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Welcome to the the Office of the President

Finding Common Ground Address to the Medical Society of South Carolina

February 21, 2000

Thank you for that kind introduction. It is a great honor to be asked to join you this evening. I come before you tonight representing only myself, but also bringing with me the greetings and good wishes of the entire Medical University. It strikes me as very symbolic to appear before the Medical Society so early in my presidency.

For as everyone in this room is aware, the Medical University, or more precisely its forerunner the Medical College of South Carolina, was created over 175 years ago under the patronage of the Medical Society. I daresay that there are some in this room who are direct descendents of those present at the founding of the Medical College. Those of us, whose ancestors were nowhere near Charleston at the time, are heirs, nevertheless, to the insistence on first-rate medical education in this community and in the State.

This is not to say that the history between the Medical Society and the Medical College has always been harmonious. As with any parent-child relationship, there have been some stormy periods. Only eight years into its existence, the six founding faculty members of the Medical College rebelled against the governance of the Medical Society. The faculty resigned their positions in 1832 and created a second medical school. The Medical Society replaced the departed faculty and attempted to maintain a medical school under its governance. Alas, the new faculty could not compete successfully with their departed distinguished colleagues. Within seven years, the two schools were united, with the Medical Society granting it independence of governance.

Of course, a separation of the Medical College from the Medical Society did not assure peace between the entities. Tensions between the town and the gown communities flared up again when the Medical University proposed to build its own teaching hospital about fifty years ago. In some respects, this episode again raised the question of independence of the Medical College, as it had relied upon Roper Hospital for clinical education up until that time. The creation of a separate hospital, however, introduced a new element into the relationship — competition.

Over time, the reality of separate hospitals gained acceptance and a state of peaceful coexistence was restored to the local medical scene. Within the past decade, however, a number of factors conspired to raise the level of tensions again. Principal among these factors was the Medical University's effort to build an integrated health care delivery system. The Medical University, like most of its academic peers, purchased and developed primary care practices — the so-called "gatekeepers" of the health care delivery system. This move was intended to position the institution for the managed care environment. Many physicians in the community, however, saw it as intrusion into an area that was not the province of the specialty-oriented Medical University.

The situation went from bad to worse when the University entertained proposals from outside organizations to manage its hospital. The University's Board of Trustees elected to enter into negotiations with the for-profit, Columbia HCA. Again, the Medical Society and the Medical University were headed on a collision course. The Medical Society intervened legally, questioning the constitutionality of the proposed lease agreement. The State Supreme Court ruled that the Medical University could proceed with the affiliation. By that time, however, the management and legal problems of Columbia HCA made them an unattractive affiliate for the Medical University.

In reflecting upon what we might refer to as "the recent unpleasantness" between our organizations, it occurs to me that neither of us has gained much in the process. This is not to say that there have not been winners. For example, the news media, which thrives on controversy, has had a field day. The lawyers, too, have found our tensions to be rewarding for them. Lastly, the divisions between us have created a natural environment for health care payers to market exclusive, deeply discounted contracts.

Now I am convinced that a democratic society should support a vigorous press, a responsible judicial system, and a competitive free market. It just seems to me that the interests of the press, the lawyers, and the insurers are being well served without our collective assistance.

What is most disturbing to me is not that we have aided and abetted these groups, but rather that the people who have lost the most are our patients. With some justification, the public-at-large views the hostilities between us as a self-serving contest between two privileged groups. Rarely have the issues been framed in terms of the best interests of the patients. Rather, the battles appear to be fought over issues like market-share. On both sides of the conflict, the financial well being of the physicians appears to be a prime motivating force. The cynics among us might conclude that we have ceded to others our moral responsibilities as advocates for the health of the community.

No doubt this short excursion through the history of the relationship between the Medical Society and the Medical University is greatly oversimplified. In the interests of brevity, I have sacrificed detail, although hopefully not accuracy. My purpose tonight is not to dwell on the troubled times of the past. Rather, I am here to talk about the days and years ahead. It is my strong desire that the future will be marked by ever increasing cooperation between the Medical University and the Medical Society.

The naysayers among us may conclude that the recent past in our relationship is merely prelude to the future. Some probably believe that a line has been drawn in the sand and that neither party has the desire or courage to reach across it. I am here tonight to extend my hand across that line.

Even as a relative newcomer to the scene, that is not an easy thing to do. There have been times in the recent past when the rhetoric on both sides got very personal. It is difficult to suppress the emotions that arise under such circumstances. If we cannot get past these feelings, however, we will be trapped in a vicious cycle of conflict. It is time to break that cycle, for the benefit of both our organizations, but more importantly, for the benefit of the community.

If the letters that I received from private practitioners after my election are any indication, it appears that there is a strong desire for reconciliation. How then do we start? At the risk of stating the obvious, I think that tonight is a start. The most important first step is to open the channels of communication. Tonight is one forum for that purpose, but hardly the only one. Since taking office, I have had several occasions to meet with members of the Medical Society and with representatives of CareAlliance. What began as awkward, dare I say uncomfortable, conversation now flows much more freely. The simple act of getting together to discuss matters tends to defuse tensions and suspicions.

