Kids' Health Blog

A recent article from the Minnesota Hospital Association’s Ebriefing, by Dr. Daniel K. Zismer, who is the associate professor and director of the MHA and Executive Studies Program, conveyed why he feels that there are significant challenges to the private practice business model in our futures.

No doubt there will always be some room for private practice. He feels that there are six common challenges that are causing private practice models to be stressed and thus leading to more and more physicians wanting to be employed with hospital systems.

Those pressures are the following:

1. the cost of electronic health records. It is staggering for groups to have to implement an electronic health record. It is neither a luxury nor a strategic differentiator any longer but is rather a required ticket to relevancy he says. We will need it to be part of an accountable care organization and to be relevant to the consumers in health care into the next decade.
2. Health systems can outspend private practice for physicians. The larger the system the more money they have available to go out and seek the more specialists, and especially the higher end specialists, while private practice has difficulty. For those who want to be employed there is no practice investment.
3. Reimbursement lightning strikes. The larger the organization the more they are able to handle quick strikes by the government or the payers of reimbursement problems. While the larger systems also have this difficulty it is not to the same degree.
4. Young physicians wants and needs. Almost 85 to 95% of residents and students coming out of residency want to be employed. They no longer are looking for the private practice model.
5. Routine practice overhead inflation curves. Groups are having a more difficult problem keeping up with the inflation cost of operations, thus physicians take home less compensation. Independent physicians will endure this dynamic until the economics of private practice become unsustainable.
6. Routine practice recapitalization – It is getting harder to find dollars to capitalize things. These forces are out there for everyone and will continue to be a cultural change that is occurring in medicine.

Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.

Now I admit an inherent bias in my thinking, but the question arises constantly: Why do you need a free and independent children’s hospital versus a children’s hospital within a larger system?  Is it because of my job at Children’s when I think in these terms or is there some data behind thinking this is better for children?

A recent white paper by the Chartiss Group that was presented to CEOs of children’s hospitals discussed the evolving nature of these hospitals in light of what is happening in our economy. They remind us that birth rates have declined dramatically over the past few years, which of course will have a great impact for us over the next four to five years.  Hospitals that take care of children are seeing an increasing prevalence of chronic diseases and an increasing prevalence of children with technology dependencies.  Both of those groups have an increasing demand for pediatric services.  At the same time, we are seeing thankfully a greater and significantly improved survival rate. Along with this there is a major increase in the growth of obese populations and socioeconomic shifts in Medicaid.  There are more and more children having their care done in the outpatient world and there has been a reduction in neonatal discharges.

What the Chartiss Group found was that the adult hospitals and adult systems do not have the ability to compensate for volumes and other service lines, thus the country is seeing an increased consolidation of pediatric care, more and more within free-standing children’s hospitals.

Also, a few years ago we felt there might be a 3 percent annual growth in pediatric patient days; in reality it is now closer to just 1 percent.  Between 2003 and 2009, the number of patients with at least two or more complex, chronic conditions admitted to hospitals went from 5.6 to 7.7 percent and those children with technology dependencies went from 10.9 to 13 percent.  What we also know is that when the Medicaid population goes up, their utilization of hospitals also goes up.

What was most important — and for all of you out there who sometimes wonder if you should be taking care of children in community hospitals or hospitals within hospitals — to remember is that there is also superior, quality performance at children’s hospitals.  Outcomes at free-standing children’s hospitals are better. Their actual mortalities percentage of expected mortality is lower whether it is in complex children or technology dependent children.

In this healthcare economy, we also have to look upon price.  Children’s hospitals need to differentiate themselves based upon low-cost services, access and quality; they need to promote innovative care models to better leverage subspecialties; align with community; and access additional market opportunities to preserve regional positions.  They also need to invest in an achievable set of destination programs, begin partnership discussions with dominant adult systems, manage financial performance, prepare for Medicaid fee reductions and improve performance. We must also rapidly develop contingency to manage population and work with health plans in the state to shape payment reform.

It’s scary, but also leaves us with great opportunities.

Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.

Knights, Knaves, or Pawns?
Sachin H. Jain, MD, MBA; Christine K. Cassel, MD

I recently read this article in the Journal of the American Medical Association (JAMA) and it was quite disturbing for me. According to the authors, a British economist named Julian LeGrand suggested after World War II that public policy is grounded on the concept of humans being either knights, knaves or pawns.

Human beings motivated by virtue are knights, those who have rigid self-interest are knaves, and those that are passive victims of their circumstances, pawns.

These authors take this concept and apply it to today’s American healthcare system. The question is which one are you? According to these authors, physicians are either in practice for the betterment of society (knights) their own selfish gain (knaves), or they are automatons whose actions are defined more by external rules and regulations (pawns).

