During the Christmas holidays, Thomas Royer, M.D., then the new interim CEO of Parkland Health and Hospital System in Dallas, TX, played piano in a lounge for senior citizens because it was his annual tradition for 45 years, and he wasn't about to stop now—even if some may have felt he was tickling the ivories on the deck of the Titanic.
Even with the holiday mood, he was mindful of the difficult job he had taken on. During those early days as interim CEO, he met with hospital leadership teams, employees, and visited the inpatient and outpatient units as part of the task he had voluntarily assumed: to right the sinking Parkland.
Royer, who was named to the interim leadership post on December 1st, has been overseeing the safety-net hospital as it works to overcome dozens of deficiencies identified by the Center for Medicare & Medicaid Services.
These were shortcomings that the federal agency last year deemed so dire as to create an immediate and serious threat to patient health and safety. At risk were millions of dollars in Medicare and Medicaid payments.
After several months on the job, Royer remains unfailingly polite, and willing to talk about Parkland at a time when many of his peers in similar situations, might have been more tight-lipped.
"Transparency" is his watchword, says Royer. Over the last several months, the 70-year-old has been working 14- to 16-hour days, cleaning house of employees, restructuring physician and nursing teams and navigating political storms. His six-month contract expires in May, but he's hoping for a six-month extension to finish the job he started.
"I'm energized and committed" to improve Parkland, Royer says, telling hospital administrators: "I'm willing to stay as long as the board wishes to support me in this role, to help patients, staff, and physicians. I'm focusing on what's important and I think we are making improvements. I believe we will be very successful over the next six to nine months. I find it very rewarding."
Royer is leading the safety-net system as it works toward compliance to maintain eligibility for an estimated $417 million in annual Medicare and Medicaid contracts.
CMS ordered a review in July 2011 of the entire hospital facility after identifying dozens of deficiencies deemed so serious as to create an immediate and serious threat to patient health and safety. In September, Parkland and the Dallas office of the Centers for Medicare & Medicaid Services signed a systems improvement agreement, which requires Parkland to be compliant with all CMS rules and regulations by April 2013.
The hospital system hired the consulting firm Alvarez & Marsal Healthcare Industry Group to guide it through the systems improvement agreement process. A 300-page gap analysis report prepared by A&M detailed ongoing deficiencies, including systemic issues in the role and organizational structure of nursing and nursing practices. Royer has said that about 75% of Parkland's problems involve inconsistent nursing practices across the system.
Royer took over Parkland at a time of his life when other physicians his age would be fishing, playing with the grandkids, or soaking in the sun. In 2011, the surgeon had just stepped down from being president and CEO of Christus Health, where he held the top job for 14 years. Previously, he served as Chairman of the Board of Governors of the Henry Ford Medical Group and Senior Vice President of Medical Affairs of the Henry Ford Health System in Detroit from 1994 to 1999.
Royer says he wants to help Parkland plan for his successor as well. "Obviously, to create permanency (the hospital) needs to recruit a permanent CEO and a person who is a lot younger than I am. I am willing to help train that person, and help in transition."
Before taking over as the interim CEO at Parkland, Royer says he was in the midst of "semi-retirement, doing some speaking and working on a book." He says he essentially completed the unpublished book, named "Dr. Tom's Learnings," about his views on leadership, when the opportunity presented itself to take over the interim role at Parkland. While Royer used the word "opportunity," some would choose a different word for jumping at the chance at being interim CEO at Parkland.
"Colleagues encouraged me to throw my hat in the ring for the interim CEO role. I did that because I felt that the mission for Parkland is so important—caring for the most vulnerable—and I felt that Parkland is such an important critical access hospital, not only for the patient population, but for all of Dallas."
Royer felt from the beginning he was a match for what he needed to do. "I certainly took the opportunity to read the CMS report and original report. I didn't feel there was anything (that) I was not unfamiliar with," Royer says, "working with a team to put into place action plans to build the corrective action process, building on all that success."
Parkland holds a historic bookmark in a tragic page of American history. For Baby Boomers growing up, the name Parkland resonates as the hospital where John F. Kennedy died following his assassination on November 22, 1963. For those with exceptional memories, it might be the first hospital name they remember as kids growing up.
Royer sees Parkland in another light—today's light.
"The volumes are usually near or at peak," Royer says. "Just last night, we had 200 people in the emergency department to be seen. We had to go to total diversion because we had no beds."
"This is a very large institution, very large and complex," he says. "I've never seen sicker patients in my life, with the comorbidities we have here."
Of course, clinical challenges are at the heart of what has gone wrong at Parkland, with physicians also playing a role, especially with documentation issues. Some physician issues have been forwarded to a "peer review" committee, Royer says.
Another area that the hospital wants to improve is the relationship with UT Southwestern, whose medical students serve Parkland. The hospital will improve its mentoring and coaching programs, he says.
Royer emphasizes the importance of carrying out a "strong leadership program" at Parkland, as well as improved internal and external communications. He has initiated leadership and employee forums in which he eventually hopes to meet all of the hospital's 9,000 employees, including 1,600 physicians.
That's a tall order for one leader in a short amount of time, but he tries to keep it personal. When he's introduced to staff, Royer asks to be called Dr. Tom. When he left Christus, he wrote his books about leadership and teamwork. "I decided to record my 'learnings' in my quiet time," he says.
To excel at leadership, "you have to have passion. In order for me to hone my skills as a better leader, I've also become a better person, a better parent, spouse and better friend. The greatest 'learning' for me is that popularity is not parallel with good leadership." In taking on leadership in that way, "it's worth it," he says.
As Steven A. Schroeder, MD, begins his work as chairman of the new National Commission on Physician Payment Reform, there's one thing he wants more than anything: that his group's findings don't end up collecting dust on a shelf.
The 13-member commission has been formed to examine physician payment structures, including the impact of the annual Medicare reductions to doctor salaries, and the focus of Accountable Care Organizations (ACOs).
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The doctor-centric panel boasts as honorary chairman former Sen. Majority Leader Bill Frist, D-TN, who has bona fides as a heart and lung transplant surgeon. Frist tells HealthLeaders Media he fully intends to be a working member of the group.
Other members include hospital medical directors, academic research specialists, and representatives of WellPoint, CVS, and the Brookings Institution.
The group will meet over the course of one year, and its goal is to produce a detailed analysis and recommendations on physician pay by early 2013. Launched by the Society of General Internal Medicine, the commission is funded by the Robert Wood Johnson Foundation, the California Healthcare Foundation, and the Sergie Zinkoff Fund for Medical Education and Research.
Frist says the commission will focus, in part, on what he sees as a great divide among politicians and clinicians in response to healthcare policy.
"Much of the policy in Washington D.C. is driven by the budget and deficits, entitlements, and Medicare," Frist tells HealthLeaders Media. "All of that is fine, but the health service aspect is usually the aspect that is ignored in Washington, D.C. Typically, health service delivery is overlooked by the Washington D.C. budgeteers. This commission gives us the opportunity to marry both camps, which too often end up with conflicting views on the issue of physician reimbursement."
"Physicians are drivers of most of the healthcare dollars," adds Frist, "but too often they are not at the center of healthcare reform discussions."
The commission started work last week with Schroeder, former president of the Robert Wood Johnson Foundation and professor of health and health care at the University of California, San Francisco. He predicts that the panel would "comment on challenges" facing the different physician payment formulas.
"Doctor payment is such a critical issue now," Schroeder says, ticking off a mind-boggling list of concerns. Among the ones he cited: the SGR (sustainable growth rate) payment formula; geographical and specialty distribution of physician pay, and the increasing demands for physician services, such as primary care. Of further concern is the overall impact of healthcare reform, especially related to the currently uninsured.
