Hospital hardball

Maine physicians are being pressured to pick sides in a nasty fight over economic credentialing.

By Ken Terry
Senior Editor

A conflict between the Central Maine Medical Center of Lewiston and most of the town's cardiologists has divided the medical community, angered patients, and threatened the viability of CMMC's new heart institute, scheduled to open in April 2003. The struggle ensued when CMMC decided to follow a path chosen by an increasing number of hospitals: signing exclusive contracts with certain specialists and limiting or denying privileges to physicians on the staffs of competing institutions (see "Economic credentialing is on the rise").

The diagnostic cardiologists in the Lewiston-Auburn area have long referred patients to the interventional cardiologists and surgeons at two large groups in Portland, some 40 miles away. They expected the members of those groups to be given privileges at CMMC's new heart center.

But leaders of the 250-bed Lewiston hospital see things differently. They want a dedicated group of physicians to build the new program from scratch. One reason is to meet the quality and cost requirements of the state certificate of need, says CMMC spokesman Chuck Gill. It's also impractical, he says, to have surgeons and interventionalists shuttling between cases at CMMC in Lewiston and Maine Medical Center (CMMC's direct competitor) in Portland.

The bottom line, however, is that the hospital doesn't want to rely on people in a competing cardiac program. "You can't be on two teams at the same time," says Gill.

Lewiston cardiologists join the big Portland groups

The Maine Medical Center and many of its cardiovascular specialists opposed the certificate of need for the Lewiston center, preferring to keep all of the region's procedures in Portland.

But after the CON was granted two years ago, the big Portland groups began holding merger talks with the Lewiston cardiologists. In March 2001, one of those cardiologists, soloist Roy J. Ulin, merged his practice with Maine Cardiology Associates, and a year later, a three-doctor Lewiston practice headed by Robert J. Weiss merged with Cardiovascular Consultants of Maine, a 16-doctor group.

When Ulin joined the Portland group, the Lewiston hospital announced that he'd have no privileges at the new heart center, and Weiss was warned that the same would happen to him if he carried out his merger plan. But Weiss wasn't deterred. He took his message to the media, to the legislature, and to the state official who'd approved the CON. The message: By banning the local cardiologists from the heart institute, CMMC was disrupting doctor-patient relationships.

"They sold this CON to the state on the basis that patients could choose excellent care locally," Weiss said in March, when the hospital's ban on cardiologists affiliated with outside groups remained in force. "But the only choice they're now giving is stay in town or stay with your doctor. That's not going to be well received: The overwhelming majority of patients, especially at a stressful time, want the doctor-patient relationship to be reinforced."

Bowing to public opinion, the legislature in late April passed a bill allowing Department of Human Services Commissioner Kevin Concannon to reconsider the CON and impose new conditions on the hospital if he discovers that the hospital omitted relevant information from the CON application. By then, CMMC had already rescinded the ban prohibiting the diagnostic cardiologists from practicing in the new facility. But it still won't grant privileges to surgeons or interventionalists in their groups. That means the cardiologists would have to refer to one of the employed physicians at the institute if the patient wanted to go there. To Weiss, this is unacceptable.

"We may use their surgeons, but we should be able to pick our own interventionalists," he says. "The doctor/patient relationship suffers if we're forced to use only certain people that the hospital has picked."

Weiss' group plans to recruit another interventionalist and base him or her in Lewiston, with backup from the group's other angioplasty experts. Unless the hospital grants privileges to that doctor, he says, it's going to lose some patients. "We're not going to use the new center if we can't participate in it fully, because we don't feel it's the best form of patient care." Neither will Ulin, unless it's an acute case or the patient really wants to stay close to home.

Commissioner Concannon agrees with Weiss that the hospital should let outside interventionalists in. "I don't think the hospital can say, 'We don't think you ought to be able to bring interventional cardiologists into your group, unless they're fully owned by our hospital.' I think that's wrong."

Where do primary care doctors stand?

Nearly 90 percent of the primary care physicians in the Lewiston-Auburn area are employed by either CMMC or St. Mary's Regional Medical Center. Although CMMC denies that it pressured its primary care physicians to change referral patterns, Roy Ulin and his associate, Jennifer L. Hillstrom, report that some CMMC doctors stopped sending them patients after they merged with the Portland group.

