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 Kristine Aznavoorian, RN, MS.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
"When it comes to evidence collection and an examination, we just try to do it as efficiently as possible without traumatizing the child any further than they already have been."
Kristine Aznavoorian, RN, MS, had been a practicing pediatric nurse in Boston for about five years when she became aware of the subspecialists known as Pediatric Sexual Assault Nurse Examiners, or pedi-SANEs.
"It fascinated me," Aznavoorian recalls. "These children are looking for certain help, and I really enjoyed that thought of helping them in a very crucial and traumatic time of need."
Now, in addition to her work as a pediatric emergency nurse at Boston Children's Hospital, Aznavoorian also works part-time as a pedi-SANE for the Massachusetts Department of Public Health at the Essex County Children's Advocacy Center, where she investigates two or three sexual abuse cases each week.
For pedi-SANEs, there is no such thing as routine. The one constant, though: Dealing first-hand with the young victims of heinous crimes is never easy.
"Every case is different," says Aznavoorian, who has been a pedi-SANE for two years. "Every child deals with a traumatic event a little differently. It depends on the developmental level of the child, how old they are. It plays into how they are going to handle the situation, but it is across the board."
In some cases, if there is an opportunity to gather physical evidence of sexual assault for prosecutors, Aznavoorian asks the victim or their families for permission to perform a physical examination.
"The older the children are, the more they kind of get what is going on exactly," she says. "And depending upon what their unique situation is depends upon if they are going to be open to coming to see me, or if they are open to having an exam done. I never know what kind of child we are going to get and if they are going to be willing to see me or even talk to me."
"I try to go in as if I were with any of my patients, such as when I work as a staff nurse in the emergency room. I go in. I introduce myself. I am as friendly as possible. Children feel afraid if they feel certain vibes from medical professionals so I try to give off an open and friendly vibe. Every child reacts a little differently," Aznavoorian says.
"We try to keep the parents in the room. As the children get a little older and become adolescents then maybe they want a little more privacy and they don't want the parents around. But when they're younger we typically have the parents stay because they know their child well and they know best how to comfort their child," she says. "It takes a lot of patience, especially with younger children. But you work as slowly as possible just to make sure they are not afraid. We have a 'stop' rule. If the child is scared or upset or crying, we stop. We don't force the children to do anything they don't want to do. When it comes to evidence collection and an examination, we just try to do it as efficiently as possible without traumatizing the child any further than they already have been."
It's important work. But it is also stressful.
"The burnout factor is actually a concern within our program. It's tough work. I definitely don't take things home with me. I do my job. I focus on the family and the child," Aznavoorian says. "We have monthly meetings where we share our feelings with the rest of the pedi-SANEs and talk about the struggles that we having doing the job and the work that we do. We rely on each other to talk about the tough days and the good days."
The rewards aren't monetary. The satisfaction comes with knowing you have played a role in helping a child recover from a potentially devastating ordeal.
"The older the children are the more they realize that what happened was wrong or wasn't supposed to happen. They tend to think that as a result something is wrong with their body and that people can tell what happened to them just by looking at them," Aznavoorian says.
"This particularly is true with the adolescent population and the young teens. They think something is wrong with them. It's happened to me on numerous occasions where I examine these children and they look at me and say, 'Really? You can't tell something happened?' I say 'No, I can't tell. Your body is perfectly normal just like every other 11-year-old body would look like.' And they are so excited about that. That is what keeps me doing what I do every day."
Evidence is mounting that when physicians know the laboratory costs of tests prior to ordering them, they show a decrease in ordering rates, and not only for high-cost tests.
A new study adds to a growing body of evidence suggesting the potential for significant healthcare cost reductions when physicians know the up-front cost of ordering routine lab tests.
The latest study involved 215 primary care physicians at Atrius Health, an alliance of six non-profit medical groups, and a home health and hospice agency in Massachusetts that uses an integrated electronic health record system. Physicians in an intervention group received real-time information on laboratory costs for 27 tests when they placed their electronic orders, while physicians in a control group did not.
Changes in the monthly laboratory ordering rate between the intervention and control groups were compared for 12 months before and six months after the intervention started. Six months after the intervention, all physicians taking part in the study were asked to assess their attitudes regarding costs and cost displays.
Lead researcher Thomas D. Sequist, MD, found a significant decrease in the ordering rates of both high and low cost range tests by physicians to whom the costs of the tests were displayed electronically in real-time. This included a significant relative decrease in ordering rates for four of the 21 lower cost laboratory tests, and one of six higher cost laboratory tests.
"What we are trying to do is promote value amongst our clinicians. We are not trying to cut back on needed healthcare, but we provide so much care to patients that [some] is actually not needed," Sequist says. "At the same time much of the care that is needed isn't getting provided for them. What we are really trying to do is have our doctors look through this lens of value."
