While not expected to reach pre-recession levels anytime soon, physician executive pay continues to rise steadily, survey finds.
Despite the healthcare industry's recent emphasis on cost containment, including executive compensation, physician leaders' pay is up 8% since 2013, according to the 10th biennial Physician Leadership Compensation Survey, released by Cejka Executive Search and the American Association for Physician Leadership.
While this overall increase still lags pre-recession two-year growth rates of 12% reported in 2007, physician leaders in technology roles such as chief information officer (CIO) or chief medical information officer (CMIO) saw their compensation jump 18% ($372,500 vs. $315,000) from 2013 to 2016.
"Physicians in these transformative roles are often tasked with 'connecting the dots' across the organization and care continuum to achieve the greater efficiency and effectiveness of care required by newer reimbursement models, including population health management and accountable care," Joyce Tucker, Cejka Executive Search executive vice president and managing principal, said in an statement accompanying the survey results.
The self-reported compensation data collected from 2,353 physician leaders also revealed the following differences in median compensation:
Emerging C-suite roles, such as physician in chief, chief strategy officer, chief transformational officer, chief innovation officer and chief integration officer: $499,000 vs. $469,000, up 6%
Chief executive officer/president: $437,500 vs. $410,000, up 7%
Chief medical officer: $388,000 vs. $365,000, up 6%
Chief quality/patient safety officer: $375,000 vs. $375,000
Additional factors that influenced physician leaders' pay included post-graduate degrees and certifications, time spent on administration, and performance-based incentives.
Finally, rebounding physician executive pay can be attributed to broader and more complex work being performed. For example, 61% of physician executives reported that they have more strategic input than the previous year, while 54% have multiple or shared administrative reporting relationships.
Of those, 49% (versus 24% in 2013) are administratively accountable to more than one person, and 29% (versus 19% in 2013) have shared direct reports.
Two weeks after CMS released the final rule, medical groups continue to sort out what this massive payment change means to them.
MACRA may not hold the same mystery it did earlier this year, now that the Centers for Medicare & Medicaid Services has released nearly 2,400 pages of details in its final rule, but practices are still clamoring for information, says Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA).
For its 2016 annual conference, held earlier this week in San Francisco, MGMA created a track of concurrent sessions titled "Under the MACRAscope." All of the sessions had been filled to fire-regulation capacity on Tuesday, when Gilberg answered a few questions. The following transcript has been edited.
HealthLeaders Media: What are you hearing from MGMA members now that the final rule has dropped? Is there a sense of relief? Anxiety?
Gilberg: The rule alleviated the immediate pressure that would have otherwise occurred if CMS finalized its proposed rule, which would have been like flipping a switch on January 1 to a whole new program.
There's a huge improvement in the final rule, at least for 2017. CMS significantly lowered the bar to avoid a penalty in 2017. All you have to do is send in one quality measure for one patient one time in 2017 and you will not get the 4% Merit-Based Payment Incentive System (MIPS) penalty in 2019.
But we're also telling members not to just do the bare minimum and forget about it, because the program will ramp up over time. We're saying that if you have the capabilities in place and are experienced with previous programs like PQRS and Meaningful Use, you can do quite well under MIPS.
But if you have no experience or you're struggling with those programs, you have an opportunity now to try some new things, look at your EHR, or take other steps to prepare for future success.
HLM: What are your members' biggest pain points—setting up infrastructure, taking risk?
Gilberg: Well, practices aren't forced to take on risk right away, but CMS will have some new advanced alternative payment models (APM) in 2018. We expect the final list of APMs to come out sometime before January 1, 2017.
In the meantime, we're getting a lot of questions about the low-volume threshold, which CMS raised to 100 Medicare patients, or $30,0000 in Medicare revenue. While many single-specialty practices, such as in pediatrics or OB-GYN, will clearly know they're exempted from the rule, it becomes a little more complicated for multispecialty practices.
The rule allows group-practice-level reporting that would mitigate the burden of reporting on every specialty individually and focus on high-impact areas, but these groups are still sorting out what may be the best way to participate.
HLM: CMS did not reduce the lag time between reporting and incentive years as many groups had hoped. Is this still an area of concern?
Gilberg: If there's any area where the rule misses the mark completely, I think it's that—the difference between the performance year and the incentive year that the fact that physicians won't receive a feedback report until August 2018 on care they delivered as early as January 1, 2017.
Our members will be quick to tell you that information is not actionable for quality improvement purposes. It's just a retrospective report card.
If CMS really wants this to be a quality program, it will have to provide real-time data that practices can use in time to intervene. The need to catch gaps in quality and cost along the way is at the root of why the industry is moving toward value based care.
But the feedback loop is so disconnected right now that most people are just trying to figure out how to comply with the rules.
As the continuum of cancer care grows, more hospitals are going the extra mile for their patients.
This article first appeared in the November 2016 issue of HealthLeaders magazine.
It doesn't matter that the care is good if the caring doesn't happen," says George Raptis, MD, acting executive director of Northwell Health Cancer Institute, which encompasses cancer services throughout 21 hospitals and approximately 500 ambulatory sites in metropolitan New York.
"We have to do more for our patients than care for them," he says. "They spend their frequent flyer miles. They spend significant time waiting to see us. They spend significant time getting treatment. And on a humane level, we need to do more than have them stare at the wall. We have to make them feel better."
