A 61% increase in the number of Qualified Clinical Data Registries (QCDRs) will allow physicians to report more relevant data and may spur the creation of more specialty-specific quality measures going forward.
Physician specialists concerned about the lack of meaningful specialty-focused quality measures available for reporting under the Merit-Based Incentive Payment System (MIPS) may enjoy more flexibility in meeting those requirements going forward, according to analysis from Avalere Health.
To be eligible for a bonus payment under MIPS this year, physicians must report on six quality measures in three areas:
Performance against quality measures
Practice improvement activities
Implementation of meaningful use components
One reporting option is a QCDR, a tool to collect data, established by the Centers for Medicare & Medicaid Services (CMS) in 2014.
Earlier this month, CMS released Version 1 of its 2017 QCDR list, expanding the number of approved registries by 61%—from 69 to 113 total registries. Thus, physicians who report on MIPS through QCDRs will have more than 700 quality measures available for reporting in 2017. Some of the newly approved registries come from the American Psychiatric Association, the Collaborative Endocrine Surgery Quality Improvement Program, and the Society of Dermatology Physician Assistants.
Version 2 of the list, expected later this month, may contain additional approved QCDR (non-MIPS) measures for inclusion in 2017.
This expansion will not only allow clinicians to potentially report on measures more relevant to their specialties, according to analysts, but QCDRs may also be a valuable vehicle to test possible measures for specialties where measures have not yet been developed.
“In acknowledgment of the needs of specialists, CMS’ shift towards data collection through the use of QCDRs is a step in the right direction.” said Kristi Mitchell, a senior vice president at Avalere. “Moreover, the development of QCDRs will provide greater opportunities for engagement and innovative partnerships between industry, professional societies, and measure developers. That said, there will be an even greater need for CMS to harmonize all of the measures to eliminate redundancy and reduce reporting burden.”
Effective immediately, Ryan O’Connor, MBA, CAE, will assume the position of AMGA Interim President and CEO. The search for a permanent leader is underway.
Three months after the death of longtime president and CEO Donald W. Fisher, PhD, CAE, the American Medical Group Association (AMGA)’s succession planning committee has appointed a temporary leader.
Ryan O’Connor, MBA, CAE, has been with the AMGA since 1996, most recently serving as the association’s vice president of membership and marketing, responsible for the strategic direction and management of membership development, recruitment, and retention, as well as the marketing and educational programs for the organization.
Notably, O’Connor has overseen AMGA’s membership activities for more than 15 years and has posted net membership gains each year since 2000. AMGA’s membership and education department activities currently generate approximately 75% of the association’s revenues.
“I am pleased to accept the role of Interim president and CEO and to support AMGA as it continues advancing high-performance health,” O’Connor stated. “I look forward to working with the board and our dedicated and experienced team to continue to deliver on our promise of empowering the delivery of coordinated, patient-centered, high-quality, value-driven healthcare.”
O’Connor’s appointment was unanimously approved by the AMGA board of directors.
“We believe Ryan’s extensive experience with healthcare organizations positions him well for this expanded role,” said Donn Sorensen, MBA, FACMPE, chair, AMGA board of directors and executive vice president, Mercy.
“Ryan has been a key player in leading AMGA’s growth, and we’re certain his strategic skills, industry insight, and commitment to the organization will ensure AMGA remains a leader in the transformation of healthcare,” Sorensen added.
The interim appointment will continue until a new president and CEO is appointed, according to the AMGA. The search process for a permanent president and CEO is underway.
Healthcare organizations must make it easier and safer for distressed physicians to get psychiatric care, says an expert who has learned from many survivors' families that their departed loved ones had received no help at all.
"We don't know whether that's increasing or decreasing, but anecdotally it's not going away," says Michael F. Myers, MD. "I continue to get emails from colleagues or learn of doctors either in NYC or other places who have ended their lives—so our work isn't done."
Myers is a professor of clinical psychiatry and the immediate past vice-chair of education and director of training in the department of psychiatry and behavioral sciences at SUNY-Downstate Medical Center in Brooklyn, NY.
HealthLeaders:You've indicated that many physicians suffer from untreated mental illnesses. Are suicides caused by these underlying conditions, extreme work pressures, or both?
Myers: It's a combination. It's important that we understand that despite the fact that practicing medicine is very stressful, it always has been. Normally, if a doctor is feeling his or her usual level of resilience, he or she can get through quite a lot.
They will even often say, "I'm used to working hard, the threat of lawsuits, sometimes losing patients—but right now I'm a mess and I need help because I'm afraid I'm going to hurt myself."
I wish more doctors feeling like that would go for help.
HLM: To what extent does stigma keep doctors from getting help?
Myers: I found that for 10% to 15% of the families I interview, their departed loved one had not received any help at all. They had catastrophic fears they would lose their job, they would lose their medical license, their malpractice insurance, hospital privileges, and their patients.
Are these fears over the top? Yes. But there is a bit of truth in some of them having to do with medical licensure when questions are asked that are outdated, such as, "Have you ever suffered from a psychiatric illness?"
So it's one of my initiatives through this book to emphasize that when doctors do go for help, it's extremely important for those who look after doctors be very sensitive to these worries that physicians have about stigma.
It's hard enough to not feel well, but to be living with an illness that you feel ashamed of is very sad. It saddens me, too, when I learn of so many physicians who went from feeling ill to killing themselves without any intervention from a primary care doctor, internist, psychiatrist, psychologist, pastor, nobody.
And the care available works. A lot of these illnesses in psychiatry are treatable, but we need to make it easier and safer for doctors to get help.
HLM: What can healthcare leaders do to help promote physician resilience?
Myers: One is to just be knowledgeable about this subject and not be in denial. Within your physician work force, most will be fine; but like in any group, there are others who are more vulnerable.
