The 'real' danger of consolidation

Anthony Sclafani, MD, director of facial plastic surgery and otolaryngology professor at Weill Cornell Medicine in New York City, joined Becker's to discuss the benefits — and disadvantages — of consolidation.

Question: What is the "dark side" of consolidation? 

Dr. Anthony Sclafani: A major ASC advantage relative to the hospital is the ability to be agile and responsive to the needs of the patient and the surgeon. Consolidation, while offering benefits from standardization and economies of scale, puts that agility and responsiveness at risk. A well-run consortium avoids siloing of ideas and maintains appropriate focus on remaining agile and open to new ideas.

Q: How do you see consolidation affecting healthcare?

AS: There's a lot of advantages to it. And we all talk about advantages, but one thing that you want to make sure the patient doesn't get lost in all this consolidation, because certain places do things very, very well. On the other end, there clearly are advantages to coordinated and more thought-out patient treatments and having greater resources to help. But on the other hand, I think that situations sometimes bring out the best in smaller organizations that are able to be more creative — and have to be more creative. I think if you don't recognize that sometimes good solutions come out of small places, you lose that. The push toward consolidation is ultimately a push toward regulation and standardization. That's where I think the dangers exist, that you lose the need to be different, to be creative, because you're stuck doing what everybody else in the organization is doing. 

If the organization is doing it, they probably have good reasons to do it. And there's probably proof of it, but you can't totally discount those ideas. I think when you start discounting those ideas, you lose a lot of the vibrancy of what role smaller organizations can play. That is a problem. Being in New York and part of a large organization, there are absolutely things that are getting done that are phenomenal and really push the envelope and move the needle forward so patients get better care. But unfortunately, when things get regulated, sometimes there's that inertia that develops. More projects bring more people, but sometimes that leads to the right people not having their voices heard. To me, that's the real danger of consolidation — losing the ability to be nimble, to be creative, to be proactive, because organizations have a greater notion than smaller organizations.

Q: Is that felt among individual physicians as well?

AS: I think so. If you're used to working in a place with 200 people and things are done a certain way, then that group consolidates with a 1,000- to 10,000-person organization, things are going to change, and that person's voice has less impact. It does affect the individual physician, and that's probably one of the reasons why surgeons are going to outpatient surgery centers, because they feel they have a greater voice. But they don't always have the right answers because they're looking at it from a very narrow window. So how do you combine the system with the 35,000-foot-view with the guy in the trench? 

It's the art of regularization; how do you keep that fresh boots-on-the-ground mentality? When you see your leaders walking around and going on rounds, it does make a difference. I think that makes a difference from a morale standpoint, from an information standpoint, and to break down those filters that limit frontline information going up to the decision-makers.

Q: As a department director, is there anything you've done to mitigate the effects of that feeling of disconnect among your staff?

AS: Within my department, it's like every management textbook goes: You need to have that flow of information up to the top, you have to remove barriers. And we do. 

It's a hard line to balance, but I think the successful places will do that. When you hear about all these mega-institutions merging into a mega-mega-institution, you wonder how effective that's going to be. The question is, through consolidation, do you lose the inefficiencies only, or do you have to lose some of humanity and the innovativeness? Twenty years ago, people said super large hospital systems would never work. But that's really where we are now.

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