Reader feedback

Physician Executive, March-April, 1998

Dear Editor:

McGraw and Rodriguez's article, "Is There a Physician Union in Your Future?" (The Physician Executive, Volume 23, Issue #8) is both timely and very useful... if a physician executive reorganizes the message. This reader clearly recognizes the themes expounded on physician autonomy in clinical decision-making and, by the way, fees are important, too. No one would dispute the issue of insurance companies dictating the patient's care. No one would dispute the attending physician being in the best possible position to manage that care. However, I believe it is eminently critical to dispute the underlying motivation of this argument. While we see insurance companies cost-cutting, taking a major financial piece, and competing amongst themselves for market share primarily based on price, we also see physicians (and hospitals, and DME suppliers, and home care companies) "suffering" financially from a relative diminution of payable reimbursement fees.

Since this is the game, i.e., market-driven consumerism, physicians and others play, yet unhappily. The quiet desperation revealed in the doctor's lounge and the medical society meetings has turned to a more active desperation-unionization. Clearly, a firm argument can be supported for physicians driving the process. After all, in traditional fee-for-service systems, the physicians are the revenue-generators. Less appreciated, yet equally valid, in a capitated environment, the physicians are the cost-reducers. Either system offers physicians power and, unionization is a form of a "call to arms" to retake that power.

Understanding this view will enable physician executives in all roles to craft a strategic plan to empower physicians and realign the control of patient care. The focus must be on designing appropriate fee structures and building a support system. Aggressive negotiations by payers and payers should define the market. Then, education, the real thrust, is mandatory.

Physicians are a remarkable breed, already entrenched in life-long professional commitment to learning. Give them the tools. Teach them the criteria utilized to contain costs, to positively impact on the bottom line. I have found physicians to be extremely receptive to this learning when it is presented in a supportive, safe manner. I, too, agree that this is idealistic and that it will have limited appeal. The current business technology of "risk sharing" is the guarantor of the needed receptivity.

Matching the financial rewards with the measures of quality will drive the learning. A partnership of all entities to share the risk and reward will result in tremendous pressure to perform and, no single group of professionals are more performance-oriented than physicians. Unions would not only be unnecessary, they would be impediments. Learning organizations consisting of all stakeholders, physicians included, would be the order of the day.

I impress upon all of your readers, my colleagues, to "call it like it is." We're talking reimbursement! Craft the best deals for the constituency you have fiduciary responsibility to. Place equal energy into partnering for learning. And, above all, empower physicians through risk sharing. Let's avoid unionization of physicians--it cannot help. Let's hear the cries of active desperation and forcefully respond to correct the perceived financial inequities. Let's develop those much lauded integrated delivery systems, those learning organizations, to the benefit of our external customers, our patients, and our internal customers, our providers.

Our central theme is health. Health is balance. Health is synergy. Let's avoid the extraneous, i.e. unions. We have the tools; we have the power. Let's listen, let's hear, and let's effectively respond to create the health!

Respectfully Submitted,

Edward A. Gilkey, MD, MS, MBA

Mount Holly, New Jersey

The virtues of an MBA?

I read with interest the article in the November/December issue of The Physician Executive by Dr. Lazarus about additional education for physician managers. I found it curious that in the midst of his article extolling the virtues of an MBA, Dr. Lazarus makes the point that there may be more appropriate kinds of information that physicians pursuing management careers should be familiar with, other than the standard offerings of traditional MBA programs. The examples he uses are questions from the application for a program that is not an MBA program at all, but rather the new Masters in Medical Management, jointly sponsored by Tulane University and the American College of Physician Executives.

Having recently graduated from the Tulane program, and so having answered the very questions that he uses as examples, I would only try to point out what I believe the issue really should be. Additional, formal, graduate level education is important to those of us who are pursuing full time careers in medical management. We need the knowledge base, we need the non-medical degree, we need the experience of going back to the classroom and learning non-clinical information, and we need to work at changing many of our clinical paradigms if we are to successfully work with lay administrators.