Improving Quality in Healthcare

Figure 1. Dr. Katz is a little jaded about quality metrics (1).

Everyone is in favor of quality healthcare and improving it. However, to date, initially highly touted quality measures prove to be meaningless metrics in about 5-10 years. That is, when the measures are scientifically studied, they are found to be of little worth. The cycle is then repeated, i.e., new and highly touted measures are again selected and found to be useless in 5-10 years. The latest in this cycle may be the Centers for Medicare and Medicaid’s (CMS) Merit-based Incentive Payment System (MIPS). The theory underlying MIPS has been that paying for quality rather than quantity will incentivize healthcare providers to improve quality. As part of the deal creating the Affordable Care Act (Obamacare) MIPS was established as a pay for performance system which promised to improve healthcare while reducing costs. However, healthcare costs have continued to rise (2). Data on improvement in quality has been lacking.

Now, Bond et al. (3) have reported a study suggesting that MIPS incentivization of quality improvement in healthcare quality has questionable benefits. Among US primary care physicians in 2019, MIPS scores were inconsistently associated with performance on process and outcome measures. Bond’s study included 3.4 million patients attributed to 80,246 primary care physicians. Physicians were divided into thirds based on their MIPS score. Compared with physicians with high MIPS scores, physicians with the lowest MIPS scores had significantly worse mean performance on 3 of 5 process measures: diabetic eye examinations, diabetic HbA1c screening and mammography screening, but significantly better mean performance on rates of influenza vaccination and tobacco screening. MIPS scores were inconsistently associated with risk-adjusted patient outcomes: compared with physicians with the highest MIPS scores, physicians with the lowest MIPS scores had significantly better mean performance on emergency department visits per 1000 patients but worse performance on all-cause hospitalizations, and did not have significantly different performance on 4 ambulatory care-sensitive admission outcomes. Nineteen percent of physicians with the lowest MIPS scores had composite outcomes performance in the top quintile, while 21% of physicians with the highest MIPS scores had outcomes in the bottom quintile. These findings suggest that the MIPS program may be ineffective at measuring and incentivizing quality improvement among US physicians.

It is unclear why improvement  in intermediate surrogate markers is used rather than improvement in outcomes. Bond’s study measured MIPS scores against ER visits and hospitalizations. Patients, providers, insurers, bureaucrats, politicians, taxpayers- in other words, nearly everyone- would agree that reductions in ER visits and hospitalizations is desirable if it can be accomplished without patient harm. Similarly, reduction in unexpected deaths and improvement in patients’ feeling of well being are goals that all can support. However, the goals of healthcare are different depending on which population is asked. Patients might support their well-being, insurance cost, and provider access as being most important, whereas payors might support costs as most important. Providers might support efficiency of care and reimbursement as important. So ultimately what surrogate markers like MIPS do is choose one point of view which often does not affect outcomes (4).

There are many ways to achieve a goal depending on expertise, resources and patient characteristics. Flexibility in care allows the person most likely to understand the efficiencies of their particular system- the providers- to use their local knowledge to benefit the patients. Outside influences emphasizing surrogate markers, cost, or politics have historically failed. Unless one is willing to accept healthcare shown not to benefit patients as acceptable, MIPS should be eliminated. Replacing MIPS with an equally flawed system set of surrogate markers will likely not help.

It seems that outcome measures offer several advantages over process measures. Outcome measures include unexpected mortality, hospital readmissions, safety of care, effectiveness of care, timeliness of care, efficiency of care, and patient well-being (5). These are all thought to be important by patients, insurers, providers and even politicians. In my view, the process leading to these ultimate outcome goals is less important and the process producing the same or similar results will likely vary between providers and hospitals.

CMS should refocus their quality efforts on outcomes rather than processes which have failed as quality indicators. Physicians must decide whether they wish to continue participation in systems such as MIPS and the accompanying increase in paperwork. Unless something changes the trends of increasing paperwork over meaningless metrics will continue.