Talking to Schroeder, you get the sense that the commission may not be up for political fights, like the one currently dogging the SGR formula. That formula, which many physicians simply want to banish forever, is the center of continued dallying by Congress over specific funding.
Most recently, lawmakers passed a 10-month patch to stop potential 27% cuts to Medicare payments to physicians that would have begun March 1. The agreement was the 14th short-term "doc fix" to the SGR in the past 10 years, according to the American Medical Association.
The Frist and Schroeder commission isn't likely to do anything dramatic to influence the SGR, so don't hold your breath. But it's extremely early, so who knows?
Schroeder downplayed any potential fistfights over SGR. "Right now I look at that as a very important contextual issue, but probably fixing it is outside the scope of what our commission is going to recommend," Shroeder says. "It's up to Congress. They are getting lots of advice, from kicking the can down the road to granting a waiver to other kinds of things."
While the commission may make some note of the SGR issue, it isn't likely to create a lot of noise. That's a disappointment.
When it comes to ACOs, though, the commission may engage in some in-depth discussions, and that's welcome.
Schroeder immediately raised some questions about the framework of ACOs in the interview with HealthLeaders Media. "I think there's a gap between the rhetoric and the hope for ACOs, and the potential number of people who will be covered by them in the short run," he says. "I think it's going to be difficult to create from whole cloth."
Although Schroeder didn't exactly tip his hand about where the commission may be headed on ACOs, the fact that he raised even the slightest question is good news that there will be some debate about ACOs.
Other parts of the commission's agenda on potential physician payment plans includes an in-depth look at patient-centered medical homes and value-based purchasing. "Those organizations will be considered to the extent that payment reform is featured," Schroeder says.
Besides exploring how physicians are paid, and indeed, how much, the commission will examine questions about patient treatments and various aspects of services and technology as well as the evolving healthcare funding from fee-for-service to quality, Schroeder says.
There's no doubt the country has to change its funding for healthcare, with physician income a part of it, Schroeder says. "Our demand for care outstrips our ability to pay for it. That's what every country wrestles with. We have features that make us a real outlier. We spend a lot, and people are concerned we don't have great value."
Schroeder continues: "if we move toward bundled payments or capitation, (we can look) at the ways we can maximize value, transparency and good conduct. Those would be the principles going in to our discussions, and can be modified as other members weigh in."
The commission will look at efforts to incorporate quality into the current pay system and assess the opportunities and risks of the healthcare payment configurations, such as those implemented in the ACOs, according to Schroeder. In addition, members will consider incentives and safeguards surrounding forms of physician payment that may maximize good clinical outcomes, Schroeder says.
"I am daunted by the charge we have, and hope we are up for it, because it is such an important issue," Schroeder says of the commission. "A lot of commissions I've been on and read about, a report winds up sitting on a shelf. We want people to say at the end of this that our findings really made sense and it's going to be helpful."
This article appears in the February 2012 issue of HealthLeaders magazine.
Smooth working relationships among nurses and physicians are seen as vital to increasing value in healthcare delivery, but there is a vast divide in the perception of how doctors treat nurses, the HealthLeaders Media Industry Survey 2012 reveals.
When asked how pervasive physician abuse or disrespect of nurses is, there was a clear disconnect between the two. While 42% of nurse leaders said it was common, only 13% of physician leaders said it was common. Likewise, 58% of nurse leaders said it was uncommon, while 88% of physician leaders said it was uncommon.
HealthLeaders Media Industry Survey 2012 The priorities and concerns of nearly 1,000 of your colleagues in healthcare leadership are revealed in this year's comprehensive multi-part survey, our fourth annual HealthLeaders Media Industry Survey. Download the Free Reports
Pam Kadlick, RN, BS, MBA, MSN, vice president of patient care and chief nursing officer for 112-staffed-bed Mercy St. Anne Hospital in Toledo, OH, says she is surprised at what she cited as a high level of disrespect reported by the nurse leaders.
The findings illustrate fundamental "ineffective communication or having different expectations" among the two groups, with physicians sometimes having a misperception of nurses' roles, and nurses in conflict with physicians over the "misunderstanding of what needs to be done at a given time," Kadlick says. She acknowledges that such communication problems could manifest themselves when a physician "cuts off" a nurse's suggestion or comment.
"I do believe nurses and physicians are on two different pages when it comes to communication," Kadlick adds. "Time is a commodity for physicians today. When they present to do rounds, they want to have pertinent data given to them. Nurses have a tendency to give a very detailed report, more than what a physician may want to hear; hence, the physician may interrupt, seem to be abrupt, even rude at times."
When confronted as being rude or disrespectful, a physician often would be "truly taken aback, as they do not see it this way," Kadlick says. Referring to reports of alleged abuse, Kadlick says she believes that "while there are validated incidents of true disrespect for nurses by physicians, these incidents are minimal."
As health systems improve care coordination and increase the roles of nurse navigators, Kadlick says she expects the communication between nurses and doctors to get better.
"I do see it improving on the acute care level, with care coordinators working with primary care physicians," Kadlick says. "As you add care coordinators and change the delivery models, you will see registered nurses more at the bedside than tied to the computer, and the communication will be getting better. You have more advanced nurse practitioners popping up in the acute care settings. We are getting there, but still moving at a snail's pace.
"Physicians have acknowledged how important it is to have that mid-level provider to help them with their greatest commodity—time," Kadlick says.
But as health systems work to improve value-based care, nurses see themselves as becoming increasingly important to coordinate care and should have more of a stake in care delivery, the survey of nurse leaders shows. Indeed, nearly one in 10 respondents say he or she believes nurses will help save healthcare, though most (28%) say they see hospitals as the key to righting the healthcare ship, followed by the government (13%).
While most healthcare leaders acknowledge that the industry is in a mess, not one lays the blame on nurses. Of the more than 1,000 survey respondents, most say government is the culprit (40%), followed by health plans (22%), and even 6% cited physicians.
Nurse leaders are in sync with their colleagues in blaming the government for industry woes (37%), followed by health plans (23%), physicians (8%), hospitals (5%), vendors (3%), patients (1%), technology (1%), and nurses (0%).
"I think when they start pointing fingers at who is to blame, why nurses aren't pointed out is because they aren't reimbursed by third-party payers," says Kadlick. "They aren't seen as the ones delaying discharges in acute care settings or ordering unnecessary diagnostic tests in the outpatient facilities."
In an area of disconnect between nurses and doctors, about 77% of nurse leaders said in the survey that the quality of their organization would be positively affected by increasing the scope of care for nurses, while only 10% thought it would worsen. When physician leaders were asked that question, 48% said it would improve, while 26% said it would worsen.
As nurses become more involved in coordinated care and multidisciplinary approaches, Kadlick says the impact of nurses on quality will be more fully appreciated. "The nurses can do more—add value to the interaction with physicians and for patients' care," Kadlick says.
According to the survey, patient experience and satisfaction is the top priority among nurse leaders; 72% rank it among their top three priorities. Next is clinical quality and safety at 55% and cost reduction and process improvements at 45%.
"I think nurses believe they could have a voice to make things better, although I think it's misleading to think they can fix it," Kadlick says. "The only true way to do that is to get all the shareholders together to put out a model, and everyone has a voice in planning."
With the advent of healthcare reform, it's a chance for the industry to recognize the evolving role of nurses, Kadlick says.
"When I see the patients coming into the acute care setting, and the baby boomer nurses starting to retire, new nurses are being recruited," Kadlick says. "It's time to be more proactive for nurses with patients and providers.
