The Commercialization of Patient-Related Decision Making in Hospitals

A qualitative study of the perceptions of doctors and chief executive officers

Background: Hospitals must make a profit to ensure their continued existence. The observed rises in case numbers and case-mix indices lead us to suspect that the admission, treatment, and discharge of patients are now being influenced not just by purely medical factors, but also by economic considerations with a view toward making a profit—i.e., that decision-making has become partially commercialized. In this study, we investigated whether doctors and hospital chief executive officers (CEOs) share this perception of their professional environment.

Methods: In a qualitative study, doctors and hospital CEOs were interviewed. The survey was carried out in two waves over the period 2013–2016. 22 pilot interviews, 41 guided interviews, 3 focus groups, 1 written expert questionnaire and 1 workshop discussion were conducted. Responses were evaluated according to the “grounded theory” of the social sciences.

Results: Some of the doctors’ and CEOs’ perceptions of the patient-care situation differed markedly from each other. The CEOs mentioned the need for a profit orientation and stressed that they obeyed the legal requirement not to have any direct influence on medical decision-making, while acknowledging that physicians’ actions might be influenced indirectly. The doctors, on the other hand, reported feeling increasing pressure to consider the economic interests of the hospital when making decisions about patient care, leading not only to overtreatment, undertreatment, and incorrect treatment, but also to ethical conflicts, stressful situations, and personal frustration.

Conclusion: The doctors’ responses indicate that the current economic framework conditions and the managers of hospitals are currently influencing medical care to the detriment of the patients, physicians, and nurses. It is important to acknowledge that economic pressure on hospitals can undermine the independence of medical decision-making. The dilemmas facing doctors and hospital CEOs should be openly discussed. The economic framework conditions and steering concepts should be changed as suggested by these findings.

Every patient starting treatment wants to know they can trust the doctor and the hospital. Physicians promise (1) that “maintenance and restoration of patients’ health” will be their “paramount duty.” From this, their official code of conduct derives the precept that “with regard to their medical decisions, physicians may not take any instructions from nonphysicians” (1). This principle is violated whenever medical decision making in the hospital is affected directly or indirectly by nonphysicians on financial grounds in such a way that patient wellbeing no longer represents the “paramount duty.”

There is no doubt that medical and managerial actions in Germany are increasingly being influenced by limited financial resources. In contravention of their legal obligations, the federal states finance only around 50% of the necessary investment, the rest having to be raised by the hospitals themselves. Emergency rooms cannot cover their costs, and hospitals’ outlay on treating so-called extreme cases cannot be recovered in full. These losses have to be compensated by profits from the treatment of inpatients. The same is true for losses caused by overcapacity, by annual adjustments of standard state-level case reimbursements that fail to match increases in costs, and by other factors.

This article presents one part of the findings of a qualitative study (2). In contrast to the large number of studies (3–16) on developments in case volumes published between 2011 and 2014, all based on statistical data routinely collected by hospitals or health insurance providers, our study represents the viewpoints of hospital protagonists. The intention was to reveal further possible links between the financial constraints on hospitals, operational management, and doctors’ decision making with regard to patients.

The aim of our study was to verify whether doctors and chief executive officers (CEOs) perceive any influence of hospitals’ economic interests on physicians’ actions and thus on the practice of medicine and patient care. Advice is given on what to do if this is so. Implementation of these recommendations may help to exclude or at least restrict the commercialization of decisions that affect patients.

Method

We selected a qualitative study design in line with the “grounded theory” of Glaser and Strauss, a well-established method in the social sciences (17). We questioned 32 doctors and 31 CEOs in detail in face-to-face pilot and guided interviews between the end of 2013 and fall 2016. The interviews were documented verbatim in writing. Furthermore, three focus groups were conducted with a total of 22 participants, and three further group discussions took place. In the attempt to throw light on the reasons for the pronounced differences between the doctors’ responses and those of the CEOs, the interviews were followed by written questioning of five CEOs and five doctors and a workshop discussion with 12 participants (seven CEOs and five doctors).

