VHA Findings

When Doctors and Hospitals Collide
As doctors and hospitals drift further apart, contracting professionals face tough challenges.

Just at a time when hospitals need all the help they can get from doctors in reducing costs, doctors are less willing and able to give it to them. Even though many doctors believe product standardization efforts are worthwhile, they simply don’t have the time or inclination to devote themselves to such efforts. That’s not only true for standardization programs, but also for the entire gamut of initiatives on which physicians have traditionally worked with hospital administration, usually through the medical staff organization.

According to “Physician Hospital Relationships: Forging the New Covenant,” a new study from VHA, “Hospital issues rate near the bottom as a major concern for most doctors. Economic issues and lifestyle concerns keep them awake at night. For many, the best opportunities involve competing with their hospital, not rescuing it. The two sides are migrating into separate and sometimes colliding universes.” VHA is the Irving, Texas-based alliance of not-for-profit healthcare providers.

The medical staff organization has been the hospital’s traditional link with its physicians, holding responsibility for myriad activities, including credentialing, privileging, peer review and consideration of clinical, infection control and patient safety issues. But as physicians wrestle with other priorities, the medical staff organization is weakening. In some cases, doctors are willing to concede more control to administration, something that would have been unthinkable 10 or 20 years ago. “The result is the prospect of a fundamental shift in the way that doctors and hospitals relate to and work with each other,” say the study’s authors.

The study is the third in a series on hospital-physician relations by VHA. The findings were based on an Internet-based survey of 1,006 physicians in December 2003, followed by structured interviews of 20 chief medical officers the following quarter. Because the hospital relationship was the focal point of the study, medical and surgical specialists were heavily sampled. Nearly four out of five doctors had been in practice for 20 years or less. Three out of five had never served as an officer in their hospitals’ medical staff organizations. One in four had served in the past, and one in eight was currently serving in that capacity.

Losing touch
When asked, “What keeps you up at night?” 34 percent of the physicians answered “income/reimbursement,” and 30 percent said “malpractice/liability/lawyers.”

“Significant numbers of physicians are already seeing declines in net income as a result of the overhead required to serve managed care contracts,” according to the study’s authors. To make up the shortfall, 69 percent of the respondents said they have increased their caseloads. This has dire consequences for hospitals trying to enlist their physicians in quality or cost initiatives. “All doctors have to sell is their time, and, given their expensive overhead, most activities outside their practices have a direct, negative impact on income,” say the study’s authors.

It’s not that physicians are grossly dissatisfied with their relationships with the hospitals where they practice. In fact, two-thirds rated their relationships with the hospitals to which they admitted the most patients as excellent or very good. Instead, physicians are simply losing touch with hospitals.

“Historically, the hospital was a gathering place for physicians and an important venue for both formal and informal clinical education,” say the study’s authors. “Over time, however, many services that were once provided in the hospital moved to the outpatient facilities and medical offices. As a result, physicians are finding fewer reasons to visit the hospital. In order to preserve professional relationships, they have come to rely heavily on societies such as the American Academy of Family Practice and the American College of Cardiology.”

At the same time, in their search for traditional revenue sources, many physicians are building and operating facilities outside the hospital. For their part, “healthcare organizations around the country are discovering that if they do not provide opportunities for collaboration, then interested doctors will find the support somewhere else,” according to the study. To date, only 35 percent of physicians investing in joint ventures with hospitals have found those joint ventures to meet their expectations.

For contracting professionals, the bottom line is this: Even if the IDN’s physicians are inclined to get involved in product standardization activities, they probably can’t devote much time to it. (This despite the fact that of the 36 percent of the doctors who were aware of their hospital’s or IDN’s product standardization programs, nearly two-thirds found them to be effective or nearly effective. Only 6 percent felt they were somewhat or very ineffective.)

Shadows of their former selves
“Medical staff organizations in most American hospitals are mere shadows of their former selves,” write the study’s authors. “Attendance at general staff meetings has dwindled, and few physicians are interested in assuming responsibility for leadership positions. Attendance at committee and department meetings has declined as well. The role of the [medical staff organization] as guardian of clinical performance and patient safety has been supplanted by its use for contesting issues with the administration or an arena for conflict between competing physician groups.”

In such an environment, how is the hospital to move forward with standardization initiatives, particularly those involving standardization of high physician-preference items? In a phrase, “with great difficulty.”

To the extent they can, hospital staff, nurses and others are picking up the slack caused by inactive medical staff organizations. In some cases, hospitals are hiring full-time medical directors, rather than begging physicians to get involved on a voluntary basis. These physicians are paid by the hospital and, depending on their responsibilities, report to either the chief medical officer or another administrator.

Recommendations
Faced with these difficulties, contracting professionals and hospital administrators must keep cool, say the authors. They must be upfront about their IDN’s financial situation, but they must accept the fact that the hospital cannot be all things to all doctors. No matter the decision, somebody’s going to feel slighted.

“Organizations that wish to engage physicians on issues like healthcare quality, access and improving the performance of hospitals should recognize that they are competing for mind share and that common ground with physicians will best be found in areas that include considerations for financial and liability issues.”

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