SUPPLEMENT ARTICLE
Hospital Fundamentals Peter L. Althausen, MD, MBA,* Austin D. Hill, MD, MPH,† and Lisa Mead, MBA*
Summary: Under the current system, orthopaedic trauma surgeons must work in some form of hospital setting as our primary service involves treatment of the trauma patient. We must not forget that just as a trauma center cannot exist without our services, we cannot function without their support. As a result, a clear understanding of the balance between physicians and hospitals is paramount. Historical perspective enables physicians and hospital personnel alike to understand the evolution of hospital–physician relationship. This process should be understood upon completion of this chapter. The relationship between physicians and hospitals is becoming increasingly complex and multiple forms of integration exist such as joint ventures, gain sharing, and co-management agreements. For the surgeon to negotiate well, an understanding of hospital governance and the role of the orthopaedic traumatologist is vital to success. An understanding of the value provided by the traumatologist includes all aspects of care including efficiency, availability, cost effectiveness, and research activities. To create effective and sustainable healthcare institutions, physicians and hospitals must be aligned over a sustained period of time. Unfortunately, external forces have eroded the historical basis for the working relationship between physicians and hospitals. Increased competition and reimbursement cuts, coupled with the increasing demands for quality, efficiency, and coordination and the payment changes outlined in healthcare reform, have left many organizations wondering how to best rebuild the relationship. The principal goal for the physician when partnering with a hospital or healthcare entity is to establish a sustainable model of service line management that protects or advances the physician’s ability to make impactful improvements in quality of patient care, decreases in healthcare costs, and improvements in process efficiency through evidence-based practices and protocols. Key Words: governance, hospital/physician alignment, co-management (J Orthop Trauma 2014;28:S18–S24)
HOSPITAL–PHYSICIAN RELATIONSHIPS The inception of the physician–patient relationship, particularly in trauma, occurs in the hospital. Hospitals cannot perform a procedure, run an emergency department, or achieve their healthcare mission without physicians. Physicians typically need hospitals to access the capital and technology that provide the facilities for them to practice Accepted for publication April 9, 2014. From the *Reno Orthopaedic Clinic, Reno, NV; and †Austin Skeletal Trauma Specialists, Austin, TX. The authors report no conflict of interest. Reprints: Peter L. Althausen, MD, MBA, Reno Orthopaedic Clinic, 555 North Arlington Avenue, Reno, NV 89503-4724 (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
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medicine and for the education and training of future physicians. Effective, efficient patient care relies on this mutually dependent relationship. Although the daily dealings of physicians and hospitals appear outwardly cordial, there is often underlying distrust and concern about what motivates each side in their decisionmaking processes. Physicians see themselves as advocates of quality patient care and practice efficiency. They want control over the scope of their practice with minimal barriers between themselves and their patients. The business of the hospital is not foremost on their mind when treating a trauma victim. Often this leads to the 2 sides talking over each other in different languages in an attempt to achieve similar outcomes. Establishing a trinity of mutual beneficence between the hospital, physician, and patient is now the standard of care. With profit margins shrinking due to the increasing costs of healthcare delivery, litigation, and decreasing payer reimbursement, the inefficiency of adversarial relationships will no longer be viable or tolerated. In the beginning, medical staff membership fostered physician autonomy with minimum interference from the hospital. These nonprofit institutions were aligned with the physician’s mission of patient care. In time, the agenda of the increasingly “corporate” hospital included increasing efficiency in order to realize greater gains to the financial bottom line. The alignment surrounding patient care began to diverge. This marriage was one of necessity–each needed the other–but it was not without competing interests and discord. To create effective and sustainable healthcare institutions, physicians and hospitals must be aligned over a sustained period of time. Unfortunately external forces have eroded the historical basis for the working relationship between physicians and hospitals. The market is changing, demonstrating increasing competition and reimbursement cuts, as well as increasing demands for quality, efficiency, and coordination. Coupled with the payment changes outlined in healthcare reform, the current status has left many organizations wondering how to best rebuild the relationship. The principal goal for the physician when partnering with a hospital or healthcare entity is to establish a sustainable model. This includes creation of a service line management system that protects the physician’s ability to make improvements in both the quality of patient care and process efficiency through evidence based practices and protocols.
