There was good news for health plans and health systems at the inaugural conference for a new health law center at Yale Law School last November: Getting today’s newly minted physicians to accept value-based payment and ACOs—and the goals that go with them—may be easier than you think.
The happy tidings came from William Sage, MD, JD, a University of Texas law school professor and a professor of surgery and perioperative care at the university’s new Dell Medical School. He suggested that for a number of reasons, today’s young doctors are more receptive to managed care than were their predecessors in the difficult 1990s.
New modes of health care financing move away from volume and toward shared risk, says William Sage, MD, JD, of the University of Texas Law School. In that sense, the new generation of doctors has arrived just in time.
“We don’t really account for generational change when we talk about how professionals think,” Sage tells Managed Care. “Or we may react to just one aspect that makes us uncomfortable—saying, for example, ‘Millennials don’t work as hard as baby boomers did.’”
But it’s an important fact that today’s young doctors are different across the board, he argues. Their life experience has prepared them to be open to collaborating with other professionals and to delivering cost-effective, population-focused care—and if you are running a health plan, that’s really good news.
Sage says he was asked at Yale to talk about the effect of ACOs and other new delivery models on physicians, and that there seemed to be an implicit assumption that the effect was negative. “I thought that was erroneous,” he says.
Sage’s message fits into a developing picture of today’s young doctors that’s mostly—but not completely—reassuring. It recalls the largely enthusiastic verdict that E.M. Forster gave in Two Cheers for Democracy when he lauded popular government but withheld a third “cheer” because of its tolerance of mediocrity. Young doctors understand not just the Hippocratic Oath but also the need for prudent use of resources. Cheer! They play better with nonphysician colleagues. Cheer! And the missing third huzzah? Some observers fear that these savvy young docs—so adroit with anything involving a screen—may have lost something in personal skills at the bedside.
Why docs are different now
“I’m sure there are things we’re losing,” Sage concedes. “But it would be hard for me to suggest that anything we’re losing could outweigh the possibility of saving a trillion dollars of wasted health care expenditure every year in this country that could be used both privately and publicly for other really pressing and underfunded needs.” And by and large, he believes, today’s young MDs are ready to start chipping away at that trillion.
The roster of positives about medicine’s current generation? Here are some checks that Sage puts in the plus column:
- more willing to work in teams with other health professionals
- expect to be engaged in the community and to have contact with health care outside of the acute-care hospital setting
- more apt to move in fluid groups rather than rigid tribal categories
- more evenly distributed by gender
- much more comfortable than their predecessors working as part of a large organization
- less insistent on entrepreneurial independence, thanks to a desire for work–life balance
- much more comfortable with electronic information exchange
All of these characteristics, says Sage, make today’s doctors better suited to modes of health care financing and delivery that are moving away from fee-for-service and volume to shared-risk arrangements and incentives that reward value. They can be traced, in turn, to the ubiquity of computers and social media in the lives of today’s young adults and—to a limited extent—to important changes in medical education.
Computers, of course, lie at the heart of the rapid change in health care today. And we know from Eric Topol’s 2012 The Creative Destruction of Medicine that health care—just in time for these savvy new docs—is on the cusp of a “wondrous revolution” in which their data will help us all—eventually—live longer, healthier lives. But what does a skeptic say?
Cheers from a noncheerleader
It’s not fair to tag Robert Wachter, MD, professor and associate chair in the Department of Medicine at the University of California–San Francisco, purely as a health-tech Cassandra. He acknowledges computerization’s tremendous potential, just as Topol concedes its problems. But Wachter’s 2015 book The Digital Doctor did rain on Topol’s parade with a number of worrying examples showing that, as he writes, “health care’s path to computerization has been strewn with land mines, large and small.” So it’s interesting that this realist agrees with Sage’s good-news report on today’s young docs.
Young doctors “want appropriate professional autonomy—they don’t want to be treated as someone who can’t be trusted,” says Robert Wachter, MD, of the University of California–San Francisco.
“It strikes me as completely accurate,” says Wachter. “Certainly it’s true that younger people today don’t enter the field with an expectation of unfettered autonomy. It must be 10 or 15 years since I last heard one of my residents or students say, ‘My goal is to go out there, hang up a shingle, and be a self-employed entrepreneur’,” says Wachter.
Today’s young doctors are indeed “perfectly comfortable with computers,” Wachter says, but he adds an IT-related wrinkle. Older physicians are usually pictured as grumpy about today’s health IT while their younger peers are content with it, he says, but that’s not quite right. “Of course the younger doctors expect medicine to be digital,” he says. “But they’re just as unhappy as older docs with the state of digital technology in medicine, because it’s 15 years behind what they see in the rest of their lives.”