Richard A. Robbins MD

Editor, SWJPCCS

References

1. Lehmann C. Comics for Docs: Medical Cartoons Poke Fun at Today's Practices. Medscape. July 15, 2022. Available at: https://www.medscape.com/slideshow/medical-cartoons-6015473#2 (accessed (1/12/23).
2. Kurani N, Ortaliza J, Wager E, Fox L, Amin K. How Has U.S. Spending on Healthcare Changed Over Time? Peterson-KFF Health System Trasecker. February 25, 2022. Available at: https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed- time/#Total%20national%20health%20expenditures,%20US%20$%20Billions,%201970-2020 (Accessed 1/4/23).
3. Bond AM, Schpero WL, Casalino LP, Zhang M, Khullar D. Association Between Individual Primary Care Physician Merit-based Incentive Payment System Score and Measures of Process and Patient Outcomes. JAMA. 2022 Dec 6;328(21):2136-2146. [CrossRef] [PubMed]
4. Robbins RA, Thomas AR, Raschke RA. Guidelines, recommendations and improvement in healthcare. Southwest J Pulm Crit Care. 2011;2:34-37.
5. Tinker A. The Top Seven Healthcare Outcome Measures and Three Measurement Essentials. Health Catalyst. June 29, 2022. Available at: https://www.healthcatalyst.com/insights/top-7-healthcare-outcome-measures (accessed 1/5/23).

Cite as: Robbins RA. Improving Quality in Healthcare. Southwest J Pulm Crit Care Sleep. 2023;26(1):8-10. doi: https://doi.org/10.13175/swjpccs002-23 PDF

Not All Dying Patients Are the Same

A recent publication in the SWJPCCS by Jones-Adamczyk and Mayer (1) points out how Arizona’s Jesse’s law prevents the appropriate discontinuation of unwanted interventions in dying hospice patients. The road to hell is paved with good intentions and Jesse’s Law is an excellent example. As pointed out by Jones-Adamczyk and Mayer, Jesse’s law should have addressed unreasonable surrogates instead of preventing all surrogates from taking an action that is often in the best interest of a loved one. Jesse’s law is named for Jesse Ramirez who suffered traumatic brain injury in a rollover accident. Traumatic brain injury patients are different from many end-of life patients such as those dying from terminal cancer. Prognosis from traumatic brain injury can be difficult to predict especially early in its course (2). In contrast, prognosis of patients with widely metastatic cancer late in its course generally is not. Identifying futile care requires a great deal of knowledge of medicine and the culture, spirituality and personal preferences of the patient, best determined by a good-faith discussion between the patient’s surrogate and the care givers. The authors of Jesse's law failed to make exceptions for patients who do not want futile interventions such as feeding tubes when it is inappropriate. They are the real culprits in creating chaos in the care of terminal patients near death.

The example of a patient cited by Ms. Jones-Adamczyk and Mayer illustrates the need to modify Jesse’s law. But what should be done in the meantime by patients, surrogate decision makers and ICU teams since they cannot remove a feeding tube without a court order under current Arizona law? Patients should prepare their advanced directives with specific mention of feeding tubes and artificial nutrition. Unfortunately, there seems little alternative for surrogates and ICU teams. Until the law is changed, they will need to spend time trying to convince a court to allow feeding tube removal unless they are willing to act outside the law risking their career, livelihood and even jail time.

The real problem with Jesse’s law is that it removes the most knowledgeable and best decision makers and substitutes the courts. This is part of the trend of those unknowledgeable in healthcare stepping into clinical decision-making (3). This erodes trust in physicians and nurses, may lead to criminalizing appropriate end-of-life care, or worse, prolong the suffering of the dying patient. Arizona patients and care givers deserve better.

Richard A. Robbins MD

Editor, SWJPCCS

References

1. Jones-Adamczyk AL, Mayer PA. Unintended Consequence of Jesse’s Law in Arizona Critical Care Medicine. Southwest J Pulm Crit Care Sleep. 2022;25(5):83-87. [CrossRef]
2. Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008 Aug 5;5(8):e165; discussion e165. [CrossRef] [PubMed]
3. Robeznieks A. How the AMA fights to keep politics out of the exam room. AMA ASSN News. July 19, 2022. Available at: https://www.ama-assn.org/news-leadership-viewpoints/authors-news-leadership-viewpoints/andis-robeznieks  (accessed 11/18/22).

