Commentary: Scrubs united with suits to provide quality care and profits

Central MessagePhysicians and administrators need to listen more carefully to one another. Physicians need to be more flexible and more quickly adopt better practice patterns that deliver better quality care at a lower price. Similarly, administrators need to present accurate data that measure clinically meaningful metrics, like the EQI that inspires change.See Article page 690. Physicians and administrators need to listen more carefully to one another. Physicians need to be more flexible and more quickly adopt better practice patterns that deliver better quality care at a lower price. Similarly, administrators need to present accurate data that measure clinically meaningful metrics, like the EQI that inspires change. See Article page 690. Physicians too often see administrators as solely pecuniary, and administrators too often see physicians as dogmatic and unwilling to change. As a previous Executive Vice President and Chief Operating Officer for 5 years at a $9 billion healthcare system while concomitantly practicing thoracic surgery for more than 25 years, I have come to learn the truths and falsehoods of both views. In reality, whether we wear scrubs at work or a suit, we are aligned to deliver the highest quality care with the best experience at the lowest cost to our patients. We are all on the same side, the patient's. As Dr Ashrafi and colleagues1Ashrafi A. Atay S.M. Wightman S.C. Harano T. Kim A.W. Estimating revenue, costs, and operating margin of any hospital-based thoracic surgery practice using a novel financial model.J Cardiovasc Thorac Surg. 2023; 166: 690-698.e1Abstract Full Text Full Text PDF Scopus (1) Google Scholar have adroitly shown in their well-written article, one can devise a financial model that estimates the contribution margin from thoracic procedures contingent on the payers in the United States. Doctors and surgeons should know that the reimbursement fee from private payors is a negotiated price. It is often fixed after the negotiation of rates are locked in via a 4- to 5-year contract with slight increases per year (if we are lucky). These minimal increases usually do not match the increasing price of the cost of doing business each year, especially with the escalating labor and supply chain costs that have occurred recently. Physicians also should know that of the many clinical programs that most hospitals or academic medical centers offer, only 3 or 4 actually are profitable. Even more concerning is that it is only those patients in these highly selective services who have private insurance (which is often only 20%-40% of that book of business) and generate the majority of the income that pays for our entire academic medical enterprise and mission. This small fraction of our overall services must pay for everything, including the labor force and their benefits, research, training, teaching, and the daily upkeep and cost of new expensive infrastructure that is required to keep a medical center and its facilities in code and functioning at the highest level. So what is actionable from Ashrafi and colleagues’ article1Ashrafi A. Atay S.M. Wightman S.C. Harano T. Kim A.W. Estimating revenue, costs, and operating margin of any hospital-based thoracic surgery practice using a novel financial model.J Cardiovasc Thorac Surg. 2023; 166: 690-698.e1Abstract Full Text Full Text PDF Scopus (1) Google Scholar and how can we help as practicing physicians? As they mention, we need to be more keenly aware of our costs and reduce the few that we control. For example, length of stay, total operative time, intraoperative costs including operating after hours using overtime staff, the time of discharge of our patients (8 am is better than 10 am because it impacts patient flow), patient complications, infections, and hospital readmission. These are by far the main determinants of our costs. Physicians' care should be nimble, dynamic, and data driven. However, we must show some vision. The truth is we can do better. As an administrator, our dashboards often illustrate that some physicians have half the operative time and a third of the length of stay for the same care delivered to the same risk-adjusted patient compared with one of their colleagues. Why? How can this be? The answer is too often a physician's eristic dogma and resistance to change. It is not the complexities of our varied practice or the different comorbidities of our patient pools. We can all do better in these regards and stand on each other’s shoulders. If we as a division of 8 diverse thoracic surgeons at New York University Langone, as discussed by Ashrifi and colleagues,1Ashrafi A. Atay S.M. Wightman S.C. Harano T. Kim A.W. Estimating revenue, costs, and operating margin of any hospital-based thoracic surgery practice using a novel financial model.J Cardiovasc Thorac Surg. 2023; 166: 690-698.e1Abstract Full Text Full Text PDF Scopus (1) Google Scholar are able to perform 99% of our lobectomies and segmentectomies robotically, remove the chest tube on the day of surgery in 80% of our patients, and send most everyone home at 8 am on postoperative day 1 (yes some with a chest tube), why can't all of us? For too long, we as physicians have hidden behind the “I'm waiting for the prospective randomized trial” argument, “I do not feel comfortable,” and “It is not safe to.” We can no longer afford to wait for the physician's comfort level to make changes that others in their own healthcare system or hospital have already shown are safe and effective, and do safely every day. Now, some will argue that this is not scalable or that they have a different culture, less resources, different or less expertise, or less support staff. If your partner can perform the operation minimally invasively, or in half the time you do, or if he or she removes the chest tube the day of the operation after lobectomy and segmentectomy or does not even use a tube after a thymectomy, why can't you? The answer is you can. We all have to be willing to question everything we do every day to improve our patients’ care. What can we do as administrators to help? We need to work together better and listen to the doctors we serve better when they ask for resources that will increase the value of our care. For example, they may ask for more minimally invasive platforms or proctors to teach video-assisted or robotic lobectomy skills. Likewise, we as physicians can work better together and get out of our silos. We should round together, share best of practice ideas, and innovate and then implement with vision. We should come into each other's operating room every day and help one another with difficult anatomy. We should discuss new techniques and importantly share more efficient ways to conduct and perform commonly performed operations. We should openly challenge each other in a friendly, positive, and collegial manner to provide patients better care. It is better to go home sooner and earlier in the morning. As administrators, we have too often lost the hearts of the doctors whom we are paid to serve. We have provided them report cards (should we be scoring our doctors or should other doctors to this?) that measure the wrong metrics, used data that are completely wrong, and have failed to understand the differences in physicians’ practices and infrastructure, or how to account for it with risk-adjusted data that make comparisons fair. For these reasons, we created accurate quality metrics and dashboards called the “Efficiency Quality Index” (EQI),2Cerfolio R.J. Chang S.H. Efficiency Quality Index (EQI) – implementing a novel metric that delivers overall institutional excellence and values for patients.Front Surg. 2021; 7: 604916Crossref PubMed Scopus (7) Google Scholar which provides a score for each specific operation or the care of one specific condition. The EQI only measures metrics of quality outcomes that doctors decide are the optimal surrogates of quality for each operation. The EQI only leverages accurate data that are vetted and approved by the doctors.3Cerfolio R.J. Resistance to change from super performers: the EQI, ego and the safety card.Ann Thorac Surg. Published online September 14, 2022; Abstract Full Text Full Text PDF Google Scholar It affords apples to apples comparisons, and once egos are set aside the EQI quickly and fairly improves care to all patients no matter which doctor cares for them. Together, we—suits and scrubs alike—can give patients what they all deserve, the highest quality care at the best value with the best outcomes and patient and family experience. Estimating revenue, costs, and operating margin of any hospital-based thoracic surgery practice using a novel financial modelThe Journal of Thoracic and Cardiovascular SurgeryVol. 166Issue 3PreviewThe study objective was to develop a generalizable financial model that estimates payor-specific reimbursements associated with anatomic lung resections for any hospital-based thoracic surgery practice. Full-Text PDF