This article appears in the January 2012 issue of HealthLeaders magazine.
In Southern California, the 223-bed Saint John's Health Center overlaps competitive space with hospitals more than twice its size. The hospital system decided there was one way to improve its competitive edge: improve its outpatient services.
The Santa Monica hospital in 2011 built a new ambulatory surgery center, ensured that its patients had easy access, and delivered flexible scheduling options. At the same time, it recruited physicians, some from the local competition, which included the 958-bed Cedars-Sinai Medical Center in Beverly Hills and the 520-bed Ronald Reagan UCLA Medical Center in Los Angeles, 13 miles away.
"Surgery centers will be on the radar more and more because of our efficiencies," says Kevin Streeter, director of Saint John's ASC. "When I hear people say there are too many surgery centers, I have to chuckle. There's always room for growth. It's a business, and it will keep moving."
Indeed, the drive to outpatient care has many hospital system leaders with their feet on the accelerators. These systems are developing more ambulatory surgery and imaging outpatient programs. "This has been the evolving trend; there are just a lot more modalities that can be provided in an outpatient setting," says LaVone Arthur, vice president of business development for the more than 1,000-licensed-bed Baylor Health Care System in Dallas.
Still, some leaders are considering evolving economic trends and the local demographics, and insisting that they may need to step back and consolidate their outpatient programs for cost savings. Even the most ardent proponents of outpatient care say its pace may slow down, depending on a local community's need for integrated care and the specific demand for multidisciplinary approaches.
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Steve Geidt, CEO of the 313-bed Saddleback Memorial Medical Center in San Clemente, CA, which is an 80-minute freeway drive from Saint John's, says the hospital is developing new imaging outpatient programs to meet the competition and improve patient access. "We're going to push everything we can to freestanding because they have a lower unit price," says Geidt, whose hospital system, MemorialCare Health System, purchased an imaging center from a physician group in 2010 to increase imaging capability for its patients, and increase its patient traffic in heavily competitive Orange County. Saddleback also has a location in Laguna Hills in Orange County.
But Geidt is not without some trepidation. As he looks ahead for outpatient centers, he asks, "Where do all the components fit in? That's our challenge. There's a lot of movement in the marketplace, a lot of the freestanding centers are looking and saying, 'This is a good time for a sale or a merger.' But the business model won't sustain a whole lot of freestanding centers. Ultimately, we are going to have a great deal more consolidation."
"Like most systems, we evaluate where the right place is to put the service," Edward Karlovich, CFO of the hospital and community services division for UPMC, says of outpatient planning. "You have to balance that with the economic realities of the world we all live in. You will see situations where we have created outpatient imaging facilities or surgery centers tied to our hospitals. And then, in other geographic areas, we have not done the same thing. Anybody who's looking at this as one broad strategy to apply will find it very difficult."
Those demographic forces are certainly different for each locale. While Saddlebrook is tentatively moving forward with some plans, Saint John's believes it had no choice but to jump into the outpatient arena in a competitive market.
In addition to the lower cost of providing services associated with outpatient facilities, they also can provide convenient access for patients. Traffic and parking were among the factors that Saint John's considered for its multispecialty, outpatient surgery center, which was designed for easy access for patients for same-day surgery with various specialties such as ophthalmology, podiatry, general surgery, and gynecology.
"The inevitable march of medicine means migrating toward outpatient as we get better at what we are doing now," says Howard Davis, MD, chief medical officer for Saint John's. He acknowledges that the pace of growth may slow down in some outpatient procedures, but he adds, "The health system has to be more than a hospital and look beyond its four walls."
Indeed, outpatient care is a dominant part of the healthcare landscape, the result, in part, of Medicare payment "differentials" that favor hospital-based programs, as opposed to physician-owned freestanding centers, according to the Medicare Payment Advisory Commission report to Congress on Medicare payment policies, issued in March 2011. Under Medicare's calculations, "the combined fees for visits of hospital-based practices are often more than 50% more than rates paid to freestanding practices," MedPAC states. Physician-run freestanding centers "may reorganize as hospital outpatient centers in part to recover higher reimbursements."
MedPAC reports continued growth of outpatient centers owned by hospitals. From 2004 to 2009, the volume of Medicare outpatient services for fee-for-service beneficiaries increased 23%. In 2009, patient visits to higher-paid outpatient-based practices owned by hospitals grew by 9%, while visits to lower-paid freestanding centers owned by physicians grew by less than 1%.
Saint John's outpatient plans certainly reflect the nationwide outpatient growth pattern. Mark Payares, PT, DPT CSCS, a physical therapist and program manager, was hired in 2011 to initiate an outpatient physical therapy and wellness program, which had been dormant at the hospital since 2000. The hospital leadership believed it needed to make a significant effort in that area to compete, and the wellness center will be on the hospital campus, Payares says.
"We have been without an outpatient therapy department since the earthquake in the early 2000s," he says. "The hospital shut it down. The only physical services until earlier this year was inpatient. Outpatient therapy can be profitable. It adds to the continuity of care, especially for areas like total joint or chronic pain."
Payares says he is constantly aware of the competition: He lives near the orthopedic center in Santa Monica.
Failure and success
When the JPS Health Network bought a new 30-bed inpatient hospital in Arlington, TX, in 2005, health system officials believed the boutique facility would meet the community's needs for years to come.
The idea of the JPS Diagnostic and Surgery Hospital in Arlington was to attract more insured patients to the hospital, which had focused on low-income patients. Within a few years, it was clear that plan was not working. The hospital administration didn't need a calculator to pinpoint its fiscal problem: The average daily census for the facility's 30 inpatient beds stood at one.
"For the patients we sought to serve in that area, there was not much of an inpatient need," says Chris Dougherty, senior vice president for community health for JPS Health Network, which includes 537-licensed-bed John Peter Smith Hospital in Fort Worth, TX, and dozens of outpatient sites in the county.
"Not only did we have one patient in the daily census, but we also tried to keep an emergency department staffed with physicians, and the price was high," Dougherty says. "We decided we would be much better served and it would be much less expensive for us if we converted it to an ambulatory surgical center. In the 1980s and 1990s, these boutique hospitals worked for some and still work for some. But it wasn't a good match for us. It was really an outpatient center that was needed here."
In an unusual move, as far as Texas health officials saw it, JPS asked in 2010 to downgrade its facility from a general hospital to an outpatient facility. "They didn't see it before," Dougherty says. "But there will be more to come, I'm sure." Making the change to outpatient saved the hospital about $1.6 million each year, according to Dougherty. "For a tax-assisted hospital system, that was vitally important."
JPS Health Network is aligning some of its outpatient programs with primary care practices "because we want to start transforming our care to patient-centered medical homes as building blocks for ACOs," says Dougherty. "We have several primary care sites right now, four of them within Arlington. We are going to consolidate them into one site and combine that with an outpatient pharmacy. In that way, we bring savings and have economies of scale. We can save $1.1 million just by doing that."
"It is an incredible opportunity for us for more primary care visits for prenatal care and the right diagnostics for lifestyle enhancement," he adds. "We want to build medical homes as quickly and as substantially as we can to provide comprehensive care."
