Who Should Control Healthcare?

The American Academy of Emergency Medicine (AAEM) is urging stiffer enforcement of decades-old statutes that prohibit the ownership of medical practices by corporations not owned by licensed doctors (1). These century-old laws and regulations were meant to fight the commercialization of medicine, maintain the independence of physicians, and prioritize the doctor-patient relationship over the interests of investors and shareholders (2). Thirty-three states (click to see list of states that prohibit corporate ownership) plus the District of Columbia have rules on their books against the so-called corporate practice of medicine. In Arizona ownership by nonprofit entities is permitted, however as most of us know, nonprofit healthcare organizations are nonprofit in name only. Furthermore, over the years, companies have successfully sidestepped bans on owning medical practices by buying or establishing local staffing groups that are nominally owned by doctors and restricting the physicians so they have no direct control.

Those campaigning for stiffer enforcement of the laws say that physician-staffing firms owned by private equity investors are the guiltiest offenders. Private equity-backed staffing companies manage a quarter of the nation’s emergency rooms (2). The two largest are Nashville-based Envision Healthcare, owned by investment giant KKR & Co., and Knoxville-based TeamHealth, owned by Blackstone. Court filings in multiple states, including California, Missouri, Texas, and Tennessee, have called out Envision and TeamHealth for allegedly using doctor groups as straw men to sidestep corporate practice laws (2).

Physicians and consumer advocates around the country are anticipating a California lawsuit against Envision. The trial is scheduled to start in January 2024 in Federal court. The case involves Placentia-Linda Hospital in northern Orange County, where the plaintiff physician group lost its ER management contract to Envision. The complaint  by Milwaukee-based American Academy of Emergency Medicine Physician Group alleges that Envision uses the same business model at numerous hospitals around the Nation. Furthermore, the complaint alleges that Envision uses shell business structures to retain de facto ownership of ER staffing groups, and it is asking the court to declare them illegal. “We’re not asking them to pay money, and we will not accept being paid to drop the case,” said David Millstein, lead attorney for the plaintiff. “We are simply asking the court to ban this practice model.” Although Envision filed for Chapter 11 bankruptcy, AAEM has vowed to pursue the lawsuit (3,4).

The plaintiff — along with many doctors, nurses and consumer advocates, as well as some lawmakers — hopes that success in the case will spur regulators and prosecutors in other states to take corporate medicine prohibitions more seriously. The corporate practice of medicine has “a very interesting and not a very flattering history” said Barak Richman, a law professor at Duke University (2). This is a gross understatement in my opinion. The physicians, nurses, and technicians are not responsible for poorer care at higher prices that we now see. Businessmen are responsible by squeezing caregivers and patients for every penny, a practice some call “hyperfinancialization”(5). It is not surprising charging as much as possible while delivering minimal care has evolved. Businessmen in healthcare maximize profits in these situations, especially when they can avoid any responsibility for the healthcare delivered. Rather, a system of “quality assurance” has evolved which is more concerned with controlling caregivers than quality (6).

If not businessmen, then who should control healthcare? Doctors are alleged to be poor businessmen. If by this it is meant that physicians are more likely to try and deliver the best healthcare at the best price rather than bill the maximum for minimal care, I would hope most of physicians would plead guilty. Most physicians are concerned about delivering quality healthcare at reasonable prices. I suspect that the rumor that doctors are poor businessmen was started by business interests for their own financial gratification.

Not all doctors are qualified to lead healthcare. Some are straw managers which will do whatever their business supervisors tell them to do. Physician leaders practicing medical administration should be held to the same high standards that doctors are held in care of patients. Therefore, some degree of local control must be kept. Those of us who advocate for better healthcare can hope the courts enforce existing laws where applicable. We also need to take action in supporting each other for the good of medicine and the health of our patients. However, we also need to do a better job policing ourselves. Those ordering unnecessary or questionable diagnostic testing or treatments need to be called out. If successful, the Envision Case could prompt legislators, regulators and prosecutors in other states to focus attention on clinical practice of medicine prohibitions in their own states and take up arms against potential violations or reinvigorate prohibitions of clinical practice with new legislation and/or regulation.

