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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.

Dr. Bonnette

Physicians of the future will have a greater understanding of health care costs and a greater stake in reducing them, predicts Jim Bonnette, MD. (Photo by Rose Raymond)

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.

Retail therapy

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.

Medical tourism

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?”

Cost-cutting strategies

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.”

4 Responses

  1. Sarah on Dec. 6, 2013, 8:11 p.m.

    Why should physicians feel threatened by cheaper healthcare retailers? Most doctors, let alone patients, know the cost of the services they are receiving. Cheaper prices will only lure in those that are paying cash for their medical services, which will be extremely rare when it becomes illegal to opt out of purchasing health insurance.

    Although, I agree that medicine in America is careless in its spending practices, I don’t see the personal incentive for physicians to be more mindful of their spending.

    I view medical spending like recycling. If I recycle one pop bottle, it doesn’t make a difference. If I order one less unnecessary CT scan, it doesn’t make a difference.

    If everyone recycles a pop bottle, maybe it will make a difference. If everyone orders one less unnecessary CT scan, maybe it will make a difference. But I need to have faith that EVERYONE is going to recycle that pop bottle, or order less CT’s to make my effort even matter.

    The difference is there is little PERSONAL incentive for a physician to order less. You spend more time explaining your clinical reasoning to an unhappy patient. You feel more uncomfortable to prove you were right in your medical decision making if you get sued.

    At least I feel good about putting the pop bottle in the recycling.

  2. Jon Schriner D.O. on Dec. 7, 2013, 9:11 a.m.

    Throughout the world you can not get instant CT, MRI’s, knee or hip surgery, heart surgery, or emergency room care for minor problems. Except in Lawyer driven USA. Americans are going to have to accept that you can’t get that because your plan can’t afford that. I teach M.D.’s who come here from other countries to train, and they marvel at the accessibility of procedures and care here. We have the worlds greatest number of Lawyers and a loose legal system. We have a FDA which most other countries do not have. We have access that no other countries have. Our Physicians all drive BMW’s and Mercedies that foreign Physicians don’t have. We are the land of opportunity that theorist of the countries don’t have. We have CT ‘s and MRI’s on every street corner that no other country has. And “we” use them often. Guess what the problem is! Our time is changing and we know it, but the American public has not realized that yet. Fail to diagnose or treat someone immediately in their eyes and guess what law suit you will be wearing next.

  3. Carmen Arif on Dec. 11, 2013, 11:37 a.m.

    Clearly the old model is not working. Doctors are practicing to avoid lawsuits. I’m a simple consumer not a doctor. I search for foreign born and educated ducts because they aren’t in it for the money (at least not yet) and don’t fear the American lawyers (at least not yet). They practice to get respect so they have pride in what they do. So they diagnose not for the lawyers but for the pride. I’malmost 56 and have encountered many doctors along the way. When doctors follow an accepted protocol in order not to be sued they become non-thinking sheep (followers). It’s disgusting. I want a doctor who can think and is willing to think and will diagnose me according to knowledge and experience NOT PROTOCOL. Insurance companies are in this case the devil in the details. They are making American doctors stupid. Insurance carriers are NOT doctors they need to stay out of practicing medicine. The best way to reduce costs and keep medicine relevant and intelligent and costs down is to switch to patient responsibility. NO INSURANCE. Doctors who price themselves out of the market will be poor. So they will charge according to what the market can pay. So will MRI’s and diagnostics. And there should be a cap on cost. Doctors and diagnostics can not charge more but can charge less. Medicine and capitalism are bad bed fellows. Get insurance companies completely banned from medicine. Put doctors with pride to work. Teach pride in school. Practice with pride. Lawyers are to sue only got negligence and the patient only gets the cost to fix the problem (not this treble crap) and to take the doctors license away. Negligence MUST BE DETERMINED by the patients suffering and a panel of retired doctors who do not get paid for the verdict. Clearly if you amputate the right leg and it should have been the left you are negligent. Common sense. We the consume/patient feel abused by the system and this new healthcare mandate only helps the insurance companies. It’s way overpriced.

  4. Student on Jan. 14, 2014, 8:23 a.m.

    I would also like to urge that we should remember the debt that American students are in compared to MD’s that come from oversees.

    I am currently a 4th year medical student, and my undergraduate and medical school debt has crossed 300,000 and I am not living a luxurious life. I have taken the lease amount of debt possible.

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