Among 27 laboratory tests examined in the study, interventional physicians demonstrated a significant decrease in ordering rates compared to control physicians for five tests. This included a significant relative decrease in ordering rates for four of 21 lower cost laboratory tests and one of six higher cost laboratory tests. A majority of physicians reported that the intervention improved their knowledge of the relative costs of laboratory tests.
"What our survey showed is that most doctors are really interested and willing and engaged in the idea of how much things cost as part of an overall value equation for the care we are delivering, but they have no idea how much things cost and how they would start to bring those things into the decision-making process," Sequist said.
"Secondarily, if you showed them these real-time costs as a part of educating them, does it have an impact on their decision making process? We found in particular for things that are lower cost but higher volume are more discretionary in nature, so doctors may be ordering them more reflexively or feel like they are common things that all or many patients should have done. When you starting showing doctors the cost it may help them think a little more about the value of the tests, the combination of how much it costs and how much it is improving that patient's health outcome."
"Whereas when you look at the things that are less discretionary, the more expensive tests that get offered infrequently, when we showed the cost to doctors they tended to have less of an impact on utilization, probably because the doctor at the point of ordering a less frequent but more expensive test has probably thought a little more about the added value of the test and by the time they ordered it they really believed the patient needed to have it done."
Sequist's study adds to a growing body of evidence suggesting that significant savings can be achieved by eliminating needless lab tests. In October neurosurgery residents at the University of California San Francisco Medical Center demonstrated that a reduction by nearly 50% in the use of five common lab tests has no effect on patient care.
The reductions generated $1.7 million in savings for payers in fiscal 2011–12, and another $75,000 in decreased direct costs for the medical center, according to a study in Journal of Neurosurgery.
In theone year before the project, the residents identified 45,023 of tests for serum levels of total calcium, ionized calcium, chloride, magnesium, and phosphorus in the neurosurgical service. In fiscal year 2011–2012, this number was reduced 47% to 23,660. The residents' findings were part of an in-house initiative at UCSF that encourages clinicians to identify department-specific cost savings and quality improvements in care delivery.
In April, researchers at Johns Hopkins University School of Medicine reported in JAMA Internal Medicine that that when doctors are told the price of some diagnostic laboratory test as the tests are ordered, they respond like informed consumers and either order fewer tests or shop around for cheaper alternatives.
The Johns Hopkins study identified 62 diagnostic blood tests frequently ordered for patients at The Johns Hopkins Hospital. Researchers divided the tests into two groups and made sure prices were attached to one group from November 2009 to May 2010 at the time doctors ordered the lab tests.
They left out the pricing information for the other group over the same time period. When the researchers compared ordering rates to a six-month period a year earlier when no costs were displayed, they found a nearly 9% reduction in tests when the cost was revealed as well as a 6% increase in tests when no price was given. The net charge reduction was more than $400,000 over six months.
The week's largest healthcare deal announcement involves the largest health system in northwestern Illinois. Other news of merger talks comes from central New York state and Wisconsin.
Northern Illinois' Cadence Health and Rockford Health System have jointly announced that they're in merger talks.
"The Rockford Health System Board of Directors has engaged in a deliberate, comprehensive and strategic process to identify a partner to further strengthen the clinical services we provide to Rockford and the region," RHS CEO/President Gary Kaatz said in prepared remarks. "Cadence and Rockford Health System match up on all criteria, including commitment to local governance, superior clinical services and best practices, and a focus on community benefit."
RHS and Winfield, IL-based Cadence will spend the "next several months" refining the partnership, which would be subjected to regulatory review and approval.
Cadence CEO/President Mike Vivoda called the two health systems "like-minded organizations, both with a singular vision of providing excellent patient care with outstanding clinical outcomes guided by the highest standards of quality and safety. Together, we can build a leading multi-regional health system that meaningfully improves access to care, elevates quality, and lowers cost to deliver the best care and value to the communities we serve."
RHS is the largest health system in northwestern Illinois and southern Wisconsin, with nearly 1 million patient visits each year. The system includes: Rockford Memorial Hospital, a regional, tertiary care hospital with 396 licensed beds and a medical staff of more than 440 physicians; the Rockford Health Physicians physician group with 168 physicians in 34 medical specialties; the Visiting Nurses Association, providing home care, hospice and medical equipment; its fundraising arm, the Rockford Memorial Development Foundation; and Van Matre HealthSouth Rehabilitation Hospital, a 55-bed freestanding rehabilitation hospital.
Cadence provides healthcare to the more than 1.1 million patients in Chicago's western suburbs. The system was formed in March 2011 as a result of the merger between Central DuPage Health System based in Winfield, and Delnor Community Health System based in Geneva, IL. Cadence Health employs more than 7,400 people and includes Cadence Physician Group, a local network of more than 250 primary care physicians and specialists on the medical staff at CDH or Delnor Hospital.
