There Is Life Outside the Operating Room Charles R. Hatcher, Jr., M.D. Presidential addresses generally consist of “state of the profession” or “state of the specialty” remarks, given from the vantage point of one who has attained a modicum of seniority and is perceived, at least, to have met some of the challenges of the profession with a degree of success. Though tempted to break this pattern, circumstances today compel me to offer such comments. Years ago, you and I perhaps saw medicine as the only profession for us. Given the value placed on human life in Western culture, the physician received the utmost respect and affection from society. No other profession offered such tangible and intangible rewards for service to humankind. We pursued medical knowledge and skill with complete abandon, seeking only what was best for our patients and giving no thought to cost, liability for an imperfect result unrelated to negligence, competition from practitioners less appropriately trained and skilled than we, and competition driven largely or exclusively by the economic environment. While we were in the operating room doing our “thing” and moving from one technical triumph to another, cataclysmic forces within and without medicine have changed the practice of cardiothoracic surgery forever. In the words of General George Patton, “the world grew up and it’s in a hell of a shape.” Having been privileged to assess the current medical environment from a position of leadership, I would like to discuss certain of the challenges we face with you-to present with some reservations possible courses of action open to us-and finally, with your kind indulgence, to recount how I entered ”life outside the operating room” in an attempt to preserve and enhance the practice of cardiothoracic surgery in my institution and in our practice locale. In this era of massive federal deficits, it is not at all surprising that government agencies such as HCFA*seek reductions in health-care costs. Previously content to restrain the rising costs of health care, the federal government is now determined to achieve an absolute reduction in the costs of certain medical services. In 1985, 250,000 patients underwent coronary bypass surgery in the United States, 25% covered by Medicare. Medicare paid out $1.5 billion for coronary artery surgery, or 30% of its total budget. Because of the total dollars involved and the high visibility of the work we do, a reduction in
*Health Care Financing Administration. Presidential Address delivered at the Twenty-third Annual Meeting of The Society of Thoracic Surgeons, Toronto, Ont, Canada, Sept 21-23,
1987. Address reprint requests to Dr.Hatcher, The Emory Clinic, 1440 Clifton Rd, NE, Atlanta, GA 30322.
allowable surgical fees for coronary bypass surgery is imminent. These mandated reductions will, in all likelihood, be put into effect within the next year and are likely to be in the range of 10 to 15%below current fees. It is hard to decry economy in a deficit situation, but The Society of Thoracic Surgeons has questioned HCFA rationale on a number of issues. To those who would anticipate a reduction in bypass surgery fees as a result of increased volume and experience over the past several years, we have responded that the bypass operation of today is not the same operation performed in the 1970s-that improved medical therapy and angioplasty have relegated surgery to the older, sicker patients with advanced coronary artery disease and frequently associated medical disease, thereby making surgery more difficult, more time consuming, and more frequently associated with serious complications. Additionally, there is the need to achieve as complete revascularization as possible, hence an increase in the number of grafts per patient and the desire to provide maximum long-term benefits dictating a general increase in the use of internal mammary arteries. We have indicated our pride in low surgical mortality even in the patient population of today, but we have cautioned against the overzealous interpretation of raw mortality data lest we denigrate surgical procedures that are properly indicated and well performed. Overemphasis on mortality statistics could result in the future denial of surgery for patients in highrisk clinical subsets. Last, we have deplored the use of such data to seek partisan economic gain or to imply surgical superiority when this may not be justified. Realizing that an across-the-board percentage reduction in allowable surgical fees is politically attractive, we urge that certain inequities be addressed before the application of such a cut. Specifically, I refer to excessive personal and regional variations in fees and the increasingly widespread “uncoupling” of fees. When Medicare was introduced in 1965, it was a political necessity for the government to assure all surgeons that their usual and customary fees would be paid. Individual and regional variations in fees were built into the system at that point and have been maintained more or less intact until the present time. The adjustment of such fee variations, when clearly excessive, should be achieved prior to the application of any across-the-board percentage reduction in fees. While stopping short of demanding a standard national or regional fee for a particular surgical procedure, the American College of Surgeons has nevertheless asked for the adjustment of excessive individual and local fee variations within a given state. With surgical fees frozen or increased minimally in recent years, it is understandable why some surgeons have uncoupled a total surgical fee into a series of fees