Second, we need to identify some initiatives to work on together. There are plenty of opportunities for this type of collaboration, so we may have the luxury of being a little selective. It seems to me that there are at least four types of cooperation that we might envision. The first is in the area of new and expensive technology. Over the past few years, we have been engaged in an "arms race" in expensive medical equipment. As soon as some new piece of technology comes along, we both have to have one. Neither one of our systems wants to be seen as falling behind on the technological curve. The result, of course, is that the community ends up with an oversupply of the new technology, driving up the cost of care.

A much more logical approach for us and for the community is to consider purchasing big-ticket items together and share in their utilization. Without question, there are many operational issues involved in sharing major equipment. For example, where will it be located and who will manage it? In my opinion, however, these are just logistical matters. The real challenge is to make the decision to cooperate in the first place.

A second potential area of cooperation is in the organization and delivery of support services. A potential example of this type of collaboration has arisen in the past few weeks. In this instance, the Medical University offers a support program for patients with diabetes mellitus. This program focuses on providing patients with the knowledge and skills needed to manage their illness effectively. Topics covered include counseling on diet, medications, and devices, such as the insulin pump. Although some of these services can be billed to an insurance company, most cannot and therefore are underwritten by other sources.

Roper Hospital operates a similar program independently, also with institutional subsidy. The question thus arises: "why not merge the two programs, thereby integrating services for the community and hopefully gaining efficiency and cost savings in the process?" Again, I do not want to diminish the operational considerations involved in such a collaboration, but surely they can be overcome. If we bear in mind what is best for the patients, why would we not want to assure a jointly supported community-wide resource?

A third potential area of collaboration is in community service. Both the Medical University and CareAlliance have made substantial investments in providing services to the community. Our efforts have been concentrated in a program entitled: "The Healthy South Carolina Initiative." This initiative includes 28 separate projects that were competitively peer-reviewed and funded. They cover a broad range of activities, from a mobile dental van that visits schools, to an educational program on healthy eating delivered in cooperation with local churches, to a training effort to help low income women obtain employment. Many of these efforts are complementary to those initiated by Community Health Partners. It only makes sense that we look at better coordination of our efforts in the future to assure that our limited resources are used to the greatest advantage of the community.

A fourth potential area of collaboration is in public policy. Now I will readily confess that many physicians are uncomfortable with the suggestion that we should be active in influencing public policy. Some would prefer that these tasks be left to professional organizations, such as the American Medical Association. After all, physicians are not trained as lobbyists or politicians and most of us are pretty busy with the day-to-day tasks of patient care.

Let me also be clear that I am not talking about advocacy on behalf of the interests of physicians, although I would not deny that there is a place for such advocacy. My focus here is on the role that physicians can and should play in assuring the health of the community. As the number of medically uninsured persons grows, physicians should be at the vanguard of advocating for basic access to care. Unfortunately, when it comes to the formulation of public policy on these issues, individually and collectively we have tended to be passive observers, rather than active participants.

Let me be specific about the opportunity that you and I have today to influence public policy in a significant way. As we meet tonight, the debate about the use of the tobacco settlement funds is taking place in Columbia. As you are all well aware, the entire premise of the lawsuit against the tobacco companies was to reimburse states for their costs of providing care to patients with smoking-related illnesses. Once the money arrived in the state coffers, however, our elected officials began to develop other ideas about how he funds might be utilized. The governor, for example, has proposed that only 60 percent of the funds go to health care, with 20 percent going to economic development and the remaining 20 percent going to tobacco farmers. Within the health care portion, the governor is proposing several new initiatives, rather than stabilizing the funding for currently under-funded efforts.

My intent is not to criticize the governor's proposal. Others have suggested other uses of the funds that I find equally remote from the original intended purpose. I suspect that we might even have difficulty reaching agreement in this room about how these funds might be used most appropriately.

I would hope, however, that we could agree that the tobacco settlement funds should not be used as just another unrestricted revenue stream to the state. These funds should be used for their intended purpose, paying for health care. To do otherwise, especially at a time when our Medicaid system and the disproportionate share program are both at risk, is an abandonment of the intended beneficiaries. For those of you who have not written to your elected officials on this topic, I implore you to do so. The medical community should be responding with a single common voice on this issue. Together, the voices of the Medical University and the Medical Society will be much stronger than either would be alone.

In closing, let me reiterate my call to bring our two organizations into closer cooperation. I have described several ways in which we can foster collaboration. First, we can purchase and utilize expensive equipment together. Second, we can merge support service programs to the mutual advantage of our patients. Third, we can join together in sponsorship of community outreach activities. Fourth, we can be united in helping to shape public policy on health-related issues, such as the use of the tobacco settlement funds.

It is time for the Medical University and the Medical Society to end their recent conflicts. We should do so, because it is good for both of our organizations, because it is good for the public that we serve, and because it is the right thing to do. Thank you very much.