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High Quality in Veterans’ Health Care and Clinician Autonomy: Are They at Odds? (Part 2 of 2)

By Dr. Ram Krishnamoorthi
. 1 Comment(s)

 My last post discussed the evidence that has accumulated about the quality of care that the Veterans Health Administration (VHA) provides to veterans. The VHA has been shown on a large system-wide scale to surpass the private sector on accepted quality measures for preventive care, care for diabetes and for other chronic diseases. As reported in a recent Annals of Internal Medicine paper, adhering to nationally accepted guidelines for acute care for cancer has also been as good as or better for veterans than for Medicare beneficiaries in the fee-for-service sector.  In addition, an independent survey group found that veterans have expressed more “customer satisfaction” with VHA care than the general population has rated its private sector health care experiences.

The VHA’s accumulation of impressive accolades for health care quality can be attributed to a system of performance improvement and a culture created by Dr. Ken Kizer, the Undersecretary for Health for the Department of Veterans Affairs in the 1990s. After years of scandal, ridicule, and substandard care for the nation’s heroes, Dr. Kizer transformed the VA into an integrated health care system, connecting hundreds of clinics and hospitals electronically and promoting coordinated, patient-centered primary care. Today, innovative solutions such as Patient-Aligned Care Teams (the VHA equivalent of the medical home), a home tele-health system, 24-hour nurse telephone triage, and a web-based health record accessible to veterans, continue to provide care effectively and, according to Philip Longman, author of The Best Care Anywhere, with lower cost than the private sector.

At the heart of the VHA’s quality culture are performance measures. Hundreds of health care activities, both clinical and systems-centered, are measured, and vast amounts of data are collected to promote continuous performance improvement based on targets established by the VHA Central Office.  Targets include well-established ones, such as Hemoglobin A1c targets for diabetes, beta blocker drugs for heart disease, colon cancer screening; and ambitious ones, such as enrollment in smoking cessation classes, advance directive discussions, appointment access targets. Both internal auditing and an external performance review process hold hospitals and physicians accountable for meeting performance targets. Financial incentives are established for meeting targets, resulting in performance bonuses for clinicians and their hospitals.

The question arises, is a culture based on standardized, centrally determined performance targets at odds with physicians’ clinical autonomy? Do performance targets and their accompanying financial incentives create a staff of physician employees, following cookbook medicine and compromising on the art of individualized patient-centered care?

Much was written about clinician autonomy during the 1990s when insurance companies, especially Health Maintenance Organizations (HMOs), reached new heights in managing physicians’ care. While Managed Care bent the cost curve and claimed to promote prevention and disease management, American patients backlashed loudly, and so did American doctors, who were spending more time on the phone and with paperwork, fighting non-physician “suits” from insurance companies to get approval for their care choices and treatment plans.

Dr. James Reinertson of the Institute for Health Care Improvement summarized physicians’ justification for lamenting their loss of clinical autonomy in this era in his piece “Zen and the Art of Physician Autonomy Maintenance": “Physicians’ fierce attachment to clinical autonomy has a basis in this truth: no two patients, and no two doctors, are the same, and that the art of medicine happens somehow in the relationship between those individuals.” Even at Kaiser Permanente, a staff model HMO that most closely resembles the VHA model, a survey revealed that physicians’ control over their clinical decisions was the most important mediator of professional satisfaction, along with strong social support among other health care providers. 

Indeed, physicians have come to expect clinical autonomy, coming as a professional reward after 10 or more years of training, a gauntlet of hours and emotional steeling, and after seeing role models who were great clinical artists. It is difficult to convince doctors that all of this can be reduced to clinical guidelines, protocols, and statistical probability.

But are the guidelines and evidence-based medicine to blame for compromising clinician autonomy? Aren’t these guides written by clinicians, some of our mentors and the experts who wrote our textbooks?

In the VHA, it seems that physicians do not disagree with the actual clinical performance measures, for the most part. Most are accepted standards published by professional specialty societies, such as diabetes care goals, and in the case of systems goals, by the Joint Commission for Accreditation of Health Care Organizations (JCAHO). For example, performing “medication reconciliation” (ensuring that the doctor’s list of medications accurately reflect what a patient is actually taking) is just good medicine.  

Physicians’ complaints come, instead, in gaps in the system’s resources to be able to achieve mandated targets and their inability to participate in the higher-level discussions about the logic of certain goals. In addition, data are collected and reported for these measures, but they may not reflect the true complexity of physicians’ practices and their patients’ lives. For example, receiving disapprobation from the central office for poor hypertension control in a veteran who is non-adherent to his meds feels unfair and misses the point. Physicians note that in order to achieve the spirit of the measures—rather than the numbers themselves—there need to be systems changes, more assistance, and often, more evidence and research for medical situations that don’t meet cookbook defaults.

Published data about VHA physicians’ sense of job satisfaction are lacking. But, I can attest that VHA physicians love their mission: to serve veterans, an extraordinarily appreciative group of men and women who prefer the VHA because they are treated with dignity and often have nowhere else to turn. Clearly, we enjoy the same professional satisfaction that physicians everywhere share and wish to apply the same moral ethic in centering our care on individuals. As Dr. Reinertson wrote, using evidence-based medicine when it is applicable and when it is balanced by tailored care is based on the very science that brought clinicians respect and autonomy in the first place. Patients come to us as clinical scientists, expecting a consistent application of science where it is known. And, clinicians can be free to apply the art where there science is still uncertain and circumstances vary from the norm.

Our current gripes should not be with measuring and establishing standards of quality, but rather the lack of “system” in our healthcare that burdens doctors with targets that are not achievable in high-volume, short-visit practice environments. Instead, an integrated health care system like the VHA, one that coordinates care for chronic disease, prevents illness, and promotes health with low tech /high touch solutions, is one that will provide the highest quality. For the nation, the system need not be government-run or large and bureaucratic to take advantage of integration, but can arise out of American entrepreneurship guided by rational financial incentives.

We, as physicians, should advocate for this integration. Because the most effective approach to retain our clinical autonomy is to share it with other colleagues, engage in the pursuit of new scientific knowledge, and implement the known science through innovative practice models with multiple disciplines and multiple modalities of care.

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  1. Rebecca Jones MD

    Doctors can be autonomous as long as we communicate with each other. As we know, medical schools are starting to select for an applicant's ability to work with others. This is a necessary skill whether we work on our own or in an integrated hospital setting. Medicine can no longer function as the wild west and we are better for it. But no amount of regulation or EMR can force doctors to be team players; and autonomous doctors who are team players will surpass any mandated system.

    Then there are accountability and responsibility. We tend to consider doctors and the patients themselves (or pre patients, before they get sick) responsible for keeping the person in question healthy. But there are social factors that press in on a person's ability to avoid illness, and I would love to see a true system that takes that into account. Balance, for instance, the huge profits agribusiness makes, with the health costs of its products. If the only parts of the "system" that are accountable are doctors and patients, then physicians are going to find their task of keeping people out of the hospital, harder and harder.

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