Rome (NY) Memorial Hospital Explores Collaboration with Bassett Medical Center
Rome (NY) Memorial Hospital and Bassett Medical Center said they have signed a non-binding letter of intent to develop a collaborative relationship. Now the two health systems will open a due diligence process of at least six months to finalize an agreement that would enable RMH to become a corporate affiliate of Bassett while remaining an operationally distinct hospital with local autonomy, RMH President/CEO Basil J. Ariglio said in prepared remarks.
"Two years ago, our Board of Trustees made the decision to explore opportunities to collaborate with other organizations to prepare for the changing healthcare environment," Ariglio said. "We developed specific community objectives based upon feedback from a cross-section of community constituencies and initiated discussions with several organizations."
Ariglio said the RMH board voted unanimously to pursue the collaborative with Bassett "because we share a common vision of what's necessary to improve the delivery of healthcare services in our region. Establishing a relationship with Bassett will also help Rome expand primary care access and address physician shortages.
Bassett President/CEO William F. Streck, MD, said an affiliation would come as healthcare delivery evolves into the new reimbursement models that reward population health outcomes and value over volume. An affiliation would give RMS and Bassett opportunities to exchange best practices that reduce costs and provide better outcomes for patients.
Bassett Healthcare Network is an integrated health care system serving an eight-county region covering 5,000 square miles in upstate New York. Bassett includes six corporately affiliated hospitals, skilled nursing facilities, health centers and health partners in related fields. With 130-licensed acute care beds, RMH would become the second largest hospital in the Bassett system. RMH has its own 80-bed skilled nursing facility and affiliated primary and specialty physician practices.
UW Health and Aurora Health Care Announce Collaborative Talks
UW Health and Aurora Health Care say they are discussing how the two integrated health systems can work together using accountable care conceptsto improve healthcare delivery and lower costs for Wisconsin and the region.
Talks will include ideas for enhancing the mission of the UW School of Medicine and Public Health, which has had a 30-year partnership in medical education with Aurora. Both systems said in a media release that they can build on their collective strengths in clinical quality healthcare that is among the most cost effective in Wisconsin and a commitment to enhancing the health of populations.
Hospital and health system leaders explain why 30-day readmissions is the clinical quality metric that presents their greatest challenge and describe their management strategies around it.
Primary care physicians waste on average about 30 minutes each day, and nurses waste 60 minutes per physician per day, on tasks that could be altered to take substantially less time, a study finds.
Red-flagging and eliminating inefficiencies to improve patient flow may go a long way toward relieving the looming shortage of clinicians in the primary care workforce.
A study in this month's Health Affairs says easily implemented, system-wide changes that save a few minutes here and there during the workday could yield dramatic gains in physician capacity while reducing physician burnout and improving care.
"Very little attention is paid to opportunities to get more out of our current workforce, not by working harder, but by working more efficiently," says study co-author Scott Shipman, MD, a pediatrician and director of primary care affairs and workforce analysis at the Association of American Medical Colleges in Washington, DC.
By some estimates there will be 15 million to 24 million additional primary care visits each year in the near future when millions of people are expected to gain access to health insurance under the Patient Protection and Affordable Care Act, further stressing an already overworked primary care clinical workforce.
After observing first-hand the workflow at physicians' offices and interviews with clinicians, Shipman and co-author Christine A. Sinsky, MD, a general internist at Medical Associates Clinic and Health Plans in Dubuque, IA, estimated that primary care physicians waste on average about 30 minutes each day, and nurses waste 60 minutes per physician per day, on prescription renewal tasks that policy changes could substantially reduce.
The two physicians believe that eliminating 30 minutes of wasted time each day could translate into 30–40 million more primary care visits available each year without a single additional provider.
"Other efforts to overcome the primary care shortage, by training more, losing fewer, or finding someone else, they all have their place but in and of themselves those are relatively inefficient strategies," Shipman says. "Training more physicians takes a long time and a lot of resources and with current trends in terms of specialty choice it may not yield the workforce we most need."
"Losing fewer physicians has a lot of potential if we change the model of practice to address burnout. But driving inefficiencies out of practice will have a secondary effect on that… The non-physician clinicians such as nurse practitioners and physicians' assistants have an important role, but that too requires training and cost of training and bringing more people in when we can do a lot more with the people we have if we just look critically at how to root out even some of these inefficiencies on a widespread basis."
The study identified these ways to improve efficiency:
Teamwork and delegation, because research suggests that staff could perform tasks that consume 15% of the time physicians spend on patient care outside of visits.
Redesigned work flow that co-locates physicians with the rest of the healthcare team throughout the day and facilitates "real-time" communication, which can save a physician 30 minutes each day.