"Our consult and patient volume dropped considerably," says Hillstrom. "We can't prove that the hospital said, 'You can't refer to these physicians.' But it's clear the heat was on them."

The public criticism and the shift in referral patterns have hurt Ulin. "There are people I've been friendly with who've suddenly stopped referring to me. That's painful on a personal level, and probably on a financial level as well, but we're surviving that."

Since Weiss's practice merged with the other Portland group, referrals to Ulin have increased, and Weiss reports that a few CMMC-affiliated primary doctors are continuing to send him patients. But he doubts that that will continue after the new heart center opens. Fortunately, he says, the bulk of his business has always come from doctors at St. Mary's.

FP Susan A. Thomas, who's employed by CMMC, is disappointed in the cardiologists who didn't get involved in the CMMC heart program. These doctors, she says, are "undermining the community." She's also concerned about their financial relationship with the Portland consultants. While she still refers to all of them, after the heart institute opens, "the cardiologists that give us the best service and put quality into our community are the ones who will get our business."

Weiss worries that if the hospital hires interventionalists and they don't have enough cases to keep them busy, they'll start competing with him for diagnostic test referrals. On the other hand, if the hospital opened up the institute to all comers, it might not be able to recruit cardiologists or surgeons, notes Thomas. "It would be less attractive if they felt there were a couple of dozen cardiologists trying to compete."

FP Douglas M. Farrago, who works for St. Mary's, supports the cardiologists' effort to place their own interventionalists in the heart institute. "But if both of the heart centers are optimal in their ability, it's not going to make that much of a difference, and the patient should have a choice. Hopefully, CMMC will let the outside cardiologists come in. If they don't, and CMMC hires tremendous cardiothoracic surgeons, I hope Dr. Weiss will recognize their excellence, and let patients go wherever they want to go."

FP John M. Yindra works for a local community health center and admits patients to both area hospitals. He understands CMMC's position on hiring its own physicians to meet the CON goals for numbers of cases. "If the new physicians do good work—and I'm sure they will—I'll feel very comfortable sending my patients there."

He says of the Portland groups that merged with Weiss and Ulin: "They didn't support our bid to do our own center. Nor have they been supportive since we got our CON. There seems to be more of a motivation to protect their patient base than to make the hospital successful. And since I work in this community, I want the hospital to be successful."

Economic motives aren't far below the surface

The Portland groups naturally wanted mergers with the Lewiston cardiologists. Cardiovascular Consultants of Maine derives 15 percent of its cases from Lewiston, says interventionalist Bud Kellett, and the group wants to "maintain contact with our patient base," keep getting referrals from Weiss, and continue doing clinical trials with him.

"If a patient gets admitted to CMMC in this closed-shop model, it's unlikely we'll ever see that person again," Kellett notes. "It means an erosion of the patients we've seen in the past."

Weiss cites several reasons for merging with the larger group. First, he knew he'd have to hire an interventionalist to compete with the heart center's employed physicians, but his practice alone couldn't support one. So it made sense to spread the cost over a larger group. Second, the hospital's threat to ban him from the heart center if he joined the Portland group made him realize that he was vulnerable to losing privileges even if he remained independent. And third, he assumed that working with physicians he knew and felt comfortable with would make for better patient care.

Weiss stresses that he didn't make this decision for economic reasons alone. In fact, he knew that he and his colleagues would have to take a 15 percent pay cut to hire an interventionalist under the terms of the merger. "If we were just doing this for money, we wouldn't have merged."

But would the Portland groups really support the Lewiston heart center if they were allowed to practice there? Weiss and Kellett say their group would be willing to do all their Lewiston cases locally, but that the hospital won't even discuss granting new privileges.

Kellett denies that he and his colleagues are too far from Lewiston to do the job. Not only could the group hire a Lewiston-based interventionalist, but three of the group's other angioplasty experts live within a 30-minute drive of CMMC. So they could back up the Lewiston person, who could also benefit from doing cases in Portland to keep up his skills, says Kellett.