Cite as: Robbins RA. Not All Dying Patients Are the Same. Southwest J Pulm Crit Care Sleep. 2022;25(5):88-89. doi: https://doi.org/10.13175/swjpccs052-22 PDF

Medical School Faculty Have Been Propping Up Academic Medical Centers, But Now Its Squeezing Their Education and Research Bottom Lines

One of my former fellows emailed me an article from Stat+ titled “Hospitals Have Been Financially Propping Up Medical Schools, But Now It’s Squeezing Their Bottom Lines”. The article reports that hospitals have been financially supporting medical schools and are feeling their bottom line squeezed (1). An example cited is the purchase of the University of Arizona Medical Center in Tucson by Banner Health and an agreement by Banner to help both of Arizona’s financially struggling medical schools. Financial statements show that Banner has dedicated roughly $2 billion to the schools and a faculty medical group it bought as part of the 2015 deal. Banner is blaming these expenses for shrinking its operating margin from 5% before the deal to 1% today (1). The businessmen who purchased the academic medical centers initially embraced these mergers but now are facing the financial reality of managing a medical school (1). It seems likely that there will be increasing friction between hospitals and their affiliated medical schools competing for funds. These editorial points out the other side of coin, i.e., that the medical schools are financially shoring up academic medical centers.

Count me as one who is not overly sympathetic to businessmen in charge of academic medical centers. They now collect the pro fees from physicians, paying themselves first. Banner is a good example where the CEO made in excess of $25 million in 2017 compared to the average $155,212 earned by physicians (2). This means the CEO earned more in 2 days than the average physician earned in a year or about $164 for every $1 earned by a physician. As medical education has become more expensive, medical schools now find themselves increasingly reliant on the money they get from their faculty seeing patients and less able to count on other revenue sources, like federal research funding or tuition (Figure 1).

Figure 1. Source of medical school income (1). Click here to view Figure 1 in a new enlarged window.

Furthermore, many physicians, especially pulmonary and critical care physicians, worked above and beyond during the COVID-19 pandemic (3). The pandemic’s resulting disruptions affected academic and educational pursuits such as research productivity, access to mentoring, professional development and networking and personal wellness (3). These disruptions were compounded for faculty at high COVID-19–volume medical centers where clinical responsibilities were necessarily prioritized. Many recognize that it is important to prepare for a postpandemic accelerated burnout syndrome that disproportionately affects early-career physician-scientists at high-volume centers. However, rewards for service have largely been unfulfilled (3).

One quick comment on the validity of hospital ledgers. Physicians are usually shown the finances that businessmen want them to see. The accounting can be prepared to justify further physicians sacrifice of even more time and money. Hospitals tend to see the money generated by physicians, nurses and other healthcare providers as “their” money (1). They see a revenue stream going to a medical school as robbing them of “their” profit and want to know what they get for it (1).

All the above stems from the “hyperfinancialization” of medicine and applying a corporate structure to institutions which should be not-for-profit other than in name only. It is hard to pinpoint an inflection point in medicine, the point in which the direction changed and the mission changed. Maybe it is because in reality the inflection point is not a point but a large blotch, a series of smaller dots in coalesce into a bigger stain brought on by greed. I worry that the core of medicine has been forever damaged; that the doctor patient bond has been replaced with institute/provider - patient service. This model has proven to be more costly, less rewarding and associated with higher burnout. Yet, we continue to move forward with this model. Mergers between community-based physicians and hospitals which are supposed to bridge the gap between evidenced-based care and practice-based care has only served to devalue the intangibles in medicine further, always looking for what can be standardized and more importantly… billable. A corporate structure with a board, CEO, and a variety of vice presidents and other corporate titles has not served the public well. Physicians make less, administrators make more and hospital services have declined or not improved (4). One needs to only look at outcomes such as life expectancy and costs as a percent of GNP (gross National product) to recognize there is a problem (5).