"We wanted to see what we could do to create a more welcoming environment and get people more engaged from the get-go," says a system's integration coordinator.
Prior to 2014, the physician onboarding process at Great River Health Systems (GRHS) was fairly typical. During a standard half-day orientation, recruits would review and sign required accrediting documents and such—and begin seeing patients the same afternoon.
"We've learned that while that approach is a satisfier to the employer, we didn't think it was a satisfier to the provider to be 'thrown into the sharks,'" says Melissa Jones, integration coordinator at the 130-provider regional system in Iowa.
Why strive to improve the provider experience of onboarding? When it comes to clinician retention and the hefty cost of recruiting a new provider, the onboarding process offers a one-time opportunity to establish rapport, linking a clinician and his or her family to not just the healthcare organization but also to the community.
Consider the following tactics that have garnered GRHS great feedback so far.
1. Connect Early and Often
To make the most of an expanded onboarding process (which now involves a 2.5-day orientation for all providers, including advanced practitioners), it helps to set the stage at the point of recruitment, Jones says.
For GRHS, this means that Jones will visit with candidates during their interview process. "That way, if they do come on board and sign a contract, we've already put a face with the name and gotten to know each other a bit," she says. "It's very brief but engagement really starts at that point in the process."
It's also not unusual for candidates to sign contracts up to a year before beginning work with the system, in which case it's important for Jones and her team to keep in contact with providers and their families to foster the new relationships.
2. 'Humanize' Candidates and Their Families
A valuable element of these informal meetings is that they allow the integration team to learn about providers' likes and interests outside of work, and facilitate introductions of like-minded employees and family members.
Though Jones admits that it's sometimes tricky to draw this personal information out of some individuals, the payoff in trying is that the clinician and his or her family become more likely to find connections and activities that help head-off the spouse dissatisfaction that often causes clinicians to leave jobs.
3. Expose Newcomers to All Departments
In addition to helping newcomers find their place within a community of about 25,000 people, GRHS has discovered the power of orienting providers to the health system as a whole.
"Before, if you were going to be working in department X, we would typically only expose you to department X," Jones says.
"However, we want to do our best to keep referrals and our business within our own walls as often as possible, and we were learning that our providers for the most part were only familiar with the areas in which they were working."
To address the disconnect, new clinicians are now exposed to all of the system's departments to more deeply understand available services to which they may refer patients or have patients accessing themselves.
4. Check in and Follow Up
Finally, just as early relationship-building helps optimize onboarding and promote retention, Jones recommends following up with new clinicians within 6 months to a year of beginning practice.
"It can be as simple as taking the provider out to lunch and asking the provider, 'How's it going? What can we do to make your life better? What's working? What's not working?'" Jones says. "Just having those informal conversations helps us learn what we're doing well and develop what we can do better."
Leveraging physicians and nurses who care as much about the healthcare business as they do patients.
This article first appeared in the May 2017 issue of HealthLeaders magazine.
Healthcare leadership is evolving in a way that must merge the silos of clinical care and administration, resulting in a growing minority of C-suite positions occupied by physicians and nurses. There are numerous industry drivers of the clinician leadership trend, not the least of which includes mounting industry emphasis on value and quality. And amid various financial pressures and a need for clinicians to help facilitate change, it behooves organizations to close the gap between providers of care and executive leadership.
For some institutions, clinician executives are anything but novel. The Mayo Clinic, for example, boasts a 108-year tradition of physician leadership.
“I’m pleased to see the idea expanding,” says John Noseworthy, MD, president and CEO since 2009 of the Mayo Clinic in Rochester, Minnesota. “I suspect it means that these organizations are trying to find a way to provide more focus on the patients while keeping the tension between business and patients in balance,” he adds, noting that the Mayo model is one of dyad leadership, in which virtually every physician leader is paired with a nonclinical administrative partner.
A scientist at heart, Noseworthy aims to study any topic until he can communicate easily with the “true experts” on that topic, he says. “Once I do that, look out. I’m then the biggest champion of an empowered team, and I let that team run as fast and hard as it can go. Once the Mayo staff owns a solution, we are unstoppable,” he says.
Noseworthy came into his own leadership role by way of altering his original plans to become a neuroscientist and becoming a clinician-investigator instead. “This was plan B, and it not only suited me much better than plan A, but it helped me discover my gift for leadership, which is bringing really smart people together to accomplish what one could not do alone,” he says.
Link to quality
Many hospitals, as ranked annually by U.S. News & World Report (USNWR), are led by physicians. The publication’s 2016–17 Honor Roll was no exception, with physicians at the helm of the top five–ranking hospitals in the following order: Mayo Clinic, Cleveland Clinic, Massachusetts General Hospital, Johns Hopkins Hospital, and UCLA Medical Center.
What’s more, a 2011 study in Social Science & Medicine shows that hospital quality scores—now increasingly tied to reimbursement—are approximately 25% higher in physician-run hospitals than in manager-run hospitals.
In each of three specialty cases studied (cancer, digestive disorders, and heart and heart surgery), the mean Index of Hospital Quality score of hospitals where the CEO is a physician is greater than the mean score of the hospitals where the CEO is a professional manager. For example, the mean IHQ hospital-quality score of the cancer hospitals led by physicians is 31.63, while the mean quality score of cancer hospitals led by nonphysician managers is 23.61; for cancer, the mean of IHQ scores in the sample is 28.0.
Whether physician leadership boosts hospital performance or physician leaders are drawn to high-performing hospitals seems a circular argument, but the former explanation is plausible, says Noseworthy. “It wouldn’t surprise me at all if it’s true because of the way physicians are focused on service to the patient from the beginning of medical school. That’s not to say that administrators aren’t patient-focused, but that concern for patients is often why people become physicians and nurses.”
