Strategic Questions for Physicians—Part 2
Specialist physicians, like their primary care colleagues, also face strategic questions. Of course, a decision to retire rather than change is always an option. But specialist physicians have to decide if their hospital is viable, since they cannot practice their specialty fully in the absence of one. Much hinges, then, on what happens to the hospital. I have previously suggested their only real option is to start thinking of the hospital as a cost center, not a revenue center. Lest you think that answer is too stark, let me quote from another recent paper.
“To explore how the pandemic may evolve, we posit three scenarios with respect to these three factors: 1) a dream case where everything goes as well as could reasonably be expected; 2) a catastrophic case in which everything goes badly; 3) a middle case, in which some things go well, but others don’t. In evaluating the consequences of these scenarios for the nation’s health care system, we make one important additional assumption: the linchpin for a return to the health care system’s pre-pandemic “normal” state lies with the nation’s ability to assure the safety of segments of the population that are most vulnerable to the pandemic, especially the elderly and the chronically ill. These groups comprise 5% of the population that consumes 50% of health care resources.”
The authors’ best-case scenario has the pandemic resolved 18 months from now and the system back at pre-pandemic levels by July 2021. They note that even under this wildly optimistic scenario:
“a significant number of financially-weak hospitals and clinical practices will have closed their doors or merged with strong local institutions that have the capital to ride out the pandemic storm. There will be fewer primary care practices, community health centers, rural hospitals, independent small and moderate size hospitals, inner-city safety net hospitals and money-losing services of all types.”
Under the catastrophic scenario, massive government bailouts will be needed to keep the system afloat, which will constitute creeping nationalization of the system. Or it could be somewhere in between.
“Under any likely future, the health care system will emerge from the pandemic less capable and smaller. The federal government can mitigate some adverse effects by supporting now…the critical services that are most at risk: primary care practices and safety-net institutions…It can also confront the growing problem of non-competitive health care markets that will grow in number under almost any scenario.
Consequently physicians, especially those who use a hospital, must get involved in controlling expenses if they want to provide care for their patients. And make no mistake, care will not mean “doing my procedure” come what may. We are going to be held accountable for each decision to intervene. You may think you already are, but right now you don’t have much say in how these decisions are tabulated. If you want to keep some “wiggle room” for clinical discretion, you must get involved in setting the standards and making the tough judgment about what is and what is not essential care in given patients. It won’t be quite as dramatic as making triage decisions during the pandemic, but it will be only a little less severe.
What about quality standards? We know fully half are opinion-based. The other half contribute to increased costs without good evidence and the link between any of these process measures and important clinical outcomes is uncertain. In a time of economic constraint, all such measures will be examined for their impacts on costs as well as outcomes.
Unfortunately, the traditional response has been for physicians to have a fit, complain about the suits (or lawyers), then sulk away. And while we may want to blame the suits, we have been willing participants in a system where “run and gun” behavior has been rewarded handsomely as it served the needs of other players who benefited from the rising consumption of medical resources. But retrenchment is going to be the order of the day for organizations that want to avoid bankruptcy. And personal reduction in income expectations necessarily comes with it. I can hear you say “economic credentialing,” something physicians have opposed. I can imagine in a short period of time most specialists being salaried and subject to both quality inspection and fiscal inspection by the organization writing the checks. This moves the decision from “credentialing” to “employment law,” and employers have a lot freer action in the latter arena. Further, hospital boards may choose to “economically credential” by discontinuing whole types of service or individually choose to deny renewed or initial privileges using economic indicators. For them, it may be the proverbial lifeboat situation.
Now employment has not worked well previously except in situations where the physicians were responsible for their own governance. But to do governance, physicians have to come to together and do the work necessary. We generally know who are the stars, the bench players and the outliers in our organizations. The question is: will we act on that knowledge to bring our practices into alignment with fiscal realities so we can continue to give our patients necessary care in a patient-centered way? I think this is the challenge, but what do you think? Is there a way around this? I haven’t been able to think of one, but maybe you have a good idea that shows promise. Let me know.
3 August 2020
 Blumenthal D, Schneider EC, Seervai S, Shah A. 3 Scenarios for How the Pandemic Could Change U. S. Health Care. HBR. 24 July 2020. Accessed 27 July 2020 at https://hbr.org./2020/07/3-scenarios-for-how-the-pandemic-could-change-u-s-health-care.html.
 Mendu ML, Tummalapalli SL, Lentine KL, et. al. Measuring Quality in Kidney Care: An Evaluation of Existing Quality Metrics and Approach to Facilitating Improvements in Care Delivery. JASN 2020;30:602-614. doi:10.1681/ASN.2019090869.
If asked about the greatest advances I have seen, my outside the box answer would be the insight that the quality and safety of medical care is as much about system design as it is about human performance. Current efforts to make providers financially accountable, though, threaten the utility of this insight.
Medical organizations have a lot of data, much of which is not "actionable." However, if taken as a vital sign, such data can lead to important actions that indirectly improve "the numbers."
Beyond Evidence-Based Medicine
The problem with EBM is that we are trying to use the method where it does not really apply.
Experimentation may seem risky, but is essential for progress. How do we do it safely in challenging times?
Meaning or Money
The question: is health care about money first or mission first?