead of choose specialties that can help them pay back the loan,” he stated. “Physicians can walk away with $300,000 or $400,000 in debt when they graduate from medical school, and then they still have three or four years of training. It’s kind of unfair for them to start repaying that debt and delay starting a family, buying a home, and all the other things a middle-class person would want to have, simply because they have this huge debt.

“They can’t go into pediatrics. They can’t go into family medicine. They need to go into high-paying specialties to pay back their debt. That’s crazy. We need high quality, well-trained, intelligent physicians across the board. We shouldn’t have a skewed system where we force them into cubby holes when they might want to be somewhere else.”