"Nurses as a whole should take responsibility to be more involved in care coordination; it's that opportunity for us today," Kadlick adds.
This article appears in the February 2012 issue of HealthLeaders magazine.
Physicians and others in healthcare are flooding GOP coffers with money for congressional and senate campaigns. And individual healthcare contributors are giving more money to President Obama than each of the Republican candidates.
Confusing?
How about this? Some of the heavyweight physician political action committees (PACs) obviously are interested in the outcome of the presidential race. But they don't funnel a dime into the presidential campaigns.
Yes, it's political season, and contradictions litter the landscape.
The political spending this time around comes while physicians' diagnoses of the healthcare business in America isn't great. That's reflected in the HealthLeaders Media Industry 2012 survey (PDF) which shows that at least 53% of physician leaders say that healthcare is on the wrong track. And 36% say that government is to blame for the healthcare industry mess, with 26% saying government laws and mandates are among the top three drivers of healthcare costs.
That's a lot of dissatisfaction in the wake of the healthcare reform initiated by President Obama. Those complaints are reflected in funding choices revealed in healthcare campaign financing reports—particularly among physician PACs—filed with the Federal Election Commission.
Some 97 healthcare professional PACS, which include physician organizations, have contributed $8.9 million to federal campaigns, with $5.2 million (59%) directed to Republicans and $3.6 million (41%) to Democrats, according to FEC figures released this month and compiled by the Center for Responsive Politics, and reviewed by HealthLeaders Media. The center is a non-partisan, non-profit group based in Washington D.C. that tracks campaign spending.
(Besides the physician PACS, others, including hospital, nursing homes, health services and HMOS political action committees, contributed about $ 21 million, some 58% to Republicans and 42% to Democrats, the data shows.)
This year's donations by physician and nurse organizations contrast with substantial Democratic contributions in 2010, and with the last presidential election in 2008. Two years ago, a total of $26.3 million was contributed, with $14.6 million to Democrats (56%), and $11.6 million to Republicans, (44%). In 2008, a total of $24.5 million was contributed, with $14.2 million (58%) for Democrats, and $10.2 million (46%) for Republicans.
Donations to Presidential Candidates
Of the $136 million Obama has raised to date, members of the healthcare industry, including physicians and nurses, have contributed less than $1 million ($967,291 to be exact,) and hospitals/nursing homes, $715,849, according to the Center for Responsive Politics.
Of the $42.3 million former Massachusetts Governor and presumptive Republican nominee Mitt Romney has received, $642,703 was garnered from healthcare professionals and $314,377 from hospitals and nursing homes.
Romney's leading rival, Rick Santorum, the former Pennsylvania senator, has received $47,431 from health professionals, and $54,200 from hospitals and nursing homes. His mother, incidentally, was a nurse.
The healthcare boost to Republican congressional candidates and the overall support for Democrat Obama is not surprising to some election experts.
"Basically, these groups want to curry favor with both sides," says Brian Dowling, senior fellow for government studies at the Heritage Foundation, a conservative think tank in Washington D.C, to HealthLeaders Media. "With healthcare reform, Republicans have promised to repeal it, and that's part of the agenda. Physicians and healthcare representatives want to be part of it, and be a player in the room if they repeal 'Obamacare.' If Obama wins, he will definitely continue to implement healthcare reform, and he's not going to repeal it, but healthcare wants to be in the room."
Focus is on Congress
PACs are particularly focusing on congressional races, especially in light of "one of the most significant issues being the ongoing ''doc fix' issue, related to reductions in Medicare reimbursements to physicians. It's been a yearly exercise and [lately it's been] ' a monthly exercise," Dowling adds. Congress recently voted to postpone the cuts to the end of 2012.
Indeed, most of the large physician PACs, such as the American Association of Orthopedic Surgeons and the American Society of Anesthesiologists, funnel their largesse to congressional campaigns, not presidential races.
Officials of healthcare PACS say they aren't concentrating necessarily on the politicians or their parties, but the policies.
When the American Society of Anesthesiologists' leaders get together, "we don't use a specific formula for making campaign decisions," Jeffrey Mueller, MD, chair of the ASAPAC executive board tells HealthLeaders Media. "We have a saying on the ASAPAC executive board, 'not red, or blue, just working for you.' Our members are very active locally in helping us to identify candidates of both parties who understand anesthesiology. In the end, ASAPAC goes where our members want it to go."
"ASAPAC leadership realized some years ago that no party has a lock on understanding the issues that are important to anesthesiologists," Mueller adds. Indeed, in an evaluation of campaigns over the years, the Center of Responsive Politics noted in a statement, "You're sleeping if you believe the American Society of Anesthesiologists strongly favors one political party over another."
But in this election cycle, the ASAPAC, like many other physician and healthcare groups especially, are favoring the GOP, with only the American Physical Therapy Association among the top five spending PACs leaning toward Democrats so far, according to the Center for Responsive Politics. Based on the February filings with the FEC, the top spending PACS are:
click to view
top-spending PACs
Although not in the top ten among those cited by the Center for Responsive Politics, the American Medical Association is listed as a perpetual heavy hitter in contributions to congressional campaigns. According to the latest filings, the AMA PAC has contributed $125,200, with $75,700 to the GOP, and $49,500 to Democrats. It contributed $1.1 million in 2010, with 57% to Democrats, and 43% to Republicans.
When asked about the contributions, an AMA spokeswoman said, "AMAPAC does not weigh in on who people should support in presidential races."
Representatives of physician PACs say they can get more accomplished in congressional and senate campaigns than in the presidential races, with more contributions already being generated, though not filed yet with the FEC.
The American Academy of Orthopedics Surgeons PAC, for instance, says it now has $1.7 million in contributions, an amount that will not be filed with the Federal Election Commission until this summer. Every four years, the members vote on whether they should contribute to the presidential campaign, says Stuart Weinstein, MD, the PAC for the American Academy of Orthopedic Surgeons.
Essentially, the AAOS believes it can be more effective both in terms of resources and achieving policy goals by contributing to individual congressional races.
"Everyone realizes that when you talk about presidential campaigns, you are talking about massive amounts of funding for each candidate to compete," Weinstein says. "We feel we can have a greater impact on issues affecting our patients in our profession by building relationships with members of Congress. We always consider that question for each election cycle: What do we want to do for our members? Our philosophy is that we're a bipartisan PAC. We support both Democrats and Republicans, and we are most supportive of candidates who understand what we want—appropriate access for specialty care."
Mueller, of the American Society of Anesthesiologists agrees. "Congressional races offer our members the best opportunities to fully participate in campaigns," he says. "The large scale of a presidential campaign simply doesn't offer the same meaningful experience. For the time being, we think our resources are best used where our anesthesiologists can more fully engage with the candidates."
Whether it's dealing with the "record number of drug shortages or making progress on fixing payment issues, there are members on both sides of the aisle and in both chambers of Congress who understand these issues and how they relate to our specialty," Mueller says.
At this point, the healthcare PACs are "looking for a target audience," says Dowling of the Heritage Foundation. "In this case, it's Congress. It's paying for influence."
This article appears in the February 2012 issue of HealthLeaders magazine.
Often seen as self-styled Lone Rangers out to save healthcare with their clinical know-how, physicians must do a better job becoming involved in partnerships to overcome turf wars and ego-driven barriers to coordinate care and improve patient outcomes.
Improving relationships within hospital systems is critical, with the need clearly reflected in the HealthLeaders Media Industry Survey 2012, says Michael J. Dacey, MD, FACP, senior vice president for medical affairs and chief medical officer for the 359-bed Kent Hospital in Warwick, RI.
