When I first became involved in healthcare—a very long time ago—I tried to compliment a hospital administrator who had just completed giving me a partial tour of his facility. He replied with a statement that I’ve heard many times since from others in similar shoes.— “You know,” he said, “we could run a really good place here, if it wasn’t for doctors and patients.”
He meant, of course, to be at least partially facetious. But his words arose from attitudes that were remarkably common not so long ago. While physicians were necessary to the very function of a hospital, the medical staff was all too often perceived (not always inaccurately) as self-centered, narrow in focus and concern, and obstreperous. Hospital administrators, on the other hand, were trained in management and paid to look rationally at the big picture, taking seriously their responsibility to meet payroll and keep the doors open, however difficult that might be. In order to survive economically, hospitals and physicians needed each other, but neither side had to especially like it.
The world has changed. Healthcare providers are increasingly expected by governments, private payers, and the general public to assume clinical and financial risk in the care of their patients. As value-based payments increasingly extend that risk away from single episodes of service to the patient’s or community’s health status over time, hospitals and their affiliated physicians gradually share increased risk, whether they want to or not. And as more clinical services can acceptably be provided in non-inpatient settings while the population as a whole becomes healthier, a growing proportion of all physicians can maintain successful practices without venturing inside a hospital for weeks or months at a time as hospital-based care is increasingly provided by full-time hospitalists, intensivists, emergency physicians, and nurse clinicians with advanced training. But regardless of the physical distance, the economics of value-based payments make doctors and hospitals financially interdependent.
The most successful hospitals —large and small, urban and rural, academic and non-academic— are and will continue to be those in which administrators and attending physicians work well together, share common goals clinically as well as economically, and have established procedures for conflict resolution and crisis management.
The actual form of those relations can and will differ from one place to another. In some, the majority of the physicians will be hospital employees or full-time contractors; in others, the hospital will have an exclusive arrangement with an independent, self-governing group practice or an independent practice association; while other hospitals will operate successfully with an organized medical staff composed largely of small groups and solo practitioners. Every community has its own medical culture, or several. But however much hospital administrators or practicing physicians may still fantasize about divorce, they can’t live without each other, and they can only prosper as partners.