117 Ann Thorac Surg 45:117-121, Feb 1988. Copyright 0 1988 by The Society of Thoracic Surgeons
118 The Annals of Thoracic Surgery Vol 45 No 2 February 1988
for the various aspects of surgical care provided. With proper coding and with attention to allowable fees, it is possible to produce an uncoupled fee significantly in excess of a standard global surgical fee for a particular procedure. This itemization is not in the best long-term interests of surgeons, and a standard all-inclusive surgical fee should be reinstated before any across-the-board cuts are applied. It is my impression that the authorities seek reduced expenditures and are not too concerned with reform; therefore you should expect an across-theboard reduction in surgical fees of approximately 10% within the next year or so. Concern about the high costs of health care is not limited to the federal government. Business and industry are attracted to a variety of alternative health-care delivery systems such as HMOs, IPAs, and PPOs. Such systems usually offer a prepayment or fixed-cost feature. Ideally, business would like a reduction in health-care costs. In the interim, knowing what their health-care costs are going to be is an attractive budgetary consideration. In return for the targeted referral of an increased or sustained number of cases, many surgeons have accepted reduced fees. All too frequently, the increased volume of cases does not materialize and the surgeon ends up simply performing his or her work at a discount. Some caution is to be recommended. Since HMOs and such systems must depend on the decreased utilization of expensive services or a reduction in quality of care for their financial viability, their long-term success is by no means assured. Recent decades have seen remarkable changes in hospital administration. Prior to World War 11, hospitals were run by doctors. As doctors entered military service necessity demanded lay administrators, and by the end of the war a new profession-hospital or health administration-had become established. This transfer of authority from physicians to administrators continued largely by default, as physicians were pleased to be freed from the administrative and business details of hospital management. Nursing services were separated more and more from physician supervision, with reporting done directly to hospital administration. This administrative alienation of nurses and physicians has been most unfortunate. The nursing profession has suffered in the attempt to become an independent health profession without the education or background to do so. Medical care has suffered from the loss of the close professional relationship-indeed the partnership of doctors and nurses. As nurses detached themselves from physician supervision, service demands resulted in the creation of a new type of health professional-the physician’s assistant. Physicians’ assistants provide a vital service in the delivery of health care but should not be accepted as a final substitute for a close working relationship between doctors and nurses. The standard administrative model for hospitals now envisions a non-M.D. administrator as the CEO of the hospital, reporting to a board of trustees with only token physician representation and the medical director and
medical staff having little direct authority over hospital operations. There are many capable and very cooperative hospital administrators, but there is no substitute for physician authority over the operation of a hospital. Physicians must be willing to accept administrative responsibility in their institutions. We prefer the operating room-we love to perform surgery, but as we mature, all of us must give some time to administration and some of us must give all of our time. As much as we would like to do so, we simply cannot abdicate control of our work environment to others. The lack of physician control can only be exaggerated by the emergence of large chains of proprietary hospitals at a time of surplus physician manpower. Local administrators in proprietary hospitals must, of necessity, be sensitive to corporate decisions at a higher level and therefore are less able to accommodate their own medical staff. Proprietary hospitals have demonstrated gross inefficienciesin the nonprofit hospital sector as they provide care of high quality and still return a profit to their investors. The response of many nonprofit hospitals has been improved operational efficiency and attention to the bottom line, i.e., to operate more like for-profit hospitals. If that be the case, the tax advantages accorded nonprofit hospitals will require reevaluation by society. Presumably tax advantages are given