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Will bylaws' clash change physicians' admitting privileges?

From the April ACP Observer, copyright 2005 by the American College of Physicians.

By Bonnie Darves

A battle is brewing over hospital admitting privileges and the medical staff bylaws that dictate which physicians receive the cherished "active" membership status.

The issue? Some hospitals are modifying their bylaws to give full privileges only to primary care physicians who admit a certain number of patients. Everyone else is relegated to "associate" status. For proponents of tighter credentialing, the argument is simple. Primary care physicians who spend little to no time in the hospital don't need—or deserve—full privileges. That includes voting rights and a shot at leadership positions.

Critics, however, counter that as hospitals offer more outpatient and ancillary procedures, primary care physicians need a say in how local hospitals operate to better serve their patients.

While there is nothing particularly new about fights over hospital privileges—the topic has been a hot spot for decades—observers worry that the current clash may radically affect the relationship between primary care physicians and hospitals. At the very least, they say, different classes of admitting privileges could widen the gap between those internists who work in hospitals and those who don't.

Narrowing 'classes' of privileges

Which physicians should have full privileges—including voting rights—and what's required to earn or keep that status have long been a source of conflict.

In the 1980s, the "who's in and who's out" debate centered around involvement in medical affairs and committee meetings. In the 1990s, it was residence requirements: Citing quality concerns, hospitals modified bylaws to require active physicians to live close by to ensure their availability for an urgent consult.

"The war is not new; it's a new battlefield," said Robert Berg, JD, an Atlanta health care lawyer with Epstein, Becker & Green who has counseled physicians and hospitals on bylaws-related issues for two decades. While in theory, he said, hospitals could "allow a completely open medical staff," he understands why they don't.

"It takes time, money and resources" to provide physicians with admitting privileges, he pointed out. Hospitals that must choose between those who do or don't frequently admit understandably lean to granting complete privileges—and potential leadership positions—to active admitters.

What's behind the latest conflict? Some analysts say it's driven by hospital administrators, while others point to subspecialist groups that increasingly fill hospital leadership roles. Most agree that the growing use of hospitalists has set the stage for discussing different classes of privileges for office-based physicians.

Winthrop F. Whitcomb, ACP Member, a hospitalist who runs the country's longest-standing inpatient medicine program at Mercy Medical Center in Springfield, Mass., doesn't necessarily view hospitalists as a causal factor in the current controversy. But he acknowledges the role the field's growth has played in forcing hospitals to rethink privileges for physicians who no longer admit patients.

"There is just no way to vouch for somebody's competence without observing them deliver care," said Dr. Whitcomb. "Physicians who sit on credentialing committees have the responsibility to continue to renew physicians' privileges on observed skills—or skills and competencies observed by a reliable intermediary."

Physicians who favor creating narrower classes of admitting privileges agree that it's hard to assess the delivery of care by physicians who see inpatients infrequently.

They also argue that low-admitters cannot keep up to speed on fast-changing developments in hospital medicine. And they claim that physicians who don't spend much time in the hospital have no meaningful stake in hospital operations. As a result, proponents claim, those physicians shouldn't have a say in issues like policy decisions, capital budget allocations and quality improvement initiatives.

Opponents of different classes counter that community-based physicians have a great deal at stake, regardless of how many patients they admit. Because more and more patients are using outpatient and ancillary services at hospitals, they say, primary care and referring physicians should play a vital role in how a facility operates. Without full appointment status, these physicians cannot advocate for their patients or exercise any control over the care those patients receive.

While physicians argue over who should receive full privileges, hospitals find themselves walking a tightrope. Community physicians, after all, significantly contribute to a hospital's bottom line.

"The reason the hospital wants to keep connected to those physicians in the community is because they want their patients," said Lawrence L. Faltz, FACP, senior vice president for medical affairs and medical director at Phelps Memorial Hospital Center in Sleepy Hollow, N.Y., and former Governor for ACP's New York Hudson Valley Chapter. "The whole issue of staff membership becomes a complex web of more than just quality, economics and control."

Dr. Faltz suggested that one way to address the problem might be to rewrite bylaws to create a "federated model" for varying levels of medical staff membership. Such a system would give low- or non-admitting internists a modified-privilege status, allowing them to elect representatives to the medical executive committee and ensure their concerns are heard.

A two-class system

Rhode Island Hospital in Providence, R.I., may go that route, according to Yul D. Ejnes, FACP, a general internist in Cranston, R.I., and vice-chair of the College's Health and Public Policy Committee. As a longtime member of the hospital's credentialing committee, Dr. Ejnes has wrestled with how to assess the qualifications of colleagues who come up for their two-year recredentialing after having few or no admissions.

