Economic pressures are creating an adversarial climate in some areas and pushing physicians and hospitals together in others.
By Robert A. Berenson, Paul B. Ginsburg, Jessica H. May
Hospital-Physician Relations
Health Affairs
December 5, 2006
Because many services performed in hospitals can safely and conveniently be performed in ambulatory settings, physicians have become owners of entities directly competing with hospitals for patients in a new medical arms race. Hospitals and medical staff physicians face growing tensions as a result of physicians’ growing reluctance to take emergency department call and the consequences of hospitalists replacing physicians in the care of inpatients. Although there are increasing expectations that health system challenges will lead hospitals and physicians to collaborate, in many markets the willingness and ability for hospitals and physicians to work together is actually eroding.
http://content.healthaffairs.org/cgi/content/full/hlthaff.26.1.w31/DC1
Creating Accountable Care Organizations: The Extended Hospital Medical Staff
By Elliott S. Fisher, Douglas O. Staiger, Julie P.W. Bynum, Daniel J. Gottlieb
Many current policies and approaches to performance measurement and payment reform focus on individual providers; they risk reinforcing the fragmented care and lack of coordination experienced by patients with serious illness. In this paper we show that Medicare beneficiaries receive most of their care from relatively coherent local delivery systems comprising physicians and the hospitals where they work or admit their patients. Efforts to create accountable care organizations at this level–the extended hospital medical staff– deserve consideration as a potential means of improving the quality and lowering the cost of care.
Fostering local organizational accountability for capacity.
The most important reason, however, to focus on hospitals and their affiliated medical staffs is to establish accountability for local decisions about capacity. Higher spending across U.S. health systems is largely attributable to greater use of discretionary “supply- sensitive” services: visits, specialist consultations, tests, imaging services, and the use of institutional settings (rather than outpatient settings) for care. Patients’ preferences do not explain these differences in care, and responses to survey-based clinical vignettes reveal that physicians in higher-spending systems have developed a more intensive practice pattern in exactly these discretionary clinical settings.
These findings are most consistent with an underlying causal model that highlights our current lack of accountability for capacity. Because such a high proportion of decisions are in the “gray areas” of medicine, physicians adapt their practices to work with whatever resources are locally available (such as making more frequent referrals in systems with more specialists). And–in the current payment environment–they are always able to stay busy themselves by seeing their own patients more often. Local decisions that influence capacity (capital investments, recruitment, and physicians’ choices about practice location), therefore, are likely to be the first step in the causal chain leading physicians to adopt more-intensive practice patterns–and leading to the overuse of supply-sensitive services.
Comprehensive measures of longitudinal quality and costs at the hospital staff level would bring the impact of such decisions to light. Hospitals that recruited additional specialists or expanded their acute care facilities could expect to see those decisions reflected in their longitudinal performance measures. Similarly, decisions to invest in care management, reduce acute care capacity, forgo unnecessary specialist recruitments, or more effectively manage postacute care resources could result in improved quality and lower costs.
http://content.healthaffairs.org/cgi/content/full/hlthaff.26.1.w44/DC1
Gain Sharing: A Good Concept Getting A Bad Name?
Allowing physicians to share in the savings they help produce could lead to greater accountability in health care.
By Gail R. Wilensky, Nicholas Wolter, and Michelle M. Fischer
Gain sharing, of the type we have described, is envisioned as an important transitional strategy, leading U.S. health care to higher levels of accountability and improved performance. It would allow the physicians that produce the savings and that can do so in ways that maintain or improve quality of care to share in the results of their efforts, even when not formally aligned in IDSs (integrated delivery systems). Although safeguards need to be put in place to protect against abuses, the results of the current system are abundantly clear: continued unsustainable increases in spending and unacceptable levels of quality.
http://content.healthaffairs.org/cgi/content/full/hlthaff.26.1.w58/DC1
Hospitals And Physicians: Not A Pretty Picture
By Jeff Goldsmith
Hospital-physician relationships in the United States have deteriorated markedly in the past few years. An asymmetry of obligations to caring for the uninsured and inappropriate financial incentives have worsened the conflict between hospitals and physicians in many markets. Sadly, the resources and political bandwidth consumed by managing this conflict have been diverted from the fundamental challenge of providing universal health coverage–the root cause of much of this conflict.
http://content.healthaffairs.org/cgi/content/full/hlthaff.26.1.w72/DC1
Comment:
By Don McCanne, MD
A well functioning health care system continues to strive for optimal value. That requires balancing efforts to maximize quality while controlling spending. (Some suggest that access is a third variable, but access to appropriate services and facilities should be a given.)
What role should money play in achieving this balance? Should providers receive explicit financial rewards for meeting quality goals that should be expected as part of the individual’s professional duties? Should providers (physicians) receive explicit financial rewards merely for reducing another provider’s costs (hospitals)?
Terms such as fee-splitting and kickbacks are now out of vogue, but have the concepts left us? Is “gain sharing” merely a euphemism for kickbacks?
Gail Wilensky, in her drive to reduce health care spending in this nation, has been an advocate of erecting financial barriers to care, even though health outcomes may be impaired. Her insensitivity to the needs of patients seems to be consistent with her advocacy of kickbacks. Is greed really an acceptable driving force, as long as it achieves the goal of reducing health care spending?
Money should play a role in improving quality, but the way to do that is to allocate what funds are available to a health care system designed to achieve the highest quality that can be expected. Elliott Fisher and his colleagues describe a process that is based on system design to benefit patients rather than system design that acquiesces to greed.
What is sad is that, as Jeff Goldsmith has stated, we continue to accept the asymmetry of obligations to caring for the uninsured and inappropriate financial incentives, largely because we have failed to meet our fundamental challenge of providing universal health coverage — the root cause of much of this conflict.