Who do patients really need: physicians or administrators?

August 22, 2018

A trend of shuttering hospital departments and firing physicians to save money is dangerous and short-sighted.

A recent interview with Cathy Jacobson, president and CEO of Froedtert Health, a large health system in Wisconsin, sent chills down the spines of physicians everywhere.

While she started the interview by stating that her organization’s goal (or in CEO terms, “culture”) is to put the patient first, she followed with a contradictory statement–explaining that patients don’t need primary care physicians: “Patients need primary care, but not necessarily a physician relationship.”  

I suppose we should thank Ms. Jacobson for telling doctors what we’ve secretly suspected for quite some time: Corporate entities undervalue physicians and consider us replaceable.

This should come as no surprise to those who are following news reports and social media. 

In April, 27 pediatricians were fired in Texas when Dallas area Children’s Health sold most of its clinics to MD Medical Group. According to CEO Alvaro Saenz, the ironically newly-named ”MD Kids Pediatrics:” “puts a greater emphasis on nurse practitioners and physician assistants, while staffing one to two pediatricians per location.” 

Ah, the irony. While MD Medical Group enjoys the branding element of employing “MD” in its name (in addition to MD Kids Pediatrics, they also operate Clinicas Mi Doctor and MD Family), they have fired MDs (and DOs) and replaced them with NPs and PAs. 

I spoke to three of the pediatricians who were fired as part of this acquisition, who were unwilling to be named due to concerns over losing their severance package. They told me that they and their physician colleagues were completely shocked by the sudden firing. ”We thought we were going to retire from this place,” one told me. 

In retrospect, there were warning signs. 

Several months before the firing, the pediatricians told me that administrators demanded that they increase their patient volume from seeing 18 to 20 patients per day to 24 patients per day. The system had also recently made cost-saving changes by firing each physician’s triage nurse several months prior and creating a centralized call center, despite concerns expressed by the group’s pediatricians. 

The doctors I spoke with noted that the pediatricians who were retained tended to be the newer doctors just out of residency and those who saw a higher patient volume. 

One of the fired pediatricians recently spoke to a colleague who was kept on staff.  “This doctor was told that they could agree to the new policies or they could go, with no severance. They were also informed that NPs were already ‘lined up’ to take over for the terminated pediatricians.”

When doctors are let go, the community suffers

Administrators are slashing physician jobs in other parts of the country as well. In Baltimore, multiple pediatricians lost their jobs when Medstar Franklin Square closed its pediatric emergency room and inpatient pediatric services. Anna Reed, MD, one of the pediatricians whose position was terminated explained the trickle-down effect that the closure has had on the community. 

“In addition to having no pediatric trained emergency physicians, the facility is no longer able to provide other services for children, like sedation for imaging tests and managing complications in newborn babies,” she told me “If a baby has a problem after delivery like jaundice, they now have to be transferred to another facility.” 

Reed’s termination also left a training deficit in the local family medicine residency program. “A large part of my job was to train residents in pediatrics. Without in-patient pediatrics, the residency program has to scramble to find places for training physicians to rotate, or they won’t be able to graduate,” she said. Reed also noted that pediatricians at the hospital provided the only child protective team in Maryland, a service that treats abused children and works closely with the state attorney’s office.

Children in other communities are being effected similarly, as hospital systems in Missouri, Pennsylvania, and Chicago have ended pediatric services

In Missouri, the for-profit hospital system Community Health Systems closed down the only obstetrics department within a 50-mile radius, forcing the only obstetrician servicing the town to shutter his practice. 

And in North Carolina, Charlotte-based Atrium Health is terminating a contract with 100-member anesthesia group Southeast Anesthesiology Consultants to contract with a Scope Anesthesia, a group whose website proudly proclaims that a large part of its vision is “forming dedicated partnerships with highly trained CRNAs.” 

While we don’t yet know if the new group will be utilizing CRNAs at a higher rate than its predecessor, internal Atrium memos state that the system has plans for “an improved model for providing anesthesiology services that would reduce patient costs while maintaining safe, high quality care.” 

Southeast expressed concerns that this new model would require anesthesiologists to supervise a higher ratio of CRNAs, and that CRNAs could potentially be providing anesthesia without physician supervision. They cited a presentation that Thomas Wherry, the founder of Scope Anesthesia gave to Atrium Health, in which he noted “no state requires nurse anesthetists to be supervised by anesthesiologists.” Scope denies such plans.

This trend of shuttering hospital departments and firing physicians to save money is dangerous and short-sighted. Patients do need physicians, and despite views expressed by Cathy Jacobson, they do need an ongoing relationship. This has been demonstrated in multiple studies. Sustained continuity of care-or seeing the same physician over time-improves quality of care by decreasing hospitalizations and emergency room visits, as well as by increasing preventive care. Seeing a regular physician also improves care in patients with chronic conditions. And most importantly, continuity of care by the same doctor reduces mortality rates.

On the contrary, having more health system administrators does nothing to improve patient care. 

Despite the growth of healthcare administration-currently there are ten administrators for every one doctor-the only quality improvement shown by increasing management has been a 1.2 percent reduction in 30-day hospital readmissions. And despite high hospital CEO pay (with a mean compensation of nearly $600,000 per year), there was no correlation between compensation and processes of care, patient outcomes, or community benefit.

An analysis of the growth in healthcare management led economists at the Harvard Business Review to argue that to improve healthcare costs “the most immediate goal should be to eliminate many nonclinical jobs.” In fact, they stated that “it is far more desirable to reduce nonproductive administrative labor than to reduce clinical wages.” 

Are you listening, Ms. Jacobson?

Rebekah Bernard, MD, is a family physician and the author of How to Be a Rock Star Doctor: The Complete Guide to Taking Back Control of Your Life and Your Profession. She can be reached at her self-titled site, Rebekah Bernard, MD.