Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD


It Happened Without a Shot Being Fired

By Rob Tenery, MD on December 7, 2015

The change happened right under our noses, and many of us probably haven’t noticed. Especially after a busy day operating or seeing patients in our offices, attending a meeting of the physician hospital staff was the last thing I wanted to do.  The staff meetings were a requirement to maintain admitting privileges at the hospital. Most of the time the administration would ply the physician staff with a good meal, as the business of the hospital was conducted.

Before the meeting began, there were the always-present sign-in sheets, so the physicians who attended were given credit for showing up, even if they were called away for an emergency. The order of business was always the same---- the threat to read the complete minutes of the last staff meeting which was always passed unanimously so as to bring the meeting to a close sooner. Then the physician Chief-of-Staff introduced the new physicians who had joined the staff who had already been reviewed and passed on by the physician Board of Trustees (BOT) who, themselves, were elected by the whole physician staff on a yearly basis. Then there was the report by the Chief Executive Officer (CEO) about goings-on in the hospital such as renovations and activities that had very little to do with actually how medicine was being practiced in the hospital. The CEO’s report, which had previously been presented at the physician Board of Trustees meeting was informational only and needed no action by the staff.

The meeting then turned to new business items. Much of the discussions centered on bylaws changes and elections of physicians to the next Board of Trustees. The physician staff present then voted for or against the recommendations presented to them. Sometimes physicians from the audience brought up individual concerns that were usually referred to be studied further by the BOT and possibly brought back with an answer at a future meeting.

Then, the meetings stopped! No more sign-in sheets. No more minutes from previous meetings or reports from the hospital’s CEO. No more new business or votes taken!

It probably started in the 1970s when some hospitals began hiring their own pathologists. There were some concerns raised, but mostly by the pathologists who were displaced or bought out. Since they only made up a small number of physicians, the medical community put up only token resistance. Then came the radiologists and the emergency room physicians who were being contracted by the hospitals. Since their incomes were derived by care they delivered to patients at the hospital emergency rooms and radiology departments, it was only a minor compromise to let the hospitals handle the collections and deal with the reimbursement negotiations.

Many physicians, especially family doctors, internists and pediatricians were carrying two loads--- their patients at their offices and the patients they were treating in the hospital. So, when the idea of turning their sickest patients over to physicians who made their specialty caring for hospitalized patients, many were eager to unburden their practices. The move toward ‘off-loading’ grew exponentially as the specialties of hospitalists, pediatric and adult intensivists, neonatologists, obstetrical anesthesiologists, and trauma specialists all carved their niche in the health care delivery system. Physical medicine and inpatient psychiatry have always mostly been hospital based.  Granted these situations of contracting physicians as employees are much more likely to occur in areas of high-density population with an abundance of physicians and ancillary staff. But these ideas are now gradually filtering into the less populated areas with establishment of satellite clinics and bringing most of the smaller community hospitals under the protective arm of the larger hospital-based delivery systems.

This is the macrocosmic view of what is transpiring in most major medical centers. The physician practices that need hospital settings to care for their patients are being swallowed up by the system because the system is not only able to deliver the care, but negotiate the reimbursements. Even if the Affordable Care Act is partially overturned by the next administration, hospital based Accountable Care Organizations (ACOs) as opposed to physician led ACOs, are becoming the norm for institutional delivery of health care. The mindset by those that run the systems is for patients to think of ‘their medical center’ as their doctor, and not of an individual as their doctor--- the depersonalization of health care delivery.

The practice of medicine in the hospital setting is big business. The bigger the medical institutions become, the more impersonal they seem to be. In order to compete, hospital based ACOs have to be proactive with respect to profitability. They take on their own agendas that may or may not be to their physician staff’s liking. The physician staff becomes just one component of their operations. Since third party payers stepped in, the hospitals have largely become in charge of the reimbursement negotiations with the payers. Thus, the physicians caring for patients in the hospital setting have a diminishing role at the negotiating table. The options for the physicians are to go along or leave.

That is not to say that physicians are powerless to impact the institutional polices where they practice. Economies of scale also come into play from the physician point-of-view. The more profit the physician or group can generate for the hospital, the more input they have in the system. Additionally, departments (general surgery and radiology for example) can come together to put more pressure on the administration.  What can come into play are restraint of trade implications. So, those actions should not be taken without legal consultation.  

There will continue to be ‘outpatient’ care. Thus, the private practice of medicine will still exist. But as the hospital/payer relationship becomes more powerful in determining reimbursement levels, even these physicians will be affected.

The next and final step in the takeover by the hospital based ACO model is, instead of allowing the physicians to continue to utilize the hospital resources; they hire them as subcontracted employees.  Once the physician becomes an employee, they are part of the system, just like the nurses, technicians and other ancillary staff. To make easier to swallow, the hospital administration appoints physicians who are employed by the hospital to act as liaisons with the physician medical staff. Thus, on the surface, it appears the physicians both practicing ‘in-house’ or still in their offices have a say in the delivery of health care. But, attend a physician hospital staff meeting, if there still is one, and it’s easy to see that their influence is in name only!

In this complex milieu of big hospital, big payer and big government, an area where the little doctor must be consulted is in the individual physician’s obligation to the institution other than abiding by the rules with respect to caring for their own patients. These are matters that concern emergency call coverage and consulting on other patients currently under the responsibility of the institution.  In these situations there is often little or no prior patient/doctor relationship, resulting in a much higher chance of litigious outcomes and low to no reimbursement. Thus, before any changes are implemented in institutional policies or agendas (moving from a level II trauma center to a level I trauma center), these policy changes must be adopted by a properly configured representation of all of the current medical staff (contracted or not) that could be affected.  

I never thought I’d say it, but I long for the days when I was forced to listen to the motion to accept the minutes from the last hospital staff meeting. To meet the new staff members and vote on any bylaws changes. But what I miss the most is electing physicians who will speak for me--- our fellow physician members of the medical staff. That was when we had a voice, and we let it slip away. Like many things in life, we don’t appreciate them until they’re gone!





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