HISTORICAL PERSPECTIVE The interdependence of the hospital physician relationship began late in a 19th century America experiencing significant population increases and industrialization. J Orthop Trauma Volume 28, Number 7 Supplement, July 2014
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Historically, only the poor or isolated received medical care in institutions and physicians tended the middle or upper class patients in their homes. As medical practices grew in their sophistication and complexity, there was a shift toward the professionalization of healthcare and the development of a competitive market for medical services that increasingly took place in hospitals. During the late 19th century and early 20th century, control over clinical decision making was left to the physicians. Physician autonomy and control received institutional endorsement in 1912 when the American College of Surgeons (ACS) formed to pursue standardization in medical treatment. Hospitals felt compelled to adhere to their requirements in hopes of avoiding external regulation. The ACS requirements included the development of formal medical staff structures, committees, meetings, and policies to supervise standards within the hospital. The oversight of clinical affairs was assigned to physicians to be clearly separated from the administrative part of the organization. All hospitals before the 1920s operated without much money. Hospitals needed paying patients to help finance the growing costs of providing medical care in their facilities. Much as they do today, physicians controlled the fate, technologically and economically, of the facilities because they brought in paying patient. Hospitals began opening their medical staffs to community physicians resulting in the majority of physicians having hospital privileges by the 1930s. Physicians were given access to hospitals and their support staffs to take care of their patients without having to deal with operational issues. This access was in exchange for donating services where needed, such as taking call in the emergency room or participating on hospital committees. The following decades saw the emergence of the hospital administrator to manage the institution’s growing operations and financial issues. Power was shared between the founders or trustees of the hospital, the administrator, and physicians. Conflicts–such as the expansion of hospital outpatient departments, the addition of nonphysician managers to run specialized services, and hospital hiring physicians– began to arise. There remained a lack of clarity of the medical staff’s role and authority because there was no formal decision-making structure for physicians. This further disintegrated the relationship as administrators lacked a clear party to deal with as problems arose. The passage of Medicare and Medicaid in 1965 widened access to health insurance coverage, and further established divergent paths for physicians and hospitals. Medicare Parts A and B separated payments for hospitals and physicians. This, along with increasing regulation in healthcare, further drove wedges in the physician–hospital relationship. Legal rulings during this time established hospital liability for contractual relationships with physicians and assigned responsibility for their behavior inside the institution, extended antitrust enforcement to healthcare, and abandoned rate regulations of hospitals. These served to change dynamics within the relationship but were only the beginning. A new Medicare prospective payment system using diagnosis-related groups was passed in 1983. Hospitals now focused on cost management in their dealings with 2014 Lippincott Williams & Wilkins
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physicians—reviving old physician complaints about diminished clinical autonomy and the corporate practice of medicine. Purchasing of physician practices, sponsored primary care networks, and employment of primary care physicians came and went in the 1990s and then came back in recent years. Although they seem to have learned from some of their employment mishaps in the 1990s, there is no solid evidence that hospitals have yet learned how to make physician employment profitable. Hospitals have pursued growth of those service lines, including orthopaedics, that generated significant revenues and margins for the hospital while physicians began to build or acquire their own imaging equipment or ambulatory surgery centers. This stripped away ancillary services that contributed significant hospital profits, reported by the National Hospital Association as 75% of hospital profits by 2008. Hospitals, feeling threatened by this competition, began creating physician joint ventures that helped retain some of their profitable outpatient volume and keep physicians from leaving the hospital campus. The changes in physician income growth potential and the continuation of diverging philosophies within the physician–hospital relationship have affected the hospital bottom line in other ways. The formerly voluntary compact with hospitals under which physicians traded medical staff privileges for covering medical service after hours and on weekends creates demands that are particularly acute for surgical specialists. Physicians now expect stipends for covering call, dramatically increasing hospital costs. All of these changes converged as the first nationwide healthcare reform became a reality. The survival of physician practices and hospitals are now more entwined than ever.
