Friday, November 16, 2007

Hospital and Doctor Relationships: Anything New Under the Sun?

I recently came across a 1986 book The Corporatization of Health Care Delivery, published by the American Hospital Publishing, Inc, a subsidiary of the American Hospital Association.

The book includes chapters on new models, hospital-physician competition, joint ventures, medical staff networks, how to pay doctors, and preventing malpractice losses. It contains diagrams of the independent corporate model, the traditional specialist divisional model, the parallel model, the joint venture model, and the malpractice pyramid.

Nothing new there.

The title of the book “The Corporatization of Health Care Delivery” says it all. In 1986, in AHA’s eyes, hospitals and their various corporate models were where the power, the glory, the center, the pivot, and the fulcrum of health care delivery. I suspect this remains so in most communities.

But there are new changes and new strains in the relationship – a few new things under the sun.

· One is the increasing business savvy of American physicians, fostered in part by business training in medical school, MD/MBA programs, and physician executive programs.

· Two is the realization that one man’s meat is another man’s poison. Hospitals have always had a power advantage over physicians because of their corporate structure and physicians’ “open democracies” But physicians are now developing more disciplined corporate structures of their own in centralized group practices, specialty hospitals, outpatient surgery and diagnostic facilities.

· Three is the accelerated migration of specialists outside of hospitals, thanks to advances in non-invasive or minimally invasive technologies in the realms of anesthesia and imaging and intravascular device placement. This is weakening traditional hospital-physician loyalties.

· Four is the rapid advance of “convenience care” – retail clinics, urgent clinic, multispecialty ambulatory care clinics – outside the central hospital campus. Whose patients are these new health consumers demanding convenience in nontraditional outpatient settings anyway?

· Five is the dawning of recognition that hospitals and physicians have different priorities. Hospitals and their boards tend to focus on protecting the corporate mission of the hospital, which includes the business function and caring for the sick; while physicians concentrate on serving patients within their practices and protecting their own bottom lines. What’s good for the goose may not be good for the gander.

· Six are the multiple effects of a new generation of doctors and economic pressures from the uninsured – more emphasis on 40 hour weeks, paid vacations, and malpractice coverage, forgiveness of training debts by physicians; more hospital employment; more hospitalists; more demands by physicians for payment for coverage of the emergency rooms.

· Seven are increased pressures on hospitals to create safe (e.g. the MRSA problem) and quality environments (e.g., P4P with measurable evidence of quality) with payments denied or tied to both.

· Eight is the relentless rhetoric about failures of hospital and physician electronic record systems that actually talk to each other and problems forming RHIOs (Regional Health Information Organizations) which require competing health systems and doctors sharing data with competitors.

Yes, there are new things glittering, glimmering, and glowing faintly under the hospital-physician sun, but they don’t brightly glisten or glare in the noonday sun because grinding evolutionary processes tend to occur at dawn or nightfall.

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