Dawn of the planet of the value based

sunrise clark

It is the dawn of a new era.

Many cogs are now required to turn the wheels of our nation’s juggernaut health care industry. Physicians, historically the driving force in medicine, are not generally the “cog” type. This juxtaposition can have unhealthy consequences for all of us.

In his August Wall Street Journal article “Why Doctors Are Sick of Their Profession,” Dr. Sandeep Jauhar documented the pathology in our nation’s medical history. And while I agree with the good doctor’s diagnosis, I am not as comfortable with his treatment plan, which includes:

  1. “giving rewards for patient satisfaction”
  2. “replace the current fee-for-service system with payment methods such as bundled payment, in which doctors on a case are paid a lump sum to divide among themselves”
  3. “pay for performance, which offers incentives for good health outcomes.”

At first glance, Dr. Jauhar’s suggestions would appear to be reasonable measures. But employing such metrics may not sit well with our current physician workforce for a number of valid reasons.

In days past, the medical profession attracted highly intelligent practical dreamers in search of a career that allowed and rewarded unfettered blending of art and science; answering a “calling” that revered the heartfelt patient-physician relationship. If you were a “Renaissance man” or woman, crossing medicine’s threshold felt like coming home. Now in this modern medical renaissance, home is not necessarily where the heart is. Home is now inhabited by impostors masquerading as quality and value.

In days past, creativity and problem solving were vital to success in health care. Now strict adherence to guidelines, meeting quotas, and saving money for third party payers are paramount. Now the “rough spots” in the delivery line -physicians who view patients as individuals as opposed to populations – are being made smooth or else discarded.

Given a metric that determines their “bonus,” worker bees will instinctively aim for that mark. So if earning money to send their kids to college depends on getting a “five star” customer satisfaction rating, then expect health care professionals to make flashing a salesman’s smile the priority. Running a clinic on time will become more important than taking time to comfort that patient who’s problem unexpectedly deserves more attention than the automated schedule allowed…can’t risk upsetting twenty people for the sake of one, you know.

The story goes that Albert Einstein once wrote on his blackboard: Not everything that counts can be counted, and not everything that can be counted counts.

Regardless of the origin, this statement rings with truth. More than an observation, it is a challenge.


I held a hand the other day. There was no procedure code for it. It did not satisfy any quality metric. Truth be told, it was probably more beneficial and more appreciated than the epidural injection that preceded it.

We are living in the dawn of the planet of the value based. Students now embarking upon their medical school journey will emerge light years away from where they began. When they graduate and step into the blinding sunlight of the real world, will they even recognize it?

Or, as in the climactic scene from Planet of the Apes – when Charlton Heston’s character realized man’s demise was his own doing – will they cry out…

You finally really did it!

You maniacs!

You blew it up!



I hope not.

I will do what I can.

But, then again, I am a rough spot.



3 thoughts on “Dawn of the planet of the value based

  1. Who Determines Physician Effectiveness?
    Paul J. Hershberger, PhD1; Dean A. Bricker, MD2

    [+] Author Affiliations
    JAMA. Published online October 13, 2014. doi:10.1001/jama.2014.13304

    An excerpt:

    “…Because so many variables beyond physician control affect patient outcomes, relying solely on outcome data (or proxies for outcomes) to determine physician effectiveness may be both inaccurate and unjustified. There is a parallel with public school teachers who are increasingly evaluated using student outcomes, even though student achievement is affected by many variables other than the teacher’s qualifications and skills, such as socioeconomic factors. However, until better measures of overall physician effectiveness are identified, physicians, like teachers, must do their best to affect outcomes in the face of performance measures that are influenced by circumstances outside their control.”


