Run by Mt. Sinai Hospital, a Chicago center treats refugee patients exclusively. But differences in culture, religion, and language pose daily challenges at the West Rogers Park health center. Since 1975, about 130,000 refugees have resettled in the Chicago area, and many pass through the doors of the Touhy clinic, which opened in the early 1970s. Except for the physicians, the staff members are themselves former refugees.
A former nurse manager is locked in a high-profile legal battle with the Peoria, IL-based Proctor Hospital. A trial is set for this year after the 7th Circuit of the U.S. Court of Appeals in Chicago reversed a lower court's decision to dismiss the case. Phyliss Dewitt, whose employment record was spotless, claims the hospital fired her because of her husband's high medical expenses. Experts say more conflicts of this kind are likely as economically stressed employers confront escalating healthcare costs and the reality that a small number of sick employees or family members account for the vast majority of medical expenses.
Pfizer Inc. is joining with two Boston hospitals to test whether computerized patient records can be used in helping federal regulators detect dangerous drug side effects. Massachusetts General and Brigham and Women's hospitals are encouraging 30 of their doctors to report serious side effects to the Food and Drug Administration by making the reports part of their normal routine filling out electronic patient charts. If successful, the pilot program could point the way for increasing the number of side-effect reports filed and for improving their quality.
The goal of improving physician relations is healthcare's equivalent of New Year's resolutions like spending more time with family and friends, quitting smoking, or losing weight. They're all worthy endeavors, but they're often doomed to fail because they lack sufficient planning, accountability, and support.
Still, improving physician relations will likely remain a top priority for hospital CEOs in 2009. So how can administrators show doctors that they are really listening to their concerns? "By actually listening," jokes Bill Donatelli, a regional vice president with QHR, a hospital management and consulting company. And even if your organization can't afford that new MRI machine or da Vinci Robot Surgical System, Donatelli says, CEOs should "provide straightforward answers in a timely manner and look to see if there is some alternative that can be provided."
That seems simple enough: Be honest, time sensitive, and really listen. Unfortunately, nothing in healthcare is ever simple—especially physician relations. During the past year of talking with industry experts and hospital executives, I've heard plenty of thoughts on how to build a better hospital-physician relationship. Here's a snapshot of some of those ideas.
Give physicians a voice. Asking physicians their opinions on improving patient care or crafting the strategic direction of the hospital is one way to garner a mutual respect. For example, Delnor-Community Health System in Geneva, IL, has several physicians on the hospital's board of trustees and quality committee. The physicians are out there on the frontlines and know what can improve quality, says board member Melissa Coleman. "If you are initiating or implementing a quality initiative, get doctors involved and let them drive it," she says.
Scripps Health in San Diego, CA, created a physician leadership cabinet to help guide the strategic direction of the organization. When Chris Van Gorder stepped into the CEO role in 2001, the health system had lost $21 million and his predecessor had been forced to resign after receiving five votes of no confidence by the medical staff. In 2006, the system posted an operating margin of $129 million, and the percentage of physicians who are satisfied with Scripps hospitals rose from 78% in 2003 to 86% in 2007. This advisory group of physician leaders has been a key component to regaining the medical staff's support and turning around the hospital's operations, says Van Gorder.
When it comes to quality and patient safety, James A. Rice, PhD, vice chairman of The Governance Institute, says physician leaders should inform the hospital board and administration what processes they are establishing to guard against medical errors, enforce hand washing, and handle credentialing and privileging issues. He also advises administrators to include physicians in strategic planning discussions on technology trends that may impact clinical outcomes or quality. Board members, senior executives, and medical staff leaders should all come together to look at the efficacy of the technology, as well as the capital consequences for the hospital, Rice says. "That is another partnership or culture of respect that is important to build between the board, management, and physician leaders."
Align goals. Physicians aren't motivated by HCAHPS scores or improving the hospital's ranking on the Centers for Medicare & Medicaid Services' core quality measures. Doctors are focused on patient outcomes and eliminating waste. They want more time with their patients—not more time filling out paperwork for various quality ranking organizations. But this doesn't mean that the goals of docs and administrators are mutually exclusive.
If the hospital's goal is to look good on CMS' Hospital Compare Web site, that probably won't engage physicians, says James L. Reinertsen, MD, president of the Reinertsen Group and a senior fellow at the Institute for Healthcare Improvement. But if the hospital's goals are to improve patient outcomes for specific disease by using clinical indicators to monitor the organization's progress on evidence-based medicine and CMS guidelines, that is more likely to garner physician support, he says.