to the nonprofit hospital ih compensation for indigent care and the “good it does for society.” As proprietary hospitals show that they deliver about the same amount of indigent care as nonprofit hospitals, these arguments become less cogent. Obviously, nonprofit hospitals serve a vital role in the care of patients of all types, offering treatment for all conditions, introducing experimental technology, and maintaining a teaching environment. Congress must remain convinced that it is in society’s best interest to support the nonprofit hospital system by appropriate tax exemption. Cardiothoracic surgeons must relate to the other surgeons of their institution. If cardiothoracic surgery is a separate department or if a cardiothoracic surgeon is the department chairman, interdisciplinary problems are minimized. If cardiothoracic surgery is a division within a department headed by a general surgeon, tensions may develop. We are a high-visibility, high-income surgical specialty accorded the highest prestige by society. We must, therefore, work especially hard to be team players, to be concerned about the problems of others, and to take the time and make the effort to support departmental activities. Only a few years ago, cardiothoracic surgery furnished one department chairman after another. That has not been the case of late. Cardiothoracic surgeons who are department chairmen may become even rarer if we permit our isolation and hyperspecialization to continue. We must appreciate the fact that general surgery has been severely fragmented and that further erosion of general surgery is to be avoided. Faced with the constriction of their own specialty and noting the remarkable progress being made in the surgi-
119 Presidential Address: Hatcher: There Is Life Outside the Operating Room
cal subspecialties, it is quite understandable that a defensive attitude pervades much of the leadership of general surgery. We must remember that general surgery is our mother specialty; we are all trained and certified general surgeons. It is most appropriate for us to support general surgery, but we must make it perfectly clear that general thoracic surgery belongs to our specialty and that we do not intend to see it slip away from us. In fairness we must examine the emphasis we have placed on general thoracic surgery in many of our training programs. We must improve our training in general thoracic surgery and continue to stress its importance to our specialty. And we must train a sufficient number of thoracic surgeons to provide for the proper distribution of service to the population. We relate closely to cardiologists. Traditionally, patients have been well served through careful evaluation by a cardiologist, and after an appropriate period of medical therapy, referral for surgery based on clear indications. Indeed, cardiologists have prided themselves on protecting patients from overly aggressive surgeons. The introduction of percutaneous transluminal coron a angioplasty ~ ~ (PTCA) as a form of treatment for coronaiy artery disease has revolutionized the practice of cardiology. An unfortunate DRG* error a few years ago, which permitted hospitals to collect as much in fees for patients having PTCA as for patients undergoing bypass surgery, overstimulated ambitious hospitals to offer or expand this service. Cardiologists suddenly found themselves with a form of interventional therapy that they themselves could perform with great economic benefits. The cardiologst who was formerly so cautious and conservative about referral for operation has frequently become willing to try angioplasty in almost any patient and usually without consultation with cardiology colleagues or cardiac surgeons. The number of angioplasties performed has increased exponentially, so that angioplasties will outnumber bypass operations by 1990 and number some 500,000 per annum. Angioplasty is certainly an effective and proper therapy for certain patients with coronary artery disease. Strangely, few prospective randomized studies comparing angioplasty to bypass surgery have been conducted. By the time we had ten years’ experience with bypass surgery (as is the case now with PTCA), countless studies had compared surgery to medical therapy and these studies were demanded and then questioned in infinite detail by the same people who have seen no need to subject angioplasty to the same scrutiny. We must, of course, recognize PTCA as a viable therapy, but we have every right to demand scientific comparison with surgery, and in each of our hospitals we must hold our cardiology colleagues to management programs based on hard data. I hLave listed several of the major challenges to be faced by cardiothoracic surgeons. With your kind indulgence I would now like to present the approaches taken to several of these challenges by my cardiothoracic surgical “Diagnostic related group.
Fig 1 . Emory Heart Team, 1986. (Front row, left to right) Dr. Kamal Mansour, Dr. Charles Hatcher, Dr. Peter Symbas, Dr. Douglas Murphy. (Back row, left to right) Dr. Robert Guyton, Dr. Willis Williams, Dr. Joseph Craver, Dr. James Sink, Dr. Joseph Miller, Dr. Ellis Jones.
