We Can All Get Along: It’s the Patient, Stupid

My last blog used the infamous Rodney King episode in Los Angeles as the springboard for suggesting that integrating care—physicians, hospitals and patients working together—is essential to achieve the best clinical outcomes for the chronically ill while constraining the runaway costs of healthcare. A recent article in The New York Times (http://www.nytimes.com/2012/12/25/opinion/approaching-illness-as-a-team-at-the-cleveland-clinic.html?_r=0) makes it clear that this is not a theoretical concept. Physicians at one of the great healthcare organizations in the country, the Cleveland Clinic, have been forming focused teams that can mobilize to efficiently diagnose and treat a variety of illnesses, including neurological, cardiovascular, oncologic, urologic and nephrologic.

Key success factors include a deep commitment to the team approach, a strong culture of excellence and responsible stewardship of resources, comparative-effectiveness research and evaluation and a staff model of physician engagement. The latter includes one-year renewable contracts with employed physicians, the use of structured annual performance reviews and financial incentives based on quality outcomes. Michael Porter, the Harvard Business School guru of healthcare organizational structure, has said that the Cleveland Clinic represents “a model of where we need to go.”

How much of the success of the Cleveland Clinic and other similar organizations depends on the staff model—something that has barely touched nephrology but has been exploding on the scene in a big way in other primary-care fields and subspecialties? Only 38% of physicians in the United States were in independent practice at the end of 2012, and this number is expected to shrink to 30% or so by the end of 2013. Many would say that employed physicians, given the right incentives based on quality outcomes and a fully integrated care-delivery system, are the most able to deliver on the promise of better outcomes at lower cost, at least for the chronically ill complex patient.

Whether or not you agree with this premise, it is important to keep in mind some key principles if you do choose to become employed by a care-delivery system or hospital. These principles are articulated by the AMA in a recently published position paper: AMA Principles for Physician Employment (http://www.ama-assn.org/resources/doc/hod/ama-principles-for-physician-employment.pdf).

A few of the key points are worth reprinting here:

(a) A physician’s paramount responsibility is to his or her patients.… Given that an employed physician occupies a position of significant trust, he or she owes a duty of loyalty to his or her employer. This divided loyalty can create conflicts of interest…which employed physicians should strive to recognize and address.

(b) Employed physicians should be free to exercise their personal and professional judgment in voting, speaking, and advocating on any matter regarding patient care interests.…

(c) In any situation where the economic or other interests of the employer are in conflict with patient welfare, patient welfare must take priority.

(d) Physicians should always make treatment and referral decisions based on the best interests of their patients.…

(e) Assuming a title or position that may remove a physician from direct patient-physician relationships—such as medical director…—does not override professional ethical obligations.… Physicians who hold administrative leadership positions should use whatever administrative and governance mechanisms exist within the organization to foster policies that enhance the quality of patient care and the patient care experience.…

Good advice (and there is lots more) for all of us.

As Plato asked more than 2,000 years ago,

“Is it not…true that no physician, insofar as he is a physician, considers or enjoins what is for the physician’s interest, but that all seek the good of their patients? For we have agreed that a physician strictly so called is a ruler of bodies, and not a maker of money, have we not?”

Striving to bring quality to life,
Allen R. Nissenson, MD

Follow me on twitter @DrNissenson

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