Supreme Court expands view of interstate commerce in peer review proceeding

At the end of May, the U.S. Supreme Court allowed an antitrust claim by a physician against a hospital for an allegedly improper peer review proceeding. Previously, hospitals were allowed to defend against antitrust claims regarding a peer review decision involving one physician on the grounds that the activities did not affect interstate commerce. The Supreme Court has apparently removed this defense by letting stand a Court of Appeals decision allowing a physician's antitrust claim against a hospital that has suspended his privileges.     

How to keep the Joint Commission happy and plaintiff's attorneys frustrated

With the first minimum standard by the American College of Surgeons in 1918, the credentialing of physicians became formalized Since those days, in which a physician was basically required to be licensed and of high professional, moral, and ethical character, many requirements have been added. All have been appended for the safety and quality of care of our patients. However, liability attorneys have discovered credentialing requirements and found them a veritable gold mine for litigation. As rapidly as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) offers another standard to help us protect not only our patients but also ourselves in this litigation-bent atmosphere, attorneys engineer a way to bring suit, using the standard as if it were a requirement for prevention of negligence rather than a self-imposed goal for attainment of quality. This article presents a method of credentialing medical staff members that neutralizes the threat of antitrust actions alleging the compromising of livelihood by the denial of membership or clinical privileges. Additionally, the methodology offers maximal protection and integrity of credentialing procedures while optimizing compliance with Joint Commission standards.     

A case of wrongful use of quality management. Summit Health, Ltd., v. Pinhas

Summit Health, Ltd., v. Pinhas liberalized the jurisdiction of the Sherman Antitrust Act to include cases of intrastate hospital credentialing. The U.S. Supreme Court decision eased the requirements for plaintiffs to sue when they perceived that health care organizations were acting as monopolies. The court removed the defense that a plaintiff had to prove that the decision of a health care organization affected interstate commerce for the case to be heard in court. Important as the case is in antitrust law, however, greater lessons can be gained by health care organizations from analyzing the events that led to the lawsuit.     

Venice Hospital decision vacated. Key Enterprises of Delaware, Inc. v. Venice Hospital

The United States Court of Appeals for the Eleventh Circuit recently ordered an en banc rehearing of its widely reported hospital downstream diversification antitrust case. The so-called Venice Hospital case had found antitrust liability in the operation of a durable medical equipment (DME) joint venture between a hospital and a DME vendor. The Eleventh Circuit, however, has vacated its prior decision and, pending its en banc opinion, reinstated the district court's decision that the defendants did not violate antitrust law.     

Constitutional rights versus malpractice insurance settlements

The increasing costs and complexity of malpractice litigation have created an statutory right that allows malpractice insurance companies to settle malpractice claims regardless of the desires of the defendant physician. In the past, the consequences of settling a malpractice claim out of court were not as important as they are today. The Health Care Quality Improvement Act of 1986 mandates that any settlement in behalf of a physician be documented in the National Practitioner Data Bank (NPDB), which must be consulted every time the physician is credentialed. This NPDB requirement denies due process to health care providers and thus becomes a violation of the federal and many state constitutions. Physician executives and medical leaders must bring these issues to the table and negotiate solutions before damage to practicing physicians and the U.S. health care delivery system caused by this legal paradox become too severe.     

Physician credentialing. A centralized verification system

The current system for credentialing physicians in the U.S. is staggeringly redundant, prone to error, and expensive. The process for establishing a recent graduate's practice can involve an average of five applications to have privileges at several hospitals and HMOs. A centralized verification system needs to be developed to streamline this process. The amount of information that would have to be stored for all physicians in the country would be immense. However, the technology currently exists to store such information on a much grander scale. Credit unions, banks, and insurance companies utilize such computer systems effectively and with reasonable confidentiality.     

Physician fee-setting requires scrutiny.

To avoid antitrust liability from physician fee-setting in HMOs and PPOs, participating physicians should share the risk of profit and loss. "Health Law" is a regular feature of Physician Executive contributed by the law firm of Epstein Becker and Green, P.C. Douglas A. Hastings, Esq., a partner in the firm's Washington, D.C., offices serves as column editor.     