colleagues and me at Emory University. Our experiences are presented for the possible interest you may have and they are obviously not applicable to all practice situations. In 1971, I became Chief of the Section of Cardiothoracic Surgery at The Emory Clinic and Chief of the Division of Cardiothoracic Surgery in the Department of Surgery of the Emory University School of Medicine. I immediately set out to recruit a team of the finest young aggressive academic cardiothoracic surgeons (Fig 1). It has been my great privilege to be associated with the cardiothoracic surgeons at Emory. Their clinical accomplishments far exceed my own, and whatever I have achieved is due to their encouragement and support. Our service has enjoyed tremendous clinical success from the start, but it was soon apparent to all of us that the challenges and problems I have outlined threatened to stymie or thwart our best efforts to develop and control our service. Therefore, a conscious decision was made that I should become more active in the administration of The Emory Clinic, as it provided the economic base for our clinical activities. In 1975, I was elected Director and CEO of The Emory Clinic by a unanimous vote of the partnership. The former rather socialistic financial system of the Clinic was replaced by a system of rewards based on productivity, and the growth and expansion of developing specialties and new technologies were encouraged. The results are apparent in Figure 2. While retaining a single Department of Surgery (and one Chairman of Surgery) for the School of Medicine, the surgical subspecialties are separate sections in The Emory Clinic. The Clinic charted its course as an affiliate of the Robert W. Woodruff Health Sciences Center, a separate legal entity from the School of Medicine, drop-
120 The Annals of Thoracic Surgery Vol 45 No 2 February 1988
Fig 3. Robert W. Woodruff Health Sciences Center budgets. Fig 2. Revenues of The Emory Clinic.
ping "University" from its title to become simply The Emory Clinic. In such a system, the for-profit private practice activities of the Clinic are conducted at arms length from the University, which is a nonprofit corporation. Thus, the University is not threatened by malpractice litigation against the physicians of the Clinic, i.e., the faculty of the School of Medicine engaged in the private practice of medicine, and the Dean of the School of Medicine is not involved in any way in the private practice of medicine. Previously a facilities payment was made to the University by the Clinic, based on a fair return on the market value of the facilities and equipment provided by the University. As the Clinic became more efficient and productive, it was appropriate that a new payment formula be created so that the University could benefit from this prosperity. Otherwise an adversarial relationship between the Clinic and the School of Medicine could be anticipated. Therefore, the annual facilities payment was set at 10% of net professional collections. These monies minus modest operating expenses are provided to the Dean of the School of Medicine as unrestricted income. As the Division of Cardiothoracic Surgery and other surgical subspecialties are entirely selfsupporting through their practice at the Clinic, The Emory Clinic and Division of Cardiothoracic Surgery are regarded as valuable resources of the medical school. By the early 1980s it was evident that further progress at The Emory Clinic would require closer cooperation and coordinated planning with the hospitals to which our patients were admitted. That opportunity developed in 1984 when I was invited by the President of Emory University, Dr. James T. Laney, to become Vice-President for Health Affairs and Director of the Robert W. Woodruff Health Sciences Center. The Robert W. Woodruff Health Sciences Center consists of six divisions owned entirely by Emory University: the Schools of Medicine, Dentistry, and Nursing, Emory University Hospital, Crawford Long Hospital, and the Yerkes Regional Primate Center (Fig 3).
