September 26, 2011

Physician Integration: Hospital Medical Leaders Share Challenges, Strategies

Written by Sabrina Rodak

Healthcare leaders are finding that physician integration will be critical for achieving the increased efficiencies and coordination necessary for meeting healthcare reform standards and for producing savings. Although integral to the formation of accountable care organizations, hospitals are pursuing physician integration regardless of plans to create an ACO because of the changing landscape in healthcare. While these changes are just beginning, several chief medical officers and medical affairs executives share challenges and strategies to establish a successfully integrated system.

A common challenge noted among leaders is the lack of specific information regarding ACOs and other models for physician integration. Sharing knowledge and educating others is thus key to beginning to align physicians with a health system. Kersey Winfree, MD, CMO of Oklahoma City-based SSM Health Care of Oklahoma, says education is needed at both the basic level — what integration means — and at a higher level, addressing the implications of integration and other changes in healthcare delivery.

Simply teaching fact-based information will not itself lead to success, however. Dr. Winfree says, “It’s not just getting physicians to comply with a set of rules; you need to get them to commit to and transform practices.” For instance, physicians will have to shift from a volume- to value-based system of care. Alan Pope, MD, vice president of medical affairs and CMO of Camden, N.J.-based Lourdes Health System, says one challenge is transferring physicians from an independent model in which they have control of a person’s care to a team approach in which they represent one component of the patient’s care.

Dr. Winfree echoes this idea: “Historically, physicians have not been part of any employed workforce. They have been independent practitioners or in group practices that might have a non-hospital employer.” He says physicians will have to learn how to operate as part of a labor force and hospital leaders will have to learn how to manage this new force.

Governance structure
A second challenge to physician integration is deciding what governance structure to use when aligning physicians with hospitals’ missions. Michael Nochomovitz, MD, president and CMO of Cleveland-based University Hospitals medical practices, says that for hospitals new to physician integration, “The hardest thing is creating an appropriate structures for physicians with which hospitals can interface.”

Many healthcare leaders say including structures other than employment is helpful in integrating physicians. In Alexandria, Va., Inova Mount Vernon Hospital’s Vice President of Medical Affairs Donald Brideau, MD, says that while potentially more complicated, establishing a model that does not force physicians to become employed may attract more physicians. “One strategy is not trying to make all physicians become employed, [but to] develop much more sophisticated measures of partnership,” he says.

Larry Donatelle, MD, vice president of medical affairs at Affinity Health System’s St. Elizabeth Hospital in Appleton, Wis., also says that while perhaps easier to align incentives when physicians are employees, hospitals should not exclude other more inclusive models. Affinity Health, for instance, has a medical group separate from the hospital and governed by physicians. Springfield, Mo.-based St. John’s Clinic, which is part of the Sisters of Mercy Health System-St. Louis, is a physician-led professionally managed multispecialty organization with its own governing body and hierarchy. Fred McQueary, MD, president of the clinic, says the clinic and hospital work together to solve issues. “One is not subservient to the other; they are incentivized to be working towards the same [goals].”

Baptist Memorial Health Care in Memphis, Tenn., has also created an autonomous physician organization as part of their plan for integrated care. Richard Drewry, Jr., MD, vice president and CMO of BMHCC, says “The most important part of the relationship is in the first 90 days. How do we interact with [physicians]? Do we interact as a large health system, or do we interact with them in a way that’s flexible and willing to look at different ways of doing things?”

Part of being flexible is allowing physicians not employed by the hospital to become integrated. Dr. Nochomovitz says in addition to a base of employed physicians, University Hospitals includes independent physicians through its institutes, which include the Digestive Health, Eye, Harrington-McLaughlin Heart and Vascular, Neurological, Transplant and Urology Institutes. The only criteria for physicians to align with University Hospitals are that they meet quality measures, use certain protocols and share data. Dr. Nochomovitz explains a possible motive for hospitals to want to limit their integration plan to employed physicians: “Sometimes organizations find it difficult to deal with independent physicians. They feel they need to control physicians. We don’t believe that; we don’t view them with trepidation, [but instead] see as it as an opportunity.” This system offers both independent and employed physicians the ability to integrate with University Hospitals.

Physician leadership
Besides choosing a system of interacting with physicians — employment, partnership, etc. — hospital leaders need to decide how to involve physicians in leadership positions to achieve success in integration. Although several hospitals described above have physician organizations separate from the hospital, they all ensure that physicians work closely with hospital administrators in decision-making. Dr Winfree says, “Physician leadership is going to be critical to the success of integrated models.”

Because many physicians aligning with hospitals previously worked in independent practices, providing physicians with a level of control is essential in getting them to buy into the system. Jim Boswell, CEO and vice president of physician services of Baptist Memorial Medical Group, an affiliate of BMHCC, says, “One of the biggest challenges in physician integration is for physicians to realize they have a voice, they still have autonomy.”

One model that allows hospitals to involve physicians in leadership is a co-management agreement in which a physician is paired with a hospital administrator. Dr. Pope says Lourdes Health System uses this model. He explains the benefits of physician leadership: “Physicians are the ones in the trenches day to day, seeing and caring for patients across the continuum of care. Many hospitals recognize that if physicians have the interest and ability to provide leadership, they can often be very strong champions as well as critical thinkers for designing a better healthcare system.” To identify physician leaders, Dr. Winfree says SSM Health Care of Oklahoma is surveying physicians about their interest in leadership positions.

Hospitals that combine hospital administrator and physician perspectives may be able to more easily create efficiencies compared to those that don’t. Dr. Brideau says, “Physicians get trained in one particular way and managers get trained in a very different way. Yet, you need both sets of skills.” Simply adding physicians to a system is insufficient to cut inefficiencies and costs; partnering physicians at the leadership level will help the system create a more coordinated organization.

St. John’s Clinic is led by practicing physicians, according to Dr. McQueary. “A driving factor behind our success as an organization is any physician involved in administration is a practicing physician. [He or she] is still ‘in the trenches.’ [The leader is] able to relate to physicians on a professional and peer level, which helps drive understanding and trust,” he says. Dr. McQueary believes that ensuring physician leaders are practicing physicians increases their believability as leaders. These physicians practice half time and are individually partnered with a professional administrator to complete the administrative team. Similarly, Dr. Brideau says that a message to physicians by physician leaders resonates more than the same message delivered by hospital administrators.

Placing physicians in leadership positions may also help physicians invest in the system. Dr Drewry says physician integration “should be a relationship, not just a transaction.” An important part of building a relationship is fostering trust among physician and hospital leaders. Dr. Donatelle says that Affinity Health System’s transparency with its plans and engagement with physicians has helped build trust and strengthen their relationship. The hospital has established a physician advisory council to share “information about our current operations and growth strategies for the future” with primary care, specialty, and subspecialty physicians.

As hospitals continue to work towards physician integration, it may be helpful to spend resources developing strategies for education, governance structures and physician leadership. While tangible products like electronic medical records are also essential, working on abstract elements that require communication and trust-building may ultimately drive the success on an integrated system.

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