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Musings of a Philadelphia Physician who has served the community for six decades

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Flexner Report, Revisited

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Specialty Care In The Era Of Managed Care

Book Review

Specialty Care In The Era Of Managed Care

Cleveland Clinic versus University Hospitals of Cleveland
John A. Kastor, M.D.

0-8018-8174-9
The Johns Hopkins University Press

Abraham Flexner's 1910 Report practically canonized the notion that medical schools must be owned by universities. Forty years later, Dwight Eisenhower firmly disagreed. Asked why ever would he give up the pleasant life of Columbia University president to get into the nastiness of national politics, he replied, "The White House doesn't run a medical school." During the same era, Secretary of State Dean Acheson and Senator Robert Taft, political enemies but personal friends, were riding to New Haven together to a Yale trustee meeting. The two agreed it was unfair for 40% of university budget to be spent on 1% of the student body, and decided Yale should get rid of its medical school. Their subsequent motion failed by only one vote at the meeting. And as a final Flexner footnote, Princeton University which shrewdly never owned a medical school, is now nonetheless in the news over the central underlying discordance -- managing huge sums which, either by contract or donor restriction, are inflexibly assigned to a single department, thus substituting the donor's priorities for those of the University president. Medical school ownership of teaching hospitals raises the same issue except in reverse. It is politically impossible to treat an affiliate as a cash cow without learning the harsh reality of the Golden Rule: the affiliate with the gold will promptly remake the rules.

Understanding these issues but seldom emphasizing them, John A. Kastor has done us all a great favor by studying and publishing the unseemly disorders which result, in many cities and institutions. His particular focus in this book is on Cleveland, where all that matters medically is the prospering Cleveland Clinic and its struggling rival, Case Western Reserve. The book is mainly focused on a particular question: under managed care, should teaching hospitals adopt the Cleveland Clinic's style and organization, in order to prosper as they do? In the end, he cannot quite bring himself to recommend it. Essentially, the Clinic is run by doctors, for doctors. The clinic pays salaries, but (so far) bills fee-for-service. The over-reimbursed procedural specialties such as surgery subsidize the under-reimbursed cognitive specialties (prompting East Coast colleagues to sneer at "organized fee-splitting".) Cleveland's Clinic, like all group practices, must devise strategies to a)induce acquiescence to the subsidy of internists by surgeons, b)discourage physicians from starting competitive practices in the neighborhood or c)turning their salaried incentive into an instant 40-hour week. Not everyone will submit to what is between the lines, most notably at the Clinic's Florida satellite. But since the alternative is to hire non-physicians with concealed animosities to doctors to run hospitals and medical schools, all physicians who actually treat patients must give the physician-run group practice model some thought based on experience with its alternative.

We all have an unfortunate tendency to assume that weakness of character is the main cause of the executive misbehavior so widely observable in all corporate environments. In the medical world, a much more powerful force is generated by shifting quirks of reimbursement. Once the pecking order is established between hospital and school, medical school and university, it gets violently upended by the underdog suddenly getting riches from the Senate Finance Committee, then upended again by Ways and Means a few years later. Or bureaucrats in Rockville, in Baltimore, or the Executive Office Building. Eisenhower was wrong, the White House does run medical schools and hospitals, when they would very likely be better run by physicians. In fact, Flexner's offhand interposition of the University into this dogfight seems a little quaint. Just to mention the indirect residency reimbursement program, the institutional research overhead allowance, the old cost-plus reimbursement of hospitals, the institutional patent revisions, is to start a list which can get to be quite long. In most of these cases, an institutional component which needed to be subsidized in the past has now become prosperous and is asked to return the subsidy. The chief executive is then caught between duty to his institution, the threat of investigation if funds shifting is suspected, and his own sense of fairness. That these upheavals are so frequently pacified without serious harm to the patients, is a credit too seldom given.

Dr. Kastor's writing is somewhat hampered by a need to footnote, document and defend everything he says. Nevertheless, the book will be read by physicians like a novel with a great many villains. It's encouraged reading. One hopes that the next book in the Kastor series will examine the Florida satellite clinics of the Cleveland Clinic and of the Mayo Clinic, one making money and the other losing money. Maybe some basic issues of effective medical organization can be resolved by making different comparisons.

But don't expect permanent axioms to emerge; Medicare Risk contracts are coming. Under capitated systems, administrative incentives are slanted to discourage expense, especially expensive surgical procedures. Perhaps group practices will soon face a need to have their internists subsidize their surgeons, reversing the traditional arrangement. The threat to colleagiality, so evident in this book, is destined to continue.

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