Physicians angry with Swedish for hiring own doctors
The doctors' votes on the administration of Richard Peterson, now coming in by anonymous mail ballot, are due Tuesday. Peterson, president and CEO since 1995, has angered some doctors, who say he has not consulted them on strategic decisions made by Swedish, the state's largest nonprofit health-care system.
Doctors, particularly specialists, complain that Swedish, a growing force locally as it expands and acquires other hospitals, is hiring staff doctors for practices inside the medical center that will compete with community-based physicians.
"This is bad medicine for Seattle," said Dr. Robert Winquist, a private-practice orthopedic surgeon who has admitted patients to Swedish since 1980. "It's a risk that private practice will disappear."
Peterson and other hospital leaders declined requests for an interview, saying in a statement released yesterday it is "inappropriate to publicly discuss the no-confidence vote ... at this time."
Such disputes between hospital administrators and doctors are becoming more frequent around the country, health-care experts say.
"The underlying problem is that both groups are going after the same money to survive," said Leo Greenawalt, president of the Washington State Hospital Association. "It used to be that the hospitals and doctors had two separate lines of income, but now they're both competing for the same dollars."
Although such disputes are often framed as "communication" or "honesty" issues, Greenawalt said that in truth, tighter reimbursements, higher malpractice costs and the increasing share of revenue coming from outpatient procedures are pitting doctors and hospitals against one other.
Doctors at Swedish realize the hospital will sometimes compete with them, said Dr. Dane Travis, a private family doctor who practices at Swedish's Ballard campus. But, he said, there is an "honorable way to communicate about competition" that doesn't simply inform doctors after the fact.
"Physicians were feeling blindsided by the decisions," he said. "What we've asked is that people stand with honor and say, 'Here's what we're doing, and yes, it may impact you, and if you have a better idea, then come forward.' "
"Critical failure"
Dr. Michael Hart, a general surgeon who is employed as chief of staff at Swedish's First Hill campus, said that while medical leaders there didn't support the no-confidence vote, they agreed there had been a "critical failure" by the administration in communicating with doctors.
"Physicians feel our voice in the direction Swedish is going, our place at the table to discuss these decisions — which affect our future — hasn't been sought or hasn't been heard," Hart said.
In an interview last month, Swedish's vice president for medical affairs, Dr. Nancy Auer, acknowledged lapses in communication with medical staff on plans to open a new neuroscience center, for which three specialists already have been hired. "We kind of got the cart before the horse," she said.
The administration is now exploring new ways to involve doctors in planning, efforts Travis described yesterday as "heartfelt and sincere."
Auer said the medical center has no plans to hire doctors widely. It now employs 270 physicians out of about 1,200 active medical staff; about 100 of those are medical residents, she said.
But, Auer said, it's a new era in medicine.
Independent practice, she said, "is not the reality today," as malpractice insurance, medical-school debt and electronic medical-records regulations make it less likely a doctor can survive without being employed by a hospital or large medical group.
Meanwhile, Swedish was forced to contemplate new financial vulnerabilities when a group of doctors a few years ago proposed opening an independent outpatient surgery center, and a malpractice crisis last summer threatened to leave the hospital without neurosurgeons on call, Auer said.
"We would all like it to be like it was in 1985, but it's not any more," said Auer. "There's a new reality in the practice of medicine."
More hospital CEOs will lose their jobs over physician-relations problems than for any other single reason over the next few years, said Daniel Zismer, a Minneapolis health-care consultant who wrote last year that physician relations are the "Achilles heel" of hospital CEOs.
Zismer attributes most disputes to financial pressures on doctors and hospitals.
Typically, Greenawalt said, doctors and hospitals don't fight over less-lucrative areas such as the emergency room, obstetrics or mental health, but over well-reimbursed services such as heart catheterization, orthopedic or neurological surgery and imaging.
In most cases, both sides accuse the other of breaking an unwritten contract, Greenawalt said. The hospital complains that doctors are taking lucrative procedures out of the hospital and into free-standing surgery and imaging centers — which the physicians often own.
Meanwhile, the doctors complain the hospital is setting up services to directly — and unfairly — compete against private practitioners.
"The perspective of many doctors is, 'We the doctors have made you (the hospital) what you are today,' " Greenawalt said. "To them, it seems like a complete betrayal for the hospital to compete against the doctor."
Swedish's dispute, which began earlier this year with the hospital's efforts to hire neurosurgeons for the new neuroscience center, seems destined to become a case study in such dynamics.
A petition circulated by 10 specialists, including neurosurgeons, orthopedic surgeons, a pain specialist and an interventional radiologist, asked Swedish's medical executive committee to call for a vote of "no confidence" in the administration.
Peterson met with medical staff in June; doctors met the next week to decide what to do. Nearly 60 percent of the 542 doctors who mailed anonymous ballots earlier this month decided to proceed with the no-confidence vote.
Travis, the Ballard doctor, predicts the vote now under way will show confidence in Peterson, in part because of steps already taken to involve doctors in decisions.
If the vote goes against Peterson, however, it would come at a particularly awkward moment for Swedish, now negotiating to merge with Northwest Hospital, its latest target for acquisition.
Earlier mergers subsumed Providence and Ballard Community hospitals, which became Swedish satellites. In 1980, Swedish acquired Doctors Hospital and Seattle General Hospital, and closed them.
Recently, Swedish announced plans to open a free-standing emergency room in Issaquah and later, a 175-bed hospital, if state authorities approve.
Swedish's vigorous expansion and acquisition plans have left some doctors wondering how much choice they and their patients will have in the future.
"Swedish has taken an aggressive approach in eliminating hospitals as competition, and they are now starting to eliminate physicians as competitors," said Winquist. "If the public has ever valued independent private practitioners and their ability to be the patient's pure advocate, they should care."
"Open staff" model
Auer says Swedish is dedicated to the "open staff" model, which depends on independent community physicians who choose to send patients to Swedish. "Swedish's reputation is built on the fine physician care that's been provided here over the years," she said.
Still, last year the board changed hospital bylaws regarding employment of doctors. Employment is now one type of relationship the hospital may have with doctors instead of being a last resort.
Greenawalt, the hospital association president, predicts that hiring doctors won't become widespread. But he also predicts that hospitals, "under incredible pressure to survive," will continue to reach for lucrative services, even if doctors complain.
"I think for the foreseeable future it's the way it's going to be," Greenawalt said. "Table manners go out the window when there isn't enough food on the table. There's a restricted pie, and they're going to fight over it."
Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com