Tuesday, September 13, 2011

Healthcare's Dark Side Starts with Leadership Failure

Healthcare's Dark Side Starts with Leadership Failure

Philip Betbeze, for HealthLeaders Media , September 2, 2011

Last year, the Minnesota Board of Medical Practice publicly reprimanded Stefan Konasiewicz, MD, a neurosurgeon, for "unethical and unprofessional conduct," citing four cases that resulted in injury, quadriplegia, or death for patients under his care.
It was a long time coming, it turns out, because that reprimand was only the final chapter of a story that, due at least partly to a screwy payment system that pays for procedures, not quality, ends up shaming physicians and administrators who are trying to do the right thing.
The local News Tribune picked up the story and decided to do a little investigatingsurrounding the particulars of Dr. Konasiewicz's career at St. Luke's, a 267-bed multi-specialty hospital in Duluth, MN,  which also operates 34 primary and specialty clinics in northeastern Minnesota, northwestern Wisconsin and the western Upper Peninsula of Michigan.
In short, it's a story that details a long-term leadership failure that didn't address the actions of one of the top revenue producers at the hospital. Those actions harmed patients, exhaustive reporting done by the News Tribune suggests.
The story details how the influential doctor was able to keep practicing at the hospital long after most rational observers would agree he should have been disciplined. In fact, senior leaders, including St. Luke's CEO and President John Strange, seemed to forget their roles as the leaders of the institution. Many clinicians told the paper that they informed Strange and his colleagues of lapses in patient care or inappropriate procedures concerning Konasiewicz, who worked at St. Luke's between 1997 and 2008.
Several current and former physicians told the News Tribune that Dr. Konasiewicz was paid based on the number of procedures he performed, and had an unacceptably high complication rate—so high that his colleagues reported him several times for discipline at medical committee meetings.
Almost universally, they contend that he was allowed to continue to practice simply because he brought so much revenue into the hospital.
In fact, when Strange took over as CEO in 1996, the hospital was awash in red ink, a trend that continued through 1998. But by 2005, the newspaper reports, finances at St. Luke's were significantly better after five straight years of profit. At the same time, the newspaper says, the number of surgeries the hospital performed increased 164 percent — despite having about the same number of physicians on staff and no increase in the number of hospital beds. And, by the way, Konasiewicz was the hospital's highest-paid physician.

To his credit, Strange did speak to the News Tribune about his involvement in the lack of action regarding the neurosurgeon, saying essentially that while he held a seat on the hospital's medical executive committee, he does not have a vote and was not in a position to make a judgment on whether or not good care was provided.
Apparently, neither was the medical executive committee, which is composed mostly of physicians and has the ability to discipline doctors or restrict their privileges.
Where do I begin?
Strange's comments ring hollow not because of his pleas of ignorance and his lack of a vote on the medical executive committee, but because they reveal that the purported leader of a major institution apparently believes he is not ultimately accountable for the care of the patients under his hospital's roof. Well, if he's not, then who is?
The story further details the high rate of malpractice litigation against Dr. Konasiewicz -- who, unsurprisingly, was unwilling to be interviewed.  That should have served as ample warning that his decision-making surrounding spinal surgery was suspect, even if his motivation is assumed to be pure—a big assumption.
The worst part of the story is not the appearance of special treatment the hospital leadership allegedly gave Dr. Konasiewicz, but rather the fact that patients continued to be placed in a dangerous and conflict-rich situation. 
Though part of the tragedy of this story is the unwillingness of a group of people led by Strange to jeopardize the existence of a significant cash cow, this is, ultimately, an egregious result of misalignment of incentives, an issue that changes in payment protocols and reimbursement itself are intended to improve.

Let's not pretend that money doesn't call the shots in healthcare, as it does in almost every other business. If it didn't, we wouldn't have the annual whack-a-mole exercise that CMS performs annually to try to cut reimbursement rates for procedures that have been exploited to the max.
This is what you get when you have payment for procedure and a willingness to look the other way on patient safety. In reading about this episode, I'm shocked, but not surprised. Are you?

Philip Betbeze is a senior leadership editor with HealthLeaders Media. He can be reached atpbetbeze@healthleadersmedia.com.