Richard A. Robbins MD

Editor, SWJPCCS

References

1. American Academy of Emergency Medicine. Emergency Medicine and the Physician Practice Management Industry: History, Overview, and Current Problems. Available at: https://www.aaem.org/publications/key-issues/corporate-practice/emergency-medicine-and-the-physician-practice-management-industry-history-overview-and-current-problems/ (accessed 8/23/23).
2. Wolfson B. ER Doctors Call Private Equity Staffing Practices Illegal, Seek to Ban Them. Kaiser Health News. December 22, 2022. Available at: https://www.virginiamercury.com/author/kaiser-health-news/ (accessed 8/23/23).
3. Condon A, Thomas N. From private equity to bankruptcy: Envision's last 5 years. May 18, 2023. Available at: https://www.beckershospitalreview.com/finance/from-private-equity-to-bankruptcy-envisions-last-5-years.html (accessed 8/23/23).
4. Holland & Knight Law. Federal Bankruptcy Court Stays Envision Healthcare Litigation in California. August 3, 2023. Available at: https://www.hklaw.com/en/insights/publications/2023/08/federal-bankruptcy-court-stays-envision-healthcare-litigation (accessed 8/23/23).
5. Robbins RA. Who are the medically poor and who will care for them? Southwest J Pulm Crit Care. 2019;19(6):158-62. [CrossRef]
6. Robbins RA. The Potential Dangers of Quality Assurance, Physician Credentialing and Solutions for Their Improvement. Southwest J Pulm Crit Care Sleep. 2022;25(4):52-58. [CrossRef]

Cite as: Robbins RA. Who Should Control Healthcare? Southwest J Pulm Crit Care Sleep. 2023;27(3):33-35. doi: https://doi.org/10.13175/swjpccs039-23 PDF

Kiss Up, Kick Down in Medicine

This past week the phrase “kiss up, kick down” was used to describe Ronny Jackson, then a nominee for the Secretary of Veterans Affairs (1). Wikipedia defines the phrase as “a neologism used to describe the situation where middle level employees in an organization are polite and flattering to superiors but abusive to subordinates” (2). Like most, I do not know Jackson and have no knowledge of the truth. However, the behavior attributed to Dr. Jackson is pervasive and harmful in medicine.

Kiss up, kick down is part of a blame culture. McLendon and Weinberg, see the flow of blame in an organization as one of the most important indicators of organization robustness and integrity (3). They argue that blame flowing upwards in a hierarchy proves that management can take responsibility for their orders and supply the resources required to do a job. However, blame flowing downwards, from management to staff, or laterally between professionals, indicate organizational failure. In a blame culture, problem-solving is replaced by blame-avoidance. Weinberg emphasizes that blame coming from the top generates "fear, malaise, errors, accidents, and passive-aggressive responses from the bottom", with those at the bottom feeling powerless and lacking emotional safety (4).

Calum Paton, Professor of Health Policy at Keele University, describes kiss up kick down as a prevalent feature of the UK National Health Service culture. He raised this point when giving evidence at the public inquiry into concerns of poor care and high mortality at Stafford Hospital in England (5). According to Paton, credit was centralized and blame devolved or transferred to a lower level. "Kiss up kick down means that your middle level people will kiss-up, they will please their masters, political or otherwise, and they will kick down to blame somebody else when things go wrong."

The VA scheduling scandal is a similar American example where management failed to provide the number of providers necessary to care for the patients. When caught, management attempted to blame the physicians (6). This is hardly surprising given that the physicians are often leaderless without anyone to speak for them. Too often physician leaders are not chosen from the best and brightest to protect the best interests of the patient and staff. Rather they are selected because they are the most compliant with management (kiss up).

Physicians near the top of a hierarchy are usually administrators peripherally involved in patient care. They may not always act with the best interests of the patient and staff but with what is best for their bosses and themselves as both the Stafford and VA examples illustrate. As such, they can be expected to “roll over on anyone” (kick down), a phrase used to describe Dr. Jackson (1). Furthermore, their practice skills may be weak or outdated making them particularly dangerous to the organization.