HealthLeaders Media Industry Survey 2012 The priorities and concerns of nearly 1,000 of your colleagues in healthcare leadership are revealed in this year's comprehensive multi-part survey, our fourth annual HealthLeaders Media Industry Survey. Download the Free Reports
"Many hospitals now have millions of dollars each year at stake on quality and patient satisfaction measures," he says. "In many cases, a hospital's entire profit margin and then some will be accounted for by successful performance on these measures. In order to succeed with these, hospitals and doctors must work together."
It may not be easy.
The industry survey reveals that 10% of physicians blame themselves for the "healthcare industry mess," although three times that number—30%—see physicians as the ones who will save healthcare. And 13% say that physician disrespect and abuse of nurses is prevalent at their organization.
"It has become increasingly apparent that doctors have to work with other people and share the care of patients with other professions, whether they are nutritionists, pharmacists, or nurse practitioners," Dacey says. "You've got to be more collaborative, work as a team. There's a different mind-set."
Of physician leaders in healthcare organizations nationwide, 36% said the government was "most to blame for the healthcare industry mess." Another 23% blamed health plans, and 10% blamed physicians themselves.
Physicians should be blaming themselves for a big part of the healthcare morass, one physician leader suggests. "We order too much, [practice] too much defensive medicine, keep patients in hospitals too long," says Douglas Garland, MD, medical director of the MemorialCare Joint Replacement Center, part of 1,006-bed MemorialCare Health System in Long Beach, CA. "We truly care about people and good outcomes, but not in rationing care, which doctors must learn to do. We made our bed and now we must sleep in it."
Patients need to learn, too, Garland says. "They want their own doc, not a doc in the box; they want the latest and the best," says Garland, also cochair of the orthopedics, neuroscience, and rehabilitation program for the 420-licensed-bed Long Beach Memorial Medical Center.
And who's going to save the healthcare industry? Well, the doctors say the doctors, that's who. In the survey, 30% said that physicians would save healthcare, far outdistancing the other stakeholders, such as the government (13%) and hospitals (13%).
"So much for humility," Dacey comments. "The real answer, of course, is all of the above working together," he says.
"Most doctors believe that very few administrators understand physicians and the problems they face," Dacey says. "And most administrators at both hospitals and insurance companies would say the same thing about doctors. And both groups are correct."
Relations between physicians and nurses are particularly important as systems move toward multidisciplinary approaches and use of nurse navigators with physicians for specialized care within service lines.
The survey results indicate mixed attitudes about physicians related to their nursing colleagues. While 48% said increasing scope of care for nurses would improve the quality of care, 26% said it would worsen.
When asked how pervasive physician abuse or disrespect of nurses is at individual organizations, 13% said it was common, while 88% said it was uncommon.
"I think it's an underreported thing, no question," says Dacey. "The truth is almost always the doc is not willing to listen to the nurse's input. The nurse may be right or wrong, but why won't [the doctor] listen? A lot of it is ego. I'm sure if you talked to the nurses, they would switch those percentages, and 88% would say it's common."
Dacey says, however, that more nurses are becoming assertive related to those issues, and physicians can "lose privileges and get sanctioned" by a medical board.
Physician and nurse relations are often dependent on where they work in the hospital, Dacey says. While ICUs or emergency departments may generate team concepts, a physician working on a medical floor "may feel that I'm going to be there for 20 minutes, and I don't have to take the heat" and start being abusive, Dacey says.
"Of course," he adds, "any disrespect should not be tolerated. Nurses are our partners."
Physicians say they believe that healthcare can't solve its own problems, with 60% saying there is too much self-interest among stakeholders.
"There is a lack of alignment amongst physicians, hospitals, insurance companies," Dacey says. "Each has traditionally had its own set of interests that were at odds with one another." Referring to job satisfaction, 24% of physicians said they were very satisfied and 49% satisfied, while 12% said they were dissatisfied and 1% very dissatisfied.
"Obviously, we would like more of our colleagues to be very satisfied," Dacey says. "I'm surprised that the numbers are not worse. It speaks to the real benefits of being able to make a difference in people's lives that even overcomes the paperwork, malpractice, and others from job satisfaction."
This article appears in the February 2012 issue of HealthLeaders magazine.
Like many of us, physicians have a tendency to fall in love with their gadgets. Not that there's anything wrong with that, as comedian Jerry Seinfeld might say, but then again, maybe there is.
Especially if they grow too fond of the gadget makers.
I'm not talking about personal technology like smartphones or iPads. I'm talking about expensive medical devices, particularly implantable ones used in cardiology and orthopedic procedures, and the companies that manufacture them. A single cardioverter defibrillator implant, for instance, can cost as much as $19,000.
Physicians might be smitten by what the device can do, even if they don't know the price tag. And sometimes they have relationships with manufacturers.
Sometimes, there might be nothing wrong with that. But physicians play a key role in procuring those devices.
A little-noticed General Accountability Office report released last month points out potential problems of the physician-device maker connection, noting that "strong" physician relationships with manufacturers or doctors' preferences on different models of implantable medical devices (IMDs) may undermine the ability of hospitals to make prudent purchasing decisions.
"The influence of physicians on hospitals' IMD purchasing decisions is a particular factor to the IMD market that affects prices hospitals' pay," the GAO report states. "While physicians are generally not involved in price negotiations, they often oversee strong preferences for certain manufacturers and modes of IMDs."
As a result, individual hospitals or hospital systems may have less bargaining power relative to the few cardiac and orthopedic IMD manufacturers, the report adds. It could become an extremely costly proposition.
Physicians rely on manufacturer representatives to provide technical support during procedures. In essence, physicians may be loyal to certain manufacturers with whom they have a consulting or professional relationship. Higher costs can result from these affiliations, the GAO notes.
(Of course, some of those relationships raise other questions. A U.S. Senate committee has been investigating physician ties to a medical device company amid questions of covering up potential problems with a spinal implant device.)
Implantable medical devices, including cardiac and orthopedic devices, represent a significant share of hospitals' supply costs, with a wide variation of costs for each item. From 2004 through 2009, expenditures for hospital IMD procedures jumped from $16.1 billion to $198 billion, an increase of 4.3% per year, and a rate equal to that of Medicare spending for other hospital procedures, the GAO report states.
According to the report, one hospital paid 83% more than another for the exact same knee implant.
Orthopedic and cardiac procedures accounted for nearly all IMD-related Medicare expenditures from 2004 through 2009. That is only expected to continue to grow. A recent HealthLeaders Media Industry 2012 survey (PDF )shows that 23% of physician leaders say that has a revenue growth potential of 6% or more over the next 3 to 5 years for orthopedic programs; with 16% saying heart programs will have similar growth. Some 46% say they anticipate growth in both service lines at least 1% to 5%.
There is a way to begin fighting the explosion of costs: If the physician-hospital relationship is strong, hospitals can consider evaluating purchases from many IMD suppliers, and using this competitive information to gain leverage for lower prices, the GAO suggests.
One of the systems that has been successful in reducing implant costs, for instance, has been the University of California San Francisco Medical Center, which established a protocol involving physicians and administrators in purchasing arrangements, says Eula Mckinney, MsHA, director of the general surgery, orthopedics, pain management and spine service lines for USMC.
UCSMC began tackling the problem of expenses a few years ago after it projected millions of dollars of losses in spinal implant costs. In response, the medical center established a committee implant purchasing structure involving administrators and physicians that enabled them to work "in harmony," Mckinney says.
