Resources & Information

From the President: Keeping patient welfare ahead of corporate interests

Dr. Kilpatrick

In November, it was my honor and privilege to be sworn in as NCMB’s 123rd Board President. As I reflect on the opportunity to serve the people of North Carolina and the medical profession in this role, I find myself gravitating towards NCMB’s vision statement, which signals our organization’s desire and intent to be a “proactive and progressive” leader in medicine.

What exactly does that mean in the context of medical regulation? Board Members and staff often talk internally about the need to “stay in our lane”. This can be somewhat limiting when considering ways to positively impact some of the most pressing challenges facing our profession, since we must always remember that NCMB is an impartial regulatory body and not an advocacy group. Even so, I have been pleased that NCMB frequently finds opportunities to be thoughtful and creative in how it approaches its licensing and regulatory work, keeping the vision top of mind.

One of the most recent examples of how NCMB practices “proactive and progressive” regulation relates to the increasing “corporatization” of medicine.

For a variety of reasons, which many licensees are no doubt familiar with, more and more of NCMB’s licensees are working as employees or contractors. Licensees in such employment arrangements typically are subject to policies and business practices determined by administrators or owners, who may or may not be medical professionals themselves.

While it is certainly possible for physicians, PAs and other medical professionals to deliver high quality care under such terms, it is also true that NCMB has noted an increase in enforcement cases where problems arise primarily due to policies or decisions made by someone other than the licensee.

We have seen cases where licensees discharge patients home from the hospital against their own clinical judgment because the patient did not meet criteria for admission or continued inpatient treatment, as established by their employer. We have also seen cases where it is obvious that profits are put before patient care, such as a recent situation where licensees were dismissed from employment not because care was below standard but because they were not bringing in enough revenue. In these instances, it can be challenging to decide how best to hold a licensee accountable for substandard practice or other misconduct because it is obvious that the licensee is not in full control of the situation.

NCMB does not have jurisdiction over non-licensees. That means the medical board cannot control the decisions or policies put in place by hospitals, health systems, or other owners and employers. However, NCMB cannot simply overlook substandard practice because it emerges amid convoluted circumstances. Ultimately, as our mission mandates, we must protect the public. Therefore, despite the increasingly complex environment in which medicine is practiced, we believe that professional ethics demand that a physician or PA take responsibility for the quality of the care they provide.

So what is proactive and progressive about this directive? Well, through NCMB’s Policy Committee, we are seeking to proactively educate licensees about the potential pitfalls we think employed physicians and PA’s may face. The committee is in the process of finalizing a new position statement that highlights some of the issues I have touched on in this short article. You can read the proposed position statement here.

In the upcoming months, NCMB is planning to send licensees an anonymous survey that will include questions about how workplace issues have impacted patient care.

I urge licensees to do their homework and go into any employment situation with their eyes open about who has the final say in clinical decisions. It is also important to consider how the employer’s policies may negatively impact patient welfare. Ideally, informed licensees will be able to avoid putting themselves in situations where their professional knowledge and ethics regularly chafe with company policy.

In closing, I invite you to share your thoughts about the challenges of practicing as an employed physician or PA by emailing forum@ncmedboard.org. We are always interested in perspectives from ground level.

Thank you for the opportunity to serve.

 Comments on this article:

Thank you for taking a controversial stance for the integrity of our profession.  Increasingly, we deal with pressures coming at us in the form of administrative tasks, non-sensical prior authorization and flat out denial of our plan of care, not to mention the attention and energy spent on quality metrics that have little to no effect on patient outcome.  Since I graduated residency some 23 years ago, the environment in health care has shifted considerably and it pains me to see so much bandwidth taken up with these efforts and not on expanding and maintaining our scope of practice, and improving access for patients.

By Andrea DeSantis DO, FAAFP on Feb 25, 2023 at 7:34am

Thanks Dr. Kilpatrick,
I think this tension between physicians and employers is also a great source of disillusionment among physicians. There was a recent opinion piece in the New York Times about this topic by Dr. Eric Reinhart: “Doctors Aren’t Burned Out From Overwork. We’re Demoralized by Our Health System”, which addresses this issue.

Best,
Mark Weissler.

By Mark Weissler on Feb 25, 2023 at 8:07am

Thank you!

By Elena Messina on Feb 25, 2023 at 8:22am

Congratulations Dr. Kilpatrick!
As a retired physician, I am now a keen observer (and consumer) of our current healthcare “system”.
The monetization of medicine has clearly influenced some of the anomalous profession behaviors that you have mentioned.
While the focus our the work of the Board will necessarily pertain to individual physicians, the issues are clearly intertwined with other influences.
Our health care and the management of patients has become fractionated to a degree that it is almost impossible for even a well informed patient to negotiate within the “systems”.
Wishing you and the Board wisdom and success!

By Paul Cunningham on Feb 25, 2023 at 8:46am

Kudos, and thank you for addressing this elephant in our industry.

By John Latz, MD on Feb 25, 2023 at 9:48am

When a business entity or its administrator is able to dictate or significantly influence the professional practice of a physician, either through financial penalties or sanctions (which includes termination of employment, decisions that limit salary advances, etc.), may not be making the medical decisions directly, but at some point that business or administrator ceases to be merely an employer or contractor and becomes a de facto practitioner of medicine. With any right - such as the right to influence medical decisions - come responsibilities - such as the responsibility for adverse outcomes.

It behooves the NCMB to (1) petition the state legislature to deem such actions as the practice of medicine, (2) support lawsuits against such business to let the Court make this determination.

