Center for Improving Value in Health Care
Jan 14, 2013 | 0 comments | Posted by Edie Sonn
Controlling Costs, Integrated Care, Payment Reform, Rewarding Value, Triple Aim, Accountable Care Organizations
Saturday’s New York Times carried a front-page story about negotiations between administrators and the physicians’ union at the New York Health and Hospital Authority over a new pay-for-performance arrangement. Physicians’ raises will be tied to their performance on indicators such as patients’ assessments of physicians’ communication with them, how quickly ED patients are transferred to beds and how quickly patients are discharged, as well as quality metrics such as 30-day readmission rates for certain diagnoses.
There are many fascinating elements in this article, including the dispute between physicians and administrators over the right performance metrics to use. Physicians are negotiating for additional ones including attending community meetings and providing smoking cessation counseling. The array of indicators under discussion illustrates the difficulty of determining what constitutes high-quality care and offers a glimpse of the potential power of patients to affect provider pay.
But as I read about this wrangling, the question that overshadowed it was: the doctors have a union???
Historically, unions have been established for low-wage, hourly workers who need to join together to advocate effectively because, individually, those workers are powerless. “Professionals”—those with advanced degrees and the salary and place in society that such degrees can confer—have generally neither felt the need to unionize nor been a logical focus for union organizers. How the mighty have fallen, if physicians—once at the top of the professional heap—now feel that their work has become so commoditized that they are labor and no longer management, that they must unionize in order to preserve some measure of autonomy and control.
Is this an unintended consequence of the movement toward accountable care that organizations like mine advocate? Are physicians so terrified of payment based on outcomes that they feel they must band together to ensure a powerful voice in this brave new world?
I would argue the opposite: that it is the traditional fee-for-service, pay-for-piecework system that made physicians feel like seamstresses at the Triangle Shirtwaist factory, dependent for their livelihood on the number of units they produced/patients they saw/procedures they administered. While that approach certainly had some advantages for physicians’ pocketbooks, those advantages have been systematically undercut by static Medicare reimbursements (and the annual threat of cuts) and the ripple effect of those on contracts with commercial insurers, which key off Medicare levels. And, for physicians working in the safety net (such as at New York’s public hospitals), shrinking Medicaid reimbursements increase the pressure. So new payment systems tied to value not volume can ease that pressure while working in the interest of patients, not just physicians.
However, the New York story seems to have an added wrinkle. While not stated explicitly in the Times article, it appears that the unionized physicians at New York Health and Hospitals Corporation are employees of the corporation, not free agents on contract. This leads to another intriguing exploration. Doctors generally seek employment in part for the reasons stated above: they want relief from the “hamster wheel” of fee-for-service as well as from the headaches of administering multiple contracts and managing a practice. And, increasingly, new med school graduates prefer the predictability of a set schedule that employment can offer.
But if employed physicians are unionizing, it makes one wonder about the trade-offs they faced after signing that employment contract. No job is a bed of roses (as my father used to say, "That’s why they call it ‘work’"). But did giving up autonomy for predictability result in feeling more like an automaton?
To review, let’s trace the possible trajectory here: our Rube Goldberg health care delivery and payment system made physicians feel like cogs in a wheel. So some have traded the considerable headaches of independent practice for employment. And a subset of those seem to have found that, once employed, they are even more “cog-like” and must join together in a union in order, paradoxically, to preserve some shred of independence.
I realize that I risk laying myself open to misinterpretation here, so let me be clear: I don’t think that hospital employment of physicians is ipso facto bad. In fact, it can be very good, because it can align incentives among these different parts of the delivery system and make it easier for them to work together and coordinate care to benefit patients. Nor do I think that unions are bad. I have worked with a number of them over the years and stand in awe of how these organizations have enhanced our country’s economic engine by giving workers a voice.
My interest lies in exploring the implications of these developments for patient care. When employed physicians feel that their interests diverge enough from those of their employers that they must unionize to protect themselves, can incentives ever really be aligned to benefit patients? Nationwide, we see plenty of integrated systems with employed physicians where incentives do seem to be aligned, so it is not the fact of employment that is a problem. Is there something about being employed by a public hospital system serving disproportionate numbers of publicly insured and uninsured patients that makes it harder for physicians and administrators to work in tandem? I don’t think so—Denver Health is a public safety net system that employs its physicians. And, while I’m sure that the doctors there may not whistle a happy tune every day, Denver Health is a model of coordinated patient care.
While I wish both the administrators and physicians of the New York Health and Hospital Authority luck with their negotiations, I wish much better luck to their patients. I hope the agreement the providers ultimately reach truly rewards meaningful outcomes. I hope it gets them on the same page—a page with a picture of the patient.
About the Author: Edie Sonn is CIVHC's Vice President of Strategic Initiatives. Contact her at email@example.com.
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