Consolidating outpatient services
Despite the push for outpatient care, there is some hesitation. Hospitals need to step back and consolidate some of their outpatient programs to make way for cost-savings reflecting needs of the local demographic area, according to David Bronson, MD, president of the Cleveland Clinic Regional Hospitals.
The 4,400-licensed-bed Cleveland Clinic has a main campus, eight community hospitals, and 18 family health centers in Northeast Ohio among its facilities. In 2011, Cleveland Clinic closed the 211-bed Huron Hospital in East Cleveland, citing dwindling volumes of patients. The health system's action outraged many in the community.
Bronson says the health system had little choice but to change its policies regarding Huron Hospital. He noted competition from nearby academic medical centers and that the population that Huron served had steadily decreased from 40,000 to 17,000 over three decades.
"It's really related to changes in population and the changes and shift toward ambulatory care," Bronson says of the Huron move. "There will be continued pressure to prevent utilization of hospitals by being more aggressive in having ambulatory services." Huron Hospital was replaced with a new outpatient Huron Community Health Center, which focuses on chronic disease and wellness services particularly suited for that community, Bronson says.
Bronson says Cleveland Clinic weighs its outpatient planning carefully. For example, as part of the shift toward an increased need for outpatient care, the health system is currently undertaking a consolidation of its adult inpatient psychiatric services from five hospitals to two hospitals, while simultaneously maintaining several outpatient psychiatric locations. "It's easier to staff from a physician standpoint and manage it better."
Without the need for round-the-clock coverage, outpatient settings offer more flexibility for physicians, increased access to private practices, and improved management because of a smaller setting, Bronson says.
There may be a shortfall in reaching expectations for hospitals that plan for outpatient facilities. "One of the risks you have is overcapacity on the ambulatory side in the long run," Bronson adds. "There's probably more imaging available in this country and equipment than we are going to need in the long run. You can't put a da Vinci in every operating room every time. That would not be necessary in a controlled economic environment."
Still, there are considerable benefits. "We've shifted a lot of work to outpatient facilities where patients prefer to be treated; we've mastered gallbladder and plastic surgery and even mastered partial knee replacement on an outpatient basis. It's less costly, and it's a way of trimming costs off the healthcare system," Bronson says. "And there will be continued pressure to prevent utilization of hospitals by being more aggressive in having ambulatory services."
Strength in a market
Health systems focusing on outpatient centers are trying to develop strength in their own market and working toward integrating with physician practices, specializing in certain areas. "That has been the market trend," says Brett Hickman, a partner in the health enterprise practice of PricewaterhouseCoopers, the global professional services firm.
"I would say in the upcoming year we're going to see more acute care organizations focusing on developing an ambulatory care access model," says Hickman. "Health systems are adding spokes to the hub of their main campuses. A lot of organizations are trying to differentiate themselves in four or five areas and are working diligently to bend the cost curve. Whether it's in cardiac care, diabetes, orthopedics, or cancer, there is a focus on the integrated care model to get costs under control."
When UPMC closed the inpatient services at 149-bed South Side Hospital in 2009 and enhanced outpatient services, hospital leadership believed it didn't have much choice. One of the major areas of concern was a "significant population decline in our region," says Karlovich, describing a situation similar to Cleveland Clinic's predicament with Huron Hospital. "It then becomes a challenge to keep all these facilities operating. The community might be getting smaller around the local facility," he says. UPMC has more than 20 hospitals and more than 4,500-licensed beds in its system.
The hospital system consolidated South Side with UPMC Mercy, which has 535 beds, and reopened as UPMC Mercy South Side Outpatient Center in 2009. UPMC South Side and UPMC Mercy are less than two miles apart. UPMC purchased South Side Hospital in 1996.
It was important to not only consolidate services with Mercy and South Side, but also to retain a surgical presence in the community, Karlovich says. Already, the system had a "very robust sports medicine and orthopedics program" located near the South Side area. "It was an operating decision to keep those functions going," he adds.
Karlovich says it's important for hospital systems, as they evaluate outpatient growth or whether to consolidate programs, "to rate the economies of scale."
"What I mean by that is," Karlovich adds, "is if you have physicians who are doing both inpatient and outpatient services on a general population, they may not be able to do it in two places and instead should focus energies on one place. In theory, if you have an MRI in your hospital, and then you have that in an outpatient setting, all of a sudden, then your volume is pulled away to outpatient—aren't you in fact creating an increased cost structure?"
For outpatient centers to succeed, "you really have to have a very narrow focus, and as long as you do that, you can be very successful," Karlovich says. That's important because "what might look like a solid economic opportunity today, maybe five years from today may not be as solid an economic opportunity. It would be very difficult to say there is one 'broad strategy' in this environment. Each of the outpatient strategies is tied to an area and the geographic needs and competitive marketplace in which they operate.
"It's a very nebulous time in which we are operating," he says. "I think you are going to see people feel their way through the process."
Managing and partnership
For a while, officials of the Baylor Health Care System had been running outpatient programs themselves, but with increased specialization, Baylor has increasingly turned to partnerships to manage outpatient operations.
"The healthcare market is a competitive one, and especially in large urban areas, while we see large growth possibilities in Dallas, so do other systems in the city," says LaVone Arthur, Baylor's vice president of business development. "Opportunities present themselves in different parts of the city. Suddenly, there is an access area where people didn't have convenient healthcare, so you try to get into that market."
A significant partner for Baylor has been United Surgical Partners International, based in Dallas. USPI has ownership interest or operates 190 surgical facilities, with 133 jointly owned with not-for-profit health systems such as Baylor. Baylor has more than 30 joint venture partnerships with USPI and other program managers in ambulatory care settings.
"We were looking for a partner that had an expertise in that modality of care. We look at these relationships with a focused factory concept to harness that expertise that allows us to focus on the acute care that is our greatest expertise," Arthur says. "What they bring to the table is intellectual capital, partnerships, and management expertise," she says of Baylor's various partners "With an outpatient service, you know that there are existing buildings that can be converted to provide outpatient care, so there's a lot of flexibility from a capital standpoint for how you can do it," Arthur says.
In planning for outpatient facilities, James Cavanagh, vice president and CIO of the 610-licensed, 570-staffed-bed St. Joseph's Healthcare System of Paterson, NJ, says hospitals don't have many choices. "There seem to be two approaches to dealing with the notion that business is moving away from the hospital to outpatient settings. One is to ignore that; the other is to be a part of that activity and capture some of the revenue," says Cavanagh.
At St. Joseph's, hospital officials are examining various management approaches to running outpatient facilities, Cavanagh says. "We are looking at partnerships with physicians, or bringing in joint ventures or partnership with outpatient services. This is one of our approaches with imaging centers and a cardiology practice. We are looking at doing ambulatory surgery outpatient in the future. The partnerships are all different. In some cases, there's a management structure with our own service line, or we may outsource management.
"I think it's just the nature of the business that people will peel off the more profitable business and take them to outside settings," he adds. "I think from a hospital's perspective, if you aren't going to be part of that, you are just going to lose revenue, and it's harder and harder for hospitals to survive that way."
This article appears in the January 2012 issue of HealthLeaders magazine.