While making patients feel better includes helping them manage symptoms of disease and side effects of treatment, that's not all. Northwell, like a growing number of organizations, has also embedded an array of nontraditional support services into its oncology service line, aimed to help guide patients with cancer and their families through the entire continuum of care.
"You cannot provide chemotherapy alone," says Raptis, who specializes in breast oncology.
"If a person doesn't have easy access to rehab medicine for decreased range of motion, those patients are going to walk around with arms that are stiff and painful or be on pain medicines that have side effects," he explains.
"If I don't ask if they're having financial toxicity, then they're going to be anxious and they're not going to get the care they need."
To address these needs, more hospitals are providing patients access to financial counseling, social workers, support groups, palliative care, wig banks, music therapy, art therapy, massage, reflexology, and more.
Making the business case to provide these extra services isn't always easy, but Raptis and others insist that approaching cancer care holistically helps build patient loyalty, boosts clinician resilience, and is conducive to better clinical outcomes.
"Do I want more for these patients?" Raptis asks. "Yes. Would I do much more if I had the resources? Absolutely. How am I planning on doing that? Each year I push the bar a little further, and to do that I have to show that our financial performance as a service line is good."
Success key No. 1: Rethink care teams
For Lancaster (Pennsylvania) General Health/Penn Medicine, a 631-licensed-bed nonprofit health system with a comprehensive network of care encompassing Lancaster General Hospital and Women & Babies Hospital as well as a 300-member physician practice, an enhanced focus on patient-centered supportive care began with the opening of a new cancer center in July 2013, according to Randall Oyer, MD, medical director of the oncology program at Lancaster General's Ann B. Barshinger Cancer Institute.
"We wanted to make sure that the new cancer center wasn't just a building and wasn't just the same work moved into a different location," he says. "We began to change our care model so that the new cancer center was meaningful to patients, meaningful to staff to amplify their work, and would provide the opportunity for us to work with our community to support its needs."
The organization's first step toward these goals was to build a supportive care team, which focused on providing patients with emotional, spiritual, and nutritional support.
"We made our social worker, our chaplain, and our first oncology dietitian our support care team—and that did a number of things," Oyer says. "One, it began to shine the focus on patient support beyond medical chemotherapy and radiation. Two, it began to develop a core support team. And three, it brought new thinking to the table to ask, 'What are the gaps? Who else should be part of this care team?' "
To that end, the team grew to include behavioral health professionals, physical therapists, and financial counselors.
These individuals are organized into "disease teams," working together to take care of patients with, for example, lung cancer or breast cancer, Oyer explains. "It's not a nutrition department and a radiation department, but disease teams that create the handouts and the synergy that our patients need."
It's not uncommon for patients' treatment to be undermined by transportation problems or psychosocial barriers, both of which can impact patient outcomes, says Alon Weizer, MD, ambulatory care unit medical director of the University of Michigan Comprehensive Cancer Center. The center is part of UM Hospitals and Health Centers, and patients can meet with multidisciplinary teams in one of 17 multidisciplinary and 10 specialty clinics, organized by cancer type. In 2015, the center conducted 97,147 outpatient visits, 58,419 infusion treatments, and 4,590 radiation consults.
In the days before patient navigators, counselors, and others entered the oncology scene, patients' nonmedical challenges often went unaddressed, creating frustration for patients and oncologists.
"In the past, you had the physician at the top and it was a bit like a pyramid, where the physician would handle everything or be the one to delegate responsibilities to the rest of the team. I view that pyramid as flattening at this point," Weizer says. "We have a whole team of people who bring particular expertise, and it makes the actual healthcare delivery easier because it allows every individual that participates in the healthcare team to function at their highest capability."
Now, rather than having to manage crises on the back end, the team can problem-solve proactively. "If we know up front that travel is going to be an issue, a lot of times the navigator will address that even before the patient comes to clinic," he says.
Success key No. 2: Connect with your community
Even outside of the exam room UM's patient support services are expansive, including counseling, support groups, complementary therapies, a survivorship program, and numerous other resources and amenities. As with other organizations, these programs are funded largely by donations.
"Much of this is heavily dependent on philanthropic support and so there's a lot of effort within the cancer center to maintain that generosity," Weizer says. "But at the same time, there are many people willing to donate and support these efforts because they know that patients and families derive a lot of meaning from the work."
Oyer notes that the United Auxiliary of his hospital continued its 75-year tradition of supporting community needs by participating in the cancer center's supportive care and survivorship programs, both in terms of helping to outline the model of care and provide financial support with a $1.5 million endowment.
Likewise, in addition to the funds budgeted and donated for Northwell's support programs, volunteerism and creativity go a long way, says Raptis. "It's a little bit of shared cost for everyone, but in the end we don't look at things we do in silos. Quite frankly, if you take good care of patients it is good business. It's our mission."
Success key No. 3: Play the long game for ROI
In the long run, investing time, energy, and dollars into supportive care benefits patients and caregivers, says Penelope Damaskos, director of social work at Memorial Sloan Kettering Cancer Center in New York City, a private cancer center, treating more than 400 different subtypes of cancer each year.
The center offers individual and family counseling, numerous support groups, spiritual and religious care, and art and music therapy programs.
"We work from a strength-based perspective to help patients identify the strengths not only within their own coping repertoire but also in their families and communities," she says. "And we help them activate those strengths so that it helps them move through the cancer treatment trajectory much more quickly and effectively."
