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Health systems frequently rely on surgical cases for revenue, and the COVID-19 pandemic resulted in frequent disruptions in surgical operations for the last few years. estimated that over 28 million surgical cases were cancelled or postponed globally during peak medical disruptions, resulting in a wide-ranging set of negative clinical, financial, operational, and psychological outcomes for those working in the surgical setting. Decision makers have found themselves having to balance meeting surgical volume goals against unexpected demands: managing staffing shortages, circumventing supply chain disruptions, and handling patient backlogs.

As hospitals and health systems aimed to maintain clinical operations, surgeons have been asked to do more with less. Surgeon and hospital alignment is critical to deliver high quality, safe, and consistent care -- but pandemic-related challenges have made existing problems with alignment more apparent. We aim to explore the changing facets of the surgeon-hospital relationship and potential opportunities for realignment as the practice of surgery -- and healthcare more broadly -- adapts to and eventually emerges from the pandemic.

Financialization of the Surgeon-Hospital Relationship

Over the last 2 decades, the surgeon-hospital relationship has shifted from a partnership between a guild of independent practitioners and the hospital (their workshop) to one where surgeons are viewed as agents, either as contractors or direct employees of the health system. The percentage of surgeons who in independent practice has decreased significantly in recent years. The of vertical physician-hospital integration efforts has been to improve efficiency and stability. However, employment does not automatically result in alignment. the results have been mixed, and these models have only had a small impact on improving physician-hospital alignment.

At their core, these models rely on financial contracts focused heavily on revenue targets, case volume expectations, relative value unit (RVU) goals, and surgeon engagement via monetary incentives and disincentives. The financialization of the relationship represents a departure from historic partnerships, which relied on reciprocal expectations of trust, influence, and commitment between surgeons and hospitals. A surgeon's value may now be measured in the number of cases they produce annually as opposed to the quality of care they provide, the value they bring to the health system in providing specialized services (and accreditations such as magnet status), and their role in providing care that improves the health of the population.

The employment models make many surgeons feel replaceable and disenfranchised in decision-making at the hospital level, despite being committed to the professional and service missions. In response, surgeons may focus more on clinical volume and less on comprehensive and appropriate care. Further, surgeons may be asked to give up autonomy and perioperative decision-making, with the understanding that macro decisions are now the prerogative of the management and not up to the surgeon. These dynamics not only risk the goals of vertical integration efforts (i.e., higher-quality, lower-cost patient care), but also contribute to growing frustration and professional burnout. Further, they may stifle innovation from the individual surgeon.

Many surgeons report lack of autonomy, administrative burden, and pressure for higher patient volumes as significant drivers of burnout. This pressure for increased volume with decreased autonomy may also negatively impact the surgeon-patient relationship as patients may as driven by financial motives. Burnout may also negatively impact quality of care and patient safety.

Realigning the Relationship

Decades of research has shown that financial incentives are only one type of motivating factor at work. Reducing the surgeon-hospital relationship to unidimensional, financial levers overlooks important opportunities for engagement. Surgeons are intrinsically driven by , for example, the shared reward of providing quality care or improving the surgical craft. Shifting from a language of financial and volume targets to one of shared purpose (improved patient outcomes) can lead to changes that put surgeons and hospitals on the same side.

For instance, hospital initiatives such as implant vendor standardization, when presented through the lens of a financial relationship (even with potential benefits for both hospitals and surgeons), may be viewed by surgeons as cost and quality cutting efforts that subjugate surgeons' autonomy and conflict with their role as patients' fiduciaries (trusted advisors, decision-makers, and champions). The result is reluctance or resistance to these changes -- and potential fueling of stress and burnout. Yet, if this same initiative were delivered through a lens of shared purpose -- focusing on how it will enable a surgeon to deliver better care and reduce harm (e.g. by capitalizing on volume-outcome relationships) -- the conversation can shift to adoption, understanding, and developing shared decision-making processes for implementing the change (e.g. including scenarios when standardization would be overruled). The holistic nature of the relationship frames how each change is viewed, whether it will be adopted, and its impact.

However, this is not a simple matter of changing the "pitch" or framing of decisions within the surgeon-hospital relationship -- it also requires changes to the content and substance (i.e. contract terms) inherent in these relationships. COVID-19 provides an opportunity for fully re-considering these terms, as the aftermath of the pandemic is likely to see a "" of broader payment models and policies, as governments, insurance companies, and payors pursue value-based care models. There is likely to be an increasing shift away from fee-for-service models and toward capitated population-based care. The surgeon-hospital relationship has to shift to accommodate for this.

Another strategy to better align hospitals and surgeons is to create opportunities where both can more directly share responsibility and control for patient outcomes. For example, there has recently been an increased drive to direct appropriate surgical patients toward outpatient and ambulatory surgical settings. Outpatient surgical venues can provide timely, physically-distanced care to patients, decompress the hospital, and contain costs. As hospitals increasingly seek to expand surgical care to these ambulatory sites, there's an opportunity to engage surgeon groups and develop joint efforts that leverage strategic leadership, co-management, and co-ownership. This structure gives both hospital leaders and surgeons "skin in the game" (not just financial benefits, but a sense of ownership and shared purpose), making them more likely to commit to improvements in patient outcomes, patient experience, and waste reduction efforts, thereby enhancing the net value of care.

Ultimately, we need new communication, contractual, and organizational models that realign the surgeon-hospital relationship based on shared purpose (high quality and lower-cost care), mutual trust, and cooperative decision-making. When this relationship is overly transactional, it becomes unidimensional, zero-sum, and top-line (i.e. revenue and volume) driven. Working together collaboratively to prioritize patient welfare will help surgeons and the health systems that rely on surgical care bounce back from the current crisis stronger, more competitive, and more capable of navigating future challenges.

is a spine surgeon and associate professor in the Department of Orthopaedic Surgery at the Johns Hopkins School of Medicine. is an associate professor of management and organization at the Carey Business School. is co-director of the Center for Spine Health at Northwestern School of Medicine.

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