Using that committee structure, which included a physician champion designated for purchasing, the hospital system has reversed its losses and has a notched a competitive price index better than 83% of hospitals with implant costs, she says. The overarching plan was to "have accountability and manage costs, delivering high quality without compromising clinical care," she tells HealthLeaders Media. "The high quality component is required."
The administration and physician teamwork is essential, she adds. The message from administrators to physicians: We need your help to improve cash flow and manage our costs. Their cooperation led to a "trusting relationship" between the two groups, she says.
"The vendors know because of the relationship I have with physicians, they just don't get everything they want at this hospital," Mckinney told me recently. "They know they have to go through the protocols that have been established."
The physicians help establish the protocols; the docs helped draft them. "That makes a significant difference because (physicians) are at the table making decisions," she says.
Too often, hospital systems don't carry out such a coordinated program. And physicians' relationship alone with device manufacturers has a significant impact on hospitals' expenditures related to devices.
If manufacturers determine that a physician is unwilling to switch device models, they can be more aggressive in negotiations, which could result in higher prices for hospitals. There are other concerns, according to the GAO report. In some instances, it says, device manufacturers have been able to leverage "gag clauses" that have allowed them to keep prices secret.
"Confidentiality clauses barring hospitals from sharing price information make it difficult to inform physicians about device costs and thereby influence their preferences," the GAO report states.
Those secrecy provisions are working to drive up costs, with physicians left in the dark over prices, says Curtis Rooney, president of the Healthcare Supply Chain Association, which represents 15 group purchasing organizations for hospitals, including those of hospital systems and healthcare provider alliances.
"The doc gets trained on the product and the doc never sees the price of the product, but the hospital buys it because it feels the need to keep the physician happy," Rooney tells HealthLeaders Media. "With the confidentiality clauses, the hospital is wearing the blinders, and the hospital can't share the price information with their own physicians."
Sen. Max Baucus, (D-MT) who chairs the Senate Finance Committee, asked for the GAO report, and says he's pushing for increased transparency in the medical device industry because there is too little information available about costs of the implantable devices.
"The more people know about the actual costs of these goods and the options they have, the better they are able to incorporate them into clinical care," Rooney says. "A lot of efficiency is to be had there. If you can't talk about prices, then you are in the dark."
There is something most definitely wrong with that.
When it comes to malpractice, it seems physicians have developed their own case of "white-coat syndrome."
Their worries about malpractice litigation might actually be making it worse, and hurting healthcare in the process. That's because doctors are keeping their mistakes under wraps, or performing too many tests or costly procedures to avoid a trip to the courthouse.
Instead, physicians should be opening lines of communication with patients, admitting when something goes wrong, and curtailing excessive treatments. They can fight the tort war one step at a time from the moment they pick up that stethoscope.
Two recent reports express urgency about the need to change.
A recent HealthLeaders Media Industry 2012 survey (PDF) shows that a whopping 58% of physician leaders said they ordered a test or procedure for primarily defensive medicine reasons in the past year.
That figure is all the more stunning because only 2% reported ordering a test or procedure for primarily revenue-related reasons.
"We order too much, (practice) too much defensive medicine, keep patients in hospitals too long," Douglas Garland, MD told HealthLeaders Media. He is medical director of the MemorialCare Joint Replacement Center, part of the 1,006-bed MemorialCare Health System in Long Beach, CA.
Results of a recent survey published in Health Affairs revealed that as many as 20% of physicians won't tell patients about errors because of doctors' fear of malpractice litigation. As many as 55% exaggerated or failed to tell patients something about their health because, in part, the physicians didn't want to upset their patients. At least 1 in 10 physicians told patients something untrue in the past year.
"When we noted that 20% of physicians said in the last year they had not fully disclosed an error or a mistake to a patient because they were afraid of a lawsuit, it certainly could have been any error they were referring to," Lisa I. Iezzoni, MD, M.Sc, a professor of medicine at Harvard University and director of the Mongan Institute for Health Policy at Massachusetts General Hospital told HealthLeaders Media.
"We don't know from the survey results; we didn't ask that. But you can imagine the errors span a continuum of severity. Some errors may have caused minor discomfort or no discomfort whatsoever. Other errors can be life-threatening. It's hard to know exactly what that 20% remembered; they weren't asked that question," she says.
While physicians' statements are not always linked to malpractice concerns, doctors are aware that the possibility of litigation is always a factor. Indeed, more than 60% of physicians aged 55 and older have been sued at least once, according to the American Medical Association.
Physicians also know how costly—financially and emotionally—la malpractice suit can be. In a policy report issued at the end of 2011, the American Medical Association stated that the average cost of defending a physician against a medical liability claim was $47,158 in 2010. That's an increase of 62.7% since 2001. Still, 63.7% of all closed claims against physicians were dropped, withdrawn, or dismissed.
For physicians, the local malpractice environment sometimes influences their "attitudes and behaviors," including how honest they are about errors, according to Iezzoni.
Her study showed that cardiologists and general surgeons were most likely to report never having told patients an untruth in the previous year, while pediatricians and psychiatrists were least likely to report never having told untruths.
More physicians practicing in universities or medical centers, (78.1%) completely agreed with the need to report all serious medical errors than physicians in solo or two-person practices (60.5%).
The reason appears simple: small practices don't have as much legal leverage, so physicians from these practices with less clout are also less likely to be as forthcoming.
But many experts agree that concealing medical errors, being dishonest, or practicing overly defensive medicine isn't the way to thwart malpractice litigation.
Research shows that the more likely physicians are to discuss errors with patients, the less likely they will be sued, Iezzoni says. Perhaps it makes the doctors seem less god-like and more human, so patients can relate to them.
"Some physicians may wonder about revealing errors to certain patients if no serious harm resulted from them. I know a lot of physicians are reluctant to talk about medical errors. But the more open you are in talking about errors, the less likely patients are going to pursue litigation, and the more likely you are going to gain the trust of patients, and be able to move forward in a therapeutic way," Iezzoni said.
Among other things, informing patients about the errors can "reduce anger," she adds. "If you talk openly to patients in situations where errors happened, it makes patients understand better what happened, why it happened and makes them less likely to pursue litigation as a solution to it."
Iezzoni notes that academic literature stretching back to the 1990s has shown that "openness" in communication between physicians and patients has potentially positive impacts on avoiding malpractice suits.
As for Iezzoni and her colleagues, their biggest concern wasn't simply the malpractice issue. It was the totality of honesty in communications between physicians and patients, for whatever the reason.
Why aren't doctors always upfront with patients? "I think there are probably as many reasons as there are doctors and patients," she says.
In our conversation, she listed some possibilities. "Maybe doctors don't want to upset patients. Maybe doctors feel if they tell patients the truth about their prognosis, it's going to cause the patient undue amount of stress. Maybe doctors aren't trained to talk to patients about different truths," Iezzoni says. "Maybe doctors don't feel they have enough time in 10 to 15 minutes to have a complete conversation about a patient's prognosis."
"Patients themselves are going to have different preferences for how open they want doctors to be," she adds. "There are certain patients who may say, ' I don't want to know everything, just tell me what to do, give me the highlights. Then there are those who want to be frank and open and have a complete discussion about what their prognosis is. They want to know everything."
Iezzoni noted the ABIM (American Board of Internal Medicine) Foundation's Charter on Medical Professionalism, published in 2002, urged doctors to be "open and honest" with patients and to disclose medical errors promptly. With this latest survey, it doesn't appear physicians are following the guidelines or standards of communication laid out by the foundation, she conceded.
