I was reading The Week article regarding the Supreme Court Justices agenda this week reviewing public-sector unions and reflected more deeply as I read this following clinical case. I thought how appropriate and where are we going and is it the best road to take to care for our patients?
But maybe this shouldn’t be part of our bottom line, include all, socialistic mentality?
As related by Noam Scheiber, January 9, 2016 in the New Your Times, consider, that early in the morning on Aug. 12, 2015, a 68-year-old man named Barry turned up at PeaceHealth Sacred Heart Medical Center in Springfield, Ore., confused and feverish.
The case was not a candidate for even a minor subplot on “House.” The admitting doctor stopped one of the patient’s medications and inserted an IV to deliver fluids, and by late the next morning, he had largely recovered.
Still, Dr. Rajeev Alexander, the hospitalist who took over his care, was determined to make an accurate diagnosis.
For nearly half an hour, Dr. Alexander, a perpetually rumpled man, chatted with Barry and Linda, his sister, about the events that had landed him in the hospital, the food processing plant where he once worked, the stroke that had impaired his mind. “It was a very scary night last night,” Linda, his caretaker, said. “He was just sitting on the floor, like you would sit a 6-month-old when they haven’t got their balance.”
Dr. Alexander considers it proper technique to review each mundane detail with a patient. He is full of scorn for the eureka style of medical diagnosis depicted on television, and by his own admission, he reads a CT scan with the sophistication of a barber.
Eventually, Dr. Alexander would discard the more exotic theories that had crossed his mind — meningitis, or possibly a condition known as serotonin syndrome — and settle on a far simpler malady: dehydration, which aggravated a chronic kidney problem.
He was nonetheless unapologetic about the time he had invested.
“Real life is all about the narrative,” he said. “It’s sitting down and talking about bowel movements with a 79-year-old woman for 45 minutes. It’s not that interesting, but that’s where it happens.”
Dr. Alexander’s method is at the center of an emotional debate in medicine, in which the imperative to increase efficiency in a high-cost health care system is often at odds with the deference traditionally accorded to doctors.
It’s a debate that came home to Sacred Heart in the spring of 2014, when the administration announced it would seek bids to outsource its 36 hospitalists, the hospital doctors who supervise patients’ care, to a management company that would become their employer.
The outsourcing of hospitalists became relatively common in the last decade, driven by a combination of factors. There is the obvious hunger for efficiency gains. But there is also growing pressure on hospitals to measure quality and keep people healthy after they are discharged. This can be a complicated data collection and management challenge that many hospitals, especially smaller ones, are not set up for and that some outsourcing companies excel in.
“They assure you of relief of some headaches,” said Dr. John Nelson, a past president of the Society of Hospital Medicine. He compared outsourcing doctor groups to a management company to hiring a lawn service. “You’re relieved of having to get the mower out. You’re not necessarily assured that you’re happier with your yard.” In recent years, according to the society, 25 to 30 percent of hospitalists have worked for multistate management companies, which also employ doctors in other disciplines, like anesthesiology and emergency medicine.
Outsourced hospitalists tend to make as much or more money than those that hospitals employ directly, typically in excess of $200,000 a year. But the catch is that their compensation is often tied more directly to the number of patients they see in a day — which the hospitalists at Sacred Heart worried could be as many as 18 or 20, versus the 15 that they and many other hospitalists contend should be the maximum. (Mark Hamm, executive vice president of EmCare, a physician services firm based in Dallas that has no connection to Sacred Heart, said the hospitalists employed by many staffing companies typically see 15 to 18 patients a day, though he said that was true of those who were directly employed by hospitals as well.)
It was the idea that they could end up seeing more patients that prompted outrage among the hospitalists at Sacred Heart, which has two facilities in the area, with a total of nearly 450 beds. “We’re doctors, we’re professionals,” Dr. Alexander said. “Giving me a bonus for seeing two more patients — I’m not sure I should be doing that. It’s not safe.” (A hospital representative said patient safety was “inviolate.”)
Some Sacred Heart hospitalists left for other jobs, and the rest formed a union, one of the first of its kind in the country.
To everyone’s surprise, Sacred Heart’s administration agreed to junk its outsourcing plan, but this retreat did not usher in a love fest. Instead, there has been a long, grinding negotiation with the administration over the proper role of the hospital doctor, which continues to this day.
