Tag Archives: physicians

House Bill Aims to Curb Employers Ability to Force Doctors to Leave State

I prepared this potential op-ed prior to the death of HB 2931 in the Washington legislature. Non-compete clauses (also known as restrictive covenants) in physician contracts have had a devastating effect on the primary care workforce in Vancouver, Washington and other border regions of the state.

I understand the need to protect employers from the costs of recruiting a physician who then turns around and threatens to compete from across the street (really… who does that?) On the other hand, large groups in the state have thrown their weight around and hospital systems have thrown temper tantrums. I would prefer to eliminate restrictive covenants for family physicians, but there is good evidence from numerous sectors fo the economy that putting sharp limits on the enforceability of restrictive covenants is good for the economy. The best example is Silicon Valley,  where companies treat their employees very well, manage them extraordinarily well and continue to work with the intellectual capital they attract long after it leaves to spin off new entities and foster even more innovation.

Other physicians need the support, but so do baristas, hairdressers, nail spa workers and tattoo artists, who are unfairly unlimited by the legacy companies. I have to believe it makes these companies lazy and less considerate than they would be otherwise.

There were several bills, but I addressed the one widely regarded as the most likely to cross to the senate. In the Senate there was SB 6625 sponsored by Senators Conway, Hasegawa, Keiser, Chase, which restricted non-competes to 6 months for hourly wage workers. HB 2406 was sponsored by Representatives Manweller, Sells, Stanford, Magendanz, Tarleton, Moscoso, Ormsby and S. Hunt and stipulated that non-compete clauses were null and void in the case of a listed number of low hourly wage work such as fast food and dry wall applicators. HB 2931, sponsored by Representatives Stanford and Ormsby was the most sophisticated of the three and tried to outline certain parameters for which it is inappropriate to impose a non-compete. In short, if you are not an executive, non-competes would not be enforceable beyond one year.

None of the bills proposed geographic limits as “reasonable” in a non-compete.

All I can say is “we’ll be back,” even though I am poised to become an employer of physcians and stand to benefit from the applicability of these absurd covenants. There is still this thing called “doing the right thing.” Here is my unpublished opinion piece.

 

House Bill 2931 limits how employers can impose non-compete agreements on prospective employees and will be good for all industries in the state, although it will have an unexpected beneficial effect on health of Washingtonians. The bill received a vote on the House Floor Tuesday and will now go to the Senate for consideration.

 

Non-compete agreements in health care protect hospitals and larger medical groups, ostensibly from the high cost of physician recruitment. However, once a doctor agrees to be employed by a medical group, these agreements become a not-so-subtle means of controlling the doctors. An unhappy doctor could be required to leave the city, county or state because the agreement states that he or she is not allowed to practice their profession under any circumstances within the exclusion area. Since doctors have families and children, the non-compete agreement becomes a leash which can only be broken at substantial personal cost, which many families simply are not willing to accept. In one draconian example, one employer in Southwest Washington defines the geographic exclusion area as three counties. The doctor is often left with a Hobson’s choice of staying at an unhappy job with incompetent and potentially dangerous management or leaving town. No one is left to advocate for you, the patient.

 

Non-compete agreements are outrageous and unethical in healthcare. They disrupt the doctor patient relationship and hurt our workforce. When physicians leave the state, even for a short period of time, they rarely come back. Most medical groups spend a huge amount of money recruiting, but nobody tracks losses when doctors leave. In the end, it is the patients who suffer when they lose a trusted provider. I have never seen an administrator look an elderly woman in the eye and explain how his contract forced her doctor out of town.

 

It should come as no surprise that the Washington Hospital Association is profoundly opposes HB 2931. The Washington State Medical Association debated the issue heatedly, and emerged officially neutral. At least one large group made veiled threats to leave the association if even a watered down proposal were considered. The Washington Academy of Family Physicians is the only group that supports the bill, reflecting the public health orientation of primary care sector. Oddly enough, Republicans tend to like bills like HB 2931, because they foster free markets. Democrats like them because they protect employees. This is a bipartisan issue that aims to clip “Big Corporate,” not “Big Government.”