With the high percentage of defensive medicine practiced, as well as physicians trying to hide potential errors to offset potential malpractice litigation, Iezzoni notes, "We need to do a lot more work from the patient and physician side to get to the point there is more openness and frank discussion about the patient's health and patient's prognosis."
"Patients need to feel comfortable going into the doctor's office, and saying, 'Look I want to have a conversation about how I want you to talk to me about my health.'"
Engaging in that conversation with complete honesty could be a first step toward avoiding a malpractice suit.
A strange thing is happening as physician practices transition toward HIPAA version 5010 electronic transactions.
Docs aren't getting paid.
Physicians are flooding their advocacy groups with complaints and questions about "cash flow problems." One physician broke down in tears about his inability to pay his staff.
"We haven't seen anything like this before," said Robert Tennant, MA, senior policy advisory at MGMA, referring to the emails from distraught doctors.
The problems have intensified over the past month. Since the mandated transition to HIPAA Version 5010 began Jan. 1, data disruptions, unforeseen rejections of claims, and improper mailings because of address issues have stopped docs from getting paid.
Beyond that, communication snafus with clearinghouses and secondary payers have been a problem. The bottom line: These issues and more are resulting in payments not making it to physician offices, according to MGMA.
While the number of physicians impacted, has not been specified, it is likely in the thousands. A flurry of meetings and emails between the Centers for Medicare & Medicaid Services and physician groups is underway, but authorities don't expect any resolution to the issues for weeks.
Problems have been reported with both Medicare administrative contracts and commercial plans. Some physicians have resorted to taking out lines of credit simply to meet payroll and other expenses. No one seems to be able to pinpoint specific reasons for the cash flow problems.
American Medical Association President Peter W. Carmel tells HealthLeaders Media that over the five weeks since the 5010 standard was implemented, physicians have been "experiencing very alarming problems that have resulted in significant interruptions in claims processing and cash flow." As a result, more postponements should be made for any enforcement deadline of the HIPAA Version 5010, he says.
Recently, CMS's Office of E-Health Standards and Services (OESS) announced a 90-day period of "enforcement discretion" for compliance with the new 5010 HIPAA transaction standards. CMS extended the 5010 compliance deadline to March 2012 to allow more physician practices the opportunity to implement the new billing-coding standard without incurring penalties.
When asked about the payment issues and the CMS 5010 enforcement deadline, Carmel says: "The AMA fully expects that another extension to the 5010 enforcement deadline will be needed to resolve the emerging issues. We are reviewing timeline recommendations for an extension, but it is clear that no enforcement action should be taken until the vast majority of physicians are being paid in a timely manner under the 5010 standard."
"These problems are particularly troubling since cash-strapped physicians are burdened with meeting several other government requirements, including quality reporting, e-prescribing, meaningful use, and of course, ICD-10," Carmel adds.
Specifically, MGMA has called for an extension of the enforcement delay from March 1, 2012 to June 1, 2012. In a letter to HHS Secretary Kathleen Sebelius, MGMA has recommended to instruct MACs (Medicare Administrative Contractors) to "immediately" provide advance payments for physician practices that are struggling to meet the Version 5010.
Moreover, HHS was asked to permit clearinghouses and health plans to accept and adjudicate Version 5010 claims that do not have all the required data content, and instruct the MACs to expeditiously adjudicate all outstanding claims.
Physician groups say that the government needs to take prompt action because physician practices may eventually face delayed revenue and operational difficulties, reduced ability to treat patients, or even the prospect of closing practices. MGMA officials have not specified any specific impacts from the situation.
The situation highlights the delicate balance of uncertainties between government mandates and private physician groups. It spotlights the issue of the fragile, and possibly tentative steps needed to enforce new deadlines. Physician groups also raise concerns about the moves toward ICD-10, considering that the magnitude of that mandate is even greater than Version 5010's reach.
"It's clear that problems will not be resolved overnight," Carmel said this week.
Many physicians report not having been paid by Medicare or TRICARE since November 2011, as a result of the Version 5010 issues, according to the letter sent by MGMA President and CEO Susan Turney, MD, MS, FACP, FACMPE, to Sebelius.
As for CMS, it has little to say publicly on the issue. "HHS has a correspondence response process and CMS will be contributing to development of HHS's response," says Joe Kuchler, a spokesman for CMS, referring to a letter from MGMA. "In the meantime, MGMA's letter is considered open correspondence and we can't comment on specific issues."
While practices have contacted their MACs to receive clarification on the reason for rejected claims, they are provided with little to no information beyond a vague explanation that problems must "lie with your clearinghouse," according to Turney's letter.
Oddly enough, some practices are taking drastic action to try to circumvent the cash flow problems with electronic records. They are reverting to paper claims, Tennant says. "If they have to drop back to paper, we don't recommend it, but if that's the only way to get paid, they may have to take that step," he says. Eventually, however, paperwork may eventually lead to a further backlog of claims, and potential delays in payment.
Tennant says MGMA is recommending that physicians take their cases, if necessary, directly to CMS. "The more complaints CMS hears, the more chance they will take action," he says.
This article appears in the January 2012 issue of HealthLeaders magazine.
Like the rhythm of the beating heart, there is the steady drumbeat of knocking on the hospital's doors.
It's those cardiologists.
With declining reimbursements and eroding practice income, cardiologists are increasingly seeking hospital employment, prompting health systems to consider an array of possibilities for physician alignment.
Most hospital systems are using the standard employment model as they bring physicians into their systems, but others are using comanagement or other paradigms, such as professional services or business enterprise systems, for invigorated cardiology programs. In the process, they are improving internal committee oversight and management structures, and influencing changes within group practices.
"Physicians are sitting alongside the administrative team at all levels of the heart institute," says Lisa Shannon, COO of Spectrum Health's Grand Rapids, MI, hospitals. "So many times an administrator is unable to move things forward to change quality or decrease costs unless it is physician-led." Spectrum Health has employed, integrated physicians, and also those who are not salaried within the system. Physicians who aren't employed are included in the committee structure, says Shannon, noting, "We certainly have room and need their input."
As the nation moves toward value-based purchasing, hospitals are evaluating systems such as bundling for episodes of care, which is shown to improve efficiencies, according to Nancy Harrison, director of the acute care episode project for the 681-licensed-bed Hillcrest Medical Center in Tulsa, OK, which is part of Ardent Health Services, a Nashville-based system that owns nine acute care hospitals and one rehabilitation hospital with a total of 1,731 licensed beds.
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Healthcare leaders are considering prospects for new payment systems, for value-based efficiencies, and possible accountable care organization structures, says Tim Attebery, system vice president for cardiovascular services for the Wellmont Health System in Kingsport, TN.
"We want a seat at the table as we talk to physicians and physicians are coming together; they may be in several ACOs," says Attebery. "Cardiology and heart disease is the No. 1 subspecialty of any population."
Roger Noble, RN, director of cardiovascular services for FirstHealth Moore Regional Hospital in Pinehurst, NC, says the 395-licensed-bed hospital is evaluating several employment models to hire cardiologists, who are now under contract with the hospital. One of the models being considered is an integrated plan, such as a professional services agreement in which a hospital or health system operates a physician clinic and contracts with an independent group to provide professional services.
The hospital, part of FirstHealth of the Carolinas, a private, not-for-profit system with 582 licensed beds, may decide to diversify its employment models and not just stick with one, Noble says.
"Because of our geographic location, we have a market lock that allows us to do something we maybe wouldn't be able to do in an overly competitive environment," Noble says.
Success key No. 1: Overcoming alignment challenges
Two years ago, the leadership team at the 422-licensed-bed Borgess Medical Center in Kalamazoo, MI, moved toward a full-employment model for physicians in cardiology programs, but hospital officials figured out quickly they had to confront some significant obstacles to attain their goal.
