Balancing Local and System Interests (Aren’t we on the same team?)

How can we best balance system growth and regionalization of care and not alienate community physicians?

As a clinical leader in a growing non-profit health system, I continue to encounter a disconnect between the plans of the tertiary/quaternary care hospital and its programs and those of the community facilities. To the historian in me, this is a medical manifestation of federalism versus confederacy, but this academic interest does not offset the frustrations of these debates. I understand the basic friction: the main campus wants complex patients sent there so that patients can benefit from the experience of its teams and the multidisciplinary care that they provide, BUT, the community facilities seek to maintain good relationships with local providers, who are often not employees of the system, by allowing them to take care of any patient with any problem, provided that care is delivered at the community facility.


I am trying to grow my department and a service line across our system, so I have a federalist view of this situation. There is a wealth of data describing improved patient outcomes with increased physician and hospital volumes for a given condition or procedure. Experienced multidisciplinary teams typically follow protocols or pathways that can shorten length of stay and, potentially, decrease costs. Acquisition of expensive medical devices such as surgical robotic systems, advanced endoscopy equipment, and even radiation delivery systems intuitively drives regionalization of care. Finally, physicians at the higher level of care often perceive a certain amount of “cherry picking” of cases or patients by community providers, who then refer or transfer sicker patients at off hours.


However, the leaders of the community hospitals frequently block or obstruct efforts for community outreach clinics or practice expansion by “main campus” physicians, citing their loyalties to the community providers who could take their business somewhere else. The provider and facility volumes are not comparable, and the outcome measures available (which are not fully risk-adjusted) are insufficient for objective comparison. If the community providers are providing contemporary care and doing it well, at comparable cost, then they should continue to do so and the main campus teams could learn from them. Community leadership seems hesitant to engage in a true assessment of outcomes and cost, citing fears of alienating the community providers and losing their business. Thus far, one acceptable strategy that we have found is to create a multidisciplinary clinic model for a given condition at the community hospital and invite both community and main campus providers to participate – but this has not yet proven to be a universal answer.


There are clearly some areas where community facilities excel, and so there exists in a health system the potential for regional specialization. Unfortunately, in certain areas of medicine, an internal medical arms race exists that challenges a system approach. I am certain that there is a balance between federalism and confederacy, and the sweet spot may vary from system to system. Perhaps this situation is a routine growing pain for a health system in the youth of its expansion. Perhaps you have some suggestions or strategies that I could implement?


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Participant comments on Balancing Local and System Interests (Aren’t we on the same team?)

  1. Are there any cases or patients that you can send to the community facilities? Community hospitals fear that it will become a one way referral street with all of their paitents getting siphoned off to the larger academic center. If some patients or cases that can be better managed at community hospitals are referred to them, there is more of a feel of a give and take relationship that can be more symbiotic. There are often cost savings that can be realized at community hospitals compared to larger medical centers.

  2. I would consider establishing a Systemwide Committee with representation from community providers. Committee goals can include a dashboard (quality, process, financial, patient experience etc), establishment of pathways etc. This will begin dialogue between providers and campuses, hopefully lead to meaningful collaboration/shared learning, guided by data.

  3. Your story is all too familiar to me. Here are a few things that we have been successful with:
    -System Strategic Service Line (SSL) to align for clinical standardization & spread of best practice, growth, marketing, supply chain, capital & IT, employee training standardization, and innovation.
    -System-wide physician decision making model via a quarterly System Strategic Collaborative Council
    -System-side subspecialty councils
    -Efforts to shift elective, lower-risk procedures to community hospitals (ortho SSL does this well with elective joint replacement)
    -Efforts to evaluate patients prior to transfer (so we aren’t just shifting the mortality to the academic medical center)
    -Allows us to align marketing efforts
    -Allows coordination of equipment & supply chain buying power
    All of that said, new system c-suite leadership at my facility is shifting away from SSL’s to even further centralize the clinical work under one office (and move those resources to spread councils to more departments). I fear that they underestimate the importance of the relationships in the work that has been accomplished thus far as well as the time spent on important business initiatives beyond clinical standardization.

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