Reader feedback - Letter to the Editor

Physician Executive, Sept-Oct, 1999

Dear Editor:

We would like to compliment The Physician Executive on its comprehensive collection of thought-provoking articles about conflict in the last issue (volume 25, Issue # 4). As leaders in health care grapple with how to prevent and manage conflict on individual and system-wide levels, there are three points to emphasize about using conflict management consultants, mediation consultants, and mediation-based systems.

The relationship with consultants and the variety of conflict management strategies available will not help an organization move towards greater productivity and effectiveness without the active sanction and participation of the senior management. Leaders of the organization must be highly visible and verbal in their support of the system they want to implement. For employees to develop trust in a new system, they should not be asked to do what the leaders are not willing to do themselves. The leaders should model the interpersonal skills required to prevent conflict, use mediation to resolve their own disputes, and adopt a facilitative style of leadership when appropriate.

Programs that rely on in-house mediators are more successful when staff know that an external mediator is available. One of the most important factors is that all concerned trust In the impartiality of the process. It is only then that participants will disclose information and consider alternative points of view with the honesty required for a long-lasting resolution. With a properly implemented and supported program, employee trust increases over time, allowing people to feel more comfortable with in-house mediators, However, even in the best of circumstances, there will always be valid reasons why a well-trained in-house mediator can't be, or can't be perceived to be, truly neutral. To maintain credibility if there is a question as to who should mediate a specific case, let the outside mediator make the call.

Build a strong relationship with the consultants. To start, they will need information about the organization, such as its culture, priorities, mission, history, and other general information. Long-term periodic monitoring and fine-tuning your conflict resolution system by consultants who have been encouraged to understand the organization ensures the program's longevity. Consultants can also offer valuable feedback because of their outsiders' perspective. Many consultants can train staff to make decisions collaboratively and to facilitate meetings with agendas that can be expected to generate conflict. Additionally, consultants can offer advice regarding conflict resolution problems and processes, but can never have, or even appear to have, a vested interest in the outcome of any mediation or facilitation activities.

Yours truly,

Doreen Moreira, MD, CPE, FACPE

Elizabeth Z. Williams, JD

Principals

Conflict Free Workplaces

NCWHPE@aol.com

Global fees--an intriguing concept

Douglas Emery is to be congratulated for his succinct presentation of a difficult and intriguing concept, There are several areas that might deserve expansion (The Physician Executive, volume 25, issues 3 and 4).

The author correctly notes that capitation tends to bias the financial interests of providers against the health interests of their patients. However, it is not clear how global fees would resolve this problem of "fiduciary role compression."

There are circumstances where there is significant interplay between actuarial and technical risk. Primary and secondary preventive medicine services are the most obvious examples.

There are a few conditions where global fees for episodes of illness have been set up as "carve-out" products, such as Coronary Artery Bypass Grafting. It strikes me that the generalized implementation of an episode of illness payment system is likely to be very much more complex. At a minimum, one would need to separately address:

1) Preventive medicine services

2) Care of minor and self-limited diseases

3) Care of chronic illnesses (including decompensation and complications)

4) Acute "major medical"/surgical illnesses

5) Obstetric care

6) Catastrophic illness

The amount of detail required under each of these major headings might range from large to exhaustive. Has anyone had any experience using payment by episode of illness on a generalized basis?

David B. Cook, MD

Chief Medical Officer

The Key Family of Companies

Indianapolis, Indiana

DCOOK@keybenefit.com

Going into business with the hospital is hazardous

There is a major problem with Mr. Kleinke's concept regarding the relationship between doctors and the hospital (The Physician Executive, volume 25, issue # 3). For somebody who has been in practice for 30 years in many hospitals, I can tell you that to go into business with the hospital is not beneficial and is actually hazardous for the welfare of the community and the doctors on the staff In general.

I am going to give you a few examples. The administrators, by and large, are after the group practices that bring many patients to the hospital. They are not interested in quality care or in the delicate chemistry that exists among the physicians on the staff. By offering money to set them up in group practices, they invariably offend solo practitioners who have served the community and hospitals for many years. Because of the relationship to the hospital, the hired physicians have an edge over the other physicians because they are financially secure, whereas the other guys have to work hard to make a living.