Leonardo da Vinci was a study in contradictions: He was an artist and a scientist who often didn't finish what he started. He despised war but invented deadly weapons. As the painter of the Mona Lisa, he was highly praised, but only completed a few other artistic works. He studied elements of flying, but never published his ideas.
Da Vinci's inconsistencies made me think of the da Vinci Robot, his namesake device that some see as revolutionizing healthcare and others see as revolting: Indeed, it is a study in conflict itself.
Surgeons control the da Vinci from a console designed for minimally invasive techniques.
The robot was once again in the news recently in the wake of a report from the ECRI Institute that identified the da Vinci robot, as well as some other technologies, that fail to improve care—or were weak—based on data the institute collected. The ECRI Institute, based in Plymouth Meeting, PA, researches cost-effectiveness in patient care.
ECRI acknowledges that, as more physician residents are trained in the da Vinci robot, there is growing pressure among hospitals to acquire it, which costs between $1 million to $3 million apiece. What's more, applications for robot-assisted surgery have "outpaced supporting clinical evidence for improved patient outcomes, cost-effectiveness and commensurate reimbursement," ECRI states.
Some physicians acknowledged to me that in certain surgical areas, such as in cardiothoracic surgery, the da Vinci at this point doesn't lend itself to more efficiency, and is no better or worse than other treatment options. One physician told me it's "going to be the future." That's a bit of a bit flimsy reason to use it now.
Still, in its report, ECRI didn't capture the full possibilities of the da Vinci. Physicians in the field of head and neck cancers, for instance, say they are thrilled by the prospects that the da Vinci represents, offering better patient care options than they have seen in decades.
Neck and throat cancer is devastating because of its impact on speech, swallowing, and facial structures.
Currently, about 80% of all head and neck cancers are caused by tobacco and alcohol use. More than 50,000 Americans are diagnosed with cancers of the head and throat each year, including the tonsils, tongue base and voice box.
Looking ahead, healthcare industry experts expect to see increasing instances of oral cancer tumors related to sexually transmitted diseases. In 2009, the Food and Drug Administration opened the door for use of the da Vinci surgical system for transoral otolaryngologic surgical procedures to treat tumors in adults.
Robert DeFatta, MD, PhD, ENT, a surgeon at the Head and Neck Center at Sacred Heart Hospital in Eau Claire, WI, praises the da Vinci robot as the vehicle for entering a "new era" of treatment that, among other things, reduces the amount of chemotherapy needed in treatment. In addition, it has mitigated the need for feeding tubes, and enabled patients to return to normal speech and swallowing soon after surgery, tells HealthLeaders Media.
With the robot and the so-called Transoral Robotic Surgery (TORS), DeFatta says he can reach into areas of the throat that were virtually inaccessible before, while maneuvering the da Vinci device and treating patients in that delicate area with precision, control, and ease. Benefits to the patient include shorter hospital stays, easier recovery, less tissue damage, and lower risk of infection.
In the past, cancers of the throat were treated with a combination of radiation and chemotherapy, which frequently resulted in the patient needing a feeding tube for the rest of his or her life, DeFatta says.
The conventional open surgery for tumors involving the throat typically required a large incision that produced significant cosmetic deformity, as well as the possibility of speech and swallowing problems.
"There's no way you can visualize it as well as you can with the da Vinci," DeFatta says, referring to the doctor's view of the surgery procedure. "It's a three-dimensional view of what you have." These patients cannot swallow, they cannot go out to eat with their families. When you turn to the da Vinci, you can take out the tumor with lower amounts of radiation, a lower dose of chemo, and for thousands of people, that's a huge difference."
"I can only speak for what I do," DeFatta says. For surgeons in his field, "by not using it they are missing the boat," he adds.
DeFatta isn't the only throat and neck cancer surgeon who is enthusiastic about the possibilities of the da Vinci.
"It is the paradigm shift in our treatment, with minimally invasive robotic surgery that leaves patients with improved ability to swallow and speak and function," Tod C. Huntley, MD, FACS, co-director of head and neck cancer services at St. Vincent's Health System in Indianapolis told me for an article in the January issue of HealthLeaders Magazine.
Patients are now discharged in less than five days as opposed to multiple weeks of inpatient recovery from the traditional surgery, Huntley says.
In his field, DeFatta says it appears the da Vinci robot will be increasingly put to use in surgeries for obstructive sleep apnea when it is caused by the collapse of the upper airway due to a large tongue base. He says patients that have the TORs procedure typically go home in two to three days, compared to 10 days with conventional surgery.
In ECRI's opinion, the da Vinci is part of potential "costly robot wars" in healthcare. The organization's report says that although proponents tout the da Vinci's improved visualization capabilities, as well as its precision and dexterity, "real unanswered questions are how much value they add, and, more importantly, how and when they definitely improve patient care and long-term outcomes."
While ECRI cites cardiology and other procedures used with the da Vinci, it also mentions head and neck cancer surgery, where doctors say it appears to be opening doors to improve patient care.
But the robots are used in many procedures, and there are still unanswered questions about them, not unlike the incomplete scientific and artistic picture left by da Vinci the man. Despite ECRI's viewpoint, the enthusiasm expressed by certain surgeons using the device show that the full story of the medical robot is still incomplete. Much more needs to be studied, and written.
When I get press releases on physician burnout or stress, my first reaction is to hit delete. Dog Bites Man. Physicians stressed? Is that really news?
Of course docs are stressed, not only from the nature of the job—saving lives (pretty stressful in itself)—but also due to the evolving nature of healthcare reform (which many don't like), mulling whether to get out of the business (especially if they are baby boomers), and considering whether to realign themselves with hospitals (which many are doing). Then there is the worry about malpractice litigation (often constant).
But it seems there is news on the stressed physician front. A recent survey and report by Physician Wellness Services, a Minneapolis, MN-based company that counsels physicians and hospitals on wellness and related issues, and Cejka Search, a St. Louis, MO-based physician executive search firm, shows more physicians are getting stressed and it's getting worse. Moreover, the report concludes that the health systems where they work aren't doing much about it. (Disclaimer: Cejka Search is an advertiser with HealthLeaders Media.)
Yes, physicians are stressed, and their numbers are growing every day. The impact extends beyond the lives of individual doctors and could be consequential for patient care and for physicians' relations with other professionals, such as nurses.
How bad is the problem? The survey shows that 87% of 2,000 physicians reported they were moderately to severely stressed, and 63% said the stress has increased "moderately to dramatically" over the past three years.
Yet only 15% of hospitals, clinics, and other healthcare organizations offered support in a way they thought would be helpful to deal more effectively with stress or burnout, the report says.
For physicians, the work-related stress factors are:
Administrative demands
Long work hours
On-call schedules
Concerns about medical malpractice lawsuits
All those factors are essentially built into today's job of being a physician, at least for the docs who stick with it.
"The result of this cumulative stress is declining job satisfaction, motivating physicians to change jobs or leave the practice of medicine altogether," the report states. If low morale leads to physicians doing their jobs improperly, then there is concern about patient safety issues, of course.
