Reader feedback.

Dear editor.

Frist Scores a First for Physician Executives

The wish that we all may have been waiting for has finally been granted. One of our own, Sen. Bill Frist, MD, (R-Tenn.) has been elected to the post of U.S. Senate majority leader. The position is arguably the most powerful in the senate and certainly commands one of ultimate respect and access to the most powerful law making body in the United States.

Although Frist is not without his own set of demons--the name Columbia/HCA does not exactly exude the highest level of ethical and moral character--in a social climate when everything from the clergy to the local lawyer has diminished in perceived value of ethical and moral standards, the perception of the physician still remains unscathed.

In the midst of probably the worst medical crisis since the inception of health care, the physician leader has emerged as the one who still fights for what is "right" for the patient. Even at their own personal expense and ever-mounting liability, physicians have emerged as true leaders for what are the needs of the masses first and their own agendas second.

This, you realize, all comes at a price--not in monetary value, but in time, frustration and emotional mental energy. Overcoming these obstacles to merely practice medicine today is difficult. In order to lead others, especially in the public eye of the United States Senate, becomes nearly Herculean.

Physician executives have the "War of the Worlds" to fight, but the arsenal of Napoleon at their disposal.

How does one accomplish anything?

I think the answer is not one of complexity but one of simplicity. What are the primary goals we wish to achieve? Is not the highest quality care at the most efficient cost for all patients a reasonable request? How do we achieve this? Achievement of any goal is based on solid building blocks that must be strong, but flexible to withstand the stresses to be encountered.

The building blocks of a health care system are the providers, those people that see the patients face-to-face, hear their problems and see their pains on a daily basis. These people, the providers, are the ones who are ultimately responsible for their care, whether the outcome is good or bad.

The managed care insurance companies, the hospitals and the high tech equipment are the tools used to build a health care delivery system. The physician executives must lead the population through it, They must assure its integrity and maintenance, by keeping constant check on the highest ethical, moral and fiscal standards known.

It is only through this that the system can withstand the stress of the ever-changing process we call health care in the United States. I hope Frist, as a physician-executive mentor and modern-day hero, lives up to and surpasses all of our expectations.

Robert Aquino, MD, MS, PhD

Astoria, N.Y.

Disruptive Behavior and Physician Alienation

Your series of articles on disruptive physician behavior (The Physician Executive, Vol. 28, Issue 6, November/December, 2002) points out the increasing antagonism among professional staff, hospital staff and hospital administration. The physician is often in the position of being assumed to be guilty with little or no due process. Your series of articles fails to point out the increasing alienation that physicians feel in the environment where they have worked so hard to foster excellence.

Physicians are trended, have their privileges limited, have oversight by multiple committees and medical boards. In the meantime, hospital staff has become less effective in communicating the course of patients verbally and on the medical records. Root problems include improper staffing and the complexity of the medical record that is often so cluttered with dividers and forms that meaningful communication is nearly impossible.

When faced with these issues in our medical staff, I have often asked the question: "When is the last time we asked Physician X what the hospital could do to improve his ability to practice excellent medicine?"

The answer is disturbing and alarming. "Never."

Indeed, physicians are not consulted about ineffective communication, documentation and staffing, etc. Physicians who seem to have a particular need for excellence often are the ones most frustrated and often the ones who are most ignored.

It's time we turn this apple cart upside down and look at the opportunities created by the physician who is willing to speak his mind.

Steven G. Roshon, MD, FACP 

Sandusky, Ohio 

Hospitalist Financial Primer Sets Unrealistic Expectations

I've recently become a member of the ACPE and was extremely disappointed in the recent publication of the article, "A Financial Primer" by Adam Singer, MD. (The Physician Executive, Vol. 28, Issue 6, November/December, 2002) I hope this is not typical of the quality of future articles the editorial board of The Physician Executive chooses to print in their journals.

I've read the article several times and have concluded that Singer no longer practices medicine. The balance is not economic entitlement and work ethic, but economic reality and health care necessity that drives hospitals into the difficult position of providing quality care at reasonable costs.

