1. 22 SEPTEMBER/OCTOBER n 2015
Health Care Professionals
IS IT TIME TO RE-EVALUATE
THE C-SUITE?
n Myles Gart, MD, MMM
In this article…
Should the role of chief medical officer be broken up into various other positions?
“I do not believe you can do today’s job
with yesterday’s methods and be in business
tomorrow.” — Nelson Jackson
AS THE DYNAMICS OF OUR COUNTRY’S HEALTH
care system change, so too must our methods of managing
the intricate web of patient encounters.
We have all heard the buzzwords: “population health,”
“bundled payments,” “full risk” and “value-based purchas-
ing.” These phrases signal the movement from a reimburse-
ment model predicated on frequency to one based on pa-
tient outcomes. In essence, the new reimbursement paradigm
forces us to reconsider yesterday’s methods.
Traditionally, hospitals used their resources to report qual-
ity data, as the Centers for Medicare and Medicaid Services
(CMS) required. They maximized reimbursements by capturing
all patient comorbidities and by working with physicians to
minimize the length of stays. This model improved the profit
margin with medical diagnosis related groups (DRGs) such as
congestive heart failure, acute myocardial infarction, stroke,
pneumonia, and chronic obstructive pulmonary disease by
standardizing care, improving quality and lowering costs.
Surgical services were the financial engine for hospitals
because of their high per-case contribution margin. Admin-
istrative oversight was limited mainly to staffing and support
services because there was little need for standard evidenced-
based practices. Recently, this dichotomy has expanded on a
national scale with DRG improvement projects focused solely
on medical disease states.
Now, however, with payment structures shifting away from
a DRG-based fee-for-service, surgical services are quickly be-
coming cost centers. As a result, hospitals require an entirely
different C-suite structure, and along with that change comes
the need for a new administrative skillset.
RESTRUCTURE — The American Society of Anesthesiology
(ASA) has proposed a concept to address the current frag-
mentation in surgical care. The concept draws on medical
care’s patient-centered medical home (PCMH) and is termed
perioperative surgical home (PSH).
PSH is a patient-centered, physician-led, multidisciplinary
and team-based system of coordinated care. It guides the
patient through the entire surgical experience from decision
to discharge. PSH is above all value-based and thus provides
a strategic opportunity to engage employers and payers.1
With the aim of meeting the dual goals of improving work-
force health and decreasing productivity loss, employers sit
at the forefront of health care redesign. This is a tremendous
responsibility that demands an administrative skill set, over-
sight and vision currently lacking in the C-suite.
Senior management positions have ballooned over the
years to keep up with the complexities of medicine. In addi-
tion to the traditional positions of chief executive officer, chief
financial officer, chief nursing executive and chief medical
officer, hospitals now have a chief experience officer, a chief
population health officer, a chief innovation officer and a chief
information officer.2
Is the current composition and influence of senior leader-
ship commensurate with changing health care needs? Is it
time to re-evaluate the C-suite?

2. Physician Leadership Journal 23
CMO OUT? — We should base who gets a seat atop the phy-
sician executive administrative pyramid on who is capable of
reducing clinical variation and fragmentation in care. Leaders
should be visionary, capable of working with multidisciplinary
teams, and able to improve quality in measurable ways.
The cost of C-suite positions is high. The positions, either
directly or indirectly, need to reduce costs and improve qual-
ity under risk-based and capitated contracts. On the other
hand, if there is a managerial gap in a vital clinical area such
as surgical services, then organizations need to create posi-
tions that will secure the critical outcomes essential for future
financial viability.
Ultimately, I ask: Is it time to break up the chief medical
officer role? Historically, the CMO served as the conduit be-
tween the physicians and senior management, focusing solely
on inpatient medical care.
In the new health care paradigm, clinical management
oversight must span the entire spectrum of a patient’s epi-
sode of care. It cannot be confined solely to encounters in the
hospital. This oversight is now impossible to manage with one
position. It is my belief that the creation of a chief of medical
services (COMS) and chief of surgical services (COSS) is neces-
sary for the success of any health care system.
