Physicians, administrators clash over efficiency

Oregon doctors unionize for greater leverage on administrative policy
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By Matt Kuhrt

When a healthcare system in Oregon sought to outsource its hospitalists, the physicians currently employed in those roles opted to unionize to resist the move. The move worked, in the sense that the system abandoned its outsourcing plan, but the continuing negotiations bring into sharp relief the struggle for efficiency, and the very different things that word means to doctors and administrations, as documented in an article in the New York Times.

The primacy of a doctor's reliance on his or her own professional judgment can make an efficiency target linked to a financial metric into a perverse incentive or an outright affront, in part because the definition of "quality care" depends on how it's measured.

Rajeev Alexander, M.D., explained to the newspaper that he sees the doctor-patient relationship as a hospital's unit of production. This coincides with the unionized doctors' indicated preference for less work and less pay during negotiations with the healthcare system. Their concerns tend to be focused on avoiding physician burnout, and they frequently see added administrative overhead as actively disrupting their relationships with patients.

When it comes to efficiency and flashpoints such as staffing ratios, this perspective can make common ground difficult to locate. For administrators bent on trimming costs, financial incentives may ultimately be the only ones that matter. The doctors, therefore, have become frustrated with administrative proposals based on the premise that they need a financial stake in the hospital's performance in order to be sufficiently motivated to do their job efficiently.

"Every single time we walk up to a patient, everything is on the line," said David Schwartz, M.D., underscoring the suggestion that doctors don't lack sufficient incentives so much as their employers may not understand their priorities and incentives appropriately. "You come down and make a decision about my patient, then we'll talk about skin in the game."

To learn more:
- read the story in the New York Times

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