The Dynamic State of
       Physician-Hospital Alignment:
 Using Collaboration and Strategy to Drive Success


           ...
“Triumph of
                                  HOPE
                                   over
                              E...
Learning Objectives
  1      Recognize key drivers of alignment.


  2      Create a physician alignment plan.


  3      ...
Agenda for Today
                            Imperative for Alignment
   •    Transformation of Health Care Industry
   • ...
Imperative for Alignment




                                            5
American College of Healthcare Executives
The Path to Alignment
                    • To work together, especially in a joint intellectual
Collaboration
           ...
What’s Going on Out There?
Patients, physicians, hospitals & government agree on one thing:

                             ...
Transformation of Health Care Industry
       Research                        Consumer                           Industry ...
Consolidation Among Providers is
 Altering Traditional Revenue Sources
                   Provider Issues                 ...
Physician Shortage is a Result of Both
Increasing Demand and Shrinking Supply
    Increasing Demand                       ...
Physician Workforce is Aging…
            Like the Rest of Us
                                                            ...
Physician Workforce
   • Shortage: 124,000-159,300 by 2025
               Variables: increased utilization, younger
      ...
The Decline in Physicians’ Real Income
                                                                                 Ph...
2005 to 2007                                                                                Women represent
 46% increase ...
Physician labor market
                                                                                                   ...
The Mood of Medicine
  “But in the days when a successful career was built on a number of
  tacitly recognized pillars-out...
ACHE Top Issues 2007
                    1. Financial challenges
                    2. Care for the uninsured
           ...
ACHE Hospital-Physician Issues:
         2006 Survey
  • Physician recruitment
  • Physician-hospital competition as oppos...
Better Together:
        Business Case for Alignment
                         • Patients still follow physicians to hospit...
Credit Rating                           “Contemporary” Credit Ratings
                                                    ...
Focus: What strategies are being used to
           strengthen physician-hospital alignment,
           & which strategies...
ACPE Survey
                                     ACPE Survey
     Private practice relationship significantly lower than e...
Whose Perception is Reality???
                          Perceptions of Existing Relationships with Active Staff
         ...
Imperative for Alignment

            Do these trends reflect what you are observing?

             • locally?
           ...
Strategies that Work




                                            25
American College of Healthcare Executives
2005 Noblis National Study Key Findings
       Infrastructure
       Infrastructure                     Substantive       ...
Noblis’ 2005 Physician-Hospital Alignment Study
               • Physicians are going to be either collaborative partners ...
Noblis-ACPE 2008 Survey
  • Physician-hospital relations: disconnect at the top
  • Physician-Hospital alignment
         ...
Alignment Model

                             Strategic initiative

            Multiple parallel strategies & tactics


 ...
30
American College of Healthcare Executives
Physician-Hospital Alignment
         Critical Success Factors
                        Medical staff leadership

         ...
Physician-Hospital Alignment
          Strategic Plan Metrics
                                            • Joint ventures...
American College of Healthcare Executives   33
Relationships
                             Formal & informal leaders
   Who is the
    medical                  Governance...
What About this Autonomy Thing?
           Unique Highly Specialized Profession


           Autonomy: “Independence of ac...
So…What Makes Physicians
           Really Unhappy?
            • Lifestyle
                   Work schedule
             ...
2008 Noblis-ACPE Study:
           What are the most important activities that strengthen
                     hospital-ph...
Generational Profile
                           Generations predict values & behavior
                               Gener...
Generational Clashes
                                       Tensions
        • Jealousy & competition

        • Perceived...
Economic Impact of Physician Relationships
   Percent of Non-Primary Care Office Visits Referred by Another Physician
    ...
Difficult to Get Traction…
When You are Playing in a Sandbox
      Education about each other’s interests
  •
      Entitl...
It Might Be All About You…
                         What are your generational views?




                              Ar...
What Management Can Do…
       Practice what you preach: Build respect among senior
       executives


       Be role mod...
Trust
  • Please don’t start off by promising a
    “new compact”
  • BOT, Executives and Medical Staff Leaders present
  ...
Leadership Development

                          Leadership Training

        BOT-Medical Staff-Executives retreats

    ...
American College of Healthcare Executives   46
Physician Motivation
                    Do the right thing for my patient
                •
                    I am acco...
What do Physicians Want?
      #1: How the administration responds to my ideas and needs
  •
      Easier to care for pati...
Quality
   • Key Strategy… not a program… it is what we do… the
     services, the processes
   • Long term physician and ...
Quality & Physician Alignment
         Quality Culture: I’ll know it when I see it and feel it.

                         ...
Quality is Good Business
   •   Top 5: ACHE Top Issues
   •   Strategic business goal
   •   Direct financial incentives
 ...
Financial Markets
                                     Successful quality strategy
       Strong physician buy-in
  •
    ...
The Value Proposition: Efficiency
              What can I do                           Look how much
                    ...
Infrastructure Support
                                   System support
   • Clinical staff
           Lean Management
  ...
Information Technology
  Information Technology
      Provider Order Entry & data retrieval
  •
      Web Portals
  •
    ...
The Value Proposition:
                 Hospitalists & AHPs
     • Less call & less competition         • Intended consequ...
Physician Liaison Program
  • Pattern recognition & early intervention
          I can predict the past with 100% accuracy...
American College of Healthcare Executives   58
Physician-Hospital Alignment &
               Governance
      Mission…do the right thing for patients
  •
      Active in...
Let’s Get a Bit Personal
  Executive incentive compensation measures typically include:
      Profitability
  •
      Qual...
ECHN BOARD

                                                           Board PA/I Committee
       OFFICE OF              ...
Governance Structure
                                        BOT
      Bylaws, nominating process & committee structure th...
Governance Style
                                            • Set planning goals
           Medical Staff,
           Exe...
Who are Physician Leaders?
   Elected leaders
        Opinion leaders
               Contracted leaders
               • V...
Being a Physician Leader

  • May be difficult to identify true physician
    leaders
  • Physicians may view leadership v...
Changing Medical Staff Governance
          Good ole days                                             Now
    Loosely asso...
American College of Healthcare Executives   67
Ventures
      Joint Ventures
  •
      Service Line & Medical Directorships
  •
      Call Coverage Agreements
  •
      ...
Legal Advice
  Need up-to-date, practical & reasonable counsel more than
  ever before