GOVERNANCE In the United States, community hospitals are categorized by state/local government entities and as not-for-profit or for-profit. Each acute care hospital is required to achieve and maintain compliance with local, state, and federal requirements. Additionally, if the hospital accepts Medicare and/or Medicaid funds, the Centers for Medicare and Medicaid Services (CMS) requires additional certifications through the Medicare conditions of participation. This oversight is usually performed by an approved entity such as The Joint Commission. In 2010, community hospitals were categorized into 3 ownerships: 1. State/local government: 21.4% 2. Not-for-profit: 58.3% 3. For-profit: 20.3%
NOT-FOR-PROFIT HOSPITAL ORGANIZATIONAL STRUCTURE The board of directors is primarily responsible for strategic orientation, fiduciary duty, public accountability, and advocacy. The board is comprised of a combination of senior management from the hospital and community leaders and at least 1 member of the hospital medical staff. The chief www.jorthotrauma.com |
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executive officer (CEO) reports directly to the board and is responsible for the senior management staff. The CEO also attends the board and medical staff meetings and provides leadership on the implementation of strategic initiatives. The primary function of the chief medical officer (CMO) is to establish and maintain healthy collaborative relations between the medical staff and the hospital. The chief quality officer may report to the CMO or CEO and this position holds overall management responsibility and accountability for quality and safety programs. The chief operating officer ensures compliance with regulatory bodies and organizational processes. The chief nursing office provides leadership and direction for all aspects of nursing. The chief financial officer is responsible for the overall financial operations of the hospital (Fig. 1). Their job duties and responsibilities include: CEO • Provide strategic leadership • Establish long-term goals • Promote inpatient services • Organize lines of authority • Promote favorable customer relationships • Coordinate service issues of the medical staff • Oversee operations and assume responsibility for all unit and department functions • Provide program and service evaluation • Implement the operational budget • Attend governing body meetings and medical staff meetings • Supervise leadership staff • Ensure compliance with regulatory bodies Chief operating officer • Design and implement organizational processes • Direct the development of short- and long-term goals • Develop policies and procedures • Oversee quality assurance standards • Ensure compliance with the The Joint Commission, CMS, and other regulators • Supervise assigned staff Chief financial officer • Provide financial information for decision making • Focus on cost management, revenue enhancement, and benchmarking comparisons
FIGURE 1. Example of nonprofit hospital organizational structure.
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• • • •
Ensure the functioning of the revenue cycle Negotiate contracts with other facilities Prepare budgets and forecasting Present monthly financial information CMO • Establish and maintain a positive working relationship between the hospital and the medical staff • Provide leadership for quality improvement activities • Distribute data and advice to improve quality • Facilitate standardizing and implementing best practices • Support the implementation of the electronic medical record • Organize and attend medical staff meetings • Attend meetings of senior management • Provide physician leadership Chief nursing office • Ensure the continuous and timely availability of nurses • Implement findings of current research into nursing policies and procedures • Participate in designing improved patient care systems • Support organizationwide performance improvement projects • Direct and implement appropriate cost containment measures • Provide subordinates with overall administrative direction • Manage overall responsibility and authority for nursing functions Hospitals utilize committees to vet many decisions. These committees are often led by or report to one of the leadership positions. Hospitals have vertical chains of command and budgets that are in place well in advance which can prove frustrating for physicians when requests are made that require a quick decision. As you can see in Figure 2, multiple offices and committees must be involved in the decision-making process to hire additional staff such as a physician assistant (Fig. 2).
ROLE OF THE ORTHOPAEDIC TRAUMATOLOGIST Orthopaedic trauma care is, in general, a high volume, high hospital utilization surgical service. Hospital administrators understand that they need surgeons and surgeon leadership to drive hospital profits. The insightful hospital administrators will engage the orthopaedic traumatologist and attempt to develop collaborative relationships to improve operational performances and outcomes which, in turn, improve national benchmarks. Hospitals are under increasing scrutiny from federal funding sources to meet performance metrics in order to qualify for reimbursement and, on occasion, bonuses. The business-trained orthopaedic traumatologist can favorably participate in this equation to the benefit of both physician practices and hospital reimbursement. The orthopaedic traumatologist is frequently advised from their administration that “trauma is losing proposition.” Recent objective data suggest hospitals with orthopaedic trauma systems are actually profitable when the service is looked upon as an individual profit center. Utilization of 2014 Lippincott Williams & Wilkins
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FIGURE 2. Example of hiring process for physician assistant.