The paper’s authors also reached ambivalent conclusions. “The findings do not prove that doctors make more effective leaders than professional managers. Potentially, they may even reveal a form of the reverse—assortative matching—in that the top hospitals may be more likely to seek out MDs as leaders and vice versa,” writes Amanda H. Goodall, PhD. “Arguably, however, the better hospitals will have a wider pool of CEO candidates from which to choose, because of the extra status and wealth that they attract. This makes the fact established in this paper an interesting one. The study results show that hospitals positioned highest in the USNWR ranking have made judgments that differ from those hospitals lower down: On average they have chosen to hire physician-leaders as CEOs.”
Caring for the business
Despite the benefits of clinician leadership long appreciated by organizations such as Mayo Clinic, most hospitals remain run by professional managers. As of 2014, just 5% of hospitals were run by physicians, according to the American College of Physician Executives.
“There’s a lag in terms of known statistics,” says Peter Angood, MD, president and CEO of the American Association of Physician Leadership (AAPL) in Tampa, Florida. “What we do know is there’s a strong desire from hospitals and health systems to have clinicians become more involved in the C-suite and as CEOs.”
Allegheny Health Network (AHN), a Pittsburgh-based integrated health system with seven hospitals and numerous outpatient sites across Erie and western Pennsylvania, is a prime example of a system making distinct changes along these lines.
In mid-2016, AHN announced a leadership overhaul in which physicians Jeffrey Cohen, MD, and Mark Rubino, MD, MMM, were promoted to president of flagship Allegheny General Hospital in Pittsburgh and president of Forbes Hospital in Monroeville, respectively.
Later that year, Louise Urban, RN, took on expanded leadership opportunities as president and CEO of both Canonsburg and Jefferson Hospitals, overseeing operations in a large geographic region south of Pittsburgh. Around the same time, Marcee Radakovich, DNP, RN, continued her rise through AHN leadership ranks to become vice president of operations.
Claire Zangerle, MSN, MBA, RN, on the other hand, joined AHN as a newcomer to become the system’s first chief nurse executive. “We are excited about the impact she is already having in developing a global strategy for nursing at AHN, focused on recruitment and retention, and redesigning our care pathways,” says Cynthia Hundorfean, MBA, AHN president and CEO.
Throughout the system, a total of 12 physicians and nurses now hold executive roles, says Hundorfean, who joined AHN in February 2016, after an extensive tenure in administration at the Cleveland Clinic.
Hundorfean’s administrative experience at the Cleveland Clinic instilled in her an appreciation for clinician leadership, and she was clear about her intentions to replicate her former employer’s traditional governance model at the outset of her new presidency.
“The whole objective was to have the voice of the clinicians within the network at the table when we were making decisions,” she says.
On an even deeper level, she sought to incite a philosophical shift among the network’s caregivers. “I really wanted the physicians to care about the health and well-being of the organization as much as they did their patients,” she says. “At the end of the day, the patient is coming to see the clinician, not the administrators. So in order to make a quick change in a health system, you need to have the physicians on board. And when I arrived at [AHN] a year ago, I found that there weren’t enough clinicians with seats at the table.”
Meanwhile, executive recruiters report increased demand for (and upon) clinical leaders throughout the industry.
“There are so many organizations looking for these people,” says Linda Komnick, a senior partner and co-practice leader with executive search firm Witt/Kieffer’s Physician Integration and Leadership practice. “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 several opportunities,” she says.
There are a number of reasons why the candidate pool is small, Komnick adds. “The demand for physician leaders has grown as organizations are looking for individuals to oversee initiatives aimed at clinical integration, population health, and alignment and engagement of both employed and independent physicians,” she says. “In the pipeline there is a dearth of physician leaders who have the tools to take on these roles. We’re starting to see that change as younger physicians become interested in administrative roles early in their careers, but it will take years to bridge the chasm between the number of physician leaders required and those prepared to take on these roles.”
What’s more, the job descriptions have become more rigorous, says Christine Mackey-Ross, RN, a senior partner and co-practice leader at Witt/Kieffer. “Clinicians are in the thick of strategic decisions. They’re expected to not only bring a clinical voice to deciding what’s best for patients and practitioners, but they are expected to have the same business acumen as any other member of the leadership team.”
Clinician interest in pursuing an administrative track, rather than being thrust into it, is also becoming more common, Komnick says.
For Susan Distefano, RN, MSN, CEO of Children’s Memorial Hermann Hospital in Houston since 2011, executive ambitions were born out of her desire to answer what she calls ‘“somewhat naïve’” clinical questions.
“One of my guiding principles has always been to push myself to the next level of knowledge in anything I’m doing,” she says. So as a nurse, she became motivated to better understand the processes, costs, complexities, regulations, and innovations behind various approaches to care. “Once I answered the clinical and physiologic-based questions, there was always another level to dive into while working in a large infrastructure in a large system.”
In her current role, Distefano’s oversight focuses around the 310-staffed-bed tertiary and quaternary women’s and children’s facility, part of the 14-hospital Memorial Hermann health system serving Houston and the Southeast Texas community.
Her past experience at the bedside influences her leadership on a daily basis, she says. “It allows me to discern and identify which programs to really invest in and get excited about,” Distefano says.
A recent investment that made the cut, for example, was the hire of a surgeon with special expertise in reducing spasticity in children. Historically, children stricken by this condition, sometimes from birth, receive physical therapy, occupational therapy, and eventual surgery upon reaching school age, which yields only slight functional improvements, she explains.
“This surgeon trained under an expert where they take kids into surgery around two years of age, and the children are walking quite a bit and hitting some of their milestones almost effortlessly when compared to the late-surgery group,” she says. “Because I’m a clinician and I’ve seen that first group of patients and families struggle with incremental improvement, it was an easy investment in that physician.”
