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At a recent daylong continuing medical education meeting focused oninpatient diabetes management, six speakers discussed various aspects ofglycemic targets, insulin management, and nutritional support before more than150 primary care physicians and endocrinologists. I noticed that each speakermade at least one derogatory comment (some physicians made many more) about acommon challenge in hospitals: the antagonistic role of hospitaladministrators in blocking the pathways for better patient outcomes.
Despite clear data showing that glucose control in the hospital environmentimproves patientoutcomes,1 eachspeaker—and each physician in the audience who spoke in thequestion-and-answer session—reported being required to defend a newpractice paradigm to a hospital administrator who ultimately needed to fundthese changes in practice behavior.
Let's put ourselves in the place of these administrators. Each chiefexecutive officer, whether working at a not-for-profit or for-profit hospital,must report to a board of directors and is responsible for ensuring thefinancial success of the organization. This chain of command is no differentfrom that of any other type of company within or outside the health careindustry.
Spending more money on something new or not required for financial gainwill not generate the same enthusiasm as an investment that clearly will beprofitable. If patient outcomes are improved as a result of the investment, somuch the better, but medical end points cannot get in the way of financialobligations—at least as far as the fiscal bottom line is concerned.
The unfortunate reality for those of us who are not involved inhigh-technology procedures with tremendous financial incentives is that ourrequests for new treatments or programs to improve patient outcomes will notbe heard as eagerly as those of our procedure-based colleagues.
Yet our requests often receive closer scrutiny in terms of actualcosts.
Consider the situation taking place at hospitals in nearly every communitynationwide. Say you are CEO of a community hospital with a diabetes-educationstaff of one nurse and one dietitian. You have a $100 million operating budgetfor the entire hospital and $1 million to start a new program. Would youprefer to recruit a team to perform gastric bypass surgeries or to build astate-of-the-art diabetes center, complete with a multidisciplinary team ofnurse educators, nutritionists, pharmacists, and, yes, even a physician?
The obvious return or "low-hanging fruit" would convince you tofund the high-profit surgical procedure. With no clear benefit from enlargingthe diabetes evaluation and management staff, you might keep it at its currentlevel or even consider downsizing. After all, reimbursement for teaching andcognitive services is meager, and few payers will pay the actual costs.
Clinical research, however, is beginning to suggest that prevention pays(Lowering Risks Pays Off for Nondiabetic Patients," seepage 1). Two new studiesshow that reducing health risks through lifestyle changes—such as weightcontrol, a balanced diet, and increased physical activity—is acost-effective way to slow the onset of type 2 diabetes in nondiabeticpatients. One study concludes that lifestyle intervention in high-riskpatients results in a thirtyfold savings compared with treatment withmetformin. "The tide may slowly be changing," the article reports,"as studies like these provide further evidence that improving healthmakes economic sense."
Ironically, hospitals have a greater incentive to treat the devastatingcomplications of diabetes than to implement programs that help prevent many ofthe problems we all treat on a daily basis. This to me is the heart of theapparent impasse and the overall reason diabetes care in the United States isso poor—despite the fact that most of these complications could beavoided orpostponed.2
Most of us went into medicine to help patients lead better lives. Medicalschool did not train us to defend and fight for our patients againstadministrators. Yet we practice in a new paradigm that requires us to do so(or perhaps the new guidelines for inpatient diabetes management have made memore aware of an old problem). In the 1990s, the enemy in this battle wasmanaged care. The new enemy is the hospital administrator who is expected toput financial matters above patient care. I believe this adversarialenvironment is due to the growing competitive pressures among hospitals overthe past decade. The issue also is complicated by the evolution of hospitalownership of many physicians' practices.
As with pharmaceutical companies, the medical device companies, and mostother health care–related companies, for hospitals, the bottom linedictates that financial success always will trump patient care. For thisreason, stringent, enforceable care guidelines must be put in place to protectour patients.
In my experience, the only real spurs to drive hospital administratorstoward putting patient care first are accreditation requirements and,unfortunately, lawsuits. Nothing else seems to make a difference. That is whywe may need more—not less—involvement from the Joint Commission onAccreditation of Healthcare Organizations.
It is clear to me that the only ones who really watch out for our patientsare clinicians whose main interest is improving patient outcomes. n
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Footnotes
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References
2. Saydah SH, Fradkin J, Cowie CC: Poor control of risk factors forvascular disease among adults with previously diagnosed diabetes.JAMA 291:335–342, 2004.
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  B. P. Childs The Complexity of Diabetes Care Diabetes Spectr, July 1, 2005; 18(3): 130 - 131. [Full Text] [PDF]
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