 

In many industries, non-compete agreements are merely an over-reaching effort to own their workforce. As one misdirected lobbyist asserted at the House Labor Committee, “our people ARE our intellectual property.” One wonders how Silicon Valley has thrived, since California is a place where these covenants are nearly completely unenforceable. Perhaps economic development is constrained when tech companies are allowed to impose draconian non-compete clauses?

 

There are numerous options which would make covenants more fair to communities, patients and doctors, but none of the corporations that run the state’s health care apparatus will even discuss the matter. It is time to reclaim the natural rights of individuals to work where they please without undue interference from anonymous corporations. Now it is up to the Senate to make HB 2931 law.

 

Employed Physicians

This old post is here because I have been thinking a lot lately about the impact of employed physicians on a community’s health. Since this post was written, I have worked for a large hospital-based primary care practice where I was being pressured to produce referrals and tests. When I left, the company waived any non-compete clauses. If they had elected to enforce them, my current community would have been deprived of a family physician in an area of primary care penury. So the lack of independence in primary care may lead to overuse of specialty and technological services and deprive communities of the specific function (primary care) that makes health systems more efficient. This 2008 post contains the seed of an idea to develop a sustainable business model for the independent primary care physician in the interests of the public health. But there are several steps I will have to fill in, so stay tuned. Meanwhile, enjoy…

 

I had an interesting conversation with a feller from Texas the other day. I was telling him how I had formed my impressions of docs in employed situations from my experience on the East Coast. It just seemed that the solo practitioner was almost dead, if not completely so. Even in rural Maryland, it was more likely to find groups of two or three docs in private practice fiercely holding on to their independence in the face of large single- or multi-specialty groups encroaching from the suburbs. Many of the large groups have found Stark-compliant ways of working with nearby hospitals, or, in some areas, are outright owned by the hospitals.

I reflected to my acquaintance how different it was out here in the Western desert regions, where it seemed the employed docs sometimes felt they could act like it was their own shop and close up with less than a day’s notice to stay home with the kids or go duck hunting or take whatever break is justified by a hard-working, highly-valued provider of a needed service by a grateful community.

You can’t do that when there are 50 physicians and 300 employees whose work schedules are dependent on physicians providing billable services on razor-thin margins.

Well, maybe you can. It’s all about the supply and demand equation, isn’t it? If there aren’t enough primary care physicians to go ’round, the tolerance for behavior inconsistent with a larger organization’s overall well-being is better tolerated. And certainly the local physicians’ culture has an important role to play. Texas docs, I was told were nearly never in large groups and they never tolerated overbearing administrative intrusions to their clinical or vocational independence.

I walked away from my conversation with a tall and lanky Texan (sorry for the cliche, but he was tall and nearly lanky), with an understanding of how different the situation is for physicians across the country and how my approach to change management and performance management is colored by my East Coast experience.

In areas where managed care penetration is high, employed physicians predominate by choice, and a high regard for academic analysis output exists, there is an atmosphere of understanding and willingness to work within a corporate environment. Evidence-based medicine, quality and performance improvement are all perceived as methods to improve health care delivery systems for the betterment of the community. Physicians understand the choice to enter employed positions and accept the trade-offs, giving up some independence for the sake of fewer administrative headaches, better benefits and perhaps, a reasonable lifestyle.

In areas where one or more of these conditions do not hold, physicians resent encroachment on their judgment, style or authority and mistrust the motives of administrators of all stripes. EBM, QI, and PI are bridles of control to be avoided at all costs and administrative entities are regarded to exist for their personal betterment and not the benefit of communities nor the doctors, Such physicians enter into an employed arrangement begrudgingly and only if they feel that their work is not subject to the kind of oversight that will reduce their independence.

OK, I’m dumb. I didn’t realize the obvious until now. I have grown up in academic environments which are so dominated by various stakeholders that the independence of the community physician a distant recollection from the stories of William Carlos Williams; the vague memory of a historical work of fiction read in childhood. The East coast and its large cities are places where independent practitioners are aberrations or mavericks worthy of awe, disbelief and admiration.

