Let’s Be Prepared                                                             March 11, 2013

By Leonard Zwelling

            The email was beamed out over the institutional system. The Faculty Senate was sponsoring yet another Faculty Forum, this one on Clinical Productivity and Institutional Finances. My guess is that what this is really about is trying to get an explanation from the leadership team members who have agreed to attend, why there has been such an energetic push to increase the number of patient encounters. The assumption is the push to greater Clinical Productivity is based upon a concern for Institutional Finances. This seems to be coming rather late in the game as we are more than halfway through the fiscal year and we have heard nothing but doom and gloom about the monthly budget shortfalls. I have had repeated conversations with my clinical colleagues about the leadership of the Divisions and Departments pushing for greater and greater clinical loads. Detailed metrics have been devised to track individual and collective clinical productivity with the not so subtle implications that a future at MD Anderson is linked to increasing one’s productivity as measured by these tracking tools. The missing ingredient is the why?

            So what might that why be?

            The most obvious why is that we are seeing fewer patients than in previous years and are making less revenue as a result. However I heard a presentation from Dr. Burke only a month ago in which he demonstrated that we were seeing about as many more patients this year when compared to last as we had seen last year when compared to the year before. So decreased volume does not seem to be the problem especially since rarely does a month go by when Dr. Rodriguez does not send out an email about the hospital being full.

            Then perhaps we are making less per unit of work.  That is possible if the insurers have ratcheted down what they pay us and/or our payer mix has shifted to less profitable patients (e.g., Medicare and Medicaid) from more profitable ones (privately insured and foreign cash payers). Since we have learned from the Time Magazine article by Steven Brill that the amount of money we take in from these two groups for the same services can be an order of magnitude different, that’s a possible source of financial difficulties. However, I am unaware of any faculty member that is in a position to decide who gets through the front door and who does not with the exceptions of those physicians expressly charged with this duty who work for Dr. Burke. If our payer mix has shifted, there is not much the faculty can do to alter that.

            Perhaps we are making less from our non-operating income like investments or philanthropy. But the Dow is at record levels and if we are not the recipient of generosity to the extent we used to be, whose fault is that? Surely not the faculty’s.

            But the real problem with our finances that has probably caused the push to increase clinical productivity is a simpler one. We spend too much.

            If it is our spending that has created this perceived dilemma, it would be best if we all knew that before we engaged in any discussion about increasing clinical efficiency for its own sake. It would be my suggestion that the leadership provide the faculty with a full accounting of every single dollar that has come in and gone out for the past 18 months so that we might ascertain which of the scenarios I describe above has caused this problem. We need to see every single dollar of income and every single dollar of expense no matter if it is being spent on the North or South campus, at IACS, on the Moon Shots, on Global Programs, Regional Centers, Banner, Orlando, Espana or on recruitment. Only if we all are working from the same objective set of figures can we understand whether we are really doing worse than last year or just worse than the leadership had hoped for when it built the budget. Furthermore, we need to know now whether we are still in the black or have we spent so much that we really cannot catch up by running faster this year. I am worried less about the budget and more about the actual tally in the bank at the end of the year. Plus or minus?

            Without these numbers the forum is likely to digress into a finger-pointing exercise or even worse, the usual bit of performance art where the leadership speaks for 30 minutes and numbs the faculty into submission. If real questions are ever asked they are usually of the soft ball variety only made that much softer by the answers which usually amount to “we’ll get back to you”. That the Senate is taking some questions in advance is a positive sign, but think how much more perceptive those questions would be if the faculty asking them had the same data as the administrators who will be charged with answering them.

            To have this be a meaningful forum, we all need to be as prepared as possible to have thoughtful interactions with one another and not get into arguments about whose facts are the right ones. We all need to be prepared with similar information. With that as a foundation, I believe that a solution can be built, but without the trust that comes from transparency, whatever edifice is constructed will be yet another Tower of Babel on Holcombe.