Building Trust Between Physicians, Hospitals, and Payers: A Renewed Opportunity for Transforming US Health Care

Trust begins with dialogue. It's a skill just as important as being able to hear rales in the chest of a patient with pneumonia or to detect rebound in a patient with an acute abdomen.

With dialogue, opposing viewpoints are shared. Problems are seen more clearly; common ground and collaboration often result.

There is little opportunity, however for physicians to practice their dialogue skills. Hospitals used to serve as convenient sites for physicians to informally meet and discuss issues that affected their practices. But today many doctors, particularly those in primary care, no longer make hospital rounds. They rarely talk to one another. Increasingly they are isolated.

Hospital general staff meetings are poorly attended and limited mostly to discussions of hospital policy. Little time is allotted for community issues. Even grand rounds have become hurried affairs, too often dominated by ‘slide shows‘ that dampen dialogue and have more of a soporific than an educational effect.

Ideally, hospital meetings are the perfect venues for doctors and administrators to practice the skills that make for good dialogue.

Physicians need to bring this issue to their general staff meetings.

2/28/19

I am exceedingly dissapointed at JAMA’s decision to publish Building Trust Between Physicians, Hospitals, and Payers: A Renewed Opportunity for Transforming US Health Care.

This was essentially a public relations piece from the insurance industry with no concrete steps as to how they will move to improve trust. As per usual, the authors continue to write in an alternative reality where “outside forces” are what limit them from paying their contracted rates, justifying the financial hardship they place on patients and providers.

Right now, there is enough momentum of patients moving outside the traditional payment models of healthcare into self-funded and concierge style services and enough physicians leaving practice entirely, that the major payors feel the need to buy some roses to make up for multiple black eyes they have inflicted. A simple look at the rapid closure of medical clinics, the early “retirements” of doctors and, even, suicide rates of US physicians shows how deep this abuse goes.

I’m afraid trust is too far eroded and, when the day comes for these executives to need excellent medical care, there will not be highly-trained, pedigreed doctors in the US to care for them. Then, this divorce will be final.

In the absence of an ideal system of health care in which all patients collectively pay all providers for all medical care, the only element of trust becomes that exclusive and at times elusive trust between the patient and the physician. There daily is less and less reason for trust between the patient and the physician on one hand and the avaricious profiteers of big insurance, big pharma, the corporate lords of health care, organized medicine, bureaucrats, and one percenters on the other hand. The interest of the patient and the physician is in health care; the interest of all the other parties is in the gratification of greed for profit and power, health care be damned; and they warrant no trust at all.

From the cynical desk of an aging physician in the twilight of a 50+ year career practicing the art and science of medicine for the benefit of health care.

Your article is insightful but a dimension of trust --transparency-- is inadequately addressed. For physicians, hospitals and plans, the availability of prices, business relationships, disciplinary actions, executive compensation and conflict of interest disclosures is requisite to building trust. Plans are not readily transparent in their utilization and denial evaluations nor their assessment of provider performance. Hospitals are not forthcoming in their pricing and physician disciplinary efforts. And physicians shun transparency. The "new world order" is largely defined by widespread availability of information: some valid and reliable, some misleading, some accurate and all impactful.

Our nation's healthcare industry labors within the constraints of an entrenched institutional codependency between the regional providers of Complex Healthcare and the diverse economic payers of this healthcare. The prevailing Power Law Distribution Curve that dominates the economics of our nation's health spending has failed to solve the cost and quality problems of our nation's healthcare. The distribution curve is skewed abnormally by distributing only 5% of health spending to 50% of our citizens. The other OECD nation's are closer to 10% with much lower per capital total health spending.

Unfortunately, this scenario is adversely effected by the loss of social capital, community by community. Well defined by the books of Robert D. Putnam, our nation lacks any strategy to mobilize a correction of this problem, community by community. And thus, we see a worsening level of maternal mortality, child neglect, childhood obesity, adolescent suicide/homicide, substance overdose mortality, mid-life addiction/disability, homelessness and decreasing longevity at birth (now 4 years in a row). Clearly, the rejuvenation of Social Capital and its norms of trust, cooperation and reciprocity must be locally driven, community by community.

The best evidence for our future healthcare reform should be rooted in the scholarly career of Professor Elinor Ostrom, 2009 Nobel awardee. The concept of social capital should reflect a direct awareness of the publications of Robert D. Putnam. (1, 2)

The provisions of the Congressional Smith Lever Act of 1914, adapted for healthcare should apply. This Act's industry is the most efficient and effective among the OECD nations. Our healthcare industry is certainly the least efficient and possibly the least effective.

References

1. David Sloan Wilson et al. Generalizing the core design principles for the efficacy of groups. http://dx.doi.org/10.1016/j.jebo/2-12.12.010 

2. Robert D. Putnam. Social capital measurement and consequences.  http://smg.media.mit.edu/library/putnam.pdf

This well-constructed apologia for payers succinctly outlines their talking points. But (I believe) to most physicians in the trenches, the jargon and double speak hide a monotonous corporate linguistic obfuscation.

Thorstein Veblen may well have defined the payers as a special subset of the leisure class profiting from the work of physicians who actually care for patients.