Many, including myself, remain skeptical of the intrusion of business interests into medical education. The oversight of academic medical centers provided by organizations such as the Accreditation Council for Graduate Medical Education (ACGME) that protects the public’s interests remain inadequate. Presently only a written statement must be provided every 5 years that “documents the Sponsoring Institution’s commitment to education by providing the necessary financial support for administrative, educational, and clinical resources, including personnel.” This is to be reviewed, dated, and signed by the designated institutional official (DIO), a representative of the Sponsoring Institution’s senior administration, and a representative of the Governing Body (6). It seems unlikely that review every 5 years by a DIO and other officials employed and dependent on medical center support is likely sufficient.

To provide oversight I recommend that a system be developed to hold medical center administrators accountable for decisions that lead to a decline in efficiency at both in the medical center and their affiliated medical schools (4). If they are in charge of medical care as they seem to think they are, then deficiencies need to be laid at their feet - the same for medical education and research. After all they now credential the healthcare providers and any deficiencies would seem to have resulted from a poor work environment or  poor administrative judgment in credentialing. It is time that administrators are held to the same standard. Physicians are required to have continued medical education, board certifications, etc. for credentialling. Present hospital systems where a board elects its own members with the nomination and blessing by the hospital CEO need to end. The chief of staff should be elected by the hospital staff and the majority of members of a hospital board need to be independent of the CEO and knowledgeable about the practice of medicine at that medical center (7). If administrators are not acting in a manner that promotes the doctor patient bond, increases the access to care, promoting cost containment in a transparent manner, and promote physician well-being, then it is time for them to go. 

Richard A. Robbins MD

Editor, SWJPCCS

References

1. Bannow T. Hospitals have been financially propping up medical schools, but now it’s squeezing their bottom lines. Stat+. April 14, 2022. Available at: https://www.statnews.com/2022/04/14/hospitals-medical-schools-financial-relationship-tension-squeezing-bottom-line/ (requires subscription).
2. Robbins RA. CEO compensation-one reason healthcare costs so much. Southwest J Pulm Crit Care. 2019;19(2):76-8. [CrossRef]
3. Kliment CR, Barbash IJ, Brenner JS, Chandra D, Courtright K, Gauthier MC, Robinson KM, Scheunemann LP, Shah FA, Christie JD, Morris A. COVID-19 and the Early-Career Physician-Scientist. Fostering Resilience beyond the Pandemic. ATS Sch. 2020 Oct 23;2(1):19-28. [CrossRef] [PubMed]
4. Jeurissen PPT, Kruse FM, Busse R, Himmelstein DU, Mossialos E, Woolhandler S. For-Profit Hospitals Have Thrived Because of Generous Public Reimbursement Schemes, Not Greater Efficiency: A Multi-Country Case Study. Int J Health Serv. 2021 Jan;51(1):67-89. [CrossRef] [PubMed]
5. Cohen J. Dismal U.S. Life Expectancy Trend Reflects Disconnect Between Dollars Spent On Healthcare And Value Produced. Forbes. Nov 1, 2020. Available at: https://www.forbes.com/sites/joshuacohen/2020/11/01/dismal-us-life-expectancy-trend-reflects-disconnect-between-dollars-spent-on-healthcare-and-value-produced/?sh=3657f353847e (accessed 5/2/22).
6. Accreditation Council for Graduate Medical Education. Institutional Requirements. Available at: https://www.acgme.org/globalassets/pfassets/programrequirements/800_institutionalrequirements2022.pdf (accessed 5/2/22).
7. Robbins RA. Time for a Change in Hospital Governance. Southwest J Pulm Crit Care Sleep. 2022;24(3):43-5. [CrossRef]

Cite as: Robbins RA. Medical School Faculty Have Been Propping Up Academic Medical Centers, But Now Its Squeezing Their Education and Research Bottom Lines. Southwest J Pulm Crit Care Sleep. 2022;24(5):78-80. doi: https://doi.org/10.13175/swjpccs023-22 PDF

Deciding the Future of Healthcare Leadership: A Call for Undergraduate and Graduate Healthcare Administration Education

Good medical leadership is the cornerstone of quality healthcare. However, leadership education for physicians has traditionally been largely ignored, with a focus instead on technical competence. As a result, physicians in many cases have abdicated their role as medical leaders to others, usually businessmen without medical training or expertise, and often a lack of understanding of the human issues inherent to healthcare. Recently, the Southwest Journal of Pulmonary, Critical Care & Sleep published a manuscript, “Leadership in Action: A Student-Run Designated Emphasis in Healthcare Leadership”, describing a curriculum designed to develop future healthcare leaders (1). Hopefully this and similar curricula will prepare physicians in setting direction, demonstrating personal qualities, working with others, managing services, and improving services (2). 

