Physicians in the Balance — The Zero Sum Game

The World English Dictionary defines “Zero Sum Game” as a “contest in which one person’s loss is equal to the other person’s gain.” Healthcare systems in most countries are facing aging populations with a growing prevalence of co-morbid chronic diseases. These individuals are complex and costly to care for, a situation that is at odds with a world in fiscal crisis. The Zero Sum Equation in healthcare is the need to distribute a fixed pool of funds and resources while demand for health services continues to grow.

Initiatives such as the Patient Centered Medical Home and Accountable Care Organizations (in the U.S.) and primary care networks and teams (in Canada) are being developed along with expanded use of technologies such as Electronic Health Records, Remote Patient Monitoring (RMT), and Telehealth systems to provide more efficient care and improve quality, while at same time increasing the capacity for more patients.

A June 4 article in The Economist titled “,” raises questions about the future of the medical profession in healthcare systems that are looking for less costly solutions to complex health policy questions. Making a limited pool of resources go further is a major challenge and while many healthcare professionals are working hard to achieve the goals of accountability, efficiency, and better care, there are consequences that can be demoralizing for all members of the team.

I would like to share an anecdotal story regarding the experiences of a care team in a small community in rural Western Canada. A town of approximately 8,000 residents and a small local hospital established an innovative primary care and integrated care clinic using a range of care providers including physicians, nurses, nurse practitioners, counselors, dieticians, etc. Funded under an alternative payment model (salaried physicians, not fee-for-service), the clinic has been structured to provide comprehensive team-based preventive care using Electronic Health Records. In addition, an internal performance measurement system of weekly reports allows clinicians to compare their quality of care for patient populations against their peers and distribute their patient load equally amongst team members. Hard work, goal setting, and performance measurement produced tangible results. Visits to the local hospital emergency department were down, as well as hospital admissions. This was considered a great success. Everyone could pat themselves on the back for doing a great job and meeting the demands of the overall healthcare system.

However, the result was not a redistribution of funds and resources to provide upgraded equipment or services for residents of the town (as some might have hoped). Because hospital visits and admissions were down, the budget to the health district was reduced and the funds distributed to other sectors that were deemed to be more needy (or were less efficient). From the care team and administrator’s perspective, this was challenging. Rather than creating a buffer within the local health system as a result of improved performance, budgets were reduced. This resulted in a feeling by many that they were being punished for doing a good job. Pressures did not ease. Once the expectation for continued high performance was established, providers had to maintain their achievements or face a lack of resources. If they worked even harder and identified greater efficiencies, they could expect to be “penalized” by reduced funding in following review cycles. The net result was counter-productive as existing policy reduced the incentive to continually achieve higher levels of performance. This is an example of policy that may achieve exactly what government is seeking (providing more services at lower cost); however, it resulted in a demoralized and stressed workforce.

The healthcare provider environment is changing. In order to respond to the needs of an aging population with a higher prevalence of chronic diseases, a concerted effort is being make to train and integrate providers with lower skill levels and manage a range of conditions that do not require direct oversight by physicians.

There is no doubt that the sands are shifting for the medical profession in response to a need for more manpower. As resources are more thinly spread in this particular “Zero Sum Game,” all providers (including physicians) had better prepare to do more for less.

The following video reviews the medical training program at LIJ School of Medicine in New York.

How do you see healthcare systems adapting to the demand for clinical providers? How do you envision the role of physicians in 2030 supported by and using a wide range of information technology tools to deliver care? Add your thoughts and comments below.

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