Recent hospital Board/medical staff confrontations over loyalty and competition have ripened into full blown warfare and some hospitals in California, Arkansas, Ohio and Idaho have declared war and have imposed restrictions and loyalty oaths on their medical staffs that would make even John Ashcroft blush. See "Hospitals Take No Prisoners," Modern Healthcare, February 16, 2004 p. 10.
There are a number of retaliatory strategies that can and are being implemented by hospitals against the perceived disloyalty of medical staff members. Hospital strategies include one or more of the following.
1. Execution of loyalty oaths as a condition of medical staff membership.
2. Exclusion of physicians holding financial interests in competing facilities from participation in leadership positions within the hospital.
3. Removal of physicians who hold competing financial interests and who demonstrate a change in referral patterns in either volume or payer mix from the medical staff.
4. Recruiting competing specialty providers to provide direct competition to disloyal physicians.
5. Requiring certain patient volume levels sufficient to insure "safety" of patients by presenting a fair opportunity for the hospital to evaluate and judge competency. ("Economic Credentialing")
6. Negotiating exclusive contracts with third party payers to use only the physicians on the hospital's medical staff that are part of the hospital's approved provider organization or alliance.
7. Lobbying against physician applications for Certificates of Need (in CON states).
8. Lobbying for the recomposition of Certificate of Need legislation (in non-CON states).
9. Attempting to direct and control referrals by medical staff to only "loyal" physicians.
10. Lobbying for moratoriums on physician owned "whole hospital" exceptions to Stark and Anti-kickback legislation.
11. Commencement of close "peer review" audits and review of disloyal physicians.
The hospitals in which these kinds of retaliatory measures are implemented tend to have a number of characteristics in common.
First, the hospital administration embraces a "command and control" leadership style supported by a CEO with a huge ego who identifies himself or herself as being "the Hospital."
Second, there is a complete breakdown of trust at all levels within the organization, particularly between the administration and the medical staff.
Third, communication and understanding of accurate financial information concerning the hospital is largely absent.
Fourth, physicians feel disenfranchised, under appreciated and often misled by hospital administration.
Fifth, there is a disconnection between physician leadership favored by administration and large segments of the medical staff who perceive their favored colleagues as being in the pocket of administration.
Sixth, there are few, if any established relationships between the hospital board and the "producers" on the medical staff.
The downward spiral of relationships and conflict are reminiscent of the foolish fumblings of European diplomats toward the Final World War described by Barbara Tuchman in The Guns of August. The use of tactics of the business equivalent of war by a hospital against its own medical staff should be unleashed only in the direst of circumstances, if ever. Often the value of economic power is based on its "in terrorem" effect, which can and frequently does dissipate with use. Economic war is indeed a failure of diplomacy and rarely leads to satisfactory results, particularly in the context of a necessarily symbiotic relationship between a hospital and its medical staff. Hospitals might be well advised to observe the warnings of Winston Churchill on the vagaries of war in My Early Life: A Roving Commission.
"Let us learn our lessons. Never, never, never believe any war will be smooth and easy, or that anyone who embarks on that strange voyage can measure the tides and hurricanes he will encounter. The Statesman who yields to war fever must realize that once the signal is given, he is no longer the master of policy but the slave of unforeseeable and controllable events."
George Foreman now frequently describes the deflating effect on his emotions when he fought Mohammed Ali in Zaire when he hit Ali with a punch "that could stop a Buick." Ali, after absorbing the punch taunted Foreman with the question, "Is that all you got George?" Foreman now answers the question, "Well, yes, that's about it."
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