  2. The Greater Louisville Medical Society’s President’s eVoice

    By Bruce Scott, MD
    From “Louisville Medicine”
    February 2015



    Health Care is Business, Healing is Art

    What do you call the head of a corporation with 38 employees, real estate holdings, web site and marketing plan, and an annual budget of over $4 million – CEO, chairman of the board, business man, how about doctor? I am a physician and the President and CEO of our six physician medical practice, a small business. I recently heard a quote that rings increasingly true: “Healing is an art, medicine is a profession, and health care is a business.”

    In fact, physicians are not only healers, caregivers and patient advocates; we are major drivers of our economy. A recent study by IMS Health (“The National Economic Impact of Physicians,” April, 2014) found practicing physicians have a $1.6 trillion economic impact nationally and an estimated $11.5 billion impact in Kentucky. Physicians in our state directly employ 85,000 individuals with wages and benefits totaling over $6 billion, and they pay local and state taxes totaling over $400 million. Physicians in metro Louisville employ an average of almost 14 full-time individuals, with over $1 million in wages and over $90,000 in taxes to our local economy. Spending on physician services accounts for only 16 percent of the health care dollars, and these expenditures have a positive ripple effect through our economy. Every dollar spent on physician services returns an additional $1.62 in other business activity, not to mention the improved health of our patients and the community.

    As the natural leaders of the health care team, regardless of the practice setting – solo, group, employed or academic – physicians need to develop leadership and business skills. Traditionally, the point of medical education has been to teach students and residents how to treat and care for patients (I wonder whoever came up with that idea) thus most graduating residents are not prepared for the business side of practice. When I finished residency, I, like most intelligent residents, let my spouse decide where we would live and I chose the practice I would join based upon who I wanted to be my partners – caring physicians, well respected surgeons and overall good people, not considering for a moment whether they were good at business or not.

    Physicians have long been so focused on taking care of patients (let’s be clear, that’s a good focus to keep) that they have ignored the business side of health care and turned the reins of leadership of medicine over to the administrators, the health care executives and the MBAs. As a result, the health care industry sometimes seems to have lost focus of the most important thing – the patients. The world of modern medicine has changed profoundly in a relatively short period of time. Health care has transitioned away from fee for service with independent doctors providing care to their private patients and moved toward “value based payment” and “pay for performance” provided to populations. Whether we like it or not, there is a general belief that therein lays lower cost and better quality.

    A variety of economic forces are driving numerous mergers and acquisitions and the migration of physicians from being independent practitioners to working as employees for large health care systems. Louisville has certainly been no exception. Regardless of our mode of practice, we can no longer ignore the financial implications of our decisions as leaders of the health care team. Physicians, as well as other members of the health care industry, naturally look at ways to improve overall effectiveness and efficiency but physicians alone bring a unique perspective because of our understanding of patients and their needs.

    The Greater Louisville Medical Society has become more connected with the Louisville business community through involvement in Leadership Louisville, our Community Connections committee and our Wear the White Coat experience. This fall, the Wear the White Coat experience again gave 20 high profile business and community leaders a behind-the-scenes look at medicine by affording them the opportunity to shadow GLMS physicians in their practices. GLMS created the program a number of years ago in the interest of building two-way relationships between community leaders and physicians. We want them to appreciate that physicians are part of the business community and to recognize the important role they as community leaders can play in improving the health of our patients. This year, I presented the economic figures detailed above. This program is called Wear the White Coat because each leader is provided a white coat to wear during the time with their physician partner. At the closing dinner each community leader spoke of his or her experience and observations. All participants explained how they were struck, some to the point of tears, by the very special bond that they saw between the physician and their patients.

    The few comments about the business side of medicine were only to express disdain for the administrative burdens that interfere with that bond. At first, I was frustrated that none of the participants commented on the impact of the business of health care; but after hearing each of them voice their respect for the healing and care that we provide, I realized that they truly had “worn the white coat,” a symbol of the values of caring and compassion so integral to the patient/physician relationship, and that they had recognized that the most important part of the profession of medicine is not the health care business but the art of healing.

    Bruce A. Scott, MD
    GLMS President




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