ethics news & views

Doing ethics at Emory Hospitals: an interview with CEO John Henry

Kathy Kinlaw and John Banja recently spoke with John Henry, Sr., CEO of Emory Hospitals & Wesley Woods Center.

Question: Does the current nature of health care raise ethical concerns? Are new issues presented or are the ethical concerns ones that have repeated over the years?

John Henry: I still think that the health care ethical concerns deal with rationing of care, and it is a little bit different today then it was ten years ago. Managed care companies decide what is appropriate in dealing with continued treatment; they also are not just managing care but managing payment. If I operate on Mr. Smith on Friday, and he went into the ICU on Friday and spent Saturday and Sunday in the ICU, I can guarantee that one of those ICU days will be denied as not necessary, regardless of the fact that we think that it might have been necessary. Weekend stays are one of the issues.

Another ethical concern we always have is decisions near the end of life, which I became involved in in 1987 . I don’t think any of those concerns have gone away. The real issue comes down to the rationing of care. When is it appropriate to give up on someone’s life and who should have the right to make that decision? The aspect that I worry a lot about that comes up from time to time is that there are people that I know right now that have living wills that basically know that they never want to be put on a respirator. They never want to be in this certain condition. But their children have decided that’s not how it’s going to go. Momma or Daddy didn’t really fully understand what was going on and it’s really up to me to counteract what my parent really wanted.

One of the other things that concerns me is pharmaceutical ethics. How many people out there that are elderly can’t afford drugs? One aspect of this is managed care. We have Aetna and we have Cigna, and Aetna has one policy for drug benefits and Cigna has another kind. What is on the preferred list is different. One of the things that we are going to try to do at Emory is have one pharmacy benefit manager. Of course the other thing that is a nightmare for our attending physicians is knowing what drug is on what formulary and at what discount price. Now the good news there, is that some formularies have already been added into the Emory Electronic Medical Record. So if you wanted to know what the drug of choice was for an antibiotic, the list of drugs would be there. I think that it is ludicrous for us to have these multiple lists out there and that the poor patient doesn’t have a clue about what is going on.

Question: Are physicians aware of the cost constraints that administrators have to deal with everyday?

John Henry: My son, who is an orthopedic physician, knows exactly what managed care will pay not only him but the hospital. If something is denied, a letter is written. Physcians do take time to pick up the phone and call the physician in charge, not a nurse reviewer. When one of the medical representatives of the plan is involved, I would say 90% of the denials are reversed.

Now the real problem that comes in is how you handle the denials. There are certain practices that will handle a denial as an immediate write off, which is the way I think it should be handled. Others will say that the denial is part of accounts receivable and they work it. They don’t write it off. What we do is write it off but we continue to work, and when we get it reversed that’s when it drops immediately to the bottom line. But if we don’t handle it that way then our receivables just continue to go up and they are bad receivables. I would say that community doctors that are on staff here and most of the community doctors that I’m aware of in Atlanta know what is being paid to them and they know what is paid to the hospital. If you are on a salary and you don’t have the feedback from your section or your department then you may not know and it may not be important.

The Emory Clinic is much better than ever before on dealing with much of this, and it has happened in the past two years. My family members say that in a week after they are seen by the doctor, they get an acknowledgement from the health insurance that a claim has been processed. Within another three to four days they get a bill from The Clinic for the co-pay. It depends on how responsive clinics are at getting charges in. Most community doctors submit their bills within 24 hours after surgery.

One of the ethical things that we have also got to deal with is coding. It’s a compliance issue as you know. I don’t think it's ethical when you are splitting hairs. For example, if you operated on me and you took care of me in a certain way, you are the only one that knows that. If you code that and didn’t document in the chart the reason why you coded that, that’s when it becomes a compliance issue. But in your heart of hearts if you knew what you did was this way, then I don’t think that’s an ethical issue. I think the payers are involved ethically because of the fact that they have made all this stuff so complicated. There is no way that when you have a coding book like this that you can keep up with all of that day in and day out and know what is going on.

Question: Do you think that practices and institutions are having to spend a lot of resources not only on the appeals process but also on making sure that they are in compliance? Is that a problem?

John Henry: Regulation is a big problem. I could pull out an AHA book and show you the regulatory problems. Regulations are awful for us; about thirty cents on the dollar is spent trying to comply with regulations that have no value to the patient and no value to improving quality of care. If the resident has done a history and physical, the attending physician can’t bill unless present; he has to come back in and repeat the history and physical in order to be able to bill. That is wrong. If in your practice you have a standard of care and this is the way you want all you patients handled, why can’t you end up with protocol-driven medicine? We want evidence-based medicine; it should be protocol-driven medicine. The joint commission says do it, but what you have to do is put your protocol in and go through anywhere you don’t follow the protocol and why you overrode it.

Question: Does it “pay” for a health system or hospital to give attention to ethical concerns (both clinical and organizational ethics issues)? How are hospitals and health systems today doing in addressing ethical issues as compared to when you began?

