Authors: Eric Lister, MD and Todd Sagin, MD
Publisher: – Health Administration Press – 232 pages
Book Review by: Nano Khilnanai
The authors of this book point out in the Preface itself that the health care system in the United States needs to improve dramatically in three basic ways.
At the very core of this system are the provider and the recipient of care: the doctor and his patient. This book deals essentially with how to deliver care to the satisfaction of the patient and his doctor in terms of best outcome or effect, reasonable cost, and overall enhancement of health.
Drs. Lister and Sagin show that when the characteristics of such ideal care are achieved in the basic unit of care, which is the doctor-patient relationship, all the other people and institutions involved in health care – the patients’ families, the hospitals and their staff members, the employers, the insurers and other entities – benefit.
In this book, they lay out their plan to bring about lasting positive change in the United States health care system by improving one critical aspect of health care: the hospital-doctor working relationship. They look at the different types of employment arrangements and compensation that have existed over the past, how they have changed, and what exist today. They spell out the advantages and disadvantages of each type.
Then they point out what elements must exist in the most ideal working arrangement, that redound to the benefit of all units of the health care system in the U.S.
Dr. Eric Lister is managing director of Ki Associates and he lectures and consults around the country on physician leadership and how to achieve success in hospital group practice. He is an advisor for The Governance Institute.
Dr. Todd Sagin is a co-founder of HG Healthcare Consultants, and is a popular speaker. He is also a regular faculty member of the Governance Institute, where he is a principal advisor and lecturer for its Medical Leadership Institute.
They state that a study in 2008 by Don Berwick and his colleagues concluded: in order to reform the U.S. healthcare system, three aims must be pursued simultaneously from the ground up (and not from top down): improve the experience of care, improve the health of the population, and reduce the per-capita costs of health care.
How are these aims to be accomplished? Drs. Lister and Sagin unequivocally state that “we must develop new models of care delivery that powerfully integrate critical resources.” They discuss in this book how to create those new models of care.
Principally, they strongly urge the widespread creation of group practices owned by physicians that would partner with the hospitals. This makes better sense than ownership by hospitals of physician group practices. This also makes better sense than direct employment of physicians by hospitals, they state, citing their years of experience on the adverse effects of hospitals controlling and running physician groups.
They point to the 1980s and early 1990s when “hospitals took huge losses and wound up divesting the practices they had purchased at a dear price only a few years earlier.”
The latter case – direct employment of individual physicians by hospitals – has not helped keep down the cost of care, which is a critical need in this country. Rising cost of hospital stay and the atrocious cost of medication and treatment, coupled with the rising cost of the middlemen – the health insurance companies – have imposed unbearable burdens on companies and individuals.
Drs. Lister and Sagin also point out the financial and time constraints placed upon physicians in solo practice. There is widespread and valid complaint by doctors that the pressures of managing the business aspect of their solo practices leave them less time on patient care and treatment. Decreasing payments from health insurers and Medicare have lowered their revenues. And the increasing burdens of staff salaries, equipment purchase and financing, malpractice insurance premiums and all other operating costs have put a squeeze on their net income.
We believe that as long as the financial interests of health insurance firms and the increasing cost of administering the government’s Medicare and Medicaid programs collide with those of the other people involved in the system – hospital administrators, doctors and patients – it would be difficult to find bring overall costs down. Only a situation wherein all parties win, can be beneficial to all. But how do you create such a desirable situation?
This book focuses on how to improve one aspect of the health care system equation: the hospital-doctor-patient relationship in terms of care and cost. But it does not address the issue of hospitals’ and doctors’ declining payments – for services rendered to their patients – from health insurers and government agencies involved in health care.
Nor does it address the care recipients’ rising financial burden caused by the insurance cost as well – the insurance that is a must these days for anyone in the U.S. to receive treatment, except for emergency care in a hospital. Those aspects of health care – their causes and their solutions – are, I suppose, too complex and detailed to be addressed in this book. We would urge readers to look at works by experts in those areas.
At one time in the past, you will recall that the cost of health care was quite reasonable when HMOs and PPOs were not in the picture. The salaries of executives and rank-and-file employees, operating expenses and the profits derived by these organizations have greatly added to the burden of health insurance expense on you and your employer, evidenced by relentlessly-rising insurance premiums year after year, sometimes in the double digits.
This book looks closely at the hospital-physician relationship within the tripartite equation, while keeping in mind that their mutual goal is to provide quality care to patients.
The authors make a case in this book that well-organized physician groups (with a multiple of specialties in each group) that would partner with hospitals, is the most ideal arrangement, to deliver optimal care to patients. They offer their guidance and recommendations on how best to achieve this, based on their education, experience and wisdom gained from their long years in medicine.
They have divided their book into four well-organized parts:
Part I gives the reader an overview of the hospital-physician working relationship that has evolved over the years and what factors have affected the development of the physician workforce.
Part II explains the differences between straightforward individual physician employment by hospitals on the one hand, and on the other, the employment of groups of physicians or hospital group practices, as they are commonly called. It explains why the latter arrangement has been mutually more satisfactory.
Part III points out what must be done by the members of the hospital group practice to achieve higher standards of care, so they can have an advantage in quality, service and operational efficiency over the medical staff of a hospital.
Part IV provides the conclusion that group-led health care systems are best positioned to provide superior care – care that is seamless and integrated. It also gives the reasons why.
This is a very well organized book written with great insight. It provides a strong foundation for its principal thesis, and ample evidence based on historical perspective, that it works best. Along with this, a detailed path is laid out by Drs. Listen and Sagin on how best to develop a successful, well-functioning hospital group practice. I urge you all to read it.