  Numerous places to stumble & rea...
Joint Ventures
                                   Clinical Services
    • ASC, Endoscopy, Imaging, Oncology-Radiation
    ...
Lessons Learned Regarding JVs
                                     “Joint ventures are very complex arrangements. There
  ...
Medical Directorships
  • Reimbursement for officer, chair, chief,
    medical director & other roles
  • Role growing to ...
Service Line Management
  • Hospital contracts with physician
    management company to manage clinical
    service
  • Op...
ED Call Coverage
  • Emblematic of struggle between hospitals’ and physicians’
    needs & interests
  • Time is $
  • Muc...
ED Call Coverage
 • Solutions reflect empathy, business needs,
   and communication
 • OIG Advisory Letter (9/07)
 • Multi...
THE FABLE OF THE SURGEON & THE TENT

  • Porridge for one is expensive
  • The pot of gold at the end of the rainbow is a
...
Physician Employment is
               Different This Time
  • Substantial economic advantages for systems that           ...
Hospital Group Employment
           Business Structure                                   ROI
    Practice management     ...
Employment Pitfalls
  • Assume loyalty of physicians…and
    manage just like other employees
  • Failure to manage BOT, m...
Medical Staff Development Plan
              (MSDP)
       Community need

       Business/Strategic need

       Regulato...
Physician Resource Assessment Model*
   Population Characteristics                                     Mix of Specialties
...
MSDP Confounding Factors
                                     • Takes 1.3-1.5 to replace older physicians
                ...
Recruiting
  • High level team
         Broad input finds the good, bad & ugly early in process
         CEO involvement
 ...
Better Together or…
                     Bitter Together?
     Pay for Performance

                     Gainsharing

    ...
Special Situations:
                    Mergers & Acquisitions
             Clinical staff care about their service; it
  ...
Special Situations:
                Mergers & Acquisitions
                 Medical staff…big unknown
  • Influence &/or b...
Special Situations:
                Mergers & Acquisitions
                    Gain                                    Los...
Special Situations:
                Mergers & Acquisitions
  • Merger advisory group membership
         Merger of equals ...
Strategies that Work
            What has your organization tried?


            How effective have you been?


          ...
How to Make it Work for You




American College of Healthcare Executives   90
American College of Healthcare Executives   91
Conduct a Formal Physician-
       Hospital Alignment Process
 1) Assess the current situation – interviews, surveys, data...
10 Things to Do Back at the Ranch
       Create a physician strategic advisory group
       Get physicians, BOT, and Admin...
Thoughts for the Future
           Who will be the physician leaders of medical staff & BOT?

            • Will physician...
Making it Work for You

             How ready is your organization to implement
             these strategies?


        ...
Amy MacNulty
      Amy MacNulty is a Senior Principal and Northeast Region Manager
       Amy MacNulty is a Senior Princip...
Joel J. Reich, MD, FACEP
      Joel J. Reich is the Senior Vice President for Medical Affairs for
       Joel J. Reich is ...
Contacts
Amy MacNulty                                Joel J. Reich, MD, FACEP
Senior Principal                            ...
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The Dynamic State of Physician-Hospital Alignment: Using Collaboration and Strategy to Drive Success

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The Dynamic State of Physician-Hospital Alignment: Using Collaboration and Strategy to Drive Success

