While physicians are charged with directing referrals, diagnostic tests and treatment options, every physician operates under the rules, regulations and restrictions of the government, the payers and the employer.
American doctors are working in one of the most complex healthcare systems in the world.
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Primary care physicians, in particular, are at the center of the medical home, with the vital responsibility of playing the role of manager and gatekeeper of every patient's journey through the healthcare system. Yet, while physicians are charged with directing referrals, diagnostic tests and treatment options, every physician operates under the rules, regulations and restrictions of the government, the payers and the employer.
More and more doctors are feeling pressure from regulations that are at best time-wasters, and at worst, not designed for optimal patient outcomes.
This is where physician involvement in tackling regulatory limitations comes into play. A daunting concept for most doctors, changing policies can seem virtually impossible for busy physicians. But at the same time, it can be a vital step to improving the healthcare system within which doctors must work to help patients.
Advocacy, the method by which doctors can achieve effective change in the healthcare system, is a powerful and underutilized process. Advocacy involves promoting your goals through a systematic plan of action. For physicians, advocacy begins with a plan.
Virtually every doctor wants to have more freedom over day-to-day work. Yet, making change happen begins with defining a specific goal. Achieving that goal requires determining who has the power to implement those changes. For example, policies may be implemented by the federal or state government, by payers or by the employer.
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Pamela Wible MD, a primary care physician in Eugene, Oregon, explain that it is important to avoid simply complaining about the situation, but instead, to present a solution to whoever is in charge.
Presenting a realistic plan for a solution to your problem allows the people from whom you are requesting a change to better visualize the outcome that you are looking for.
Next: hard lessons learned
Jesanna Cooper MD, an obstetrician in Birmingham, Alabama, actually sought a change in her practice that required major modifications in her healthcare system bylaws. Cooper wanted to expand her practice to include midwifery services.
“I saw this as a way to better serve my patients as well as grow my practice,” she says. “The midwifery model of care has been shown to decrease C-section rates and increase breastfeeding rates in populations of medically low-risk women. However, the hospital bylaws at the institution where I practice obstetrics did not allow midwives to obtain privileges.”
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After deciding what she wanted and gathering quality indicators in support of her plan, Cooper spent three years working towards her goal.
“I attempted to gain buy-in from physicians within the Women and Infants department as well as from the chiefs of other departments, particularly surgery and anesthesia. It took two years to get a vote on this issue, but it passed without conflict once presented. I then worked with the Women and Infant's department to put together a credentialing form. At this point, it had been three years of lobbying efforts and negotiations.”
Cooper points out some of the impediments to her efforts.
“I mistakenly thought that quality indicators and evidence would be my strongest tools in eliciting change. However, this was not the case. My plans did not fit well with the administration's plans for our service line. My eventual success, however, was due to the support of other physicians across several departments. My experience underscores the need for physicians to organize and work together to affect changes that will benefit both our patients and our profession. “
Yet physicians who believe that quality care should be the highest priority in healthcare are surprised and ultimately deflated when these goals are not the priority for everybody. A pediatrician from New York State who does not want his name used, explains that he spent two years attempting to lobby local policy makers for reimbursement for phone consultations.
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His practice is located in a busy suburban area, and also serves patients who live in nearby rural areas with limited physician access. He says that parents often call with concerns about their children, and that many of these phone calls do not require a drive to the emergency department in the middle of the night, particularly in bad weather.
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After several meetings with local legislators, he felt optimistic enough to travel to Washington D.C. to meet with representatives about the issue. His experience was discouraging. He says, “scheduled meetings were cancelled at the last minute, and I felt like I had been wasting my time.”
After two years attempting to influence policy, he says, “I have gone back to practicing medicine the old fashioned way. I spend time on the phone with concerned parents at all hours of the night, and I take care of them as best I can-completely uncompensated. I realized that I don’t have time or energy to deal with changing the system.”
Wible takes a somewhat different approach. She explains that as a self-employed physician, she sees patients in a small office and that she has decreased her overhead by eliminating no value intermediaries, who would eat away at her reimbursement. While she follows rules set by the government and by payers, her practice model frees her up from following the usual employer-designed rules that are set up to support administrative staff through physician-generated reimbursement.
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She says that most doctors cannot imagine following her practice model because so many layers of managers and administrators make the prospect seem impossible. But, Wible explains that she follows all real policies and regulations, has medical malpractice insurance, built her own electronic medical record system and bills payers. She just took the time to learn what the real regulations are, and found that many of the rules doctors follow are habits and not rules, and that dealing with the rules as written is an important step in terms of decreasing what doctors need to fight for.
Overall, advocating for change in the healthcare system requires personal energy and commitment. It is all but impossible to create change alone. Often, effective advocacy means reaching out to others to communicate your message and getting others on board.
The anonymous pediatrician says that his lone efforts may have hindered his progress, while Cooper explains that her success was largely eased by acceptance and buy-in from other physicians.
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Knowing the details of healthcare regulations and policies is a key factor in ensuring that the plan of action makes sense. As Wible points out, some policies are really created for the profit of the employer, and therefore do not necessarily have to remain a part of a physician’s life for his or her whole career.