Finding Common
Ground
Address
to the Medical Society of South Carolina
February 21, 2000
Thank you
for that kind introduction. It is a great honor to be asked to
join you this evening. I come before you tonight representing
only myself, but also bringing with me the greetings and good
wishes of the entire Medical University. It strikes me as very
symbolic to appear before the Medical Society so early in my presidency.
For as everyone
in this room is aware, the Medical University, or more precisely its
forerunner the Medical College of South Carolina, was created over 175
years ago under the patronage of the Medical Society. I daresay that
there are some in this room who are direct descendents of those present
at the founding of the Medical College. Those of us, whose ancestors
were nowhere near Charleston at the time, are heirs, nevertheless, to
the insistence on first-rate medical education in this community and
in the State.
This is not to say
that the history between the Medical Society and the Medical College
has always been harmonious. As with any parent-child relationship, there
have been some stormy periods. Only eight years into its existence,
the six founding faculty members of the Medical College rebelled against
the governance of the Medical Society. The faculty resigned their positions
in 1832 and created a second medical school. The Medical Society replaced
the departed faculty and attempted to maintain a medical school under
its governance. Alas, the new faculty could not compete successfully
with their departed distinguished colleagues. Within seven years, the
two schools were united, with the Medical Society granting it independence
of governance.
Of course, a separation
of the Medical College from the Medical Society did not assure peace
between the entities. Tensions between the town and the gown communities
flared up again when the Medical University proposed to build its own
teaching hospital about fifty years ago. In some respects, this episode
again raised the question of independence of the Medical College, as
it had relied upon Roper Hospital for clinical education up until that
time. The creation of a separate hospital, however, introduced a new
element into the relationship — competition.
Over time, the reality
of separate hospitals gained acceptance and a state of peaceful coexistence
was restored to the local medical scene. Within the past decade, however,
a number of factors conspired to raise the level of tensions again.
Principal among these factors was the Medical University's effort to
build an integrated health care delivery system. The Medical University,
like most of its academic peers, purchased and developed primary care
practices — the so-called "gatekeepers" of the health care delivery
system. This move was intended to position the institution for the managed
care environment. Many physicians in the community, however, saw it
as intrusion into an area that was not the province of the specialty-oriented
Medical University.
The situation went
from bad to worse when the University entertained proposals from outside
organizations to manage its hospital. The University's Board of Trustees
elected to enter into negotiations with the for-profit, Columbia HCA.
Again, the Medical Society and the Medical University were headed on
a collision course. The Medical Society intervened legally, questioning
the constitutionality of the proposed lease agreement. The State Supreme
Court ruled that the Medical University could proceed with the affiliation.
By that time, however, the management and legal problems of Columbia
HCA made them an unattractive affiliate for the Medical University.
In reflecting upon
what we might refer to as "the recent unpleasantness" between our organizations,
it occurs to me that neither of us has gained much in the process. This
is not to say that there have not been winners. For example, the news
media, which thrives on controversy, has had a field day. The lawyers,
too, have found our tensions to be rewarding for them. Lastly, the divisions
between us have created a natural environment for health care payers
to market exclusive, deeply discounted contracts.
Now I am convinced
that a democratic society should support a vigorous press, a responsible
judicial system, and a competitive free market. It just seems to me
that the interests of the press, the lawyers, and the insurers are being
well served without our collective assistance.
What is most disturbing
to me is not that we have aided and abetted these groups, but rather
that the people who have lost the most are our patients. With some justification,
the public-at-large views the hostilities between us as a self-serving
contest between two privileged groups. Rarely have the issues been framed
in terms of the best interests of the patients. Rather, the battles
appear to be fought over issues like market-share. On both sides of
the conflict, the financial well being of the physicians appears to
be a prime motivating force. The cynics among us might conclude that
we have ceded to others our moral responsibilities as advocates for
the health of the community.
No doubt this short
excursion through the history of the relationship between the Medical
Society and the Medical University is greatly oversimplified. In the
interests of brevity, I have sacrificed detail, although hopefully not
accuracy. My purpose tonight is not to dwell on the troubled times of
the past. Rather, I am here to talk about the days and years ahead.
It is my strong desire that the future will be marked by ever increasing
cooperation between the Medical University and the Medical Society.
The naysayers among
us may conclude that the recent past in our relationship is merely prelude
to the future. Some probably believe that a line has been drawn in the
sand and that neither party has the desire or courage to reach across
it. I am here tonight to extend my hand across that line.
Even as a relative
newcomer to the scene, that is not an easy thing to do. There have been
times in the recent past when the rhetoric on both sides got very personal.
It is difficult to suppress the emotions that arise under such circumstances.
If we cannot get past these feelings, however, we will be trapped in
a vicious cycle of conflict. It is time to break that cycle, for the
benefit of both our organizations, but more importantly, for the benefit
of the community.
If the letters that
I received from private practitioners after my election are any indication,
it appears that there is a strong desire for reconciliation. How then
do we start? At the risk of stating the obvious, I think that tonight
is a start. The most important first step is to open the channels of
communication. Tonight is one forum for that purpose, but hardly the
only one. Since taking office, I have had several occasions to meet
with members of the Medical Society and with representatives of CareAlliance.