  1. 1. The Dynamic State of Physician-Hospital Alignment: Using Collaboration and Strategy to Drive Success Amy S. MacNulty Noblis Center for Health Innovation Joel J. Reich, MD, FACEP Eastern Connecticut Health Network 1 American College of Healthcare Executives
  2. 2. “Triumph of HOPE over EXPERIENCE” Samuel Johnson, 1791 Samuel Johnson, 1791 2 American College of Healthcare Executives
  3. 3. Learning Objectives 1 Recognize key drivers of alignment. 2 Create a physician alignment plan. 3 Share “lessons learned”. 3 American College of Healthcare Executives
  4. 4. Agenda for Today Imperative for Alignment • Transformation of Health Care Industry • The Mood of Medicine Strategies that Work • Key Findings of National and ACPE Study • Alignment Model – How Effective is Your Organization? How to Make it Work for You 4 American College of Healthcare Executives
  5. 5. Imperative for Alignment 5 American College of Healthcare Executives
  6. 6. The Path to Alignment • To work together, especially in a joint intellectual Collaboration effort. (or, To cooperate treasonably, as with an enemy occupation force in one's country.) • A promise or pledge. (or, A hostile meeting of Engagement opposing military forces in the course of a war) • A state of agreement or cooperation among Alignment persons, groups, nations, etc., with a common cause or viewpoint. Getting to a truly shared goal 6 American College of Healthcare Executives
  7. 7. What’s Going on Out There? Patients, physicians, hospitals & government agree on one thing: UNHAPPINESS Demand & Access • Quality, Safety & Service • Financial viability • Health reform • Coverage expansion • Cost control • Medical home • Pay for performance • 7 American College of Healthcare Executives
  8. 8. Transformation of Health Care Industry Research Consumer Industry Technology Trends* Trends Trends Trends • Expansion of • The “Responsive • Strained Access to • Electronic Medical Telemedicine and Customer” and Capital and Tax Records/CPOE Robotics Medical Tourism Exempt Scrutiny • Expansion of Point of • Regenerative • Growing Incidence of • Increased Stress on Care Testing Medicine Obesity the Workforce • Wireless • Restorative Medicine • Access to In Home • Physician/Hospital Communication Therapies and Easy Relationships and Devices • Stem Cell Research Access to Medical Medical Homes • Home Health Care • Regional Data Remote Monitoring • Access to Online Sharing and Expansion of Medical Records RFID Technology Source:* Piquepaille, R (06/27/08). A Portable Solar-Powered ECG Unit. EmergingTech http://blogs.zdnet.com/emergingtech/?p=992 8 American College of Healthcare Executives
  9. 9. Consolidation Among Providers is Altering Traditional Revenue Sources Provider Issues Purchaser Issues Hospitals seeking efficiencies Consumers more aware of price • • and quality Hospitals diversifying, focusing • on outpatient and wellness care Baby boomers moving to the • Medicare program Increased emphasis on • standardization, integration and Medicare and other payers • consolidation of services expecting “value” for payment Evolving physician/hospital Commercial insurers under • • relationships pressure from employers to reduce cost Consumers picking up more of the • healthcare “tab” Source: (06/08).Come Down from the Ledge. HealthLeaders. 32-36. Grote, Kurt, Levine, E., & Mango, P. US Hospitals for the 21st Century. HealthLeaders, Retrieved 08/11/08, from http://www.mckinseyquarterly.com/ 9 American College of Healthcare Executives
  10. 10. Physician Shortage is a Result of Both Increasing Demand and Shrinking Supply Increasing Demand Shrinking Supply Aging Aging physician population workforce Physician Physician Shortage Shortage Changes in Growing practice patterns population Education Longer life system spans Need for constraints Physician Prevalence of Workforce chronic disease Planning 10 American College of Healthcare Executives
  11. 11. Physician Workforce is Aging… Like the Rest of Us 2007 Merritt Hawkins Survey Physician 49% of physicians > 51 plan to make a change in 49% of physicians > 51 plan to make a change in Population is next one to three years next one to three years Aging Plan to retire 14% Plan to retire 14% Plan to work on a temporary basis 4% Plan to work on a temporary basis 4% 47% of physicians 47% of physicians Plan to work part-time 7% Plan to work part-time 7% > 50 > 50 Plan to close their practice to new 8% Plan to close their practice to new 8% 36% of physicians 36% of physicians patients patients > 65 > 65 Plan on taking a combination of the 7% Plan on taking a combination of the 7% above steps above steps Source: 2007 Survey of Physicians 50 to 65 Years of Age, Merritt Hawkins & Associates, 2007 11 American College of Healthcare Executives
  12. 12. Physician Workforce • Shortage: 124,000-159,300 by 2025 Variables: increased utilization, younger physicians work less hours • Medical Schools increasing 15%…but physician supply dependent upon graduate medical education Residency grads static for years • Recruiting very difficult American Association of Medical Colleges. The Complexities of Physician Supply and Demand Projections Through 2025. 2008. 12 American College of Healthcare Executives
  13. 13. The Decline in Physicians’ Real Income Physicians’ Revenues Have Not Kept Pace with Expenses % Increase 1998 – 2008 Multi-specialty Group Practice Operating Expenses: 65% Medicare Payment Rates: <2% Source: Health System Change Tracking Report No. 15, “Losing Ground: Physician Income, 1995-2003,” June 2006; Butcher, “Many Changes in Store as Physicians Become Employees,” Managed Care, July 2008. 13 American College of Healthcare Executives
  14. 14. 2005 to 2007 Women represent 46% increase in physicians working part-time 50 percent of US medical students % of All Physicians Practicing Part-time 18.1% 17.2% 14.5% 14.5% 14.0% 13.1% 24% of female 8.6% physicians <50 work 7.6% part-time vs. 2% of male physicians 29 or 30 – 34 35 – 39 40 – 44 45 – 49 50 – 54 55 – 59 60+ less Age Groups Top Reason to MEN – Unrelated professional or personal pursuits Top Reason to Work Part-time WOMEN – Family responsibilities (including pregnancy) Work Part-time Source: 2007 Physician Retention Study, Cejka Search and AMGA; “Will There be Enough Doctors”, HealthLeaders, October 2007. 14 American College of Healthcare Executives
  15. 15. Physician labor market continues to be under Shortages exist in Significant gap Aging population will extreme stress Who will many specialties between supply and alter demand for care for our demand in 2020 Referrals tough physician services patients? to get… Looming shortage recruiting takes of physicians years State likely to face a severe shortage over next 20 years Likely to face physician shortage in 2015 Shortage will continue to pose major problems School too small to meet State’s growing health care needs All agree demand outstrips production Physician to Extant physician population ratios Still far below the shortage will Physician marketplace increasingly national average become more unfavorable needs new physicians severe Source: Center for Workforce Studies, Association of American Medical Colleges, August 2007. 15 American College of Healthcare Executives
  16. 16. The Mood of Medicine “But in the days when a successful career was built on a number of tacitly recognized pillars-outsize pay, long-term security, impressive schooling and authority over grave matters-doctors and lawyers were perched atop them all.” “In a culture that prizes risk and outsize reward-where professional heroes are college dropouts with billion-dollar websites-some doctors and lawyers feel that they have slipped a notch in social- status, drifting towards the safe-and-staid realm of dentists and accountants.” The Falling Down Profession Source: NY Times, January 6, 2008 16 American College of Healthcare Executives