Physicians who put patient needs first often find themselves at odds with what is best for management. It may be time to reconsider how physician leaders are chosen. The medical staff is probably in the best position to judge which physicians are the best physician leaders rather than the obsequious leaders often chosen by management (7). If the medical staff chosen physician leader can work with management, the organization will have a dyad leadership. If not, then the physician leaders with the support of the staff can oppose those policies deemed harmful to patients or the organization.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Blake A. The lengthy list of allegations against Ronny Jackson, annotated. The Washington Post. April 25, 2018. Available at: https://www.washingtonpost.com/news/the-fix/wp/2018/04/25/the-list-of-allegations-against-ronny-jackson-annotated/?utm_term=.9ee75ad66c9b (accessed 4/28/18).
2. Kiss up kick down. Wikipedia. Available at: https://en.wikipedia.org/wiki/Kiss_up_kick_down (accessed 4/28/18).
3. McLendon J, Weinberg GM. Beyond blaming. Aye Conference Article Library. 1996. Available at: http://www.humansystemsinaction.com/beyondblaming/ (accessed 4/28/18).
4. Gerald M. Weinberg: Beyond Blaming, March 5, 2006, AYE Conference. Available at: http://www.ayeconference.com/beyondblaming/ (accessed 4/28/18).
5. Mid Staffordshire Public Inquiry Transcript - day 103. June 21, 2011. Available at: http://webarchive.nationalarchives.gov.uk/20150407092403/http://www.midstaffspublicinquiry.com/sites/default/files/transcripts/Tuesday_21_June_2011_-_transcript.pdf (accessed 4/28/18).
6. Robbins RA. Don't fire Sharon Helman-at least not yet. Southwest J Pulm Crit Care. 2014;8(5):275-7. [CrossRef]
7. Robbins RA. Beware the obsequious physician executive (OPIE) but embrace dyad leadership. Southwest J Pulm Crit Care. 2017;15(4):151-3. [CrossRef]

Cite as: Robbins RA. Kiss up, kick down in medicine. Southwest J Pulm Crit Care. 2018;16(4):230-1. doi: https://doi.org/10.13175/swjpcc060-18 PDF 

Beware the Obsequious Physician Executive (OPIE) but Embrace Dyad Leadership

Obsequious is defined as “obedient or attentive to an excessive or servile degree”. Obsequious comes from the Latin root sequi, meaning "to follow”. An Obsequious PhysIcian Executive (OPIE) is more likely to be servile to the hospital administration than a leader of the medical staff. This is not surprising since they are chosen for a “leadership” position not by the physicians they purportedly lead, but by the hospital administration they serve. OPIEs become the administration’s representative to the physicians and not the physicians’ or patients’ representative to the administration. Their job often becomes keeping the medical staff “in-line” rather that putting the success of the medical center first.

My own views have developed over 40 years of observing OPIE behavior in a multitude of medical centers. Although there are many exceptions, OPIEs often share certain characteristics:

1. Academic failure. OPIEs are usually academic failures. They are the antithesis of the triple threat who excels as a physician, teacher and researcher. In contrast, they excel at nothing and often are obstructionistic of others’ attempts to accomplishment anything meaningful.
2. Advanced degrees not pertaining to medicine. Frustrated by their lack of success, they seek advancement by alternative routes such as nontraditional career paths or obtaining degrees outside of medicine, e.g., a master’s degree in business administration (MBA). Though they will argue that they are just serving a need or advancing their education, more likely they are seeking the easiest path for advancement, especially if their past accomplishments are best described as “modest”. Beware the unaccomplished physician with a MBA.
3. Blame others for failure. Not all ideas, even from good people, are successful. Some are bad ideas destined to failure. When an OPIE’s idea fails, they blame others. Worse yet, they lie about a staff in order to place themselves in a good light. This appears to be one of the root causes of the waiting time scandal at the VA. In contrast, a leader accepts responsibility for failure and proposes a new and hopefully better plan.
4. Bullying. OPIEs often fail to see two sides to any argument and are usually impatient and short-tempered with any who disagree. Rather that attempting to build a consensus, they attempt to bully those who show any resistance.
5. Retaliation. If bullying fails, OPIEs seek retaliation. This can be through various means-often denial of resources. For example, one chief of staff sat for over a year on a request for a Glidescope (a fiberoptic instrument used for intubation) in the intensive care unit and then was faultfinding when a critical care fellow did not use a Glidescope during an unsuccessful intubation intubation. OPIEs might limit clinic space or personnel but then disparage the physicians when patients are not seen quickly enough to meet an administrative guideline. Lastly, if all else fails they may retaliate by invoking quality assurance. Quality is often ill-defined and it is all too easy in this day of “patient protection” to slander a good physician.