Glued to the screen
Wachter worries more than Sage does about the downside of today’s medical generation. “They grew up looking at screens, and perhaps texting their mother when she was one floor away,” he says. “Sometimes they’re perfectly comfortable sitting in front of a screen all day while their patients are two floors away wondering where their doctor is. That doesn’t mean they don’t care. But they’ve gotten used to the notion that most of their life comes in and out via that screen. And I wish we would bring back a little bit of the old sense that what a doctor does is spend a lot of time at the bedside talking to people and touching them. For some of the younger physicians, that’s not as natural an act.” Wachter sees a feedback loop taking hold: young doctors feel awkward at the bedside, so they spend less time there, and so get even more awkward at dealing with patients in person.
Tech-savvy young physicians can use their skills to forge collaborative relationships with patients, John Bulger, DO, of Geisinger Health Plan, says about fears that technology makes young doctors too distant.
John Bulger, DO, chief medical officer of Pennsylvania-based Geisinger Health Plan, agrees that this is a danger, but also offers a more optimistic possibility by flipping the issue on its head. “I’m 46, and I started in a paper world,” he says. “Doctors in my generation had to teach ourselves how to incorporate computers into care.” Precisely because they’ve grown up with screens ubiquitous in their lives through social media, phones, and tablets, he believes, today’s younger physicians “may be able to bridge that gap between the screen and the patient better.” Rather than seeming to divert their attention away from patients, they may be able to use computers and data as tools in collaboration with patients.
For all his concerns about bedside manner, Wachter praises the medical students he sees at UCSF as “incredibly bright and enthusiastic, with wonderful values.” He recalls ruefully one day when he addressed a group of them and, for some reason, was in a mood to shake them up. “You folks are entering a profession completely different from the one I entered 30 years ago,” he warned them in his gravest voice, “because you will be under relentless, unremitting pressure to figure out how to deliver the highest-quality, safest, most satisfying care at the lowest possible cost.”
Says Wachter: “One student raised his hand and asked: ‘What exactly were you trying to do?’ I remind myself of that when we’re going through these transitional pains. What’s odd is not that we’re being forced to think about value and get better at delivering it. What’s odd is that that’s new.”
Young doctors today are better primed for that “new” challenge partly because their conditioning and attitudes have changed, Wachter suggests. “Take the whole notion of systems thinking. The way I was socialized as a student and resident back in the ’80s was that the work of a doctor was to take care of the patient in front of you. It was somebody else’s job to create the system. In the last 10 or 15 years we’ve learned that the system is us.”
‘Health care delivery science’
It isn’t just socialization; young doctors are different today partly because their formal training is different. Many medical schools are adjusting their curricula to stress the principles and methods of team-based care, preventive and cost-effective medicine, and population health.
Since the 1980s, there’s been a lot of talk about medical education reform, but not much was actually happening, according to Sage. That’s changed. Now, curricula are being rewritten to include “flipped” classrooms (class time is spent on exercises while lectures are on take-home videos), online simulations, and competency-based education. The accrediting bodies have revised their standards, says Sage, and teaching methods have followed: “In the last five years or so, I’ve finally begun to see distinct changes not only in how medical students are taught, but also in what they’re taught,” says Sage, who applauds the AMA—which has always been considered the old guard of medical professional opinion—for supporting medical education innovators.
It’s a new day, says Susan Skochelak, MD, the AMA’s group vice president for medical education. Many medical schools now focus on what she calls “health care delivery science.”
“I do think it’s a new day,” says Susan Skochelak, MD, the AMA’s group vice president for medical education. The AMA has been working with 11 leading medical schools—and just added 21 more—to change the medical curriculum so that students come to understand the health care system, team-based care, and the requirements of population health, Skochelak says. She estimates that in participating schools, some 30% of curricula now focus on what she calls “health care delivery science”—methods of organizing quality, team-based care that are as rigorously studied as the efficacy of physical interventions. To make room for the new material, less time is spent reteaching the basic science already learned in pre-med undergraduate programs and “binge-and-purge” absorption of voluminous clinical facts “that change all the time when you get out of medical school anyway. ” Medical education is indeed adapting to changes in health care delivery, but it needs to change a lot more, says Catherine Lucey, MD. She’s a colleague of Wachter’s at UCSF, and says her article in the Sept. 23, 2013, JAMA Internal Medicine was a “call to arms” for change. For the most part, the article charged, medical education—however clinically and pedagogically excellent—remains stuck in an old model of care delivery in which “the personally expert sovereign physician … was autonomous, independent, and authoritative.” Fortunately, she says, a number of medical schools are stepping up to the challenge she issued.