The US suffers from a crisis in healthcare partially rooted in a lack of physician- and patient-oriented leadership which has led to “hyperfinancialization” in many instances. Beginning in the 1980’s there has been an explosion in administrative costs leading to reduced expenditures on patient care but a dramatic rise in total healthcare costs, the opposite of efficient care (3). The substitution of primarily businessmen for physicians as healthcare leaders has at times led to the bottom line being the “bottom line” for assessing success in healthcare. Although it is true that metrics of “quality of care” are often measured, quality of care is hard to define and implement in a way that functionally addresses the concerns of the healthcare system, patients, and physicians. Furthermore, the concept that business personnel acting alone can improve the quality and efficiency of healthcare is difficult to support. It seems to us that the combination of business acumen, an understanding of financial realities, an appreciation of physician needs and their careers, and a deep understanding of the human side of patient care is what is needed. We believe that educating and empowering physician leaders could begin to address this need.

As can be seen in many instances in the country, new medical schools and many training programs are being created as part of, and “report” to, large health care systems, including for-profit, “not-for-profit”, and non-profit organizations(4-6). We must be very cognizant of the potential conflicts in priorities that may occur in such situations, as well as potential opportunities. While a concern could justifiably be that a system or organization focused primarily on finances might neglect the human or science-based aspect of medical training, there could also be opportunities to create leadership training that takes advantage of leadership qualities and skills from both business and medicine. On the other side of the coin, university-based training programs cannot neglect the realities of today’s healthcare system where a facility with administrative and financial issues is required for successful leadership.

We must begin to train physicians to be administrative leaders early in their careers. Leadership training in medical school such as the program described in the article by Hamidy et al (1), and other programs like a residency dedicated to providing a broad medical experience as well as administrative experience under the supervision of physician administrators would be a great start. We already see many physicians in leadership returning to school to complete MBA programs, but training must start earlier if physician leaders are to be successful. The Institute of Medicine has recommended that academic health centers “develop leaders at all levels who can manage the organizational and system changes necessary to improve health through innovation in health professions education, patient care, and research” (7).  To this end, a few healthcare organizations such as the Mayo Clinic, the Cleveland Clinic, the University of Nebraska Medical Center, and UT Tyler are all headed by physicians and could provide the necessary education with administrative emphases on care and financial stewardship, rather than pure profit (8-11). These better trained administrators would hopefully earn the cooperation of their providers and business partners in providing high quality care that is focused on the humanity of our patients, while keeping in mind strong financial stewardship. 

Richard A. Robbins MD, Editor, SWJPCCS

Brigham C. Willis, MD, MEd, Founding Dean, University of Texas at Tyler Medical School of Medicine Medical Center, Tyler, TX USA; Associate Editor (Pediatrics), SWJPCCS