The medical director as educator: an interview with Elizabeth M. Gallup, MD, JD, MBA. Interview by Richard L. Reece

Richard L. Reece, MD, interviewed Elizabeth M. Gallup, MD, JD, MBA, on July 9, 1999, to talk about the evolving role of the physician executive. Dr. Gallup discusses how medical directors have evolved from a purely clinical role to participating in the business side of medicine as well. The traditional medical director, a Dr. No who denies treatment and watches clinical performance, is now becoming an educator helping physicians to manage their behavior and change their practices based on comparative data. Her book, How Physicians Can Avoid Surrender and Lead Change: Gaining Real Influence in Your Own Health Care Organization Before It's Too Late, (American College of Physician Executives, 1996) promotes acting together as a group if physicians want to stay independent and not become employed. Independent physicians can form IPAs and act together as a group, avoiding some antitrust laws. Unless physicians get together and act as a group, she says, they are doomed to further and further erosion of their economic interests as well as their clinical autonomy.     

The National Practitioner Data Bank: the first 18 months

In response to a need for information on the quality of professional practice and a perceived threat to the preservation of the peer review process, as well as to concern about the cost to society of incompetent physicians, Congress passed the Health Care Quality Improvement Act of 1986. The Act established a legal basis for protecting peer review and quality assurance activities. It also established a national reporting system, the National Practitioner Data Bank (NPDB), which is intended to ensure that appropriate information is available to be used in the peer review process.     

How to fire a physician

How does one fire a physician? In a word, carefully! Most of the legal protections for other employees apply just as well to physicians. And physicians have access to an expanded realm of protections because of the nature of their profession and because of its role in the health care delivery system. The ordinary employee cannot raise antitrust; the fired physician may very well raise just that issue. And yet the need to terminate a physician will sometimes, even though rarely, occur. How can the organization be certain that it has treated the physician fairly, has documented any and all offenses in a defensible fashion, and has generally followed accepted practices in all aspects of dealing with the physician? The author provides some guidelines for dealing with the problem or the incompetent physician.     

Developing loyal physicians: a five-point plan

Now, more than ever, health care centers are forced to compete for physicians. There could be no greater argument in favor of establishing the position of Vice President for Medical Services. A physician executive is infinitely more qualified and better prepared to understand the probable reaction of different types of physicians when "loyalty" to the organization is the central issue. The Vice President for Medical Services seems best positioned to remind the Chief Executive Officer and the Board to keep sight of the legal, and moral, duty to "exercise reasonable care in the selection of a medical staff and in granting specialized privileges," including selecting practitioners who are "worthy in character and matters of professional ethics."     

Constructive tension: hospital/medical staff relations.

The missions of the hospital and its medical staff are not the same. The only reason for a hospital to exist is to provide a support system for physicians. It is in the best interests of patients and the public for physicians not to become "organization men." In turn, however, it is incumbent on physicians to show restraint in the provision of costly services. The guiding principle must be the selection of what is most relevant to the improvement of services to patients.     

'90s may be decade for physician payment reform

The '80s in health care were characterized by reform of Medicare payment for hospital services. The '90s are likely to be characterized by reforms in the manner in which physicians are paid for services to Medicare beneficiaries. In this article, the authors examine the steps that are already under way or proposed for reforms in the payment for physician services under Medicare.     

Physician-sponsored networks. Will physicians take back medicine?

Until about the late 1980s, American physicians and their allies, hospitals and the health care manufacturing industries, dominated all facets of the health system--the clinical, the economic, and the political. The bulk of these providers' revenue flowed to them from a highly fragmented insurance system whose governing principle was to provide each insured patient free choice of doctor and hospital. Two distinct, concurrent shifts threaten to erode the medical profession's traditional dominance. The first is a rapid, general shift of control from the supply side of the health sector to its demand side. The second is a shift away from government control, over which organized medicine held much sway in the past, toward private regulators--the executives of the managed care industry. Is the trend towards greater dependence of practicing physicians on non-physician executives inevitable, or can physicians retain--and, in part, regain--their hitherto autonomous position in the health system?     