It will remain to be seen, however, whether that theory holds in an increasingly risk-based environment, says Weizer, whose cancer center is participating in Medicare's Oncology Care Model, a five-year bundled-payment pilot that began on July 1.
Lancaster Cancer Center, Lancaster General Health Physicians Hematology & Medical Oncology, and Lancaster Hematology Oncology Care are also among nearly 200 nationwide participants.
"The way we've thought about complementary therapies and family support services from a bundled-payment perspective is that, yes, if we can proactively identify barriers that patients have to care, fundamentally that should reduce or diminish any delays that people have with their treatment, which ultimately should result in better outcomes," Weizer says.
And even if the extras for patients and families don't augment organizations' bottom lines now, chances are they will.
"You have to play the long game," Weizer says. "The ROI might not necessarily make sense in the short term, but I think for the way care is going to be delivered in the future, we all need to be guided by what's the right thing for the patient to have the best outcomes and for us to reduce the morbidity and, frankly, improve the value of the care."
Healthcare organizations must also be mindful of not providing patients any gift or service that may be construed as an inducement to Medicare beneficiaries. For example, Medicare regulations preclude organizations from giving beneficiaries free transportation, Oyer notes.
"While the Oncology Care Model does give us the opportunity to be more creative and requires a complement of services, we are always cognizant of, and compliant with, Medicare regulations," he says. "We view the complement of supportive services provided by Lancaster General as a cancer patient's Bill of Rights. We employ professional specialists to provide chaplaincy, financial counseling, nutrition, and social work services free of charge. These services are provided to patients who are receiving cancer care at Lancaster General in compliance with standards from the American College of Surgeons, which is the accrediting body for Lancaster General's cancer program."
Success key No. 4: Emphasize survivorship
Speaking of longevity, more people are surviving cancer than ever before, with a record 15.5 million U.S. survivors in 2016, reported by the American Cancer Society, and it predicts they'll total more than 20 million in another decade.
But remission does not mean a person's cancer journey is over.
"The posttreatment phase, we realize now, is a distinct phase of cancer treatment and can represent another sort of unexpected crisis for patients," says Sloan Kettering's Damaskos. "More and more people are living with cancer as a chronic disease, so it's widened the continuum of care."
Oncology social workers, through individual and group counseling, can help patients who've completed treatment cope with feeling "out of sync" with their peers, who are experiencing hypervigilance, or are anxious about an uncertain future, she says.
Formal survivorship programs can not only help patients navigate postcancer chapters but celebrate them as well.
Northwell, for example, gathered nearly 2,000 cancer survivors and their families at its 10th annual Don Monti Cancer Survivors Day held in June.
"It's the happiest day here for all of us," Raptis says. "And the patients love it. They feel we're doing something very special for them—and we are—but it's also special for the faculty and staff."
Staff involvement in survivorship is invaluable, says Damaskos. "They're dealing with acuity all the time. So to be able to work with people who are post-treatment, they can see the other side or another perspective and see their patients thriving in many instances," she says.
An initiative that aims to boost primary care delivery performance emphasizes efficiency and adaptability among providers.
"This isn't just a project; it's a transformation," says Sara Lander, MD, internist at Internal Medicine of St. Luke's in Chesterfield, MO, one of three sites selected by the Peterson Center on Healthcare to participate in an initiative to test a high-performance model for primary care delivery.
Launched last spring, the nonprofit Peterson Center, which describes itself as an "organization dedicated to making higher quality, more affordable healthcare a reality for all Americans," began working with three average-performing primary care practices.
In its Limited Market Test, Peterson faculty and other experts stay in close contact with the groups to help them apply a model derived from Stanford University's Clinical Excellence Research Center.
The idea is that once the test practices refine the model to suit their practice and patient needs, it will be easier and faster to replicate the model in more groups during ensuing phases of the project.
So far, the work of practice transformation has been intense but rewarding, says Lander, St. Luke's co-clinical lead for the project.
"We're doing this not just for Peterson, but we're doing this for ourselves and we're doing this for the long-term outcome," she says. "It's incredible what we've accomplished in the first six months."
The Gift of Efficiency
The model consists of 22 actionable modules based on 10 key characteristics of high-value providers, such as conscientious conservation, upshifted staff roles, and responsible in-sourcing.
Some of the most impactful changes for St. Luke's surround practice and staff efficiency. For example, a new medical assistant (MA) prep process gives MAs a larger role in filling gaps in care, thereby streamlining physicians' day and allowing them to spend more time on medical care.
To allow MAs to do more top-of-license work, the practice hired a clerical employee to handle faxes and other administrative tasks that took MAs away from patients.
Like many medical groups, the four-physician practice has struggled with physician dissatisfaction and staff turnover, says Lander.
"I think we're still in the process [of solving the problem], but using our staff efficiently and effectively makes our lives easier. We can really focus on the medical issues and taking care of the medical needs of our patients, which I think is really the joy of practice for a lot of us."
Readiness for Change
Much of the work Lander and her team are doing now, including improving efficiency, expanding patient access, and optimizing portal use is also setting the groundwork for the group to become a patient-centered medical home.
"I think it's going to put us at an advantage when we go through that transition," Lander says.
She also expresses confidence in weathering the shift to value-based care, including MACRA implementation. "We work a lot on meeting care gaps and standards of care, with focus on high blood pressure and diabetes control, for example. We have processes in place to ensure that we're capturing that and doing that care the best we can."