Acknowledging the double-edge of technology, including the "time sink" that can be created for physicians entering patient data in electronic medical records, while also seeing efficiencies created by software programs that triage patients and guide treatment decisions and don't require an office visit, which can improve care quality and reduce the burden on physicians' time.
Re-examining policies ranging from having a computer automatically sign out a user for security reasons, requiring users to sign in recurrently, to limitations in non-clinicians' ability to assist in routine, protocol-driven care.
In a phone interview, Shipman discussed the study and some of the themes that emerged from it. The following is an edited transcript of that conversation.
HLM: Has primary care workflow always been inefficient, or has it gotten worse because of the increased demands and because the practice of medicine has gotten more complicated?
Shipman: It's some of both. There has been an element of inefficiency that hasn't been highly prioritized in medicine. This goes beyond primary care but is certainly relevant for primary care. Because both demographic demands and recognition of the unsustainability of the rising cost of healthcare have become more prominent the focus on where to root out inefficiency becomes more prevalent.
Complexity is an important part of this in two perspectives. There is complexity in terms of how a primary care practice best meets the needs of its patients. As we advance in our understanding of the many dimensions that include health above and beyond the typically narrow medical care that doctors have always provided, we think more and more about how to serve those needs and it is increasingly impossible for a physician as single person to meet the narrow medical needs and broader social needs that a patient has in maximizing their health and wellness.
From that standpoint it is more complex and certainly advances in medicine have made care more complex and mastering care more complex.
As a single technological advancement, the electronic medical records is one that we have to be honest about, because so far its implementation has been not an aid to efficiency of the physicians' time.
Unfortunately, we have taken yesterday's model of documentation where the doctor did the documentation and continued that with electronic medical record and that has been shown time and again, in both quantitative and qualitative ways, to be a burden on physicians cognitively and on their time, way out of proportion to what documentation used to be. There is an added complexity that has been brought on by that tool as well.
HLM: Will these inefficiencies be addressed more quickly with the advent of physician-employees, or will it make matters worse because salaried physicians will lose their sense of urgency?
Shipman: All employed settings aren't the same and it is not intrinsically the case that private practice doctors have more of an incentive to be efficient than the employed physicians. In some cases, the risk of changing the practice model feels greater in a private practice setting.
What is needed is a revamping of the way medicine is practiced and what a physician does on an hour-to-hour, day-to-day basis. That change may be more risky when everything is on the line by virtue of your role as the breadwinner for the practice. Whereas, in an employed or larger setting, there may be greater opportunity to push for those changes or to enable those changes in the way care is delivered.
HLM: Who needs to lead this efficiency movement?
Shipman: It's an opportunity that physicians shouldn't pass up. They have an opportunity to be in the lead here. They understand better than anyone where their inefficiencies are.
The problem for primary care physicians is that they spend so much of their time running at full speed just to keep up they don't have the time to reflect on how it can be done better. At some level if the physicians don't take the initiative and the screws keep getting tightened down in driving for greater efficiency in overall healthcare delivery and reduced or controlled costs others will step in and push forward.
Imparting lifesaving knowledge throughout a population can help community members form bonds of trust with healthcare professionals. It can also enable population health advocates to generate community interest in other proactive healthy lifestyle choices.
First, the bad news: A study this week in JAMA Internal Medicine from researchers at Duke Clinical Research Institute in Durham, NC, shows that cardiopulmonary resuscitation training rates are low in rural and poorer counties, and in areas with higher minority populations, particularly in the South, Midwest and West.
Each year, the Duke study notes, more than 350,000 people suffer cardiac arrest outside of hospital walls and less than 9% of them survive, an average that fluctuates considerably with geography. That is because the rates of bystanders performing CPR vary from 10% to 64% depending on where they live.
It seems logical to presume that if survival rates more than double when bystanders administer CPR, then the best way to get them to perform CPR is to train them in this relatively simple procedure.
In a first-of-its-kind study, Duke cardiologist Monique L. Anderson, MD, and fellow researchers analyzed a year's worth of CPR training data from the American Heart Association, the American Red Cross, and the Health & Safety Institute for 13.1 million people living in 3,143 counties, with a median county training rate of just under 2.4%, which again, fluctuates considerably from county to county.
The researchers looked at associations between annual rates of CPR training completion and a county's geographic, population, and healthcare characteristics. As is so often the case in population health studies, rural, poor, and minority populations did not fare well.
I asked Dr. Anderson to explain why some populations aren't getting CPR training, and she flipped the question.
Knowledge is Power
"We need to take a step back and ask 'why are some people CPR-trained?'" Anderson says. "The American Red Cross, the American Heart Association, and the Health & Safety Institute have a pretty good community base for CPR training, but it's largely healthcare institutions and professionals and persons who require CPR training on the job for safety reasons such as (Occupational Safety and Health Administration) requirements or lifeguards."
