False virtue and failed leadership

I am a physician practicing in Wilson for 21 years. Over this time, I’ve assumed various leadership roles at the local and state level. I’ve also had to live with adverse consequences of bad decisions made by others in healthcare leadership. In observing the complex dynamics of healthcare, I’ve learned key variables leading to failure in healthcare leadership. These issues apply to other arenas such as education, media, business, sports, and politics. Existing leadership hierarchies fail the public for reasons that include a misunderstanding of the meaning of virtue (or a willful distortion of the concept), or a lack insight (or willful disregard) for how a policy is bound to lead to unintended and harmful consequences.

When a leader acts from their own sense of superior self-virtue, things are bound to go wrong. When a leader acts with an eye toward the greatest good and minimum harm for the greatest number of people, outcomes will be better. If a leader has experience in their field and an instinct for possible harms from unintended consequences of well-meaning policies, things work out better. A concern for unintended consequences acts as a restraint against excessive, impractical, or unwise policies. The goal of policy should be favorable outcomes for policy consumers, who are defined as those directly and indirectly affected by the policy.

Some leaders take actions claimed as virtuous but which in fact are designed not to help the public, but rather to enhance that leader’s stature amongst others in leadership positions, or to impress others who wield power and who could affect that leader’s future professional prospects. A decision by this sort of leader, who is not truly motivated by service to the policy customer, leads to bad outcomes. This is a narcissistic form of leadership that masquerades as virtue. These leaders never acknowledge their failed leadership because they don’t care about the harms they inflict on policy consumers. They only care about their own professional advancement.

Leaders should be judged on outcomes, not intentions. Both intended benefits and unintended harms of policy proposals should be critically analyzed and weighed. Leaders who speak of virtue but ignore or downplay possible unintended harmful consequences should be viewed with suspicion. A leader who attempts to explain in a practical, real-world sense the intended and potential unintended consequences of their proposals should be viewed more favorably. After a policy is enacted, a mechanism is needed to retroactively measure benefits and harms. This should be done by objective third parties. If unintended harms are significant, and the leader is found to have purposefully downplayed predictable downside risks, they should be held to account. Formal mechanisms for removal of failed leaders are necessary to protect the public from future harms. Many failed leaders are protected by allies within their institution whose fate may be tied to theirs, or who adhere to a similar ideology that may sound good but does not work in the real world. Some leaders rise to power through Machiavellian machinations rather than merit. Leaders should be judged solely on outcomes, not on an academic or career pedigree, or for having taken the right leadership courses.

Finally, our current problem with leadership in healthcare and other areas is linked to shifting cultural mores. Our current iteration of culture promotes decision making for instant gratification- feeling good at the point of decision- rather than viewing decisions as difficult things that might have untoward and unintended consequences. When a culture chooses a bad decision, it will reap an unpleasant harvest from the bad seeds sown, but this does not happen until the bad crop grows to maturity. If a culture makes decisions based on thoughtful analysis of long-term outcomes rather than a short term need to feel good at the point of decision, our nation could move toward a better class of leadership.

If a citizen views a complicated decision as an opportunity to feel good about themselves in the moment, with the mindset “I am a good person, so this is my preference”, poor outcomes will ensue. Making decisions from a continual need to feel good about ourselves is self-defeating and is a form of narcissism. Sometimes the better decision will make us feel bad in the moment- take for example a good mother or father who has just disciplined their child.

True virtue is judged on outcomes, not intentions. “Virtue” based on good intentions is false virtue if unintended consequences result in excessive untended harms. Failed leaders need to be held to account for bad policy decisions and removed from power. Allies of failed leaders who protect them, with an eye toward protecting their own position, also need to be held to account.

Keith Lerro, M.D.

Wilson, NC

Why ICOP?

The challenges that community oncology has faced in recent years have inspired innovators to develop new platforms and ideas, many of which have been implemented with various degrees of success.

Struggling oncology practices, especially those squeezed by large hospital conglomerates, seem to have had no choice but to sell out; we can’t blame them; they were squeezed by powers that they could not resist or fight.

Smaller practices, on occasion, have joined larger ones to augment their purchasing power. This aggregation is good as long as practices can stay independent so that community oncology survives and succeeds.

Other practices have investigated large national aggregation models, many supported by investors, and they seem to be doing well. In these recent models, practices that join are required to sign contracts in which they lose all or part of their independence, though they do gain benefits in terms of volume-based contracting, management, and even potentially taking advantage of ancillary services and pharmacy benefits. This loss of destiny and control has made these platforms less appealing to many independent-minded practices. This has mandated a different model, one in which practices maintain 100% independence in everything, purchasing, management, staffing, billing, everything.

Realizing that no size fits all, specifically that none of the above scenarios fits many of the independent oncology practices, we at ICOP produced a model in 2020.