Major affiliates of the Center are those institutions not owned by the University but in which we provide the overall supervision of medical care. These affiliates are: The Emory Clinic, Henrietta Egleston Hospital for Children, Atlanta Veterans Administration Medical Center, Grady Memorial Hospital, Wesley Woods Geriatric Center, and the Georgia Mental Health Institute. I have created a new position, Director of Hospitals, to direct and coordinate the activities of the two University hospitals and our five major affiliate hospitals. Mr. W. Daniel Barker, an outstanding hospital administrator and former President and Chairman of the Board of the American Hospital Association, was appointed to that position. Since 100% of the patients of Emory University Hospital are patients of The Emory Clinic, it seemed logical to name Dr. Garland Perdue, the newly elected Director of The Emory Clinic and the Chief of Vascular Surgery, as Medical Director of Emory University Hospital. Currently the Clinic and hospitals work and plan together as a single unit. Working closely with the President and Chairman of the Woodruff Health Sciences Center Board of Trustees, Mr. Barker and I have officially unified major hospital activities such as purchasing, personnel, and data processing, and have insisted that such hospital activities be separate from the University when such separation is clearly in the hospital's best interest. We have coordinated with the University activities when such coordination has not compromised hospital efficiency. Hospital financial reserves are managed at the Medical Center level to develop facilities, personnel, and programs. This is a significant departure from the previous practice of having each hospital administrator and CEO control these reserves and commit them only to the facilities and personnel of that institution. Joint funding by The Emory Clinic and the Robert W. Woodruff Health Sciences Center has financed construction of the new Clinic outpatient facility as well as complete renovation and major expansion of the original Clinic building. A new admission-discharge area, a bridge across Clif-
121 Presidential Address: Hatcher: There Is Life Outside the Operating Room
ton Road between the Clinic and Emory University Hospital, a new patient tower, and a new psychiatric inpatient facility at Emory University Hospital have been completed or are under construction at the present time. One thousand new parking spaces have been constructed to accommodate this expansion. At Crawford Long Hospital, owned by Emory University ‘but operated as a communityhniversity hospital, The Emory Clinic utilizes approximately 30% of bed capacity. Therefore, we determined to bring this hospital to full parity with Emory University Hospital. The Wadley R. Glenn Pavilion operating theatres and recovery rooms were completely renovated. A private proprietary hospital across the street was puchased, converted to an outpatient facility, and connected to the main facility by a pedestrian bridge. To provide convenient, attractive office space for The Emory Clinic and community physicians, a nearby medical arts building and parking garage were purchased and placed under hospital administration, and to accommodate our faculty working in the Crawford Long area, the cardiovascular research laboratory space has been increased by a 22,000-square-foot addition. A 40% increase in bed capacity plus improved support facilities have been approved by the Planning Committee of the Henrietta Egleston Hospital for Children, and construction awaits our transfer of adjacent Emory land for the expansion. A children’s heart center is a key element of this expansion. Working closely with the Fulton-DeKalb Hospital Authority and the Boards of Commissioners of the two counties, a new 29-year contract has been developed that calls for Emory University to direct all medical care at Grady Memorial Hospital. A $150 million bond issue for renovation of Grady Memorial Hospital has been approved by the Authority and Commissioners and will be put to the voters in early 1988. An intense lobbying effort has resulted in a $62 million renovation and expansion project for the Atlanta Veterans Administration Medical Center, and a successful heart surgery program has been established in that hospital. These projects have all been commissioned in the past four years. Such emphasis on clinical facilities and ser-
vices must complement the teaching and research programs of the Schools of Medicine, Dentistry, and Nursing. New deans of these schools have been appointed, who share our mission. The star in the crown of any academic health science center is, of course, the school of medicine. Our new medical dean has placed a major emphasis on research. In support of that emphasis, older laboratory space is being improved and construction of a new 225,000square-foot, $40 million research building began this spring. The lead gift of $10 million for this facility was donated by a patient who had undergone successful bypass surgery performed by a member of our team. I have pledged support for recruiting 100 new research faculty of principal investigator quality over the next ten years. Center funds, clinic funds, and school funds are used in creating the recruitment packages for this faculty. These are some of the contributions our cardiothoracic surgeons have made to our medical center and our university. There is much for a cardiothoracic surgeon to do outside the operating room. All of you must commit some time and effort to these activities if our specialty is to survive and to flourish. The combined Society of Thoracic Surgeons-American Association for Thoracic Surgery manpower study chaired by Dr. Floyd Loop showed that at the present time 83% of the cardiac procedures performed in the United States are performed by surgeons under the age of 54 years. This means that cardiothoracic surgeons must anticipate declining clinical activity in their final decade of practice. I know of no greater pool of talent in medicine than mature cardiothoracic surgeons. We have extensive experience in decision making-we have routinely made clinical decisions with life and death implications. What an appropriate background for medical administration at the highest levels. Your participation in the medical world outside the operating room will not provide the intense pleasure you have known as a skilled surgeon. It is more fun to be Sir Lancelot than to be King Arthur. But you must become involved-you have too much to offer to do otherwise. You will enjoy it more than you think, and our profession will be much the better for your commitment.