Elsewhere in the country, in smaller cities and younger landscapes, the independent practitioner has thrived and the battle for physicians’ independence is much more vigorous.

It is possible to engage physicians any number of ways in future improvements to health care. The lessons of the East tell me that the best way is not confrontational. Without physicians, no meaningful reform is possible, despite the best efforts of other stakeholders. On the East Coast, docs have been beaten into submission. It took a long time, created a lot of ill feelings and did not accomplish much. The rest can do it faster, more collaboratively and with greater focus. The first step is to get a clear understanding of the situation and adapt to local environments.

A Splintered House

This is the text of a speech I gave to the Clark County Medical Society’s New Physician Reception in 2013.

Thank you to our sponsors and guests, to the Board of the CCMS and especially to each of you for coming. To all the new physicians; welcome to Clark County and to the medical society. I want to take a few minutes tonight and talk to you about our medical society and its history, my personal spin on what has happened to medicine in the 72 years since CCMS got started and how the House of Medicine became splintered. I would also like to talk a little about what our future might look like under the current and coming reality. Life is changing quickly for physicians these days.

“Clark County Medical Service Corporation” was established in 1941. The articles of incorporation, written under the name “Clark County Medical Society, Inc.”, were signed by Clyde B. Hutt, MD, as President and L.E. Hockett, MD as Secretary/Treasurer and were approved and filed on December 3, 1942. The constitution and by-laws of 1942 were amended on May 6, 1947 and adopted by membership on May 4, 1948. The bylaws have stood unamended since the last review and overhaul accomplished in 1991. They have withstood the test of time.

Medicine was simpler back in 1941. The bulk of CCMS membership knew each other. The largest group in town was the Vancouver Clinic and it had four doctors: a GP, a surgeon, a pediatrician and an OBGYN. If you wanted to hang a shingle, you may have wanted to meet the local docs so they could tell patients about you and maybe put in a good word for you at local merchants and businesses or maybe the bank. The county medical society was a way to let people know what your special interests and skills were and this was the way you got most of your referrals.

No I am not going to wax sentimental about the golden age of medicine. County medical societies had a dark side: they were exclusive and closed old-boys clubs that enforced standards of behavior in a manner that would be frowned upon today. They focused too much on their own interests and not enough on the health of the people they served. Keeping an eye on the money worked well for the US medical societies, and their parent organizations all the way up to the AMA, until the first turf wars erupted. I don’t need to belabor strife within the House of Medicine.

At the turn of the last century, there was a tug of war in the House of Medicine regarding the need for specialization: Some thought that generalism was necessary to understand the whole person, others thought that specialism was the way of increasing the relevance of physicians and to provide the best possible care for individuals. This was all derived from scientific medicine and the notion prevalent in an industrial society that there was more value in specializing.  Sir William Osler, perhaps the largest historical proponent of scientific medicine was ambivalent about the notion: “[Specialization]’” he said and I am quoting here, “must then be associated with large views on the relation of the problem, and a knowledge of its status elsewhere; otherwise it may land him in the slough of a specialism so narrow that it has depth and no breadth, or he may be led to make what he believes to be important discoveries, but which have long been current coin in other lands. It is sad to think that the day of the great polymathic student is at an end; that we may, perhaps, never again see a Scaliger, a Haller, or a Humboldt—men who took the whole field of [human] knowledge for their domain and viewed it as from a pinnacle. “

One of the earliest specialty societies was the American Academy of Pediatrics, hatched about 15 miles from here at an AMA meeting in 1930. In 1933, dermatology, OB-GYN, ophthalmology and ENT were the founding members of the ABMS. 1941 marked the year that the CCMS was founded and that Anesthesia became America’s 15th recognized specialty. Today we have splintered into between 130 and 157 specialties and sub specialties depending on how you count them and nearly as many specialty societies.

I think that is the word that best represents the House of Medicine today: splintered.

But somehow I think that people with an MD or a DO degree after their name may share certain characteristics more than a similar day-to-day existence within their own narrow silos of specialty and employment.