  17. 17. ACHE Top Issues 2007 1. Financial challenges 2. Care for the uninsured 3. Physician Hospital Relations 4. Quality 5. Personnel shortages 6. Patient Safety 7. Governmental mandates 8. Patient satisfaction 9. Capacity Most top issues dependent upon physician hospital relations. American College of Healthcare Executives 17
  18. 18. ACHE Hospital-Physician Issues: 2006 Survey • Physician recruitment • Physician-hospital competition as opposed to collaboration • Hospital staff shortages • ED call coverage payment • Hospitalists Personal communication with ACHE 10/08 18 American College of Healthcare Executives
  19. 19. Better Together: Business Case for Alignment • Patients still follow physicians to hospitals for elective Growth (profitable) procedures • Errors & rework costly in human life, suffering, time & dollars Quality/safety & • Accreditation & licensing depend upon it utilization • Process Improvement management Better use of everyone’s precious & costly time Satisfied patients & staff = business growth • P4P likely to morph into global payments Reimbursement • Joint hospital-physician mco contracting 19 American College of Healthcare Executives
  20. 20. Credit Rating “Contemporary” Credit Ratings “Contemporary” Credit Ratings Rating Factor Aa A Baa “BIG”* Getting value/volume from Getting value/volume from Physician Dependency active staff active staff % of inpatient annual Less than 11%-39% Greater Focus on specialists Focus on specialists admissions contributed by 10% than 40% Integration Strategies Integration Strategies top 10 leading physicians − Employment & − Employment & Composition Employment Model Employment Model − IT − IT Diversification of Broad Sufficient Some Deficient − Access to Joint ventures − Access to Joint ventures specialists deficiencies Medical Group activity in Medical Group activity in Degree of physician High Fairly Low Non-existent market market loyalty High − Strong medical group…risk − Strong medical group…risk Competition from active Minimal Low Moderate High of leaving market of leaving market staff − Small practices…risk of − Small practices…risk of Physician shortages and Limited Sufficient Highly Pervasive losing market losing market turnover Fluid Joint Venture philosophy Joint Venture philosophy − Half vs. none − Half vs. none Recruitment Successful Challenging Average age 45 50 50-60 60+ Source: Adapted from Standard & Poor’s Academic and research ACPE Presentation, New York, 4/08 orientation * Below Investment Grade Source: Adapted from Moody’s Not-For-Profit Hospitals and Health Systems Outlook, January 2008 20 American College of Healthcare Executives
  21. 21. Focus: What strategies are being used to strengthen physician-hospital alignment, & which strategies are most effective? Hospital Perspective Physician Perspective Healthcare Strategy and Market ACPE survey of 10,000 • • Development (SHSMD) survey members of 3,000 members 400+ respondents • 362 respondents 15 interviews to-date • • 60+ interviews • Source: Noblis/AHA, Strategies for Strengthening Physician-Hospital Alignment: A National Study, 2006; ACPE Member Survey 2008 21 American College of Healthcare Executives
  22. 22. ACPE Survey ACPE Survey Private practice relationship significantly lower than employed physicians. Private practice relationship significantly lower than employed physicians. National 2005 survey (362 responses) ACPE 2008 survey (324 responses) Hospital relationship with Hospital Employed members of the active 41% 52% 7% 47% 36% 17% staff Doing very well Doing very well Some things are working; others need work Some things are working; others need work More serious problems More serious problems Hospital relationship with Private Practice Physician 16% 63% 21% 33% 38% 29% referring physicians (PPP) (not members of the active staff) 22 American College of Healthcare Executives
  23. 23. Whose Perception is Reality??? Perceptions of Existing Relationships with Active Staff Percentage Rating “Very Positive” 70% Similar disconnect Similar disconnect between CMO’s and between CMO’s and Medical Directors in Medical Directors in Noblis 2008 study Noblis 2008 study 34% 31% 30% President/CEO Physician Relations Physician Leader Strategic Planner Source: Noblis/SHSMD (AHA), Strategies for Strengthening Physician-Hospital Alignment: A National Study, 2006 23 American College of Healthcare Executives
  24. 24. Imperative for Alignment Do these trends reflect what you are observing? • locally? • regionally? • nationally? Are there other trends you think will bring physicians and hospitals together or pull them further apart? 24 American College of Healthcare Executives
  25. 25. Strategies that Work 25 American College of Healthcare Executives
  26. 26. 2005 Noblis National Study Key Findings Infrastructure Infrastructure Substantive Physician Substantive Physician improvements to improvements to involvement in leadership involvement in leadership increase efficiency/ increase efficiency/ decision making development decision making development accessibility of care accessibility of care Support for Support for High quality/safe High quality/safe physician practice physician practice patient care patient care growth growth Interrelated Strategies Selective alignment Selective alignment Information Information of economic of economic systems systems interests interests Visibility/ Visibility/ Communication … Positive Communication … Positive accessibility of accessibility of Openness… organizational Openness… organizational CEO/Senior CEO/Senior Trust…Respect culture Trust…Respect culture Management Management 26 American College of Healthcare Executives
  27. 27. Noblis’ 2005 Physician-Hospital Alignment Study • Physicians are going to be either collaborative partners or active competitors. Key • Decreasing physician reimbursement causing physicians to spend more time in office and/or competing with the hospital for ancillary services. Alignment Findings • Of the 10 most effective strategies, half involved employing physicians. % Respondents Ranking as Highly Effective 1) Employ intensivists 75% 2) Employ a vice president of medical affairs (or equivalent leader) 74% 3) Employ hospitalists 74% 4) Provide financial support for recruitment to independent practices 72% Ten 5) Sponsor retreats limited to physician leadership and senior management 70% Most 6) Have a formal physician relations program with professional staff responsible for 68% Effective spending time with active medical staff members and their office staffs in an effort to Alignment strengthen physician-hospital relationships Strategies 7) Sponsor planning retreats that include board members, physicians, and senior management 68% 8) Actively involve physicians in planning and developing clinical service lines or centers of 66% excellence 9) Employ primary care physicians 65% 10) Employ some office-based specialists 64% 27 American College of Healthcare Executives
  28. 28. Noblis-ACPE 2008 Survey • Physician-hospital relations: disconnect at the top • Physician-Hospital alignment Provide good service Improve efficiency/accessibility of care-information systems & medical staff structure Make QI/peer review part of the contract for medical directors, joint ventures • Leadership & VPMA role • Physician on BOT and committees • Medical Staff strategic advisory groups, planning retreats 28 American College of Healthcare Executives