Evidence of Success
Predictably, the practice, which is part of St. Luke's Medical Group, is already seeing improvement in its patient and employee satisfaction scores.
But there have been qualitative wins, too, says Lander. "Our staff will tell you that there's more teamwork," she says. "People are doing less of what we used to call scut work."
What's more, the little wall at the checkout desk where staff members can post thank-yous and shout outs to coworkers is getting more crowded. "You can physically see there's this sense of teamwork and patient satisfaction that has really grown," Lander says.
Patients with serious illness don't always get the help managing symptoms that they could, but broadened awareness and skills development throughout healthcare teams can help.
Palliative care specialists are expert in providing patients and their family members with relief from the symptoms, pain, and stress of a serious illness. Despite this seemingly narrow focus, however, the goals of palliative care are best achieved when all members of the healthcare team are well-informed.
Here are three concepts about palliative care that all clinicians should understand.
1. Palliative care is not just for the dying.
The overwhelming majority of surveyed adults—about 80%—admit they don't know what palliative care means, according to R. Sean Morrison, MD, director of the Hertzberg Palliative Care Institute at the 1,171-bed Mount Sinai Hospital in New York City and director of the National Palliative Care Research Center.
"When you ask the same question of physicians, they say they know what it is, but they get it wrong because they equate it with hospice or end of life."
Palliative care encompasses much more than care provided during patients' final moments. Nonetheless, it's common for physicians to feel anxious that patients or family members may misinterpret a referral for palliative care, says Mohana Karlekar, MD, medical director of palliative care at Vanderbilt University Medical Center in Nashville, TN.
"I explain to patients and families that this specialty is focused on taking care of people who have a serious illness at any point in their life," she says.
"Some individuals are facing a brand-new diagnosis, others have been on treatment for some time, while other folks might be nearing the end of life."
Palliative care means maximizing a patient's quality of life through symptom control, or developing a plan of care consistent with a patient's values, also referred to as goals of care. Palliative care can also be considered in discharge planning for patients receiving hospice services.
2. Palliative care often occurs too late, if at all.
There is no universal, standardized screening for problems such as poorly controlled pain, repeat hospitalizations, or caregiver exhaustion that could trigger an evaluation for palliative care. Therefore, patients usually get this type of help (when it's available) later in the care trajectory than necessary.
"Right now, access to palliative care depends almost entirely on your treating physician thinking about making the referral," says Diane Meier, MD, FACP, a professor of geriatrics and palliative medicine at the School of Medicine at Mount Sinai in New York, NY.
"If your treating physician doesn't do that, you almost certainly will not access the care," says Meier, who is also director of the Center to Advance Palliative Care, which provides tools and training in palliative care.
Another barrier to palliative care is the discomfort it elicits among clinicians not trained in the field, notes Karlekar.
"We're trying to create a culture change in which everyone understands that a goals-oriented conversation is important, and that these conversations happen throughout the disease trajectory, not just at the end of life. In this manner, treatment plans should better align with an individual's goals."
3. All clinicians need core palliative care skills.
There is a shortage of palliative care services in the U.S. because of limited residency slots in this relatively new field, among other reasons.
To help address the problem, experts advocate strongly for enhanced mid-career training in core palliative care skills, such as communication and pain management, for all clinicians. Vanderbilt, for example, has created a series of courses in these skills for its nurses and midlevel providers.
Educating the current workforce is just as important for health systems as building out formal palliative care programs, according to Morrison. What's more, these skillsets can benefit anyone involved in patient care.
"If you're 35 and come in with pneumonia, you'd like to know that the team taking care of you knows how to treat breathlessness," he says.
In response to clinician feedback, CMS has outlined a more gradual payment transformation intended to evolve over years to come. Physicians and major medical groups are responding with guarded optimism.
In the months leading up to the final rule, clinicians and healthcare organizations spoke out forcefully about their concerns about MACRA. With the release of its 2,398-page final rule on Friday, Centers for Medicare & Medicaid Services (CMS) officials appear to have heard them.
The feedback CMS received through scores of written and face-to-face comments can be summed up as a plea to make clinicians' and practices' transition to its new payment system as simple and flexible as possible, Acting Administrator Andy Slavitt said during a press briefing Friday.
"Ultimately, we're not looking to transform the Medicare program in 2017," he continued. "We're looking to make a long-term program successful," Slavitt said.
A significant clarification provided during CMS's briefing on Friday is that MACRA is not a revenue-neutral program. "It has some revenue-neutral features, but it has additional elements," said Slavitt. Those items include the 0.5% positive payment adjustment across the board, a 5% bonus for advanced APMs in addition to earned quality dollars, and a total $5 million in bonuses for top performers in the MIPS program.
The only clinicians who should receive a negative adjustment in 2017 are those who are not exempt but choose not to submit any data to CMS, stated Slavitt. "We have an extensive effort [underway] to educate, inform, and reach out to physicians who may not have heard about MACRA or not heard much about MACRA to keep that to a minimum."
Nonetheless, it appears that the bonuses will come out of the penalty pool, notes Joel Brill, MD, chief medical officer for Predictive Health, LLC, in Paradise Valley, AZ. "It's a zero-sum game," he says.
"So to the degree they have made it easier for practices to escape penalties, there is less bonus money available. This means that the more sophisticated practices who would tend to do well comparatively will get less bonus money than otherwise," Brill says.
