For-Profit Enterprise in Health Care (1986) / Chapter Skim
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9 The Changing Nature of Physician Influence in Medical Institutions
9 The Changing Nature of Physician Influence in Medical Institutions
Pages 171-181
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From page 171... ...
Although physicians are responsible for patient care decisions, institutional management and resource allocation decisions made by administrators, managers, or trustees have profound implications for patient care. Such decisions determine or influence, for example, what equipment is available, what services are offered, how heavily and by whom various floors are staffed, what management information system is used and for what purposes, what kinds of utilization review and pre-admission screening the institution uses, and so forth.
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From page 172... ...
the development of payment systems that put hospitals at risk for the economic consequences of physicians' patient care decisions, (5) an apparent increase in medical institutions gaining direct control by employing physicians or entering into contractual relationships with physicians that are little different from an employer-employee relationship, and (6)
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From page 173... ...
The formal responsibilities of hospital medical staffs, or designated members of medical staffs, for institutional quality of care is well recognized (Scott, 1982, JCAH, 19841. Some evidence exists that greater physician participation in hospital decision malting and more highly structured meclical staffs are positively associated with higher quality of care (Flood and Scott, 1978; Palmer and Reilly, 1979; Shortell and LoGerfo, 1981; Shortell, 1983:91)
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From page 174... ...
Many ofthese are undoubtedly in single-hospital communities, where the FOR-PROFIT ENTERPRISE IN HEALTH CARE exit option does not exist; for example, the Hospital Corporation of America estimated that 20 percent of their hospitals in 1983 were the only hospital in the county (Phyllis Virgil, Hospital Corporation of America, personal communication, March 15, 19851. However, the increasing supply of physicians, the growth of alternative delivery systems that control physicians' access to patients, and the predicted decline in the number of hospitals (as a result of heightened competitive conditions in the industry)
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From page 175... ...
If the feasibility of individual physicians shifting their admitting patterns is indeed diminishing, as the committee believes, then other methods of balancing medical concerns with the institution's administrative or economic concerns become more important. However, it should be noted that groups of physicians such as independent practice associations, incorporated medical staffs, or large group practices are increasingly dealing with hospitals; the economic importance of such groups may increase the potency of the exit option.
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From page 176... ...
Finally, for-profit hospitals have particularly low levels of salaried physicians; American Hospital Association data show an average of 0.28 physicians or dentists on the payroll of investor-owned system hospitals in 1982, compared with 6-8 physicians and dentists in freestanding or nonprofit system hospitals and 80 in hospitals that are part of publicly owned systems (Morrisey et al., 1986: Table 10~.6 Thus, on the few dimensions on which data exist, exit options now appear to be more available for physicians practicing at for-profit hospitals than at other hospitals. Although no systematic data are available about the newer arrangements that may make the exit more difficult, the large investor owned hospital companies have taken the lead among hospitals in developing insur
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From page 177... ...
Although few data are available, exit options may now be more limited for physicians in nonhospital settings particularly in the various types of ambulatory care settings and in HMOs where salary and contractual arrangements, reinforced by the growing supply of physicians, may e~ectively tie physicians to the setting. Regarding voice, there are many other mechanisms by which physician influence might be expressed in the form of a fulltime medical director, full- or part-time department chairmen, participation in management committee meetings, and so forth.
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From page 178... ...
In instances in which contractual arrangements exist between institutions and groups of physicians- up to and including the entire medical staff the relative balance of power may well make for effective voice mechanisms. In new types of ambulatory care centers, where it appears that individual physicians are increasingly being hired on salary or contract- frequently in situations in which physicians are hiring other physicians mechanisms of voice may now be in a relatively undeveloped state.
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From page 179... ...
an effective voice in decisions that have implications for patient care concerns will be of growing importance, if patient care concerns are to be effectively advocated in the face of growing economic pressure and managerial power. If physicians indeed find themselves increasingly tied to particular institutions, any lack of confidence on their part in the means by which their concerns are made known should lead to farther exploration of mechanisms by which collective pressure might be brought.
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From page 180... ...
Although the number of employed physicians is growing, recent National Labor Relations Board cases have interpreted physicians to be managers, rather than employees, because physicians sit on various administrative committees within health institutions. On this basis, one recent court decision defined full-time physicians as part of management and part-time physicians as employees with rights to protection under the National Labor Relations Board Act.
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From page 181... ...
Morrisey (1983) A Survey of Hospital Medical Staffs Part 1.
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