When asked what I do, I still reply “I’m a pediatric emergency physician,” but honestly, these days I’m mostly an administrator. I’m a suit. I deal with things like contracting and billing, staff productivity measures, even surgical inventory management. {That’s a thing?} Which sounds, frankly, less noble {and less “sexy”} than the first answer. So I want to try on a new answer: I’m a steward.
Stewardship is “the activity or job of protecting and being responsible for something; the careful and responsible management of something entrusted to one’s care.” The term is often applied to finance and natural resources, but has also been used to refer to pastoral care. I like this definition because it emphasizes not only the actions of making careful decisions and avoiding waste. It also encompasses the special relationship between the steward and the resources being managed, the elements of trust, of accountability. All healthcare providers are, in essence, stewards – we are entrusted to care for our patients and to manage their health. But even those who wear scrubs rather than suits to work are stewards in the business sense.
I realize that referring to medicine as a business gives many healthcare providers hives. But the fact is, while I believe medicine is more than a business, it is still a business. If you are wondering if what we do is a business, ask yourself, “Do we charge money for what we do?” The answer, of course, is “Hell, yeah.” Albert Schweitzer may not have been in the business of medicine, but the rest of us are.
Stewardship is critical on two levels. The first is the organizational one. Many of us are in the non-profit sector of healthcare. The gap between the revenue we get for the services we provide and the expense of providing those services {salaries, supplies, mortgage, utilities, etc.}, is our margin, which we hope is a positive number. {These days, accountants don’t use red ink for bad numbers, they use parentheses – parentheses are bad. That’s why I’m using brackets instead.) The margin doesn’t go to executive bonuses, or to pay off shareholders. That extra revenue is what we have available for two things. It supports those parts of our mission that we don’t get paid for {charity care, injury and illness prevention, community engagement, research and education}. It’s also what we rely on to invest in new and replacement equipment, facilities, and programs. It is a cliché to say “No margin, no mission,” but that doesn’t make it any less true.
Our hospital and health system is a tremendous asset to our community, one that has been entrusted to us. Our vision is that the children in Wisconsin will be the healthiest in the nation, and I truly believe that our community would be less healthy if we were not here. We are challenged by many changes in the healthcare environment. Spending on healthcare has reached unsustainable levels, and while it is leveling off, we will continue to get paid less for what we do. Which is why all of us need to be good stewards. By focusing on making what we do cost less, we will ensure that the margin that supports our mission can be sustained.
We also must be good financial stewards for the sake of our individual patients and families. One of the most striking effects so far of the Affordable Care Act is the acceleration of employer sponsored consumer-directed plans, also known as high deductible health plans, in response to the ACA’s tax on so-called “Cadillac” health plans starting in 2018. While only 4% of employer health plans were HDHPs in 2006, they were over 20% in 2012. For 2014, over 40% of employees in our system selected an HDHP {including me}. Ironically, this is a solution that has long been promoted by free-market health economists. The idea is that by having patients have more “skin in the game,” in the form of high deductibles and hefty cost-sharing, they will shop more carefully for health care services. While the several thousand dollars of out of pocket expenses are going to make me think twice about what services I seek and where, for many of us they are an inconvenience. But for many of our patients and families, it’s more than that. A parent may be deciding whether to have their child’s tonsils out or save for college. It may be a choice of filling a prescription or having a meal. We may find the idea distasteful, but it’s reality. If we don’t control our costs, families will either be forced to go elsewhere, or go without.
Our hospital, our patients – these are things that have been entrusted to our care. We say “kids deserve the best.” Let’s be good stewards, so they can have it.
Starting With Curious 