Doctors aren't currently reimbursed for discussing end-of-life issues with patients, and many physicians, including the AMA, welcome the provision in the House healthcare bill that would begin compensating them for counseling patients. Cecil Wilson, AMA's president-elect, described the opposition to the provision as "one of the more egregious examples of mischaracterization that I have seen."
There are several dimensions to consider when evaluating whether a potential physician recruit will be a good fit for the hospital or the community, including:
Commitment to quality and service. Placing a high priority on a culture of quality and safety will help a hospital attract and retain the best physicians. By the same token, physicians who are not willing to adhere to the highest standards of quality and patient service will not be comfortable with the scrutiny they will face. Physicians unwilling to be measured against clinical benchmarks and patient satisfaction norms will not be good additions to the medical staff.
Commitment to vision and values. Successful healthcare organizations have strategic plans that include a well-articulated mission, values designed to shape behavior at all levels, and a compelling vision of what the organization seeks to accomplish within the next three to five years. New physician recruits should embrace the organization's values and be willing to make an enthusiastic commitment to the organization's future.
Comfort with physician colleagues and practice expectations. Recruits should be told about the makeup of the existing medical staff such as what percent of physicians are in primary care versus specialty care, what percent are board certified, what percent are fellowship trained, how many are recognized as ?top docs? in the area, how many are nearing retirement, and where the most respected physicians went to medical school and received their residency training.
Recruits should be given additional information about other physicians in their specialty, such as how long they've practiced in the community, whether their practices are accepting new patients, their prevailing work ethic (e.g., the size of the average patient panel, the number of admissions they generate, the number of surgeries or other procedures they perform, and the extent of their on-call responsibilities), and whether they attract patients from outside the service area or whether patients leave the community for care. The hospital should also facilitate face-to-face meetings with established young physicians to help the recruit understand the dynamics of establishing new referral relationships and building a practice in the community.
Enlisting staff and community support
Many examples exist of new physician recruits unable to build a sustainable practice in a community, despite a demonstrated community need for physicians in their specialty. Sometimes, this occurs because one or more physicians on the existing medical staff subtly discourage referrals to the newcomer for fear they will lose patients and practice income. Other times, the physician simply does not become well-known in the community.
The best approach to avoid this situation is to enlist support for the new recruit within the medical staff and the community early in the recruitment process. Sharing the results of the community need analysis with medical staff members is one way to clarify the opportunities for new and existing practices. Sharing the results of the annual physician survey is another proactive strategy, especially when the survey documents dissatisfaction with the current breadth, depth, or quality of the existing medical staff in the given specialty.
If a new recruit represents a new specialty or subspecialty, adds an important new clinical capability, or meets a critical need in the community, the physician's impending arrival should be featured in newsletters mailed to the community or highlighted in postings on the hospital Web site. The advance notice to the community should be part of a formal marketing plan that builds enthusiasm and support for the new recruit by underscoring how the community will benefit from the added capabilities the physician has to offer.
The new physician should also make personal visits to established physicians who are potential referral sources to explain his or her unique capabilities and practice style. Within allowable guidelines, all new practices should receive support from the hospital in the form of advertising, media exposure, open houses, introductory meetings, and other means of connecting new physicians to potential patients and colleagues.
Massachusetts enacted universal healthcare three years ago, and since then many have looked at us as a potential model for the nation. We've insured close to 98% of our population, adding nearly 450,000 to the insurance roles—an enviable achievement. But the strains are evident.
With physician shortages, especially in primary care, we've discovered that universal coverage does not mean universal access to care. Some patients are having difficulty finding a primary care doctor, and long wait times exist. And like others, we struggle mightily with the cost issue, exacerbated by a shrinking budget battered by a severe recession.
But the will to succeed exists, and we move ahead. A special panel on payment reform has recently recommended a new way to pay hospitals and physicians, with the goal of reducing costs.
Reforms at the state and federal levels aim to improve quality, reduce costs, and make healthcare more affordable. Physicians know that rising costs are unsustainable for the individual, the employer, and governments. We also know plenty of opportunity exists to improve the quality of care.
Physicians want to be—and should be—part of the process to build a better healthcare system. We are, after all, those who deliver the care. But this willingness is tempered with a certain degree of concern, born of experience. The last two decades have produced many big ideas to improve quality and affordability, launched with high hopes and great expectations. But most of these notions have failed, often making matters worse and driving a wedge between patients and their physicians.
Our hope for reform, at all levels, is that efforts, besides enhancing care and cutting costs, will restore dignity to the patient-doctor relationship.
Physicians believe there must be four cornerstones to healthcare reform, each patient-centered and each as important as the other:
Healthcare spending must be affordable and sustainable. Volumes of evidence prove that when people can't afford healthcare, they don't take their medications, see their doctor, or engage in preventive care. People who defer their care get sicker, and treating them becomes more expensive and more difficult.
Spending levels must be sustainable and realistic to provide the care that patients need. One important lesson from past efforts is that cutting hospital and doctor payments alone doesn't create long-term savings, even if they succeed in squeezing out short-term savings. There needs to be a systemic approach to developing sustainable spending, or the short-term savings cannot be sustained.
Reform must support and promote high-quality care. Cutting costs without promoting quality will not be accepted by patients or physicians and would doom any effort.
Reform must support a diverse, pluralistic healthcare system—large and small hospitals, independent practices, community health centers, nursing homes, rehabilitation facilities, home healthcare, mental health, dental care, and all venues where high-quality, high-value care is delivered. Patients value choice, a value deeply embedded in our culture. Any reform that deprives people of meaningful choice will not succeed and will hinder progress.
Current proposals could make things better, but only with great care and extreme diligence. Moving to a new system will require a careful, orderly transition taking many years. Physicians will need time, funding and training to acquire the technologies, to learn how to manage this new financial risk, and to acquire expertise in new areas of the law and governance. Further, practices are not equally ready to move to a new system, and some areas of the country are better equipped to do so than others. In particular, practices in the less-populated would be especially disadvantaged by an overly rapid movement to a new system.
In a similar way, patients will also need time to familiarize themselves with a new system. They will have new roles and responsibilities, and their transition needs must be designed just as carefully.
We all know that the status quo in healthcare is not an option, and much hope has been placed in these new efforts. We subscribe to President Obama's statement that we should keep what works and improve what isn't working. Let's use the wisdom we've gained from past experiments to guide us to effective, long-lasting reform.
Mario Motta, MD, a cardiologist in Salem, MA, is president of the Massachusetts Medical Society.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
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