American Medicine – Play Nicely

I have written much about what is wrong with the American healthcare system.  Many of the problems, I believe, are systemic.  Change the system, and there are many problems that will go away.  Today, however, I encountered a problem for which there are no solutions.

Human nature.

Our practice has been very involved in working on the cutting edge of change.  We were early adopters of EMR, blazing a trail for many who have followed.  We have struggled hard to make a system that works better within the current payment system and have largely succeeded.  We are in the top quartile of pay among primary care physicians and have done so while achieving a quality of care that surpasses that of most other offices.  We have been recognized nationally for both our use of EMR (receiving the Davies Award from HIMSS) and for our quality (recently becoming certified for the Diabetes Physician Recognition Program from NCQA).

Through all of this we have always maintained an attitude of sharing with other practices.  Why should others have to go through the hard things if we know a way around them?  The templates and work solutions we have developed for our office have always been freely shared with other offices that asked for them.  My reasoning was that the real goal was not for me to pull ahead of other offices, but to improve care.  It does not hurt me for other offices to succeed.

Some have made a business out of innovation – selling the innovations to others.  I have no problem with this, but I really don\’t want to do anything besides practice medicine.  If I find a better way to do so, I don\’t see any reason not to share.

Today we were given notice that one of our nurses had accepted a job at another primary care office in town.  This office uses the same EMR system that we do and has had members of their staff visit office several times to learn from us.  We have helped them with clinical content and interfaces (although they always seemed reluctant to take advantage of our offer to help).  Apparently this office has realized that our nurses are being well-trained on the EMR system and have "targeted" them.  I am not sure exactly how this is (I am taking the word of my office manager – who is not quick to jump to such conclusions), but if this is true I am deeply saddened.

The fact is that this group has the reputation for not playing nicely with others in the community, seeking their own success at the expense of other practices in town.  I won\’t go into details (as I don\’t know who will read this), but they have engaged in what I have seen as a larger subset of physician groups across the country that I call empire builders. 

The main goal of an empire builder group is not to succeed, but to dominate.  They want to be the one who calls the shots when it comes to managed care contracts, hospital rules, and medical societies.  The initial impetus for this is reasonable: insurance companies won\’t pay attention to you when you have minimal market share.  If you have enough market share, you have a much stronger negotiating position when it comes to contracts.  You can threaten to walk away from the table and have it be a genuine threat to the payer or hospital.  Given how powerless primary care physicians feel, this is certainly an understandable position to take.

The problem occurs when they move from seeing the insurance company as the adversary (which they basically are) to seeing other primary care physicians as adversaries.  Undermining other groups\’ success is another way to increase your market share.  I have seen this not just in primary care, but in specialty groups, and in towns divided by loyalties to different hospitals.  Successful physicians look at other groups and envy their success.

What\’s wrong with that?  Isn\’t it just capitalism at work?

Yes and no.  If this were a saturated market for physicians, all gains in business would necessarily have to happen at the expense of other physicians.  In primary care (in our area), however, there are more than enough patients to go around.  Why hurt other offices when you can succeed without doing so?  Do we always have to cringe when other physicians achieve great success?  What is it in the human heart that makes it so important to be the "king of the mountain?"

My partner made the comment: "well, that\’s the last time we will share anything with them!"  While I find myself agreeing with his emotion (and am reluctant to be so freely generous with this group), I hate the fact that I want to engage them at their own level.  Wouldn\’t joining in their rock-throwing game simply justify more bad behavior on their part?  Yet I don\’t want to be a sucker either.

For us to mount a successful assault at the real enemy: the dysfunctional system; we need to stop fighting among ourselves and understand that raising the water level will raise all the boats.  If we change the method of reimbursement, eliminate waste, or come up with a more efficient delivery system, we will all taste more success.  A house divided cannot stand.  If the ACP, AAFP, AMA, and AAP all have different agendas, we won\’t go far in making real change.

Can we just play together?