Retail politics: Health care expert details threats to physicians
The U.S. has the most expensive health care in the world. It spent about $8,508 per person on health care in 2011, according to the international Organisation for Economic Co-operation and Development (OECD). That’s 50% more than the next-priciest country, Norway.
Think tanks, retailers and other interested parties are trying to find ways to bring down the costs of health care for U.S. patients and insurers. Unfortunately, the solutions they are finding, which include health clinics inside grocery stores and medical tourism, will likely lead to lost patients among primary care physicians, said Jim Bonnette, MD, during a presentation at the AOA’s 2013 Advocacy for Healthy Partnerships conference in Atlanta on Nov. 23.
The chief medical officer of Oliver Wyman, a health care consulting firm, Dr. Bonnette said physicians who want to compete in coming years will have to engage patients the same way businesses engage consumers. Physicians should also find ways to bring down the cost of health care themselves, he said.
Almost every grocery store and national pharmacy is working on implementing convenience clinics, not unlike CVS’ MinuteClinic, that will broaden their customers’ access to health care and do so at lower prices, Dr. Bonnette noted.
“[Physicians] provide all the health care people could want—when we’re open,” he said. “But we’re not open when they want us to be open. Guess who is open? Retailers. And retailers know that you don’t know anything about consumers. [Retailers] know how to modify consumer behavior, and they see this as an opportunity to change the way health care is delivered and get a piece of everyone’s wallet.”
Dr. Bonnette urged the audience to consider the differences between how retailers interact with their customers and physicians with their patients. Contemplate what patients may want in other situations besides health care, he said, and think how you might be able to apply that to the way you practice medicine. Many health care organizations are already experimenting with consumer engagement, he noted, though some struggle to view patients through the same lens that retailers do.
“The University of Michigan is my health care provider,” Dr. Bonnette said. “They think I’m engaged because I use their portal. I use the portal because I can’t get anybody to answer the phone. That is not consumer engagement.”
An Oliver Wyman survey revealed that people like the retailer clinic care model because it provides more convenient access to care, Dr. Bonnette said. A subsequent survey asked people what they would sacrifice for greater access.
“They would trade all of you for access,” Dr. Bonnette told the roomful of physicians. “Access means more to them than that personal relationship does. … Time is very meaningful to people.”
Of course, most physicians can’t afford to keep their offices open 24/7 or even every day—but Dr. Bonnette suggested that they consider finding a way to give their patients what they want.
“If you don’t want to work 7 a.m. to 10 p.m., seven days a week, partnering with somebody who’s open those hours might be useful for you,” he said.
Access is also on the minds of patients who leave the country for surgery. They need the procedure but can’t afford it at U.S. prices.
Medical tourism is not yet widely practiced by Americans—it accounted for just 0.04% of U.S. health care spending in 2011, according to the OECD. But Dr. Bonnette thinks this could change. He cited the example of Ascension Health, a St. Louis-based health system that is building a hospital in the Cayman Islands to offer heart surgery at a reduced price. At this new hospital, a cardiac bypass will cost roughly $6,000-$10,000, versus an average of about $45,000 in the U.S.
“Thank goodness for you, they’re only targeting South America for medical tourism,” Dr. Bonnette said about the new venture. “But do you think that insurers in the U.S. might strike a deal with this hospital in the Cayman Islands at that price?”
One reason future physicians will face greater competition is the high cost of care. So to be competitive, physicians need to find a way to lessen the cost of their services, Dr. Bonnette noted.
A few ways to do this, he said, are participating in accountable care organizations, which tie physician reimbursement to quality and outcomes; transitioning to team-based care; and engaging in “population management,” in which patients are divided according to health status and provided with specialized care.
In the latter system, physicians work with a specific population based on their skill set. For instance, a physician who is exceptionally empathetic may be tasked to care for less healthy members of the population, and he or she will have fewer patients. Physicians who are better at motivating patients will work with a healthier segment of the pool, have more patients and focus on preventive care.
As an example, Dr. Bonnette cited the Alaska-based Southcentral Foundation, which saw a 50% drop in urgent care and emergency room use after switching to a population management model.
Ultimately, Dr. Bonnette sees the physicians of the future having both a greater understanding of health care costs and a greater stake in reducing them, perhaps by being more invested in patient outcomes. He asked the room to consider what they would do if they were responsible for all of the health care costs for a patient who smoked. Here’s the reaction he predicted:
“ ‘I will relentlessly pursue darn near everything I can think of, and the rest of my team can think of, and all my partners can think of to get [the patient] to stop smoking,’ ” he said.
In some cases, he noted, that may involve enlisting a team of nonphysician experts who have a better understanding of how to motivate patients. In the population management health models, social workers and behavioral health experts are typically on staff for this purpose.
To adopt a population management health care model or to partner with a retail clinic, physicians will have to think about their patients very differently. Tara B. Hughes, OMS III, said she would have a hard time thinking of her patients as consumers.
“It’s really hard for anybody who wants to take care of people to refer to a patient as a consumer or a customer,” said Hughes, who attends the Des Moines (Iowa) University College of Osteopathic Medicine. “It’s difficult to keep that perspective when you relate it to health care. It’s the life of another person.”
But Hughes said she agrees that physicians are going to have to adopt this attitude.
“Target and Walmart are going to start providing health care, and the advantage they have is they’re a one-stop shop for everything,” she said. “So physicians are going to have to start thinking cleverly about how we can provide optimal health care and make sure that we continue to stay relevant.”
Terry D. Reiff, DO, said he struggled to see how rural physicians would enact some of the practices Dr. Bonnette suggested.
“Many of the ideas I heard are driven by large clinic, large organizational medicine,” said Dr. Reiff, a family physician in Whitehall, Mont. “We’re in a very rural area. There’s no large multicenter provider program. We are 25 miles from the nearest hospital.”
Team-based care in particular would be hard to adopt in an area where few people live and work, Dr. Reiff noted.
“When people talk about teams, they say, ‘We have a physical therapist, a nutritionist and a diabetes expert,’ ” he said. “We don’t have any of that. Our nearest dietician is 30 miles away.”