  29. 29. Alignment Model Strategic initiative Multiple parallel strategies & tactics Balance in key areas 29 American College of Healthcare Executives
  30. 30. 30 American College of Healthcare Executives
  31. 31. Physician-Hospital Alignment Critical Success Factors Medical staff leadership Specific strategic goals & tactics Communication Strategic metrics ROI difficult to measure 31 American College of Healthcare Executives
  32. 32. Physician-Hospital Alignment Strategic Plan Metrics • Joint ventures • Active staff size • ED call coverage • Average age • Physician loyalty • % of admits by top 10% Splitters • MSDP fulfillment • Physician leadership Recruitment goals • Physician liaison visits American College of Healthcare Executives 32
  33. 33. American College of Healthcare Executives 33
  34. 34. Relationships Formal & informal leaders Who is the medical Governance style staff? How do they get along with each other? Who are How do you get along with them? you? Relationships are time & energy intensive but not RELATIONSHIPS capital intensive strategies! American College of Healthcare Executives 34
  35. 35. What About this Autonomy Thing? Unique Highly Specialized Profession Autonomy: “Independence of action.” * Should we mourn or rejoice? A return to patient care RELATIONSHIPS *Society for General and Internal Medicine Study Group American College of Healthcare Executives 35
  36. 36. So…What Makes Physicians Really Unhappy? • Lifestyle Work schedule Call Patient care: quality & service • Relationship with patients and colleagues • Administrative aspects of practice • Income • Future • Dissatisfied physicians leave medicine at a RELATIONSHIPS rate of 2-3 x satisfied ones American College of Healthcare Executives 36
  37. 37. 2008 Noblis-ACPE Study: What are the most important activities that strengthen hospital-physician relationships? Listen, communicate, engage, dialogue, obtain input, e.g. survey Listen, communicate, engage, dialogue, obtain input, e.g. survey Decision making, involve in leadership activities/development Decision making, involve in leadership activities/development Treat as partner, collaborator Treat as partner, collaborator Improve efficiency, operations, productivity Improve efficiency, operations, productivity Address data & IT, EMR Address data & IT, EMR Honesty, respect, trust, transparency Honesty, respect, trust, transparency Financial support, joint ventures, align incentives Financial support, joint ventures, align incentives RELATIONSHIPS American College of Healthcare Executives 37
  38. 38. Generational Profile Generations predict values & behavior Generations in active practice Baby Boomers 1946-1964 Generation X 1965-1977 Generation Y 1978-1986 Private practice identity • Employed MDs are slackers… Baby Weathered tough storms: Medicare, Managed Care, Malpractice Crisis • Boomers Resent that “everything” is given to employed physicians Succession Planning • Practice FMV may lead to acquisition & employment Gen X & RELATIONSHIPS Medicine is a profession…not a lifestyle • Gen Y American College of Healthcare Executives 38
  39. 39. Generational Clashes Tensions • Jealousy & competition • Perceived & real alterations in referral patterns 28% expect to 28% expect to stay at first job • IT competency stay at first job > 4 years > 4 years • Mobility of employed physicians disruptive & expensive! Hopeful News • Cultural values change….not basic commitment • Quality and Peer Review RELATIONSHIPS American College of Healthcare Executives 39
  40. 40. Economic Impact of Physician Relationships Percent of Non-Primary Care Office Visits Referred by Another Physician 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% RELATIONSHIPS Source: National Health Statistics Reports. US Department of Health and Human Services. Number 3, August 6 American College of Healthcare Executives 40
  41. 41. Difficult to Get Traction… When You are Playing in a Sandbox Education about each other’s interests • Entitlement to different things… • Social & educational sessions • Share technology: IT, EMR, robot • “Group counseling” • It’s our burden to understand them… • RELATIONSHIPS American College of Healthcare Executives 41
  42. 42. It Might Be All About You… What are your generational views? Are you physician friendly? Have you really gotten over a bad piece of history? RELATIONSHIPS American College of Healthcare Executives 42
  43. 43. What Management Can Do… Practice what you preach: Build respect among senior executives Be role model: Mentor your directors & managers Clarify responsibilities: Thin line between front-line empowerment & interference Promise only what you can deliver: Collective memory embarrasses elephants RELATIONSHIPS American College of Healthcare Executives 43
  44. 44. Trust • Please don’t start off by promising a “new compact” • BOT, Executives and Medical Staff Leaders present when major decisions are made. • Dialogue is a conversation between 2 or more people • Admit mistakes…only if you have ever made any • Acknowledge the past, live the present, and anticipate the future • Getting to Yes really works…gaining an understanding of the other party (empathy) is RELATIONSHIPS first step American College of Healthcare Executives 44
  45. 45. Leadership Development Leadership Training BOT-Medical Staff-Executives retreats Mentoring Coaching RELATIONSHIPS American College of Healthcare Executives 45
  46. 46. American College of Healthcare Executives 46
  47. 47. Physician Motivation Do the right thing for my patient • I am accountable for the care of my patient • Intrinsic Getting past “I can’t practice cookbook medicine” and “blame” • Help me get my job done…and have a life • Give me meaningful quality proposition & real power to • change things Peer pressure, competition and public reporting • Patient satisfaction: My patient vs. all patients • Extrinsic Risk management • Aligned incentives…sometimes • SERVICE American College of Healthcare Executives 47
  48. 48. What do Physicians Want? #1: How the administration responds to my ideas and needs • Easier to care for patients: timeliness of order fulfillment, nursing staff • reports, quality of nursing staff Physicians most satisfied in their first 5 years and > 20 years on staff • Physicians employed by the hospital are more satisfied • than non-employed physicians Surgeons are the least satisfied • Correlation between satisfied patients, employees, • & physicians 2008 Press Ganey Hospital Check-Up Report - 2008 Press Ganey Hospital Check-Up Report - SERVICE Physician Perspectives on American Hospitals Physician Perspectives on American Hospitals American College of Healthcare Executives 48
  49. 49. Quality • Key Strategy… not a program… it is what we do… the services, the processes • Long term physician and patient loyalty • Unique opportunity to connect to both groups • Fulfillment of personal and institutional mission: Do the right thing • Quality is better than free Direct 150 P4P programs by government, incentives: insurers and businesses Direct Public reporting, Never Events, lawsuits & SERVICE disincentives: regulatory enforcement American College of Healthcare Executives 49
  50. 50. Quality & Physician Alignment Quality Culture: I’ll know it when I see it and feel it. Medical Staff Process I can trust…led by leaders I trust • Make it worth my while • Set meaningful goals that I can relate to Go for simple process changes that improve quality and work life Confidentiality is sacred…to the point permitted by law • Hospital Clearly communicated commitment…and actions…to improve care, • services and processes Delegation to clinicians • Elimination of mindless data collection and reporting SERVICE • Clean usable data and let me figure out what it means American College of Healthcare Executives 50