"I HATE being a doctor," wrote one unnamed and extremely disgruntled physician in response to the survey. "It has changed so much since I started. There is no reward for working your butt off, all future docs will be shift workers. Non-doctors and doctors who are traitors (administrative docs) have too much control over me and my patient's [sic] care. Doctors who provide care are left holding the bag of litigation responsibility but no control over quality of care…I can't wait to get OUT!!!"
"Physicians are seeing that organizations are not really providing the necessary service and support to help them achieve a work/life balance," Alan Rosenstein, MD, medical director for Physician Wellness Services, tells HealthLeaders Media, referring to the survey and report findings. "Some of that would be administrative support and being sensitive to their time demands, or being more proactive in offering them services such as wellness programs or coaching, or something to support them to emotionally adjust to stresses in their environment."
Of doctors who utilized programs inside their healthcare facilities to deal with stress and burnout, 31% said they used wellness initiatives, 29% used workshops and education, 19% used onsite exercise facilities or classes, and 15% used counseling or other behavioral services.
Health systems need to address physician stress and burnout concerns "because this is a serious issue," says Rosenstein, "and right now it's continued burnout because the solutions aren't there. One solution is physician awareness and they do it themselves and take the time to exercise, for instance, and recognize the downstream consequences of stress and burnout."
"On an organizational level, people need to realize physicians are burned out and mistakes can happen," Rosenstein adds. "There's no cookbook that offers one solution. There needs to be a cultural and leadership commitment to this. Whatever is done, through human resources or a medical staff office or a physician wellness committee, it's the intent that is critical to begin making those connections with physicians."
How do physicians want help with stress? Their top choice by far in the survey (63% of respondents) is receiving more "ancillary support," such as physician aides or other staff members to help with paperwork or charting.
Respondents also say there is a need for more "advanced providers such as nurse practitioners and physician assistants who can provide accessible and effective care as physicians scale back their hours."
It is interesting that physicians are calling for more nurse practitioners and physician assistants to help with their workload, as many at the same time decry "Obamacare."
For the most part, docs aren't fans of Obama or the Democrats. Yet the administration may be the driving force behind putting in place help to offset their workload. Under the Patient Protection and Affordable Care Act, $32 million is earmarked for developing more than 600 physician assistant positions, and another $30 million for 600 nurse practitioners, as well as 500 new primary care physicians by 2015.
Ironically, if doctors can't rely on their own hospital systems to initiate programs to help them deal with stress, they may find relief coming from Washington.
Doctors still control what may be their best options for addressing stress and burnout: 63% say they rely on exercise, and 59% say they spend time with family or friends.
I think one physician says it best in the survey: "We have to find a way to help docs recognize burnout. We didn't get through medical training by thinking how it affected us; we just put our heads down and muscled through," she writes. "You can do anything for eight years, but you can't live that way for 40 years. We need to encourage ourselves to develop an external barometer so someone can tell us we're burning out."
After being president and CEO of the Medical Group Management Association for 12 years, William F. Jessee, MD, FACMPE stepped down last October, which gives him the chance to spend more time examining the landscape of physician and hospital integration.
From his vantage point it's a rocky landscape.
Few hospitals and physicians are yet up to the challenge of properly aligning themselves, even though the pace of hospitals acquiring physician practices is accelerating across the nation, Jessee tells HealthLeaders Media.
Since leaving MGMA, Jessee has been senior vice president and senior advisor for Integrated Health Strategies, of Minneapolis, a consulting firm for physicians and hospitals with alignment and performance issues.
Discussions with hospital clients are showing that too many "don't have organizational goals or strategies for their physician practices. Hospitals simply bring in (physician) practices because they are out there," Jessee says. After a contract is signed, he adds, "now they are trying to figure out: what do I do next?"
It's not only hospitals stumbling in alignment strategies, Jessee says. Many physicians expect large payments, but they should lower their expectations of hospital employment and not be "greedy" when it comes to anticipated incomes, he adds.
"I think what the doc must to do is to step back from the prospect of short-term economic gain and ask themselves, 'how can I do a deal with the hospital that is a win, win for both of us?'' Jessee says. "If they are both happy with the deal, they are more likely to have a lasting relationship than if a (doc) felt after a deal was made, 'Boy, did I really sucker the hospital administration.'"
Jessee discussed some of his best-of-alignment ideas in an interview:
1. Hospital CEOs should ask: Why do you want this physician?
Too often, hospital systems are merely bringing physicians on board for employment because they believe competing systems are courting them. Too often hospitals haven't done the necessary homework to do a good job, says Jessee. In seeking physicians, he says, hospital CEOs often are standing alone and not soliciting input from their management or physician leadership, or doing enough analysis of fiscal returns, or raising other potential deal-breaker issues.
Hospitals need to have a strategic objective first and foremost in acquiring physician practices. "If you can't answer that question, all the other stuff becomes kind of irrelevant," he says. CEOs may be excited about it, but there is no buy-in from hospital boards or physician leaders.
To hospital leaders, "The first questions I ask are, 'Why did you acquire this practice? What was your objective?'" Jessee says. Often, he hears that "the reason a hospital or health system enters into a practice acquisition is because the physician wants to sell or because if we don't buy it, our competitor will."
"Those are hardly what I would call good strategic reasons," he says.
2.Hospitals should establish strategic objectives in hiring physicians:
Jessee says the board, management team, and physician leaders must clearly support and gain buy-in for strategic objectives. That is an "essential prerequisite to a successful transition," he says.
Jessee tells the story of one hospital CEO who brought in a cardiology practice that failed to deliver business the hospital sought, yet gave the physicians guaranteed incomes.
The CEO hired an outside cardiologist to drive patient referrals. When that faltered, the CEO sought to hire one of the local cardiology practices. None were interested. So he went to another town 25 miles away and hired four cardiologists who hadn't used the hospital.
"I started thinking to myself, how many ways can you screw something up?" Jesse asked.
The scenario underscored the need to have board and physician buy-in to the plans. "How does your board and physician leadership feel about this?" Jessee asks. In the case he discussed, "the board was really angry because we were losing so much money over this and they weren't brought in to discuss it. And the physician leadership believed the hospital was bringing in outsiders to compete with them. They've been longtime supporters (of the CEO) and now they are out to get the CEO."
3.Hospitals must examine the overall fiscal picture
When hiring physicians, hospital executives should examine an array of fiscal possibilities. That includes benchmarks, payer-mix incentives, and total revenues collected. In addition, total revenues collected as well as efficiency of the physician practices should be reviewed. Finally, specialist referral patterns and potential litigation issues as well as physician performance should be evaluated, Jessee says. And they must eyeball the fine print: Does a doc have a potential conflict such as ownership in a pharmaceutical company?
"Before purchasing a practice, be sure you understand how cost-effective its physicians are," Jessee wrote in a report for Integrated Health Strategies. "If their cost-per-case (usually driven significantly by physician choice of drugs, supplies, devices etc.) is higher than the hospitals' revenue for those cases, additional volume will only make the problem worse."
4. Physicians must evaluate their goals
Jessee says that physicians must forsake short-term gains and be flexible in relationships with hospitals.
As physicians, "you are obligated to change your mode of decision-making. It is no longer management who will decide what is best. As a doctor, if you want those (management) guys to be on your side, and for an integrated system to work, you've got to be part of the decision-making process."