Linking Electronic Medical Records Use to Physicians’ Performance: A Contextual Analysis

Electronic Medical Records (EMR) studies have broadly tested EMR use and outcomes, producing mixed and inconclusive results. This study carefully considers the healthcare delivery context and examines relevant mediating variables. We consider key characteristics of: (i) interdependence in healthcare delivery processes, (ii) physician autonomy, and (iii) the trend of hospital employment of physicians, and draw on theoretical perspectives in coordination, shared values, and agency to explain how the use of EMR can improve physicians’ performance. In order to examine the effects of physician employment on work practices in the hospital, we collected 583 data points from 302 hospitals in 47 states in the USA to test two models: one for employed and another for nonemployed physicians. Results show that information sharing and shared values among healthcare delivery professionals fully mediate the relationship between EMR use and physicians’ performance. Next, physician employment determines which mediating variable constitutes the pathway from EMR use to physicians’ performance. Finally, we highlight the impact of shared values between the hospital and physicians in enhancing information sharing and physicians’ performance, extending studies of these behaviors among network partners in industrial settings. Overall, our study shows that EMR use should be complemented by processual (information sharing), social (shared values), and structural (physician employment) mechanisms to yield positive effects on physicians’ performance.     

Medicare private contracting: increasing patient choice and access?

Congress modified the Medicare program through the Balanced Budget Act of 1997 to expand patient choices for payment to physicians and certain other practitioners by allowing private contracting. This represents a shift in policy that has broad consequences for health care financing and program integrity. The effect of private contracting on quality and access to care remains unknown. Quality and access should be the most important measures of its success or failure. Out of pocket costs to seniors and vulnerable patients must also be watched closely.     

Associations between stress at work and attitudes towards retirement in hospital physicians

There is a need to understand the associations between attitudes towards retirement in specific occupations and various psychosocial and work-related factors. This study identified correlates of retirement thoughts and retirement preference in hospital physicians. The sample comprised 447 (251 male and 196 female) physicians from three hospital districts in Finland. After adjustment for gender, age and salary, minor psychiatric morbidity increased likelihood of retirement thoughts and retirement preference. Retirement thoughts and retirement preference were more common in doctors reporting low job control, poor teamwork and unjust supervision than in doctors perceiving their working conditions more favorably. Work preference was associated with high overwork. The associations of work characteristics with retirement thoughts and retirement preference largely persisted after control for indicators of health and social circumstances. In conclusion, in addition to demographic and financial factors and health, retirement attitudes in hospital physicians seem to be related to organizational and managerial factors that are potentially amendable to intervention. This has implications for retaining hospital physicians who might otherwise retire.     

What happened, what next?

Many physicians and other health care professionals breathed a collective sigh of relief when the 103rd Congress adjourned without passing the Clinton Health Security Act or any other health care reform legilsation. The ambition of this brief paper is to describe why health care reform did not pass in 1994, the issues that need to be resolved if we are to pass legislation, the political forces that will need to be addressed before legislation is passed, and the type of struggles we can expect to see in the coming session of Congress.     

Associations between stress at work and attitudes towards retirement in hospital physicians

Abstract

There is a need to understand the associations between attitudes towards retirement in specific occupations and various psychosocial and work-related factors. This study identified correlates of retirement thoughts and retirement preference in hospital physicians. The sample comprised 447 (251 male and 196 female) physicians from three hospital districts in Finland. After adjustment for gender, age and salary, minor psychiatric morbidity increased likelihood of retirement thoughts and retirement preference. Retirement thoughts and retirement preference were more common in doctors reporting low job control, poor teamwork and unjust supervision than in doctors perceiving their working conditions more favorably. Work preference was associated with high overwork. The associations of work characteristics with retirement thoughts and retirement preference largely persisted after control for indicators of health and social circumstances. In conclusion, in addition to demographic and financial factors and health, retirement attitudes in hospital physicians seem to be related to organizational and managerial factors that are potentially amendable to intervention. This has implications for retaining hospital physicians who might otherwise retire.     

Locum tenens solve staffing problems.

The use of locum tenens physicians (physicians who work temporary assignments) began decades ago when primary care physicians arranged coverage for their private practices while on vacation. Today, the placement of locum tenens physicians has evolved into a national business. The reason for the increase in the use of locum tenens physicians is because of the benefits they can offer. They can prevent a hospital, HMO, clinic, or physician practice from losing market share due to a gap in medical coverage.