Close the Hospital, Fire the Physician: The Case For Harshness in Healthcare

Compassion is upheld as a central virtue in healthcare. But what the $2.8 trillion industry that fatally harms upwards of 440,000 patients per year might need is a good dose of mercilessness — toward itself.

Subpar hospitals will need to close. Bottom-tier physicians (if hospitals even know which ones those are) need to be fired, or their contracts should not be renewed. Patients and their families should stop donating money to hospitals, especially if said money will fund something like an expanded waiting room.  

These were some of the ideas brought up at the Aspen Ideas Festival last week during a panel discussion featuring Toby Cosgrove, MD, CEO of Cleveland Clinic and Jonathan Bush, CEO and co-founder of athenahealth. There is plenty of talk about healthcare becoming more accountable, but Dr. Cosgrove and Mr. Bush explained what that really looks like. (And it has nothing to do with an ACO.)

The first issue? We have too many hospitals. This has been raised by a few different thought leaders (Dr. Zeke Emanuel's take was especially interesting). Our volume-driven system extends beyond tests and procedures ordered. We've come to think that a country with more hospitals is a healthier one, which is faulty logic. Mr. Cosgrove threw out some statistics: The hospital occupancy in the United States right now is 65 percent. There were a million hospital beds 20 years ago. "Now there are 800,000 and we still have too many," he said.

Mr. Bush agreed, saying the weak links in healthcare need to go on and become something else. It's easier said than done, of course. It will hurt, and communities will feel the pangs. It's analogous to America's sensitive problem with end of life care: Are we keeping something or someone surviving rather than thriving? Is it time to let nature run its course?

Mr. Bush said yes, and he brought up another ruthless idea: Patients and families should stop donating money to hospitals. "I don't care if they name a pavilion after you," he said. "You're a murderer if you donate."

It's some provocative language, but I think what he's saying is this: If a hospital can't stay open and offer high-quality care by its own merits — if a patient's donation is somehow involved in the likelihood of such — maybe it deserves to close. Donations may keep subpar, even low-quality hospitals on life support. Patients go to these places for care, but also for medical errors and patient safety issues, which can ultimately kill them. (There's where the murderer accusation comes in.)

Another harsh reality? "When the nuns or the community hospitals come to Washington to ask for a bailout — because they will, because they will close, because they must — do not let your congressman bail them out," said Mr. Bush. "It's going to be very painful for your congressman, because they have tons of jobs and they're not exactly sure where those people in the hairnets and the smocks are going to go next. And they're terrified. But they must go somewhere else, because they are hurting their patients, they are shortening their lives, they are dehumanizing and they are making the product too expensive."

So where would patients go if their community hospital closes? Ideally to one that is much better and specialized at the type of care they need. Dr. Cosgrove said hospitals must give up the notion that they can be all things to all people, and we must recognize that hospitals were born in a time when their functions and means of transportation were quite limited. "Now we have great transportation and very sophisticated things you can do in a hospital," he said. "So move the patients to the place."

Cleveland Clinic is the poster child for this, as people from across the country travel to the Midwest town for cardiothoracic surgery.

Mr. Bush said Cleveland Clinic has mastered this surgery to such an extent that "there are not enough hot dogs in Cleveland to get all the hearts to Cleveland Clinic." He said Mr. Cosgrove essentially went to large, self-insured employers and said, "'Listen, I actually do a lot of these [heart surgeries], I mess them up less and I got some capacity. I'll fly them in and do it for less than it's costing you to do them in the community hospital two times after you fix the first one.'"  

And finally, Dr. Cosgrove talked about the way Cleveland Clinic treats its 3,200 physicians. "As far as I know, we're the only hospital system in the country that has one-year contracts and annual professional reviews for the physicians," he said.

The system is serious about both: Last year 8,000 man hours were spent on physicians' professional reviews, and some one-year contracts were not renewed. "We expect productivity, and if somebody is not producing in whatever their obligation to the organization is, they may not stay with us," said Dr. Cosgrove. Cleveland Clinic also force ranks physicians in a transparent way, so everybody knows who is best, average and below average. "We force rank them into top 10 percent (who we should celebrate), the middle and the bottom, who we should either move up or out."

Move up or get out; get better or get gone: That's the type of language healthcare needs more of. For all the talk about patient-centered care, compassion and "first do no harm," this industry has a tendency to exert extra compassion on itself rather than functioning more visibly like a business driven by forces like any other.

The thoughts mentioned above aren't pretty, but bright minds are talking about them with urgency and excitement. Closing hospitals, firing doctors, hanging up on calls for donations: It sounds reprehensible, except it's not at all. It's the new reality. It used to feel crass to talk about healthcare with business lexicon, but it's getting easier and easier by the day. This isn't good news to hospitals that have been asleep at the wheel, masking their faults with do-gooder hyperbole about their missions. People may not have much patience for that fluff too much longer.


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