Roy Ulin says he merged with the other Portland group because he couldn't keep up with the demand as a solo cardiologist, and he wanted to recruit a partner. "Merging seemed to be the best thing for my patients," he adds, "because we assumed they'd be able to go to whatever heart center they or we felt was appropriate, and they'd also have the expertise of a large group available to them."

In the long run, he notes, he'd like to expand his Lewiston practice to include four to six cardiologists. That would be impossible if the heart center excludes outside interventionalists. "If we don't have the interventional service, our competitors will be able to attract the cardiologists and we won't. As a result, we'll become smaller and smaller."

In their face-off with CMMC, Weiss and his fellow cardiologists drummed up impressive support from patients, the media, and legislators in their fight against what they regard as economic credentialing. As a result, they've regained their privileges and might even gain entrée for their own interventionalists. If not, the cardiologists will continue sending their patients to Portland, and the $10 million heart institute will suffer.

"CMMC can hire whomever they want, and I'll deal with the competition," says Weiss. "But by excluding me and my colleagues, they're also excluding my patients, because patients will not choose the hospital over the doctor."

On the other hand, Lewiston's primary care physicians identify strongly with their community and want the Lewiston heart center to succeed. If that means the independent cardiologists lose business, they won't lose sleep over it, but they do want the bickering to end.

Revealingly, the Maine Medical Association hasn't taken sides in this dispute. "We have no position, because we have a lot of members on both sides of the issue," says Gordon H. Smith, executive vice president of the MMA.

But he deplores the "front-page mess" that the controversy has created. "It has damaged community support for the heart center, which was very strong before the dispute started."

Will the struggle between the hospital and the cardiologists ever be resolved? Smith doubts it. "The feelings are just too deep."

Economic credentialing is on the rise

The Lewiston, ME, cardiologists who were initially banned from the new heart clinic of Central Maine Medical Center claim they were victims of economic credentialing. Since they were barred because they merged with outside cardiovascular groups, CMMC's action seems to fit the AMA definition of this practice: "the use of economic criteria unrelated to quality of care or professional competency in determining . . . medical staff membership or privileges."

Contracting exclusively with a group of cardiovascular specialists, however, is not economic credentialing, maintains CMMC. "Every hospital in the country has contracts with certain groups of doctors, such as radiologists, anesthesiologists, pathologists, and physicians who staff the emergency department," says Chuck Gill, a CMMC spokesman. "This is the same type of approach; it's just a different specialty."

And exclusive contracts are legal, says Alice Gosfield, a Philadelphia-based health care attorney. Hospitals justify these contracts on the basis that they want to be able to control for quality, availability, and round-the-clock coverage, she says. In the cardiovascular field, such agreements may also be designed to guarantee that heart surgeons will have enough cases to maintain their proficiency.

Economic credentialing is not illegal in most states. Nevertheless, some states—including California and Texas—prohibit hospitals from dropping or restricting the privileges of physicians who practice at other institutions. Illinois stipulates that hospitals must provide a fair hearing before they deny privileges to doctors for any economic reason; the action must also be reported to the hospital licensing board. In fact, 17 states have statutes that address economic credentialing in some way, says the AMA.

The association is receiving more complaints from physicians who've been excluded from hospital staffs because they practice at a competing institution. Gosfield has also noticed a growth in economic credentialing of various kinds. "Hospitals are more threatened, and economic credentialing is a way of consolidating their power," she says. "They want more referrals, more business in the institution, more heads on the beds."

While economic credentialing is burgeoning, there hasn't been a corresponding increase in the number of lawsuits over it. The majority of disputes are related to hospital-based specialists and specialty hospitals, with some notable exceptions: A South Dakota hospital dumped a group of orthopedic surgeons who'd set up a competing ambulatory surgery center, and the state Supreme Court upheld the hospital's right to do so. Last year, a New Jersey hospital was going to remove doctors' privileges unless they reduced their length of stay, but the hospital backed down after the doctors went to the media and threatened to sue.

 

Ken Terry. Hospital hardball. Medical Economics 2002;15:72.