Exclusive Contracts: Are we losing our moral compass?

Exclusive Contracts: Are we losing our moral compass? 

                        As physicians and surgeon we are trained to withstand extremes of adversities inside and outside the operating rooms. Through long years of training we remain focused on the science and art of medicine as applicable to our patients. We all have stayed away from our loved ones during the long years of medical or surgical residency. Subsequently we go through a stringent written and a grilling oral examination to obtain the final Board Certification. In a complex field like Cardiac Surgery this training may be inadequate to practice independently. Therefore many of us underwent low paid concentrated training in a high volume center to sharpen our skills. In Cardiothoracic Surgery this could take anywhere from 13 to 17 years of our lives.  How does one react to the decision of the hospital administration to grant Exclusive Contracts to a group of surgeons that excludes you from practicing the art that took a lifetime to master.  The Certification of American Board of Thoracic Surgery or State Board Licensure seems to have no meaning if the recipient cannot practice the chosen art freely.  While Exclusive Contracts may be legal, they are unjust and unethical.  The Hospital CEO’s are completely justified in granting Exclusive Contracts provided they are done scrupulously to serve the patients and not the privileged group of physicians. Therefore the CEO’s must think harder and deeper before granting Exclusive Contracts. While taking all the factors into consideration they must use appropriate moral compass to guide such decisions exclusively in the best interest of the patients.  -- 

	Pankaj Kulshrestha, M.D.Dayton Cardiac Surgery East Medical Plaza 627 Edwin C. Moses Boulevard, Suite 5J Dayton, OH 45417 Tel: (937) 938-9194 | Fax: (937) 938-9242 www.daytoncardiacsurgery.com

Exclusive Contracts: Retrograde Effects of Special Privileges

Exclusive Contracts: Retrograde Effects of Special Privileges 

  With recent restructuring of the health care delivery systems, a number of physicians are either employed or have strong financial ties with the hospital.  Hospitals perceive a benefit in giving exclusive privileges to a group of physicians in the form of Exclusive Contracts which prohibits other equally qualified physicians from practicing their science and art. In a field like Cardiac Surgery, although competition is effectively eliminated by an Exclusive Contract, it does not necessarily benefit the privileged group of surgeons.  On many occasion the hospital and the surgeons lose a referral due to non- availability of the surgeon from the privileged group. In general any special privileges are un-american and inherited from Old World systems of government. While Department of Justice allows such Exclusive Contracts, in my personal opinion, for certain individuals to have exclusive privileges granted to them by law to exercise any art, trade, or profession, with all the advantages derived from it, whilst other equally competent and as well qualified should be debarred therefrom, is not only unjust towards the public at large, but that it lays the foundation for an odious monopoly with all its dictatorial and dogmatic power.  No art or science could be benefited in this way, and the security and monopoly conferred by such legal protection would tend to beget indifference and carelessness that would effectually serve to produce a retrograde rather than a progressive effect. Therefore all reasonable Cardiac Surgeons and physicians must speak out against the unjust practice of Exclusive Contracts in order to protect our freedom to serve our patients unfettered from outside pressures. 

Pankaj Kulshrestha, M.D. 
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	Pankaj Kulshrestha, M.D.Dayton Cardiac Surgery East Medical Plaza 627 Edwin C. Moses Boulevard, Suite 5J Dayton, OH 45417 Tel: (937) 938-9194 | Fax: (937) 938-9242 www.daytoncardiacsurgery.com

Exclusive Contracts and Role of Medical Executive Committee

Exclusive Contracts and Role of Medical Executive Committee 

Recently the medical executive committee of a prominent local hospital made a decision that only one group of cardio-thoracic surgeons should be allowed to practice at the hospital. This decision was made without any input from the excluded cardiothoracic surgeon, who was left to his own devices. Vested self-interest of the favored group was never taken into consideration. With the advent of Affordable Care Act, such scenarios are going to be commonplace.  While such exclusive contracts may not be ethical, they are considered legal by DOJ. Therefore Medical Executive Committee must identify and manage the physician opinions and vested interests regarding each issue that comes before it and not allow one group’s self -interest to take precedence over others. In such challenging times, MEC must seek virtue of Solomonic sapientia in charting a course that balances the needs of all physicians on the medical staff to succeed while not forgetting that patients are the center of the medical universe. 

   

Pankaj Kulshrestha, M.D.Dayton Cardiac Surgery East Medical Plaza 627 Edwin C. Moses Boulevard, Suite 5J Dayton, OH 45417 Tel: (937) 938-9194 | Fax: (937) 938-9242 www.daytoncardiacsurgery.com

Exclusive Contracts and Sanctum Sanctorum

 How does a country founded on the freedom of choice succumb to Exclusive Contracts. The Exclusive contract is a covenant between a hospital and a group of physicians that allows the group to provide exclusive service in a particular field thereby preventing other physicians from practicing in that hospital. The excluded physicians are not allowed to practice their own specialty in the given hospital.  The qualifications, skill levels or reputation of the physicians are not taken into consideration. This is solely based on economic credentialing. In some cases exclusive contracts are negotiated by influential but ageing surgeons with declining surgical skills in order to eliminate their competition. While the lawyers dwell only on the legality, the Exclusive Contracts defile the sacred ground of patient –doctor relation.                              

