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Chapter 2

Power Shift

When opportunities in a profession change, so does the profession.1

Paul Starr

Traditionally physicians have been honored with high status and respect. Those whose role it is to relieve suffering are valued highly in all cultures, as death and disease are a universal part of human experience. As the 18th Century scientific revolution advanced the tools of care with medical breakthroughs that provided relief of physical suffering previously undreamed of, the healer role became focused less upon the relief of spiritual suffering. The 19th and 20th Centuries saw surgeries performed with anesthesia, a rapid deceleration in death associated with childbirths, and infectious diseases remedied with antibiotics. As the professionals who controlled the means to new treatments and interventions, physicians assumed a prestigious social status that was typically accompanied by a generous level of wealth. However, in the last quarter of the 20th Century a shift in the health care ecosystem has taken place that has impacted the physician’s social status, authority, and prestige.

One of the drivers for this shift has been the advent of information technology. Technological innovations have re-balanced asymmetries of information access between physicians and patients along the continuums of care. In order to operate with maximal efficiency, the highly complex health care delivery system requires integrated knowledge management in a patient-centric context. With this technology-induced change comes a transformation in the culture and a necessarily fresh approach to relationships with peers and teams, new collaborative problem solving, shared leadership, and shared decision-making. This cultural transformation is a shift in power traditionally held by physicians in their professional role from one focused on authority and autonomy to one focused on leadership and collaboration.

There are four areas in which the locus of control in the health care delivery system will alter the medical profession. First, the physician-patient relationship will continue to undergo significant changes. In 1982, Starr identified three claims to be met for the “legitimation of professional authority”:

• Knowledge and competence is validated by peers;

• The validated knowledge and competence rests on a rational and scientific basis; and

• The professional’s judgment and advice are structured around relevant values.2

The exponential expansion and availability of information brought about through the Internet permits direct access by patients to medical information while also permitting the expansion of evidence-based medicine with clinical decision support. As patients and physicians interact in an information-rich world, the peer-validated knowledge and competence of professional authority is challenged by the open, consumerist culture of the Internet. Second, social and structural authority of physicians with peers and clinician team members has been impacted through the use of electronic health records and other health information technology solutions and has shifted the balance of power and responsibilities in the care delivery process.

Third, the authority and autonomy of physicians in their clinical role does not necessarily translate to similar authority in the health care organization in which they work, as the industry continues its transition away from its cottage industry culture to one based in corporate infrastructure. The governance of corporations depends upon boards of directors and professional managers. So the shift in power created by the corporatization of medicine reinforces the need for business acumen and education in management if physicians are to have a seat in the boardroom.

Fourth, economic trends over the past four decades directly contribute to the loss of autonomy by physicians. These trends include changes to the principal-agent relationship, reduction in monopolistic power, and changes in the health care labor market.

In light of the complexity of the U.S. health care system and changing global economic landscape over the past quarter century, these trends have contributed to shifts in the physician’s authority and control over health care services. While health reform initiatives are developed and approved for application at federal and state levels, the implementation of new policy takes place at the micro level in regional integrated delivery systems, multispecialty groups, physician hospital organizations, and clinically integrated networks.

Physicians have less autonomy today in the past, and in many respects their span of control is changing as well. The demographic and economic pressures driving health care reform ensure that these changes will persist. A great deal of status anxiety among physicians is driven by these factors, so transition to a position of leadership within the evolving industry requires physicians to take on new roles and skills tat translates traditional authority in forms that are congruent with the new needs of patients.

Physician and Patient: A Shift in Position

Consumer sovereignty is impacted by the advantage physicians possess in the asymmetries of information and medical knowledge with patients. Internet access has altered but not eliminated this asymmetry. Patients still rely upon their physicians to diagnose and recommend treatments based upon their clinical experience, which necessitates a compact intrinsic in the relationship, based upon trust by the patient in professional judgment and ethical behavior. In 2002, studies in six countries on four continents revealed that the citizens of all countries viewed the patient-physician relationship as second in importance to family relationships. The patient-physician relationship scored higher than spiritual, financial, and co-worker relationships. While the relationship has always been highly valued, it is certainly not static. In all countries studied, the relationship was rapidly evolving. Authoritarian, paternalistic relationships, where “doctor says” and “patient does,” are increasingly in the minority. They have been replaced by collaborative partnerships with 50/50 decision-making, and advisor relationships where the physician serves as resource and guide, but patients take responsibility for decisions on their own health care.3

Since the 1990s, the health care and medically related information available to the general public via the Internet has grown exponentially, bringing about a shift in the balance of information accessible to consumers. Increased transparency of cost and quality information on physician and hospital services is resulting in a stronger base of knowledge possessed by patients. Consumer-directed tools such as Vitals (www.vitals.com), Health Grades (www.healthgrades.com) and the Department of Health and Human Services Hospital Compare website (www.hospitalcompare.hhs.gov) are but a few of the web portals that have emerged in the past ten years to provide consumers with improved information to make more informed choices about the health services they need.

