MIAMI BEACH—Panelists tackled several issues in otolaryngology, and healthcare in general that require action to make improvements. The Triological Society Combined Sections Meeting touched on the ethical questions surrounding payment reform, how to address a lack of professionalism, and ways to combat—and how to prevent—burnout.
The Ethics of Payment Reform
Michael Stewart, MD, MPH, professor and chairman of otolaryngology-head and neck surgery and vice dean of Weill Cornell Medical College in New York City,
outlined the ethical challenges of the healthcare system and questions surrounding payment reform. “The patient is really insulated from the cost, so there’s really no incentive for the patient or the provider to actually try to reduce cost,” he said.
Additionally, physicians are recommending a treatment for which they’re paid. “Most of us can get our heads around that and think they can handle that, but there is an ethical issue here,” he said. “And, in some circumstances you have to be recommending a treatment for which you will be paid less.” Extensive testing usually will be viewed by a patient as high quality, resulting in good patient satisfaction scores, even though the otolaryngologist might actually be wasting resources.
There is also a “disconnect” between physicians’ training to give their full attention and resources to the patient in front of them and their responsibility to the population to do the greatest good for the greatest number, he added.
But payment reform comes with ethical questions of its own. Bundled payments, payments for outcomes rather than for individual services, might cause what he refers to as “adverse selection,” adding, “If we’re only going to get paid for populations, nobody’s going to want the tough cases.”
“It certainly may drive care to less expensive providers, but [those providers may be] less efficient or less expert,” he said. “While it might actually cost less to send a patient to a primary care physician than a specialist, the specialist may get the right treatment the first time and, in the end, save the healthcare system money, even though that first treatment might be more expensive.”
As physicians move forward with “one foot in each canoe”—with some payments based on volume and some on outcomes—the goal should be to do the right thing regardless of the payment model, he added. “We should standardize our care, our care should be evidence-based, and it should be efficient. We should try to do as much as we can for as little cost as we can.”
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.”
“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).
Burnout can lead to problems with professionalism, errors, patient satisfaction, and turnover, as well as thoughts of suicide, she added.Ways to prevent burnout include setting reasonable work expectations, giving employees control, and rewarding and recognizing employees in ways that are really meaningful.
Dr. Couch’s approach involves building a sense of community in the workplace and a culture of fairness that includes trust, respect, and good communication. Mentorship can be particularly valuable, she said. “Sometimes it seems that no one cares. If you had even one person looking out for you, one person who’s sponsoring you or mentoring you, that might make a huge difference. And I believe it does.”
Having employees feel they can report serious problems related to burnout is important, but it’s also important to know when to report and when not to, and that might not always be easy to determine. “I think you have to have systems that allow for you to have good conversations, that allow for you not to have conflicts, and allow for you to not be reported,” she said. “As I look back on my career if I had reported everything I saw and didn’t have a lot of important conversations off the record, I think that would have actually harmed somebody who really was going through a rough time.”
There is no choice but to report egregious behavior, but, she added, “this is a difficult subject.”