Randal Weber, MD, chair of head and neck surgery at The University of Texas M.D. Anderson Cancer Center in Houston, and his department are working on a bundled payment project. “It’s very complicated and it has a lot of risk because there are some outliers that could just wipe out all of your profit margin,” he said. “And ‘profit’ is not a dirty word, because that’s how we build new buildings [and] start new programs.”
Explore this issue:February 2014
“The folks who pay for care don’t really do a great job of credentialing providers, physicians, and hospitals to send patients to get the best care,” he added. “Frequently, it’s … a lower common denominator that may not be as good.”
Dr. Stewart agreed and said one potential direction of reform could be to send patients to specialized centers and leave the simpler cases to other providers in a manner similar to the European model, which is one reason the costs are lower in those systems.
While it’s true that an expensive outlier can have a big effect on profit margins in a bundled payment system, he added, it’s important for a center to have enough patients to be able to absorb those outliers.
Breaches in Professionalism
Jo Shapiro, MD, chief of otolaryngology-head and neck surgery at Brigham and Women’s Hospital in Boston, said it’s important to understand that when someone is unprofessional, either by being disruptive in the workplace or performing unnecessary surgeries, he or she is generally trying to do the right thing but just isn’t successful at doing so. “I don’t know anybody who walks into the hospital and says, ‘I think I’m going to rip off the federal government and do unnecessary surgery,” Dr. Shapiro said.
There’s evidence that disruptive behavior affects patient safety as well as the practice’s or hospital’s bottom line, because the people around the behavior tend to become less productive.
At Dr. Shapiro’s institution, the Center for Professionalism and Peer Support is a place where colleagues can go to air their concerns in private discussion with the director. “I think we should have a place where we can discuss those concerns so that people in a position to do something about them can look into it and do something if it turns out that the concerns are valid,” she added.
Marion Couch, MD, PhD, interim chair of the department of surgery at the University of Vermont College of Medicine in Burlington, said feelings of burnout start in medical school and continue to be an issue through many otolaryngologists’ careers, even as surveys show that nearly three-quarters of physicians said they would choose the career again. Additionally, more than 80% of otolaryngology chairs experience at least moderate levels of burnout, she said (Laryngoscope. 2005;115:2056-2061).