This is how it works.

Innovative Community Oncology Practices (ICOP) works through a different platform:

1. Practices keep doing exactly what they have been doing, with zero change.

2. ICOP contracts with pharma for rebates in addition to what they get from their respective GPO. This rebate considers all ICOP purchasing power as one entity, although each ICOP practice maintains its Tax ID, NPI, and others.

3. ICOP receives the additional rebate from pharma and redistributes those monies to ICOP members.

4. There is no joining fee.

5. Practices can join and exit at their will, no strings attached, NONE…

6. ICOP does not have a sales force to propagate our concept. Our members are our sales force, word of mouth, and this website, of course.

7. There is no minimum or cap on practice size to join ICOP.

8. Start up and enhance clinical research for ICOP sites via the affiliated Sargon Research Network.

9. Information sharing about best practices

10. Assisting ICOP affiliates when challenges arise.

There is no doubt that ICOP members have exceeded our own expectations in terms of pharma contracts. We are predicting a surge in the number of contracts in the coming few months. Our growth curve is healthy, and all members are excited.

Inflation

Current inflationary trends will affect every business sector of American society, some more than others. Although we do care about society at large, ICOP is focused on addressing the longevity and survival of independent community oncology, which has been compromised to a great extent in the last decade. These compromises, in the past and present, make community oncology more vulnerable to inflation. Therefore when the price of gasoline and bread rises, we, the owners of independent oncology practices, have to adjust the wages of our employees to offset these rising prices because we care about the well-being and financial livelihoods of our associates.

The cost of running a business is naturally affected by this inflation, not just the higher wages paid to employees. We have to pay extra for heating and cooling. We expect a rise in the cost of supplies needed to administer chemotherapy and other services. Ironically, we don't get paid for these supplies. Long ago, CMS and payers decided the cost of tubing, fluids administered, needles, port access devices, angiocaths, and many other things would be included in drug administration fees. We absorb that cost. Any additional increase in the cost of supplies is a net loss from our bottom line. I don't foresee a reversal of bundling fees: history has taught us a lesson- that payers keep lowering our reimbursements and rarely increase despite the normal annual increase in the cost of living.

In the current environment, the cost of living is trending toward a double-digit increase. In fact, we just learned that wholesale prices had gone up 9.6%. That increase is generally passed on to the consumer because the tail of the supply distribution chain will not absorb the increase in cost. Massive inflation is daunting to all of us and is already impacting independent community physicians, oncology practices in particular.

The most alarming observation to me is the labor shortage. The laws of supply and demand have come true to their scientific promise. We at community oncology have quickly adjusted to the labor shortage by raising wages for existing employees and for future hires, as we had no choice. But, again, without a substantial adjustment to our fee schedules, community oncology is in a bind.

We should not expect private payers to meet our needs voluntarily- they don't do that, and have not done that historically- but there is light at the end of the tunnel.

Most payers use a fee schedule based on CMS reimbursement rates. That means if CMS raises their fee schedule, payers should follow suit (if they honor their current contracting schedule) unless they decide to adjust their percentage of what CMS pays.

So far, the Government seems eager to give substantial raises to their employees as they target physician fees whenever a cut in health care spending is planned. So what should we do?

First, political activism is critical. We need to start calling our federal elected officials, educating them (a hard task) on the danger community oncology is facing. Second, as I have explained in the past, diversifying the scope of our services makes us less vulnerable to government actions and policies. Examples of diversified services are clearly outlined and implemented at our cancer center, including imaging services, on-site primary care clinics for medium and large-size employers, Covid mitigation services, and many other lines of services we share with our Sargon/ICOP Summit attendees. Thirdly, the only professional service community oncology can excel at without reliance on Government and payers is Clinical Research. We factually negotiate contracts in earnest and transparency. We accept trials that are economically viable and profitable to our practices. Sponsors of clinical trials want to attract well-performing sites and are willing and able to pay the prices needed and required. Moreover, sponsors do pay on time, with no preauthorization and no retroactive verification chart review, as payers and CMS often do, which sometimes requires us to pay back what we have earned legally and professionally.

Yes, clinical research is cumbersome, especially for the research virgin sites. But we have succeeded in overcoming those challenges through our Sargon Research Network, where we help practices start from scratch with the hope of intent that those affiliates will soon be as successful in research as Gabrail Cancer Center has been in the last two decades.

I know I have highlighted the negative side of inflation and its impact on the future of community oncology. Still, I am an optimist, zooming on solutions that I have outlined above to provide tangible long-term solutions to our everlasting unpredictable challenges. Unfortunately, those challenges are, for the most part, manufactured by the Government. But as President Ronald Reagan (the Great One) said, " Government is not the solution, it is the problem.”

Nashat Y Gabrail, MD

Gabrail Cancer and Research Center