Any casual reader of this blog will note that I don't really find any value in the myriad of management practices that have been added to medicine since businessmen and their friends in government have taken over. The only reasons that these practices have been added is strictly political and rhetorical. Nothing has been overhyped as much as management adding value to medicine with so few results. Nothing has done quite as much to detract from the quality of care than these same business practices. At this point they have become as entrenched as gun legislation and will be every bit as intractable. These problems are very difficult for the typical consumer/patient to see. The obvious points of contention are insurance company denials either for medication or medical care. They peaked in the 1990s when managed care companies thought that they would just put specialists out of business and had primary care physicians acting as "gatekeepers". If you are old enough you may recall having to get a referral from your primary care physician to see specialists, for various services. and in some cases even to go into an emergency department. It took them a while but these businesses learned that being that transparent in denying care was probably not in their best interest. It also created a large burden on primary care physicians who were now uncompensated reviewers for the insurance company business practcies. Eventually that system was scrapped in favor of shifting financial risk around - some to consumers and some to physicians and physician groups. There are many ways it can happen, I thought I would provide a few examples below.
Managers like to use a shared decision making model in their manipulation of physicians. I guess they don't consider physicians to be particularly bright people. I don't know if that happens when you are socialized in the business world and automatically consider your decisions to be the best based on scant data, a lack of measurement standards and perceived quality of a good idea. Whatever the reason, the approach generally only works because the physicians have no leverage. Consider the following example. Ten physicians are in a group providing hospital coverage for admissions to a community hospital. It can be any specialty. They are working a 7 days on and 7 days off model and each of them typically admits 10-14 patients per day at work. They are stretched to the maximum so that anyone requiring emergency leave seriously disrupts the schedule. Their colleagues are expected to cover. The administration would like to open an 10% additional bed capacity and meets with all of the physicians about this to problem solve over how that might happen. The physicians are asked the question: "We are here to all figure out how to increase the number of admissions by 10%. Do you have any ideas about that?" That leads to a general discussion of how the physicians are overworked and already spending too much time from home on the electronic health record. A consensus builds and the physicians say they need more staff and staff to cover unpredicted absences. At that point the administrator states: "No - I guess I didn't explain myself very well. We are here to decide how to provide more services without increasing the cost by hiring new people." The physicians finally get it. Sharing in this case means, I will ask you for your input, but it is meaningless and I will require that you work harder even though you are probably burned out right now.
Another popular sharing model where physicians share more than anybody else is financial risk sharing. The first introduction was when RVU productivity units were introduced. The initial administrative argument seemed to be that not everyone was carrying their own weight. The RVU system was portrayed as being inherently more advantageous to those people who were really productive. It would allow them to make more more than the slackers in the department. That was a good theory to try to appeal to physicians competitive natures, but in most departments - schedules and productivity was already saturated. There were no slackers. That point goes to the administrators. The second risk sharing introduced was the "holdback" model. This said that 10-15% of everyones' productivity would be held back until it could be assured that the production figures were met and then it would be released to the physicians in the group. Keep in mind this was money that was already billed and earned. There was no similar "holdback" from administrators or other personnel. A take off on this risk sharing was getting physicians in administrative meetings and showing them endless spreadsheets of overhead costs and how much they would have to "produce" in order to get either their holdback or some other form of reimbursement.
The ultimate form of risk sharing today seems to be the contract that comes in and puts everyone at risk by not even recognizing the physician billing. In this case the insurer comes in and says - this is how much we will pay you on a per diem basis to cover these patients for various problems. You agree not to charge use anymore than than - no matter how much care each one of those patients needs. This last model is the most insidious. It caps any insurance payments (losses) and puts any physicians and their clinic at complete risk for catastrophic loss but more importantly it is a war of attrition. With this model as the only source of funding, it allows administrators to view physicians as "costs" rather than resources and eliminate them, underfund them, overwork them, and burn them out. It is a tried and true pathway for how managed care organizations using this model can adversely impact the quality of care in every organization they contract with, but especially the ones that don't understand corporate doublespeak.
Too many of my colleagues tolerate corporate doublespeak in management systems. They don't seem to understand that risk sharing does not really mean that anything is shared. It means that they are left holding the bag. These same systems tell us how "younger physicians" are more accepting of these models. Medical professional organizations and specialty boards are talking the talk. We have the American Psychiatric Association talking about various collaborative care models where psychiatrists don't need to see patients any more. The speciality boards have designed a number of expensive and complicated performance metrics that have no basis in reality and CMS (Centers for Medicare and Medicaid Services) has done the same. It is hard to imagine that when I started out in Medicine we did not have to deal with all of this administrative fantasy. We went to work each day and it centered on the facts, patient care, and the medical science of the day -
Not what somebody forced us to believe for a few months at a time while they were wasting our time, energy, and money.
George Dawson, MD, DFAPA