Over the years, "docs have historically done a very good job of playing one hospital against the other," he says, noting that a trustworthy relationship is essential.
Indeed, for both doctors and hospitals, it is essential that they really do their homework before entering an integrated model to avoid regrets and ultimately asking consultants like Jessee, "Now what do I do to get out of this mess?"
Underlying it all is the need for foundational trust.
"Building a trust relationship and learning the behaviors of one another are what either firms up a relationship or it can destroy trust. It's a lot easier to destroy trust than to build it."
"It's a matter of getting physicians to realize that if they see their future as having a closer relationship with a hospital—and more and more docs are seeing that—they have to all be trustworthy partners," Jesse says.
For some physicians, 2012 may be either the best of times, or the worst of times. But mostly, the New Year promises to bring uncertain times to the profession.
Sure, intriguing possibilities lie ahead for physicians who embrace IT, or physicians who seek and gain hospital employment. But what of those doctors who are installing a $60,000 EMR system in their small practice, then can't figure out the system?
And what lurks for physicians who labor under the ongoing threat of reduced Medicare and Medicaid reimbursements?
Uncertainty.
Amid the ambiguity about the business of being a doctor, "there is much despair among the physician population," says Lou Goodman, PhD, president of The Physicians Foundation, a non-profit formed with a $115 million endowment.
The foundation seeks to advance the work of practicing physicians by conducting research and policy studies that impact both practicing physicians and healthcare. Goodman is also CEO of the Texas Medical Association.
His organization's Physicians Watch List for 2012 focuses on issues likely to impact doctors this year, from the changing nature of medical practices to acute shortages of primary care physicians. Never mind the various physician alignment strategies being negotiated, and the flurry of regulatory requirements ahead.
"The ground is changing; it's really a shifting sand," Goodman says. "Physicians want to stay in a stable medical practice, but it's hard for them to make decisions under the economic climate. They might have thought about hiring an additional nurse, or partner, or an assistant, but they aren't doing it. They aren't adding more examining rooms and they aren't expanding. And they are joining hospital systems if they can."
One thing not on the list is continued uncertainty in Washington D.C. about the ongoing SGR (Medicare Sustainable Growth Rate) formula fight in Congress.
The SGR issue is not on the foundation's list because, well, the struggle to get rid of the SGR is seemingly always on physicians' to-do list.
Over the holidays, Congress made some inroads?but not many. President Obama signed a 60-day delay of the 27.4% SGR reduction in physician payments that was scheduled for Jan. 1.
Besides the SGR formula issue, which Goodman calls "being on the edge of the cliff," he and others cite four crucial issues that physicians face in 2012:
1. Physician Alignment: Many doctors are choosing hospital and group settings versus private practice because they feel more employment security, but both sides are having difficulty making the adjustment. Hospitals will "continue to hire and partner with physician practices and that seems to have accelerated with the healthcare reform bill and the accountable care provisions," Linda Green, PhD, a professor of healthcare and pharmaceuticals at Columbia University's Columbia Business School, tells HealthLeaders Media. "If hospitals want to be a part of that, they obviously need the physician piece. A lot of them don't have that."
"These [hospital-physician] marriages are happening at a greater rate. Those [physicians] left out are at an age that they may retire in five years or so, and it's voluntary," Green says. "Those who are younger are definitely looking for dance partners and hospitals right now are welcoming them."
Although hospitals and physicians are getting together, they aren't always a comfortable fit, Green says. "What I'm hearing hospital leaders saying is that getting a physician to truly buy into the program is an obstacle. There is the culture of the physician and the culture of the hospital," she says. "The hospital wants more evidence-based medicine, more IT support, more of a point of service delivery system. It's not the way most physicians operate. A lot of them [physicians] are going to be very resistant."
2. Patient Focus: "All doctors want to have access and availability for their patients," says Goodman. That seems like a given. But as he sees it, the added regulations and administrative responsibilities have physicians focusing less on patients. "Only one physician in 10 believes that health reform will enhance the quality of care they are able to provide to their patients," says Goodman, referring to foundation surveys released in 2011. In contrast, about 56% believe it will diminish that quality of care, he adds.
The need to provide higher quality in an environment characterized by increased reporting, problematic reimbursement and high potential liability will place "extraordinarily high stress" on physicians, particularly those in private practice, says Goodman. In 2012, "physicians will increasingly need to balance these competing factors in ways that do not compromise the care they provide to patients," a foundation report states.
Adding to the concerns: the continual, pressing shortages of primary care docs and other specialties, Goodman says. The Association of American Medical Colleges estimates a current shortage of 13,700 doctors nationwide in all specialties. Within the next three years, that number is predicted to spike dramatically to 63,000.
3. Health IT: With the impending release of the Stage 2 Meaningful Use final rule, physicians will meet impending deadlines to install computerized systems and EMR. In the meantime, physicians point to paperwork as the problem. About 63% of physicians surveyed by the foundation said that non-clinical paperwork has caused them to spend less time with their patients and 94% said the time they devote to non-clinical paperwork has increased. Indeed, many doctors say the "paperwork is killing me," Goodman reports.
Still, is EMR the answer? "Maybe in big practices. But in smaller practices, having an electronic record may take more time than a paper record. It may not improve quality and reduce costs and it may not be as effective," he adds. In a small practice it costs about $60,000 to put in an electronic record system, and they may have an electronic and paper record side-by-side for a year."
Generally, smaller physician practices often "don't want to invest in IT, and would want to affiliate with a larger physician practice or hospital," says Green.
Green noted that the Intermountain Health System in Salt Lake City, UT has installed IT systems that are easier for physicians to use. "Intermountain Health has created IT-supported electronic health records that are intuitive in a way physicians might use manual records," Green says. "It gives them benefits right away, providing information on antibiotics for example, that they would not ordinarily easily get. Once they start using the system they see how easy it is to use."
4. Docs As Business Managers: Whether it's dealing with IT systems or hospitals, as physicians brace for changes in 2012, they should also consider this: Doctors can't be only doctors anymore in an evolving, fast-paced business climate. Being a clinician is only part of the job.
Goodman says that more and more, physicians will be assuming greater "business and people management responsibilities" within practice and hospital settings.
Hospitals are relying on physicians to take on more leadership roles as the facilities expand multidisciplinary care in service lines ranging from cardiology to oncology.
The foundation states in a report, "In 2012, physicians will need to acquire new types of nonmedical leadership skills to be effective in expanded roles while still maintaining their trusted relationships with patients."
Doctors need to develop more as team leaders and as members of a team. In that way, patients can be better served.
As Goodman notes, there's a "new medical landscape" for 2012.
To share notes, or not to share—that is the question.
What would happen if physicians' notes about patients were actually read by patients? Would it cause an onslaught of worry, anxiety, and extra work for already over-extended physicians? Could those notes become a catalyst for patients' cooperation in their own care?
It depends upon whom you ask.
After studying nearly 173 primary care physicians who shared notes with more than 38,000 patients at three hospitals, researchers found that patients were enthusiastic about the note sharing, but physicians less so.
