Correspondence

Administrative Costs and Health Care Reform

N Engl J Med 1993; 329:1656-1657November 25, 1993

Article

To the Editor:

Dr. Blumenthal states (Aug. 5 issue)1 that “One of the most effective ways to exert [physician] leadership may be [for physicians] to participate in the development of administrative systems that make the quality of health care the best it can possibly be.” Pray tell, how? The problem is that in most hospitals physicians are not expected or even permitted to participate, except as instruments of administrative desires.

Kenneth J. Levono, M.D.
F. Gary Cunningham, M.D.
University of Texas Southwestern Medical Center, Dallas, TX 75235-9032

1 References

1. 1

   Blumenthal D. Administrative issues in health care reform. N Engl J Med 1993;329:428-429
   Full Text | Web of Science | Medline

To the Editor:

As a physician who is the director of a university tertiary care referral center, I have become convinced that the primary way to control the administrative and clinical expenses of hospitals is to have physicians as executive directors and senior managers in hospitals, because only physicians possess the ability to negotiate with other physicians to make proper fiscal decisions about matters that require some clinical understanding. Physicians must receive specialized training in medical and business administration to function in the present times in order to provide quality care and to control administrative and medical costs.

Z. Stern, M.D.
Hadassah University Hospital, Jerusalem 91120, Israel

To the Editor:

Physicians, I think, generally perceive the merit of roles in utilization review and quality assurance. What they resent are some of the physicians who actually fill these roles. Department chairpersons and medical directors, for example, no longer seem to have any clinical roles, nor do they act as mentors. They spend their days attending meetings, creating forms from data bases, filling out forms, and sometimes playing police. Not having real hands-on clinical roles, they can lose their clinical skills and the respect of their colleagues. Chairpersons and directors are hired by hospitals to take part in the administration of the hospital and soon somehow are seduced into being full-time administrators. It is unfortunate that this human fascination with creating order is more valued by society than the hands-on care of clinical service. I disagree with Blumenthal, who believes that nonuseful administration can be easily eliminated. Health administration itself is not just a symptom. Administrators give rise to administrative products and ultimately to more administrators.

Ben Zimmer, M.D.
Medical College of Pennsylvania, Pittsburgh, PA 15212

Author/Editor Response

Dr. Blumenthal replies:

To the Editor: Each of the letter writers expresses commonly held views and frequently asked questions concerning the administration of health care organizations. Drs. Leveno and Cunningham suggest that hospital-based physicians are powerless, mere “instruments of administrative desires,” and therefore unable to exert leadership to improve quality in these organizations. Though many physicians may feel this way, their collective technical and moral authority in clinical affairs is unquestioned in most health care institutions. If physicians took the initiative to devise sound, evidence-based systems to measure and improve outcomes of care, hospital administrators would undoubtedly welcome this development. In any case, they would have great trouble resisting it.

I agree with Dr. Stern that, all else being equal, physician-administrators have certain advantages in managing health care organizations. These include their deep understanding of health care processes and their greater legitimacy, as compared with that of nonphysicians, in dealings with professional staff. However, the number of physicians with the skill, experience, and temperament to manage complex health care organizations is insufficient to meet the need for such people and is likely to remain so for the foreseeable future.

Dr. Zimmer's opinions are all too common among physicians and lead inevitably to a sense of hopelessness and helplessness on the part of the physicians employed by health care organizations. Such views, however, raise the following question: How is it that physicians who are valued friends and colleagues one day seem to be transformed overnight (in the eyes of clinicians) into hostile, parasitic bureaucrats when they assume administrative roles? At least three answers are possible. First, most physicians undergo a drastic, sudden change in character when they move into the administrative suite. Second, practicing physicians are often extremely intolerant of administrators and make insufficient effort to understand the demands and requirements they face. Third, under the circumstances of our dysfunctional health care system, those demands and requirements force administrators (physicians and nonphysicians alike) to engage in behavior that is burdensome and unrewarding to themselves and the professionals they work with. Since the last explanation is potentially remediable, it seems to me the most useful one to explore further.

David Blumenthal, M.D., M.P.P.
Massachusetts General Hospital, Boston, MA 02114