One of the latest buzzwords in healthcare is dyad leadership, a term that refers to physician/administrator teams that jointly lead healthcare organizations (1). A recent editorial touted the success of the partnership between Will Mayo MD and Harry Harwick at the Mayo Clinic in Rochester (2). My own positive example comes from Mike Sorrell MD, Charlie Andrews MD, and Bob Baker at the University of Nebraska Medical Center in Omaha. However, simply putting a physician and administrator together in leadership positions does not guarantee organizational success. In fact, if not done correctly, it leads to confusion, resentment, lack of consistent direction and divided organizational factions.

Based on their Mayo Clinic experience, Smoldt and Cortese list five key success factors they believe bring success to a dyad leadership (2):

1. Common core values. Perhaps the most important factor in a successful dyad is that members of the physician/administrator team have the same core values and goals. Furthermore, these need to be consistent with the staffs' values and goals. Smoldt and Cortese (2) point out that at Mayo Clinic the core value of “the needs of the patient come first” is deeply imbedded. The staff of an organization will primarily deduce leadership core values from their daily actions. Administrative bonuses or increased reimbursement are not necessarily common core values, and if emphasized over patient care, the dyad is doomed to failure.
2. Willingness to work together toward a common mission and vision. In a medical center, if the administrative leadership and staff can work together toward a vision, it is more likely to be achieved. If leadership becomes too territorial or engages in OPIE behavior, the ideal of leveraging each other’s strengths will be lost. If the staff perceives that the dyad is emphasizing their personal goals and finances over institutional success, the staff will be unwilling to work with or support the dyad.
3. Clear and transparent communication with each other and the organization. To gain the most from dyad leadership, each member of the team should leverage and build on the strengths of the other. The more time the individuals spend together as a leadership team and with staff at a medical center, the more frequent and open the communication will be. If over time, communication declines, it is probably a sign that the dyad is not working and is often followed by the OPIE behaviors of bullying, lying and retaliation.
4. Mutual respect. A team works best if its members operate in an atmosphere of mutual respect. If the dyad team does not share or show mutual respect for each other, mutual respect will likely also be lost among the healthcare delivery team. It is especially important for the dyad to remember that respect must be earned, and a big part of earning respect is to show respect for the views and positions of the staff.
5. Complementary competencies. No one organizational leader is good at everything that needs to be done in a medical center. Employing a dyad leadership approach can expand the level of competence in the top leadership. For example, in a physician/administer leadership team, it is not unusual for the administrator to have better financial skills than the physician. It goes without saying that physicians and nurses have better medical skills in their own scope of practice than an administrative/physician dyad.

Integrated delivery of care is an absolute for a successful medical center. OPIE behavior dooms the medical center. Establishing a physician/administrator dyad leadership team with the right administrator and physician can be a good step towards success.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Zismer DK, Brueggemann J. Examining the "dyad" as a management model in integrated health systems. Physician Exec. 2010 Jan-Feb;36(1):14-9. [PubMed]
2. Smoldt RK, Cortese DA. 5 success factors for physician-administrator partnerships. MGMA Connection Plus. September 24, 2015. Available at: http://www.mgma.com/practice-resources/mgma-connection-plus/online-only/2015/september/5-success-factors-for-physician-administrator-partnerships (accessed 10/4/17).

Cite as: Robbins RA. Beware the obsequious physician executive (OPIE) but embrace dyad leadership. Southwest J Pulm Crit Care. 2017;15(4):151-3. doi: https://doi.org/10.13175/swjpcc121-17 PDF