The concept of hospitalists generating revenue substantial enough to cover costs is a goal worth striving for. However, Singer's model of a physician working 275 days per year implies his colleagues/subordinates would effectively work a minimum of 5.3 days per week, 52 weeks per year. No vacation. No CME time. No sick days.

When, in this schedule, is there time to provide "services to nursing homes, rehabilitation facilities, teaching programs, research..." to augment revenue and maintain a healthy personal life? This simply is not realistic and can only lead to job dissatisfaction, physician burnout and attrition problems--ultimately adding to hospital-acquired costs such as recruiting.

The absence of an office is an obvious benefit in terms of specific costs a hospitalist practice avoids. However, "CME, marketing materials and others" are real expenses and need to be part of any sound business plan. Malpractice, FICA taxes, pension, staff education to meet OSHA regulations, etc., must be included in this formula.

These expenses, which are imposed on hospitals, may be foreign to middle management corporations that ironically increase the cost of a service being sold to those that need a cost increase the least.

Juxtaposed against Singer's article is the article "Financial Benchmarks for Hospitalist Programs." The authors point out the financial benefits of a hospitalist service that yields a positive margin; despite the fact that expenses exceed patient-derived revenue. Noticeably missing is the cost of a hospitalist management firm. Obviously present is the benefit of cost savings by virtue of decreased LOS.

Additional benefits of a hospitalist service extend beyond the metrics that are easily factored into the balance sheet.

Examples include:

* Subspecialists being able to concentrate on their areas of expertise while the hospitalist maintains the patient's health, thus allowing high profile, procedural services (cardiology, orthopedics, neurosurgery) to shine

* Primary care physicians choosing to focus on their office-based practices while establishing a sense of loyalty to the hospital that services their needs most efficiently and cares for their patients with dignity and respect

The viability of hospital medicine is not based solely on revenue generated by the service, but the demand for such a service by our patients and physician colleagues. If it is valued (hospitalist corporations have certainly determined that it is), people are willing to pay for it (30 percent of patient revenue).

It appears the profession has not found its niche as a revenue generator, but as a cost avoider. There is no marketing glamour in treating uncontrolled diabetes, COPD, pulmonary edema, sepsis; but there is a medical reality and necessity for doing so, and hospitalists are better at this than any other specialty. These physicians deserve to be paid well for their knowledge, not prostituted for their time.

William Y. Childs, DO, FACOI

Jackson, Mo.

"Right" of Health Care Draws Debate

The article by Howard Haft, MD, MMM, CPE ("Is Health Care a Right or Privilege?" The Physician Executive, Vol. 29, Issue 1, January/February, 2003) was excellent.

For the first time, the author opened the dialogue regarding a very fundamental issue, "The right of every American to basic health care." The framers of the Constitution could not imagine that in the 21st century millions of Americans will have no access to basic health care, otherwise they would have included it in the Constitution.

In 1992, the Clinton administration lost an excellent opportunity to correct the health care crisis and provide universal health care for all Americans. Regretfully, the current administration has not shown any interest to provide health care for the millions of uninsured.

As a result of a rising number of uninsured, an aging population, advanced technology, new drugs and litigation, the health care costs will continue to rise. The insurance companies continue to raise their premiums that consequently increase the number of uninsured and will make the situation even worse.

The current system is a vicious cycle and will eventually fail. I strongly believe at some point there will be a 28th Amendment to the Constitution and the right to basic health care will be afforded to every citizen of this country.

Farr Ajir, MD, MBA, FACS, CPE

Westlake Village, Calif.

Howard Haft's proposal to amend The Constitution of the United States of America raises many questions for me.

Why would he recommend an amendment for the right to basic health care before recommending a right to a balanced diet or basic housing or potable water or sanitary sewer systems or clean air? These are more basic to life and health than health care delivery.

If there is a right to basic health care, what are the individual responsibilities that complement that right? If an individual does not fulfill their responsibilities to health, do they still have the right to individual health care paid for by the community?

Is there a risk of lessening the individual sense of responsibility for personal health if the society has determined health care is entitled to all? If so, how would that shift in personal responsibility affect the population's self-perception of its state of health?

Amending the Constitution to describe a right to a set of goods and services with the expectation that defining that right implies the goods and services will be funded diminishes the meaning and value of the Constitution itself. The preamble of the Constitution is a statement of philosophy and values, not a guarantee of goods or services.

