We have an emergency!
As we have repeatedly established, autonomy of medical care components (i.e., doctors, hospitals, payors and universities/innovators) is a non-negotiable necessity if we are to rebalance medicine and make patient well-being the priority. Understanding this, we quickly see that doctors across America are rapidly becoming employed in arrangements where their autonomy—defined as self-governance; acting in accordance with moral duty over self-interest— has been completely subverted. The result is burnout, loss of productivity and an unbalanced medical care environment.
Many see the loss of doctor autonomy as the most important cause of the Medical Care Crisis.
If so, then we are indeed in a state of emergency.
To understand the nature of the emergency, let’s trace the path of the traditional independent doctor-hospital relationship shown below (a model that still exists in some communities):
Prevalent during most of the twentieth century, this model featured two distinct and independent care components: doctors and hospitals. As separate businesses doctors and hospitals interfaced only when doctors applied for admitting privileges to the hospital. Doctors needed beds and operating rooms to take care of their patients and hospitals needed doctors to cover patients that came to the hospital seeking care. Doctors commonly had privileges at more than one hospital. This allowed patients to choose which hospital they preferred, all while keeping the same doctor. Doctors chose the hospital most appropriate and available for the clinical needs of their patients. There was a credentialing process for doctors seeking admitting privileges at each hospital. There was also a medical executive committee that oversaw peer-reviewed quality. Both the doctor and hospital were completely autonomous.
As the administrative burden of practice increased and third-party reimbursement tightened, doctors found it progressively more difficult to make financial ends meet. By the turn of the century, they began to seek alternatives to independent practice. Hospitals represented a stable reserve for many doctors. Hospitals needed doctors to staff beds and doctors needed administrative and financial assistance to maintain their practices. Hospitals began to employ doctors. While this seemed logical, employment of doctors posed many questions for hospital administrators. For instance, where do we place doctors in the hospital organizational chart? To whom do they answer? Are they like all the other employees in the hospital? How do they interact with doctors on the medical staff that are not employed? Will we allow the employed doctors to admit patients to competing hospitals? May employed doctors keep and oversee their own offices and staff?
For years, there were no consistent answers to these questions. There were dozens of different arrangements. However, over time, uniformity developed. Even though doctors produced a fee for their services (fees that were levied to payors by the hospitals where doctors worked) they slowly became relegated to the status of all other hospital employees. Like nurses and other clinical staff, they reported up through the ranks of administration to the corporate executives in charge of the hospital. Why should doctors be treated any differently than other team members—right?
As a result of this reasoning, the figure below became the model for hospital employment:
As can be seen, doctors (and the doctor-patient relationship) reported to non-clinical administrators like all other employees. And patients became customers. Notice in this arrangement who has the ultimate authority/control. It is administrators and lay board members. Work hours, schedules, rules of conduct, clinical productivity and patient well-being now belonged to administrators with no clinical acumen or training. Notice too how doctor (and patient) autonomy is eliminated. Doctors no longer recruit their own partners and staff. Partners are hired as co-workers. Doctors in this arrangement lose their sense of purpose, their clinical esprit de corps, their professional differentiation and dedication. They become ‘renters’, not ‘owners’, often overworked, exhausted and in an extreme state of clinical burnout.
This is our current situation of corporatization; doctors with no autonomy—our state of emergency.
As with any emergency, we need action. We need a new arrangement, a different model—a model perhaps like the one below:
Used at many medical schools/universities, this model maintains hospital employment but places the doctors in a separately incorporated multispecialty medical group—a group that is self-led and managed. It reports to the same CEO and board of directors/trustees, but it is completely autonomous from the hospital—self-governing and accountable to a single financial bottom line. The medical group has a transactional relationship with its hospital partner (and vice versa) where annual purchased services for medical direction, teaching and after-hours call coverage are negotiated. They hire, pay and fire their own staff. They do their patient billing and collecting. They hold their physician partners accountable. They oversee all medical care and are expected to act in accordance with moral duty rather than self-interest. In other words, the doctors act as professionals who oversee the profession. In this model, doctors retain a sense of purpose; purpose that creates culture and drives performance. Meaning is restored and clinical burnout alleviated.
If the loss of doctor autonomy is the most important cause of the Medical Care Crisis, then autonomous employment models for doctors like the one described above are going to be essential. Only then will the emergency be diverted. And only then can the medical care environment become rebalanced.