Health care administrators: a call for equal transparency and accountability

While physicians are constantly being asked to prove their value with a growing constellation of metrics, health care administrators seem to have escaped a similarly high degree of transparency and accountability about the value of their specific roles. What I mean is that physicians are certainly not equally informed by objective measures of the performance of their administrators. Given the remarkable growth in the health care administrator to physician ratio (10:1 now) over the past decades and their escalating salaries, it begs the question: why not?

Specifically, I think most physicians would like to know and deserve to know: What are those administrators doing with their time? How do they objectively define, measure, and report their value? Also, what individual financial incentives do they have in making their administrative decisions? And ultimately, are they really essential, or could multiple roles be combined into one? Although certainly high-level administrators oversee and evaluate subordinate administrators, in my experience, physicians are not included in any assessment of value in the administrative world; in that sense, physicians are being treated as subordinates, despite the undeniable fact that they are the keystone of revenue in health care. Administrative leaders have essentially sealed off their world from clinicians, tapped into revenue from the high-value services that physicians provide, and often give the condescending impression to physicians that: “It’s complicated. Just see your patients (and bill), and we’ll take care of everything else”.

However, I think it is self-evident to any observant physician that administrative tasks and meetings tend to breed more administrative tasks and meetings, and, in my direct experience in administrative roles in health care, actual productivity and value can be very easily supplanted by a “busy day of meetings” in which no one could actually state what, if anything, was accomplished. This contrast in productivity has been particularly evident when my busy clinical day (of urgent decisions and critical actions–and billing) is interrupted by a “useless” administrative meeting. Any conscious brain has to ask: “These guys are paid to do this?”

One time, I invited my clerkship medical student to attend a hospital staff meeting with me. I asked her ahead of time to pay close attention and make a list of the things that were actually decided or accomplished in the meeting. As I predicted, her list was empty–and I agreed.

Another time, I submitted a list of unsafe clinical cases that I had recently witnessed in the health system to a high-level physician administrator, and I was invited to a lunch meeting to discuss my concerns. The fact that he had time “on the clock”–with so many important responsibilities–to drive to and from a restaurant for lunch with me (on my day off) was puzzling–after all, I had already taken a significant amount of my personal time to compose and submit all the information that I wanted him to see and act on–but the fact that nothing tangible came out of the meeting (other than an invitation to volunteer more of my free time on a committee) was another testament to me that administrators do indeed have the liberty to fill their time with low-value tasks, with little apparent transparency and accountability.

In contrast to administrators, I can demonstrate that I managed 21 inpatients, discharged 6, and admitted 2 (and everything that entails). My case mix index and length of stay, readmission rates, query response rate, core measure compliance, patient satisfaction, and many other metrics can be reported for each day if needed.

So, I think it is reasonable for a physician to ask administrators: What did you accomplish today? How did you prove your value? Just write it down and send it to me.

From a wider perspective, consider that health care expenditures represent 17 percent of the U.S. GDP ($4.5 trillion). Finance people, in general, clearly know that to make money, you must go to where the money is, and since a large amount of the money is currently in health care, that’s where they have been going, leading to a health care administration that has grown ten times faster than health care providers in the past few decades. Of course, administrators would argue that this is necessary due to the increasing financial and regulatory complexity of health care; but others could argue that administrators are simply parasites who have skillfully latched on to the purse strings of a high-income industry (consisting of highly trained medical professionals), and are sucking its blood without providing equivalent value, and inviting all of their friends to join the feast.

The only way to know and dispel distrust between physicians and administrators is for administrators to accept equal transparency and accountability.

As another example, a non-clinical administrator currently determines when our physicians can ask for additional staffing to safely manage fluctuations in hospital census; however, the physicians have no equivalent data or control to judge the productivity or value of that administrator. Is she simply pushing for a higher profit margin to get a higher bonus? Or is she basing that decision on something else? Potentially, she is basing that decision on her own distrust of physicians who are asking for help out of laziness. Unfortunately, clinical physicians have increasingly been excluded from the decisions, and physician executives, once they get a soft chair and a mahogany office, seem to just want to keep the finance guys happy.

Either way, the point is that an administrator who has that much control over my professional work should be willing and required to share (with me) her own productivity objectively. Importantly, this should include transparency regarding her bonus structures, as this could strongly influence her decisions that affect my work.

Certainly, as a clinician who values the pure practice of good medicine, I am biased against administrators who measure their days in meetings, PowerPoint slides, and cups of coffee, but I am very willing to hear their side of the story. That is, show me the data–the results. Hiding it only makes physicians more suspicious–a distrust that will perhaps prove to be the primordial soup of doctor unions.

In summary, I challenge physician groups to unite in requesting transparency and accountability from their administrators in order to assess their value, as they assess ours continuously, and to eradicate waste in health care administration. We cannot fix what we cannot see.

David M. Mitchell is a hospitalist.


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