Trust between doctor and patient is key to superior healthcare.

This fall, smack in the middle of the ongoing debate about healthcare reform in the U.S., a consummate medical professional published a remarkable book that pinpoints the structural imbalance that ails the country’s $3 trillion healthcare industry. 

In “Back to Balance—the Art, Science and Business ofMedicine” (Disruption Books), Dr. Halee Fischer-Wright, president and CEO of the Medical Group Management Association, writes: “We have lost our focus on strengthening the one thing that we know has always produced healthier patients, happier doctors, and better results: namely, strong relationships between patients and physicians, informed by smart science and enabled by good business practices that create the trust necessary to ensure that patients do what they need to do to achieve” good, long-term health outcomes.

No doubt, something is seriously amiss: among industrialized nations, the U.S. spends the most per capita, but the quality of healthcare and patients’ health outcomes rank lower than those in Germany, the UK, France, and a host of other developed countries. Fischer-Wright knows her stuff: the organization she leads “represents 40,000 practice administrators and executives in 18,000 health-care organizations across all fifty states, where more than 400,000 physicians practice, providing close to 50 percent of the health care in the United States.”

The “art of medicine,” she asserts, “is being crowded out by the science of medicine—and its emphasis on evidence-based procedures, well-meaning protocols, and advances in Big-Health-Data-churning information technology.” There is a relentless “focus on time-consuming but questionable quality metrics, endless billing procedures, and an adherence to process that doesn’t necessarily put patients first.” Case in point: the author cites findings that show that “the average physician now spends nearly two hours on paperwork [digital entries included] for every hour spent with patients, if they’re lucky.”

These factors “keep creating greater distance between patients and their doctors,” writes Fischer-Wright, who insists that “we need to bring the art, science, and business back into balance — with each side playing its part and no more to drive the healthy outcomes that we all desire from health care today.”

The art of medicine, she insists, hinges on trust, the authentic bond between doctor and patient. It is the vital importance of the “human side — the big-hearted, patient-focused, high-touch, active-listening, caring, compassionate, empathetic part of medicine that has been at the heart of the doctor-patient relationship from the very beginning.” 

“A trusting relationship between physicians and patients,” writes Fischer-Wright, “based on compassion, empathy and good communication can have a profound effect on patient health. Trust aids efforts to control diabetes, lower cholesterol, and control pain. Trust improves the mental and physical quality of life of cancer patients. Trust encourages people to get regular preventive care. Trust gives older patients better outcomes and more long-lasting independence. Relationships built on trust have been shown to reduce anxiety, depression, post-traumatic stress disorder, and a patient’s use of end-of-life care. These relationships are linked not only to lower hospital readmission rates for heart failure or pneumonia, but also to more successful treatment regimens, lower health-care costs and much higher patient satisfaction scores.” Trust is everything!

Hence, the book argues, the business and science of medicine must be de-emphasized in favor of more holistic and humane treatment and involvement of the patient, making room, quite literally, for the human touch.

Fischer-Wright proposes a number of intriguing remedies to bring the art, the business and the science of medicine into proper balance. Among them, a suggestion to “design medical care for healthier people instead of strictly for diagnosis and treatment of disease.” The human person is far more complex—emotionally and spiritually—than the sum total of his or her physical condition.

Also, she recommends: “ask the people the right questions, genuinely listen to the answers and then take the right action” for doctors to find out what their patients expect from medical care, without making assumptions. 

Finally, she calls for the creation of “empowered relationships that demand balance in the art, science and business of medicine”—the doctor, the billing person, the office assistant and the patient him or herself working toward a common goal.

Restoring the fundamental trust between doctor and patient is both the foundation and objective of these vital adjustments; it holds the key to putting “the needs of people at the center of the [health-care] industry again.”

As the CEO of a unique health-care network comprised of independent New York City-based physicians, I am most heartened by Fischer-Wright’s insistence on the primacy of the doctor-patient relationship. SOMOS Healthcare (formerly Advocate Community Providers) is a so-called Performing Provider System (PPS) operating under a mandate from the New York State Department of Health as part of its Delivery System Reform Incentive Payment (DSRIP) program. The initiative’s bottom-line objective is to save taxpayers some $12 billion in unnecessary hospitalizations by the end of the program’s five-year term in 2020.

That goal is achieved, quite simply, by providing better care in terms of prevention, diagnosis, treatment, patient follow-up with CHW handholding. This way, medical conditions may be avoided and managed, avoiding emergency room visits and hospitalizations that drive the burdensome cost of the Medicaid system. 

SOMOS Healthcare was formed by community physicians to revitalize the role of the community-based primary care physician. Like the family doctor of old, these physicians often live and work in the same neighborhood as their patients. Often, they speak the same language and share the same cultural background, ensuring sensitivity to the cultural context of patients’ wellbeing. That, we are convinced, is the key to creating an intimate, trusted bond between doctor and patient.

A cadre of specially trained staff and Community Health Workers at SOMOS Healthcare help to reduce the administrative burden of our network physicians by improving workflows, streamlining billing and maintenance of Electronic Health Records, and exchanging data with the Department of Health. SOMOS staffers are also in a position to make home visits and ensure that patients are following their medical regimes. Thus, our approach echoes the author’s recommendation that shifts the balance back to the doctor-patient relationship.

As to the encroachment of the science of medicine, our primary care physicians can readily refer their patients if specialized treatment is in order—but only after a thorough discussion and examination that takes into consideration possible cultural influences or mental health issues. Ours is a sharp departure from the impersonal, transactional, and test-driven practice of Medicaid medicine.

There is one critical area, however, where we part ways with Fischer-Wright. At the core of DSRIP is a shift to a Value-Based Payment (VBP) or Pay-for-Performance formula: increasingly, compensation for doctors is pegged to the longer-term health outcomes of their patients. We respectfully disagree with Fischer-Wright’s rejection of pay-for-performance, even as efforts she has studied over the years may have missed the mark.

For SOMOS Healthcare, pay-for-performance is at the heart of enabling our doctors to be true to their calling of delivering patient-centered health care. For too long, fee-for-service has economically favored large hospital systems. A value-based formula ensures that incentives are appropriately aligned to reward physicians for personal, relationship-based, comprehensive care.

Those with the most to gain are the people — let’s not call them patients, which connotes illness — whose health and well-being are front and center. After all, shouldn’t our health care system focus on health rather than illness?

Over time, that extra effort will include the so-called social determinants of health, such as a patient’s housing and employment situation. It’s not a matter of what Fischer-Wright labels as using “money to force compliance,” but of recognizing and supporting the risk our doctors are taking as small business owners to link their professional success to the genuine well-being of their patients. That, too, is a matter of trust; rewarding virtue is a good investment.

Post-2020, when the DSRIP mandate ends, SOMOS Healthcare is poised to continue supporting our network of community physicians as a for-profit organization, one that likely will begin to address the needs of Medicare recipients as well as our base of Medicaid beneficiaries. As our operations expand and, hopefully, as other organizations in New York State and beyond follow our example, we are confident that Fischer-Wright will discover that pay-for-performance will be a crucial element in balancing the art, science and business of medicine — be it government-sponsored or commercially driven.