"The response among physicians is a mixed bag; some are cautiously optimistic and quite a few are opposed," Tom Delbanco, MD, and Jan Walker, RN, MBA, research partners at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, MA, and several co-authors, write in the December issue of the Annals of Internal Medicine.
The researchers divided physicians into two groups: those who participated in the note-sharing study and completed an attitude survey, and nonparticipants who only filled out the survey, but declined to engage in the note-sharing process.
Overall, as many as 81% of participating physicians thought open visit notes were a good idea, but only 33% of the nonparticipating doctors felt they were, the report said.
However, patients were overwhelmingly enthusiastic about the note sharing, with 97% believing it would improve their understanding and involvement in their own care. Patient enthusiasm extended across age, education and health status, and 22% anticipated sharing their visit notes with other people, including doctors.
Physicians were mostly concerned about their notes having one major negative impact on patients: Giving them cause to worry.
While most (58%) of the participating physicians expected that open notes would result in greater angst among patients, far fewer patients (only 16%) concurred. As many as 92% of the nonparticipating physicians anticipated more worry among patients.
Delbanco and Walker hope someday it will be routine for primary care physicians to share with patients their notes about doctor visits in a process, they write, that could "transform the patient-clinician relationship." It's certainly not routine now.
While hospitals and healthcare systems with electronic medical records are increasingly allowing patients to view laboratory results, medication lists, and other parts of the medical record, patients rarely have easy access to notes written about them by clinicians, according to the researchers.
Walker and Delbanco believe that's a mistake. If more patients were able to see and review doctors' notes, they could use the information to make decisions about their health, and manage their illnesses better, the researchers said in an interview with HealthLeaders Media.
"We're saying there's this 'black box' of the doctor's notes that patients really aren't privileged to read, and we think that's ridiculous," says Delbanco, a primary care physician who created the Division of General Medicine and Primary Care at Beth Israel Deaconess, a unit he led for 30 years until 2002.
As they see it, sharing notes with patients is a simple step that could go a long way toward improving healthcare. In instances where physicians have shared written notes with patients, dialogue has ensued about certain illnesses and conditions, with the potential of improved care as a result. In addition, patients have occasionally pointed out information that physicians wrote in notes that doctors may have later neglected, with the impact of potentially reducing medical errors, Delbanco says.
To hear Delbanco and Walker tell it, the potential impact of note-sharing is similar to the use of checklists–step-by-step procedures performed by hospitals that were initiated several years ago by Peter Pronovost, MD, a Johns Hopkins clinical care specialist. Pronovost identified a rudimentary checklist of basic procedures to improve hand-washing routines and proper skin evaluation that has helped to reduce hospital infections.
The study on doctors' notes involved patients and physicians from Beth Israel Deaconess, the Geisinger Health System in Danville, PA and the Harborview Medical Center in Seattle, WA. The project, OpenNotes, is supported by grants from the Robert Wood Johnson Foundation and other foundations.
"We believe that patients get a better understanding about their care," Walker told HealthLeaders Media. "They take better care of themselves and take their medicine."
Delbanco says he has been sharing notes with patients and it has been illuminating to them as well as to him. Writing notes has clarified his thoughts about patients' conditions, Delbanco says. As for patients, some say they are more inclined to take their medication, or lose weight, for instance, after reviewing physician notes.
"We've had several patients who say to us, 'My doc's been telling me for a year to lose weight, but when you see it in the notes, that the doctor is worried, it's a different ballgame and you want to do it,'" he says.
Although note-sharing is relatively uncommon, it has been tried in certain health systems with some degree of success. The University of Texas M.D. Anderson Cancer Center in Austin, TX implemented an electronic medical records system for patients in May 2009. Few physicians have voiced concerns since the system went into effect, despite worries that it would increase workload and anxiety, wrote Thomas Feeley, MD, vice president of operations at the Texas hospital in an editorial published in the Annals of Internal Medicine. "There have been no adverse consequences and generally positive feedback."
Delbanco and Walker are continuing to study physicians' attitudes on this subject, with plans to release a follow-up report in six months. For instance, they will explore physician attitudes and how they took notes after questioning patients about specific conditions, such as obesity or cancer.
The researchers also will evaluate how often patients looked at their notes, whether they better understood their physical condition, and whether they shared the information with others. They will also address privacy concerns. Confidentiality may be the hallmark of traditional doctor-patient interaction, but open visit notes put the patient in control of whether the note will remain private, Walker says. "Those are among the questions we will have answers to in a follow-up study," Walker says.
As Walker and Delbanco continue to evaluate open notes, the debate about whether note-sharing between patients and physicians may be just beginning. At the outset, they think it should become a routine part of the framework of medical care.
"I would love this to be a standard of care in five years. Patient engagement is a huge piece of it, and this is a simple intervention that can accomplish a lot," Walker says.
Without skipping a beat, a huge medical device manufacturer allegedly found an easy way to influence physicians to use that company's brand of defibrillators and pacemakers.
How? By giving doctors kickbacks, the Justice Department says.
In a settlement agreement reached this week, Medtronic Inc. of Fridley, MN, agreed to pay $23.5 million to resolve allegations that it used physician payments as kickbacks to "induce doctors" to implant the company's products.
Daniel R. Levinson, inspector general of the U.S. Department of Health and Human Services, noted in a statement, "Patients trust that decisions to implant certain pacemakers or other medical devices are based on their own health interests and not influenced by kickbacks."
This kind of news can certainly erode patients' trust in doctors. And there's more.
The Justice Department's announcement about the Medtronic settlement was barely 24 hours old when, in a separate, unrelated case, several dozen federal and state investigators swooped into a radiology and diagnostic facility in Orange, NJ, arresting 13 doctors and a nurse practitioner in a cash-for-tests referral scheme.
"When physicians take kickbacks that influence how they practice medicine, it has the potential to taint the medical advice and care that is provided to their patients," Office of Inspector General Special Agent Tom O'Donnell said in an official statement.
Bribes and kickbacks are only part of the problem in healthcare fraud, which includes identity theft, illegal prescription drug sales, and countless other areas of wrongdoing. These transgressions do occasionally involve doctors.
The wrongdoing at Medtronic unraveled after two whistleblowers sued the company and alerted authorities to the problem, according to the Justice Department.
Because of their role, the do-gooders will receive a tidy sum of more than $3.96 million. Neither whistleblower was a physician. Justice Department officials declined to comment when I asked how many physicians may have been involved in the Medtronic case.
That's too bad. Physicians need to step up to ferret out fraud, not be a part of it. Most are honest, upholding the profession's reputation. The actions of a few can cast a long, foreboding shadow on the legions of honorable practitioners.
Shortly after he resigned as head of CMS, Don Berwick, MD, touched on the fraud issue in a conversation with journalists. In his 18-month tenure, Berwick said he found that fraud, waste, and abuse were more significant problems than he previously thought. Apparently, Berwick didn't realize how widespread the problem really is.
That's surprising. There were plenty of clues before Berwick stepped into his office in April 2011 that fraud was a big and burgeoning trouble spot in healthcare. Now that he has left, CMS appears to be struggling still with how to uncover fraud, as the behemoth agency tries to raise quality standards under healthcare reform, while also dealing with inadequate data systems that would improve its watchdog functions (more on that in a moment).