References

1. Hamidy M, Patel K, Gupta S, Kaur M, Smith J, Gutierrez H, El-Farra M, Albasha N, Rajan P, Salem S, Maheshwari S, Davis K,  Willis BC. Leadership in Action: A Student-Run Designated Emphasis in Healthcare Leadership. Southwest J Pulm Crit Care Sleep 2022;24(3):46-54. [CrossRef]
2. Nicol ED. Improving clinical leadership and management in the NHS Journal of Healthcare Leadership 2012;4:59-69. Available at: https://pdfs.semanticscholar.org/3cc3/36f891d6a4b47d951b2bd280e46f4687dd5b.pdf (accessed 3/25/22). 
3. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med. 2003 Aug 21;349(8):768-75. [CrossRef] . [PubMed]
4. Banner University Medical Center-Phoenix. https://phoenixmed.arizona.edu/banner (accessed 3/28/22)
5. HCA Healthcare. https://hcahealthcare.com/physicians/graduate-medical-education/ (accessed 3/28/22)
6. Kaiser Permanente School of Medicine. https://medschool.kp.org/homepagJCe?kp_shortcut_referrer=kp.org/schoolofmedicine&gclid=CjwKCAjwuYWSBhByEiwAKd_n_kFPWcSP0Mj_VbqHJEsnwSwT_YkIErrb1PhcWQgQnRI_odNs5qbHZRoCaMIQAvD_BwE (accessed 3/28/22)
7. Institute of Medicine (US) Committee on the Roles of Academic Health Centers in the 21st Century. Academic Health Centers: Leading Change in the 21st Century. Kohn LT, editor. Washington (DC): National Academies Press (US); 2004. [PubMed]
8. Mayo Clinic Governance. Available at: https://www.mayoclinic.org/about-mayo-clinic/governance/leadership (accessed 3/25/22). 
9. Executive Leadership Cleveland Clinic. Available at: https://my.clevelandclinic.org/about/overview/leadership/executive(accessed 3/25/22). 
10. University of Nebraska Medical Center. Meet Our Leadership Team. Available at: https://www.nebraskamed.com/about-us/leadership#:~:text=James%20Linder%2C%20MD%2C%20Chief%20Executive,Nebraska%20Medical%20Center%20(UNMC). (accessed 3/25/22). 
11. University of Texas at Tyler. https://www.uttyler.edu/president/about/ (accessed 3/28/22)

Cite as: Robbins RA, Willis BC. Deciding the Future of Healthcare Leadership: A Call for Undergraduate and Graduate Healthcare Administration Education. Southwest J Pulm Crit Care Sleep 2022;24(3):55-57. doi: https://doi.org/10.13175/swjpccs006-22 PDF

Time for a Change in Hospital Governance

The SWJPCCS has been following the case of nine oncologists who filed a lawsuit against the Anne Arundel Medical Center (AAMC), in Annapolis, Maryland, last year (1). The oncologists claimed that the hospital chose profit over the needs of cancer patients, as it slashed oncology care services to cut costs, and both fired and denied them hospital privileges when they complained. At that time, the oncologists were not free to respond because of the ongoing litigation, but now that the lawsuit is over and the dust has settled, they are free to speak, and they contacted Medscape Medical News to tell their side of the story (2).

AAMC is a private, not-for-profit corporation that operates a large acute care hospital in Annapolis, Maryland. It is affiliated with Luminis Health, the parent company of the medical center. Until October 23, 2020, the nine oncologists were employed by the Anne Arundel Physician Group. The oncologists had privileges at AAMC for many years and their “capability as physicians is unquestioned,” according to the court filing made on behalf of the oncologists." AAMC created “a very toxic and difficult interpersonal work environment, and that made it difficult to do patient care," said Carol Tweed MD, who served as the unofficial spokesman for the group. "We would go to them and let them know that we were having difficulty delivering optimal patient care because we didn't have enough staff or the resources we needed for safety — and it got to the point where we were being ignored and our input was no longer welcome." There was a continuing cascade of events, and the oncology group mulled over some ideas as to how to provide optimal patient care. The decision they reached was to discuss running their own practice. Within a week of sending their proposal for setting up their own practice, all nine physicians were fired. “Instead of arranging a discussion, we received termination letters,” "We were terminated without cause.”

The oncologists’ case illustrates several problems with hospital ownership of physician practices. First, the oncologists had signed a contract with a noncompete clause. “The only thing we wanted was to be able to practice in this town,” said Tweed. “And what is important to know is that it was never for money, and that was never our motivation for wanting to form our own practice.” The second problem is that AAMC removed the oncologist’s hospital privileges. Removal of hospital privileges carries a special stigma making it difficult to apply for hospital privileges at other hospitals.

It disturbs me that physicians or physician executives would want to practice and patients would want care from a system where quality of care was alleged to be an issue. That aside, it is clear that the hospital used its position as the credentialing agent to limit competition and solicit patients. "This isn't ethical, but they tried to do everything to keep us from seeing our patients," Tweed said. This is patient choice, but they were telling patients they could not choose us as your doctors.