Physicians have been reacting to the final rule with a degree of optimism.
"I am pleased to see the recognition of the importance of small, independent practices and the need to design the QPP program in a way that allows them to succeed," says Yul Ejnes, MD, MACP, an internal medicine physician and chair-emeritus of the American College of Physicians' board of regents.
"However, while the final rule accommodates these practices in various ways, it will still be a challenge for many of them to participate, and for many, perhaps most, this is still a very complicated program, despite the 'simplification' of combining multiple existing programs (PQRS, VBPM, and MU) into one," he adds.
In recent weeks, CMS addressed some of the most pressing concerns of physicians, including:
Speed of Implementation
The ability for groups to "pick their pace" in which they'll comply with reporting requirements under the Merit-Based Incentive System (MIPS). Due to this change and a reduction in the number of measures to be reported, CMS expects that "most small practices can succeed" in achieving neutral or positive payment adjustments (in addition to the 0.5% positive adjustment across the board). However, potential rewards will be proportional to the degree of participation, notes Ejnes.
An increase in the low-volume threshold for 2017, to less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients. As a result, about 380,000 clinicians are exempt from the program in its first reporting year.
Broader APM Options
Additional opportunities to qualify as an advanced alternative payment model (APM) and receive its automatic 5% bonus. In particular, an ACO Track 1-Plus model will be available in 2018. As a result, CMS now expects that at least 25% of participants will be in an advanced APM by 2018, and for numbers to rise significantly from there.
MGMA and AMGA Reaction
Major medical groups shared mixed reactions to the final rule as well.
Despite added flexibility in year one, the rule does not narrow the lag time between when practices report data and receive pay adjustments, noted Halee Fischer-Wright, MD, MMM, FAAP, CMPE, president and CEO of the Medical Group Management Association (MGMA) in a prepared statement.
"MGMA is pleased with the significant burden reduction for physician practices in the first year of the MIPS program and new alternative payment model options outlined in the final rule," she stated.
"It's disappointing that flexibility provided for quality reporting in 2017 largely disappears in 2018 and beyond. [CMS] missed an opportunity to close the two-year gap between the measurement and payment periods, which would facilitate improved patient care by providing actionable feedback to physicians and more timely incentives."
The American Medical Group Association (AMGA) also qualified its praise for the rule. "Ultimately, MACRA is about moving the healthcare system toward one that is based on quality and value, a goal that AMGA shares with the Department of Health and Human Services as well as the Congress," expressed Donald W. Fisher, PhD, CAE, AMGA president and CEO, in a prepared statement.
"We remain concerned, however, that in its understandable desire to provide flexibility, particularly as the program begins, CMS does not adequately recognize or reward the providers and systems who have made the investments to improve quality and decrease costs. We believe rewarding performance should be based on the value provided, not on size of the practice."
The ranks of physicians and nurses in the C-suite are growing, but aspiring leaders must be prepared for strategic roles.
As healthcare systems strive to improve outcomes and reduce costs amid the shift toward value-based care, more senior leadership positions are being occupied by physicians, nurses, and other clinicians-turned-executives.
For more insight into clinicians' growing prevalence in the C-suite, I spoke with Linda J. Komnick, MHA, and Christine Mackey-Ross, RN, BSN, MBA, both with the Illinois-based executive search firm Witt/Kieffer.
The following transcript has been edited for length and clarity.
HLM:What are some of your general observations about this trend?
Komnick: We've seen a significant shift in executive leadership bringing a clinical voice to the table. Systems today are looking for physician leaders who understand the full continuum of care, how to optimize funds throughout the organization, managing risk. They're really seen as the catalyst to guide the transformation we're all experiencing of volume to value.
Mackey-Ross: They're real executive jobs now. If you had a chair of a department 10 years ago, for example, that person's emphasis was really programmatic on recruiting physicians, the research component, maybe the education component in a community hospital setting.
But now, physicians are really in the thick of strategic decisions. They are expected to have the same business acumen as any other member of the leadership team.
HLM:Which is more significant: Health systems seeking leaders with clinical backgrounds or are more clinicians aspiring to lead?
Mackey-Ross: I think it's both. When Linda and I started doing this, we could count probably fewer than 200 physician executives in the way that we're talking about, with real portfolios of accountability.
And my guess is that it's probably in the thousands now. I would also guess that the largest-growing population of people attaining MBAs are probably physicians.
We have also worked with a small number of physicians who went to medical school never really intending to practice in the traditional sense, but with the intent of being physician executives.
Komnick: In the past, physicians came up to these leadership roles more based on their clinical skills than their management experience.
HLM:So how important is it for aspiring leaders to get an MBA? What are the minimum requirements?
Mackey-Ross: The minimum requirements depend on the role for which you're applying. Having an MBA will not get you the job, but it may help tip the scales. If I were advising a younger physician executive I would say to absolutely get it, as he or she would have a career limit without it, especially if aspiring to be a system CEO.
Komnick: I agree. Experience is always going to outweigh a piece of paper, but if you've got both, you're on top. And the degree doesn't have to be an MBA. I'm also a big fan of the MPH.
HLM: What does the supply and demand look like?
Komnick: There are so many organizations that are looking for these people. We used to have between eight and 10 candidates for these types of positions, now I'd say we have three to five, and they're each looking at two to three opportunities.
HLM: How specifically does an MBA or MPH help prepare a clinician for executive leadership?