As for Berwick, one federal official who is knowledgeable about these decisions told me the CMS leader "was concentrating on other things," such as forming Accountable Care Organizations.
It seems that fraud in Medicare and Medicaid will be a major challenge for Berwick's successor to overcome. Federal officials want physicians to play an instrumental role in helping to stop fraud, and they're backing up that desire with the power of the dollar. Healthcare reform provides fiscal incentives to do so. Berwick had estimated that fraud, waste, and abuse total about $30 billion a year for the whole healthcare system, including up to $10 billion just within CMS.
The week Berwick talked about fraud with journalists, Gary Cantrell, assistant inspector general for the Office of Inspector General (OIG) at HHS, addressed the extent of Medicaid fraud in Congressional testimony. His comments didn't make headlines, but they were revealing nevertheless, as he described the widespread scope of Medicaid fraud, including prescription drug abuse and problems in the home health care services arena.
"We are now seeing more Medicaid fraud cases involving home health services than any other single program area," Cantrell told two House subcommittees. One investigation of a leading home health services company, Maxim Healthcare Services, led to a $150 million settlement of fraud charges.
Fraud in home health services is not a new problem. There have been repeated warnings that CMS needs to address the issue.
"Auditors have been concerned about fraud in home health care for years, but the problem never seems to get solved," according to a 2009 report from the Cato Institute, a think tank in Washington, D.C.
As in Medicare, Cantrell identified "persistent fraud trends" involving misuse of prescription drugs in Medicaid. He referred to a case in Washington state in which a physician established connections with local heroin users and wrote medically unnecessary prescriptions for narcotics, including Oxycodone and Vicodin.
Cantrell also revealed that the OIG has a list of the 10 "most wanted" healthcare fugitives. Among them: an Illinois physician, Gautam Gupta, MD, sought for allegedly defrauding Medicaid and private insurance companies of more than $24 million, through weight loss clinics.
Whether it's improper billing procedures or weight loss fraud, Medicaid investigations are hampered by a lack of "national-level, timely Medicaid data," he says. While the Medicare databases are efficient, Medicaid's Medicaid Statistical Information System (MSIS) is the only source of nationwide Medicaid claims, but it is typically 1½ years old when released by CMS to users for data analysis purposes, which renders it ineffective for investigative purposes. "In law enforcement, a 1½-year time lag is an eternity," Cantrell says.
Essentially, the OIG is waiting for CMS to get its act together.
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Vineet Arora, MD.
This profile was published in the December, 2011 issue of HealthLeaders magazine.
"When I was a resident, you never had to hand off anything … That meant you stayed until your work was done."
Vineet Arora, MD, MPP, FACP, an associate professor of medicine at the University of Chicago's Pritzker School of Medicine, says she was always interested in finding out why things work—or don't—in healthcare, and that inquisitive nature led her to sleep.
Not necessarily her own sleep, mind you, although Arora will tell you when she was a resident she had her share of sleepless nights like many of her colleagues.
Arora, also assistant dean of scholarship and discovery at the Pritzker School of Medicine, is leading research that is reshaping sleep schedules for residents to improve quality and safety of patients. “You don't want doctors fatigued to the point they are hurting anybody,” she says.
“It's a fascinating area to work in. It's complex. If you change one thing in the system, you can change a lot of things. Everybody needs sleep. It doesn't matter who you are. You can't function without it. You'll die.”
Arora also has concentrated on studying handoffs from one physician to another in hospital settings as they change shifts, with a specific emphasis on communication procedures. In the 1990s, “when I was a resident, you never had to hand off anything,” she says. “A good handoff was no handoff. That meant you stayed until your work was done. People are now aware it’s a problem, and the challenge to the system is to make better handoffs.”
The importance of proper communication in handoffs cannot be overstated, but it is often difficult to address, she says. “I think it's a very big assumption you can just hand off patients to another doctor and this new doctor is going to do a surgery, for instance, with the same skill. Patients often say, 'why am I repeating the story' to a new doctor. The reason patients are repeating their stories is because there is something different. A detail is discovered that builds a new memory of the patient's condition and needs.”
Arora says she loves research and teaching, and the impact that can have on improving health systems. She uses play-acting to get a visual message across when she can. She and her colleagues put together a video in which she plays a physician who didn't do a very good job of handing off information to her harried colleague because she had to rush out of the hospital after being “super late” for dinner plans.
Arora took an unusual path out of residency, spending two years pursuing a master's degree in public policy at the University of Chicago Irving B. Harris School of Public Policy after receiving her medical degree from Washington University in St. Louis. At the time, she felt it was important to step back from medical training and concentrate on public policy. “I thought I should pause and learn this stuff, how medicine and healthcare systems are integrated,” Arora says.
Arora views her roles as mentor and educator as natural extensions of her research interests. “I see myself continuing to study and teach about handoffs and seeing if we can achieve better outcomes,” she says. “The nice thing about studying handoffs is that this area needs to be improved and be taught—a lot of our work now is focusing on how to teach it.”
“The hospital is a place of healing,” she says. “We are just at the tip of the iceberg how to improve practices, evaluate fitness for work, and attend to the needs of patients.
Arora’s resident days are long gone. “My husband will tell you, I always try to get enough sleep.”
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Robert D. Donaldson, NPC.
This profile was published in the December, 2011 issue of HealthLeaders magazine.
"We've gotten past why a nurse practitioner is in charge in this community because I market myself. I am Bob Donaldson, a nurse practitioner."—Robert D. Donaldson, NPC
There are times when patients are ushered into the emergency department in tiny Ellenville Regional Hospital in upstate New York, and they ask: Is there a doc here?
"There are no doctors here in the ED, I'm the one you are going to see," says Robert D. Donaldson, NPC, in his well-worn refrain. And yes, there have been the occasional snickers, or even calls to the C-suite to complain.
Donaldson is no doctor, but he's a nurse practitioner, as is every member of the ED staff at the 25-bed critical access hospital. Not only does he often handle his own shift, he also has clout within the hospital. He's clinical director of emergency medicine and president of the hospital's medical staff, sharing ED leadership responsibilities with a medical director, Norman Chapin, MD. The hospital is in the Catskill Mountains about 40 miles from Kingston, NY.
So is this really working, a nurse practitioner in charge? And do the physicians really like what he's doing? "You'll have to ask them," he says. He pauses. "Yes, there is an answer to that. We are admitting patients, making money for the hospital, and the hospital is in the black year after year. What does that say? The hospital has received an award for its emergency department for patient care. What does that say?"
The 68-year-old Donaldson, who had a long background in emergency nursing, came to Ellenville in 2004 at a time the hospital was ailing financially. In 2009, the hospital was having trouble filling the medical staff president position. Donaldson kept getting notices about the vacancy, and just threw them out. After he received a third notice, he asked if he could run. But first he asked top leadership if they were okay with a nurse practitioner running. "I'm not going to offend the CEO," he says. Eventually, Donaldson won a runoff against two physicians, and garnered 70% of the vote on the final ballot. Donaldson could not even vote for himself; only physicians could vote.
Donaldson believes he was becoming popular with the physicians because he did "the entire workup for them, and essentially managed their patients prior to admission. It goes a long way and makes their job really easy."