Thinking strictly as a businessperson, however, Distefano suspects she may not have recognized how substantially a single surgery could change lives or help her hospital make an imprint on the health of children in the community.
In the long run, the decision had two primary drivers of cost savings: A new neurosurgery intermediate care unit with specialized nurses allows many patients to receive the same level of neurosurgical care at a fraction of the cost of an ICU stay, she notes. In addition, Children’s Memorial Hermann Hospital has created a one-stop-shop called the Texas Comprehensive Spasticity Center, where patients can see their entire care team in a coordinated visit, streamlining the process for managing a child’s movement disorder while reducing the cost of care. Since it opened in 2014, the clinic has seen more than 200 patients and counting. Calculating those precise cost savings is difficult, though.
“While it’s impossible to precisely quantify the impact this decision has made on overall healthcare costs and utilizations for pediatric patients diagnosed with spasticity, the outcomes have been remarkable on improving our patients’ mobility,” Distefano says. “Some who once required a wheelchair for any mobility have not only been able to take their first steps, they are able to run around like any other child. This kind of functional independence saves tens of thousands of dollars a year in durable equipment like canes, crutches, and wheelchairs, and hundreds of thousands of dollars over a patient’s lifetime in numerous follow-up surgeries and procedures.”
A clinical background can also make one a savvier negotiator with payers, says Frank J. Cracolici, RN, MHA, president and CEO since April 2016 of St. Vincent Medical Center, part of Verity Health System in Los Angeles.
“The reimbursement structure in California is particularly complex and heavily managed care. And when you’re talking about risk, you’re talking about how best to move patients through the system in a high-quality, cost-effective manner,” he says. “Having that clinical background—knowing what types of treatments and procedures, and understanding membership demographics, comorbid conditions, and the overall complexity of patient care needs is essential in strategic negotiations. Gaining a better understanding of what one can expect during the course of an acute hospitalization really prepares a leader for having a more thorough discussion not only with physicians but with payers.”
For these reasons and more, Hundorfean, a nonclinician running a healthcare system, sits firmly in the camp favorable to clinician leaders. “If you get clinicians involved in decision-making, you’ll make better decisions, you’ll invest money in the right places, you’ll make better use of your clinicians’ time, and it will be a better experience for your patients,” she says.
Select for success
Nonetheless, neither administrative ambition nor clinical excellence alone make for a successful clinician leader.
“Sometimes, unfortunately, it’s a bit of trial and error,” says Hundorfean. “But you have to be very good at selecting leaders who you think have the personalities, as well as the qualifications, to be able to lead efforts that are beyond their basic skill set.” Tasks such as making budget cuts, for example, can be difficult for physicians unaccustomed to making those type of decisions, she says.
AHN’s newly created leadership development program can offer individuals a chance to experience the realities of administrative roles in advance. “Our program seeks to provide clinicians with the opportunity to be an executive apprentice of sorts to make sure the role matches their expectations and capabilities.”
There is an art and science to selecting for success. “Every doctor is intelligent,” says Lynn Massingale, MD, cofounder and chairman of Knoxville-based TeamHealth, which offers outsourced clinical care across a variety of specialties to approximately 3,400 acute and postacute facilities and physician groups nationwide. “At the same time, they don’t all have the right personalities or interpersonal skills for leadership.”
At TeamHealth, clinicians identified for leadership positions undergo evaluations—such as DiSC profiling, a personality and behavior assessment tool—that help illuminate traits of one’s personality style.
“We actually use some tools for testing prospective physician and business leaders, but we look for high emotional IQ, empathy, ability to build consensus, etc., as starting points,” says Massingale. “Then we take those prospective physician leaders and help them understand what their strengths and weaknesses are, show them the areas they need to work on to be better leaders, and over a number of courses, augment their skills in conflict resolution and communication, to fill in the gaps.”
In other words, a candidate’s tendency toward analysis or emotion, for example, isn’t nearly as linked to success as his or her willingness to be self-aware, reflective, and coachable.
“To be a strong physician leader, you need to be a good physician. I also look for people with warmth and energy,” adds Hundorfean. “But most of all, I look for leaders who are direct. I like people who say what they mean, and don’t waste time. When you’re dealing with patients, physicians have to be direct with them, and I want our physician leaders to do the same when they are talking to me, or to employees.”
Engagement and alignment
With the right pieces in place, clinician leaders appear to be a tremendous organizational asset. “We are extremely pleased with the leadership team we have assembled at Allegheny Health,” says Hundorfean.
For instance, AHN’s new clinical access medical director, Elie Aoun, MD, has in a short time helped redesign the system’s call center infrastructure and processes to make same-day appointments a reality for primary care and specialty care, Hundorfean says. “It’s a huge lift for our organization from a technological and operational standpoint and in terms of
collaborating with our many clinicians to make it possible.”
Since activating same-day appointments for specialty care in January 2017, AHN has seen a great response from patients, she says, adding that thousands of patients have called and scheduled same-day appointments.
“The provider perspective plays a vital role because Dr. Aoun, as a physician, understands the operational hurdles that specialty clinicians and practices might have in adopting a new scheduling system. Different clinical areas might have different issues, but Dr. Aoun took time to synthesize those unique issues, and he knows how important workflow, scheduling, and capacity are to an individual practice—perhaps more so than a leader who had never worked in a clinical setting,” Hundorfean notes. “Having him act as a liaison between our administrative leadership and our doctors was key to getting our caregivers on board, and instrumental in getting same-day appointments up and running as quickly as we did.”
Meanwhile, one of Rubino’s personal goals in leading Forbes Hospital is to drive patient-centered care at an organizational level, through robust engagement of physicians, nurses, and support staff.