Just as patients have gained access to better information to improve their own decision making, so too have the tools improved for physicians to support clinical diagnosis recommendations and orders for better quality medical care. Using the best knowledge to identify what to do and how to make it part of routine practice may appear obvious, but studies indicate it takes up to 15 years for medical knowledge to become incorporated into routine medical practice. Unexplained variation in clinical practice is prevalent throughout all clinical settings such that the integration of content and context is seldom ideal. Evidence-based medicine provides a bridge between science and bedside application for the practicing physician that can serve as a pathway to transition practice guidelines to a more precision-based and scientifically rigorous methodology. Use of evidence-based medicine should ensure that patient care adheres to clinical best practices and improve the health of communities. However, with evidence-based medicine and evidence-based management there are perceived threats to autonomy and control in clinical decision-making, difficulty in accessing the evidence base, and difficulty differentiating useful and accurate evidence from that which is inaccurate or inapplicable. Integrating evidence-based medicine practices into clinical guidelines requires physicians who are able to draw upon the evidence to improve the quality of care being delivered.4

One of the most important changes to emerge in the past two decades in the physician-patient relationship has been the increase in shared decision-making. The Institute of Medicine’s objective for patient-centered care cannot be achieved without a shift in asymmetries of information. Godolphin notes that there are a number of strategies for physicians to engage and barriers to overcome in shared decision-making situations with patients:

• Understanding the patient’s preferences, values, beliefs, and expectations;

• Establishing partnership approaches / philosophies to relationships with patients that position themselves as a mentor and advisor when needed in the patient’s clinical decision-making process;

• Helping patients develop and recognize choices in meeting their medical care needs. (while the gap in asymmetries of information has closed, the physician’s clinical training and experience will always hold value beyond that which can be absorbed by the lay members of society);

• Planning to devote more time to shared decision-making processes with patients; and

• Recognizing and respecting the patient’s decisions. 5

For the physician leader this shift in power in the physician’s relationship with patients is one that has organizational and managerial implications. Following practice guidelines or meeting requirements for administering services at hospitals may require certain physician behavior ad communications to adhere to established risk management, quality, or safety policies. Integrating shared decision making into practice policies will be a cultural shift for every organization.

Information Technology and Autonomy

One of the single most important elements that has impacted the shift in the power for physicians in the past half century has been the influx of technologies in the health care industry. Robotic surgical instruments, diagnostic devices and systems, electronic medical records, health information exchange, data analytics, and new coding languages, have given rise to new capabilities and power to the physician community while simultaneously reducing their control in the social structure of medicine held for so much of the 20th century. Starr notes:

…the most influential explanation for the structure of American medicine gives primary emphasis to scientific and technological change and specifically attributes the rise of medical authority to the improved therapeutic competence of physicians.6

The advancements made through technological change have enabled many of the industry’s breakthroughs and life-saving accomplishments, but also challenge physicians’ professional control. Just as robotic surgery changed the capital requirements of hospitals, decreased recovery time for patients, and required new technical skills for surgeons, so too do populations management strategies dependent upon health care information technology in the community setting alter the role of physicians. The introduction of new technology within the clinical work environment always alters processes and has unintended consequences.

A study by Campbell, Sittig, Ash and colleagues identified a set of nine unintended adverse consequences that result from the introduction of computerized physician order entry systems. Of note, the unintended power structure shift from physicians to others is based upon their loss of control over information.7

The shift in control of information has led to an increase in leadership roles held by nurses in the care delivery process and administration of health care organizations. Nurses make up the largest segment of the health care workforce and, as their responsibilities have grown to accommodate the needs of delivering patient-centered care, academic initiatives are focused on strengthening the education level of the national nursing workforce. This is resulting in a growing number of nursing leaders working in partnership with physicians to redesign the health care delivery system and processes.8 A number of factors are driving this change:

• The social architecture and fabric of health care organizations has changed. Nurses are increasingly being called upon to shape health policy, implement new systems, and to serve as change agents throughout the health care ecosystem.

• Health information technology tools have increased the need for shared responsibilities in managing health information at the patient and population level.

• The patient population continues to increase through demographic and socioeconomic changes that will drive the need for additional collaborative clinical leadership in managing care delivery programs and organizations.9

While some will view these changes and structural shifts in power as threatening, physicians will maintain a position of leadership within the shifting organizational culture by leveraging their professional training and fiduciary duties in a contextualized manner appropriate for the new working environment.

