In the era of increased regulatory scrutiny of healthcare entities, physicians are increasingly struggling to seamlessly integrate regulatory changes with high-quality medical practice. It is the belief of many physicians that the prevention of fraud, the implementation of electronic health record (EHR) systems, and the creation of value-based care models, among other landmark shifts in the healthcare industry stemming from the Patient Protection and Affordable Care Act (ACA), will not decrease the cost and increase the quality of healthcare.¹ Instead, physicians are concerned that continued implementation of ACA mandates may have “unintended effects” on healthcare delivery that could negatively impact their healthcare delivery to patients.²

Reflecting these concerns, the Physicians Foundation released its 2015 Physicians Watch List, an insight into the trends physicians are witnessing or predicting will occur in healthcare. The Watch List, based on the results of a survey of over 20,000 physicians, noted “five critical areas that will have major impact on practicing physicians” during the 2015 calendar year:

1. Increasing Provider Consolidation;
2. Increased Strain on the Physician-Patient Relationship;
3. The Implementation of ICD-10;
4. Cost of Care Transparency for Both Patients & Physicians; and,
5. Access to Physician Care.³

Healthcare providers, administrators, and compliance personnel can utilize this information, above, to develop courses of action to mitigate these concerns while also promoting high-quality, cost-efficient medical practice. This Health Capital Topics article will summarize the five areas of concern noted by the Physicians Foundation as well as provide suggested courses of action that physicians and administrators may take to potentially alleviate these concerns.

According to the survey, physicians increasingly fear that provider consolidation has negatively impacted a physician’s ability to make sound clinical decisions.⁴ In a 2014 survey of physicians conducted by the Physicians Foundation, 69% of physicians stated that “their medical decisions are sometimes or often compromised.”⁵ As provider consolidation is likely to continue in 2015,⁶ physicians fear that pressures related to cost-efficiencies associated with larger health systems may impact medical decision-making.⁷ Because physicians serve front-line roles in the delivery of healthcare in both the clinic and hospital setting, and are the “experts” who make clinical judgments on care delivery, health systems may be well-served to note the concerns of their physicians as they implement policies, procedures, and business plans. For example, as systems incorporate evidence-based practice guidelines in medical practice to promote efficiencies, health systems could solicit and utilize feedback from its medical staff and employed physicians about proposed and implemented guidelines, giving physicians a voice in the continued refinement of such policies.⁸ Further, health systems implementing evidence-based practice guidelines may find it appropriate to develop mechanisms that allow for easy identification of aberrations to the guidelines and encourage collaboration between physicians of different specialties when such situations occur.⁹

Second, physicians are increasingly asserting that the physician-patient relationship has deteriorated as new regulatory schemes have been implemented. Over 78% of physicians responded that patient relationships serve as their greatest source of professional satisfaction,¹⁰ and that limitations on these relationships can negatively affect physician morale. Additionally, 81% of physicians stated that they were working either at or beyond full capacity, an increase from 75.5% who reported this in 2012, and a major factor in limiting the development of the physician-patient relationship.¹¹ One factor affecting this deterioration is EHR usage. Utilization patterns of EHRs have been shown to correlate with levels of interaction between the physician and the patient, which can affect the interactive, symbiotic nature of the physician-patient relationship.¹² A 2013 study published in the International Journal of Medical Informatics concluded that EHR designs which are not “intuitive for patients to follow…or understand” lessen the likelihood that physician-patient interactions will result in “increasing patient understanding or common ground with the physician.”¹³ Other factors contributing to the deteriorating physician-patient relationship include heavy caseloads on physicians, which lead to shorter medical appointments,¹⁴ as well as the risk of malpractice, which can encourage defensive medicine.

Although U.S. hospitals and health systems are treating more patients, due in large part to recent insurance coverage expansions, creative and prudent administrators can still craft strategies to increase physician-patient engagement. One of the most effective ways to improve the physician-patient relationship stems from one of this issue’s most problematic causes – EHR systems. As a health system trains its physicians and clinical staff to use its EHR system, the training professional can include simple, short lessons about how to engage with the patient while utilizing EHRs, e.g., screen sharing by sitting in positions inviting patients to view their EHR and recognizing that “patients always followed the doctor gaze” during an EHR interaction.¹⁵ While “eye gaze” training seems distant to any impact on the bottom line of a health system, such training of, and its utilization by, physicians has been shown to positively influence patient behaviors.¹⁶ Such training allows physicians to be efficient with their patient communications and take advantage of what often end up being short
patient encounters.