“If we’re going to move the organization forward, it comes down to the engagement of frontline staff,” Rubino says. “It can get a little overwhelming in regard to the amount of tasks that are necessary to perform this job, but I get very uncomfortable if part of my day isn’t spent walking those floors, interacting with the nurses, doctors, and other caregivers. I learn more from that than I do almost anything else.”
Making himself visible and accessible also helps foster a culture of mutual respect, Rubino notes, which he views as essential to engagement—and engagement as critical to managing change.
“As a physician leader, I am in the best possible position to understand the issues or challenges the clinical staff may face when trying to deal with the problems at hand,” he says. “Speaking directly with the staff or witnessing the issue firsthand with my senior team provides the information to best determine a root cause and problem solve. This behavior, based on mutual respect, has a direct impact on our culture and generates engagement.”
The advantages of advanced degrees
However, physicians and nurses traditionally do not receive business or management skills as part of their training. While offerings for master’s degrees in health administration (MHA), medical management (MMM), and business administration (MBA) have become more abundant and are sometimes combined with clinical programs, formal advanced business education isn’t necessarily essential.
The most important qualification, according to executive recruiters and current physician leaders, is experience related to the role for which an individual is applying. “Having an MBA will not get you the job, but it may tip the scales one way or the other,” says Mackey-Ross.
“If I were advising a young aspiring physician executive, I would say absolutely get an MBA, MMM, or MHA,” she adds. “You’ve got a career limit without it, especially if you aspire to being a system CEO.”
Advanced degrees and certifications can also influence physician leader compensation, which rose to a median of $350,000 in 2016, according to a survey published by Cejka Executive Search and the AAPL. As compared to physician leaders with no postgraduate degrees, an MBA earned respondents, on average, 13% more, and a certified physician executive (CPE), a credential offered by the AAPL, on average, earned 4% more, researchers found.
For Vivian Lee, MD, PhD, MBA, CEO of University of Utah Health in Salt Lake City and Dean of the University of Utah since 2011, going to business school in 2005 proved pivotal to her leadership success.
“For me, the MBA was an incredible opportunity to get that training after I had already been doing some administrative work and had increasing responsibility,” she says. “It was just so rewarding to be able to spend time with not only business school faculty but also my classmates who came from many other industries.”
Studying principles of the banking industry, for example, particularly about avoiding long queues, helped Lee get one of the system’s chronically behind-schedule clinics back on track.
For example, in the design of a branch bank, the modeling that simulates numbers of customers and their service needs can be used to design the bank—number of tellers, number of parking spaces, and the like, she explains. Similar software tools are useful in healthcare to model outpatient clinics, she says.
“Additionally, we learned lessons from industry by taking groups of staff to stores like Apple and In-N-Out Burger to study customer satisfaction and customer-centered retail business,” Lee says. Those visits informed the organization’s “exceptional patient experience” initiatives, she adds.
“Many other industries have tackled the problems we’re facing in healthcare,” she notes. In addition to insights gained for managing day-to-day operations, Lee says her MBA courses better prepared her for implementing Lean management, understanding financial incentives, and more.
Likewise, Rubino and Cracolici express similar appreciation for their business coursework.
“Looking back to being offered the CEO position, the foremost thing I wanted was to make sure I had the competence to fulfill those responsibilities, and I think the combination of experience with medical staff leadership, getting my master’s [in medical management], and serving as CMO gave me the confidence and skills to assume those responsibilities,” Rubino says.
Cracolici also took on increasingly challenging administrative roles after beginning his career as a critical care nurse, and received his MHA while working as a chief nursing officer for a small community hospital. He then went on to hold titles including vice president of nursing and chief operating officer at various organizations before becoming CEO of St. Vincent Medical Center, home to 366 licensed beds and several specialty clinics.
The business skills he had to learn along the way largely surrounded healthcare economics and the nuances of running a hospital, he says. “A lot of our education was centered around how to understand the mechanics of the financial and operational issues, in addition to leadership skills.”
Cracolici is also a Johnson & Johnson Fellow at the Wharton School of Business. “The one-month immersion fellowship training was invaluable in further developing my understanding of complex organizational dynamics and the strengthening of problem-resolution skills.”
A 2016 survey by AONE also found that nurse leaders as a whole (not limited to the C-suite) who hold master’s degrees have higher earning potential. According to the survey, half of responding nurse leaders’ salaries fall between $90,000 and $149,999, while 61% of nurse leaders who have a master’s degree earn between $100,000 and $179,999 per year.
Still, it’s possible for clinician leaders to learn business skills on the job, as did Massingale and Noseworthy.
“I really wish I’d gotten an MBA early,” says Massingale. “I never did, but [TeamHealth] would have been farther down the road sooner if I did. Just learning business vernacular, understanding income statements, and having formal business skills earlier, versus learning by reading and on-the-job training, would have facilitated our growth,” he says.
Noseworthy agrees that advanced degrees can be helpful but are not a must for clinician leaders, especially with a dyad model. Mayo, like a growing number of other large organizations, provides in-house leadership curriculum.
“We have a very rich toolbox of leadership development, for physicians and administrators, from onboarding, self-assessment, mentoring, to tailored programs, such as a Leadership Challenge for administrators, a six-month action-learning program attended in collaboration with the physician/scientist partner, Noseworthy says. “It is designed to strengthen leadership skills and deliver a project. Administrators can also attend a multi-rater assessment that provides feedback to you as a leader. It is aligned with the Mayo Leadership Capabilities Model.”
A program tailored to physicians and scientists becoming chairs of departments is Mayo’s Physician Leadership Business Academy, a key development experience at Mayo Clinic, designed to elevate physician leaders’ business, finance, and strategic acumen, strengthening the important and unique physician leader and administrator dyad. “The attendees can expect a powerful cohort and action learning-based program, in which department/division chairs and high potential leaders will be able to apply content learned in real-time Mayo Clinic business challenges, Noseworthy says.