  51. 51. Quality is Good Business • Top 5: ACHE Top Issues • Strategic business goal • Direct financial incentives • Process Improvement • Better use of everyone’s precious and costly time • Satisfied patients and staff = Business growth • Errors and rework are costly in human life, suffering, time and dollars • Financial markets SERVICE American College of Healthcare Executives 51
  52. 52. Financial Markets Successful quality strategy Strong physician buy-in • Board of trustees (BOT) long-term strategy • Competitive differentiation Evidence-based outcome measures • Improved patient safety • Financial performance Consumer preference/demand = Market share growth • Better outcomes = Better payer reimbursement • SERVICE Source: Moody’s Investors Service: Improving clinical quality and patient safety of greater importance to not-for- profit hospitals, May 2006. American College of Healthcare Executives 52
  53. 53. The Value Proposition: Efficiency What can I do Look how much vs. for you today? we have done for you…. • What will give the physician some ROI on hisher time? Systems that make sense for physician and staff Improve efficiency; decrease hassles • Staffing & Support SERVICE American College of Healthcare Executives 53
  54. 54. Infrastructure Support System support • Clinical staff Lean Management Magnet Status • Happy & available staff • Good communication • Independent…but collaborative • Structure & staff to support, monitor, & measure QI, peer review, Department of Medical Affairs, IT, Physician Liaison Compensation for time • Chairs and officers: quality/safety are essential role functions SERVICE American College of Healthcare Executives 54
  55. 55. Information Technology Information Technology Provider Order Entry & data retrieval • Web Portals • Simple “no cost” data access from anywhere Compete with private laboratories Real-time transcription • Mobile voice & data devices for nurses, hospitalists, emergency physicians • IT & EMRs Hospital &/or PHO lead • Hospital owned medical group has substantial impact on system selection Integration with hospital systems • Bidirectional data transfer Server home & tech support Federal & private payer initiatives • SERVICE Hospitals fund 85% American College of Healthcare Executives 55
  56. 56. The Value Proposition: Hospitalists & AHPs • Less call & less competition • Intended consequences • Medicine Consistency, quality, P4P & utilization In-patient care Support for specialists • Surgery Orthopedics • Unintended consequences General Surgery Community physicians Ob-Laborist • further away • AHPs Alienation of some patients Orthopedics Handoff risks: community General Surgery to hospital care GI SERVICE American College of Healthcare Executives 56
  57. 57. Physician Liaison Program • Pattern recognition & early intervention I can predict the past with 100% accuracy Database issue tracking • Close the loop • Personalities • Relationships Recruiters Medical Staff members Medial staff leaders Senior Executives SERVICE • ROI American College of Healthcare Executives 57
  58. 58. American College of Healthcare Executives 58
  59. 59. Physician-Hospital Alignment & Governance Mission…do the right thing for patients • Active involvement of Board • Best Practices for Board Best Practices for Board Involvement: Involvement: Physician & patient loyalty • 1. Get Educated 1. Get Educated 2. Insist on the Numbers 2. Insist on the Numbers Accreditation • 3. Recognize need for a Pluralistic 3. Recognize need for a Pluralistic Approach Approach Transparency/public reporting • 4. Hold Leadership’s Feet to the 4. Hold Leadership’s Feet to the Fire Fire Financial strength • 5. Take Time to Connect with 5. Take Time to Connect with Physicians Yourself Physicians Yourself Source: C. Clark, Senior Principal, Source: C. Clark, Senior Principal, Center for Health Innovation, Noblis Center for Health Innovation, Noblis GOVERNANCE American College of Healthcare Executives 59
  60. 60. Let’s Get a Bit Personal Executive incentive compensation measures typically include: Profitability • Quality/safety outcomes • Core measures • MSDP/Physician recruiting • Physician satisfaction • Avoidance of Federal Enforcements Financial arrangements with physicians is a virtual minefield • DOJ & OIG enforcement actions for quality of care include civil & • criminal penalties False claims GOVERNANCE Just plain old poor quality American College of Healthcare Executives 60
  61. 61. ECHN BOARD Board PA/I Committee OFFICE OF MEC PRES/CEO SYSTEM Level Provides Direction Receives reports & Identifies projects Sends Report to Board PI report & pertinent info PI report, & pertinent info and issues and issues brought by admin VP’s brought by MS reps to Board PA/I to Board PA/I Committee Committee QIC Administrative, Staff and Medical Staff Representatives Reviews management and Medical Staff reports, CHA, CMS/Qualidigm/CPRO, and JCAHO reports & report card data. Identifies & initiates Requests projects with Medical Staff and projects MS Peer Review Administrative champions Committees Pe ly on rtin o en inf t re s& po ort rts rep & inf t en Care of Patent with o rtin on Rapid Response ly …CHF, Pe Team Pneumonia, MI MS Committees Hospital committee & Dept Support provided by QI staff and Departmental QI & Operational QI&Operational Reports Reports American College of Healthcare Executives 61
  62. 62. Governance Structure BOT Bylaws, nominating process & committee structure that encourage physician participation & link to medical staff Direct connection with physicians for quality & credentialing Medical Staff Support staff for credentials, quality & peer review Bylaws issues AHPs • ED call • Quality, safety & utilization compliance • Health law support GOVERNANCE American College of Healthcare Executives 62
  63. 63. Governance Style • Set planning goals Medical Staff, Executives & • Make changes BOT jointly • Monitor outcomes • CEO-Medical Staff Officers-BOT Chair Communication • Effective pathway to hear from physicians GOVERNANCE American College of Healthcare Executives 63
  64. 64. Who are Physician Leaders? Elected leaders Opinion leaders Contracted leaders • VPMA/CMO • Service Line/Program Medical Directors GOVERNANCE American College of Healthcare Executives 64
  65. 65. Being a Physician Leader • May be difficult to identify true physician leaders • Physicians may view leadership very differently than others • Leaders able to maintain position in the heat of battle • Leaders who manage tough issues may pay the price in clinical & personal life GOVERNANCE American College of Healthcare Executives 65
  66. 66. Changing Medical Staff Governance Good ole days Now Loosely associated autonomous • • Formal structure physicians • 20% do 80% of care Physicians needed place to care for • • Regulators: hospital is responsible for patients care quality …physicians not so sure Little incentive to participate in quality, • • Bylaws focused on quality, safety, safety & medical management patient care Bylaws focused on individual rights • • Only real authority is to restrict or Medical Executive Committee (MEC) • revoke privileges Elected voluntary leaders • MEC Inpatient medical staff business Elected & contracted leaders Quality, safety, credentials Compliance GOVERNANCE American College of Healthcare Executives 66
  67. 67. American College of Healthcare Executives 67
