Surgeons Are Prioritizing Patients amid the Corporatization of Healthcare

Surgeons Are Prioritizing Patients amid the Corporatization of Healthcare

Balancing the Ideal and the Pragmatic

As much as the ideal physician-patient relationship, organizational leadership, and workflow can and should be a part of any conversation regarding the intended purpose of healthcare, it is critical to recognize the practical realities that are inherent to modern medicine.

The flow of money into and out of a hospital or health system, whether it is considered corporatized or not, is something that also must be a priority as it supports patient care, according to Julie A. Freischlag, MD, FACS, DFSVS, chief executive officer and chief academic officer of Atrium Health Wake Forest Baptist in Winston-Salem, North Carolina, as well as the executive vice-president and chief academic officer of Advocate Health in Charlotte, North Carolina.

“There is a balance, where you do need to make money—there is no question of that—but at the same time, you always want to do the right thing by the patient,” said Dr. Freischlag, who also is ACS Past-President and Past-Chair of the ACS Board of Regents, among many other College leadership roles.

In her unique role as both an executive and an academic leader of a multistate healthcare system with $28.2 billion in revenue, as well as a vascular surgeon, Dr. Freischlag has seen how meeting financial obligations allows for care to be delivered in areas that are less economic powerhouses.

“When we set up systems, even for those that are nonprofit, we all talk about what service lines make money,” Dr. Freischlag said. “If you want to take care of trauma, if you want to take care of pediatrics, then you really do need cardiac surgery and cancer surgery service lines, and you need to take care of some patients who have insurance.”

A basic tenet of healthcare in the US is that those who can pay (usually through insurance) take care of those who cannot.

“Surgery is inarguably one of the areas where hospitals make the most money. So having many surgeons performing surgeries is key so you can afford to do other things, because not everything pays as well,” she said. “If there is no margin, there is no mission, including research and training.”

So, what can be considered a corporatized environment that merges hospitals under one banner can open opportunities to expand care. If the corporatization of healthcare is a current reality, then it is important to look to areas where it can be used advantageously such as a larger health system being able to increase access to healthcare either by addressing financial shortfalls in small institutions, building infrastructure, and so on, Dr. Freischlag suggested.

Dr. Freischlag explained that the goal of any hospital is to treat all patients who enter its doors. Purely profit-motivated institutions “that turn away, transfer, or discharge patients for any reason besides medical indication should look at their mission” and remember that patients always come first.

Outside Looking In

While the hallmarks of corporatized healthcare such as hospital mergers, consolidations, and private-equity investment continue to increase as stakeholders continue to work to determine the impact on healthcare quality, there is one area where the impact is immediately noticeable: on clinicians.

For surgeons, the corporatization of medicine can manifest challenges to internal career satisfaction and well-being, with one of the most glaring disruptions being the shift in “social location” within the hospital.

“For a long time, the center of healthcare decision-making, control of the money, decisions about directions, missions—all of that was really in the hands of the physicians and surgeons. Administrators were an important partner to operationalize the decisions made by physician leaders,” said Dr. Brandt, who also is Chair of the ACS Surgeon Well-Being Workgroup.

“Over the last 30 years, physicians and surgeons have lost their positions of power in the hospital. Not only has that resulted in the current disproportionate focus on the business of medicine, it has marginalized physicians, decreased their ability to effect change, and resulted in personal distress in the form of burnout,” she said.

A diminished decision-making authority can have implications for patient care, as treatment options are filtered through financial considerations or professional metrics. This can lead to moral injury for a surgeon because they know the “right thing to do” and yet find themselves unable to do it due to limitations placed on them by the systems they work in.

The challenges are not limited only to surgeons, however, as the essential support staff often face the brunt of a finance-focused environment.

“Everybody reaches a point where they will start to be affected by a cost-cutting measure, and I would say it impacts areas like the nursing staff more than it does the surgeons,” Dr. Schwartz said.

Extra shifts and lack of coverage “ultimately are going to affect their performance, and it’s not their fault,” he said. This is significant because as frontline workers, nurses often can be the first to see that quality is being affected in their hospitals.

Regardless of professional role, in a heavily corporatized environment, there is concern that speaking up to alert leadership about professional and personal well-being could lead to termination of employment, perpetuating the cycle, and some evidence suggests this is taking place.8

Course correcting such an environment requires a different perspective from hospital or health system leadership. Rather than intervene with patient-level initiatives, organizations should consider an “inverted pyramid” approach to management. With patients recognized as the most important element occupying the top of the pyramid, ownership—the “tip” of the pyramid, now at the bottom and the smallest element—should instead focus on helping clinicians as frontline workers.

“I would argue that organizations should be supporting that second layer—clinicians—to provide the care to that top layer, because without the clinicians you can’t provide that care at all,” Dr. Goldberg said.

“If you dismiss clinicians and act as if they are easily replaceable, that they can be swapped out for a younger, cheaper version that won’t say as much, you’ll run into issues. At any job, if you beat down the people who work for you, they’re not going to be as productive, and they’re not going to be as responsive,” he added.

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