Drawing from her similar experience at the Cleveland Clinic, one of Hundorfean’s first goals upon joining AHN was to launch a leadership development program of their own. Its purpose is twofold, she explains. While institutional leaders identify top clinical talent to participate in the program and create a pipeline of future leaders, it also gives prospective leaders a chance to determine whether they’d enjoy an administrative role.
“We are still building the leadership development program, but conceptually it will have a number of programs targeting different physicians based on experience levels,” she says. “Our physician leadership academy programs will pair classroom learning with exposure to various roles and experiences within the healthcare setting.”
The power of pairs
A less-universally adopted element of the Mayo leadership model, despite Noseworthy’s routine advice to industry colleagues, is the concept of paired leadership.
The keys to a successful dyad partnership are trust, respect, and complementary skill sets, he says. When these elements are present, physicians and administrators can share open and honest feedback with one another, which Noseworthy considers essential.
And Noseworthy has no lack of praise for his own administrative partner, Jeff Bolton, Mayo’s vice president of administration and chief administrative officer. “He comes from a background as a CFO, and prior to that he was in the social sciences. So he has a very deep understanding of humanity,” Noseworthy says. “He’s a caring, concerned humanist and a fabulous partner.”
As part of their working relationship, Noseworthy and Bolton spend half of every workday together, speak daily, and run meetings together. “But we do see things differently,” he notes. “A business-minded administrator is going to see a problem with a slightly different lens than a physician scientist.”
Those complementary points of view are part of what make the dyad work, Noseworthy says. And should the partners reach an impasse, the culture of Mayo is one of consensus building. “That doesn’t mean decisions are unanimous, but we do err on the side of getting more input rather than less,” he says, referring to the committee structure of the organization.
“I’m very fortunate that I have a really good partner to help me,” Noseworthy says, “especially when I don’t know what to do or I have a bad idea.”
In a way, Hundorfean’s appointment of clinician leaders at AHN hospitals achieves a similar objective. “When I joined the organization, I recognized early on that to be a truly clinician-led, patient-centered health system, we needed more clinically trained executive leaders in place across the network to help guide our strategy and mission. As a healthcare executive, I have found that having the insights of experienced clinicians in the C-suite is essential to ensuring that decisions are always made with the best interests of the patient in mind.”
For example, Aoun was appointed to his new position in June 2016, and AHN got same-day appointments fully up and running in six months. Same-day appointments for PCPs were in place by October, and the specialty side was ready to go by January.
“It took a big team rowing in the same direction to accomplish that—but certainly, his leadership was one of the reasons we were able to move as quickly as we did. It’s an incredible accomplishment for that team, and for Dr. Aoun,” Hundorfean says.
“We’re also moving faster in the area of patient experience,” she adds. “With Dr. Patrick DeMeo leading that process, leadership has greater credibility among the physicians to make the changes we need to make. It’s easier for doctors to talk to other doctors.”
‘Barriers and baggage’
But while some administrative and physician partners can be seen finishing each other’s sentences, not all organizations that try the dyad model experience the same level of success, says Angood.
He says that the best partners actively work to complement each other’s capabilities. “When they work nicely as a team, that tends to permeate down into the rest of the leadership and certainly down into the management,” Angood says.
The dyads that are less effective are characterized by partners who take more of a divide-and-conquer approach, he says. “Sometimes the nonphysician executive will say, ‘I know the administrative side and how to run an enterprise, so I’ll do that,’ and the physician half of the dyad will say, ‘I’m the expert in patient care, so I’ll look after that.’ That’s not an integrated dyad, and some organizations are falling into that trap.”
Individual clinicians can also be plagued by a host of “barriers and baggage” that can thwart their effectiveness, according to Massingale, whose company oversees more than 19,000 physicians. Qualities that can create challenges include resistance to change and a preference for autonomy over teamwork.
“Doctors are also used to being pretty autocratic,” he adds. “We write an order, and we expect someone to take that order off the chart and do it, whereas there’s a lot more consensus building in leadership roles.”
In addition, a widespread dilemma physician and nurse leaders face is forgoing some degree of one-on-one patient care to make time for administrative activities.
The right bedside-to-boardroom ratio varies by organizational policy and clinician preferences. Clinical leaders at AHN, for example, are almost all required to maintain some clinical practice, Hundorfean says.
Rubino says he has gradually reduced his clinical load over the years as his career encompassed greater and greater administrative responsibilities. As president of AHN’s 315-staffed-bed Forbes Hospital, he spends about 20% of his time seeing established patients of his 30-year-old OB-GYN practice and 80% on administrative responsibilities.
“I feel my level of clinical activity allows me to continue performing at the highest level. I impose a high standard on myself and would cease to operate or maintain clinical responsibilities if I or others witness anything less,” he says.
Moreover, the close relationship Rubino shares with his patients makes them comfortable sharing both good feedback and bad, he says. “They do not hesitate to tell me about their experiences at the hospital or their interactions with our caregivers.”
In addition, “I still operate, which I think gives me a certain level of credibility among my fellow caregivers because whatever clinical issues they’re facing, I’m facing as well,” Rubino says.
The Mayo Clinic espouses a similar philosophy, Noseworthy notes, which helps ensure clinical leaders are “walking the walk.”
Some leaders, on the other hand, eventually arrive at a difficult crossroads where they must choose one path, says Cracolici. “A very wise mentor of mine once warned, ‘You’re going to reach a point where you can’t work as a staff nurse on weekends and then work all week as an executive. To avoid burning out, you’re going to have to decide which one you’re going to give 150%.’ It was a challenging decision I think a lot of individuals face.”