  68. 68. Ventures Joint Ventures • Service Line & Medical Directorships • Call Coverage Agreements • Information Technology-EMR • Employment • Incentive Based Payments • VENTURES American College of Healthcare Executives 68
  69. 69. Legal Advice Need up-to-date, practical & reasonable counsel more than ever before Numerous places to stumble & really get hurt… both with relationships & regulators Having to withdraw or modify promises to physicians due to unknown legal requirements is a frequent cause for loss of deal…& loss of trust. VENTURES American College of Healthcare Executives 69
  70. 70. Joint Ventures Clinical Services • ASC, Endoscopy, Imaging, Oncology-Radiation Therapy Real Estate • Medical building REI trusts Future? • Reimbursement • Aging & shrinking independent medical staff VENTURES American College of Healthcare Executives 70
  71. 71. Lessons Learned Regarding JVs “Joint ventures are very complex arrangements. There are a lot of legal barriers, which physicians do not have the patience to understand.” Up-front education is a must “Physicians have a tendency to believe that the fact they can bring their patients to the JV will relieve them of the responsibility to invest cash. This is not true.” “We have learned that you have to keep the joint-venture process simple. We have mostly solo practices and very small groups. Very few of our Hospitals should physicians have the knowledge and sophistication expect to do the required to make joint ventures work. We have had to legwork do most of the work to structure the ventures, because they simply do not have the resources that are needed.” VENTURES 71 American College of Healthcare Executives
  72. 72. Medical Directorships • Reimbursement for officer, chair, chief, medical director & other roles • Role growing to manage specific services • Quality, safety and efficiency with incentives • Difficult to obtain valid FMV data New roles in rapidly changing environment Separating nonclinical compensation from clinical salary challenging MGMA, ACPE, Sullivan-Cotter surveys VENTURES American College of Healthcare Executives 72
  73. 73. Service Line Management • Hospital contracts with physician management company to manage clinical service • Opportunity for physicians to control clinical services, control costs, improve quality…. that's the good news and the bad news VENTURES American College of Healthcare Executives 73
  74. 74. ED Call Coverage • Emblematic of struggle between hospitals’ and physicians’ needs & interests • Time is $ • Much larger factor in primary care-specialist rifts than commonly acknowledged • Multiple legal tripwires to maneuver VENTURES American College of Healthcare Executives 74
  75. 75. ED Call Coverage • Solutions reflect empathy, business needs, and communication • OIG Advisory Letter (9/07) • Multiple solutions Contracted rates for daily coverage above “fair share” obligation Payment guarantees Creative finance plans • EMTALA Community Coverage Plan VENTURES American College of Healthcare Executives 75
  76. 76. THE FABLE OF THE SURGEON & THE TENT • Porridge for one is expensive • The pot of gold at the end of the rainbow is a mirage • The golden years aren’t American College of Healthcare Executives 76
  77. 77. Physician Employment is Different This Time • Substantial economic advantages for systems that “This is the “This is the beginning of a integrate payers, hospitals and physicians beginning of a fundamental fundamental • View physicians as “fundamental strategic asset” restructuring of how restructuring of how • Greater emphasis on developing physician leadership physicians function physicians function and systemized physician engagement in the health care in the health care *** system.” system.” • Primary care & specialty physicians William Jessee, MD, President of William Jessee, MD, President of the Medical Group Management the Medical Group Management • Younger (70-80%) & older physicians want it Association. Association. • Willingness to trade off autonomy for economic security • New generation seeking improved work/life balance *** • Payers shifting to incentive based payments, e.g. P4P and Medical Homes VENTURES American College of Healthcare Executives 77
  78. 78. Hospital Group Employment Business Structure ROI Practice management Treat as capital investment • • MCO enrollment, billing & Data tracking of downstream revenue: • reimbursement in-patient and ancillary testing Step outside…way outside… of usual If you are paying for call • • hospital roles already…makes sense HR &Legal Medical Director Professional medical group Which Beans Do You Count? administrator Inpatient & ambulatory care revenue • Quality, P4P, LOS enhancement value • Support for specialists • Managed Care Issues Continuity of care within system • Hospital investment in IT/EMR • VENTURES Joint physician & hospital contracting • American College of Healthcare Executives 78
  79. 79. Employment Pitfalls • Assume loyalty of physicians…and manage just like other employees • Failure to manage BOT, medical staff & executives’ expectations • Assign functions to hospital Finance, HR, Legal & Business directors…without adequate preparation • Overoptimistic growth projections • Failure to establish incentive compensation & long-term comp plans VENTURES American College of Healthcare Executives 79
  80. 80. Medical Staff Development Plan (MSDP) Community need Business/Strategic need Regulatory documentation of need Plan for how to support new physicians • Loan security agreement Q&A and legal documents • Employment entity & infrastructure to make it happen VENTURES American College of Healthcare Executives 80
  81. 81. Physician Resource Assessment Model* Population Characteristics Mix of Specialties MARKET & Projections INTERNAL MARKET INTERNAL Medical Staff Characteristics Assessment Assessment Assessment Assessment Physician Demand Retirement Vulnerabilities Benchmarks Perceived Need Consumer Preferences Health Status Service Line & Geographic Growth Objectives Current Physician Supply Qualitative Input Quantitative Approach Projected Projected COMMUNITY HOSPITAL As much an art as a Strong analytical NEED NEED science approach by Specialty by Specialty Making it relevant for your In-depth knowledge of strategic priorities physician demand Understanding medical benchmarks RECOMMENDED RECOMMENDED staff dynamics (generational ADDITIONS ADDITIONS Customized to Physician to Physician differences, call coverage, Staff methodology Staff productivity, loyalty) American College of Healthcare Executives 81 * Source: Noblis Center for Health Innovation
  82. 82. MSDP Confounding Factors • Takes 1.3-1.5 to replace older physicians Office ED call Are the standard • EMTALA Community Call ratios still valid? • Efficiency? IT & EMR Electronic communication How frequently do • Mobility by younger physicians you need to update • Competition plan to stay current? • Hospitalists • AHPs • Part time physicians How do you count? Younger and older physicians Do part time “FTEs” equal half of full VENTURES time FTEs? American College of Healthcare Executives 82
  83. 83. Recruiting • High level team Broad input finds the good, bad & ugly early in process CEO involvement Understand the regs…use them…don’t hide behind them • Candidate’s first impressions reflect organization process • Close the deal Rapid decision-making for changing needs Ready in HR, legal & community Contract templates Salary information Offer what they want VENTURES American College of Healthcare Executives 83
  84. 84. Better Together or… Bitter Together? Pay for Performance Gainsharing Bundled payments Participatory bonds Under Arrangement VENTURES American College of Healthcare Executives 84