The participants’ hospitals were situated in several different federal states and varied in funding, organization, and size. The doctors worked in several different specialties and were of varying seniority (Box 1). Each participant was approached directly in person. No permission was sought from superiors. We financed the study from our own funds. Further details can be found in the eMethods and in eTables 1–4.

Box 1

Characteristics of the participants

eTable 1

Breakdown of the probands/hospitals included in the pilot and guided interviews, classified by function, care level, and type of funding

eTable 2

Interview partners by federal state

eTable 3

Interviewed chief executive officers by qualification

eTable 4

Duration of employment as chief executive officer at time of qualitative interview

Results

Twenty-one of the 68 chief executive officers who were approached agreed to an interview. Those who declined predominantly cited lack of time. Only one of the doctors we approached decided against participation. With regard to medical decision-making practice, most of the CEOs expressed themselves in normative terms (“that’s how it should be”), whereas the doctors mostly made empirical statements (“that’s how it is,” “that’s how I experience it”), referring to examples and to their experience. In this way the doctors painted a different picture of German hospital medicine than the CEOs. The two groups’ responses often differed widely from one another (Table). Their relationship was often—but not always—described as tense and beset by conflict.

Table

Answers from doctors and chief executive officers to selected questions

The results of the pilot interviews were broadly confirmed by those of the guided interviews.

Chief executive officers reported pressure to achieve a sufficiently high profit (Box 2). Doctors see the resulting operational guidelines as affecting their medical decisions on patient care. Most of them rate this as problematic.

Box 2

Goals of operational guidelines*

For chief executive officers, a hospital has to be run in such a way that a profit can be made (Box 3, item 1). They reported that—in accordance with legal requirements—they exert no direct influence on doctors’ decisions (Box 3, item 2), but that operational guidelines indirectly affect doctors’ actions.

Box 3

What chief executive officers say

Almost all doctors answered the question of whether they encounter situations in the course of their work in which patient-related decisions and actions are guided not only by medical considerations with a definite “yes” (Box 4, item 1). Only one doctor, the medical director of a private hospital group, emphasized that in his institution—in contrast to many other hospitals he knew of—decisions were made purely on medical grounds.

Box 4

What doctors say

The doctors who were interviewed believed that economic considerations influence medical decisions on an almost daily basis in German hospitals and predominantly saw this as negative. In no interview was it welcomed or rated in any way positively. The responses were strongly colored by emotion. All 32 conversations with doctors revealed their need to discuss the topic. It was repeatedly stressed that “nothing like that” should be allowed to happen, that it was a “hot potato” that could not be discussed openly although it definitely should be discussed.

The scale and frequency of operational influences on medical decisions were variably perceived and rated (eSupplement Interview [in German]). The overwhelming majority of doctors perceived these influences as “continual” (“daily—in every consultation and during every ward round”), “ever increasing” (“it’s happening more and more”), and “repeated” (“not always...now and again”) (eSupplement Interview) and thus as a characteristic feature of their work. Only two doctors stated there was “no” or “slight” influence. No differences were discernable according to type of funding organization, but there were recognizable differences among hospital groups and between hospitals in the same group depending on local management.

The influence was not always indirect but sometimes direct. In contrast to the CEOs, who repeatedly underlined that they did not want patients to be admitted to the hospital and treated as inpatients in the absence of medical indications (Box 3, item 4), doctors reported that not only indirect but also direct influence on medical decisions had been exerted or attempted (Box 4, item 2).

From the doctors’ perspective, the strongest indirect influences on their decisions include assessment of staffing levels and opening or closure of departments and wards by management. This almost always leads to problems, complaints, and conflicts.

The purchasing of materials and medications was also criticized as exerting indirect influence on medical practice. According to the doctors, in many hospitals the buyers make their decisions according to cost rather than on grounds of medical quality (Box 4, item 3).

Who exerts the influence?

The majority of the doctors saw senior management, representatives of the funding organization, or the executive board of the controlling company as the central source. These bodies have the power to decide on employment, dismissal, staffing, corporate strategy and goals, bonus payments, the benchmarks of resource distribution, and the closure or opening of wards. The chain of command runs from management to the medical heads of department, who are usually bound by agreements on economic objectives, and from them to their senior physicians. Medical directors with older contracts seem to be more independent. Some more junior doctors view their seniors as representatives of economic goals.

