Golbus: There's another aspect that has to do with efficiency and matching the task at hand to the skill set needed. There is a compelling environmental mandate to increase the quality of care we provide, increase patient loyalty, and do it more efficiently to lower costs. Simply said, we have to get smarter about how we do business. When you look at a typical doctor's office, aside from physician compensation, the number one cost is usually office personnel. So if you're looking for operational efficiency, staffing models are a good place to start. While we haven't figured it all out, we try to match the task with the skill set required to ensure we don't have people overqualified doing it. In addition, we are always looking for ways to use our electronic tools to "do more with less." Do we really need a nurse answering the phones to schedule appointments?
Peer: My preference is that extenders complement a physician's practice. Certainly a lot of it depends upon whether you're in a heavily managed care environment or a fee-for-service one. Maybe you're in a state where nurse practitioners can have their own panel, but if they're truly used as an extender to a provider or a couple of providers to complement their practice, that tends to be the best model for patient satisfaction and continuity of care.
HealthLeaders: Let's talk about coordinating care under healthcare reform. How is that going to affect physician practices and the administrator?
Bethancourt: At Banner, all of our physicians have connectivity to the hospital. We're not automatically connected; they're not pushing out information to us—that will come when we have a community portal that will connect the outpatient to the inpatient. But it's a start. The other thing we're doing is in the new hospital that will be opening in southeast Phoenix, a small 30-bed hospital that can grow to be 500. We have two primary care doctors who will be on campus. But those two doctors will actually work as admitters in the hospital for the first year so they can develop relationships with the hospitalist and vice versa. We'll continue that process as those physicians "graduate" into the community and bring in two new ones.
Peer: Our case management staff tends to be our best asset to start working to do those things. It is essential that a solid case management infrastructure is created, with the appropriate case management leadership that understands the complexity of this new healthcare environment. Currently, they have what they call geographically assigned case managers, who focus in one area. We're looking to have the physicians help guide the case managers and coordinate discharge activities with them. And we're going to be able to have a good impact on reducing length of stay.
Golbus: Medicine, traditionally, has provided fragmented care. And fragmented care is usually not the highest quality care. Furthermore, healthcare historically has been great about optimizing the components, but not the system. We generally do a good job of taking care of people in our offices and when they are in the hospital. It is usually in the handoffs between those sites and other handoffs in the continuum of care where the system breaks down. Our task now is to optimize the components and the system for both quality of care and financial reasons. We are in the healthcare equivalent of the industrial revolution now.
HealthLeaders: Tim, you deal with a variety of physician practices, those owned by hospitals and those that are independent. What are some of the differences that you see in those two models in coordinating care?
Morgan: It depends on how tightly integrated that practice is with a hospital, but that's the way healthcare is going. We are still looking at case management as utilization review, or discharge planning, and then they're still behind the curve on getting up to even contemporary case management theory. You've got systems like Banner and NorthShore way ahead, and a large component where we just don't have that integration. Where we get called in, there's still disproportionate power sharing; there are noncontemporary hospital administrators and hospital CEOs who are looking for assistance to move away from the old model of hospital and ancillaries.
Bethancourt: Technology and leadership are the fundamentals that will take our physicians to a level they would otherwise not have considered. We started a mentoring program two years ago with 30 new physicians coming in, matched with mentors. The goal has been for the mentors to get the mentee on the same level as the mentor in one to two years. At that point, the mentee will become a mentor to new physicians. I would say maybe 70% of the mentees can be mentors at this time.
Golbus: Medical training has always been based on the mentorship model. At any given time, most of us are both mentors and mentees, so ideally, it cascades down. I spend a fair bit of time working with our committee chairman and division heads, who are looking to further develop their skills. My hope and expectation is that those who are mentored turn around and serve as mentors to members of their committees, subspecialty divisions, or practices. It creates a model where all physicians are engaged. Over time we'll see the cream rise to the top to assume leadership positions.