                      In a field like heart surgery the patients have no way to judge the competence of the surgeon except through the referring physicians. In most practices the referring physicians have multiple choices of the surgeons. The referring doctors will scrupulously refer the patient to those surgeons whom they will trust to operate upon themselves or their loved ones. For the poor trusting patients, this is the only safety mechanism in place. This is true for the entire practice of medicine, but more so for a surgical field like heart surgery. As physicians we create our own little sacred space with our patients. Only other physicians whom we allow in this sacred space are those whom we trust. Exclusive contracts, by eliminating the choice, breach the sanctum sanctorum between the patient and the doctor.

 

Pankaj Kulshrestha, M.D.Dayton Cardiac Surgery East Medical Plaza 627 Edwin C. Moses Boulevard, Suite 5J Dayton, OH 45417 Tel: (937) 938-9194 | Fax: (937) 938-9242 www.daytoncardiacsurgery.com

Exclusive Contracts: Who Bears the Brunt?

At first sight it might seem that exclusive contracts are harmful to the excluded physicians only.  However, the main brunt falls upon our trusting patients. Essentially, the patients of the excluded physicians are denied all the advanced technology and collective wisdom of the physicians in a given hospital. This is all the more true when a physician in a small hospital is unable to admit his sick patient to the main hospital from which he is excluded. An example in cardiac surgery may be use of nitric oxide which may not be available in a smaller hospital.  Economic credentialing denying a physician the privileges due to exclusive contracts may deny his patient the use of nitric oxide which is a life saving measure. In addition, exclusive contracts deny the patient the opportunity of the consults from experienced physicians. The excluded physicians are also not able to pursue the CME in the excluded hospital, thereby indirectly affecting the patient care. It is my sincere hope that even those physician who have never personally experienced economic credentialing, will take a stand for the sake of our patients, to eliminate such an appalling practice in a clinical fields like cardiac surgery. 

Pankaj Kulshrestha, M.D.Dayton Cardiac Surgery East Medical Plaza 627 Edwin C. Moses Boulevard, Suite 5J Dayton, OH 45417 Tel: (937) 938-9194 ' Fax: (937) 938-9242 www.daytoncardiacsurgery.com

Exclusive contracts: Are we still a noble profession?

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This message has been cross posted to the following eGroups: Connect to Justice and Ohio Medical Open Forum . ------------------------------------------- To some medicine is more than a profession - it is a calling to help others without self-interest. While primary care physicians directly serve the community, the specialists are mostly chosen by the primary care physicians. No one becomes a specialist except by the goodwill of the referring physicians. A specialist must, therefore, earn the respect and trust of his colleagues and patients. Referrals must be in the best interest of the patient and must not be based on friendship or incentives. Since the time of Hippocrates, we have distinguished ourselves as noble profession through altruistic endeavors to heal the mankind. On the other hand, the business world is solely guided by self-interest. Establishing exclusive contracts with the hospitals to gain patients is an appalling decadence of our professionalism.  ------------------------------------------- --     Pankaj Kulshrestha, M.D.Dayton Cardiac Surgery East Medical Plaza 627 Edwin C. Moses Boulevard, Suite 5J Dayton, OH 45417 Tel: (937) 938-9194 ' Fax: (937) 938-9242 www.daytoncardiacsurgery.com

Exclusion of Trust

Exclusion of Trust

                 Competition and consumer sovereignty are the two main pillars of clinical medical practices. While the non-clinical practices have long been subject to exclusive contracts, recent trend of such monopolies in clinical fields like Cardio-thoracic surgery is quite disturbing. While such contracts may be unfair to excluded physicians, the ultimate brunt is borne by our trusting patients.

                 The major concern in any dispute over monopolies is the elimination of competition, which has with it inherent harms. Exclusionary contracts quite clearly do eliminate competition from other medical practices, and disturbingly, the motivation seems to be purely financial in nature, rather than grounded in concern for the patients. The physicians who are party to the exclusive contract subsequently receive control over all procedures under their jurisdiction at the hospital. Of course, for the hospital to offer such a guaranteed revenue stream to the physicians, the contract must pose some perceived benefit to the hospital as well.

                Proponents of exclusive contracts argue that there are other fail safes in place in medicine that do not exist in other fields which control quality. Hospitals monitor quality through yearly reviews, for example. While this oversight certainly is the case, even assuming that the review board acts in the best interest of the patients and not the hospital—a shaky assumption, since the review board would be established by the hospital and therefore be susceptible to its desire to increase patient volume—the review board only acts negatively to control quality. In other words, the review board theoretically only acts when the physician is failing to meet a certain quality standard: for example, for failing to below a certain mortality rate. Instead, competition acts in a positive way as well; one physician learning a new procedure or techniques for an old procedure that reduces complications forces competing physicians to positively increase their quality as well. Without positive quality control, there is no incentive for a physician to improve upon his or her skills. In an incredibly dynamic field like heart surgery, a lack of positive quality control could quickly lead to archaic and therefore dangerous medical practices.

             Of all human powers operating on the affair of mankind, none is greater than that of competition.

Pankaj Kulshrestha, M.D.Dayton Cardiac Surgery East Medical Plaza 627 Edwin C. Moses Boulevard, Suite 5J Dayton, OH 45417 Tel: (937) 938-9194 | Fax: (937) 938-9242 www.daytoncardiacsurgery.com