These conflicts are usually over methods rather than outcomes. If hospitals want to cut LOS, so do patients, who want to sleep in their own beds. Hospitals want to manage costly and scarce resources wisely; patients want judicious use of treatments and tests. Hospitals want to keep costs down; patients want to keep out-of-pocket expenses down.
Are the loyalties of doctors to their patients sometimes at odds? The honest answer is, “Sometimes, yes.” Sometimes hospitals make providing care more challenging. Incentives affect how doctors behave. If bonuses accrue to good infection control, infection rates fall. If bonuses are aligned with keeping costs down, costs likely go down.
But such incentives play a role in how all doctors behave, not just hospitalists employed by a hospital. Self-employed physicians (hospitalists or otherwise) and members of a large medical practice group respond to incentives, as well.
One could argue these doctors might have a greater conflict of interest than hospital-based physicians. Think of the time pressures under which many physicians work, the complexity of the hospital environment, and the burden of paperwork.
Solo private practitioners whose only source of revenue is professional service fees may be inclined to keep patients in the hospital longer because that generates higher fees. They may also have a secondary agenda: Drive higher patient satisfaction by keeping patients in the hospital until they feel completely well, “protecting” them from hospital administrators who want to “prematurely” discharge them.
The real problem with incentives is aligning them with optimal care.
Once we establish that incentives are important, that their ultimate goal is optimal care, the next step is to create transparent, explicit performance criteria. There should be no mystery concerning which behaviors and outcomes physicians are expected to achieve, including those involving quality and safety. Finally, incentives need good checks and balances. There must be a good measurement system for desired performance and a method for keeping tabs to mitigate or eliminate unintended consequences.
All physicians must simultaneously manage the interests of the patient and the interests of the healthcare system—especially the hospital. When these goals are met, patient and system benefit by maximally utilizing precious resources such as inpatient beds, diagnostic and treatment technologies, and drugs. These resources are not limitless and should never be used without a great deal of critical thinking and consideration of alternatives.
There will always be tension between optimizing resources and treatment. Balancing these interests is not a problem to be solved, but a polarity to manage. Polarities are unsolvable because neither pole alone is the right answer. Focusing on one pole to the neglect of the other undermines our efforts to optimize patient needs and propagate a sustainable hospital care system. These alternatives are ongoing and interdependent and must be managed together.
To achieve the right balance, we must establish measures to alert us when one pole “tips” over the other. While I believe physicians, in the face of conflict of interests, must do what is right for the patient, it is also our duty to find ways to balance the interests of all involved. This is the key to a more sustainable, reliable, satisfying healthcare system—and to fulfilling our promise to monitor and self-govern the quality and safety of care we deliver. TH
Dr. Holman is president of SHM. He can be reached at [email protected]