In communal hospitals it is local politicians making decisions in the background, for private hospital groups it is the central management team (Box 4, item 7). Medical directors, and also professors at university hospitals and lower-ranking physicians, are subject to the directives of the management board but not with regard to direct medical decisions. Doctors’ leeway in medical decision making was rated smaller by the doctors themselves than by the CEOs. Expressed in terms of the marking system used in German schools (a scale of 1 of 6, where 1 is the highest mark), the 20 doctors in the main study assigned their decision-making freedom an average mark of 3 to 4, while the CEOs believed that the physicians had much more latitude (average mark 1 to 2). Junior doctors and qualified specialists thought their own freedom of decision was greater than that of their more senior colleagues. This group also reported using evasive techniques. They repeatedly said they actually pitied their heads of department and reported a loss of respect for them.

Personnel policy and its influence on staff and patients

The doctors reported:

• Medical procedures that could not be carried out with the proper degree of efficiency and safety, or could not be performed at all, owing to a shortage of suitably qualified medical or nursing staff (e.g., insertion of vascular catheters, cross-matching, administration of special anesthetics, implementation of particular chemotherapies)
• Deficient performance due to overwork and to decisions necessitated by inadequacy of previous procedures

According to the doctors, increased workload, lack of time, and stress affected the quality of decisions and of the preparatory processes. This led to risks for staff and patients.

The doctors stated that decisions often contained an unconscious element of rationing with regard to the amount of time and degree of attention available for tasks and patients. While the necessary diagnostic and therapeutic procedures were usually (though not always) carried out, there was not enough time for explanation and general support of patients before and after operations and diagnostic interventions. They reported that alternative treatments often could not be discussed with the patient in sufficient detail. The situation was particularly critical in smaller hospitals.

The hospital management’s staffing policy is a sore point for most doctors (Box 4, item 4). They are of the opinion that young doctors are not given adequate opportunity to familiarize themselves with their respective specialty. This leads to situations where, given their position of responsibility to the patient and to the hospital, they are subject to extreme pressure, being forced to take decisions alone, swiftly, and without sufficient expertise (Box 4, item 5). Delays and incorrect decisions are the result (Box 4, item 6). On the other hand, the doctors believe, experienced physicians are overloaded because all clinical questions and decisions are referred to them while they are preferentially involved in tasks that have to be performed as safely and quickly as possible. Young doctors are then often left to their own devices, whether in discharging routine tasks or in dealing with emergencies on the ward, in the emergency room, in the intensive care unit, in the outpatient department, or on rounds. Training courses and rounds led by senior physicians or heads of department have to be shortened or their frequency reduced.

Among the reports of negative impact on health was the following from a confessional hospital: “What worries me a lot is that with all that happens with the staff, mental problems and stress, there’s nowhere to turn. It’s ruthless exploitation, it can’t be expressed in numbers, the worries you have, how you reproach yourself when you’ve treated someone poorly, I wish there was a way of quantifying it or at least making it tangible.”

Commercialization and its influence on decisions regarding admission, treatment, and discharge

Doctors reported that their decisions on admission, nature of treatment, and time of discharge would be different if they were free of constraints. They take full advantage of, and sometimes—in order to implement operational guidelines—even go beyond the gray areas in deciding whether procedures are indicated.

The economically motivated demands on physicians mentioned in the interviews were:

• Maximize occupancy (even if greater risks to patients are involved)
• Increase case numbers
• Minimize the number of resource-intensive “unprofitable” patients
• Never ask emergency rescue services to take patients elsewhere even when your emergency department is overloaded
• Arrange length of stay according to diagnosis related groups (DRG)
• Maximize case-mix index
• Be “creative” in determining indications (unnecessary treatments)
• Make full use of profitable apparatus, procedures, and facilities (surgery, endoscopy, intensive units, ventilation equipment, specialized diagnostics, cardiac catheterization)
• “Case splitting” (discharge and readmission instead of internal transfer)
• Keep patients where they are, even if they could be treated better elsewhere
• Give priority to the care of private patients.