After he was named to head the ED, he reshuffled staff, weeding out some providers who weren't meeting hospital standards, and replaced them with nurse practitioners or physician assistants. In the meantime, the patient load within the ED increased from 8,000 patients a year to about 13,000, he says.
Donaldson acknowledges that the nonphysician provider arrangement is unusual, but says that in New York and some other states "nurse practitioners are basically equal to doctors, they can admit patients, manage patients, and discharge patients." New York is currently a collaborative-practice state, which does not require direct physician supervision.
Donaldson laughs easy and says he loves his post, juggling the clinical and administrative worlds. He is thrilled with his working relationship with physicians, and is convinced that under his leadership, the ED, now with four full-time and two-part time nurse practitioners and physician assistants on staff, is doing a standout job.
The hospital staff also has worked hard to reduce the length of stay of patients in the ED with much success, he says. Length of stay was reduced from 2 hours and 12 minutes in 2004 to 92 minutes last year.
Not every patient who walks into the ED is happy that a nurse practitioner is in charge. A patient's family member complained that Donaldson tried to pass himself off as a doctor. As Donaldson recounts the story, the CEO knew right away it wasn't true. The administrator told the person, "Donaldson is a nurse practitioner. He's proud of that. He would never pass himself off as a doctor."
Not every patient who walks into the ED is happy that a nurse practitioner is in charge. A patient's family member complained that Donaldson tried to pass himself off as a doctor. As Donaldson recounts the story, the CEO knew right away it wasn't true. The administrator told the person, "Donaldson is a nurse practitioner. He's proud of that. He would never pass himself off as a doctor."
Donaldson laughs.
He recalls in detail the patients who come back to thank him, whether it's the man who was bleeding profusely after a dental procedure and scheduled for cardiac surgery, or the mother of the 3-pound premature baby who had been near death. Donaldson talks haltingly about those cases, and his voice cracks with emotion.
Because Donaldson admits patients to the hospital, the hospital gave him attending status. After he joined the hospital, physicians voted to give equal rights to nurse practitioners on the medical staff, and that means, he says, "you are equal to a doctor as far as privileges at the facility and within the medical staff."
When he's not in the hospital he retreats to his nearby home, with the mountains as scenery and no neighbors nearby. He still thinks about healthcare, though. He is a volunteer pilot for an organization that helps transport patients to hospitals, using his own six-seater Cessna 210.
While Donaldson has certainly made inroads in how nurse practitioners are perceived in Ellenville, it's still a national problem, he says. He's says he's still fighting turf wars. "There's a huge medical lobby out there, and they got a huge amount of dollars; they don't really want to hear that nurse practitioners are doing what docs have done," Donaldson says.
In the meantime, he wants to beat the drum about what Ellenville Regional Hospital has done with its administrative structure; i.e., having a nurse practitioner in charge of the Emergency Department. "The community knows what I'm doing, and I'm on the radio every month with the local disk jockey and talk about what's happening in the emergency room," he says. "We've gotten past why a nurse practitioner is in charge in this community because I market myself. I am Bob Donaldson, a nurse practitioner."
This article appears in the December 2011 issue of HealthLeaders magazine.
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Anne Brooks, DO.
This profile was published in the December, 2011 issue of HealthLeaders magazine.
"I set for myself a little higher standard and that is what I expect my patients to do."
Anne Brooks, DO, is a doctor, not an artist, but then again, maybe a bit of both. Too many of her patients at her small clinic in northwest Mississippi, she says, smoke too much—their skin wrinkled by years of tobacco intake, their lungs brittle. She tells each of them they are having too many cigarettes, and then she takes pad to paper. She sketches their heart and lungs, and writes how "tar," that toxic material, ravages both.
The patients look quizzically at her as she completes a drawing in the small office of the Tutwiler (MS) Clinic, the osteopathic physician says. It's not that kind of tar on those paved roads, she tells them, but it might as well be how thick it lays on your lungs.
"Do you see what this stuff is doing to you?" she asks. "It's not helping you (this smoking); it's doing far worse to you than you think.
"I draw pictures of the lungs and put tar on the alveoli where the air goes in and tell them if you put tar through the air sacs, how can you breathe?" Brooks says. "They look at me and we discuss what it means. It dawns on them what is happening to their lungs."
For 28 years, Brooks, a Roman Catholic nun, has practiced in one of the poorest areas of the country; that's why she went to Tutwiler in the first place. She spends morning and night working for her patients, and in the process has become a spokesperson for the country's needy and has been lionized by various groups for her efforts in helping the poor and improving the healthcare needs of diverse populations.
Earlier this year, she was among the invited speakers at the Martin Luther King Jr. Health Equity Summit in Washington, DC. After she received the invitation, she noted there were prominent speakers also invited, with fancy academic credentials, "then there was me, too."
Brooks opened the clinic in Tutwiler in 1983 with support from Catholic Extension, an advocate of missionary work in the U.S., and opened a satellite clinic in Glendora, MS, in 1995, which has since closed. The clinic operates through donations and continues to provide access to healthcare for some of the country's poorest residents, according to Brooks. The poverty level of the population in Tutwiler is 38.5%, compared to the national average of 12.5%, according to the Department of Labor.
In recalling how she tries to motivate patients to stop smoking, Brooks concedes that she's "tough" on them because she was a patient herself. She became a nun with the Sisters of Holy Names of Jesus and Mary at age 17. Within a few years, she was diagnosed with rheumatoid arthritis and lived with a back brace and wheelchair for the next several years until her condition was successfully managed.
That occurred when she was treated by a chronic pain specialist, who used osteopathic manipulation of her joints and acupuncture, as well as nutritional therapy. Eventually, she no longer relied on the wheelchair and was challenged by the specialist to become a doctor. She went to Michigan State University College of Osteopathic Medicine and earned her doctorate at 44.To this day, she isn't sure if she had rheumatoid arthritis or not. It could have been a misdiagnosis, or untreated Lyme disease, Brooks says.
She begins each day at 5:00 a.m. and usually ends when she retires at 8:30 p.m. She sees her patients, but knows that she must take time off each day so her body recuperates. "I do see patients at the hospital, the clinic, nursing home, and occasionally make house calls. Then I go back to the clinic and finish working on my charts, and go home. I try to take my nap every day and eat smart," she says.
It’s been a tough time lately, as the recession rocked the area and left many residents without jobs or insurance for medical care. "People who lost their insurance, they aren't taking their medication. We are seeing many more of them," Brooks says. "There are people who don't live in the county and come here."
"Sometimes the disability is very simple, something that happened years ago, they had x, y, or z, an accident and it wasn't taken care of because they had no money, and so now they have arthritis or a bad knee or a limp and awful back conditions," she says.
As more organizations recognize her work, and ask her to speak at events, Brooks says she feels "surprised and incredibly honored."
"I set for myself a little higher standard and that is what I expect my patients to do," Brooks says. "I try harder and they try harder. I yell at them louder, and they laugh at me louder."
"Sometimes I get a little dramatic with them, and say, ‘What are you doing to me? They get the point."
This article appears in the December 2011 issue of HealthLeaders magazine.