Now, the good news: While it's discouraging to see that some segments of the population appear to be left behind in CPR training, this is a teachable moment.
"I don't think we have officially known where people weren't getting training until this study," Anderson says. "This study brings to light more areas for focus and intensive research. It also is an opportunity not only for CPR training organizations but community leaders and local governments to come together and ask these questions: 'What are our training rates? What are our bystander CPR rates? How does our survival look when compared nationally? And how do we come together to build systems of care program that will bring about a change?'"
The Duke research gives community health champions a cause and a blueprint and an opportunity to engage the people they serve. If successful, the results will be tangible. People will survive. CPR training is so simple and inexpensive that Anderson says she can teach it "in a matter of minutes."
For starters, as a part of coordinating post-discharge patient care with families, clinicians should ensure that there is a CPR-trained person in the home because most cardiac events outside of the hospital occur inside the house, not in public.
In North Carolina, it's now a state law that high school students must complete a CPR training course before they can graduate. Anderson says there are other opportunities to train large swaths of the population by making CPR training mandatory during the drivers' license application process.
On the local front, hospitals, health clinics, emergency responders, schools, and large employers are the logical candidates to lead a CPR training initiative in their communities.
Spreading the Message
Population health champions can speak with local media about CPR training, how simple the process is to learn—especially now that mouth-to-mouth resuscitation has been phased out in favor of chest compression—and how it can benefit everyone in the community.
Write an op-ed piece for the local paper. Get an interview on local radio or TV. Tweet it on Twitter! 'Like' it on Facebook. Post it on your Web site. All of this can be done at minimal cost. Hospitals, and other community health assets already have CPR-trained staff and organizations such as the American Heart Association, ARC and HSI can provide guidance to build CPR training programs.
"Think about it. If the county government, the major hospitals in the area and the largest businesses required all of their employees to be CPR trained we would make amazing strides," Anderson says.
Unlike other worthy and vital public health initiatives such as cancer screenings or flu shots, people undergoing CPR training are not passive recipients of services provided. They are being challenged to learn a lifesaving skill for the betterment of their families, friends, and communities.
Imparting lifesaving knowledge gives people a sense of accomplishment. It will create a bond of trust with the healthcare professionals who teach them. That is powerful stuff and it can provide that foot in the door for population health advocates to pursue other proactive healthy lifestyle choices such as diet and exercise.
A recommendation from the American Medical Association calls for physicians to determine how care teams are paid. The American Association of Nurse Practitioners calls the AMA's link of reimbursements to physician-led teams "anti-competitive."
The American Medical Association House of Delegates this week adopted recommendations for creating payment structures for physician-led team care delivery models with physicians determining who gets paid and how much.
"The success rate of physician-led team-based models of care has been proven time and again by trusted industry leaders like the Mayo Clinic, Geisinger Health System, Intermountain Healthcare and Kaiser Permanente," AMA President Ardis D. Hoven, MD, said in prepared remarks.
"In the words of Dr. William Mayo, 'It has become necessary to develop medicine as a cooperative science: the clinician, the specialist, and the laboratory workers uniting for the good of the patient.' The AMA and the broader physician community firmly believe that this approach represents the future of health care delivery in America."
The AMA recommendations call for:
Physicians who lead team-based care in their practices to receive payments for healthcare services provided by the team and to establish payment disbursement mechanisms that foster physician-led team-based care;
Physicians to make decisions about payment disbursement in consideration of team member contributions, including factors such as volume and intensity of the care provided, the profession, training and experience of each team member and the quality of care provided;
Payment systems for physician-led team-based care: to reflect the value provided by the team, with the savings accrued by this value shared by the team; to reflect the time, effort, intellectual capital provided by individual team members; to be adequate to attract team members with the appropriate skills and training to maximize the success of the team; and, to be sufficient to sustain the team over the time frame that is needed.
Not surprisingly, nurses associations are not embracing a list of recommendations that leaves physicians calling all the shots.
"We have supported integrated models of care moving towards reimbursement alignment for quality and outcomes over fee-for-service," says Tay Kopanos, DNP, FNP, vice president of state government affairs for the American Association of Nurse Practitioners.
"However the AMA's continual link of reimbursements to physician-led teams and outdated licensure approaches is not only anticompetitive, it limits patient choice and access to care. It fails to recognize not only the Institute of Medicine recommendation on team-based care, it also fails to recognize the national accreditation standards for team-based care and patients who are in medical homes that allow flexibility in team leadership."
The AMA's House of Delegates also passed a report that more specifically defines team-based roles and terms including "physician-led," "supervision," and "collaboration."