  85. 85. Special Situations: Mergers & Acquisitions Clinical staff care about their service; it is not a board game to be picked up or discarded at whim. Nor do patients appreciate being treated like pawns. We need continuous evaluation of change to ensure that quality and cost containment are being achieved. VENTURES Harvey D. Personal views: Hospital games. BMJ. 2000;321:713. American College of Healthcare Executives 85
  86. 86. Special Situations: Mergers & Acquisitions Medical staff…big unknown • Influence &/or behavior can make or break merger What does the physician gain from merger? VENTURES American College of Healthcare Executives 86
  87. 87. Special Situations: Mergers & Acquisitions Gain Loss Financially stable Altered mission • • environment…save the Religious vs secular AMC vs community hospital? Open or closed faculty • Managed care rates • New competition • PHO Facility or program • New facility • consolidation New technology Travel time Larger primary care base • Connection to CEO/BOT • Choice of specialists • Governance style • Bylaws protections • VENTURES American College of Healthcare Executives 87
  88. 88. Special Situations: Mergers & Acquisitions • Merger advisory group membership Merger of equals vs. acquisition • Study & manage the culture • Early decisions Merged or separate medical staffs Bylaws “hot buttons” • ED call coverage • Board certification • Officers, Chairs, Chiefs • Communication Early & frequent written & in person Rumors VENTURES Anticipate naysayers…they may have important things to say American College of Healthcare Executives 88
  89. 89. Strategies that Work What has your organization tried? How effective have you been? What has really bombed? What do you think are the top 3 alignment strategies? Why? American College of Healthcare Executives 89
  90. 90. How to Make it Work for You American College of Healthcare Executives 90
  91. 91. American College of Healthcare Executives 91
  92. 92. Conduct a Formal Physician- Hospital Alignment Process 1) Assess the current situation – interviews, surveys, data. 2) Process the results and develop recommendations with a Physician Advisory Group…. but be sure the right physicians are at that table! 3) Conduct a retreat to share the results and initial recommendations with the broader medical staff. 4) Develop a formal Physician-Hospital Alignment Plan outlining the recommended portfolio of strategies. 5) Obtain approval of the plan by the MEC and Board. 6) Monitor and reevaluate results of the plan and the changing environment throughout implementation. Focus on developing a multi-faceted approach 92 American College of Healthcare Executives
  93. 93. 10 Things to Do Back at the Ranch Create a physician strategic advisory group Get physicians, BOT, and Administration together at the right places: planning retreats, governance, quality Form an entity to employ physicians Create a recruiting group and do a MSDP with physician input Manage generational issues with medical staff, BOT & execs Establish a physician liaison program Recruit (or hold onto ☺) the right VPMA/CMO Deploy IT/EMR & manage new financial models via PHO Set up meaningful educational & social interactions for medical staff Develop future leadership 93 American College of Healthcare Executives
  94. 94. Thoughts for the Future Who will be the physician leaders of medical staff & BOT? • Will physician board members need to be employees? • Will physicians become the CEOs & BOT leaders? • How will we approach leadership development for the next generation? How will hospitals afford employed physicians? • Will joint hospital & medical group contracting increase revenue? • Will risk models return? Will medical staff of the future look anything like today’s? • What impact will employed physician model have on governance? 94 American College of Healthcare Executives
  95. 95. Making it Work for You How ready is your organization to implement these strategies? What are the major opportunities and barriers to implementation? What do you think the impact of the economic crisis and/or new administration will have on implementing alignment strategies? 95 American College of Healthcare Executives
  96. 96. Amy MacNulty Amy MacNulty is a Senior Principal and Northeast Region Manager Amy MacNulty is a Senior Principal and Northeast Region Manager for the Noblis Center for Health Innovation, a leading advisory group for the Noblis Center for Health Innovation, a leading advisory group to health providers. With over 20 years of healthcare experience in to health providers. With over 20 years of healthcare experience in strategic planning, physician strategies and regulatory services strategic planning, physician strategies and regulatory services planning, she is a recognized leader in developing and implementing planning, she is a recognized leader in developing and implementing strategic and physician-hospital alignment plans. strategic and physician-hospital alignment plans. In 2006, MacNulty co-authored Strategies for Physician-Hospital In 2006, MacNulty co-authored Strategies for Physician-Hospital Alignment: A National Study sponsored by AHA’s Society for Alignment: A National Study sponsored by AHA’s Society for Healthcare Strategy and Market Development. She is also the co- Healthcare Strategy and Market Development. She is also the co- editor of Noblis’ Journal for the Center for Health Innovation, editor of Noblis’ Journal for the Center for Health Innovation, Horizons. MacNulty holds a MA in Business Administration from Horizons. MacNulty holds a MA in Business Administration from Northeastern University. Northeastern University. 96 American College of Healthcare Executives
  97. 97. Joel J. Reich, MD, FACEP Joel J. Reich is the Senior Vice President for Medical Affairs for Joel J. Reich is the Senior Vice President for Medical Affairs for Eastern Connecticut Health Network (ECHN). Previously, he served Eastern Connecticut Health Network (ECHN). Previously, he served as ECHN’s Chair/Senior Medical Director of the Department of as ECHN’s Chair/Senior Medical Director of the Department of Emergency and Ambulatory Care Services. Emergency and Ambulatory Care Services. Dr. Reich serves on the boards of the Connecticut Hospital Dr. Reich serves on the boards of the Connecticut Hospital Association, NCC-EMS Council, ECHN Health Services Association, NCC-EMS Council, ECHN Health Services (multispecialty group practice), CHIC (captive insurance company), (multispecialty group practice), CHIC (captive insurance company), and Ambulance Service of Manchester, Inc. He holds a BA from and Ambulance Service of Manchester, Inc. He holds a BA from Brandeis University, a MA from The Sever Institute of Washington Brandeis University, a MA from The Sever Institute of Washington University, MD from SUNY at Buffalo, and MMM from Carnegie University, MD from SUNY at Buffalo, and MMM from Carnegie Mellon University. He completed his emergency medicine residency Mellon University. He completed his emergency medicine residency at Georgetown University Hospital. at Georgetown University Hospital. 97 American College of Healthcare Executives
  98. 98. Contacts Amy MacNulty Joel J. Reich, MD, FACEP Senior Principal Sr Vice President for Medical Affairs Noblis Center for Health Innovation Eastern Connecticut Health Network 1050 Waltham Street 71 Haynes Street Lexington, MA 02421 Manchester, CT 06040 781-482-4072 office 860-647-6866 office 781-863-5657 fax 860-647-6476 fax amy.macnulty@noblis.org jreich@echn.org www.noblis.org www.echn.org 98 American College of Healthcare Executives

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