Some physicians accuse healthcare executives of manipulating physicians and of being immune to concerns about patients' needs and the public good. There's nothing new about that. For years, some physicians have preferred to take an us-vs.-them stance against the administration rather than take part in collaborative efforts to solve problems affecting the entire organization.
"Economic credentialing" has become a focal point of these accusations. Why all the fuss? Why do many physicians think it's wrong?
Economic credentialing refers to selecting physician appointees most likely to generate revenues for a hospital. "Economic re-credentialing" refers to rescinding medical staff membership and/or clinical privileges because clinical practice habits have a negative effect on the hospital's bottom line.
A valid concept.There is absolutely
nothing wrong with the concept on which economic credentialing and re-credentialing are based. Through the "order sheet" and by performing costly operations and invasive diagnostic procedures, physicians determine variable healthcare costs, which some experts estimate to be 60% of total patient-care costs. Yet, the executive staff and governing body are responsible for the facility's financial viability.
Also, the medical staff, executive staff and board share legal and ethical responsibility to provide "quality" care-dependable performance from the standpoint of patients and their family members-on the scariest days of people's lives.
In this scenario, a physician can afford to focus on the individual patient for whom he or she is responsible. But the board and the facility's administrators must focus on the means by which quality healthcare services can be provided to an entire community.
So, there's nothing wrong with a governing board and executives listing "efficient practice" as a desirable characteristic of applicants. Likewise, there's nothing wrong with demanding efficient clinical performance from current medical staff members. "Efficient" in this context means seeking the best achievable patient results without using tests or treatments that do not contribute to that result, for the sake of patient comfort as well as cost-effectiveness. In fact, it would be wrong for medical staff leaders, administration and the board not to include this concern when selecting and evaluating physicians to practice in a capitated, managed-care system.
Also, physicians must understand that current and proposed mechanisms of financing healthcare all include use of consumers' money, in one form or another. Physicians who reject the obligation to develop cost-effective clinical practice habits appear arrogant and stand to lose public support.
The wrong way.Some versions of
implementing the expanded credentialing process are definitely wrong. For example, economic credentialing becomes wrong if a process originally intended to protect patients is totally commandeered to serve the hospital's or physicians' economic interests.
At medical center A, individuals responsible for credentialing, including the chief executive officer, first look at characteristics of physician applicants from a patient's viewpoint. In that light, characteristics of a desirable physician include good clinical knowledge and skills; a cooperative attitude, including reasonable accessibility to patients, their family members and the nursing staff; and willingness to complete patient medical records in a timely, legible and accurate fashion. Efficient practitioners are selected from among candidates possessing these characteristics.
At medical center B, the CEO urges the medical executive committee and the board to consider physician applicants first and foremost based on the financial issues the facility faces.
At medical center A, there's nothing wrong with economic credentialing. But facility B is betraying the promise of public protection made in the bylaws of the governing body and medical staff. That invites malpractice lawsuits and helps the us-vs.-them medical-staff faction maintain a power base by encouraging separateness. That's a mistake.
Using the reappointment process to deal with inefficient clinical practice habits of physicians also has a negative impact on the medical staff/executive working relationship. It is not an effective behavior-modification tool. And, as with economic credentialing, a poor public image is created when a mechanism purported to be patient-protective is used for the purpose of maximizing profit.
Try CQI. New, effective, acceptable
continuous-quality-improvement methods now exist for dealing with problems of physician performance. Valid data and positive feedback can influence reasonable physicians to pay more careful attention to the efficiency of their practice habits.
If a physician is unresponsive to such an approach, the provisions of medical staff bylaws designed to deal with problem practices or behavior should be used, without waiting until "reappointment time." The reappraisal process can then, for the most part, be a routine time of feedback for responsive physicians, analogous to the annual evaluation of employees.
Physicians are dividing into two groups. One group could be called traditional thinkers. "As it was in the beginning, is now and ever shall be" is its credo. This group mistakenly believes a physician of the '90s is obligated to be concerned solely with effective patient-care results, paying little attention to how those results are achieved.
The other group could be called forward-thinking physicians. Its members understand that the American healthcare system is re-forming-fundamentally changing itself in important ways that have little to do with political action. And they accept the need to consider the cost of treatments and procedures they order and perform.
Healthcare executives also are dividing themselves into two groups. Traditional thinkers prefer negative, legalistic "control" methods for dealing with physicians. The other group comprises forward-looking executives. They appreciate the need for dealing effectively with problem areas, but in ways that preserve a mutually productive working relationship.