Full hospital-physician integration. Some hospitals are finding that integrated delivery models are the best way to speed decision-making and align the goals of the physicians and hospital. Kelby Krabbenhoft led Sioux Falls, SD-based Sanford Health to an integrated clinic model 12 years ago. And even though the restructuring was met with some resistance from both administrators and doctors who were opposed to the concept, Krabbenhoft credits their new clinic model as one of the key reasons Sanford Health is a $1.5 billion organization today.
Similarly, Lakewood Health System in Staples, MN, also integrated the local physician group into the hospital in 1997. That alignment has enabled Lakewood to quickly adapt to constantly shifting market dynamics, which will be even more important for the healthcare organization's survival in the years ahead. "Everything is moving faster," says CEO Tim Rice. "Opportunities, when they do arise, all require a careful review and assessment, but if it takes a considerable amount of time today, some of these opportunities are lost."
Carrie Vaughan is leadership editor with HealthLeaders magazine. She can be reached at cvaughan@healthleadersmedia.com.
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More than a third of all Americans will be diagnosed with cancer sometime in their lives, and the U.S. spends billions of dollars to find ways to kill the disease at its strongest. This cure-driven approach continues to dominate cancer research. But detecting cancer early can increase a patient?s chance of survival by as much as 90%, and treatment at this stage is typically low-risk.
Primary care is in trouble, and there may be no way to save it. That was the conclusion of a 2004 report conducted by the American Academy of Family Physicians (AAFP), which projected that family medicine would not exist in the United States in 20 years unless major changes are made to delivery models and compensation.
Since then, the news has not improved. In 2007, 16% of first-year family practice (FP) residency slots went unfilled. More than 50% of the 2007 FP slots that were filled were taken by international medical graduates, underscoring the lack of interest U.S. medical graduates have in primary care.
Merritt Hawkins & Associates recently conducted a survey of 12,000 physicians—of which about 9,000 are in primary care—for the Physicians' Foundation, a doctor advocacy group.
Almost half of the doctors surveyed indicated that they are going to take steps that would reduce patient access to their practices by retiring, seeking nonclinical jobs, closing their practices to new patients, working part-time, or working locum tenens. Physician recruiters are acutely aware that primary care doctors—general internists in particular—are becoming increasingly hard to find.
The most visible solution to the primary care crisis being put forward is the medical home. The medical home is still a somewhat vaguely described model in which a primary care physician, working closely with the patient, leads a team of healthcare professionals who provide for or facilitate all the patient's needs. The idea is to expand patient access and communication with physicians.
The model is data-driven and relies on electronic medical records to help doctors make evidence-based decisions. It may feature expanded doctor hours, open scheduling, group visits, interactive Web sites, and secure e-mails, providing timely and frequent doctor-patient communication. The hope is that the medical home will, through a more preventive approach, lead to cost savings and better outcomes.
These savings can be used to pay primary care doctors more. Usually, the primary care model features a three-tiered payment system. Reimbursement is based on a management fee to reward the primary care doctor as leader of the healthcare team. The doctor also receives a fee for services provided and additional reimbursement based on the quality of outcomes achieved. More pay—in tandem with a more prestigious role in the delivery system—will keep doctors in primary care and attract new physicians to the field.
From theory to practice
That is the theory, which soon will be tested. In July 2008, Congress approved 12 three-year Medicare medical home demonstration projects to take place in eight states, starting this year.
Medicare's payment guidelines for practices participating in these pilot programs could mean an extra $50 per patient per month. The AAFP has already completed a medical home demonstration project featuring 36 practices nationwide; the results are expected to be released in early 2009.
The concept seems promising, but there are challenges, such as that there may be too few primary care doctors available to implement medical homes in any broad way. Many primary care doctors must already limit time spent per patient to less than 10 minutes to merely tread water financially. Coordinating care and communicating more thoroughly with patients online or by e-mail takes time, which primary care doctors already lack.
The medical home model also depends on the widespread implementation of electronic medical records (EMR). Of the physicians Merritt Hawkins surveyed, 77% of those who have not implemented EMR in their practices said they do not have the money to do so. Many primary care doctors are struggling with increasing overhead and a significant number do not have the time, resources, or expertise to implement EMR.
Despite these obstacles, the medical home concept deserves a try, and it will be interesting to see how the Medicare pilot project comes out. Without this—or some other fundamental rethinking of how primary care is delivered and paid for—recruiting primary care doctors will become even more challenging than it is now.
Phillip Miller is vice president of communications at Merritt Hawkins & Associates, a national physician search and consulting firm and a division of AMN Healthcare Irving, TX. He can be reached at pmiller@mhagroup. This column originally ran in the January issue of Physician Compensation and Recruitment, a HealthLeaders Media publication.