To cure physician burnout, unburden doctors

  | July 13, 2016

The great sculptor Michelangelo was once asked how he created the Pieta, one of the greatest sculptures of its time. His answer was simple: “I just take a block of stone, and chip away everything that is not the Pieta."
As a primary care internist, I have strived to do exactly this for the past dozen years. Yet I have watched as more and more has been added to doctors' plates, burdening their days, distracting them from care, and turning physician burnout into what some have called an occupational health crisis.
In a recent Mayo Clinic review, more than 54 percent of physicians reported at least one sign of burnout — double that of the general population. The response was 20 percent worse than it was in 2011 when they last fielded the survey. More worrisome, 39 percent of physicians reported symptoms of depression, and a shocking 7.2 percent reported having experienced suicidal thoughts. As Steve Adelman wrote in this publication last month, “In the same way mining is unsafe for workers, healthcare is becoming an unsafe work environment."
Many are trying valiantly to tackle this problem by offering doctors support groups or coaching programs where they are taught how to say “no" to patients, colleagues and staff. But to truly address burnout, we don't need to add more to physicians' overflowing plates. We need to take things off.
The job of a doctor has always been difficult and stressful: patients come with myriad complaints fraught with emotional overlays. We make serious, real-time decisions daily with incomplete information, and live with the consequences (including the ever-lurking fear of real or frivolous malpractice suits).
Not to mention the struggles to get paid for doing any of this. Each day comes with more and more forms to fill and boxes to check, along with pressures to generate more RVUs, meet increasingly complex meaningful use or quality bonus programs, and begin to figure out the ins and outs of participating in the proposed MACRA models.
We have turned our healthcare system into a set of complex transactions, where everything needs to be coded, sub-coded, and billed using increasingly arcane sets of rules. The lunacy of the new ICD-10 codes (with codes for “bit by turkey for the first time", and “burn due to water skis on fire") and the documentation standards one needs to justify a 99214 visit are but a few mind-spinning examples.
But transactions have never healed anyone. And they aren't the reason any of us went into medicine in the first place. What heals and fuels our calling as doctors are relationships.
So at the company I co-founded, Iora Health, we've tried to chip away at the transactions and the noise that stand in the way of good care, and focus instead on the relationships that give medicine meaning.
We began at the source of the problem: the fee-for-service payment model. It's the wrong way to pay for primary care, so we stopped doing it. Instead, we contract with progressive employers, union trusts or health plans to pay us a fixed fee per patient or some version of purely value-based payment such as shared savings up to full risk.
Our doctors do no CPT coding, and never need to submit bills for payment. This allows them to see their patients through a relational rather than a transactional lens: here is a population of patients and they are our problem, and our job is simply to improve their health and keep them out of trouble — whatever it takes.
Since we're aligned with our payers, we can also start to chip away the prior authorizations, concurrent review programs and other adversarial utilization management programs. Instead we can work with our payer partners to remove barriers to good care.
Finally, we surround doctors with a robust team. Each practice of two to three doctors also includes a clinical team manager, a behavioral health specialist, two operations assistants, and six or more health coaches, all of whom can work closely with the doctors to help patients follow through on their care plans. Moving these tasks to other talented and empathetic staff lowers cost and frees doctors to do what only they can do.
We have been doing this in 29 practices in 11 different markets, and it works. Patients love it: We regularly have a greater then 90 percent net promoter score, compared to 3 percent for the average primary care practice. We demonstrate much improved clinical outcomes, and dramatically lower hospitalizations and ER visits compared to matched control groups, leading to lower total healthcare costs. And, importantly, we have much happier doctors: over five years, we have had less than a 3 percent voluntary attrition rate.
Granted, not every medical organization will be able to focus solely on these types of payer contracts, or to avoid some of the regulatory requirements that don't apply to our patient groups. But the general principle — that our outdated, complex fee-for-service system is the root of the problem — could apply to healthcare organizations of any structure. Our model should give all healthcare organizations a lever with which to press the government for more simplicity, more common sense, and the kind of care patients are demanding.
Only when we step off the transactional track, and restore our focus on relationships that work, will healthcare begin to look like the Pieta we can envision.
Rushika Fernandopulle, M.D., is the co-founder and CEO of Iora Health.