If physicians were all knights and well intentioned, the healthcare system would place the stewardship of it firmly in their hands. They would be trusted to use and deploy resources wisely, minimize waste, and look beyond their narrow, individual, and specialty interest to protect the system as a whole. Individual physician decision-making and autonomy would be given the highest priority. They would constantly study to improve themselves, they would do clinical research to advance science, and they would do their jobs as professionals.

If physicians are knaves as conceived by society; then society would develop policies, management and educational efforts to combat and work against physicians not with them. In this scenario, physicians are interested in themselves and their financial well-being first and their patients second if at all. In this system physicians must be given a reward or incentives to motivate them to do what is right by their patients and any such schemes would have to be carefully monitored for abuse, fraud, and waste. Policies and regulations must guard against their malfeasance. I worry that this is what too many of us have become.

If society views physicians as pawns, then efforts are applied to building systems that ensure that physicians do what is right for patients because physicians cannot be trusted to do so on their own accord. Left to their own devices, physician behaviors are unpredictable. The pawn physician is merely a function of the environment in which he or she practices. Thus they must be given guidelines to follow and policymakers must decide clinical priorities. The role of health policy and regulation for the pawn physician is to guide his or her every behavior because he or she lacks individual agency and judgment to reliably do what is right.

What were the implications of LeGrand according to these authors? Unfortunately the quality of care policy discourse often reflects the perspective that physicians are an obstacle, not an enabler to a functioning healthcare system. Rather than being counted on to maintain their knowledge and expertise on their own accord, they are subject to periodic examinations to demonstrate continued proficiencies, are grounded in evidence of unwanted variation in care, clear evidence of waste, and even fraud and decline in knowledge over time. The modern U.S. physician is regarded as either a knave or a pawn and is seldom regarded as a knight any longer. Marcus Welby where are you?

LeGrand offers an important lesson and warning. It is critically important to understand and get “true motivations” right. Disaster may follow a person largely over knavish quality or if treated as knights, but the same may be true for policies fashioned on the belief that people are knaves if the consequences to suppress their natural altruistic impulses and hence destroyed part of their motivation to provide a quality public service.

LeGrand further warns that policies that treat people as pawns may lead to demotivated workers… again causing adverse outcomes for the policies concerned, while policies that give too much power…may result in individuals making mistakes that damage their own or others welfare.

The public would be wise to heed LeGrand’s advice and carefully consider whether its perceptions of physicians match reality. For their part physicians must thoughtfully consider whether and how they contribute to the perceptions that they are knights, knaves or pawns.

I’d love to hear from any of you about your thoughts on this.

Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.

In a recent article in JAMA by Robert H. Brook and Roy T. Young, April 21, 2010, Volume 303(15):1535-1536, the authors write a commentary entitled, “The Primary Care Physician and Healthcare Reform”. With changes coming from healthcare reform leading to more and more people being covered, the need for primary care physicians is actually increasing. Unfortunately the number of primary care physicians is decreasing. There are two main reasons for this:

1. the scope of practice is being constricted for primary care physicians with their ability to do less and less procedures (think of less OB and procedures) and less and less in hospital care, (think of hospitalists), as well and more importantly
2. the differential between what they get paid and what specialists get paid. The gap is substantial.

The median salary in large multi-specialty groups for primary care physicians is around $200,000. The median dermatologist salary is $351,000. Given this type of pay differential and the narrowed scope of practice, why should bright, hard-working, debt-ridden or even altruistic medical students choose primary care versus specialty.

In 2010 only 54.5% of 4,999 residency spots in internal medicine were filled, 44.8% in family medicine and in pediatrics 70.5%. In comparison at least 90% of physicians in neurosurgery, orthopedic surgery, and dermatology were filled by U.S. medical school graduates. Young clinicians are simply not willing to forfeit lifetime earnings of over $3 million.

To many of these students the authors state the primary care physician has become like the water boy on a football team, making sure that the really important members of the medical team do their work. Our dilemma is we don’t have great solutions. There could be no change and we could just let the inevitable decrease continue.

An alternative approach is to convince 50% of the students entering U.S. medical schools in 2010 to choose primary care as their professional career path. But, to do this we’ve go to change those other two variables. They need a different set of clinical responsibilities and skills, we should make them leaders in efforts to avoid preventable hospitalizations for patients with chronic diseases, eliminate inappropriate or equivocal surgery, radiological procedures, and help individuals die with the least pain and without expense for vast amounts of money.

Secondly we’ve got to come up with a way that they get paid more in comparison to specialists. Without these changes there is little hope of producing a healthcare system that provides high quality, affordable care to the U.S. population.

One thing these authors didn’t discuss is the use of advance practice nurses. Perhaps the future is that primary care physicians who want to stay in the field truly have to create systems where they work with advance practice nurses and becomes a conductor of a symphony of advance practice nurses in primary care.

