03 Mar Physician clinical autonomy at risk?

Last night, I had the opportunity to attend a great panel discussion, hosted by the University of Dallas in Irving, Texas. On the panel were prominent members of the Texas healthcare community including a Chief Medical Officer, a Chief Executive Officer of a multi-national hospital system, an anesthesiologist, a Concierge Medicine physician, and a senior hospital Administrator.

Among the topics discussed, one stood out for me: physician clinical autonomy. I believe this key issue is not being given sufficient attention in the politically charged and economically driven environment that is the US healthcare system today. I also believe that by ignoring this critical factor or even pushing it to the back-burner of our national conscience and debate, we will do long-term harm not only to the medical profession, but to the well-being of us all, our nation.

We have been here before. Remember the HMO experiment of the 90’s? I truly do not believe that what we are experimenting with now (ACOs) is much different from or can produce results that will be much different from the HMO experience. Costs will not come down, just get “shifted around”. Outcomes will not get better, just get “buried” under meaningless measures. I am not alone in this feeling. Multiple surveys and studies indicate that the vast majority of those that truly should know (physicians) would agree with what I have stated above. As a back up to my statements, consider these data points:

– As of 2015, only 35% of active physicians are in independent practices (not owned by hospitals). This number used to be 65% as recently as 2009

–  25% of hospitals (that have hired physicians or bought out their practices) are running in the red (losing money)

– Another 63% of these hospitals are either barely breaking even or making under 5% margin – not at all sustainable

– Cost cutting is now at the forefront of the hospital executives’ agenda

– Top reason physicians chose to be employed or bought out by a hospital is to avoid the hassle of running a business (independent practice) that includes dealing with the insurance payers and managing staff

– Top complaint of “hospital owned” physicians is loss of clinical autonomy! They realize, after the fact, that they are now part of a system that operates by “what’s best for the bottom-line” and not necessarily “what’s best for the patient”

Now let’s add this last one into the mix: the lowest earning physicians (Internal Med / Family Practice) earn, on average, $195,000 annually (take home pay for hospital owned physician in this role). Over a 30-year career, and using a market rate of return of 8% (historical average is 11% but let’s not squabble). In an independent practice, the same physician would earn (take home) $226,000. If you do the math, over their career, a hospital owned physician would lose over $3.4 million as compared to if she/he remained in an independent practice! Is this “opportunity cost” truly the only alternative for these physicians as well as compromising their clinical autonomy!

The physicians can instead use the same exact alternative that hospitals are embarking on (once again): BPO (Business Process Outsourcing). The physicians do not and (I hope) must not sacrifice their clinical autonomy for all our sake. I shudder to think of the bottom-line driven decisions that dictate how long I should stay in a hospital and whether or not I should be re-admitted, no matter how necessary in a physician’s opinion, because it may cost the hospital a reimbursement penalty under some mindless measure. Not to mention the top-line driven decisions that dictate all the unnecessary tests I must go through because each one adds to the top-line of the hospital’s Income Statement.

In my heart, I do not believe that hospitals are evil. That would be too easy a statement to make. It is a matter of enormous economic benefit that is driving some of the short-sighted decisions in our healthcare system. I am a finance person so I look at the trail of money: a pretty reliable indicator in many areas. I do not see physicians as a cause of the out of control healthcare costs we are facing. Indeed, I know quite a few physicians personally and cannot think of a single one that considers economic benefit above patient care. However, these same physicians, if “bought out” by a for-profit entity such as a hospital, lose their grip on their clinical autonomy and come close to, if not actually, violating the most fundamental and honorable tenet of their noble profession: the Hippocratic Oath – which for us laymen is known as “Primum non nocere – First, do no harm”. (This is actually not part of the Hippocratic Oath – but let’s not squabble – again). I sincerely hope that physicians would seek the reliable alternatives available to them for avoiding the hassles they rightfully should not be bothered with and not compromise their clinical autonomy. Nor should they throw away over $3.4 million over the course of a career that demands so much personal sacrifice from them to begin with. They certainly deserve the financial rewards of taking care of our well-being.