According to Dr. Ejnes, who is Governor for the Rhode Island Chapter, his hospital committee is considering using a combination of outpatient record review and colleague references. Under the proposal, physicians with fewer than five discharges a year would have to submit "de-identified" outpatient records for review by the department chief and elect to have "courtesy" medical staff privileges, a lower level of staff privileges and associated responsibilities.

Creating that class would give community physicians a voice and some hospital privileges—which is important, Dr. Ejnes pointed out, because medical staff membership may be required by some health plans as a condition for remaining on provider panels. At the same time, having a courtesy class enables the hospital to address its credentialing concerns on matters involving quality.

"In an ideal world, there would be a reasonable way to assess the credentials of those physicians" who rarely admit patients, he said. He added, however, that he and his fellow committee members haven't yet discovered that solution—and said the hospital is also considering a more stringent review system for low-admitting physicians.

According to Springfield's Dr. Whitcomb, Mercy Medical Center—after launching its hospitalist program more than a decade ago—decided to grant associate status to physicians who, on their two-year recredentialing review, hadn't seen an inpatient. Those physicians have the option to return to full-privileges status if they choose, after a six-month evaluative period during which their in-hospital performance is monitored by the credentialing committee.

But Mercy's two-class system has a twist: Voting rights aren't affected by privilege status. Dr. Whitcomb said he sees no reason to couple admitting privileges to voting rights or leadership roles. In fact, he thinks the changing care dynamic makes it imperative for community physicians to have a voice and a stake.

"Hospitals should actually encourage physicians who don't come to the hospital to have leadership roles, because hospitals and community physicians have diminishing reasons to be loyal to one another," Dr. Whitcomb pointed out. "Hospitals are a community resource, so they really need the engagement of community-based physicians. They need to have new ways of having them engaged in the operation, leadership and strategic direction of the hospital."

Keeping pace with change

Analysts agree that as inpatient care patterns change, the entire credentialing process—from quality oversight and accreditation issues to associated practical and economic expenditures—needs to change too.

According to Robert Wise, MD, vice president of the standards division at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), hospitals have effectively created the bind they're now in by sticking to one-size-fits-all privileging structures.

"The problem is that in many hospitals' bylaws, every time a hospital gives physicians [admitting] privileges, they give all the responsibilities," Dr. Wise said. "The truth is that only a very small percentage of physicians with privileges want to be involved in quality oversight or to take part in committee work. A large percentage of people just want to admit, do some consultation, and get in and out."

Hospitals and their medical staff often believe that physicians must be active medical staff members to weigh in on quality oversight. While that type of requirement may be in many hospitals' bylaws, Dr. Wise noted, nothing from the Joint Commission or Medicare requires such a rule.

Still, JCAHO knows that the bylaws-modification issue is a growing sore point, and it is concerned that if the issue is not resolved equitably, the controversy could lead to more fractious relationships between physicians and hospital leadership. That in turn could have an adverse effect on patient care and safety, Dr. Wise said.

The privileging debate is also spilling over into a larger issue of medical staff leadership and hospital governance—a growing tension that JCAHO has decided to address. A case in point is a recent fracas at Community Memorial Hospital in Ventura, Calif., that occurred when the hospital attempted to "decredential" surgeons who had a financial interest in a competing specialty hospital.

A recently formed leadership accountabilities task force, sponsored by the Joint Commission and headed by Dr. Wise, is trying to look at the factors causing such incidents. (Dr. Faltz is ACP's representative on this task force.) The group's goal is to bolster collaboration among all hospital leadership components—governing boards, medical staff and administration.

The task force also wants to devise a better way to delineate the role and responsibilities of each of those individual factions. According to Dr. Wise, the task force is drafting standards that will go out for field review later this spring.

In the meantime, Dr. Ejnes said, the debate over privileges is an indication of major changes in physicians' relationship to local hospitals.

"It is highly unlikely that community physicians will relate to the hospital in the same way they did decades ago, beginning and ending their day there, eating lunch in the hospital cafeteria and relying on the hospital for continuing medical education," he said.

As far as outpatient physicians needing privileges as proof of good standing, "the development of other means of certifying internists' professional standing—such as pay-for-performance—could make hospital privileges less relevant," he added. And while community physicians and hospitals will still need to remain mutually engaged, "there will be," Dr. Ejnes said, "new relationships between the two."

New York's Dr. Faltz agreed. "As more care is moved to the outpatient setting and more medical services are done outside the hospital, the hospital may have little attraction for physicians as a place to volunteer their governance or quality oversight," he said. "Hospitals, as organizational entities, will need a clever response to maintain a reasonable load of patients."

Bonnie Darves is a freelance writer in Lake Oswego, Ore.

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