Mackey-Ross: Typically, quantitative skills come very easily to physicians because they are used to analyzing data. The part that is a learning experience is the qualitative piece, which is how to work through others, how to delegate, how to redefine the meaning of team, how to build consensus, and how to manage team.
Those skills are developed well in the way most MBA programs are run, which is a team learning experience.
A shift away from the "cowboy culture" of medicine is underway, but there's still work to do in preparing clinicians to behave appropriately when things go wrong.
A retired surgeon recently confessed in a newspaper column that he perjured himself to protect a colleague during a medical malpractice trial nearly two decades ago. Lars Aanning, MD, published his column last month and then provided an interview to ProPublica.
Maybe the most shocking part of his "I lied" bombshell is that it's not so hard to believe.
Doug Wojcieszak, who endured the death of a family member due to medical errors, is well-versed in how ill-prepared physicians have traditionally been when handling medical mistakes.
Wojcieszak founded Sorry Works! in 2005, on the heels of this personal medical malpractice crisis. The organization encourages clinicians to apologize to patients and families after adverse events.
"There is a better way," Wojcieszak wrote in a blog post following Aanning's confession. "It's called disclosure and apology. We're making great progress, but, let's not fool ourselves. Dr. Aanning's column is a stark reminder of the deeply embedded culture we are trying to change."
I recently spoke with Wojcieszak about this issue. The following transcript has been edited.
HLM: This incident occurred nearly 20 years ago. Why is this kind of thing still so prevalent today?
Wojcieszak: I think this type of behavior still occurs, and has occurred for so long, because for clinicians there's an information vacuum for dealing with issues post-event. They haven't been taught what to do when they make a mistake; they're scared.
They're relying on rumors and advice from colleagues who don't know better than they do.
It's like putting a little league team on a field and saying, "We're not going to practice. The kids will figure it out." It doesn't work that way for players or for doctors.
HLM: Physicians are held to such high professional standards. Are they still undermined by the culture of medicine?
Wojcieszak: It's fear of the unknown. Part of our work is to pull the boogeyman out of the closet and debunk the myths.
The idea that physicians will lose insurance coverage if they talk is untrue. Or Aanning's fear that he'd break his employment contract by talking—also untrue.
The other big myth in medicine is that if a doctor gets reported to the National Practitioner Data Bank, his or her career is over. There's a physician shortage in this country.
If I could wave my magic wand, I would have every kid going through medical school, nursing school, dental school, what have you, take a course explaining what will happen when they make a mistake. Not if—when.
The required course would go through everything: what the insurance side would look like, the attorney side, what the patient and family are going through, what the physician goes through as a second victim.
We train physicians up the wazoo on how to get it right—and thank God we do—but we train them very little on how to behave when something goes wrong.
HLM: The perjury in this case was the outer layer of a deeper lie by omission—that the doctor believed his colleague lacked competence. Where are we on addressing that issue?
Wojcieszak: We're seeing a transformation from the traditional, male-dominated, cowboy culture of medicine, in which we don't talk about people's bad behavior and we don't talk to families.
Students coming out of medical school today are just shocked, flabbergasted that there was a time in medicine where it was routine procedure that if there was a mistake, we wouldn't tell the family.
Nonetheless, many of today's healthcare leaders were raised in the old way. They're not going to change overnight. We're going to have to go through a generation or two of not only doctors and nurses changing their mindset, but also attorneys, claims professionals, and administrators.
We're making progress but there's still work to do.
As realities of gastroenterology practice shift, GIs have an opportunity to use endoscopic therapies to address root causes of conditions they already treat.
This article first appeared in the October 2016 issue of HealthLeaders magazine.
As Hippocrates is believed to have said, "All disease begins in the gut."
And although not classified as a disease by the American Medical Association until 2013, obesity can be a chronic condition for which gastroenterologists have an opportunity, if not obligation, to intervene.
"Gastrointestinal manifestations of obesity are often the first presentation outside of some of the mechanical problems with being obese. Very often, reflux and fatty liver can present even earlier than diabetes or cardiovascular disease," says Sarah E. Streett, MD, chair of the American Gastroenterological Association (AGA) Institute Practice Management and Economics Committee and clinical associate professor of medicine at Stanford University School of Medicine. Streett also oversees AGA obesity-related initiatives.
According to the National Heart, Lung, and Blood Institute, normal weight is defined as having a body mass index (BMI) between 18.5 and 24.9.
A BMI over 25 is considered overweight, while 30 marks the threshold for obesity and more than 40 is considered extremely obese.
More than one-third (37.9%) of adults in the United States age 20 and older were obese in 2014, according to the Centers for Disease Control and Prevention, while a full 70.7% were considered overweight or obese.
"These are the folks that are already in our clinics for their heartburn or their fatty liver," says Streett.
"Obesity is also a risk factor for most gastrointestinal malignancies, so we have an opportunity to step into this interdisciplinary space and partner with our primary care doctors, with our bariatric surgery colleagues, and with our endocrinologists to actually address the root cause of what's underlying a lot of our patients' digestive disorders."
Thanks to advances in endoscopic and other noninvasive therapies, gastroenterologists today have more tools in their arsenal against excess weight than ever before.
As of late 2015, two endoscopic weight-loss devices, both intragastric balloons, have approval from the U.S. Food and Drug Administration. In addition, newer options for endoscopic procedures include endoscopic sleeve gastroplasty and intragastric Botox.
