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Ann Thorac Surg 1995;60:1473-1475
© 1995 The Society of Thoracic Surgeons
The University of Texas Southwestern Medical School and Baylor University Medical Center, Dallas, Texas
Abstract
Reassessment of the managed care environment and restructuring of our practice will be accomplished by transitional short-term actions while we institute our long-range plan. In the short term we must develop appropriate relationships with hospitals and medical groups that interrelate to our specialty, and develop a ``love our enemy'' philosophy. We must establish operating organizational units that will be competitive. Reassessment of our own practice, our unique skills, our inadequacies, our competition, and our performance through outcome studies is essential to retake positions weakened by loss of contract inclusion. Long-term strategy must develop insurance coverage in conjunction with our patients in such a way that the middleman is eliminated and the profit currently extracted by managed care is reinvested in patient care, research, and education. Whoever controls payment determines the quality of medicine and how it is delivered.
We are being squeezed on one side by the Clinton health reform, which has not been carefully planned or tested, and on the other side by cost-driven managed care. We sense an air of depression, frustration, powerlessness, and anger. There is more paperwork; government restrictions and Big Brother looking over our shoulders; hours on the phone pleading with an insurance company clerk to allow us to practice good medicine; a 90-year-old woman coming to the hospital at 3 AM for an outpatient cataract operation so she will not have to spend the night in the hospital, where fewer than half the beds are full; and the physicians throwing up their hands and retiring early.
What happened to ``The Joy of Surgery''?
The magic stuff, the grail That once moved every doctor in this room to become a surgeon, And that even now beckons Through the jading mist of tedium and time. Strip away the corrupting dullness And look afresh at our profession. Clem Heibert
Ross Perot was motivated to start Electronic Data Systems after reading Thoreau's quote, ``Most men lead lives of quiet desperation.'' This is our theme song, this is happening to us, we must rise up and take control of our destiny—resurrect the Phoenix from the ashes. Is the grail beyond our reach? Are we fettered forever by the mundane and the material? Can we recapture the sense of wonder in the worthwhileness of surgery? Can we go home again? In the movie Dead Poet's Society, the message was carpe diem—seize the day; suck the marrow out of life. Thoreau is calling us a second time from Walden Pond.
The motto of Boy Scouts is ``Be prepared.'' The motto of thoracic surgeons should be ``Get organized.'' Our problem is we are all chiefs and there are no Indians.
Ross Perot challenged us last spring to put our patients first and provide leadership for healthcare reform. Few of us have complied. We are victims of our personalities and our training. We do not follow anyone. Modern-day Pontius Pilates, we want to wash our hands of politics and organizations. However, without organization we are at the mercy of those who are organized, the middlemen, whether the government or private business.
I am suggesting a short-term strategy that is transitional and may buy us time, and a long-term strategy to retake control of the health system in cooperation with the patient and to the detriment of the middleman.
In the short term, we must position ourselves properly and establish appropriate relationships with:
We should objectively reassess our skills. Can we survive by ourselves or in a small partnership?
Some of our options if excluded from groups or contracts might include:
Not only are clouds appearing on the horizon, but the driving rain in our face is cost, price, and charge. The dollar is the bottom line. The patient is the consumer. We are the providers. The insurance company, government, or middleman is God Almighty.
There are three areas in which America excels over any other country, where we have no peer. Our farmer is the best in the world; only 6% of our population is needed to feed all of us easily. In contrast, it takes 65% of the Russians and 75% of the Chinese working on farms to feed their populations, with many in both countries still starving to death. We built the first and best airplanes in the world. Our medicine and research are world class. People come from all corners of the earth for our healthcare. All three of these shining stars are being eroded by forces outside their areas of expertise, that is, the middleman, whether profiteer or government. After assessing many options, I think the best solution is to select our leaders and behind them organize as the key to our ideal long-term strategy. The middlemen (insurance companies, lay hospital management, and managed care) are eating our lunch and threaten the very existence of the healthcare delivery system.
What can we do? As the main advocate of our patient we should take charge and operate the system, oversee or administrate the hospitals, provide our own insurance companies (nonprofit), and care for our patients in a way that is proper and true to our profession.
Physicians, in cooperation with their patients, should establish an insurance company that would self-insure them in an optimal-sized group (Fig 1
). This health insurance company would need no reserves and could invest its money to provide the basis for payment. This cooperative group of physicians and patients should take control of the hospitals either by purchase or controlling operations. The current concept of the hospital should be discarded. The outpatient department, emergency room, operating room, and intensive care unit would be maintained as a unit and the bed and breakfast aspect separated and operated by efficient professionals.
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Certain reforms could be instituted immediately that would be helpful to this cooperative. For example, all patients in the group would sign a pretreatment agreement to use a mediation committee for any significant complaint. Efficient administrative reform could be established, such as a single form for payment, and so on. Preventative medicine incentives could be developed, and outcome studies would demonstrate how excellent quality can be achieved with minimal cost.
The people who control payment determine how medicine is practiced as well as its quality. In current imagery WalMart is an example of a provider with a cheaper product. It is not quite the quality of other stores; it is adequate and because it is cheaper it puts the other stores out of business. You can maintain better quality than WalMart at a cheap rate with elimination of the middleman.
Edison, Westinghouse, Kettering, and Eastman were examples of creative independent engineers in their fields. The conversion of independent engineers to corporate employees in a generation is another example for physicians. If we do not take action, our fate will be the same.
Henry Cisneros described the inevitability of change:
If no one lifts a finger or no one cares, things change. The human body grows older, machines grow rusty. Friendships fall apart, foundations begin to settle. Left unattended, the dynamic of change is ``decline.'' The trick is to convert change into a positive force. And that takes positive action.
We cannot go back to the good old days because they are not there. What did they expect to find at Woodstock 25 years later? Not mud.
But we can go back to the original idea, the reason we went into medicine, the holy grail, the noble calling. We can rejuvenate the caring and the sensitivity and the fact that we can make a difference to our patients and our society. Remembering the Chinese proverb, ``a long journey begins with the first step,'' let us take the first step. In Churchill's words, ``The time is critical—we need action this day!''
United States Army General Douglas MacArthur said:
The history of failure in war can be summed up in two words: too late.
Too late in comprehending the deadly purpose of a potential enemy;
Too late in realizing the mortal danger;
Too late in preparedness;
Too late in uniting all possible forces for resistance;
Too late in standing with one's friends.
Hippocrates' aphorism is as appropriate today as it was 2,000 years ago.
Life is short.
The art long.
The occasion instant.
The experiment perilous.
And the decision difficult.
Footnotes
Presented at Preparing Your Practice for Change: Thoracic Surgery Into the Next Decade, Atlanta, GA, Sep 24–25, 1994.
Address reprint requests to Dr Urschel, 1201 Barnett Tower, 3600 Gaston Ave, Dallas, TX 75246.
References
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