A squeeze is on at UNC Hospitals

CHAPEL HILL -- Amid controversy generated by the UNC Health System's desire to generate a modest profit margin, and the outcry by many in the community that UNC Hospitals have forsaken their mission to care for the poor of the state, the role and plight of clinical physicians at the university has largely been ignored.

Physicians and surgeons at UNC continue to see large numbers of uninsured ("self-pay") and underinsured (Tricare, Carolina Access) patients. In my orthopedic clinics I routinely examine patients sent by other providers in health departments or private practice. These patients are often told that the surgeon will perform hip or knee replacement "for free" because this is the state hospital.

UNC physicians provide care for servicemen and women and their dependents because, with Tricare insurance, physician reimbursement is so poor that other physicians in private practice will not accept these patients. Most patients are aware that the physicians at UNC Health Care are state employees, but they do not know that the funds for salary support for most clinical physicians must be generated, for the most part, by the income earned by seeing patients and performing operations.

In addition, a new physician and surgeon compensation plan has been mandated by the CEO and implemented by the individual department chairs. Although the compensation plans vary, they must all include an incentive portion for work performed and income generated. Thus, physicians and surgeons will be squeezed between providing care for uninsured and underinsured patients and generating work units and income for salary supplementation.

Despite numerous guidelines to serve these patients, there will be a relative disincentive for physicians to see them and for surgeons to perform elective procedures for them. There will less incentive for many physicians to teach, write papers and textbooks and perform clinical research.

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Surgeons at UNC are particularly squeezed now because of critical understaffing of the operating rooms, with shortages of nurses, technicians and aides. Operating rooms are being shut down in the early afternoon or not opened at all due to lack of enough nurses and technicians. This has reached a crisis level, so that many surgeons have reduced block time. The same number of surgeons, or more, are now competing for less operating room time.

Couple these frustrations with the fact that most UNC physicians and surgeons earn approximately 50 percent to 60 percent of what their peers in local private practice earn. In response to these problems and frustrations, many of my formerly idealistic colleagues have abandoned academic medicine at UNC to go into private practice in Durham or Raleigh, or have taken early retirement.

UNC Health Care certainly has laudable goals in attempting to generate a modest profit and "incentivizing" physician work. However, these goals are taking a tangible toll on the physicians and surgeons. Any solution to these problems of patient access to care and of physician retention must include a healthy increase in state funding for hospital services and physician salaries, not just buildings and parking decks. Otherwise there will continue to be questions raised concerning the mission of UNC Health Care to provide adequate care for all the people of the state.

(Paul Lachiewicz is a professor of orthopedics at UNC-Chapel Hill.)