A concept that helps provide a deeper understanding of the complexity of power shifts is the interactive sociotechnical analysis (ISTA) introduced by Harrison and Koppel in 2007.10 Computerized provider order entry and other health information technology systems all involve transforming the clinical workflow processes within organizations as they are implemented. Throughout the process of design, test, implementation, and eventual future-state use of a new application, clinician-ancillary-administrative team members are engaged with physicians to ensure that benefits are realized from the new tools to meet goals for improving outcomes, cost, quality, and safety of patient care. Harrison and Koppel indicate that, throughout this process, relationships and communication are impacted by the dynamics involved with changes in workflow and the new systems. New triggers, alerts, and in some cases workarounds11 can emerge that inadvertently result in shifts of roles and actions that can impact quality and safety in patient care operations. Application of Harrison’s and Koppel’s ISTA model can be used to understand the requisite policy changes that are necessary to accommodate new workflows, approvals, communication patterns, and roles of various professionals in the health care system.

Physicians in the Boardroom

Even into the 20th Century physicians have operated in a cottage industry environment, but economic necessity is bringing to a close the era of smaller independent physician practices. With this industry transition, the importance of having physicians operating in the governance and leadership of the new health care corporate institutions has become a priority. Most recently CMS’s proposed rule for the new Medicare Shared Savings Program12 calls for physicians to be engaged in leadership within the governance structure of accountable care organizations.

In academic medicine the traditional positions of power continue to be held by physicians. The physician’s knowledge, skills, and ethical responsibilities have emerged as essential needs for the spectrum of other organizational types that operate in the health care ecosystem. Companies ranging from biotechnology start-ups to managed care organizations and government agencies are calling upon physicians to take leadership in order to create sustainable health care institutions.

Health Economics of the Shift

In 2011 the Medicare Payment Advisory Commission’s (MedPAC) Report to Congress provided an updated picture on the restated long-term outlook for cost growth of Medicare spending first through 2019 and then through 2035.

Given these projections, it is noteworthy that MedPAC’s top reason for the growth in health care spending over the past four decades is advances in technology. In that dynamic, the physician’s role as an autonomous decision-maker for utilization of such technologies will continue to be challenged. The exorbitantly high growth in costs will continue to push a regulatory response and a reform agenda such as value-based purchasing, bundled payment systems, and across-the-board cuts in fees. As the rapid backpedaling on the Ryan Plan by the Republican-controlled House of Representatives illustrates, a focus on the consumer-side of the equation is far less politically palatable than that focused upon the providers. Thus, physician leadership must understand the impact that economic trends will have upon the profession from a comprehensive standpoint.

Changes to the principal-agent relationship. Agency theory formulates the concept of the principal (patient) and agent (physician) relationship that should be the foundation of patient-centered decisions and programs. The economics of health insurance benefits structure, and intrinsic perverse financial incentives present across the spectrum of fee-for-service, capitation, and pay-for-performance reimbursement models, translate into moral hazard that impacts the physician-patient relationship directly.14 The inherent moral hazard of supplier-induced demand15 has given rise to the importance of pay-for-performance reimbursement systems and other value-based purchasing programs. Shared decision-making may mitigate the risks of supplier-induced demand, but it will not control the moral hazard of overutilization by insured patients without some market-dependent cost-shifting to patients from third-party payers, or provider-based global payment systems such as ACOs in which providers take on the risk of overutilization and underutilization.

Reduction in monopolistic power. The monopolistic power once held by physicians has been eliminated by their need for access to capital to provide technology-based care, and the lack of ability on the part of independent physicians to take on substantial business risk. As the holders of capital and risk respectively, large health systems and insurance companies operate in an environment of scrutiny by the Department of Justice and the Federal Trade Commission, which monitor the pro-competitive and anti-competitive effects of mergers and acquisitions of physicians’ practices. In addition over the past ten years the rise of the information technology era has brought to the market an increased consumer awareness of the quality and cost of services provided by physicians. Combined, these issues have resulted in a decrease in the monopolistic power once held by the physician profession. Insured patients understand that they have more choices and therefore can work in partnership with physicians to make better economical decisions about the management of their care. The changes coming through federal and state health reforms will affect the competitive landscape for medical services throughout every region of the country.

