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PRESIDENT’S
MESSAGE

Moral Injury, Patient Injury, and the

Coroporate Practice of Medicine

By Adam Ratner, MD, 2019 BCMS President

Most of us practice within a corporate structure of some sort. diatrics clinics coming to our state. While it can be argued that
Formal organization is necessary for the sustainable pursuit of direct integration of the payers into the delivery of health care
our healing missions particularly if more than one or two people may bring efficiencies and incentivize/force alignment between
comprise the organization. What’s most important is the culture the payers and those who attempt to heal and provide healthcare,
of the corporate entity and its leadership. it certainly doesn’t necessarily align with the interests of the pa-
Most of the physicians with whom I have had the pleasure tients. Most insurers have a short time horizon with their insured
of practicing, over my career, have been primarily driven by the patients because employers re-evaluate their health insurance
interests of their patients. Oftentimes, as caring physicians, we provider annually and switch frequently. This inherent malalign-
spend more time and energy on a given patient than we will ever ment, at minimum, incentivizes a short-term, cost-cutting ap-
be financially compensated and accept that as part of our pro- proach to health care delivery rather than a long-term
fession. Not infrequently, we expect to take a financial loss car- prevention-oriented approach to patient care.
ing for certain patients as an inherent characteristic of our We physicians are adjacent to our patients at ground zero in
healing missions. this incentive malalignment danger zone. Financial and job secu-
Publicly-traded companies and surplus-driven private for- rity pressures burden physicians to make decisions that we know
profit and non-profit entities not truly controlled by practicing are not the best for our patients but are the best we can do given
physicians aren’t set up this way. Their top leaders are typically the constraints within which we are forced to work. How many
rewarded based on the financial performance of their institu- of us believe that the RVU goals and patient scheduling and vol-
tions, not on the “quality” of the care they provide, nor the ume targets set by corporate masters optimize patient care?
number of lives improved or saved. The value of a life im- We are aware of the increasing incidence of so-called physician
proved or saved, which does not contribute to the production “burnout” and too many of us are sick of suffering with it. Re-
of a financial surplus, is essentially considered either a direct cent literature now speaks of “moral injury” to physicians as the
loss or an opportunity cost which needs to be minimized. Cor- primary cause. That is the damage we as physicians sustain be-
porate leadership of such an entity cannot both optimize pa- cause of the chronic and persistent requirement that we are
tient care quality (which is difficult to measure anyway) and forced to do the wrong things for our patients by the dictates of
maximize surplus generation which is relatively easy to measure our corporate employers and payors.
and likely directly impacts the corporate leaders’ personal in- Now that the 2019 regular legislative season is over, the BCMS
come and perceived job performance. leaders and staff will be reviewing the new political reality and
The Patient Institute’s Conditions and Diseases of Healthcare seek to bring as many physicians as possible together to create a
Systems (CDHS) project calls this increasingly common situation, targeted and aggressive legislative program to address burnout,
“incentive malalignment syndrome.” A condition where the stake moral injury and their consequences on us and our patients. If
holders, that is the patients, physicians, other health care profes- you wish to participate, please let me know.
sionals and systems, corporate practice leaders, etc., have com-
peting and incompatible incentives. Dr. Adam Ratner is President of the Bexar County Medical Society and
Dr. Sheldon Gross, our BCMS immediate past-president, serves as Professor and Interim Associate Dean of Student Affairs of the
brought to my attention at the recent TexMed meeting that one University of the Incarnate Word School of Osteopathic Medicine and Chair
of the largest health insurers is a major investor in a chain of pe- of The Patient Institute.

8 San Antonio Medicine • July 2019