As they negotiated with physician groups, they realized there was a lack of alignment in the doctors' goals, and different expectations for compensation. Hospital officials knew physicians sought a degree of control of their day-to-day operations and did not want to lose autonomy, says J. Patrick Dyson, executive vice president for strategy and corporate services at Borgess Health, which includes the Borgess Heart Institute, where most cardiology and cardiac surgery services are centered.
One of the most important system changes was to create a cardiovascular leadership council to oversee overall performance of the Borgess Heart Institute. The council consists of physicians—both employed and in private practice—from various groups that comprise the institute. The groups represent various cardiac subspecialties, such as surgeons and hospitalists.
Dyson says the hospital system ensured that the employed cardiology medical groups retained oversight of day-to-day clinical operations and had a role in governance of the service line. Although the hospital system did not have a comanagement model in which physicians and administrators have joint ownership, the leadership council system was important to maintain and develop a stronger, more representative leadership structure for physicians employed by the system, says Dyson.
Another key component centered on citizenship.
"These citizenship expectations are what is expected from physicians—behaviors on a day-to-day basis," Dyson says. Among the rules that are unique to one particular group: Nobody is late to start a clinic; if someone has a concern about an issue, how do you voice that concern? Do you get your billing done on time? How is your documentation? Is it done in time?
M. Sue Anderson of ECG Management Consultants, Inc., in Arlington, VA, who has worked with Borgess, says that the framework of operating councils has "really transformed the relationship between the hospital and physicians, and has empowered the cardiologists, allowing them to move forward to not only focus on operational issues, but also to target strategic initiatives.
"With many cardiology groups, the opportunity to play an active role in management and governance is just as important as compensation," says Anderson. When Borgess incorporated a newly employed cardiology group, it was incorporated into an existing physician structure, but was able to operate as a "separate and distinct practice," she says.
Dyson says the hospital system is using the physician alignment structure to improve the hospital clinical outcomes. Borgess has focused on various aspects of cardiac care, he says, with good results. The hospital system's 30-day readmission rate for patients admitted with heart failure is 21.4% for 1,800 Medicare patients, compared to the national 30-day readmission rate for heart failure at 25%, according to Centers for Medicare & Medicare Services data from 2007 to 2010.
Success key No. 2: Prospects for bundling
Hillcrest Medical Center has embarked on shared savings with physicians as part of a bundled payment program demonstration project in cardiology, and it has seen reduced costs and improved efficiencies, says Harrison.
The three-year Medicare Acute Care Episode demonstration project for Hillcrest Medical Center began in May 2009. The demonstration was to test the effect of bundling Medicare Part A and Part B payments for acute episodes of care, with the effort designed to improve coordination, quality, and efficiency. Five sites in a four-state area were selected as value-based care centers for designated cardiovascular or orthopedic procedures.
Under the payment methodology, CMS would share 50% of its savings with Medicare beneficiaries, not to exceed their annual Part B premium. The selected set of procedures included 29 cardiac inpatient surgical services.
Hillcrest doctors have been guaranteed regular surgical fees as part of the pilot project, but they can also receive a provider incentive from Hillcrest for keeping costs down and maintaining high-quality scores, such as low infection and readmission rates, says Harrison. Hospital officials have not disclosed payments, but Harrison notes that "participating facilities can arrange provider incentive payment methodology under their program with CMS approval." She emphasizes that physicians would have to meet "the predetermined and agreed-upon savings criteria and quality measures as defined by our agreement." The maximum cannot exceed 25% of their reimbursement for these cases, says Harrison.
Bundled payments are among the models being considered under healthcare reform to replace fee-for-service.
"The most important thing with cardiology is going to be bundled payments, with the ACE demonstrations really pointing the way where CMS will be pushing hospitals," says Anderson.
There have been satisfactory results not only with the scores, but also with physician involvement, linking them to the gainsharing initiatives, Harrison says. There has been "better coordination with our physicians and collaboration on episodes of care," she adds.
Over a 15-month period, scores on several quality measures increased, while supply costs decreased. The hospital saved up to $750,000 in Medicare payments on 37 diagnosis-related groups, according to hospital officials.
Another important area focused on improved product management and cost controls with physician involvement, she adds.
As the program began, hospital officials realized that many surgeons didn't know "the actual cost of the products they used," Harrison says.
The hospital examined "a supply list and standardized the products for quality and reduced costs," she says. "We didn't go to a sole source and didn't dictate [products] from a certain supplier. We left the decisions to the doctors. We were working with physicians from the start, involving them in the decision."
Among the benefits: 11% defibrillator implant savings, 9% stent implant savings, and 25% stent supply savings.
"We're feeling good about the results, and we think we've learned more working with physicians and quality improvements," she says.
Success key No 3: Same-day discharge
As it began focusing more on cardiac care with development of a new heart institute, Spectrum Health, a 1,370-licensed-bed system, ensured physician and administration partnership to improve clinical outcomes, targeting same-day discharge for angioplasty patients in cardiology programs.
The program highlighted specific metrics that must be reviewed and benchmarks to be achieved as part of a coordinated effort between physicians and administration, says Richard McNamara, MD, interim comedical director of Spectrum Health Frederik Meijer Heart & Vascular Institute and chief of cardiology at Spectrum Health.
"We put this in front of physicians, that these are the metrics we are going to identify and focus our efforts on," says McNamara, referring to the angioplasty and other programs. "We are engaging physicians a lot more consciously about identifying goals. And we have incentive pay to meet those goals," McNamara says.
"We went across the board, looking at clinical problems that required a lot of cooperation with administration and physicians," he adds.
The program is part of the institute's executive leadership council, whose subcommittees examine research, education, business, and medical programs.
The hospital has focused on improving efficiencies in a same-day discharge program for percutaneous coronary intervention patients, McNamara says. The procedure used to carry out the PCI process is coronary artery stenting. Nationally, at least 1 million PCI procedures are performed annually among Medicare patients.
In a review of low-risk Medicare patients who underwent elective PCI, same-day discharge has been rarely used, with only 1.25% of 1,339 patients discharged on the day of their procedure, according to an independent study from the Duke Clinical Research Institute in Durham, NC.
PCI has not been associated with an increased risk of rehospitalization or death, the institute states.
While Spectrum Health is still compiling data, its preliminary reports show that it averaged same-day discharge for 16 patients each month, representing about 30% of all scheduled elective PCIs, says Patrice Villemure, executive director of the Fred and Lena Meijer Heart Center.
Overall, the hospital database shows 281 PCI patients who had same-day discharge. "We have no major complications, which have been measured as bleeding, reinfarction, stroke," says Villemure. "Patients have been highly satisfied with the program," she adds.
"There were PCI patients stable enough to go home the same day of the procedure," says McNamara. "We felt they were responsible for a large number of beds used in the hospital. We were not getting the utilization that we wanted; there were unnecessary expenses, and that's what we wanted to change."
Success key No. 4: Collaboration
Scotland Health Care System, in Laurinburg, NC, an affiliate of Carolinas HealthCare System, joined with FirstHealth, based in Pinehurst, NC, to build the $2 million Scotland Cardiovascular Center on the outpatient wing of the Scotland Memorial Hospital campus in 2011.
The hospital systems are separated by 45 minutes, and sometimes compete for patients. Yet they joined together to build the cardiovascular center with a catheterization lab for improved patient care, a move that each hospital's leadership says can be replicated successfully elsewhere, for cost savings.
