As phrases like “physician burnout” and “program fatigue” become more common, we all must make a greater effort to understand what is working and what is not in efforts to improve the value of health care.
A very bumpy ride through healthcare debates and congressional votes on the fate of the Affordable Care Act (ACA) over the summer ended up circling back to where we started. The ACA remains the law of the land, neither repealed nor replaced, although there seems to be growing bipartisan consensus on the need to stabilize the ACA’s insurance markets in the short term, and to identify and address any other deficiencies in the law in the long term.
This also may be an appropriate time to step back and reflect on what we have learned from recent efforts to reform the healthcare system. There has been a flurry of activity since the ACA passed in 2010. The use of EHRs has become widespread, pushed forward by the Health Information Technology for Economic and Clinical Health Act and “meaningful use” incentives. The Center for Medicare & Medicaid Innovation (CMMI)—created by the ACA with a 10-year, $10 billion budget to spur innovation in payment and care delivery—has been living up to its mandate. A visit to CMMI’s website in August found 52 active or announced initiatives underway across seven categories of activity, including ACO programs (6 initiatives), episode-based payment initiatives (8 initiatives), primary care transformation (4 initiatives), initiatives focused on Medicaid and CHIP (4 initiatives), initiatives focused on Medicare-Medicaid enrollees (3 initiatives), initiatives to accelerate the development and testing of new payment and service delivery products (18 initiatives), and initiatives to speed the adoption of best practices (9 initiatives).
What’s the Problem?
At the center of many of these programs have been clinicians, and it is with them that the phrases “burnout” and “program fatigue” are most closely associated. While many still see great promise in the ability of EHRs to promote patient safety and to aggregate and analyze patient data, their introduction has taken a toll on the clinical community. A recent issue brief from the Agency for Healthcare Research and Quality (AHRQ) cites EHRs as one of five primary causes for physician burnout, noting research findings that fully mature EHRs, combined with a trend toward shorter patient visits, “were associated with physician stress, burnout, and intent to leave the practice.” a
The fast and furious approach to payment and care delivery innovation also may be taking a toll. A paper published in 2016 by Health Services Research addressed “the impact of uncertainty.” The authors note the many experiments that have been tried in health care in recent years, many of which have proved impermanent. “It would not be surprising, then, if clinical organizations viewed the next change as temporary,” the authors suggest. “This is critical because if financial returns are uncertain, organizations discount the rewards and may be less willing to commit to and invest in change.” b
Such experimentation can lead to program fatigue—the more programs clinicians see come and go, the less committed they are to the next program. Without fully committed clinicians, change becomes even more difficult to achieve.
Finding a New Way Forward
Going forward, organizations should consider how existing initiatives can be made better for clinicians, and how new efforts can be better designed, by keeping a few principles in mind.
Understand impacts on clinical workflows. One of the most significant pain points for EHR implementation has been perceived interference with face-to-face time between patients and clinicians. Increased documentation requirements, combined with the need to enter data during the patient visit, can mean the clinician must devote more time to the screen and less to the patient.
Organizations are alleviating this pressure in a number of ways. Some are experimenting with scribes or medical assistants who can attend to documentation, leaving the clinician with more time for patients. Others are building time into the workday that can be dedicated to documentation and data entry needs. And as the AHRQ brief notes, a patient-centered medical home structure that emphasizes team-based care can allow clinicians to devote more time to patients who need it the most, while significantly reducing clinicians’ stress.
Predictability matters. Clinicians will be more engaged in a program that they know is for the long term, with any anticipated changes in performance measurement or payment clearly mapped out in advance. The Health Services Research study pointed to the Alternative Quality Contract initiative launched by Blue Cross Blue Shield of Massachusetts several years ago as a model: It provided a five-year plan that let providers know how performance metrics and payments would change over a longer time horizon. The authors of the study recommend that any new program be backed by a minimum commitment of three years, with built-in opportunities for public comment and revision.
It’s not just about the money. Although financial incentives can be important, a number of studies have shown that both medical students and practicing physicians also care deeply about benefits to the patient. A program that articulates a clear patient benefit is likely to be more compelling than one that focuses on financial incentives alone.
Clinicians should have a say in the program design. Clinician input is perhaps the most critical consideration of all. Any program that will affect care delivery or payment must be designed with significant clinical input, both to ensure the viability of the program and to secure the trust of clinicians in the program’s validity.
There remains a lot of heavy lifting ahead as healthcare organizations work to provide better value to patients. The success of this effort will depend largely on the commitment, energy, and enthusiasm of clinicians. By coming up for air and making an honest assessment of how current initiatives are affecting clinicians, healthcare organizations will be much better positioned to continue their journey toward better value.
James H. Landman, JD, PhD, is director of healthcare finance policy, perspectives and analysis, for HFMA.
a. “Physician Burnout. ,” Agency for Healthcare Research and Quality, Rockville, MD.
b. Roland, M. and Dudley, R.A., “How Financial and Reputational Incentives Can Be Used to Improve Medical Care,” Health Services Research, December 2016.