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Healthcare Insights: Physicians Take Bold Action

John August

Earlier this month I participated in a meeting at a teaching hospital in which a faculty member reported on an experience from one of her residents. The resident came to her with a true sense of moral distress based on an incident with a patient. The resident was unable to determine if a prescription for the patient was filled, picked up, and properly taken by the patient. The resident was living through an all-to-common systems problem in healthcare: failure of care coordination.

This failure could happen for any number of reasons.

It should never happen!

Tragically, these failures occur on an almost unimaginable scale.

Such failure in care coordination has consequences that directly impact patients and physicians. The patient needs care, and time and effort are taken to provide that care, as human and other resources are spent.

In this case, as is repeated so often, communications in the health system has gaps, and the physician cannot easily determine the well-being of the patient, leaving the physician with the feeling that his commitment to his patient and his profession are needlessly upset. Worrying unnecessarily about the welfare of the patient creates moral distress and moral injury. Worrying about failures in the system on a regular basis increases that stress and injury, part of the on-going cycle which takes a terrible toll on the practitioner.

More broadly, we know that failure of care coordination is one of six major systems failure that cause our precious healthcare dollars to be wasted while patients suffer. We know that this type of failure costs all of us at least between $27-78 billion annually.

We also are aware of the unnecessary human suffering caused by such failures.

It is estimated that between 25-40% of our healthcare spending is wasted on six major categories, including failure of care coordination. Other categories include overtreatment, high pricing and profit, fraud and abuse, failure of care delivery itself, and administrative complexity.

Indeed, American healthcare is not a good value proposition.

Physicians across the nation face the consequences of these systems failures.

The challenge of high costs and poor outcomes in healthcare has created efforts to improve care and reduce cost through changes in insurance reimbursement. Such changes are designed to create more value for the dollars spent. These reimbursement rates have been driven largely by Medicare, the largest purchaser of healthcare services in the nation. Other public and private insurers have followed suit.

Unfortunately, these methods have put tremendous pressure on individual and small practitioners to invest in infrastructure, electronic medical records, and hiring and training staff to carry out new care delivery models. These investments are very expensive, and have caused more and more individual, small, and even larger health providers to consolidate with larger and larger systems to try to succeed. These reimbursement systems put more and more risk on providers to deliver improvement with less and less funds.

An industry transformation to this crisis has been consolidation of healthcare services and corporatization of healthcare practices. The result of this trend has produced many negative consequences for patients, and for all of us who pay for and need these services. American healthcare remains disaggregated and market -driven. As a result, market forces drive corporatization and consolidation, and without improvement in health.

Caught in this fray are the nation’s 900,000 physicians who must live up to their Hippocratic Oath of “do no harm” in an atmosphere where their skill, knowledge, experience and decision-making authority are being eroded by larger and larger systems with decision-making done far from the point of care delivery.

Physicians are responding to this crisis as never before!

In previous Healthcare Insights, we have reported on the rapidly growing trends in physician collective action, including unionization. This past month alone, we have seen:

  • More successful physician unionization
  • More collective action by physicians in response to growing awareness that the profession is under unprecedented stress
  • More prominent news and professional journal articles about physician response to their rapidly deteriorating professional lives

And, we have witnessed a strike by unionized physicians which many believe is the very first strike by attending physicians in the private sector of American health care.

Let’s look at this strike as a way of framing this new era of physician collective action on behalf of patients and themselves. Please view this video report.

As you can see, the Emergency Medicine Doctor depicted in the video clearly frames the issues:

  • The hospital he works in sold its emergency services department to TeamHealth, a national corporation owned by private equity
  • The doctors believed they had no alternative but to strike in response to their daily experience of patient safety being compromised by severe understaffing due to Team Health policies
  • The doctor clearly states that what he and his colleagues are facing is not only a local problem but a national problem as companies like Team Health buy emergency room services and then do not provide adequate staff and support to care for patients

It cannot be overstated how rare it is for physicians to strike. Their Hippocratic Oath requires that in their practice of medicine “they do no harm.” To make the choice to walk off the job means that they have determined that they can no longer tolerate the harm they see the system doing to their patients, and make that most rare decision to walk off the job seeing no alternative to stop the system-driven harm they live with each day.

And a word on Team Health: owned by private equity, it is among the growing number of businesses in healthcare that defines what is known as the “Corporate Practice of Medicine”.

Here is a brief excerpt from the article which crystallizes the crisis for physicians and patients operating under the business model of Team Health:

“The specialty of emergency medicine (EM) represents one of the most important aspects of the American health care system. This importance has been steadily increasing given the multitude of treatment and diagnostic advances that allow earlier intervention in critical illnesses such as stroke, myocardial infarctions, and trauma. Additionally, in many communities the emergency department serves as the safety net for those with inadequate access to health care. Great strides have been made in the specialty of EM and the field currently attracts top medical students who seek the challenge of this demanding practice. Unfortunately, there are major problems within the specialty that have little to do with the practice of medicine and are largely centered around the business of medicine.