By Mike on Feb 25, 2023 at 10:32am

If physicians must be licensed to practice in NC, why shouldn’t non-physicians who supervise physicians also be licensed to supervise physicians?  This way, they can be held accountable to decisions they make which either harm pts or have the potential to harm pts.  Think any legislators in Raleigh might see the wisdom & need for this?  By the way, I must tell you I am very grateful that someone at the NCMB is aware of the situation & sees the challenges that many healthcare providers face with regards to this situation.  Hopefully, a way can be found to address this issue in such a way that improves pt care & protects providers who are trying to do the right thing.

By Kenneth K. Cloninger, MD on Feb 25, 2023 at 1:23pm

I think it is great that the board is looking at the effects of the corporatization of medicine. I am now retired. However I frequently look at medical news on Doximity. I have regularly seen physicians who get fired, and contracts not renewed for trying to stand up for what is right for their patients. What really can the board do to help patients by helping physicians? Maybe if physicians were aggressively informed of the risk of board sanctions for substandard practice, they would want to stand up more. However there will still be many providers who will make deals with profit focused corporations. Why aren’t corporations policed for their treatment policies?  I would recommend against a career in medicine if asked by a young person today. I fear the future is bleak, and that corporations will control everything including having practitioners they can control completely. (New kinds of uncertified providers? Artificial intelligence?) Sorry this sounds like a downer…

By Michael DeWitt on Feb 25, 2023 at 2:04pm

The solution to problems associated with employed physicians is to stay private. I was the first Urologist in Lincoln County when i moved from NYC in 1980 and the last private Urologist when I retired in 2017. I did not make half what the salaried physicians made (Atrium) but the patients still prefer the private doctors and I could pay my bills. There is never a problem with burn out when you can practice medicine according to the Hippocratic Oath. Thank you David A.Nachamie M.D.

By David A Nachamie M.D. on Feb 25, 2023 at 2:14pm

Dear Dr. Kilpatrick,
Thank you so much for saying this. The corporatization of medicine has become more aggressive and in-your-face lately and it is high time that “we the providers” start pushing back. Holding those who too eagerly comply with unethical corporate mandates responsible for compromising patient care and not upholding their professional obligations as licensees might seem harsh to some but it is possible that it may be the only thing that will encourage others to stand up to non-clinician owners who often seem more concerned about profits than patients.
Thanks again!
Mark Vakkur, MD
Atlanta, Georgia

By Mark Vakkur, MD on Feb 25, 2023 at 3:55pm

When Physicians sold their practices and became employees, these issues were predictable and obvious.  The solution is the return of private practices owned by the Physician.

However the payment system 〈largely due to the ACA〉 is rigged to pay hospitals more than 100% of the Physician fee schedule.  According to the GAO moving chemotherapy from the private office to the hospital increased chemo costs to medicare 150-500% depending on the drug.

I am not sure how the NCMB can reverse this, put perhaps holding seminars for young MD’s on how to start and run a practice might be a start.

The NCMB could also write a letter to our congressional delegation in support of legislation currently in congress calling for site neutrality.  This would make it mandatory that a service is reimbursed the same, regardless of who is doing the billing (hospital or Doctor).

By john peterson on Feb 25, 2023 at 8:44pm

Dr. Kilpatrick, thank you for this thoughtful and candid article highlighting challenges we face when corporate profits are placed above our patients. And I would add that insurance and pharmaceutical corprate profits over patients are a part of this problem also.  All interfere with the quality of care we can provide to our patients as they influence our decision making.  Health care corporations and insurance companies keep piling on rules, policies etc. that we have to follow that we are not comfortable with, creating stress on us and the doctor patient relationship.  We have taken an oath to put our patients first and when we are limited in doing so, it is stressful.  And I feel it contributes to physician burn out and early exits from the profession.  Clearly these entities are participating in clinical decision making but if a bad outcome occurs, they are quick to blame it solely on the doctor. And if we are to continue on this path of corporatization of healthcare, I think the answer is to somehow make them responsible for corporate practices that interfere with the practice of medicine and if a bad outcome occurs, they share culpability.

These corporations are quick to say their concern is limiting the costs of heathcare and saving their companies money.  And I agree that physicians should practice cost effective medicine but quality care must be maintained. However, I have not seen the cost of healthcare go down with corporatization of medicine. I have seen costs go up and profits shifted from clinicians to corporate CEOS, administrators and others.

Again, thank you for beginning this timely discussion. And I look forward to hearing of actions we can take to address this problem.

By Eleanor Greene, MD, MPH on Feb 26, 2023 at 7:44am

My sincere appreciation to Dr. Kilpatrick and the NCMB for recognizing the impact of corporate entities on the day to day management of our patients.

By remaining independent physician, I have opted to work harder to maintain solvency rather than accepting the “golden parachute” offered by healthcare systems in my area.

When doctors recognize that these opportunities are actually fraught with danger, we may see a resurgence in the private practice model.

I think highlighting the pros and cons of various practice styles is particularly important to newly minted physicians since they may know no other option but to become an employee.

Again, my heartfelt thanks!

By Elizabeth Anderson Halabuk, MD on Feb 26, 2023 at 9:13am

I think administrative overreach and dictation of care has overtaken insurance companies as the largest threat to independent and uninhibited patient care and advocacy.  Functional monopolies have reached an inflection point where physicians have no real recourse when their care is dictated by non-bedside personnel as well as the continued trend of dumping more and more administrative tasks on physicians despite an almost exponential growth of non-revenue-producing administrative staff in healthcare organizations.

By Grant Campbell, MD on Feb 27, 2023 at 7:50am