I’d love to hear your thoughts on this.

Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.

Over the last decade the word “provider” has been used more and more when describing physicians and other clinicians. Language is an extremely important catalyst to changing cultures and the utilization of this word “provider” does have significant implications to a not-so-subtle change to our health care culture. Now I understand fully the need to move away from hierarchical thinking and actions in health care, especially in high reliability organizations, but I am also aware that this is having secondary, if not unintended, consequences.

The health care industry over the last decade or so has seen many more non-physicians providing care to patients, whether it’s advanced practice nurses, physician assistants, psychologists, chiropractors, or EMTs. Now some of this is very good because of shortages of doctors, and from pure economics, it also makes sense. Nevertheless, the unintended consequence of this language change is that physicians who take the longest to train and have the strongest background in pathophysiology and treatments are now becoming a commodity.
A commodity that then begin to think of themselves as employees instead of professionals. When they think like an employee, they begin to act like employees: losing the aspect of professionalism that differentiated them from others.

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Last month, my father-in-law fainted in a restaurant, and we thought he might be having a stroke. He required an ambulance drive over to one of the local hospitals. The police were great, the EMT was great, and the fire department was great, as were the admitting people in the emergency department and every one of the people over at the hospital. The amount of workup he received was unbelievable for someone who was probably just fainting.

He had an emergent CAT scan, an MRI and a chest X-ray. Eventually he stayed overnight to get a echocardiogram plus more lab tests. All in all he was probably somewhat dehydrated that morning, took his antihypertensive pills, dropped his blood pressure, had a drink and pretty much keeled over.

I’m not here to discuss the amount of resources used, because, of course it was my father-in-law — and it didn’t help that besides me, his other son-in-law was an internist in the same hospital and his three daughters are a psychologist, an epidemiologist and an occupational therapist. Everybody in the ED room was so health-oriented, I think the ED felt they had to do everything possible.

What I really thought about during this episode was not so much the great care they all gave, but rather the claim that hospitals have that they are patient-centered.  The attending physician, after receiving the handoff from the ED physician via electronic medical record (I was very impressed), came into the room and explained the results of the CT scan. This very bright woman explained to my father-in-law, who is not medically oriented, the findings of the CT scan. She used so many medical terms that I had to ask her to stop and tell her that “he has no clue what you are talking about. Speak in layman’s terms.” Sometimes we get so caught up in trying to tell patients technical things that we forget that unless you speak their language, it is difficult to understand.

I’ve been reading much lately by Dr. Charles Denham and, of course, Dr. Donald Berwick about being patient centered extremists. They believe that patient and family involvement starts with educating patients and families and ends with listening to them and taking them seriously.  Patient-centered care means that patient and family input is emphatically built into systems of performance improvement and if patients and families are taken seriously as real experts, and are respected for their valuable perspective of how care can be improved, then organizations can improve at improving.

Denham would say, “leaders drive values, values drive behaviors, and behaviors drive performance.” Engaged leaders need to provide the resources necessary to ensure that the systems are in place.  They need to guarantee that vital patient and family input are built into the practices adopted, leadership resources and systems.

We as leaders need to constantly remind staff and each other that the people whose lives we are guests in deserve us to speak in languages they understand.  Safe, high-quality health care is neither accidental nor static, according to Denham. Rather, it is the result of deliberate actions by dedicated people, including active listening, planning, implementation, and evaluation by organizational leaders and providers of care within their healthcare enterprise.”

Denham also says the culture is the collective behaviors of an organization, or what some have described as “what people do when no one else is looking.” It reflects the operational values of the organization, which may not necessarily be those espoused in brochures or walls in the lobby.

We’re doing better, but we can do much better. The final icing on the cake has to do with us treating patients and families respectfully, using their knowledge, and speaking to them in languages that they can understand.

Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.

Did you ever notice that if you watch commercials, 50% of them seem to be oriented to some medical problem? Heck, if you watch the nightly news, 90% of the commercials have to do with some medical problem. Whether your leg is restless, you have ED, ADD, OCD, constipation, diarrhea, severe menstrual cramps, headaches, backaches, bloating, allergies, acid reflux, asthma, emphysema, or you need a wheelchair, you can’t get by without some drug.

I’m beginning to believe that to be normal you have to have an illness. In fact, I doubt there is anybody out there right now who doesn’t have something that they would consider a chronic problem. Now I’m not saying this to be cynical about the people with “real organic illnesses” and many of these other things are symptomatic and real, but at some point we have to ask ourselves, is there any symptom we have that we don’t think about as being a disease? What does it say about our society? What does it say about what we teach our children?

Perhaps this is another reason why health care costs continue to rise when everybody says they need to feel great and perfect at all times. Just my thoughts for the week and now I need to get my knee looked at by my orthopedist.

Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.