Practice sustainability and physician satisfaction

Tuesday, July 01, 2014 12:36 PM

Kate Alfano, CMS contributing writer

Why many physicians are unhappy and what we can do about it

With 37 years as a physician and executive at Kaiser Permanente under his belt, Jay Crosson, MD, was on the verge of retiring to play golf and travel with his wife when James Madara, MD, the CEO of the American Medical Association, approached him about the AMA’s new strategic agenda. They wanted to do three things, he recalled: Get physicians more involved in quality improvement, change the nature of medical education, and deal with the question of why so many physicians seem to be unhappy and uncertain about what to do about it.

He agreed to take on the mammoth task and became the AMA’s Group Vice President of Physician Satisfaction: Care Delivery and Payment. Admittedly he had no idea where to start so he formed an advisory group of experts knowledgeable about practice in the United States.

Medicine has experienced a tremendous amount of change over the past few decades with the Affordable Care Act, changing patient demographics and the evolution of the science of medicine. All of this has created a situation that has left many physicians with a vague sense of anger and anxiety, Crosson said.

More than “physician happiness,” they had to “try to help physicians deal with what’s going on at the moment and try to improve that situation, and also try to help physicians prepare for what’s coming down the line in a way that’s socially responsible and ends up improving the quality and cost of care for the population.”

Professional satisfaction

Crosson and his team reviewed the literature on physician satisfaction but found it to be outdated. So they employed the RAND Corporation to design a field survey to take to 55 physician practices of various sizes and specialties in six states to determine what’s going on in these practices, what the problems are and how the AMA might address them. The resulting study – “Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy” – was released in October 2013.

The authors identified a number of factors or elements in and outside of practice that tended to statistically relate to satisfaction or lack thereof:

• The physician’s sense to be able to provide high-quality care
• Electronic health records (EHRs)
• Issues of autonomy and work control
• The nature of leadership
• The issue of collegiality
• Work quantity and the pace
• The ability to work with your staff
• Issues of income and practice sustainability
• Concerns with regulatory and professional liability concerns, and
• The unsettling effect of health care reform, at least in the minds of a number of physicians.

“To the extent that physicians felt they weren’t able to deliver the kind of care to patients that they felt they should be delivering as a professional overwhelmed every other issue and led to dissatisfaction,” Crosson said. “And to the extent that they didn’t feel this way, that they felt good at the end of the day about the care they were able to deliver, highly correlated with satisfaction.”

Additionally, the authors were shocked about the scope and scale of impact of EHRs on day-to-day practice. “There’s a general understanding among most physicians that the emergence of EHRs all in all is a good thing.” They understand the benefits but – “and the but is very significant” – almost every individual physician reported issues with data entry being too time-consuming, the user interface interfering with workflow, the interface interfering with patient interaction, the lack of information exchange with other providers, the expense of the system, and the fact that some of the solutions to the problems with EHRs have created more problems.

Since the release of the study, Crosson and his team have developed a work plan to address the discovered issues. The first element of the plan focuses on reversing the flow of the physician’s workday from administrative work back to patient care; recent data show that some physicians spend up to 50 percent of their workday performing administrative tasks.

They have also identified opportunities to make small but meaningful changes, like pre-visit planning, pre-visit laboratory tests, various forms of expanding the use of office staff, a systematic approach to refilling prescriptions for chronic medicines, changes to the EHR interface, lean techniques, and the use of scribes in certain types of practices.

“Not one of these things is going to turn your practice into nirvana overnight if you’re having problems but virtually every practice I’ve found can employ a set of these and make a profound difference.” Crosson recognizes that change is difficult. There have been many attempts over the years to change physician practices for the better but they don’t always take hold and grow.

“We also recognize that no matter how good we get at changing our practices, how efficient we get and patient-centered we get, there are still externalities that impact our practice or will impact our practice in the next decade and we have to do something about that.”

Next steps

The AMA plans to implement three projects to address these externalities. The first is a study that aims to understand the evolution of physician payment from the perspective of physicians so they’ll be able to help physicians understand what’s happening, project ahead and recommend a course of action. The second is a study on the consolidation of physician practices with hospitals. The AMA has teamed up with the American Hospital Association to discuss the enactment of a representative process for physicians to influence the direction of the larger organization. And the third relates to EHR usability and pressing the large EHR vendors to respond to physician needs. “As a profession and as organized medicine, we have the capability to do that and that’s what we’re coming to do,” Crosson said.

“There’s a lot that has been accomplished and much more that needs to be accomplished,” he said. “The goal here is to identify, support and grow the models of care delivery and payment that promote the long-term sustainability of and satisfaction with medical practice for our physicians, and lead to improvement in the cost and quality of American health care.”