The population of patients who may benefit from such non-anatomy-altering procedures is vast.
For starters, there are the scores of patients who meet clinical guidelines for bariatric surgery—generally a BMI of 30 with diabetes and 40 without—but never make it to the operating room.
The American Society for Metabolic & Bariatric Surgery reports that approximately 150,000–200,000 bariatric surgeries are performed every year, representing a mere 1% of the population eligible for weight-loss surgery.
The reasons patients choose to forgo surgery include fear of complications or death, fear of judgment, or belief that the operation won't help them lose weight, says Vivek Kumbhari, MD, assistant professor of medicine and director of bariatric endoscopy at the division of gastroenterology and hepatology at Johns Hopkins Medicine in Baltimore.
"There's an enormous disease burden that's being underserved," he says.
"Unfortunately, I have encountered patients who aren't qualified for bariatric surgery because they are underweight and were told to gain a few pounds to qualify for bariatric surgery," says Anthony A. Starpoli, MD, a solo practitioner at Greenwich Village Gastroenterology with locations in New York, and Poughkeepsie, New York, and attending physician at the 652-bed acute care Lenox Hill-Northwell Health Hospital in Manhattan, Beth Israel Medical Center, and NYU Langone Medical Center.
"How crazy is that?" he asks. "This is where I believe the gastroenterologist has almost a fiduciary responsibility to have programs in place to start addressing weight issues at an earlier stage of the disease."
In addition to treating all of the conditions traditionally handled by gastroenterologists, such as heartburn and abdominal pain, and performing colorectal-cancer screening, Starpoli offers comprehensive weight-loss services, including balloon placement, gastric bypass revision and repair, nutritional and behavioral counseling, and more.
Success key No. 1: Embrace obesity
When it comes to office-based gastroenterologists taking on obesity directly, Starpoli says he's considered an early adopter.
But to him, addressing the mechanical problems behind conditions he sees every day just makes sense. "How can you treat a reflux patient if you don't address their weight?" he says. "As GIs, we put them on the purple pill and we put them on this and that pill—and these pills don't really do everything."
From a business standpoint, it's also in GI physicians' best interest to broaden their services. "Frankly, looking out at the horizon, if you're banking your future on colorectal cancer screening, you've already lost," Starpoli says. "It's a very commonplace thing. There's no real new skill set involved, and I'm all about adopting new skill sets."
While Starpoli has taken the initiative to learn many skills around obesity management on his own, he suspects that gastroenterology fellowships may soon begin to incorporate endoscopic weight loss.
"The nature of these newer endoscopic, incisionless, surgical-like procedures warrants a hybrid training model, which includes GI endoscopic principles, and the learning of surgical principles and anatomy," he says.
The AGA, recognizing the shifting realities of gastroenterology practice, is working on helping more practicing physicians get involved now, with its first comprehensive guide for obesity and weight management.
The resource, titled POWER: Practice Guide on Obesity and Weight Management, Education and Resources, has been accepted for publication in 2016, and will also become available on the AGA website as a resource. The objective of the guide is to provide gastroenterologists with a comprehensive yet adaptable multidisciplinary process to direct innovative obesity care for safe and effective weight management for patients.
A follow-up whitepaper will address the financial aspects of the model, according to Streett. It will outline "what this might look like on a nuts-and-bolts level to a GI practice and to the GI practice's partners, whether they are hospital-based service lines that are already in place or something that the GI creates on his or her own," she says.
"The POWER program is designed to be flexible so that in different parts of the country, depending on what resources are available, if you're a gastroenterologist, you can develop the structure and tools to address patients' obesity in the context of their digestive disorders."
Success key No 2: Team up
The treatment of obesity is quintessentially multidisciplinary, so strategic relationships make sense, notes Streett.
The vision behind POWER is to guide gastroenterologists toward a model that works for them, which may involve joining or partnering with a practice already offering weight-management services or, for larger practices, building a team of their own, says Andres Acosta, MD, PhD, an assistant professor at Mayo Clinic in Rochester, Minnesota, and lead author of the POWER working group.
Regardless of how it's configured, weight management is best provided by a team, says Acosta, including an internist or primary care physician, bariatric surgeon, behavioral psychologist, dietitian, an endoscopist, and perhaps an endocrinologist.
"Gastroenterologists can join this team with endoscopic devices as their tool to contribute to the team and the practice," Acosta says, "or they can serve as the primary physician and invite, partner, or contract with other team members."
Opportunities in this space abound for hospitals as well.
"Every academic center really should have a weight-loss service line," says Kumbhari. Johns Hopkins Integrative Medicine & Digestive Center in Lutherville, Maryland, a part of the Johns Hopkins University School of Medicine, division of gastroenterology and hepatology, has been in operation since 2013.
"It's a critical part of patient care. And if you think about it, you're treating the source of multiple comorbidities. From a patient-health perspective it really makes sense to have a weight-loss center of some sort as part of a hospital."
His long-term vision for the weight-loss center is to have all services centralized in one building housing a nutritionist, behavioral psychologist, exercise physiologist, internal medicine physician, an endoscopist, and a bariatric surgeon, Kumbhari says.
"And basically a patient would come in saying, 'I want to lose weight. How could you help?' and they'd be seen by one or two providers and then make a decision to commit to some sort of weight-loss program. That's the vision Johns Hopkins is working toward."