Below are several solutions which could potentially improve the credentialing process and allow the oncologists and other physicians to practice high quality medicine.

1. Physician candidates should have their contract negotiated by a lawyer or agent experienced in the appropriate areas of labor law. Candidates should not sign a contract with a noncompete clause. Even though such a clause is unlikely to hold up in court, the process of fighting a large healthcare organization is expensive and medical centers have deeper pockets. The hospital administration is not necessarily a physician ally. Even if the administration is easy to work with at present, hospital administrations change and the next administration might be more concerned with profit than quality of care.
2. Credentialing should be a function of an independent medical staff overseen by an elected chief of staff. Mitchell Schwartz, MD was chief medical officer at AAMC until January 2020 and succeeded by Stephen Selinger MD in May 2021. It is unclear what role Dr. Swartz or Selinger played in this dispute. Physician candidates should be wary if the chief of staff seems to represent the hospital administration to the physicians rather than the hospital staff to the administration. Potential physician candidates should request meetings with the chief of staff to assess for themselves their sincerity in working with the medical staff.
3. An independent hospital staff could vote to require administrators to be credentialed. An administrator’s credentials could be removed by a majority physician vote if there is extensive evidence that business decisions jeopardize patient safety. It seems likely that administrators would be less likely to use credentialing as a weapon when credentialing is counterbalanced in this fashion.
4. Physicians witnessing suboptimal patient care in the face of a nonresponsive hospital administration, could use their power as physicians to advise their patients to seek care elsewhere. I personally have seen such a nuclear option lead to hospital closure if sufficient physicians believe the hospital care is inadequate.
5. Healthcare credentialing agencies could become more responsive to physician complaints. This could avoid confusing evaluations such as the Phoenix VA being named to the Joint Commission of Healthcare Organization’s "Top Performer" honor in 2011 but 3 years later being accused of suboptimal care (4).  JCAHO inspections usually are conducted by a retired hospital administrator, physician and nurse. They usually review policies and procedures but rarely meet with physicians, nurses, technicians or clerks directly involved in patient care.
6. State Board of Medical Examiners should concern themselves with quality of care rather than disruptive physicians. In some cases, disruptive physicians advocating for better care are likely justified (4).
7. Insurers, including the Centers for Medicare and Medicaid Services, could remove the incentive for hospitals to own practices by limiting payments to centers with hospital-employed physicians. These centers have charges that average about 5.8 percent higher than those that do not employ their physicians (5).

These are just a few ideas many of which will be difficult to establish. Regardless, it is time to discard the notion that physicians are just waiting to collude and fix prices but to recognize that hospital administrators have self-granted themselves too much power leading to increased charges and poorer patient care. The time for change in hospital governance is now!

Richard A. Robbins, MD

Editor, SWJPCCS

References

1. Nelson R. Nine Oncologists Sue Medical Center Over Termination. Medscape Medical News. March 23, 2021. Available at: https://www.medscape.com/viewarticle/947976 (accessed 3/14/21).
2. Nelson R. Free Now to Speak, Nine Oncologists Spill the Beans Over Firing. March 11, 2022. Available at: https://www.medscape.com/viewarticle/970124?sso=true&impID=4083165&uac=9273DT&src=wnl_tp10n_220312_mscpmrk_eom#vp_1 (accessed 3/14/22).
3. 22 Ill.194 Ariz. 363, 982 P.2d 1277, 15 IER Cases 419 (1999)
4. Robbins RA. The disruptive administrator: tread with care. Southwest J Pulm Crit Care. 2016:13(2):71-9. doi: http://dx.doi.org/10.13175/swjpcc049-16
5. Ho V, Metcalfe L, Vu L, Short M, Morrow R. Annual Spending per Patient and Quality in Hospital-Owned Versus Physician-Owned Organizations: an Observational Study. J Gen Intern Med. 2020 Mar;35(3):649-655. [CrossRef] [PubMed]

Cite as: Robbins RA. Time for a Change in Hospital Governance. Southwest J Pulm Crit Care Sleep 2022;24(3):43-5. doi: https://doi.org/10.13175/swjpcc013-22 PDF