Distefano no longer works as a nurse while serving as a hospital CEO, but has made peace with the transition. “You kind of move from being a steward or focusing on one patient or a small group of patients to affecting a larger group,” she says. “It’s admittedly a different approach. I’m not physically laying hands on patients, but I feel like I’m still improving patient care because I’m working on policy and decisions that have a broader impact. I still feel like I’m close to the patients.”
A problem that could occur as clinicians’ ranks grow on executive teams is resistance from other members of the C-suite, including the CEO, says Angood. “There might be a sense of distrust, jealousy, or loss of territory and influence,” he says. “That needs to be addressed up front and people need to be aware of it. It’s all about interpersonal relationships.”
When it comes to wider industry opinion regarding clinicians in the C-suite, Massingale has encountered examples of both extremes, from traditional leaders who don’t trust a physician’s ability to read a P&L statement to physicians and nurses who believe nonclinicians aren’t equipped to make decisions affecting patient care.
Looking at executive turnover as evidence isn’t necessarily fair, he notes, considering that the average tenure for any hospital CEO is about three and a half years. “If a physician happened to get a CEO job and is out in 3 or 4 years, as far as I’m concerned, that’s just one more average statistic and not an indictment against the clinician leader.”
For the record, Massingale holds the moderate opinion that either a “lay” leader or clinician can run a healthcare organization successfully, provided he or she has the right preparation and mindset.
Rubino, for instance, acknowledges that the 24/7 demands of running a hospital were a lot to take on at this stage in his life and career. “I’m 30 years in. I’m a grandfather,” he says. “My wife looked at me and said, ‘Really? At this point you want this additional level of responsibility?’ But I see it as an honor and privilege that I’ve been given the opportunity as a physician to serve in one of the highest levels of the organization and to have my concerns, thoughts, and values appreciated when we’re in this transformation. It meant so much to me to have that opportunity, which is why I embraced it.”
AMGA presenters shared advice on finding the right candidates for palliative care, at the right time, for the right reasons.
In a value-based environment, palliative care programs can translate to substantial savings. A recent study published in the Journal of Palliative Medicine calculated the savings derived from a home-based palliative care program (HBPC) at $12,000 per patient during the final three months of life compared to patients receiving usual care.
But when it comes to marketing this extra layer of support to patients or referring physicians, it's important not to overemphasize the financial benefits, says Dana Lustbader, MD, chair of the department of palliative care for ProHEALTH in New York.
"We have a branding problem with the word palliative," she said. "Most of the public doesn't know what advanced illness is, either. They do have an understanding of what it means to be seriously ill or have a serious illness, and they like having an extra layer of support."
For that reason, palliative care providers typically explain to patients that they provide supportive care, and rarely if ever use the term palliative care. "Most of the patients we serve just know that their nurse Mary or social worker Lisa are fantastic," Lustbader said.
She continued: "We do show a lot of cost savings with palliative care, which can help ACOs and physician groups think about building and paying for a palliative care program. But that's not the driver of why we do this. It's just the right thing to do; and it just so happens that better care costs less money."
And that better care is evidenced by quality metrics such as patients spending more time at home, experiencing less pain and fewer symptoms, and being much less likely to die in the hospital.
In fact, Lustbader and colleagues found that most of the cost savings were derived from a 34% reduction in hospital admissions in the final month of life for patients enrolled in the HBPC. What's more, 87% of ProHEALTH palliative care enrollees who died did so at home, compared with New York's average death-at-home rate of 25%.
Find the Right Patients
The most critical factor in successfully achieving quality and financial goals, however, is in identifying the most appropriate patients for the service, conference presenters agreed.
Finding patients at the top-quartile of risk for mortality, frailty, comorbid conditions, and functional limitations is best done using a combination of algorithms and patient-screening tools to identify addressable gaps in care, said Mitchell Mudra, MBA, chief operating officer at Optum.
"You can have the best palliative care program in the world, but if you're finding patients who aren't appropriate for the intervention, you're going to be wasting intensive resources," Mudra added.
Anti-clotting therapies in patients at high risk for stroke are grossly underused. A researcher speculates that physician misconceptions and poor patient education about medication to reduce the risk of atrial fibrillation underlie the problem.
"It's really a sad story," says Ying Xian, MD, PhD, of the Duke University Medical Center in Durham, NC, about research he and colleagues recently published in The JAMA Network Journals.
Their somber discovery: Out of 94,474 patients who had an acute ischemic stroke and known history of atrial fibrillation, 84% were not receiving evidence-recommended therapeutic anticoagulation therapy that could have prevented or mitigated the severity of the event.
Xian spoke with HealthLeaders about possible explanations for the two-thirds (65.8%) of patients whose records showed no documented reason to forego the therapy. The following transcript has been lightly edited.
HealthLeaders: Why do you suppose so many at-risk patients did not receive the recommended treatment?
Xian: First, two caveats. One is that I can't give you definite answers because our study design did not collect patients' reasons for not taking these medications prior to stroke. Second, lack of documented reasons precluding anti-clotting therapy doesn't necessarily mean they didn't exist.
But I can provide speculation. On the patient side, they may not appreciate the benefit of getting treated with oral anticoagulation because a stroke hasn't happened to them yet. They might not truly realize their risk of having a stroke, but they hear their physicians talking about the risks, such as bleeding.
Warfarin and some similar medications have a bit of a bad reputation for being hard to use. They require patients to get their blood checked every few weeks, which is not easy. There's also the difficulty that these medications can interact with certain foods and other medications.
HealthLeaders: What are the factors on the physician side?
Xian: There is still some concern within medical societies that patients may not benefit from treatment. Meanwhile, misconceptions persist that Warfarin is too risky to give or that baby aspirin is a sufficient therapy that carries lower risk of bleeding, but this isn't true.