The reported consequences: increased workload,
time pressure, acceleration

Almost all of the doctors interviewed mentioned acceleration of treatments, having to work too fast, increased workload, lack of time, and experiencing severe stress. They reported that pressure to establish the diagnosis could lead to incorrect decisions and inappropriate treatment. Watchful waiting and “talking medicine” are economically punished. Invasive procedures and use of apparatus were held to be preferred to conservative treatments. Many of the doctors perceived violations of the precepts of medical ethics. This was denied by the CEOs, who nevertheless repeatedly qualified their statements by saying that they did not know precisely how the doctors made their decisions in individual cases.

Discussion

The partial results of our study presented here describe the subjective opinions of doctors and chief executive officers. They bear witness to differing perceptions and different circumstances in the various hospitals. Doctors emphasize that their medical decisions are influenced by the funding situation and by operational management, often with negative consequences for treatment quality, patient safety, and the medical staff themselves. This state of affairs is apparently not discussed openly with senior managers. The majority of physicians take the view that doctors are under pressure from company executive boards and hospital managers to commercialize their patient-related decisions, because simple economy alone does not yield the necessary profit. They would often decide otherwise if they were to take only medical considerations into account (18–20).

Chief executive officers have to make profits, but are forbidden by law to exert influence on medical decisions. Nonetheless they have to ensure that the organizational processes are designed in such a way that they promote the interest of the body running the hospital. For their part, doctors are not supposed to permit their treatment decisions to be influenced by nonphysicians, but in reality are forced to do so. They may even adopt economic goals of their own accord (Box 4, item 3), although they are legally obliged to advise patients with no regard to economic considerations. This backdrop may also help to explain the CEOs’ opinions. It is often difficult to draw a clear line between permissible indirect influence and forbidden direct influence.

The majority of CEOs state that medical decisions should not be influenced by economic guidelines (Box 3, item 4). Others confirm economic influences, but restrict their answers by using terms such as “It cannot be ruled out that...” (Box 3, item 5). Medical directors are usually contractually obliged not to discuss internal hospital matters (§ 21 (2) example of a medical director’s contract of employment: “The medical director must exercise discretion with regard to all internal hospital matters, even when the working relationship has come to an end”) (21). This stipulation also applies to the conditions of the contract itself. Open debate is additionally hampered by competition among hospitals and the danger of scandalous media coverage. Furthermore, numerous studies have shown clear associations between a low degree of professional freedom in clinical decision making and the occurrence of serious health disorders (22). Recent quantitative studies have come to similar conclusions (23, 24). Without public disclosure of the problems there is a danger of gradual erosion of confidence in medicine—as is plainly already the case among doctors and nursing staff.

Limitations

Although it cannot be excluded that the study participants were led by the wording of the interview questions, we believe the questions are methodologically legitimate because they emerged from the pilot study. Moreover, the study was concerned not only with whether influence was experienced, but also with how the participants saw the influence as being mediated in their daily practice. The researchers who acquired the data are probably also not entirely free of prejudice and have their own normative ideas. In the attempt to take account of these potential distortions, the study was carried out jointly by a physician and a former chief executive officer. The attitudes and perceptions presented here come from various data collection times. In the comprehensive project report (2), they are assigned to the respective time and situation of collection.

Besides removing the taboo on discussion of the conflict between medical and economic goals, reformed funding regulations and improved health care structures are required. Intercommunication within the hospital and involvement of physicians in portfolio development and planning of services and resources need to be intensified. In this context, medical ethics must have a strong voice in the dialog between doctors and representatives of senior management. Our society could benefit greatly from discussion of the role of economic arguments in medicine and the health care system and the question of how best to balance the interests of the individual against those of society as a whole.

Conflict of interest statement

The entire study was financed privately by the authors.

Manuscript submitted on 18 July 2017, revised version accepted on
16 October 2017

Translated from the original German by David Roseveare

Corresponding author
Prof. Dr. rer. pol. Dr. med. Karl-Heinz Wehkamp
Parkstr. 116
28209 Bremen, Germany

Supplementary material
eMethods, eTables, eSupplement-Interview:
www.aerzteblatt-international.de/17m0797

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