Somehow I think that people whose primary role is to help patients navigate our current morass of regulation, government, insurance, corporations, pharmaceuticals, manufacturers of various gadgets and medical technologies from titanium hips to scribe-friendly keyboard operated EHRs… somehow these people who bear the primary responsibility for trying at least to improve the health of well-being of their patients (and by consequence our community) have more in common than their differences would suggest.

When I first got to Clark County 4 years ago, I set about charting a course to understand how I could personally influence the course of events impacting my life. I have a MPH,  so I was interested in my role as an advocate for patients and how I could impact the epidemiological measures of health. I looked at what my specialty society was doing in the local community. I found the impact was driven by individuals, many of whom were involved with the local residency. The point is that my specialty association’s largest impact was being felt at the national level and had recently hired a lobbyist at the state. At the local level it was not any association, it was the individuals. I think this is probably true for each of our specialty associations. We can do at least as well locally.

So I believe that medicine has a role in improving the health of our communities. It may follow that when we band together and work towards that purpose, we may have better chances of success. It’s a subject for another day, but medicine has a role. It must have a role if the industry is to remain relevant as a social good, otherwise, we might as well all quit and become bankers, because that’s where the real money is.

Don’t get me wrong, I proudly carry the flag of my specialty society, but the fact is that all our specialty societies are somehow vaguely inadequate to the grass roots tasks. Its not just primary care, but all aspects of medicine that are at work in this town, from the anesthesiologist and the gynecological oncologist and the cytogenetic geneticist. We have more impact as a House of Medicine united in this one common mission that we agree on than worrying about turf wars.

And the impact is felt community by community. A truism in epidemiology is that you need large numbers to detect small changes, but it tells you nothing about what happens to individuals. And communities are made up of individuals, states are made up of communities and nations are built on states. It all starts where you live and work and being concerned for the health of your neighbors and the people around you. The health of Clark County depends in a small way on each one of you. The health of Clark County needs you to speak for it and for its concerns.

One aspect that has helped the health of Clark County has been the role of CUP. CCMS has advocated and will continue to advocate on behalf of this local non-profit community-based health plan both because it works for the community’s health and because it is a significant employer. We were concerned with toxic byproducts of a recycling plant and successfully shot it down. At the state, with other medical societies, we helped overturn the rule that emergency rooms wouldn’t be paid if their services were retrospectively judged not to be emergencies. Physicians got involved to work with the DOH and saved them more money than they envisioned by their prior plan. We also fought the B&O tax which no longer applies to physicians in WA. We are now looking at the impact of a coal terminal on our coast as well as the trains have along the route, so we are supporting studies to clarify the impact and publicize our concerns. At the state we have also supported public health nurses working on STD’s, reproductive equity in the state and pushed for medical staff reviews that are not quite so abusive of physicians.

Only here in Clark County can you speak out about our lack of availability of fresh food in a wasteland of fast food. Only in Clark County can you do something about obesity in your community. Only in Clark County can you set up community forums to counter the vaccine objectors’ propaganda that makes us so vulnerable to epidemics IN THIS COUNTY!

I hope you each continue to support the county medical society, I hope you get involved, speak up, be a light for others to follow, be obnoxious if you want, just speak!!! And tell you colleagues about the society. You need to take responsibility for your own “belonging” to a group you believe in. And if the AMA or WSMA or even CCMS does something you disagree with, remember that your voice counts. Without that voice, it’s not surprising the organizations do things that don’t meet with your approval. You won’t win every battle in a democracy, but you will win some/ You will make a difference.

Finding a match in your doctor.

From The Physician Executive in 2007, but I could have written it last week.

CNN had an article on how to fire your doctor.

I agree. Sometimes it’s about chemistry. Some patients and I are like oil and vinegar, others like fire and gasoline. I have always invited these patients to seek care elsewhere with no hard feelings.

Somewhere in the corporate transition, this message got lost. My previous employer almost had a hissy fit.

The alternative is an unhappy patient who doesn’t trust their doctor, who doesn’t really like their patient but is seeing them begrudgingly out of some kind of moral obligation.

If that isn’t a recipe for a lawsuit, I don’t know what is.

Each physician-patient relationship is different. You are looking for a match. This applies to the patient, but is also good practice for the organization.