You can have a physician who is totally out of line with the systemic approach you want to take with a service line, says Pavarini. "It's better to have an independent physician who shares governance and oversight and is with the program than an employed physician who is there to pick up a paycheck and doesn't give a hoot. We've fallen in love with employment, but to me it is a limited model."
At Rocky Mountain, says Roberson, the relationship with providers—whether physicians, specialists, affiliates, or competitors—is one of trust. "And we have never betrayed that trust," she says.
"I don't think good medical care should be proprietary," Roberson says. "I don't own patients. Nor do I own the physicians. Whether physicians are employed or not, patients deserve choice. And if we can create and support choice, the humanitarian part of healthcare has been accomplished."
Parts of Rocky Mountain's strategy echoe CMS' initial description of ACOs, which will, according to CMS, "facilitate coordination and cooperation among providers to improve the quality of care for Medicare beneficiaries and reduce unnecessary costs." CMS also says ACOs must demonstrate that they are patient-centered and that they must pay attention to both clinical and administrative systems?two aspects of the Rocky Mountain model.
Although she is not quite ready to say whether the organization will pursue an accountable care model since it is still unclear how ACOs will "play out," Roberson says the organization is refining the business model it has developed over the two decades that the hospital has been open, with a renewed focus on quality and outcomes and a mission to deliver what patients, physicians, and the community need and expect. "Our strategies are solid and flexible, which allows us to be nimble," she says.
Cooperation with competition
Rocky Mountain doesn't just maintain relationships with its affiliated hospitals and physicians—it also does so with other hospitals in its market, even those with which it competes. An outreach program provides resources to rural hospitals and hospitals in underserved areas, including on-site clinician training programs, for example. And any hospital in the region can call Rocky Mountain for free advice on a patient, day or night, regardless of affiliation. "The right thing to do is to support the community where those patients live and work," Roberson says. "Because of our collaboration and affiliation, we're all working toward a united goal."
And to skeptics who say this strategy is all goodwill and no ROI, Roberson says, "When you do the right thing, the business usually follows." Working with rather than against physicians and other hospitals not only boosts patient satisfaction and positive word of mouth, but also supports appropriate referrals, since physicians and organizations know you won't try to "steal" their patients. Further, it allows the hospital to focus on the most acute cases.
Hospitals are used to working with referring physicians and physicians are used to working with specialists, but the next phase of integration will be linking all specialty services, such as cardiology programs and even, eventually, specialties that have traditionally been independent, such as urology, even if they are competitors, Pavarini says. Key specialties will likely be a part-ownership or employment model, or will at least form very close relationships with hospitals (within the limits of state regulations, of course).
Another reason to work with competitors: bundled payments shared among hospitals and postacute care facilities with no additional payments for patients who are readmitted within a certain time frame—a structure that will create a strong incentive for providers to ensure coordination of care and high quality of care all along the continuum. "That's a radical change," Pavarini says. "If providers want to reduce costs and maximize reimbursement, they'll have to work together."