"Virginia recently adopted a law that supports and promotes physician-led healthcare teams as a collaborative, consultative approach to healthcare," Hoven said. "With an aging population and a surge of newly-insured patients entering the system, we encourage other states to consider adopting this innovative approach to helping facilitate the work of highly-functioning teams of medical professionals who can meet the growing demand for healthcare."
Kopanos says states' efforts to develop guidelines for physician-led team-based care have not worked well for nurse practitioners.
"In any state that has nurse practitioner practices owned and operated by nurses or nurse-managed health centers, their ability to participate in insurance and managed Medicaid is eroded when physician leadership is a requirement," she says.
"Many nurse-managed health centers see patients, diagnose them, treat them, manage them and write prescriptions without any involvement from physicians. If a reimbursement model requires physician leadership those nurse-managed health centers close and the patients who get their care at those sites can no longer get care."
Kopanos says it is well established that not all care regimens require a physician's input, which otherwise adds needless costs and wastes resources for an already short-staffed national healthcare workforce.
"Team-based care is centered on the needs of the patient and the providers who can best meet that care. We have a multitude of providers, nurse practitioners, pharmacists, physical therapists, behavioral health experts, who at certain times based on the needs of the patient may be the best ones to lead the team for what that patient needs," she says.
"When we artificially move the licensure or reimbursement to one particular profession we are shortchanging the patients' ability to get the provider they need and to utilize our workforce more efficiently to take care of patients."
Even though compensation growth has slowed a bit—CEOs report a gain of only 4% over two years—the demand for physician executives continues to increase. Median annual pay reported by doctors in executive roles is $325,000.
The sluggish economy and the uncertainty around healthcare reform have slowed physician executive median compensation growth over the last two years. However, it's still a very good living.
The 2,364 physician executives who responded to the 2013 Physician Executive Compensation Survey from Cejka Executive Search and American College of Physician Executives reported that their compensation grew an average of 7% between 2010 and 2012 with median of $325,000 across all 19 titles and 26 organization types.
Cejka President Lori Schutte says the news on slower compensation growth isn't really surprising given the state of affairs in healthcare and the overall economy. "Compensation has slowed a little bit," she says. "While we used to see 12% increases, this year it was 7% over the last two years. That is indicative of the economy. Nobody is getting big raises."
In the C-Suite, chief executive officers reported a 4% gain over two years, the smallest median increase among executive groups, which Schutte says may reflect the reliance of their pay packages on organizational financial performance during an economically and politically uncertain period.
Seniority and longevity are rewarded, but only to an extent.
Lori Schutte, President of Cejka
The survey found "a discernible shift this year in a long-term pattern. From 2005 through 2011, there was little or no growth in compensation after an executive has spent more than 15 years in administration. For the first time since the 2005 report, the rate of increase in median compensation did not drop as significantly between those with 10–15 years and those with 16 or more years."
"It isn't necessarily how long you are in the role determines how much your pay is going to increase," Schutte says. "You may not be getting big increases every year where if you are earlier in your career, you've only been there a few years and you've had good performance, you're likely to get bigger increases. It may also be that once you've been in that job, after 15 years you may be topped out, especially if you are with the same organization. It is not that you aren't performing well, you're just at a different spot in your career."
Even as compensation growth slows, however, Schutte says the demand for physician executives continues to increase "in a lot of different areas."
"It used to be just their niche was [vice president of medical affairs] or [chief medical officer] but now it's really expanded and it continues to expand," Schutte says. "There is a growing demand for physician executives in lots of different areas – chief quality officers, chief medical information officers, and CEOs. I don't know if it is necessarily a surprise."
And increasingly, Schutte says physician executives are demonstrating the value of obtaining advanced graduate degrees such as masters in business administration.
"That shows the complexity of what they are asked to deal with," she says. "Those jobs are harder. They're dealing with many of the business issues as much as they are the medical issues. Whereas in the past it was just 'we are hiring you to direct the physicians.' Now the physicians are dealing with the business of the hospital."
Schutte says there is a clear link between advanced degrees such as MBAs and job opportunities in senior management and earning power for physician executives. The survey found that physician executives holding MBAs enjoyed a 10% difference in median compensation when compared with colleagues with no post-graduate management degree.
The difference is even more pronounced at the C-Level. The MBA is the most prevalent post-graduate business degree among C-Level executives and respondents showed that there is a 7% to 28% difference in median compensation between those holding an MBA and those with no post-graduate management degree.
"They will get paid more having an advanced degree," she says. "We have some clients who will require it and we have other clients that don't necessarily require it but prefer it, but will consider applicants based on their experience and what roles they have. So, it depends upon the individual client. It also depends on the scope of the position, how large of a facility it is, what the scope of the responsibility is. If a physician who wanted a leadership role asked me if they should get an MBA I'd tell them they'd get a good return on investment."
