Report: Don't let integration cause physician micromanagement

Physicians complain of clunky EHRs, meaningless quality metrics and bureaucratic barriers to patient-centered care.

As new owners of physician practices, many health systems are on a mission to integrate clinics with their hospitals. But many executives see the move as an opportunity to micromanage new clinics and physicians in ways that won’t improve care, according to a new report by Harvard Business School professor Robert Kaplan and fellow Derek Hass, a founder of Avant-garde Health.

“Maximizing patient throughput” is a big mistake, they write in a Harvard Business Review essay. “Yet health care executives force an increase in the number of patients seen by physicians each day by establishing productivity targets that limit office visits to fixed time periods, such as 15 minutes or a half hour. This apparent increase in productivity, however, is not sensitive to the impact of these seemingly arbitrary standards on patient outcomes.”

As regional and national hospital systems continue to grow by acquiring smaller inpatient facilities, primary care practices and multi-speciality groups, the public scrutiny on big healthcare institutions has picked up as most patients are paying more out-of-pocket than ever before.

At the same time, physicians complain of clunky EHRs, meaningless quality metrics and bureaucratic barriers to patient-centered care.

All of this is driving an impetus to deliver value to the paying patient and to free medical practitioners from the chains for fee-for-service.

“You’ll find that physicians can often achieve greater overall productivity by spending more time with fewer patients,” the authors said, giving doctors more freedom to spend time developing relationships with patients.

“It would be absurd to try to increase the productivity of musicians by having them play faster,” Kaplan and Hass said.

Financing for evidence-based dialysis  

One example they cite is chronic kidney disease. Many of these patients will eventually need dialysis, a service that Medicare covers for all age groups but at a fairly low rate that has created a lot of competition for hospital systems from for-profit chains like DaVita.

For years, the clinical research has suggested patients have better outcomes when dialysis is started with a fistula, a surgical connection of arteries and veins, or a graft, instead of a catheter. “Patients with optimal starts also cost tens of thousands of dollars less per year,” Kaplan and Hass note. “Yet more than half of U.S. dialysis patients today start dialysis suboptimally, with a catheter.”

Kidney specialists who have the time, even just 30 minutes, to counsel patients with advanced renal disease could increase the likelihood that they’ll start dialysis with a fistula or graft. Kaplan and Hass estimate that the cost of such “front-end counseling” would be less than 1 percent of the added expenditures of starting dialysis with a catheter, including the ramifications of blood clots and infections — complications that Medicare and private insurers do not want to pay for.

You’ll find that physicians can often achieve greater overall productivity by spending more time with fewer patients - Tweet this

“Even if only a small increment of patients initiated dialysis with a preferred method, the counseling time would yield a very high return in terms of future costs avoided,” Kaplan and Hass said. “The provider organization would capture those savings, because it is financially accountable for the total cost of the patient’s care.”

Another example of the return on investment on physician time for patients is in the booming business of joint replacement — so booming that insurers are increasingly trying to hold down costs with bundled payments or accountable care targets, or by discouraging patients from elective replacements altogether.

In their bid to improve outcomes, hospitals have often focused attention on managing the postoperative inpatient part of the joint replacement equation.

But Kaplan and Hass found “many missed a large and low-cost opportunity to devote more time before surgery to setting the patients’ and families’ expectations about the length of the stay and the place to which the patient was likely to be discharged (whether to home, a skilled-nursing facility, or a specialized rehabilitation center).” The clinicians in the hospitals with the most efficient costs spent more time with patients and their families before surgeries, Kaplan and Hass said. 

Clinician productivity key in the chronic condition economy

With chronic conditions like diabetes and heart disease -- the broadest growth area in healthcare where a lot of for-profit investment in primary care and technology is being directed -- clinicians surveyed by Kaplan and Hass mostly said they want more resources so they can spend more time with patients.

“If they could spend more time and money educating and monitoring their patients, the total spending on the patients’ conditions would decline dramatically,” the authors said. Health system leaders, though, often cling the traditions of fee-for-service, and often overlook these opportunities.

For hospital systems that want to be integrated delivery networks — retaining loyal patients, succeeding in non-FFS commercial and Medicare contracts, or owning their own health plan — freeing up clinicians from administrative bureaucracy may be worth a good look. Otherwise they may see their customers going elsewhere with their health needs and dollars, including retailers like Walmart or Target that are pushing into the medical services business.