John Henry: I think there is no question. I got into this business 40 years ago. Part of the culture of varied generations made it different. My mother was a stay-at-home mom who raised her four kids. I grew up on a dairy farm in College Park. I understood the ethics of what you were supposed to do. We went to church; we basically were involved in things. I think that as people came to have two family members working, there was less attention at home and the kids had more opportunity to do things differently. Basically lack of supervision caused people to have different expectations. When I was coming along and you were dating, if you were not back home by 11:00-12:00 at night you were in trouble. Today the kids don’t leave until 11:00-12:00 at night to go out on a date, so things are different. You have got to learn to do things with the times; you cannot end up not changing. But maybe we have gone too far in one extreme and we’ve got to come back. There are a lot of things that have changed that are much better, but there are a lot of things that are ethical dilemmas that probably nobody worried about before.

One issue out there is how people are going to continue to treat Medicare patients because of the cost. The other aspect is how many people are going to treat high risk patients because of malpractice suits. Let’s face it, if an EKG is being read today, a physician gets ten dollars and eighty cents, and that ten dollars and eighty cents is split; eighty percent of that comes from Medicare Part B, and twenty percent from Blue Cross. To read a chest film, a doctor must have eight years past high school, plus a four or five year residency, are 30years old when they get started and they are $175,000 in debt now. You get around ten dollars for reading a chest film. Now, you have to dictate a report, you’ve got liability coverage and you are not going to get paid that much for doing what you’re doing. Because the reward structure, in my opinion, is not what it use to be, and that causes us to have ethical dilemmas.

Question: What can a healthcare leader do to be an ethical leader? How do you make a difference in an institution?

John Henry: The only way I know to do it is not by words, but by actions. Basically if you have the reputation of being fair to people and demanding that people be accountable. They in turn are going to produce. My philosophy of management is empowerment within boundaries. You set goals, you empower people within boundaries, you measure and that’s what makes things happen. If we come up against things, I want people to think. If I have to go tell them how to get this project accomplished then basically my problem is going to be, I don’t need them. In my personal opinion, the institutions with the biggest problems are the ones that have turnstile type administrations. In other words, every three years somebody turns over. If you take a company from being good to great, about 90% of those companies CEO’s were grown up in the organization. They did not follow the current trend of being trained somewhere else and being bought in. We are in the administration we have about a 20% turnover rate. You would read in articles that old Joe got fired from that place and he was hired someplace else making more money, he got fired from the next place and got hired making more money and so on. Part of that is the greed phenomenon, and greed is an ethical dilemma. It’s a human nature problem.

Question: How do you hold people accountable in ethics? Is there a way to do that as a CEO?

John Henry: You create an environment that demands that you do certain things; that way you put the most pressure on yourself. Nobody puts pressure on me the way I put pressure on myself and I think this is true of others. You have to care about doing right and part of our concern is that it has made Atlanta a bigger challenge. When I got into this business Atlanta had less than a million people. A lot of the problems we have today is urban sprawl, yet even though we have all of these people, they don’t know their neighbors any more like they use to. When you have problems within the community, especially socially and economically, the hospital inherits those problems.

Question: In an era of healthcare mergers how do you do that well and respect the various cultures coming together, and does ethics have a place in that merging?

John Henry: I think the culture is there, going back to 1994 when I was asked to merge Emory and Crawford Long. I wanted us to be the better for blending those cultures and have the best that I could for both. It is a matter of developing relationships, and I don’t think realistically that anything is different about developing those relationships within Emory Healthcare than developing relationships with your family. Family roles are constantly changing, family responsibilities continue to change and family expectations continue to change. And if you look just at a family, and you look at that as a microcosm of the Emory Hospital and Emory Healthcare family, how do we pull all that together? One thing is that we have got to find a way to meld all those people that have value and maximize their value and minimize the problems from interaction and disruption. We have teams of people that make the best department be a “triple threat” but there is no way one person can do all anymore.

Question: Does legal compliance and regulation make addressing ethical issues more or less difficult in health systems?

John Henry: I think it’s just part of the process. In reality due to the regulations we undercode today and we are paid less than what we are entitled to because of the fear that we are going to do something wrong in coding.

Question: Do you see ways in which health care organizations would benefit from working together to strengthen ethical concerns?

John Henry: I really wish we could reduce the number of regulations and could end up some way getting incentives working with the insurance commissioner to determine what is a clean bill. One number wrong entered for a patient in the computer database with an insurance payer and your claim is picked up. They don’t tell us what is wrong; they just say it’s not a clean claim. That type of stuff has got to stop.

We have a system within our hospitals that goes through and makes sure that we are charging correctly, and that we are maximizing legally what we are doing. The insurance companies now have a system out there that is called "blood hound"–that has ten thousand different types of edits that certain insurance companies are using now–that before a full payment is made they send this claim through, and it could be kicked out due to any one of ten thousand things. To me that is unethical because it’s "what can we do to prevent payment being made."

Question: Are there ways that you can see the Center for Ethics being more helpful to you and to the health system?

John Henry: I’m not sure how we can deal operationally with many of these other issues. I basically see that this is kind of a West Nile virus that’s infected the population, and I don’t see how we can have an antidote out there to counteract. You cannot legislate morality. I think what we have to do is just continue to work through the clinical ethical decisions that the Center for Ethics helps us with.

[ Posted by John Banja at March 1, 2003 10:03 AM | More HCECG articles ]

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