For the sake of perspective, the median compensation of $325,000 reported by physician executives keeps them among the top 1% of wage earners in the United States, federal data shows.
A merger would unite two of the strongest health systems in the mid-Atlantic region. Physician-led Geisinger is known for its work advancing population health and value-based care. New Jersey-based AtlantiCare has a national reputation for performance excellence. Both have high bond ratings.
David P. Tilton, president/CEO of AtlantiCare
Geisinger Health System and AtlantiCare announced this week that they are exploring an affiliation.
"What we are contemplating is a fully integrated model," says David P. Tilton, president/CEO of Atlantic City, NJ-based AtlantiCare. "That is the way that we will most effectively share best practices, learn from each other, and develop AtlantiCare in Southeastern New Jersey. Ultimately we are trying to build a healthy community in southern New Jersey. That is what we've always been about and this opportunity with Geisinger helps us move more quickly and effectively in that direction."
The health systems signed a letter of intent this week after AtlantiCare spent a year winnowing the field. They will spend the next nine months to a year exploring their affiliation options.
If the talks are successful, a merger would unite two of the strongest health systems in the region. Danville, PA-based Geisinger has built a national reputation for its work advancing population health and value-based care, and its innovative use of healthcare information technology. Geisinger is the nation's largest rural health services organization, serving more than 2.6 million people in 44 counties in central and northeastern Pennsylvania. The physician-led system has more than 20,800 employees, including a 1,000-member multi-specialty group practice, seven hospitals, two research centers and a 448,000-member health plan.
AtlantiCare is the 2009 winner of the prestigious Malcolm Baldrige Award, and its flagship AtlantiCare Regional Medical center was designated as a Magnet hospital in 2004 and re-designated in 2008. The system includes AtlantiCare Solutions, the AtlantiCare Foundation, the AtlantiCare Physician Group and AtlantiCare Regional Health Services, with more than 5,461employees and 600 physicians serve Southeastern New Jersey in nearly 70 locations.
Geisinger CFO Kevin Brennan says "the optimal outcome would be a complete integration of both companies into a system." He rejected any suggestions that there was a "weak sister" in the proposal.
A Unified Objective
"We are both in pursuit of the same objective, which is to improve the health of our communities," he says. "Of course we are a lot larger and we own a health plan and we have a lot of national accolades for the type of advances we have been able to accomplish in population health management. But both of us are financially strong. They're A-rated and we are AA-rated, which is why we would be interested in going outside of our more traditional service area. So there is no weak sister."
Tilton says AtlantiCare "has never been stronger" as it enters the merger talks.
"Our clinical outcomes are exceptional. We are a recent Baldrige winner. We share the highest bond rating in the state of New Jersey. We have great employee satisfaction. We are hitting on all cylinders now making great progress transforming our business model and we are please with where we are and what is occurring," he says.
Why Mess With Success?
"There is a fundamental shift that is occurring in our business and it is changing the way that healthcare is provided, consumed, and paid for," Tilton says. "We see great opportunity in that set of circumstances and believe we need to innovate care models more effectively and achieve better outcomes in quality and patient experience and of course value for the healthcare consumer. This is the time when wise organizations should move forward and accelerate their transformation because the market is shifting and it is time to do it now."
"Geisinger is a national thought leader," Tilton says. "We have a national reputation, but theirs is exceptional. They've done wonderful work in adopting these new value-based models. They have been able to continue to refine their model and achieve outcomes that are very special. So, I think in that respect they've developed further than we have. Like any good relationship I hope we can add to the conversation and the work we are doing together. I see it as a very win-win opportunity for us in terms of what we need to do for the future."
How Geisinger May Benefit
Tilton says AtlantiCare "brings to the table a very high-performing organization with an incredible culture, the way people work and focus on patients first."
"I know a lot of people say that but we are doing it each and every day," he says. "The quality outcomes that we achieve, the way our employees are engaged in the work we are doing and the work environment created here, the way we connect with our community in ways that are very special in terms of engaging them and activating them around their own care, we have a very balanced approach to not only leading the organization but achieving outcomes."
"What we bring to the table is a partner for Geisinger who knows how to organize work effectively, engage our staff and physicians in that work, connect with the community in a meaningful way, and really execute very well on our plans. We are an example of how they hope to scale their model to other markets."
Tilton and Brennan say they're not concerned about a clash of cultures or egos when two successful and progressive leadership teams get down to brass tacks on deciding how to run a health system.
"When you bring two companies together you hope to take what is extremely good and make it great," Brennan says. "That is the hope here, not that there is any one model that has figured it all out. Winning a Baldrige Award sets them apart nationally. And all of the things that we've been able to innovate and demonstrate nationally with our proven care models totally differentiate us from any other type of suitor that may have been considered by AtlantiCare in their year-long process."