Dr. Alexander and his colleagues say they are in favor of efficiency gains. It’s the particular way the hospital has interpreted this mandate that has left them feeling demoralized. If you talk to them for long enough, you get the distinct feeling it is not just their jobs that hang in the balance, but the loss of something much less tangible — the ability of doctors everywhere to exercise their professional judgment.
As recently as the mid-1990s, there was no one called a hospitalist. Most doctors would simply scramble from their offices to the hospital when they had to tend to patients there. But the discipline grew rapidly thereafter — to roughly 50,000 hospitalists nationwide in 2015 from about 11,000 in 2003, according to industry estimates.
The hospitalist boom was itself a response to economic pressures and a push for efficiency in health care. Internists were seeing more patients in their offices in a day, partly thanks to the rise of managed care and smaller margins, making it less practical to run to the hospital. “It became difficult to plan your day,” said Dr. Frank Littell, a Sacred Heart hospitalist who has been practicing in the area since the 1980s. “If a patient needed to be admitted to the E.R., you had to cancel all your afternoon appointments.”
Gradually, it became clear that it would make more sense for a subset of internists to be based at each hospital, where they would handle the care of all the patients on site. The other internists could end their periodic hospital visits altogether.
Hospitalists could also increase hospital profits. They were on hand to discharge people throughout the day, emptying beds that could generate revenue again. And while paying the doctors was a new cost, hospitals at first found the efficiencies so advantageous that hospitalists were afforded the rare privilege of spending more time with patients. The doctors spent the time diagnosing and treating what were often highly complicated conditions — chronic health problems stacked on top of one another, or multiple organ failures.
This reprieve from the economic forces bearing down on the medical profession didn’t last long, however. “A consequence of how much the health care market has changed is that everybody has to be more efficient,” said Adam Higman, who specializes in hospital operations at Soyring Consulting in St. Petersburg, Fla. He noted that the increasing focus on metrics like readmission rates and hospital-acquired infections had created more work for hospitalists, who are responsible for a lot of documentation. “In some sense that comes to the detriment of the patient, there’s not as much quality time,” he said. “In some sense, that’s to their benefit — there’s a system to manage them.”
Asked if health outcomes had improved as a result, Mr. Higman said, “Readmission rates have been reduced — we can show it.” Costs are rising more slowly too, he said, no small thing in a country where many people are bankrupted by medical expenses. But, he added, “as to whether you as an individual are seeing better quality in health care — I think there’s some question there.”
In 2012, Sacred Heart’s parent, PeaceHealth, a nonprofit health care system, installed an executive named John Hill to adapt its Oregon hospitals to the latest trends in health care. Mr. Hill, in an effort to rein in the budget and improve the efficiency of a hospital that administrators said was lagging in key respects, including how long the typical patient stayed, eventually concluded that the hospitalists at Sacred Heart should be outsourced.
The basic accounting problem for hospitalists is that they are not a profit center. That is, when they treat patients, the amount a hospital can bill Medicare and insurance companies is typically less than what the hospital must pay them. The opposite is true for other specialists, like surgeons.
So it was no surprise when, in the spring of 2014, one of Mr. Hill’s colleagues came before the hospitalists and confirmed that the company would request bids for outsourcing their group. Still, the room erupted in anger and despair. The doctors were convinced that working for a management company would mean seeing many more patients per shift, and they worried about losing their jobs if they resisted.
Amid the groaning, a relatively new member of the group named Dr. David Schwartz observed, “They can’t fire all of us — there are unions.” This was a bit of a stretch: While there are hospitals around the country whose doctors are unionized, there did not appear to be a union anywhere composed of a single group of specialists. But Dr. Schwartz, a barrel-chested man with close-cropped hair and a bushy beard who would not look out of place at a graduate English seminar, thought unionizing might be worth a try.
At the time, it was only one of several options the doctors considered. They talked of forming an independent hospitalists group, of forming an alliance with an outsourcing firm of their choosing. But the alternatives gradually fell away for a variety of practical reasons, and the doctors were growing increasingly bitter.
Dr. Littell developed a riff, which the other hospitalists appropriated, about how the situation was like having your spouse of several decades announces he or she was going to play the field. “You’ve been great, you’ve always been there,” he would joke. “I just heard there could be better spouses out there.” The kicker: “The good news is, you’re in the running, too!”
Several doctors could not find it within themselves to be amused and gave notice. Eventually, about a third of the 36 in the group left. The hospital replaced many of them with contractor doctors, called locums.