Changes in labor market for physicians and nurses. In the late 1990s enrollments for certain physician specialties in medical schools started on a decline. General surgery, general internal medicine, and family practice have seen dramatic declines. The increase in both status and life-long income for procedure-based specialists over generalists along with the high cost of financing a medical education created a precipitous drop-off in the primary care workforce. Simultaneously there are significant shortages forecasted to occur nationally in the nursing workforce.16 In light of this projection, in 2009 the American Recovery and Reinvestment Act (ARRA) identified a number of programs to increase educational funding to support growth of both junior and advanced nursing degrees.17

These workforce trends have caused changes in strategy for how best to deliver optimal patient care services throughout regions of the country where the workforce shortages have had the most dramatic impacts. From the perspective of physician leaders, the shifts in power and autonomy in both clinical decision-making and administrative matters have been impacted more from the standpoint of necessity brought on by changes in the labor force than any other phenomena.

Reflection Points

As new innovations in delivery models and reimbursement models emerge, the health care industry will experience further shifts in the social power structures, levels of autonomy and control that affect the way health care services are delivered in the United States. The power held by physicians today has changed from that of the past, but their role is critical to ensuring improvement in quality, access, and cost of care. No longer will leadership derive from a position of autonomous authority. Rather, physician leadership will be dependent upon their power, knowledge, and skills to influence patient care at both the micro and macro levels. The rigors of didactic training and experiential learning positions physicians well for the role of ensuring quality of care for the patients and populations they serve. As clinicians, physicians are uniquely suited to leverage their skills to bolster their position as subject matter expert in clinical shared decision-making with patients and in health system operations.

The physician’s unique professional identity can only be maintained by self-redesign of the profession. This professional redesign will require an introspective understanding of training curricula and how the physician culture should be shaped in the future to improve abilities to lead in patient-centric operations complex health care organizations, and at the national social policy level. The transformation will require continued review of the social and environmental forces that are stressing the physician community and the health care system. Regularly examining the current situation from the perspective of various strategic lenses (e.g., health-centric, economic, political, and social) can uncover changing trends in this complex adaptive system and the changes in communication and relationships that affect the effectiveness of higher quality care and improve patient outcomes in the future. Passive avoidance as a cultural strategy merely worsens strain on the system, and contributes to victimization and dysfunctional physician behavior. The transformation from the hero to the leadership role creates a new professionalism, a new way to serve in our communities, and to provide optimal care to those in need. This is duyukdv.

References

1. Starr P. The Social Transformation of American Medicine, p. 359.

2. Starr P. The Social Transformation of American Medicine, p. 15.

3. Magee, M. The Evolving Patient-Physician Relationship, Health Politics: Power, Populism and Health. Bronxville, NY: Spencer Books; 2005, p.36.

4. Shannon, D. Did You Get an ‘A’? Physician Executive Nov/Dec 2007, 33(6):4-8.

5. Godolphin W. Shared decision-making. Healthc Q. 2009;12 Spec No Patient:e186-90.

6. Starr P. The Social Transformation of American Medicine, p. 16.

7. Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006 Sep-Oct;13(5):547-56.

8. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. pp. 221-225.

9. Hsiao W. Abnormal economics in the health sector. Health Policy. 1995 Apr-Jun;32(1-3):125-39.

10. Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care--an interactive sociotechnical analysis. J Am Med Inform Assoc. 2007 Sep-Oct;14(5):542-9.

11. Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 2008 Jul-Aug;15(4):408-23.

12. CMS-1345-P, Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations. Proposed Rule. II(B)3. Leadership and Management Structure. March 31, 2011.

13. Medicare Payment Advisory Commission. (March 2011). Report to Congress: Medicare Payment Policy. Introduction and Chapter 1.

14. Jacobs P, Rapoport J. Additional topics in the demand for health and medical care. In: The Economics of Health and Medical Care. 5th ed. Subury, MA: Jones and Bartlett Publishers; 2004. p. 86.

15. Jacobs P. The Economics of Health and Medical Care. 5th ed. pp. 87-88.

16. Institute of Medicine. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. Current Estimates of Primary Care Providers and Nurses. In: The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011. pp. 257-266.

17. H.R. 3590, Patient Protection and Affordable Care Act, §5202. Nursing student loan program; §5308. Advanced nursing education grants; §5309. Nurse education, practice and retention grants (2010).

Chapter 2 Summary

Leadership Implications and Health Policy Considerations

Leadership Implications:

1. Recognize the primary importance of the physician-patient relationship and encourage practicing physicians to embrace and cultivate it as a partnership. Reflect upon the physician-patient relationship as critical to the legitimation of professional authority.

2. Foster the development of collaborative relationships with nursing leaders and others from clinical disciplinary backgrounds.

Health Policy Considerations:

1. In the development of medical affairs policies at the provider organization level, account for the workflow impact of health information technology solutions when defining boundaries, roles, and controls governing physician role.

2. When addressing local and regional health policy reform with community health boards and local governments, understand and communicate the importance of current and prevalent economic trends and their direct impact on the communities being served.