Reader feedback.

Dear Editor:

McGraw and Rodriguez's article, "Is There a Physician Union in Your Future?" (The Physician Executive, Volume 23, Issue #8) is both timely and very useful... if a physician executive reorganizes the message. This reader clearly recognizes the themes expounded on physician autonomy in clinical decision-making and, by the way, fees are important, too. No one would dispute the issue of insurance companies dictating the patient's care. No one would dispute the attending physician being in the best possible position to manage that care. However, I believe it is eminently critical to dispute the underlying motivation of this argument. While we see insurance companies cost-cutting, taking a major financial piece, and competing amongst themselves for market share primarily based on price, we also see physicians (and hospitals, and DME suppliers, and home care companies) "suffering" financially from a relative diminution of payable reimbursement fees.

Since this is the game, i.e., market-driven consumerism, physicians and others play, yet unhappily. The quiet desperation revealed in the doctor's lounge and the medical society meetings has turned to a more active desperation-unionization. Clearly, a firm argument can be supported for physicians driving the process. After all, in traditional fee-for-service systems, the physicians are the revenue-generators. Less appreciated, yet equally valid, in a capitated environment, the physicians are the cost-reducers. Either system offers physicians power and, unionization is a form of a "call to arms" to retake that power.

Understanding this view will enable physician executives in all roles to craft a strategic plan to empower physicians and realign the control of patient care. The focus must be on designing appropriate fee structures and building a support system. Aggressive negotiations by payers and payers should define the market. Then, education, the real thrust, is mandatory.

Physicians are a remarkable breed, already entrenched in life-long professional commitment to learning. Give them the tools. Teach them the criteria utilized to contain costs, to positively impact on the bottom line. I have found physicians to be extremely receptive to this learning when it is presented in a supportive, safe manner. I, too, agree that this is idealistic and that it will have limited appeal. The current business technology of "risk sharing" is the guarantor of the needed receptivity.

Matching the financial rewards with the measures of quality will drive the learning. A partnership of all entities to share the risk and reward will result in tremendous pressure to perform and, no single group of professionals are more performance-oriented than physicians. Unions would not only be unnecessary, they would be impediments. Learning organizations consisting of all stakeholders, physicians included, would be the order of the day.

I impress upon all of your readers, my colleagues, to "call it like it is." We're talking reimbursement! Craft the best deals for the constituency you have fiduciary responsibility to. Place equal energy into partnering for learning. And, above all, empower physicians through risk sharing. Let's avoid unionization of physicians--it cannot help. Let's hear the cries of active desperation and forcefully respond to correct the perceived financial inequities. Let's develop those much lauded integrated delivery systems, those learning organizations, to the benefit of our external customers, our patients, and our internal customers, our providers.

Our central theme is health. Health is balance. Health is synergy. Let's avoid the extraneous, i.e. unions. We have the tools; we have the power. Let's listen, let's hear, and let's effectively respond to create the health!

Respectfully Submitted,

Edward A. Gilkey, MD, MS, MBA 

Mount Holly, New Jersey

The virtues of an MBA?

I read with interest the article in the November/December issue of The Physician Executive by Dr. Lazarus about additional education for physician managers. I found it curious that in the midst of his article extolling the virtues of an MBA, Dr. Lazarus makes the point that there may be more appropriate kinds of information that physicians pursuing management careers should be familiar with, other than the standard offerings of traditional MBA programs. The examples he uses are questions from the application for a program that is not an MBA program at all, but rather the new Masters in Medical Management, jointly sponsored by Tulane University and the American College of Physician Executives.

Having recently graduated from the Tulane program, and so having answered the very questions that he uses as examples, I would only try to point out what I believe the issue really should be. Additional, formal, graduate level education is important to those of us who are pursuing full time careers in medical management. We need the knowledge base, we need the non-medical degree, we need the experience of going back to the classroom and learning non-clinical information, and we need to work at changing many of our clinical paradigms if we are to successfully work with lay administrators.

I would not take exception to the financial and career opportunities that Dr. Lazarus raises. I suspect that Dr. Lazarus and I would also share the belief, held by a number of physicians, that the pathway to curing many of the ills of our sickly health care system lies along a course that includes many more physician mangers who are steeped in the rich traditions of our profession, but who also posses the requisite knowledge and background in business. There are many degrees that can provide that. Time, travel, and cost are all considerations, but the most important issue is that the physician contemplating a full time career in management must go out and pursue it. There is no other way to get it done.

Sincerely,

James D. Butterick, MD, MMM 

Chief Medical Officer

Southcoast Hospitals Group

Fall River, Massachusetts 

Liability issues in a managed care environment

Providing quality health care under managed care contracts is a major challenge for increasing numbers of physicians. Information and methods of reducing liability risks in a cost conscious environment impact medical care, as well as legal and ethical issues. Organizations such as the American College of Medical Quality have identified core principles recognizing the potential of a fully integrated managed "care" system and the pitfalls of a managed "cost" system. Physicians must be educated in both practicing, as well as documenting, defensible medical decision-making. Expert witnesses must constructively engage in the process of shaping health care to ensure that we promote the highest value and quality during this chaotic health care reform.

Three cardinal goals of any strategic plan or reengineering process presently active in health plans, medical groups, and hospitals include:

1. Maximizing positive patient health outcomes

2. Practicing efficient, cost-effective medicine with attention to resource utilization

3. Responding to customer (i.e., patient, payer, provider, purchaser, etc.) needs and satisfaction.

Standard of care encompasses the learning, skill, and clinical judgment of health care providers, and it applies to all health care activities, including medical decision-making. A violation of standard of care may potentially occur when unnecessary care is provided, in addition to the absence of providing the minimum level of acceptable care. Reviewing the necessity of past, present, or future medical care must conform to an applicable standard which is presently in a state of reform. Benchmarking and best practice clinical pathway guidelines are attempts to form a national basis for this process. The review of any medical decision-making process must always be performed by qualified and credentialed professionals and conducted in a consistent, uniform manner. The main goal is to impact positively and also appropriately on the care of patients (individual), as well as the improvement of the medical delivery system (population).

Documentation is the most reliable indicator that medical care has been provided or that medical review has been performed. It is a basic component of a continuous quality improvement process that health care has borrowed from the business world. Accurate and appropriate recording of information by medical personnel is critical to ensuring continuity of care, communication between providers, and implementation of quality to prevent violating the standard of care.

Miscommunication between patients and providers is a liability issue that has been shown to be a major factor for litigation. Patients may not tell the physician about all their medical concerns, sometimes are afraid to ask questions, and are often unclear about what happens next after a medical visit. Attention to this arena might be the major saving grace for medical providers who are attempting to deal with a rapidly changing health care system in which there are very few "rules."

Sincerely,

Ross M. Miller, MD

Medical Director, Quality Management

CIGNA HealthCare of California

Glendale, California 

Dear Reader:

Value-based health care?

Part 2 of the value-based health care article by William C. Mohlenbrock, MD, will appear in the upcoming May/June issue of The Physician Executive. Part 1, "Physicians Reestablishing Clinical Autonomy," was featured in the January/February issue.

Let us know what you think

Did one of these articles on merger mania resonate with you? What have your experiences been with the evolving health care system? Please take a moment to let us know what you think of this issue of The Physician Executive. Please fax your opinion, ideas, and suggestions for improving The Physician Executive to the Managing Editor at 813/287-8993 or via email to [e-mail].

Thank you!