If you're like me, at national meetings you cruise the display booths in the convention halls trying to keep a finger on the pulse of the field. I usually come away weighed down with reports, freebie journals, and fliers. When eventually I recycle the build-up, I've often only benefited from the physical activity entailed in carrying around the extra weight.
At the Gerontological Society of America meeting last November (yes, I am that far behind in my reading), I struck gold. On an abandoned table in the back of the hall I found a series of policy briefs from The Maxwell School of Citizenship and Public Affairs at Syracuse University. Evidently the Maxwell School's Center for Policy Research also hosts the Syracuse University Gerontology Center and over the years has put out a series of policy briefs that include many aging and health issues drawn from presentations by some of the best in the field, including Beeson Scholars Sean Morrison, Tom Gill, and David Casarett; UCLA/RAND's Neil Wenger; and former Kaiser CEO, David Lawrence.
In future posts, I will more than likely return to this treasure trove for inspiration and ideas. But today, I wanted to mine Dr. Lawrence's provocative paper, Physician Sovereignty: The Dangerous Persistence of an Obsolete Idea. As readers of Health AGEnda know, the John A. Hartford Foundation believes very strongly that caring comprehensively for the complex needs of older adults is best done by high functioning teams of health professionals. But recently I have been very discouraged by a variety of physician voices emphasizing the wish to go it alone — to have both business and clinical autonomy — in Dr. Lawrence's terms, to have sovereignty.
Dr. Lawrence points out the consequences of this wish. Not only does it fail to address the complexity of the needs of an aging population, but he argues "the result is often confusion and poor care" . . . "when a patient with a chronic disease or complex clinical problem has multiple doctors, each acting independently, each making decisions that reflect his or her view of what's best for the patient. . ." Moreover, he argues that the idea of the physician as "independent entrepreneur" "stifles innovation in care delivery by forcing potential innovations to conform to the traditional autonomous physician model and depend upon the willingness of each physician to change."
Looking forward to health reform (from 2009), Dr. Lawrence articulated the agenda of the Center for Medicare and Medicaid Innovation:
Effective reform must include restructured financial incentives for collective care; accountability for quality and safety placed with institutions and groups in addition to the individual physician; and support for aggressive research and development into how to organize and deliver care to achieve the best outcomes at the lowest cost.
But he also describes the, so far, missing ingredient of health reform, reformed training of health professionals that changes deeply rooted cultural assumptions, like physician sovereignty.
Finally, reform must include a major effort to stimulate changes in the nation’s medical schools and health professions education institutions, with incentives to implement team-based education and problem solving, and innovative team-based care models, especially for the chronically ill.
A few years ago, I asked Richard della Penna, the former head of Kaiser-Permanente's Aging Network, why, with its fully capitated payment and a horizontally and vertically integrated delivery system, Kaiser's care of older adults was so similar to fee-for-service care. (And, truth be told, so similar in quality.) His answer was that Kaiser's providers were trained in the conventional health care system and its patient/members had the same conventional expectations.
Perhaps changing payment and regulation isn't enough; we also have to change peoples' minds.