Despite having vastly more resources than a private practice, there are challenges for hospital-based systems in managing the many moving parts of a weight-loss center.
"Different divisions have their budgets and abilities to raise revenue. And when you're thinking about a multidisciplinary program, it's a challenge to bring different divisions together who have different finance groups into one center. To divvy up the revenue generated is very challenging," Kumbhari says.
To make the finances work, hospitals must have one account that is controlled by one division (the GI division, in Johns Hopkins' case), he says, and then distribute revenue to respective parties, such as a nutritionist, endoscopist, and anesthesiologist.
"The issue with us is that usually this same division is the one that takes on the 'risk' by buying the minimum product, setting up the center, marketing, and so on."
Success key No. 3: Don't be scared off by reimbursement issues
While many payers now cover obesity screening and counseling, some weight-loss medications, and bariatric surgery for those who qualify, most middle-ground endoscopic procedures are not reimbursed.
"The main barrier to dissemination of endoscopic weight loss is the fact that insurance companies are not covering it," says Kumbhari.
"If they did, I would be doing endoscopic weight loss procedures all day, every day, because there's a significant disease burden," he says. "So as a GI community and as a weight-loss community and as public health professionals, we need to lobby together to have these endoscopic procedures covered."
In the meantime, service lines can thrive serving those willing to pay out of pocket. According to Kumbhari, such patients are usually between ages 25 and 70 and have a combined household income of about $85,000.
While $7,000 or more for a gastric balloon, band, or sleeve may sound steep, it's on par with amounts Americans already spend trying to lose weight.
"Keep in mind that when somebody joins Jenny Craig or a similar program, they spend $300 or more per month in meals—in perpetuity," Starpoli says.
Nonetheless, the AGA is committed to push for better reimbursement, but encourages providers not to be scared away from self-pay business.
Success key No. 4: Get the word out
With the need for weight-loss services so grossly underserved, competition isn't really a problem for the Johns Hopkins center, which gets much of its business from the institution's 30,000 employees alone.
To help referring physicians learn about the center's offerings, Kumbhari speaks at medical grand rounds to specialists including endocrinologists, orthopedic surgeons, and obstetrician/gynecologists. "There are many women who struggle to conceive because of weight issues," he says. "If you go to those healthcare providers, you should start to build up a service."
The Internet represents the most important means of funneling patients interested in weight loss toward a service line. But website optimization isn't enough, according to Kumbhari.
"Once they find you, I think it's important to have a capability for patients to immediately interact," he says.
"People who are interested in services such as ours are professionals sitting at home late at night looking at options. If you have a 24-hour live chat, which we're looking to implement, or a phone line that is able to respond quickly, I think you will capture those patients."
Hospital employment appears to have a neutral effect on clinical quality, but that could change if healthcare leaders partner more effectively with physicians.
Think employing physicians at your hospital will inherently boost clinical quality? Think again, suggests a study published this month in the Annals of Internal Medicine. But don't jump to the conclusion that tight physician integration harms care, either.
In fact, researchers found that switching to an employment model had no effect on hospitals' readmission rates, lengths of stay, or patient satisfaction metrics.
For the study, researchers compared quality data for 2,085 hospitals that don't employ physicians to the same metrics for 803 hospitals that converted to an integration model during the study period.
Up to two years after hospitals began employing physicians, the 30-day mortality rates for patients with acute myocardial infarction, congestive heart failure, and pneumonia stayed virtually the same—10.8% at "switching" hospitals and 10.9% at hospitals that had no employment relationships.
Given that physician employment rates continue to rise steadily—up from 29% of hospitals employing physicians in 2003 to 42% doing so in 2012—these results present hospitals with an opportunity to optimize the new normal, according to study co-author Kirstin Woody Scott, MPhil, PhD.
"The key question for all of us is, 'What do we do with this, and what can we do to leverage the tightly integrated relationships that hospitals and physicians are finding themselves in to improve quality of care?'" she told me.
Woody Scott acknowledges limitations of the study, particularly that it looked at data for hospitals that integrated only two years out. "Maybe it takes longer to see the benefit," she says. "But the notion that that's all it takes—a formal on-paper relationship—that's clearly not enough."
Indeed, a recurring comment I've heard from healthcare executives is that physician employment does not guarantee physician engagement or alignment.
"A focus on true clinical integration, as well as a renewed focus on improving the quality of patient care and clinical outcomes, will be essential," the study authors wrote.
That statement "speaks to the importance of ensuring that there is an authentic focus on creating a sense of shared partnership between physicians and hospitals," Woody Scott says, "with the shared interest not primarily driven by financial survival or provider preference but rather on how these provides can work more synergistically to improve patient care."
Moving the Needle
As a member of Harvard Medical School's class of 2019, Woody Scott says she's optimistic about the future of clinical integration. "This study has been personally motivating to recognize that we—both physicians and hospitals—must and can do better for our patients," she says.
"Though this study did not show the needle moving (yet) in the direction proponents for hospital-physician integration had hoped for, our findings do not suggest that this needle is incapable of moving in this desired direction," she says.
"Rather, it is more of an accountability check to providers that there must be ways to better leverage these working relationships such that quality can improve.
"I hope it will promote better engagement between providers, creativity, and genuine efforts to sit around the table together to work collectively toward this shared goal of improving patient care, and I am excited to personally encourage and engage with such discussions as I advance in my training."