Meaning or Money
In recent articles I have been trying to think about the impact of the economic assumptions we use in organizing health care delivery systems. Just as I finished the most recent article, I read an article in Kaiser Health News that illustrated the conflict rather dramatically. The headline read “Hospitals Accused of Paying Doctors Large Kickbacks in Quest for Patients.” The article reports Wheeling Hospital, Wheeling West Virginia, was accused in a federal lawsuit of paying physician specialists who used hospital services substantially more than they could expect to bill in personal services. If proved, this would be a violation of the so-called Stark laws, passed 25 years ago, which were designed to prevent financial incentives from warping clinical decision-making. The hospital has argued in its filings against the whistleblower who initiated the suit that it took the kind of salary they were offering to get these specialists to relocate to Wheeling, saving patients from having to drive to Pittsburgh for care.
The article notes the average internal medicine physician, who earned a typical salary of $250,000, would generate at least $2.7 million in downstream revenue for the hospital. A cardiovascular surgeon, who might have a $370,000 salary, would generate $3.7 million in revenues. In January 2018, some 44% of US physicians were directly employed by hospital systems. The government has been filing numerous suits, some of which have been settled for significant sums of money, challenging arrangements hospital systems have entered into to “buy” physicians.
My point in bringing this up is not to discuss the wisdom of the Stark laws or to argue what is or is not permissible—that is for the lawyers and the courts to decide. Perhaps the way to think about this situation is that it is akin to college basketball. In that sport, the person generating the revenue is not supposed to receive anything more than a free college education, but the coach can make millions and the university even more. Of course, the kid can jump to the pros, but only a small fraction do—the rest are limited. The tension generated tempts some coaches, boosters, and universities to cheat. Some get caught, others don’t. But maybe the problem is the situation is set up unfairly. The value to the university and the coach is too many times higher than the value to the “student-athlete” even if he does not aspire to be a professional basketball player.
So, who is in favor of continuing the current college basketball arrangement—the NCAA, the universities and the coaches. In this case, the NCAA is analogous to the Federal government, where the insurance and pharmaceutical companies, and now the hospital systems, are analogous to the universities and the coaches. Sure, some programs and some coaches are censured for straying too far from the norm, but the majority aren’t.
All of these processes, though, contribute to a declining morale in the primary workforce—the physicians. Usually called burnout, it is, in my view, more the conflict between the altruistic impulse that drew physicians to the line of work in conflict with the cynical, dare I say exploitative, systems they find themselves trapped in. Since I am sure there is not a perfect economic system, I think we may need to go back to the basics.
Anna Roth, who started as a nurse, ended up CEO of a large hospital, and is now director of public health in Contra Costa Co., California, has recently talked about how to “pivot” back to what really matters. As she notes concerning the changes she has seen in her career: “We’ve been talking a lot today about how the world…has changed in health care, but what’s been the cost for providers, and for those of us who work in health care? Have these reforms actually brought us closer to the meaning [of health care]? She proposes three specific actions, or pivots: listen carefully and ask the right questions, challenge your beliefs, and trust people. Under the first point she says:
“We need to listen carefully to people and ask them what matters to them, not what’s the matter with them.”
Note this is not, at its heart, an economic question. If the doctor responds “how much is it worth to you,” money is the primary driver. If he or she responds “what kind of work is it?” then the mission is more important. I fear too many organizations have decided it is all about making sure I (or my organization) “get my share of the pie while I can.” I also fear too many doctors have decided other people are eating pie at their expense and the system is rigged to keep them from getting “my fair share.”
The existential challenge is to decide if the organization and the individual are primarily about meaning or money. “No money, no mission” remains true, but it is also true in the long run “no mission, no money.” In today’s short-term thinking environment, I suspect many have forgotten the mission, or maybe just assume the doctors will take care of it as a matter of course. As I have suggested, doctors, many of whom consider the mission primary, are disheartened and feeling exploited. Many are leaving, having given up hope. I hope we can make the pivot in time to avoid being left with just doctors for whom money is primary and the mission of caring for the sick and hurt is secondary.
11 June 2019
 Rau J. Hospitals Accused of Paying Doctors Large Kickbacks in Quest for Patients. Kaiser Health News, 31 May 2019. Accessed same day at https://khn.org/news/hospitals-accused-of-paying-doctors-large-kickbacks-in-quest-for-patients.
 Roth A. Returning to the Meaning of Medicine: Three Pivots. 5 June 2019. Accessed same day at https://catalyst.nejm.org/videos/returning-meaning-medicine-three-pivots.html.
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