THE PERFECT STORM — The confluence of clinical complex-
ity, risk contracting and fragmented care has created a fertile
climate for the creation of the chief of surgical services as
an integral member of the C-suite. No health care organiza-
tion can succeed without visionary leadership in the surgical
specialties. Below is a tentative list of COSS responsibilities:
1. Coexist in a shared operative environment with maxi-
mal utilization of services by developing a sustainable
infrastructure that supports the surgeons, anesthesia
and the patients they serve.3
2. Decrease clinical variation with the aid of robust data-
bases and clinical analytics.
3. Consolidate high-acuity procedures to reach the critical
volume that is necessary for an efficient supply chain,
specialized nursing care and standardized anesthetic
management.
4. Develop surgical programs spanning preoperative as-
sessment through post-acute care that demonstrate
high quality and value for the surgical patient, in keep-
ing with the ASA’s PSH.4
5. Matrix with medical subspecialties to maximize patient
preparation and perioperative management through
post-acute care.
6. Develop centers of excellence for local, regional or na-
tional destination surgeries.
Any consideration of a new C-suite po-
sition must of course pass the test of
improving coordination and integration
in the delivery of clinical services.

3. 24 SEPTEMBER/OCTOBER n 2015
Although the benefits of establishing the COSS position
are self-evident, there are a number of barriers to overcome:
1. It is a new idea, and health care organizations are risk
averse.
2. In a climate of decreasing reimbursement, adding an-
other C-suite position is a tough sell.
3. Most CMOs across the country have a primary care
background. There is an understandable lack of local
knowledge, resulting in the inability to see the gap in
surgical leadership or “share the turf” with an addi-
tional senior physician colleague.
4. Nationally, surgical services oversight and visionary
planning resides with a chief operations officer, who
commonly lacks experience in the intricacies of surgical
services and may balk at expanding the C-suite table.
SENIOR MANAGEMENT
POSITIONS HAVE BALLOONED
OVER THE YEARS.
There are too many departments and too many chiefs,
which has contributed to the fragmentation in services and
patient care that we now confront. Any consideration of a new
C-suite position must of course pass the test of improving co-
ordination and integration in the delivery of clinical services.5
Equally important is the ability to decrease clinical varia-
tion, resulting in higher quality and lower costs. Answering
the call would be a physician leader armed with the tools of
local surgical service knowledge, proven leadership skills and
advanced management training. The following case study
illustrates what is at stake:
EdisonHealth, Westlake, Ohio6
n EdisonHealth selects destination hospital “centers of
excellence” based on appropriateness of care.
n Hospitals receive an “aggressive, all-in” payment for
spine, valve or transplant surgeries.
n Covered patients receive consultations, care coordina-
tion (similar to the ASA’s PSH approach), plus travel,
food and lodging.
n Destination surgical services are covered at 100
percent.
n The local surgical option requires deductibles and co-
payments.
n An employer with 10,000 employees can expect 10 to
20 employees selecting the destination surgery option
and up to $2.5 million in health plan cost savings.
As we can clearly see, when surgical care becomes coor-
dinated, less fragmented, economized and based on large
volume, low clinical variation, aligned financial incentives and
strong, visionary administrative oversight, the desired financial
results will follow.
With the addition of the newest member to the health
care C-suite, the chief of surgical services, we now have the
opportunity to fill this senior leadership gap and ensure the
viability of systems looking to prosper amid the continued
paradigm shift in American health care.
Myles Gart, MD, MMM, is chief medical
officer at HeartlandPlains Health in Omaha,
Nebraska.
mylesgart@gmail.com
REFERENCES
1. American Society of Anesthesiologists, Perioperative Surgical Home Brief.
ASA Committee on Future Models of Anesthesia Practice 7/15/14.
2. Caramencio A. Is there any room left in the hospital C-suite?
FierceHealthcare, June 28th, 2012.
3. Barry MJ, Edgman-Levitan S. Shared decision making - pinnacle of patient-
centered care. N. Engl. J. Med. 2012:366:780-1
4. Warner MA. The Surgical Home. ASA Newsletter. 2012:76:30-2
5. ASA Communication 2012: The C-suite is expanding; Why It is Worrisome.
By Lindsey Dunn
6. EdisonHealth Website. Sherwood J. Matching employees with the right
hospitals for advanced/specialty care - with Rick Chelko from EdisonHealth.