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Private Practice Column

Episode 27: The Right Stuff

“The greatest leaders are reluctant ones who lead because they realize that no one else seems willing to step up.”

 -Orrin Woodward

Physicians have recently learned that no one is going to advocate for them or their patients but themselves. It has been 14 years since the Affordable Care Act was signed into law. It became apparent very rapidly that physicians had not been part of the process. Rather, it had been a fairly tightly guarded horse trading going on between the bureaucrats of Washington and the Insurance lobbyists that seem to shift so effortlessly between the private and public sectors of healthcare. The ACA set up the winner and losers of American healthcare right from the start, and furthermore, it became abundantly clear there wasn’t much anyone could do about it. Arbitrary metrics were put into place that everyone thought should theoretically measure how good we are doing as physicians. We were also pushed under the rubric of “provider” in anticipation of others being pushed into and given the same authority and autonomy as residency-trained physicians.

As part of the ACA, physician-owned hospital became further restricted. There was an exception to rural hospitals being physician-owned, but the ACA pulled back further, saying the hospitals could not expand and add additional operating rooms or beds beyond what it had on March 23, 2010. As part of this exit of physicians from the ownership space, so too did physicians become less prominent in board rooms and places where important decisions for healthcare took place.

The rise of the administrator class that had begun since the rise of the HMOs in the 1980s, became even faster. Hospital placed compliance with metrics, and threats of payment cuts, as well as unfair practices from the insurance companies on whom they depended on – the largest ones being Medicare and the Medical programs. Hospitals also depend on federal subsidies, given out in return for participation in the Medicare programs. Expectations are also set on how much charity care should be given out by the hospital. As taking care of patients is an expensive business, the threat of payment cuts became absolutely paramount to these administrators. More and more of them were hired to manage all the red tape and to keep abreast of the ever-traveling goal posts.

Organizations like JCAHO, that started out initially as the efforts of Ernest Codman in the 1910s (he instituted the first M&M conferences), became more of a dark overlord of sorts, creating more arbitrary rules, such as prohibiting nurses from wearing open bottom skirts to not letting surgeons wear surgeons’ caps, without a shred of data to suggest it affected outcomes. Physicians became increasing out of the loop and not in the decision-making spaces of healthcare.

Since the goal of the ACA and other efforts made by both Democratic and Republican administrations to curb the cost of healthcare has been so sorely a failure, many have pointed to doctors being the sole source of the failure. As physician reimbursements have gone down some 20% over the past years, and with inflation adjustment almost 34% by some reports, it just doesn’t jive. As physicians we are taught to be team players, to hunker down, to help, and to just grind it out. On top of that, we work a lot. There is not a lot of time to dissent. Now, with recent figures quoted as high as 80% of physicians ending employed, there is even less motivation from speaking out.

Of recent, the No Surprises Act data has come back for the first large batches of claims between physicians and payers. Doctors prevailed in over 70% of the claims. Meaning, that the doctors thought they weren’t getting paid properly, and an independent arbitrator agreed. The policy wonks at the Brookings Institute somehow took that to mean physicians should get paid less. I and other incredulous physician advocate tweeted at this particular person asking him in addition to other questions, what the color of the sky was on Venus. The wonk is regularly invited on Capitol Hill to tell Congress what to think and how bad doctors are. Bear in mind one of the former heads of Blue Cross is one of the largest supporters of the same, and this is putting it generously, “think tank.”

Many non-for-profit organizations have large, vertically integrated infrastructures of shockingly excessive executives. Administrators are in most cases, just extensions of the home office and execute their plans for creating larger and more bloated organizations. Hospitals are run by these extenders who in general are probably well-meaning but are not allowed to question the home office. It creates a culture of sameness and homogeny of ideas that, surprise, never makes things better.

As physicians, it is demanded of us to question. We question data, question our assumptions, and sometimes our own judgment. That sort of thinking is an existential threat to vertically integrated healthcare entities. Rather than encourage our participation, they simple label a doctor as disruptive and marginalize them. While it is true some

physicians cannot and should not exist in certain ecosystems, most want to work and take care of patients. Having working physicians carry administrative roles would help enrich an organization by essentially becoming self-aware.

Four reasons physicians make better administrators than the current model of promoting healthcare-adjacent or non[1]physician healthcare workers into high-ranking roles: 1) physicians are by nature hard-working. They are dogged, driven, and tenacious. The job will get done and if they run into a wall, they will ask “why can’t we move beyond this and get this done?”; 2) we question. Just like the aforementioned point, we ask “why is this?” Processes will get broken down and revamped, obstructions cleared, and money and more importantly lives saved by breaking down barriers to care; and 3) physicians are smart. We understand complex concepts quickly, assimilate knowledge fast, and can incorporate new data into their thinking and create new plans rapidly; 4) we don’t want the job. This is precisely why those that don’t crave power are the best leaders. They are not in it for the ducats, they are in it to make things better (now just to find these “angels”).

As physicians, we are stewards of our patients. “Healthcare” is what happens along the way. By concentrating on patients and their care, we also disenfranchise the grifters that profit from this bloated system. The pushback will be tremendous, just look at the AHA howling at the prospect of bringing back physician[1]owned hospitals. That will make the evolution of practicing physician administrators even sweeter.

And as for our national system, how would it look if the Surgeon General, instead of being a figurehead was put in charge of HHS? Our current one, who is also considering a bid for governor of our great state was absent during most of the COVID response for this administration, accused doctors of gouging patients in 2021, and furthermore stated that doctors’ claims in the IDR portal, put in place by Congress, were frivolous. Flippant and sardonic during testimony, I struggle to think who could be that way other than a lawyer. Physicians participate in M&M. Anyone with that attitude would quickly find themselves in boiling water.

Physicians are capable of self-reflection and can tolerate criticism. Accountability is in our very nature. Imagine the way suddenly so much of the dreck heaped upon us and the population of this country would be drained out of the pot. It is that which the bureaucratic class fears the most: efficiency and accountability.

And that is the stuff we are made of.