Mounting research demonstrates that aspirin is not as effective as Warfarin or a NOAC.
HealthLeaders: Is drug cost a potential problem here?
Xian: Warfarin has been used for more than 50 years, so the cost of the medication is not bad. However, we do have to consider the cost and burden to patients of having their blood tested every few weeks.
On the other hand, NOACs are newer and in general they are quite expensive. So they can represent a substantial cost to a patient without medical insurance or carrying a high copay or deductible.
HealthLeaders: What can physicians do to improve treatment rates?
Xian: Patient education is very important. It so happens that this study was founded by the Patient-Centered Outcomes Research Institute. When we were talking with our patient investigators, they consistently brought up the concern that patients diagnosed with AF did not receive enough information from their physicians.
It takes more than five to ten minutes to fully explain the risks and benefits of using oral anticoagulation with AF.
Practices that have incorporated concierge or direct-pay models find measurable benefits, including maintaining their independence.
Desiring better work-life balance, lower administrative burden, and more time with patients, 34% of medical groups are thinking about adding a new payment method within the next three years, according to a new survey from cloud-based technology company Kareo, conducted in partnership with the American Association of Private Physicians.
The options considered include concierge medicine, direct primary care, or another membership model, the survey found.
The findings are based on responses from 766 clinicians, practice managers, and practice owners surveyed during the second half of 2016.
Of these, 26% were in practices described as private (concierge medicine or direct-pay membership) versus 74% in conventional (fee-for-service) practices.
The survey reveals differences in practice life between the two groups:
Providers in conventional FFS practices spend 30 minutes or less with each patient, while most (79%) physicians using membership models spend 30-60 minutes on each patient visit.
Sixty percent of FFS providers have more than 1,000 patients, while almost all physicians employing membership models have panels of fewer than 1,000.
Conventional FFS physicians spend 11.25 hours per week on administrative work, versus 10.5 hours for concierge or direct-pay physicians. Overall, FFS physicians work about six hours more per week than their concierge/direct-pay counterparts.
While 30% of these practices have all of their patients enrolled in a membership program, 33% have 25% or less of their panel enrolled, and the rest fall somewhere in between.
Meanwhile, among those using some type of membership model, 57% participate in Medicare, 54% participate in health plans in network, and 58% are out-of-network with health plans.
The top challenge cited by FFS practices, at 35%, is financial viability, whereas 38% of the private groups see recruiting new patients as their biggest difficulty.
"The Practice Models Perspectives survey shows that many physicians working in solo and small practices are interested in testing alternate models to remain independent," the authors said.
"More importantly, those changes don't have to be complete. Providers can mix and match models to find the right balance and still experience some of the benefits of moving away from a fully fee-for-service practice."
AMGA accomplishments highlighted at annual conference underscore significance of its leader's legacy.
A celebratory annual conference ended on a sad note for the American Medical Group Association (AMGA), with the passing of Donald W. Fisher, PhD, CAE, AMGA's president and chief executive officer, on March 26, 2017.
"Don leaves a professional and personal legacy that is not bound by time or physical space," said Donn Sorensen, chair of the AMGA Board of Directors and president, east region, Mercy, in an announcement.
"His dedication to advancing the best possible patient care, to leading with integrity, and to building a great place to work, not forgetting to have a little fun while accomplishing much, have made a permanent mark on the hearts of all who knew him. We will miss him greatly."
Prior to becoming the CEO of AMGA in 1980, Fisher served as the first Executive Director (1973-1980) of the American Academy of Physician Assistants in Alexandria, Virginia. Throughout his career, he received numerous honors for his work on behalf of the healthcare professions through his activities within and beyond the AMGA.
One day prior to Fisher's death from cancer at age 71, Sorensen reflected on the AMGA's accomplishments during the final keynote of the AMGA 2017 Annual Conference held in Grapevine, Texas.
"We are celebrating our 16th year in a row of continuous growth," Sorensen told attendees. "We have 175,000 physicians taking care of 120 million Americans. That's one in three Americans being taken care of by our members. That's pretty awesome."
There were 8,000 physicians practicing in the AMGA's member organizations in 1980 when Fisher became CEO.
More granularly, Sorensen noted that nearly half of its member physicians currently participate in one of the AMGA's nine quality programs.
"So as of today, just under 100,000 AMGA physicians through these programs are positively impacting about 27 million patient lives—curing disease, prolonging life, making a high quality of life for almost 30 million Americans."
AAMC urges Congress to approve a modest increase in federal support for new doctors.
The United States is facing a projected shortage of between 40,800 to 104,900 physicians by 2030, according to a report by the Association of American Medical Colleges (AAMC).
The estimated shortfall is more severe among non-primary care specialties (33,500–61,800), than primary care physicians (7,300–43,100). Among surgical specialists in particular, current trends indicate the number of newly trained surgeons is almost equal to projected future attrition, resulting in little-to-no rise in supply.
Considering that the U.S. population of senior citizens will grow by 55% during the same timeframe, the predictions are especially troubling, stated Darrell G. Kirch, MD, AAMC president and CEO.
"As patients get older, they need two to three times as many services, mostly in specialty care, which is where the shortages are particularly severe," he said.
Healthcare Goals Boost Demand
The report modeled hypothetical scenarios in which key goals for the nation's healthcare system were met by 2030. These calculations are not included in the ranges of projections cited above.
Success in leading population health initiatives, such as weight control and smoking cessation, would decrease physician demand in the short term by 1%-2%.
But by 2030, the positive effects would reverse the trend. The need for physicians would grow by about 15,500 FTEs because the need to support an additional 6.3 million living adults more than offsets the reduced demand associated with a healthier population, the authors found.