The Constitution describes that we have the right to life, liberty, and the pursuit of happiness. Haft wants to add basic health care and goes on to say, "If basic health care is declared a right, two issues will need immediate attention: content and funding."

Following that line of reasoning leads me to ask, what is the content and funding for life, liberty, and the pursuit of happiness? Does the constitutional description of a right to a value equate with providing funding to obtain that value?

Haft says, "If we find that health care is a right, then it will become the clear imperative of our government to provide the funds to support health care benefits for every citizen." I disagree with this statement.

Haft's article is a statement of opinions based on a worldview that health care has grown "to be an integral part of the fabric of modern life and essential to the pursuit of life and happiness." Not everyone in this country shares this worldview. There are people who have never needed "health care" and who have been very successful in their pursuit of life and happiness.

As a physician, I greatly value a health care delivery system that can serve all people in need. However, I do not see a need to clutter up the Constitution with statements about goods and services found within a health care delivery system.

Health care is goods and services provided with compassion and empathy by professionals to preserve and improve health. Trying to define the content of the goods and services would be very difficult. It is impossible to codify or legislate compassion and empathy.

These virtues are fundamental aspects of effective health care that draw the best people into the health care professions. Would the attempt to define the goods and services of entitled health care have significant impact on the expectations of the people who would have the entitlement to those goods and services?

Would the gap that currently exists between expectations and content of health care be increased? Would there be a decrease in the compassion and empathy perceived by people as professionals care for them because of the missed expectations? This dynamic has already played out to a hideous extent with the advent of the variety of third-party payer systems that exist now.

My concern for the answers to these questions leads me to oppose Haft's proposed amendment to the Constitution.

Bradley W. Pope, MD

Spokane, Wash.

Howard Haft's article "Is Health Care a Right or a Privilege?" touches on an issue that has long concerned me. I would like to take this opportunity to raise another question that everyone tends to ignore when debating this issue.

At the outset, let me first state that I am not personally opposed to the provision of affordable health care to everyone. In fact, I believe that it is appropriate, but I do not believe that health care is a right. Rather health care is a necessity, the appropriate provision of which is likely beneficial to society in many ways. I will not discuss the benefits further because to do so might necessitate an article in itself.

Rather, I wish to throw down a challenge of sorts.

Why is it that our country's leaders--including many attorneys--often consider medical care a right, but do not do so for legal services? As Haft states in his article, there is no constitutional guarantee to medical care. Although I am not a learned scholar of the Constitution, there are Constitutional protections of our legal rights. However, the ability to access those protections is often dependent on financial wealth. This is much the same as may now occur for health care, but our leaders never speak of "universal legal services."

As a physician whose career has been in teaching and managed care, I have always been salaried, so fee-for-service reimbursement is not a personal issue with me. However, in principal, I do object to the government setting the reimbursement for physician services under the guise of medical care as a right while not providing the same type of coverage for legal services as a right.

Our Constitution and laws make legal services more of a right than medical care. However, the legal needs are less than the medical needs for the population at large and the visible damages from lack of appropriate services affect more individuals and are more severe when medical needs are involved.

Therefore, our politicians hop on the bandwagon for medical care as a right, while ignoring the greater foundations for legal services as a right.

With regard to the different attitude towards medical and legal services, I have always found it interesting that our political leaders have deemed it appropriate to tell physicians how much their services are worth and even established some degree of sanctions for those who decline to participate in mandated medical programs. They have not done the same in the matter of legal services for which I believe there is better foundation as a right.

It has always amazed me that anyone who has Medicare or Medicaid is most likely to have at least potential access to the most prominent and best medical and surgical clinicians for a relative pittance of a fee. But heaven help that same individual should he or she need and desire the services of a similarly qualified and prominent member of the legal profession.

I acknowledge that some of these legal wizards do provide pro-bono services, but so do some of the prominent physicians. Pro-bono services for some are not equivalent to equal access for all.

Isn't it about time that we begin to advocate, 'What's good for the goose is good for the gander."

Seymour Herschberg, MD, FACP

New York, N.Y.