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Nice system and your only recommendation is that everyone join Iora – making this an advertisement … yes? Is this a system where Athena is an investor or development partner? Team based care, with redundant staffing and one on one health coaches for each patient would be FABULOUS, so why isn’t everyone doing it? How many patient lives do you cover. How many physicians are in your system? If you say you prevent burnout, give me your provider MBI scores, not net promoter scores and turnover data. I have over 1700 hours coaching burned out physicians one on one to recovery and I know for a fact that there are burned out physicians in your system as well. They rates are certainly not as high as other less resource rich workplaces — and it is there. Burnout is always multifactorial and leading a healthcare team dealing with sick, hurting, scared and dying people and their families is never easy. Dike Dike Drummond MD http://www.TheHappyMD.com
Name: 
Dike Drummond
Email: 
test@test.com
Nice system and your only recommendation is that everyone join Iora – making this an advertisement … yes? Is this a system where Athena is an investor or development partner? Team based care, with redundant staffing and one on one health coaches for each patient would be FABULOUS, so why isn’t everyone doing it? How many patient lives do you cover. How many physicians are in your system? If you say you prevent burnout, give me your provider MBI scores, not net promoter scores and turnover data. I have over 1700 hours coaching burned out physicians one on one to recovery and I know for a fact that there are burned out physicians in your system as well. They rates are certainly not as high as other less resource rich workplaces — and it is there. Burnout is always multifactorial and leading a healthcare team dealing with sick, hurting, scared and dying people and their families is never easy. Dike Dike Drummond MD http://www.TheHappyMD.com
Name: 
Dike Drummond
Email: 
test@test.com
Iora Health is a cool system, but patients are basically cherry picked by the selection process of bargaining. Athenahealth is a cool EMR but it bans patient safety discussions and cherry picks the stats it publishes on provider satisfaction and productivity.
Name: 
Robert D. Peterson MD
Email: 
test@test.com
The solution for incompetent EHR's likely has come and gone but if I could go back in time I would wish the Federal Government would have taken the $187,000,000 they wasted on rolling out the program for the ACA and spent it on ONE system, no matter how clunky it was at the start, (like the VA's system for instance) and worked on it with physicians not IT nerds with no experience with medical practice, and slowly perfected it; got to a point where we could all be invited to use it; and not with the "agility" concept Microsoft started. Sort of like our Interstate Highway System. Government CAN do big things well and should so things like our highway system don't get sidetracked from the overall goal like the attempt to privatize EHR(and we see how that has ended up!) At least we would all be on the same system. Those in the different specialties could then chime in on changes and help design templates that would use, and are relevant to them; putting it all on one database. That way we would all literally be making the same criticisms and it would be doctor centered not IT centered(who in reality do not want our input because at least currently it is not us that they serve. While Athena may attempt to do that and Iora another layer to help serve that purpose, there are fields of worker bees in the background scanning and doing all sorts of human handling tasks, which is laudable, however if the systems to link data were all there now, we wouldn't need to have all that unseen human hand work being done; both costly and potentially wrought with liability. Iora sounds like a great concept but by joining one or any other, you only become dependent on that system and if it dries up, you have lost your freedom and independence as well. We are getting gobbled up by large corporate medicine that wants to make us just another cog in the wheel, controlling our doctor/patent relationships with "standard of care" criteria and other seemingly well meaning paternalistic measures but always driven by someone really looking at costs and profits. In the end our income potential will be just another line item on a corporate balance sheet. And with younger physicians coming out of training with literally hundreds of thousands in debt, who just want to practice medicine, but have loans that are not even written off with bankruptcy, what do you think they will do except look for the enticement of a "salaried" position for security, and that only after working like a dog to get to enjoy that privilege! If we had just created one data base, shared universally(yes folks, inter-operability is a disaster waiting to happen like the national debt), any physician with a lap top could sign up to use it and could practice from anywhere... OK, so now that we are back from Oz, what can we really do? If Athena is going to be the one to lead the way, let them do so by finding a way to bring in the new physicians we are teaching so that if the only way back to what should have been is to create such a mass of usage it will in itself be the force in healthcare to be reckoned with. The young docs will be drawn too it because it solves their dilemma, then we don't have to keep churning and burning our colleagues. posturing only to bought out by some large corporation as a way to "cash in" on our practices. Young docs can join a small group and because we have a integrated, efficient, doctor centered EHR/EPM, can more easily " eat what they kill" But if we allow ourselves to be constantly divided or we join a myriad of groups(like our EHR's) hoping the lifetime guarantee won't be their lifetime but our practice lives, we further fragment the unifying voice we are losing. We are the gladiators, but those with the large sums of cash are like Crassus currently paying to have us go in the ring against each other just like Spartacus. Hopefully Athena won't just end up becoming the Cilicians are be bought off as well...
Name: 
William Pevsner
Email: 
wpevsner@earthlink.net

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To cure physician burnout, unburden doctors