Tilton says AtlantiCare's success has been in great part due to its willingness to learn from others.
"One of the key characteristics of our organization is that we know we don't have everything figured out," he says. "That has been part of what has driven us as a learning organization for the past 25 years. We are always open to new ideas and best practices and learning from others. In my interactions with Geisinger they see the world that way too. I don't think you can perform at a high level in this field unless you were open to others' thinking. That is how you earn a Baldrige Award. You learn best practices, you shape it for your own organization and you try to execute on it. That's been part of our culture for some time."
Senior healthcare executives responding to HealthLeaders Media researchers indicate that their biggest stumbling block to an effective patient experience strategy is the difficulty of changing organizational culture.
Why is that so difficult, and what can leaders do to help bring about a culture that embraces patient experience?
Pauline Arnold
Chief Nursing and Quality Officer
Vice President of Clinical Operations
IU Health La Porte (Ind.) Hospital
On mission drift: When you ask people why they are in healthcare, the answer invariably is "I want to help people." In that helping, sometimes we didn't engage people to become part of the helping. The helping became doing it for them.
On engaging the patient: We have to change the way we think about patients and their families and the role they play in their own healthcare. Patients seek out providers to give them answers to their healthcare questions. They want solutions that they can understand and embrace. Often they have researched information on the Internet that may or may not be correct. But there is an inconsistent embracing of their own responsibility for their own healthcare and seeking to partner with the healthcare provide to achieve their own healthcare goals.
Leaders have to commit to changing their own behaviors that then support those core beliefs. Tools aren't enough and educating people isn't enough. It requires a fundamental change in how we think. Then you use the tools to help establish the consistency for the behaviors that you know are required to meet your new beliefs.
On effecting the change: You can implement a change but that doesn't become the culture until it is embedded into the DNA of what we believe in the organization. You know it's in the DNA when it happens every time. It becomes a culture of always. We are on a journey. We are not there yet.
Jeffrey M. Fried, FACHE
President and CEO
Beebe Medical Center
Lewes, DE
The reason why it is so difficult is because changing culture involves changing everything in your organization. It involves looking at every process and opportunity for communication. It looks at performance reviews, how you recognize people, the values that you communicate to the organization. It involves not just communicating but also getting everybody in the organization to embrace it and be engaged in what is happening.
What has worked for us is having a clear message about what we are trying to accomplish, setting high standards, reporting frequently on how we are doing, and letting the frontline staff who interact with the patients come up with the ideas about what we can do to improve patient satisfaction.
We are continuing to improve, and the more we can get people involved, the more creative and innovative can be the ideas they come up with. For example, several years ago our employees came up with the idea of creating a competition among the different units, departments, and floors. We looked at team sports. We have a quarter where we are focused on football and we use football analogies and terms to help promote the idea of competition when we are trying to do a better job. Then we go to basketball and baseball and NASCAR. That idea didn't come from anybody in leadership. It came from frontline staff.
Timothy Putnam, DHA President Margaret Mary Health
Batesville, IN
We are realizing that if we are really patient-centered it requires teamwork and you have to convey trust in the skill you are giving to the patient but also in the rest of the team. That takes time. It wasn't how we were trained.
We don't have a shortage of people wanting to do the right things for patients. It's getting them to understand what those right things are: recognizing that we are all caregivers, from direct patient care to all the other departments. Information technology, environmental services, dietary are all caregivers whether we interact with patients directly or not. We have to reinforce that day in and day out.
As we make the transition from volume to value we look at how we add value from the patient perspective and that is the next logical step. It fits right in with patient-centered care. What is the value to the patient? What do they want? What is going to help their health improve? And a lot of what we are finding is that to improve their health it is not additional health services. Sometimes it is social and support services, transportation, and other things that we are going to have to figure out how to engage if we are really delivering patient-centered care.
Gary Muller CEO
Marquette General Health System
President and CEO
Superior Health Partners
We have to somehow let the patient be the only thing we are thinking of during the day. This is perfect for us because we are looking at the value equation being quality and service over lower costs so the service part is just as important as anything.
There are many components. It's not just how to take care of the patients. It's about hiring the right people. It's retaining the right people. It's supporting the team. It's looking at the patients' needs first. It's coming into your job, whatever it is, and thinking my job is taking care of people. Some people do that naturally. Others just need to have that reinforced all the time, and that is where leadership comes in.
The expectations and accountabilities will be rolled into their job evaluations, rewards, and incentives. We are taking the carrot approach and putting a lot of emphasis on the patient satisfaction scores.
A big part of our culture and at any hospital starts with the physicians. We are putting a lot of emphasis on physician training and using them as part of the culture of change. That is a little more difficult. We employ about half of our physicians. We can influence them a little bit more than the private docs. A big part of it is getting them into the loop for training.
