Healthcare systems frequently depend on surgical cases to generate revenue, and the COVID-19 pandemic has led to frequent interruptions to surgical operations in recent years. A study estimated that more than 28 million surgical cases were canceled or postponed worldwide during peak medical disruptions, resulting in a wide range of negative clinical, financial, operational and psychological outcomes for those working in the surgical setting. Decision makers found themselves having to balance meeting surgical volume goals with unexpected demands: managing staffing shortages, circumventing supply chain disruptions, and managing patient backlogs.
As hospitals and health systems aimed to maintain clinical operations, surgeons were asked to do more with less. Alignment of surgeons and hospitals is critical to delivering high-quality, safe and consistent care – but pandemic-related challenges have made existing alignment issues more apparent. Our goal is to explore the changing facets of the surgeon-hospital relationship and potential opportunities for realignment as the practice of surgery – and health care more broadly – adapts to and ultimately emerges from the pandemic.
Financialization of the surgeon-hospital relationship
Over the past two decades, the surgeon-hospital relationship has evolved from a partnership between a guild of independent practitioners and the hospital (their workshop) to one where surgeons are seen as either agents or contractors. , or as direct employees of the health system. The percentage of surgeons who report in independent practice has declined significantly in recent years. the ostensible goal doctor-hospital vertical integration efforts has been to improve efficiency and stability. However, employment does not automatically result in alignment. The evidence suggests results have been mixed, and these models have had little impact on improving physician-hospital alignment.
At their core, these models rely on financial contracts with a strong focus on revenue targets, case volume expectations, relative value unit (RVU) targets, and surgeon commitment via monetary and dissuasive measures. The financialization of the relationship represents a break with historical partnerships, which were based on reciprocal expectations of trust, influence and commitment between surgeons and hospitals. The value of a surgeon can now be measured by the number of cases he produces annually as opposed to the quality of care he provides, the value he brings to the health system by providing specialized services (and accreditations such as magnet status) and its role in providing care that improves the health of the population.
Employment patterns make many surgeons feel replaceable and disenfranchised in hospital-level decision-making, despite their commitment to professional and service missions. In response, surgeons can focus more on clinical volume and less on comprehensive and appropriate care. Additionally, surgeons may be asked to give up autonomy and perioperative decision-making, with the understanding that macro decisions are now the prerogative of management, not the surgeon. Not only do these dynamics undermine the goals of vertical integration efforts (i.e., higher quality, lower cost patient care), but they also contribute to growing frustration and burnout. Moreover, they can stifle the innovation of the individual surgeon.
Many surgeons report lack of autonomy, administrative burden, and pressure for higher patient volumes as significant factors in burnout. This pressure for increased volume with reduced autonomy can also negatively impact the surgeon-patient relationship, as patients may perceive the actions of surgeons as motivated by financial motives. Burnout can also have a negative impact on the quality of care and patient safety.
Realign the relationship
Decades of research have shown that financial incentives are just one type of work motivator. Reducing the surgeon-hospital relationship to one-dimensional financial levers overlooks important engagement opportunities. Surgeons are intrinsically motivated by ideological currency, for example, the shared reward of providing quality care or improving the surgical profession. Moving from a language of financial and volume goals to a language of shared goals (improving patient outcomes) can lead to changes that put surgeons and hospitals on the same side.
For example, hospital initiatives such as the standardization of implant suppliers, when presented from the perspective of a financial relationship (even with potential benefits for hospitals and surgeons), may be considered by surgeons as cost and quality reduction efforts that subjugate the autonomy and conflicts of surgeons. with their role as patient fiduciaries (trusted advisors, decision makers and champions). The result is reluctance or resistance to these changes – and a potential source of stress and burnout. Yet, if this same initiative were conducted with a common purpose in mind — focusing on how it will enable a surgeon to provide better care and reduce harm (for example, by capitalizing on volume-outcome relationships ) — the conversation can move into adoption, understanding and developing shared decision-making processes to implement change (e.g. include scenarios where standardization would be undone). The holistic nature of the relationship frames how each change is perceived, whether it will be adopted, and its impact.
However, it is not just about changing the ‘pitch’ or framing of decisions within the surgeon-hospital relationship – it also requires changes in content and substance (i.e. the terms of the contract) inherent in these relationships. COVID-19 provides an opportunity to fully reconsider these terms, as the consequences of the pandemic are likely to see a “to restart“of broader payment models and policies, as governments, insurance companies and payers pursue value-based models of care. The hospital relationship must change to accommodate this.
Another strategy to better align hospitals and surgeons is to create opportunities where the two can more directly share responsibility and control of patient outcomes. For example, there has recently been an increased trend to refer appropriate surgical patients to ambulatory and outpatient surgical settings. Ambulatory surgical sites can provide timely and physically distanced patient care, decompress the hospital and contain costs. As hospitals increasingly seek to extend surgical care to these ambulatory sites, there is an opportunity to engage groups of surgeons and develop joint efforts that leverage strategic leadership, co-management, and co-ownership. This structure gives hospital leaders and surgeons “skin in the game” (not just financial benefits, but a sense of ownership and shared purpose), making them more likely to commit to improving patient outcomes, patient experience, and waste reduction efforts, thereby increasing the net value of care.
Ultimately, we need new communication, contractual, and organizational models that realign the surgeon-hospital relationship based on common purpose (low-cost, high-quality care), mutual trust, and mutual trust. cooperative decision-making. When this relationship is too transactional, it becomes one-dimensional, zero-sum, and revenue-driven (i.e. revenue and volume). Working together collaboratively to prioritize patient well-being will help surgeons and healthcare systems that depend on surgical care recover from the current crisis stronger, more competitive and more able to meet future challenges.
Amit Jain, MD, is a spine surgeon and Associate Professor in the Department of Orthopedic Surgery at Johns Hopkins School of Medicine. Christopher G. Myers, PhD, is an associate professor of management and organization at the Carey Business School. Alpesh A. Patel, MD, MBA, is co-director of the Center for Spine Health at the Northwestern School of Medicine.
Patel disclosed design/royalties from NuVasive, Zimmer Biomet, Amedica and Alphatec Spine. Jain disclosed consulting fees from Stryker Spine, DePuy Synthes, and Globus Medical, and received grants from the NIH.