All of the “players” in health care are getting bigger. Consolidation is the name of the game as hospital systems hire more physicians, multi-hospital systems merge, insurers develop their own “captive” provider networks and new hybrid organizations, like CVS/Aetna (and maybe Walmart/Humana) are coming with dizzying frequency. Some of this feels to me like an arms race, with size (and its attendant market power) itself the goal, rather than growth as a means to assemble the right combination of resources at the right scale to improve care.
Even so, I believe scale can improve care. Given where I sit, I don’t suppose that is much of a surprise, but I would go further to say that organizational heft is now necessary to provide high quality care through enhanced and better coordinated access to the right technology, the right providers and the right services, when and where patients need them.
It is in that context that I found a recent opinion piece in JAMA an important read. In it, the authors present a thoughtful theoretical framework for considering the potential downside of the growth of provider organizations. Titled “The Risks to Patient Safety from Health System Expansions” it includes new threats to patient safety and suggests potential strategies for mitigating them, summarized in this table:
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It is important to note that the authors do not advocate limiting the size of provider organizations or retreating from the prevalent plans for growth to avoid these risks. Rather, they conclude: “Institutions must actively plan for, monitor, and manage the resulting risks as part of a comprehensive strategy, including sharing data on quality and safety, and sharing oversight of care for the joint patient population.”
Makes sense to me. What do you think?
A recent story in Crain’s New York Business cited the difficulty small independent medical practices face coping “with declining reimbursement rates from insurers, rising overhead costs and a torrent of new regulations that have come into play in recent years.” According to the article, only 26% of NY State physicians now own their own practice, compared with national rates of physician ownership of 76% thirty years ago. Honestly, I was not surprised by the numbers. Consolidation of independent medical practices into larger organizations is old news, and it is no secret that the drivers include those mentioned.
I was, however, struck by the subsequent letter to the editor by Malcolm Reid, the president of the Medical Society of the State of New York. In it, Dr. Reid states: “Physicians should have a fair choice of practice setting to deliver care to patients, whether that is in a large health system, large medical group or within a smaller medical practice,” and goes on to say that “Many physicians enjoy independent practice because of the personal attention that can be directed to their patients without external interference.”
I am sure they do, but honestly, why should we expect the government or the public to assure that physicians have a “fair” choice? To put it bluntly, Reid (and the rest of us) should get over the idea that the organization of care should revolve around what’s good for doctors. He makes it quite clear that he is not advocating that “fair choice of practice setting” is about patients, since he concedes that effective patient-physician relationships can be maintained in a variety of practice and employment arrangements. Rather, he is saying that doctors should have the right to practice in independent practices because, well, that’s how they like to practice.
To be clear – and before the pitchforks come out – I am NOT saying that independent practice is bad, and I am NOT saying that I don’t care about how physicians feel about their practice arrangements. What I am saying is that if an independent practice is worth preserving, then the case for it has to be made on the basis of what it provides to the patients we serve, and not on the basis of what it provides to the doctors who care for them.
What do you think? Continue reading Is this about Doctors or Patients?
There is a lot of stuff written in the business literature about “corporate statements” and the role they can play in guiding strategic decisions. When done right, I think these foundational documents can be quite effective. Does anyone doubt that Walmart really does focus its efforts every day on its stated mission of “saving people money so they can live better”? Continue reading Physician Compact