EMMC quality and delivery of care should be addressed

The Eastern Maine Medical Center board of trustees is a policy and governance body. It has delegated quality of care and physician issues to its medical staff leadership. As president of the medical staff, I am the elected leader of that group and represent them in a variety of clinical and administrative forums.

I am disappointed that the Bangor Daily News has been used as a vehicle to raise questions of quality of care, express physician frustration and criticize hospital administration. While the flurry of public and private discussion of medical care at EMMC may be characterized by some as a crisis, I believe it presents us with an opportunity to improve the quality and delivery of care at this excellent institution.

The physicians who have taken their concerns to the press obviously don’t believe that the current Medical Staff structure is effective. This indicates the present structure is flawed and needs to be fixed. At a special Medical Staff Executive Committee (MEC) meeting held Monday we passed the following resolution which I hope will set the stage to allow us to listen to physicians who feel disenfranchised, and allow us to fix our system. I hope the dialog we are opening will convince physicians we are listening, and result in more participation in the process.

The MEC, as the duly appointed and elected representatives of the EMMC medical staff, constitutes the appropriate body for addressing quality issues at EMMC.

The physicians who believe concerns do not make it through the official medical staff or administrative structures will be invited by the president of the medical staff to present a detailed summary of their concerns regarding infrastructure, access, and quality to the MEC at a date and time to be determined, with suggestions for potential remedies.

The chair of the board of trustees and the chair of the Board Quality Committee be invited as guests to that meeting.

Members of the MSQPAC (Medical Staff Quality and Professional Affairs Committee) that do not sit on the MEC be invited as guests to that meeting.

With this motion, the MEC affirms its commitment to work collaboratively, within the established Medical Staff structures and processes, with all physicians, in an effort to improve the already high standard of care at EMMC.

In addition to this initial meeting, I plan to provide an open forum for all Medical Staff members to express their concerns and bring forward their proposed solutions.

While I feel confident we will improve communications within the medical staff through these internal steps, BDN readers may still be confused or concerned by the sense of discord within the medical community. As we physicians turn inward to resolve our issues, I would like to explain where I believe some of the physicians’ concerns come from.

There are pressures to deliver health care services more quickly. This is more than insurer/payer pressure to save dollars. Physicians are trained as scientists, and we understand from the data that certain diagnoses have improved outcomes if treatment is expedited. In addition, treating physicians are very aware of expectations for quick action – expectations from the referring physician, as well as the patient and their family.

Across the nation, there is a decreasing supply of non primary-care specialists. Physician work force projections and the managed care movement have resulted in the training of fewer non primary-care specialists. Adding to the supply pressure of decreasing graduates is the increasing early retirement of physicians who have worked hard their entire careers and are ready to leave both the rewards and stresses of medicine behind.

It is more difficult to recruit physicians to Bangor. Due to complex reimbursement formulas and increasing levels of nonreimbursed care, private physicians have a lower income potential in Bangor than they would in larger cities. Due to our area’s smaller and somewhat weaker economy, physician’s spouses or partners, who often have advanced college degrees as well, have fewer employment opportunities. And while those of us who have been attracted to Maine for its quality of life love it here, some physicians more accustomed to Boston or Chicago find Maine to be somewhat socially and culturally isolated.

Most tertiary care (highly specialized) hospitals have multiple residency programs. EMMC has somewhat uniquely attracted a breadth of specialists without a major medical school nearby. Its only residency is family practice. Other tertiary hospital medical staffs are often directly linked to medical schools, and have multiple residents who provide first line evaluation and treatment. EMMC does not have this resident infrastructure to lighten the load for active staff, especially on evenings and weekends.

Patients are being transferred to EMMC sooner. Economies of scale dictate that the highest technology be located centrally so it can serve a wider regional population. Also, due to the limits of staffing and reimbursement, our region’s rural hospitals can’t keep more complex cases for long periods of time. These factors necessitate the transfer of patients to the more specialized resources of EMMC sooner.

Reimbursement is decreasing. While noted several times above, this factor deserves its own clear statement. Maine’s population has higher percentages of Medicare and Medicaid patients, whose coverage often does not meet the physicians’ cost of delivering care. Maine also has a high uninsured population that may find it difficult to pay for the care they receive. In addition, private insurer’s fees schedules are not keeping up with inflation. Added together, physicians are having a harder time covering office overhead and debts from their medical education, while sustaining a desirable life style.

Hospitals are bureaucracies and private practice physicians are entrepreneurs. Nationally, as well as locally, many physicians find interacting with the hospital culture time consuming, slow to act and cumbersome.

Physician attitudes are changing. The physicians of our parents’ generation were willing to put up with the nightly calls and weekend work in order to be a doctor. A new generation of physicians – and I am not being critical, since I am one of them – increasingly expect more balance between their personal and professional lives.

The physicians frustrated by these pressures have called upon EMMC for financial help. At first glance, this seems reasonable since EMMC wants to maintain its tertiary reputation, and because EMMC has endured the same reimbursement pressures while maintaining its solid financial position. But the potential exchange of a hospital’s nonprofit revenues with private physicians – who, for the most part, are independent for-profit businesses – calls a number of legal and political questions to mind. These include the following.

Federal laws narrowly limit the opportunities for hospitals to subsidize private practice physicians. Some highly respected hospital administrators elsewhere in the nation have become convicted felons over the well-intended policies they put in place. How can EMMC avoid breaking the law while helping its private physicians?

Physicians often choose private practice over employment to retain their autonomy. Will private physicians sacrifice any autonomy by accepting the hospital’s support?

Which private practices get financial support, and which do not? How are priorities set, and who decides allocations?

The strains on physicians often result from emergency cases. One solution is for the hospital to hire physicians who can help cover those cases. But these employed physicians will often also need to care for non-emergent patients. Will their inclusion in the medical community affect the private physicians’ opportunity to generate income in their practices?

If the hospital diverts funds to support private physicians, fewer capital dollars will be available for the newest technology. The medical staff and the communities we serve expect EMMC to have the newest equipment available, so how will the hospital and its doctors balance these competing priorities?

I can’t answer these questions yet, but I am confident that with improved communication with the medical staff, working with hospital administration, and with the guidance of the board of trustees, we will. I believe that in the long run the changes caused by this “crisis” will provide us the opportunity to deliver the best quality care possible at EMMC.

James A. Raczek, M.D. is a board- certified family physician. He is the elected president of the EMMC medical staff, chief of the EMMC Family Practice Service and is employed as the administrator of the EMMC pharmacy and the Diabetes, Endocrine and Nutrition Center. He maintains a medical practice at the EMMC Family Practice Center.