Salmon Upstream, LLC

Developing and implementing real-world community solutions.

Injustice Exposure, Episode 1: Competition in Medicine.

There are aspects of American society that we hold nearly sacred, and one is this idea that competition always yields a better product. In reality, it depends on the setting.

There are aspects of American society that we hold nearly sacred, and one is this idea that competition always yields a better product. In reality, it depends on the setting. And the practice of medicine is one area where open competition is causing as more harm than good. Used appropriately, competitive medicine has a place: my lab is better because we must compete with other labs to provide better services at lower prices. But when two offices or ERs or hospitals compete for the honor of doing things to you so they can make more money than the other guy, the system is no longer working for the greater good.

Perhaps if I show you an example it may help. Let’s look at an area near and dear to my heart: cancer.

As a pathologist, I have been involved in cancer care my whole career. I have served as a physician liaison to the Commission on Cancer for our cancer center, the Alan B. Pearson Regional Cancer Center, since it opened in 2008. The CoC is the main accrediting body for community centers such as ours. To be accredited (and advertise that achievement), you have to do all the things required to demonstrate you are a quality place. This is great for patient care; the CoC stamp of approval means you are getting the best care. Right?

Well, sorta.

For sure, there are many required activities that are extremely important. Things like capturing data, monitoring the quality of your work in numerous areas, comparing your statistics with other cancer centers, showing you are working to improve what you are doing. But what if I told you the inspection process is more about checking off boxes than it is about actually taking care of patients, and being accredited is more about advertising than actual results? For example, when a CoC inspector comes to look at a cancer center (every three years), they are not required to ever set foot into a patient care area. And at our last inspection, he never did.

As a laboratory director, I have also been involved in running clinical labs for my whole career. Throughout that time, the accrediting body for labs, big or small, has been the College of American Pathologists, or CAP. The CAP lab inspection process is termed a peer to peer inspection. Labs are inspected every two years, and the inspection is performed by a team of people assembled from another lab. In the intervening year, we assemble a team to inspect a different lab. The process is very effective: for example, a blood banker is inspecting the blood bank, a microbiologist is inspecting the microbiology lab. More importantly, both sides learn from the process. We all face challenges, and seeing how another institution solves those problems or being shown a better way by someone in the same boat, this is good for everyone. And good for patient care.

Two years ago, I led an inspection to a nearby hospital lab that – important fact – happens to be a direct competitor of ours. Despite that, the inspection went smoothly. Most of the people that work in healthcare are more concerned about doing a good job than about competitive markets; that’s an arena left to the bean counters. The unexpected bonus was the fact that the lab included a site within their local cancer center. Which meant I got to tour – for the first time – another institution like ours. Unfortunately, our team was really there to inspect the lab, so I didn’t get a lot of time to discuss the ins and outs of navigating cancer patients through a rural system that is just as complex as a large referral center, but with more limited resources.

The revelation came the very next day, when an inspector from the CoC arrived to evaluate all of the ins and outs of my cancer center. And that is the way we think about things in medicine: it’s mine, with all of its ups and downs, frustrations and revelations, it’s where we all of us pour our hearts and souls, taking care of people who have this terrifying disease.

To say I didn’t see eye-to-eye with the assigned inspector is a bit of an understatement. At one point I was literally clenching my fists. If he makes Anita cry, I will lose my job and get arrested. Because I am going to hit him with a chair.

During a meeting with the entire staff (so you can verify this), I commented to our esteemed CoC representative that I thought adoption of a peer-to-peer inspection process could result in significant improvement in cancer care nationally, because it would not only allow a more thorough investigation of what is going on (he never once so much as peeked at a patient care area), but would allow us all to share our successful solutions to the difficult problems we are all trying to solve. His answer will forever ring in my head: “It will never happen. Because cancer centers are competitive entities, and they must keep their secrets to themselves.”

One more time, just because you have to choke it down repeatedly to really get it: cancer centers are competitive entities, and they must keep their secrets to themselves.

Lest you think this old codger was just an aberrancy clinging to a job well past the point when he should have been put out to pasture, the very same philosophy has been reiterated to me on two subsequent occasions by officials at the CoC.

I have not been quiet with my bitter hatred of this ideology. I have tried to get the CoC to allow me to come and present a proposal for a trial of peer-to-peer inspections. <crickets>. I drove to Williamsburg for a meeting of the state liaison physicians to make my plea in person, where I got to hear a rewording of the “cancer centers are competitive entities” adage from a CoC official via skype. At least this time there was a tinge of regret; but was at least an equal dose of “dude, you need to wake up from fantasy land and join us in the real world”.

I argued to our administration that we should just save the money (the privilege is quite expensive) and drop the CoC accreditation. In my opinion, we are better poised to identify our own problems and work out our own solutions locally than allow ourselves to be directed by some paper-pushers in Chicago just to have a plaque in the foyer.

But it turns out that plaque is considered quite valuable locally. Because, in this very real world, we are, in fact, a competitive entity. We have to convince our patients that we are worthy, so they will be inclined to be treated in our facility. Because if we don’t have patients, we don’t make any money. And without money, the lights go out.

As I write this, we have just stepped out into uncharted territory. For years, we have been trying to figure out a process where we could ensure that all of our cancer patients – not just those with a particular tumor type like breast cancer or lung cancer – receive comprehensive care utilizing all of the available assets in our system. It is not as easy as it sounds. We have created new positions. (What do I know about writing a job description? WTH is an SBAR?) And we don’t have any help. The CoC is no use. No other system that we know of is taking this approach. I put that we know of in italics because there may well by dozens of groups that have already worked out the kinks. But how would we have any idea? No one is talking. No one is going to give us pointers, no one is going to share their secrets.

Because we are competitive entities.

So explain to me how competition is helping cancer care? Because I think it may be one of the biggest hurdles to improvement. Healthcare should be about working together to best utilize every resource to take care of people the best we possibly can, not fighting over patients as if they were nothing more than potential financial assets.

So, how do we fix it?

Well, we are devoting the bulk of our efforts to figuring out our new way. Not because the CoC requires it, but because we know it is the right thing to do. And if we can get it working, we will then share it with others. Perhaps that will serve to refute the current policy. It is not an easy task, trying to do what is best in the middle of a competitive system that rewards those that learn to play the game. Think of how much better things would go if the system rewarded cooperative efforts, instead of closely held secrets.