The physician practice management (PPM) industry is at the core of these problems. The issues threaten the integrity of the specialty, the career satisfaction and longevity of its practitioners, and ultimately the quality of care delivered to emergency patients. The issues that are of importance can be summarized as follows:

  • The PPM industry dominates the EM marketplace.
  • The working emergency physician is routinely denied access to review what patient care services are billed and paid on their behalf.
  • Attempts by emergency physicians to gain access to this information can result in termination.
  • Emergency physicians are not able to fulfill their role as a check on deceptive and fraudulent billing practices as expected under the reassignment statutes.
  • Lack of access to the books of account also places the emergency physician at risk for unwitting involvement in prohibited fee-splitting arrangements.
  • The quality of care in EM is threatened by the PPM industry as their business methods have disillusioned the physicians. Additionally, PPM companies do not necessarily seek to hire the most qualified emergency provider as this may affect the profit margin.“

It is impossible not to see how the business practices described above impacts the professional lives and commitments of physicians. Moral distress, moral injury, in fact moral outrage, are all natural outcomes from working under these conditions.

There are several other growing trends in healthcare ownership and organization that we have reported on in earlier articles:

Rapid consolidation of health systems into larger and larger entities.

A consistent theme we hear from physicians is that they experience more and more loss of control of their practice which is most often called the “deterioration of the patient-physician relationship”, the core of the physician experience and purpose.

Please read the following major article from the Boston Globe about the merger of the giant health systems/academic medical centers Massachusetts General Hospital and Brigham and Women’s Hospital in Boston.

The headline of the article summarizes an expression of near-disbelief that physicians at world leading academic medical centers are experiencing:

‘Devalued, disempowered, and unseen’: Mass General Brigham doctors react to latest merger step’

Such expressions of profound personal and professional concern have already led to unprecedented actions by physicians at Mass General and Brigham to take collective action, including unionization:

  • Physicians at Salem Hospital, part of the system voted to unionize last year
  • House staff (interns, residents and fellows) voted to become part of the Committee of Interns and Residents SEIU

And a petition is currently circulating across the system to all physicians which states in part:

“We write to express our extreme concern about the anticipated merger of multiple departments of the MGH and Brigham. Though we understand that this decision was driven by a range of financial concerns, including perceived and anticipated financial shortfalls and the need to have resources for future growth and innovation, there are unintended and unanticipated consequences that could significantly impact every aspect of the enterprise including patient care, clinical access, research, innovation, and education”.

Just last month the highly prestigious New England Journal of Medicine published an in-depth article about the growth of healthcare consolidation and unionization of physicians: “It’s still too early to assess whether this new wave of physician unionization can counteract the monopolistic and corporate tendencies of hospital employers and whether unions can help satisfy physicians’ interest in governance and restore some of their professional autonomy.

Regardless of how union-organizing efforts pan out, understanding the motivations underlying this trend is critical. For most physicians who have been accustomed to making decisions about resources, service provision, and staffing, the new prevailing employment model remains something of a shock. But hospital-consolidation trends that have implications for both professional satisfaction and clinical autonomy most likely aren’t going away.

If the collective response is hopelessness and dissatisfaction, the medical field may be at risk for large numbers of physicians exiting practice at a time when demand for services is increasing owing to the aging of the U.S. population.

We believe that both the physician community and policymakers should monitor growth in unionization efforts to assess whether unions have exhibited the ability to achieve their stated goals and continue to explore parallel strategies for redressing potential harms associated with hospital consolidation. It’s clear that the medical field in the United States is in a period of adjustment, and it remains an open question how important physician unions will be during this restructuring.” 

An article with this theme in The England Journal of Medicine would have been unheard of just a few years earlier!

On May 6, 2024, 1000 medical interns, residents, and fellows voted to unionize at the prestigious University of Chicago Medical School.

In just the past thirty days we have experienced collective action by physicians as well as ideas coming from some the nation’s most prestigious medical institutions about the motivations for physicians to unionize. All these actions and ideas are based in an overarching theme: consolidation of healthcare services and the corporate practice of medicine are not delivering value. On the contrary, it has been established that these practices do not contribute to improved quality of care and reduction of the cost of care.

What does it mean?

We began this article with a story, a story of moral stress and injury experienced by a young medical student. That story is not isolated. In fact, it represents a central and overarching theme in U.S. healthcare: we do not get what we pay for.

This has been a fact for many decades. While the U.S. spends more of its GDP on healthcare than any nation in the world, our population’s health ranks at the bottom of all modern industrialized countries.

One response to this crisis has been industry consolidation: there has been a hope, even a promise that such consolidation of healthcare services would reduce redundancy and waste, improve access to care, and improve overall quality of care.

The opposite has been true.

How much longer can our nation continue on this path of tragedy and waste?

It appears that physicians are beginning to translate the individual distress they experience in such a system, and are turning to collective voice and collective action on behalf of themselves and for all of us.

John August is the Scheinman Institute’s Director of Healthcare and Partner Programs. His expertise in healthcare and labor relations spans 40 years. John previously served as the Executive Director of the Coalition of Kaiser Permanente Unions from April 2006 until July 2013. With revenues of 88 billion dollars and over 300,000 employees, Kaiser is one of the largest healthcare plans in the US. While serving as Executive Director of the Coalition, John was the co-chair of the Labor-Management Partnership at Kaiser Permanente, the largest, most complex, and most successful labor-management partnership in U.S. history. He also led the Coalition as chief negotiator in three successful rounds of National Bargaining in 2008, 2010, and 2012 on behalf of 100,000 members of the Coalition.