"As a small community hospital we have always been proactive in creating alliances with regional partners to bring the best technology and services to our community to allow patients to remain close to home," says Greg Stanley, director of cardiovascular services for Scotland Memorial Hospital.
The new relationship evolved from a long-standing, albeit much smaller, partnership. Over the past decade, FirstHealth managed a mobile cath unit that Scotland Health Care rented twice a week to perform diagnostic cardiac catheterizations.
The new cath center includes the catheterization lab as well as four preparation and recovery rooms. By having the cath lab on site, Scotland Health Care can serve patients each day, instead of only twice a week.
The lab allows the Scotland medical staff to transmit images from the procedures directly to FirstHealth, where doctors can review results and decide whether the patient needs additional care or services. Patients who need additional percutaneous transluminal coronary angioplasty or coronary artery bypass graft would be transferred to FirstHealth, which provides around-the-clock coverage for such cases.
"Scotland provides follow-up care to the majority of these patients—if we transfer for intervention or surgery, we get many of those back into our cardiac rehab program," Stanley says. "And the physicians at FirstHealth work well with Scotland cardiologists so patients can receive the advanced care when needed in Pinehurst and then return to their Scotland physicians," Stanley says.
Noble, of FirstHealth Moore Regional Hospital, agrees. While the part-time mobile lab provided some benefit to the community, "what was really needed was something five days a week," he says. "We want to improve access to care and improve the mortality rates. We'd like to deploy the lab to other areas and help people in other areas. We're lockstep in this."
The mobile lab, originally based in Laurinburg, has been replaced with a fixed lab available to patients five days a week, he says.
Under the joint-venture agreement, Scotland Health Care and FirstHealth invested $750,000 each to "purchase the fixed procedure room and support equipment," says Stanley. Scotland Health Care added another $1 million to renovate a hospital wing and then "relocated a couple of departments to make space for the new cardiovascular center," he adds.
Stanley described management of the center as a "team approach from both organizations." Stanley and Scotland Health Care's vice president of patient care services partner with administrators at FirstHealth. As for the day-to-day operations, "We utilize some of their staff on the procedure side, and we pay their organization per procedure," Stanley says.
Although there is no firm data because the project is relatively new, Stanley says more than 30 patients can use the new cath center each week, easily more than doubling volume.
Scotland Memorial Hospital statistics show that one in five emergency room visits has some sort of cardiac issue from either chest pain or high blood pressure.
"We are getting a better snapshot of cardiac disease in our county and in our region," Stanley says. "As we see it, our volumes will continue to grow on the cardiac side, and we are going to take care of more patients in a more timely manner. Patients will be getting started on the road to recovery quicker, getting cardiac rehab and some kind of medicine regimen.
"In this corner of North Carolina, there is a lot of cardiac and vascular disease, with diet, lack of exercise, food options, and smoking," says Stanley. "We can make inroads on this."
This article appears in the January 2012 issue of HealthLeaders magazine.
To organize teams of erstwhile rivals, health system leaders must manage egos, negotiate ambitions, and acknowledge that they may be bringing on board some professionals who can't stand one another.
Abraham Lincoln did this in the 1860s as he pulled together a Cabinet that included people who wanted his job, challenged other's authority, and had not much use for the others' opinions. President Lincoln managed to steer his way through by focusing on a bigger goal: victory in the Civil War.
The New York Yankees did it in 2009, winning a world championship several years after Alex Rodriquez, the mega-millionaire shortstop with the Texas Rangers, signed with the club and was forced to switch positions and swallow some ego. Rodriquez then played third base, side by side with his onetime friend, Derek Jeter, who insisted he wasn't going to budge from his shortstop position. There's still speculation about how much they talk.
Like politicians or sports teams, merging groups in healthcare are often forced to work together after being competitors for years. Can physicians who compete and dislike one another put their differences aside and join a hospital organization with the shared goals of maintaining quality and reducing costs? Can they overcome the competitive mindset? Can they achieve championship-quality healthcare?
It is a difficult process that health systems are beginning to grapple with, especially as more physicians become aligned with hospitals, says Lawrence S. Levin, PhD, a leadership and team consultant. Levin, founder and president of the Levin Group in Atlanta, and author of Top Teaming: A Roadmap for Leadership Teams Navigating the Now, the Now and the Next, often works with former competing specialty groups to develop the team mindset he says is needed for a successful practice or relationships with hospitals.
"Sometimes it gets ugly, and it can get ugly pretty easily," he says.
At St. Joseph's Regional Medical Center in Paterson, NJ, things apparently had gotten ugly for a while with doctors and their department chairman, who had apparently announced that he would "separate their skulls from their bodies" if they disobeyed him. The doctors' medical group left the hospital and then sued. A jury decided last month that the chairman and the hospital should pay the doctors $1.7 million.
"When it gets ugly with physician groups and hospital administration, it gets uglier than in a lot of other businesses and it becomes much more personal for some reason," Levin says, speaking generally and not about the Bergen County case. "You have to reset the clock. Why you are there? What do you agree on? It may sound soft and fuzzy but it's not. You understand what everyone's interests are and you proceed forward, then face the dialogue."
Levin discussed some of the moves that leaders must make in creating a functioning team out of once-competing physician groups and hospitals:
1. Forget the vision thing
Levin says that while many groups get together and talk about a vision, few actually realize it. Too often, they rely on a statement without substance.
Levin worked with merging medical groups to make their vision practical. "We pulled together the leadership from these groups, and we really began the dialogue by talking about why the people in the room were there, what they stood for. We elevated the conversation about what their frame of reference was, what they were about. Why did they go into medicine in the first place? What was the most important thing for them?"
"It was about creating a potential vision of what these groups would do," he adds. "It wasn't a vision statement; vision statements are rarely practical. They are aspirational, and when put under pressure, they dissolve pretty quickly. If you don't understand what people want and what their expectations are, what their self interests are, aspirations don't stand the test of battle very well."
2. Act like a hostage negotiator
Oddly enough, Levin finds that some standard hostage negotiation techniques are helpful in dealing with healthcare rivals planning on becoming partners. From the outset, when a negotiator speaks to a hostage-taker and wants him to change his position, "the one thing they do is get to a common ground," Levin says. "They have to agree on something to begin with. In hostage negotiations, they may agree, "It's nighttime, or that everybody is nervous, or "Nobody wants it to get worse than it is."
Once there is a point of agreement, "when you run into difficult issues, then you circle back to what you agreed on," Levin says. The same technique can be used in negotiations with healthcare leaders.
3. Don't pretend you all like one another
Levin worked with a group of hospital and physician leaders who had tried to make a deal, but at the 11th hour, after attorneys, accountants, and various business models, they broke off the negotiation. Some admitted that the deal-breaker was that they just didn't like one another.
Newly formed teams often mistakenly think it's OK if they just set aside their disagreements and not put them out front. That's what happened with this group, Levin says. Eventually, the differences rise to the surface. "What they tried was peace over trust," he says. "Peace over trust rarely works. You acknowledge the issues and make agreements around those issues, and over time you build trust. That's pretty hard to do."
"We acknowledged there were issues that were not going to fully resolve. They had some people who didn't like each other, but they had a working agreement and kept to that agreement," he says.
Why should the group go to so much effort to bridge their differences? Levin's book on "top teaming" discusses the teamwork concept and opportunities, as well as obstacles. "Top teams carry with them tremendous collective intelligence, operating experience, and the ability to exert significant influence over their company's mindset, focus, and performance," he says.
If Lincoln could do it, if the Yankees could do it, then physician practitioners can do it, too. Team-building takes work, but there's plenty of evidence it can result in great outcomes.