In addition to consolidation and deteriorating patient relationships, physicians have also expressed concerns regarding the implementation of the tenth revision of the International Classification of Diseases (ICD-10) coding system. Physician concerns regarding ICD-10 are twofold. First, physicians fear that continuing delays by the federal government as to the required date of ICD-10 use may create systemic inefficiencies that could lead to lost revenue.¹⁷ Providers have already been forced to reallocate resources originally related to ICD-10 implementation – particularly the valuable resource of time – which caused disruptions regarding cash flow for the practice.¹⁸ Second, 75% of physicians surveyed by the Physicians Foundation stated that ICD-10 will “unnecessarily complicate coding,” leading to more paperwork and less time spent with patients.¹⁹ Even with these concerns, there are actions that health systems can potentially take to limit what will be a significant transition from the current, 30-year-old ICD-9 coding system.²⁰ Engaging in strategic planning now for the implementation target of October 1, 2015 may help health systems manage the many variables involved in the coding upgrade: computer system updates;²¹ distribution and incorporation of medical documentation consistent with ICD-10 codes;²² communication with software vendors to gauge their preparedness;²³ and, staff training.²⁴ Moreover, creating a back-up plan for the possibility of another implementation delay (e.g., maintaining or storing previous ICD-9 infrastructure) will likely lessen the blow of another delay.

Another growing concern for 2015 stems from the current lack of transparency surrounding medical care costs – a concern of both patients and physicians. As health systems engage in consolidation efforts to streamline care in accordance with ACA measures, such as accountable care and bundled payment models, physicians have begun to struggle to answer what often is a patient’s most basic question: “how much will my care cost me?” The current consolidation trend has led to numerous stories surrounding physicians who performed a procedure in January 2014 at one cost, and then performing that same procedure in November 2014 (over 10 months later) for double or triple the cost.²⁵ Often, this increase in cost has a direct effect on patients, whose cost-sharing often rises due to this phenomenon (known as site of service differentials), influencing patients to skip that preventive or elective care which often prevents more serious health consequences.²⁶ Physicians fear that this growing influence on patients could affect a provider’s ability “to make the best clinical decisions for patients.”²⁷

Numerous examinations regarding the pressing issue of price transparency have indirectly provided health systems with tools and strategies to increase medical cost transparency. In an October 2014 report, the U.S. Government Accountability Office (GAO) noted that:

“Consumers are most likely to respond to information that applies to their personal circumstances, including…information on the specific procedures consumers are considering…and on cost estimates that take into account their particular insurance coverage.”²⁸

The GAO found that creating usable, clear, and searchable interfaces to produce tailored information on price and quality improves the patient’s ability to weigh decisions relating to their own medical care;²⁹ however, the GAO found the Centers for Medicare & Medicaid Services (CMS), which administers the Medicare and Medicaid programs, inadequately provided such information to its beneficiaries.³⁰ For large health systems with increasing leverage in negotiating contracts with payors, advocating for usable, clear search platforms from commercial health insurers is becoming an increasing possibility. As commercial insurers increasingly develop transparency tools for consumer use,³¹ health systems can integrate these information portals with their own IT systems, allowing providers to more efficiently share more accurate cost and quality estimates with patients and develop referral patterns that are increasingly based on patient needs.³²

On a macro level, physicians are concerned that, taken together, the healthcare trends described above will ultimately limit patient access to physician care. In its 2014 survey of physicians, the Physicians Foundation found that 44% of physicians plan to “take steps that would reduce access to their services,” e.g., working shorter workdays, retiring within three years.³³ This cutback is coinciding with increased Medicare enrollment, a recent influx of newly-insured individuals, and recent Medicaid expansions under the ACA, possibly limiting patient access to meaningful physician services while at the same time the ACA is seeking to increase access to medical care for Americans.³⁴ As a result, hospitals and health systems are facing increasing pressure to utilize their resources efficiently to serve the needs of its current and future patients. Nevertheless, like the other physician concerns described above, health systems may be able to take certain acts to limit access issues and utilize their resources efficiently. Prominent among these is the use of Community Health Needs Assessments (CHNAs). Hospitals and health systems can conduct – and commit to utilizing – a CHNA in the development of strategic behaviors to maintain profitability and (for many hospitals) its charitable mission. Hospitals and health systems that are facing increasing resource constraints can follow the example of critical access hospitals in utilizing CHNAs, which help focus these essential providers on maximizing their resources to meet community needs by clearly discovering and presenting local health priorities. In addition to utilizing CHNA, health systems can lobby Congress to lift the funding cap on residency training slots, which will promote the training of increasing numbers of medical school graduates.³⁵

Many of the concerns that physicians have at the beginning of 2015 reflect common concerns related to the U.S. healthcare industry in the current era of healthcare reform. Concerns regarding clinical autonomy, improper influences, and cost of care signify broader concerns about the ability of the ACA to positively impact the U.S. healthcare system by: improving quality, increasing efficiency, and broadening access for a larger portion of the U.S. population. Although such questions are difficult to answer and highly partisan, healthcare administrators taking a “how-to-fix” approach carry solution-oriented attitudes that can bring the needed impetus to solving not only the concerns of physicians but also of patients and other players in healthcare today.