By the time the doctors decided to hold their union election, almost all of them had become, if not pro-union, then convinced they had no better options. In early October they voted overwhelmingly to form a union that they chose to affiliate with the American Federation of Teachers, which already represented nurses at Sacred Heart.
Now remember that the teacher’s union and specifically their “fair share service fee” is one of the unions and the specific part of the union dues raising strategies that is going to be reviewed by the Supreme Court Justices. If approved by the Supreme Court does that mean that non-union physicians are also going to be responsible for the “fair share service fees” also?
By March 2015, the PeaceHealth leadership, whatever its interest in efficiency gains, was apparently not pleased that one of its hospitals had a white-collar labor insurrection on its hands. The company announced that it would not outsource the hospitalists; a move it later said was always a possibility. Mr. Hill, who declined to comment, left in May.
But backing down on outsourcing did not mean the hospital had given up on getting more out of its doctors.
To work in a hospital today is to be constantly preoccupied with money, and one of the more grating features as far as the Sacred Heart hospitalists are concerned has been the administration’s celebration of “skin in the game.” That means creating financial incentives for doctors to hit performance targets — like lowering patient’s length of stay and doing well on patient satisfaction surveys. The phrase entered the Sacred Heart lexicon in 2014, but the underlying concept has spread throughout the profession in recent years.
Dr. Robert M. Wachter, chief of the division of hospital medicine at the University of California, San Francisco, says many hospitals now give doctors financial incentives to perform well according to the criteria on which the hospitals themselves are judged under the Affordable Care Act — for example, reducing hospital-acquired infections. But there is an active debate in the profession over their utility. “If at the end of the year, 10 percent of your salary is at risk based on whether you have consistently clean hands, what patients say about you, readmission rates, that can be O.K.,” he said. The counterargument is that “you could screw things up by tying everything to financial incentives,” he said. “You stomp on their intrinsic motivation.”
The hospitalists also chafed at the way the administration had tried to centralize decisions they used to make for themselves. This might include hiring fellow doctors or the order in which they see patients on any day. They also complained of being loaded down with administrative tasks.
“We’re trained to be leaders, but they treat us like assembly line workers,” said Dr. Brittany Ellison, a hospitalist in the group. “You need that time with the patient, where his wife is ratting on him.”
For the most part, Dr. Alexander has accepted this state of affairs stoically, albeit with his trademark sardonic humor. At one point he told me that a patient with dissociative disorder was on her way to a psychiatric hospital, before observing: “Often people with dissociative disorder become managers. You have to treat people like things. A different way of saying it is sociopath.”
His personal rebellion is to linger over patients as long as he thinks it’s necessary, the hell with the performance metrics that nudge him to see more.
But just beneath his fatalism, anger occasionally flares up. “What’s the widget the hospital produces?” he asked at one point. “It’s the doctor-patient relationship. You don’t improve it with extra little tasks.”
A few weeks after the author got back from Oregon, he spoke by phone with Rand O’Leary, who was promoted to oversee PeaceHealth’s hospital services in the state last summer. He was genial and disarmingly sympathetic to the hospitalists’ concerns. He said his negotiators and the union had been “dialoguing around” a compensation model that would award doctors a bonus for hitting certain performance targets — the dreaded “skin in the game.” The targets would include how many patients they see, but would also include measures of patient health and satisfaction.
“It can’t be all based on production,” he told him. “It has to be quality — safety, a good experience. If you’re the patient in the bed, it’s important to you that you’re treated as an individual, that your needs are being met.”
Mr. O’Leary was especially proud of a ritual known as REAL rounds, which stands for “rounding embraced by all leaders,” in which administrators circulate through a different unit of the hospital each week and talk to doctors, nurses and other caregivers about their needs.
If Dr. Alexander’s medical experience has instilled a kind of fatalism, Dr. Schwartz’s has made him skeptical about human nature. During a morning of rounds, I couldn’t help noticing he was constantly on alert for ways that a patient’s version of events might not track.
“You have to take what people say with a grain of salt,” he later explained. “Especially if the story changes, or is inconsistent, I get a little suspicious and assume the worst.”
This is not just true of patients. Noting that the negotiations with the hospital administration have dragged on for roughly a year, Dr. Schwartz said, “It’s pretty obvious that they don’t want to get a contract done.” He says the administration worries that if it essentially rewards the hospitalists with a contract, it encourages other hospital workers to unionize too.
Dr. Schwartz said he and his colleagues have always wanted to talk about staffing — ideally, they wanted to agree on a minimum proportion of doctors to patients — and how this affected patient safety. But when they raised these issues in the past, he said, the administration frequently shut down or retreated to marginal details.