What began as awkward, dare I say uncomfortable, conversation now flows
much more freely. The simple act of getting together to discuss matters
tends to defuse tensions and suspicions.
Second, we need
to identify some initiatives to work on together. There are plenty of
opportunities for this type of collaboration, so we may have the luxury
of being a little selective. It seems to me that there are at least
four types of cooperation that we might envision. The first is in the
area of new and expensive technology. Over the past few years, we have
been engaged in an "arms race" in expensive medical equipment. As soon
as some new piece of technology comes along, we both have to have one.
Neither one of our systems wants to be seen as falling behind on the
technological curve. The result, of course, is that the community ends
up with an oversupply of the new technology, driving up the cost of
care.
A much more logical
approach for us and for the community is to consider purchasing big-ticket
items together and share in their utilization. Without question, there
are many operational issues involved in sharing major equipment. For
example, where will it be located and who will manage it? In my opinion,
however, these are just logistical matters. The real challenge is to
make the decision to cooperate in the first place.
A second potential
area of cooperation is in the organization and delivery of support services.
A potential example of this type of collaboration has arisen in the
past few weeks. In this instance, the Medical University offers a support
program for patients with diabetes mellitus. This program focuses on
providing patients with the knowledge and skills needed to manage their
illness effectively. Topics covered include counseling on diet, medications,
and devices, such as the insulin pump. Although some of these services
can be billed to an insurance company, most cannot and therefore are
underwritten by other sources.
Roper Hospital operates
a similar program independently, also with institutional subsidy. The
question thus arises: "why not merge the two programs, thereby integrating
services for the community and hopefully gaining efficiency and cost
savings in the process?" Again, I do not want to diminish the operational
considerations involved in such a collaboration, but surely they can
be overcome. If we bear in mind what is best for the patients, why would
we not want to assure a jointly supported community-wide resource?
A third potential
area of collaboration is in community service. Both the Medical University
and CareAlliance have made substantial investments in providing services
to the community. Our efforts have been concentrated in a program entitled:
"The Healthy South Carolina Initiative." This initiative includes 28
separate projects that were competitively peer-reviewed and funded.
They cover a broad range of activities, from a mobile dental van that
visits schools, to an educational program on healthy eating delivered
in cooperation with local churches, to a training effort to help low
income women obtain employment. Many of these efforts are complementary
to those initiated by Community Health Partners. It only makes sense
that we look at better coordination of our efforts in the future to
assure that our limited resources are used to the greatest advantage
of the community.
A fourth potential
area of collaboration is in public policy. Now I will readily confess
that many physicians are uncomfortable with the suggestion that we should
be active in influencing public policy. Some would prefer that these
tasks be left to professional organizations, such as the American Medical
Association. After all, physicians are not trained as lobbyists or politicians
and most of us are pretty busy with the day-to-day tasks of patient
care.
Let me also be clear
that I am not talking about advocacy on behalf of the interests of physicians,
although I would not deny that there is a place for such advocacy. My
focus here is on the role that physicians can and should play in assuring
the health of the community. As the number of medically uninsured persons
grows, physicians should be at the vanguard of advocating for basic
access to care. Unfortunately, when it comes to the formulation of public
policy on these issues, individually and collectively we have tended
to be passive observers, rather than active participants.
Let me be specific
about the opportunity that you and I have today to influence public
policy in a significant way. As we meet tonight, the debate about the
use of the tobacco settlement funds is taking place in Columbia. As
you are all well aware, the entire premise of the lawsuit against the
tobacco companies was to reimburse states for their costs of providing
care to patients with smoking-related illnesses. Once the money arrived
in the state coffers, however, our elected officials began to develop
other ideas about how he funds might be utilized. The governor, for
example, has proposed that only 60 percent of the funds go to health
care, with 20 percent going to economic development and the remaining
20 percent going to tobacco farmers. Within the health care portion,
the governor is proposing several new initiatives, rather than stabilizing
the funding for currently under-funded efforts.
My intent is not
to criticize the governor's proposal. Others have suggested other uses
of the funds that I find equally remote from the original intended purpose.
I suspect that we might even have difficulty reaching agreement in this
room about how these funds might be used most appropriately.
I would hope, however,
that we could agree that the tobacco settlement funds should not be
used as just another unrestricted revenue stream to the state. These
funds should be used for their intended purpose, paying for health care.
To do otherwise, especially at a time when our Medicaid system and the
disproportionate share program are both at risk, is an abandonment of
the intended beneficiaries. For those of you who have not written to
your elected officials on this topic, I implore you to do so. The medical
community should be responding with a single common voice on this issue.
Together, the voices of the Medical University and the Medical Society
will be much stronger than either would be alone.
In closing, let
me reiterate my call to bring our two organizations into closer cooperation.
I have described several ways in which we can foster collaboration.
First, we can purchase and utilize expensive equipment together. Second,
we can merge support service programs to the mutual advantage of our
patients. Third, we can join together in sponsorship of community outreach
activities. Fourth, we can be united in helping to shape public policy
on health-related issues, such as the use of the tobacco settlement
funds.
It is time for the
Medical University and the Medical Society to end their recent conflicts.
We should do so, because it is good for both of our organizations, because
it is good for the public that we serve, and because it is the right thing
to do. Thank you very much. |