“I think Dr. Sage and I are on the same page,” Lucey tells Managed Care. But she doesn’t mind being the “glass half empty” voice. While she agrees that new physicians are more open to accountability and team-based care, she says that in medical education “we need to up our game.”
Lucey lauds the innovative programs now under way at medical schools such as Vanderbilt, Penn State, and the University of Michigan. But she complains that “most physicians are still educated in a monoprofessional environment” better suited to a 1900s model when the doctor “was the team leader and was giving orders he expected all the others to comply with.” Such conditioning harks back to a day when the physician was the only medical professional in the room with an advanced degree, she says, and that “flies in the face of logic” in a time when there is advanced training for nurses, pharmacists, and often physical therapists and social workers.
Lessons for health plans
“We’ve learned from the mistakes of the 1990s,” Lucey says. Indeed, whatever one’s view about the mindset of young doctors, most observers seem to agree at least that their mindset matters. They’re not just cogs in an economic machine, and if some managed care systems in the ’90s appeared to treat doctors as if they were, that’s one of the mistakes the industry has learned from.
“Payment incentives tell only part of the story,” says Sage, and Wachter agrees. Indeed, both doctors describe a growing recognition that success in health care is a function partly of medicine’s culture, not just its economic structures.
“If all you do is goose the payment mechanism, you may get a trained-seal phenomenon where people jump a little higher because you’re paying them a little more to do so,” says Wachter. “But those changes won’t be real or durable; they won’t be embedded in the fabric of care. You’ll end up with a cadre of burned-out people who are not capable of innovation and enthusiasm and creating good doctor–patient relations because they’re not enthusiastic themselves.
“Today’s young doctors are perfectly comfortable working for large organizations and being members of teams,” he goes on. “They understand the importance of systems. But they do want appropriate professional autonomy—they don’t want to be treated like someone who can’t be trusted.” Organizations that find that balance are going to be the winners, he says, and will have better outcomes, happier patients, and lower costs.
Bulger, of Geisinger Health Plan—whose perspective admittedly may not be typical because of his plan’s close relationship with the dedicated Geisinger Health System—believes Wachter’s and Sage’s upbeat assessment of the current generation of physicians “has a lot of truth to it” and foreshadows good things for health plans. “The generation that’s coming out now understands that there’s a need for team-based care,” he says. “And I think that suggests that these doctors can help make collaboration between the medical group and the health plan side a lot more robust.”
When it comes to lessons for health plans, Sage is at first an uncharacteristically reticent prophet. “My sound bite about health plans is that they’re still trying to figure out what role they play in the future system,” he says. “This is a major area for them to think about, and each plan has to work it out for itself.”
But then he adds: “Look beyond the financial incentives.”
“To the culture?” he is asked.
“Yes, to the changing culture,” Sage replies. “And to professions beyond physicians, with greater confidence that they will work with physicians.”
Beyond the ‘iron triangle’
Coming of age in today’s era of health care, young doctors enjoy the benefit of something that isn’t strictly generational, but applies to all of us, young and old. There’s been a shift in the understanding of the core challenge of health care, says Sage. Thinking was organized around an “iron triangle” of cost, access, and quality. That was very offputting for many physicians, Sage says, whether the manifestation was government setting of limits or private companies “trying to figure out how to make money by saying ‘no’ to people, which to my mind is only a slight exaggeration of 1990s-style managed care.” (Sage hastens to add that he was a supporter of managed care then, and remains one.) He credits Don Berwick and his Institute for Healthcare Improvement with shifting the focus from grim discussions of rationing to waste and inefficiency, which have perfectly palatable, even inviting, solutions. Young doctors today believe they can help improve the efficiency of how care is delivered and the health of populations, not just individual patients, says Sage. “They feel these are challenges—regardless of the economic effects on them personally—that they can take on ethically and productively, challenges that seem consistent with the reasons they went into medicine rather than at odds with them,” he says.
Unlike their predecessors a half-century ago, today’s young doctors won’t have to be, or pretend to be, godlike figures. That should be a relief to them—and to the other health care professionals who work with them. But they will need to be as actively compassionate as they are computer-smart—meeting patients’ eyes with a reassuring smile—and to cooperate in treating America’s health care bloat as well as actively helping individual patients to stay well and lead full lives. They seem better equipped than earlier generations for the task, but we’ll know more when the next few years put them to the test.