American Medicine Today: Productivity Tracked Like A Long Island Jeep Dealership

Posted: Jan 27 2014, 4:35am CST | by , in Technology News


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American Medicine Today: Productivity Tracked like A Long Island Jeep Dealership

The brilliant Ira Glass managed the impossible in the penultimate This American Life episode of 2013 – humanizing car salespeople to the point where you begin to empathize with them, even if you continue to dread (perhaps even more so) your next visit to a showroom.

Glass takes us through a month in the life of the Town and Country Jeep dealership in Levittown, Long Island, introducing us to an eclectic group of men and one woman who are trying to hit their target of 129 cars, and earn a handsome bonus from Chrysler. There are individual bonuses available as well. Glass explains how the system works:

“So there actually is a place at Town & Country where they keep score of who has sold what. It’s in Freddie’s office, the general manager’s office. It’s a white board with each person’s sales for the month to date on it.

Every car or truck that they’ve sold is represented by a little magnetic rectangle that’s roughly the size of a nine volt battery. Everybody calls these chips. And the different colors of the chips stand for different models of cars and trucks.

And throughout the day, salesmen come and they hover around whiteboard, seeing where everybody stands. And generally, everybody is shooting for at least 15 sales a month. At 15 sales, your commission for the next month jumps from 20% to 30%.”

The easy availability of data has armed and empowered customers, meaning that dealerships now anticipate making less money on each transaction, and hope to make up the difference in volume, further ratcheting up the pressure.

You listen to the experiences of the salespeople – the divorces, the missed opportunities to watch a son’s football game, the weight gain, the rituals — and are overwhelmed by the intense pressures of the job, and by the extent to which it evokes the poignant desperation of Death of Salesman, and the violent urgency of Glengarry Glen Ross. The manager actually reminds his staff to, “Always Be Closing,” and the modern equivalent of the magical Glengarry leads seem to be customers drawn from the internet. By any measure, it seems like a brutal way to make a living.

In the month or so since the episode aired, I’ve been struck by the unflattering parallels between the experience of Glass’s car salespeople and the reports I’ve heard from physicians in a range of practice settings.

I’ve heard from physicians employed by for-profit companies that their productivity – in terms of patient encounters – is monitored using a nearly identical communal chart to the one the Long Island dealership uses to track Jeep sales. Providers are explicitly urged to increase their productivity, receiving bonuses if they hit a pre-specified number of patient encounters, and warnings about their future career prospects if they fall short.

I’ve heard from doctors at leading academic medical centers that their lives are increasingly revolving around RVUs, a billing metric (see this piece and this piece by Uwe Reinhardt, and this one by my Forbes colleague Dan Munro). An academic surgeon tells me “every meeting we have is about RVU goals.” Providers who fall short of their target may be docked a portion of their salary, while high-performing providers may have an easier time being promoted.

Perhaps some of the unhappiest physicians I’ve encountered (admittedly a highly competitive category) may be those working at Kaiser, who complain that it feels increasingly like “a patient mill” focused on throughput. Most Kaiser physicians I know invoked some kind of factory analogy when describing their job – and they’re not thrilled by the comparison.

My takeaways:

  1. The idea that medicine is or will soon be focused on value rather than volume seems, in the memorable words of Al Michaels, “totally farcical.” While there’s a lot of lip service around a shift away from fee-for-service in policy circles, I know few physicians working in the trenches who got the memo. As Dave Chase eloquently observed, patients continue to be perceived as “a vessel for billing codes.”
  2. It miserable to be a patient in this system – existing as an object to be efficiently processed – and it’s deeply dissatisfying, and generally ego-dystonic, to be a doctor. Medicine is predicated on alignment with this patient, an affinity that seems increasing challenged. One of Glass’s salesman invokes Sun Tzu’s The Art Of War (very popular in some business circles), and describes his daily fight to take down customers. This perspective is intrinsically anathema to most physicians (at least at the start of their careers), who are more inclined to invoke war analogies in the context of a shared battle against disease. Perhaps this helps explain why so many doctors, and patients who can afford it, are migrating towards concierge or subscription-based practices (like OneMedical), creating (many would say further exacerbating) a de facto two-tiered system.
  3. The physician quality in greatest economic demand appears to be speed – essentially a process metric. Other measures of physician quality have become effectively devalued, so long as they don’t immediately lead to a bad outcome (no one wants a hack surgeon). Physicians lament that the system doesn’t care if you are really good anymore. Some skeptics might say there’s little evidence that physicians traditionally regarded as “good” actually deliver better outcomes, so this devaluation is actually appropriate. Other skeptics might assert that the idea you can meaningfully and consistently link physician behavior with outcomes far in the future is a dubious premise, with a few important exceptions like checklists; thus, the idea of paying for value, and assigning value to each provider activity, may be theoretically appealing, but generally divorced from our messy and uncertain reality. Still others might point out that it’s hard to feel too sorry for doctors, since workers in most professions are scrambling for a paycheck, and U.S. physicians are paid comparatively well (though some physicians retort that this looks less rosy once you factor in debt and time for training).
  4. A couple of years ago, when technologists like Vinod Khosla seemed to suggest that a lot of a physician’s work could be done by algorithms and machines, freeing up doctors to do what they do best, doctors were skeptical, concerned that the essence of medicine would be threatened. Today, medicine’s core seems imperiled even without the algorithms, raising the question of whether improved technology could actually help physicians, in much the way Khosla proposed.
  5. Healthcare entrepreneurs banking on the arrival of value-based care would do well to heed Steve Blank’s advice, and do some serious customer development – i.e. “get out of the building” and figure out what the people you hope to sell to are really asking for – what is it they actually need?
  6. The core issue in medicine remains reimbursement, and fee-for-service appears for the moment to have easily survived yet another assault on its dominance. As I’ve noted, the most likely catalyst for change may be transitioning of employees to private exchanges, coupled with a tethering of employer healthcare contributions to the consumer price index (CPI), as my Tech Tonics co-author Lisa Suennen has explained. This would rapidly make employees considerably more price (and value) sensitive, and create the sort of market conditions most likely (or at least, more likely) to motivate meaningful change.

Source: Forbes

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