Physicians across the country would be wise to pay close attention to the developments in southwest Virginia, where the dream of a $100 million not-for-profit clinic threatens private practice as most doctors and patients know it.
After plans for the Carilion Clinic were announced last June, more than 200 Roanoke Valley doctors banded together to register their concern. They formed the Coalition for Responsible Healthcare to explore the issues surrounding the clinics development and serve as a platform for public involvement.
Of primary concern: the development of the idea by Carilion Chief Executive Officer Edward Murphy (without initial input by the medical staff or his own board of directors) to establish a wholly owned hospital/physician system that would eliminate all competition from independent physician practices in the Roanoke Valley. He set the tone by aligning local businessmen and politicians with a promise that the Carilion Clinic would bring in millions in economic development. Meanwhile, the board, many of whose members have lucrative contracts with Carilion, has largely remained silent.
What has resulted is tremendous damage to trust and respect in the hospital/physician relationship. There are three primary losers in this fight:
- Physicians are losing. Seven physicians in rheumatology, psychiatry and orthopedic surgery have moved their practices away from Carilions flagship hospital, Roanoke Memorial Hospital. Others have simply left town or retired (family practitioners and internists), and many who were interviewing for private practice positions have discontinued their interviews and will go elsewhere. Even more have moved their practices to HCAs nearby Lewis-Gale Medical Center in Salem: Seventeen in the regions largest ophthalmology practice left along with three neurosurgeons, 14 in the private radiology group, the senior gynecologist, breast surgeon and others. Fortunately, Lewis-Gales administration respects the medical staff and renews its pledge to work with the elected officers and committees of the medical staff. The exodus from Roanoke Memorial of private physicians created by the formation of the clinic is likely to result in more services and better patient care at its HCA counterpart. Finally, a legal consultant to the Roanoke Memorial medical staff has suggested in a letter to the staffs executive committee that the final effect of the Carilion Clinic may be the complete elimination of its medical staff structure.
- Patients are losing. More than 400 of them attended an open forum to speak out in protest; more than 2,000 have signed petitions asking that the clinic be reconsidered. As physician groups leave and are replaced with Carilion hires, patients are losing their long-established relationships with their private physicians and surgeons as well as their expectation of returning to Roanoke Memorial. Employers and insurers profitability is also at risk if the lack of competition drives up the cost of medical care, which is likely.
- The Carilion hospitals are losing. The Carilion hospitals are not-for-profits chartered by the city of Roanoke, and may be placed in financial jeopardy via this untested model. Decades of good hospital-physician-patient relationships are being ruptured in return for potential bottom line gains. Traditionally, these relationships have been sacrosanct and mutually supportive, but this does not appear to be Carilions goal.
So, in short, all are losing through this bold new Carilion Clinic concept. And why? According to Murphy, the clinic will improve patient care and provide opportunities for medical education and research, even though there are ample opportunities at nearby medical schools at Duke University, the University of Virginia and Virginia Tech.
More likely, the Carilion Clinic concept has to do primarily with the budget goals of the system, which, by Murphys report to the medical staff had a greater profit last year than ever before, but which, by some estimates, may operate in the red by 2011. There is considerable debate about the validity of such predictions.
The future of the quality of medical care in southwest Virginia is in jeopardy, being held hostage by the dream of a CEO who is intent on controlling the revenue stream of the entire healthcare system. In other parts of the country, competition and patient concerns about choice and quality have prevented similar situations, but Carilions increasing stranglehold on its referral base is slowly tightening the noose while the public sleepsat a cost of more than $100 million of taxpayers money.
Its our hope that the Carilion board will soon direct Murphy to rethink the Carilion Clinic. Other hospitals that have attempted to operate without a respectful relationship with their private physicians have discovered that, in the long run, it just doesnt work. An increasing number of physicians and businesses are beginning to realize that this vastly expanding self-referral network must be stopped before it chokes off all competition.
Lawrence Monahan, M.D., is an internal medicine specialist, former president of the Medical Society of Virginia and former chairman of the board of directors, Roanoke Valley Academy of Medicine.