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Hos­pi­tal ad­min­is­tra­tors, physi­cians need to team up to tackle qual­ity, ACOs, IT

Modern Healthcare - - Front Page - Emily Fried­man Emily Fried­man is an in­de­pen­dent health pol­icy and ethics an­a­lyst based in Chicago.

Ad­min­is­tra­tors, physi­cians need to join forces

Iwas speak­ing at a state med­i­cal as­so­ci­a­tion meet­ing, and some of the physi­cians in the room were an­gry. One irate man asked, “Hos­pi­tals can own physi­cians; why can’t physi­cians own hos­pi­tals?” He was re­fer­ring to the pro­vi­sion in the Pa­tient Pro­tec­tion and Af­ford­able Care Act that pro­hibits physi­cian-owned hos­pi­tals from re­ceiv­ing Medi­care or Med­i­caid re­im­burse­ment if they do not have cer­ti­fi­ca­tion from those pro­grams by Dec. 31.

I replied that there are in­stances where physi­cians do own hos­pi­tals—not only the more than 200 fa­cil­i­ties cur­rently owned by doc­tors, but also the Mayo Clinic, which owns Methodist and St. Mary’s, and other in­te­grated group-prac­tice-based sys­tems. He was not mol­li­fied.

His anger wasn’t re­ally di­rected at the new law; rather, it was aimed at non-physi­cian ex­ec­u­tives of hos­pi­tals and health sys­tems (al­though some physi­cian ex­ec­u­tives have been the tar­gets of sim­i­lar wrath).

Weeks later, a col­league who works at an aca­demic med­i­cal cen­ter was vent­ing his frus­tra­tions about the cen­ter’s ef­forts to en­hance its health in­for­ma­tion technology sys­tem and to get the med­i­cal staff on board in terms of e-pre­scrib­ing, other HIT ini­tia­tives, qual­ity mea­sure­ment and im­prove­ment, and more ef­fi­cient poli­cies and pro­ce­dures. “The docs just don’t want to change,” he lamented. “They say things like, ‘I’ve al­ways run this depart­ment this way, and I al­ways will.’ It drives me crazy.”

There are many en­mi­ties in health­care, in­clud­ing those be­tween physi­cians and nurses and be­tween nurses and physi­cian as­sis­tants, which in both cases are rooted in gen­der and turf is­sues. But an­other pow­er­ful ten­sion is the vis­ceral dis­like, in many hos­pi­tals and health sys­tems, be­tween physi­cians and ex­ec­u­tives. Of­ten, it’s pal­pa­ble; any vis­i­tor can sense it. They don’t trust each other; each group thinks the other is greedy; each group thinks the other wants to dis­em­power it.

There is ev­i­dence to sup­port both views. Five years ago, a ma­jor med­i­cal cen­ter tried to im­ple­ment a com­put­er­ized physi­cian or­der en­try sys­tem with­out suf­fi­ciently in­volv­ing the med­i­cal staff; they balked and re­fused to use it, and $30 mil­lion went down the drain. The stan­dard-bear­ers of the then-in­cip­i­ent HIT move­ment said this was be­cause the sys­tem was clunky and hard to use (as if some of the stuff we are forced to live with to­day is any bet­ter).

But that was only part of it. This also was an­other ex­am­ple of ad­min­is­tra­tion-med­i­cal staff head-butting. Dur­ing the same pe­riod, other hos­pi­tals and sys­tems were able to im­ple­ment sim­i­lar pro­grams with­out a war break­ing out.

Even ear­lier, in the 1990s, hos­pi­tals that pur­chased med­i­cal prac­tices learned some hard lessons, in­clud­ing that they of­ten paid too much, that physi­cian pro­duc­tiv­ity de­clined sharply once the prac­tice was acquired, and that physi­cians take a dim view of be­ing treated like low-ech­e­lon em­ploy­ees. Try­ing to dis­em­power physi­cians is never a good idea, tempt­ing though the idea is to frus­trated ad­min­is­tra­tors. And it can come back and bite you in the be­hind—I know of sev­eral sit­u­a­tions in which a dis­grun­tled med­i­cal staff got the CEO fired.

This long-stand­ing tra­di­tion of dis­trust and hos­til­ity of­fers end­less open­ings for jokes, anec­dotes and I-told-you-so post-apoc­a­lyp­tic anal­y­sis. But this per­pet­ual clan war is a lux­ury we can no longer af­ford.

Why? Be­cause most of the forces re­shap­ing health­care re­quire that physi­cians and hos­pi­tal and sys­tem lead­ers work to­gether much more closely. The HIT pro­vi­sions in the Amer­i­can Re­cov­ery and Rein­vest­ment Act of 2009 of­fer many car­rots in the form of sub­si­dies to get physi­cians and in­sti­tu­tional providers to adopt in­te­grated elec­tronic sys­tems and e-pre­scrib­ing. But in a very short time, those car­rots will turn into sticks, in the form of pay­ment penal­ties if providers don’t get with the pro­gram.

Fur­ther­more, there is an enor­mous need for bet­ter re­la­tions be­cause many more physi­cians are seek­ing salaried em­ploy­ment. The av­er­age med­i­cal stu­dent grad­u­ated in 2009 with a debt of $156,456, ac­cord­ing to the As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges; that’s hardly an in­cen­tive for sink­ing half a mil­lion dol­lars into start­ing a new prac­tice. More new physi­cians are women, who pre­fer salaried set­tings. Few pri­mary-care physi­cians make enough money to sus­tain in­de­pen­dent prac­tices. Last year, at­tor­ney Thomas Dut­ton pre­dicted that “within the next 10 years, 85% of all physi­cians will be em­ployed by a hos­pi­tal.”

Let’s hope it goes more peace­ably than it did last time.

And if physi­cians and ad­min­is­tra­tors can make nice, the op­por­tu­ni­ties are many. Be­tween the re­cov­ery and re­form acts, there’s a lot of money for in­te­grated ef­forts. It’s not just HIT; it’s qual­ity im­prove­ment ini­tia­tives, in­clud­ing re­port­ing of out­comes and re­wards for good ones. It’s ac­count­able care or­ga­ni­za­tions tak­ing re­spon­si­bil­ity for im­prov­ing the care and health sta­tus of de­fined pop­u­la­tions—and shar­ing in the sav­ings. It’s com­par­a­tive ef­fec­tive­ness re­search, which will re­quire ex­ten­sive re­tool­ing of clin­i­cal sys­tems, and, in some cases, re­train­ing of physi­cians and ad­min­is­tra­tors alike. It all points to one thing: Learn how to get along to achieve what needs to be done. Rod­ney King was right.

Let’s lay down our arms. Even the Hun­dred Years’ War even­tu­ally ended. There are many other ar­eas where our time and en­ergy would be bet­ter spent.

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