Debra Miller, the system vice president for labor and caregiver relations, told me that PeaceHealth had never resisted the right of its employees to organize and bargain through a third party, and that there were many who did, like nurses and dietary workers. She said that it was standard for the first contract with newly unionized workers to take more than a year to negotiate and that this case presented special challenges. “There aren’t a lot of hospital-based physicians unionized,” she said. “I think the union themselves are trying to find their way over how to deal with it.”
As for some of the central issues, like staffing, Mr. O’Leary said in December that the two sides had made progress, but there were certain proposals the hospital simply couldn’t accommodate, like a minimum ratio of doctors to patients at all times, which would be difficult to maintain during emergencies. “We have to be able to respond to the demands of the community 365 days a year,” he said, citing the example of the mass shooting last year at a nearby Oregon community college. “Getting to a hard number is a great goal, but it’s not likely that can happen in our business.” (In a bargaining session on Friday, the negotiators neared a compromise in which a committee that includes doctors would weigh in on staffing.)
Even starker than the divide over these questions are the differences in worldview represented on opposite sides of the table. During a bargaining session last fall, the administration proposed increasing the number of shifts a year. Hospitalists now earn about $223,000 a year for 173 shifts and are paid extra for working more. The hospital offered $260,000 for a mandatory 182 shifts, and up to $20,000 in bonus pay for hitting certain medical performance targets. The hospitalists work seven days on and seven days off, so this would have effectively eliminated any time off for sick days or vacation.
When the doctors pointed this out, the administration responded that if they missed a few days, it would make sure they got extra days to hit the required number of shifts for full pay.
The hospitalists assured the administration negotiators that their concern had nothing to do with money — that none of this had ever been about money. They preferred to work less and make less to avoid burnout, which was bad for them and worse for patients. At which point the administration responded that money was always the issue, according to several people in the room. (The hospital declined to comment.)
Suddenly it dawned on the doctors why they had failed to break through, Dr. Alexander said. “Imagine Mr. Burns,” the cartoonishly evil capitalist from “The Simpsons,” “sitting across the table,” he said. “There’s no way we can say, ‘This isn’t what we’re talking about. We’re not trying to get the bonus.’”
‘Everything Is on the Line’
One afternoon the author had a drink with Dr. Alexander and Dr. Schwartz at a restaurant near the hospital. Dr. Schwartz was reacquainting himself with civilian life after working nine days straight, and both men were wearing untucked button-down shirts and looking much more relaxed than they had at work.
It didn’t take long, however, before they began to trade stories of outrage suffered at the hands of their hospital overlords. Both men were particularly exercised about the “REAL” rounds that the administration said gave it insight into how the hospital workers did their jobs.
“One day when I was not in one of my better moods, the chief nursing officer showed up and asked, ‘Care to join us for REAL rounds?’” Dr. Schwartz said. “I was like, ‘Are you kidding me? Real rounds, as opposed to what we do?’”
The conversation turned, inevitably, to the dreaded “skin in the game.” I wanted to know what, exactly, they considered so offensive about having a financial stake in the hospital’s performance.
Dr. Schwartz responded by recounting the first time he had heard the expression, at a meeting with the hospital’s board of directors. A local businessman on the board had used the phrase while emphasizing the importance of providing the proper incentives for the doctors.
“It really took all of my self-control to not say, ‘What the hell do you mean skin in the game?’” he said. “We have our licenses, our livelihoods, our professions. Every single time we walk up to a patient, everything is on the line.”
He continued: “My thought was, I’ll put some of my skin in the game if you put your name on that chart. Just put your name on the chart. If there’s a lawsuit, you’re on there. You come down and make a decision about my patient, then we’ll talk about skin in the game.”
This part of the disconnect and mounting problems that we are seeing between physicians trying to care for patients and the administrators, especially with the “bottom-line” economic policies pressured by the Affordable Care Act may in fact drive more physician groups to form other unions. I remember when resident groups in New York were going to form unions to control their long hours and poor pay. Although I am a very, very big opponent to all unions in this era, unions were important in the 40’s and 50’s when employees were not protected by good labor laws. However, physicians have been put in a difficult position and maybe, just maybe unions are what are needed in this crisis, because there is no protection for the physicians and very little sympathy.
Next week I will expand these thoughts to include the possibility of striking in health care. Wow, think of that!