radiology and laboratory services, days in the hospital and intensive care unit, surgical volume, and implant charges can all contribute to high margins for the hospital’s bottom line.1–3 Equally importantly for the graduate trauma fellow is their role as physician leader. These fellowship graduates should assume an active role in quality assurance including Surgical Care Improvement Project (SCIP) protocols, CMS measurements, and patient safety metrics. These physicians should advocate for resources necessary for the care of the trauma patient including orthopaedic trauma operating rooms, operative fixation implants, hospital floor traction equipment, midlevel providers, and the like. All of the ACS requirements for accreditation of orthopaedic trauma care are clearly defined in the ACS Resource Manual (2010). There is a strong possibility that orthopaedic trauma site visits will soon be part of the general trauma surgical service accreditation process. Newly trained fellowship leaders will assume even more responsibility for continued care of these trauma services than did their predecessors. Another key element in the leadership arena for the orthopaedic trauma fellow graduate is the understanding of service line profitability. The orthopaedic trauma service will be reviewed frequently by the administration to be sure the program is in line with their strategic plan. Areas of service line improvement could include cost containment programs, implant discount strategies, early discharge, and monitoring of quality measures. For example, is a return trip to the operating room a routine step in the management of the orthopaedic fracture or is it a complication to be reviewed by the quality assurance committee? Only orthopaedic leadership can make that determination; no business executive has the experience or skill set to offer an opinion regarding these types of clinical issues. Finally, in orthopaedic trauma practice models where established private practices have long-term relationships with their trauma hospitals, some type of co-management agreement may be explored. Certain private businesses have learned effective operational plans that could be used to help hospitals manage ineffective departments and share in the savings. For example, it is well known that privately managed, physician-owned outpatient surgery centers frequently provide more efficient care, with better margins, and superior outcomes. One of the advantages of these small, effective outpatient centers is the “boutique,” patient-focused care they are able to provide by motivated employees. Patient satisfaction and Hospital Care Assurance Program scores are generally better and employee morale is much higher resulting in less frequent turnover and lower training costs. With 2014 Lippincott Williams & Wilkins
personal physician investment, great care is exercised in the management and outcomes of these surgical procedures. As the federal government shifts from a passive payer of service to a purchaser of value, new stresses have been put on both physicians and hospitals to drive new healthcare delivery models. According to CMS, 13% of the national healthcare budget is related to orthopaedics which makes it a target to generate savings. With the Patient Protection and Affordable Care Act has come accountable care organizations (ACOs), bundled payments, meaningful use, Physician Quality Reporting System, and Hospital Consumer Assessment of Healthcare Providers and Systems Survey, thereby requiring hospitals and physicians to work more closely together. Collaborative partnerships require the use of a variety of tools and strategies simultaneously. Given that the success of the hospital depends on physician alignment, and the changing environment makes alignment a prudent idea for physicians, it is incumbent on hospital administrators and physicians to support a collaborative tenor for their relationship. Although the organizational structure of hospitals and doctors are misaligned their incentives will now be dependent on alignment. All of the forces coming to bear on hospitals–high patient censuses, nursing shortages, pressures to improve quality and safety, the successful implementation of computerized order entry and other technologies–cannot possibly succeed if the hospital and physicians continue to operate as 2 separate islands. The successful medical center of the future will be marked by high levels of collaboration, a sense of shared mission, and recognition by both parties that 1 cannot possibly succeed without the other. In some settings, this sort of collaboration is facilitated by organizational structures that link the medical staff and the hospital, such as academic medical centers or clinically integrated systems such as Kaiser Permanente. Others need to explore the tools that are available to create synergy and a shared mission.
ALIGNMENT As hospital care has become more complex and sophisticated, both outcomes and efficiency are increasingly linked to the quality of teamwork, not only between various types of physicians but between physicians and the other healthcare professionals. Trauma surgeon presence and immersion in their practice environments creates fertile soil for alignment of incentives with the hospital and for the creation of high-functioning teams involving the trauma surgeon. Physicians need to become comfortable with the precepts of systems thinking. In some cases, the financial www.jorthotrauma.com |
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incentives between trauma surgeons and the hospital are already aligned when support from the institution, such as call stipends, directorships, or subsidization for indigent care, make up the difference between the dollars they can generate through professional fees for direct care and the cost of their presence. The presence of these support payments creates an alignment of incentives. According to data from the National Hospital Association, physicians who receive 30% of their income from their hospitals can be counted on to enthusiastically participate in, if not lead, hospital-based quality or cost reduction initiatives. Alignment can occur in 3 areas: • Clinical activity: defined as the correlation of the patient care approach, expectations of quality and service, and consolidation of activity in the diagnosis, treatment, and rehabilitation of patients • Economic: defined as the correlation of physician and hospital financial returns • Alignment of purpose: defined as the correlation of vision, values, and energies and a common culture Alignment in 1 area is not enough to be successful in the future environment. The future post-healthcare reform environment requires much greater integration of the continuum which in turn requires alignment on all 3 factors. Reasons hospitals should align: • Financial incentives • Recruitment and retention of medical staff • Aligned providers to create ACOs • Service line stability • Preparation for future quality and incentive reforms • Economic pressures will drive patients to healthcare providers that are better aligned and have the greatest value proposition Reasons surgeons should align: • Financial incentives • Quality of life • Infrastructure support • Powerful base that can leverage scale when negotiating with commercial payers • Access to ACOs or primary care providers • Access to data • Improve surgical experience • Seat at the table so accurate and clinically relevant metrics for evaluating outcomes are establish • Preparation for future quality and incentive reforms • Economic pressures will drive patients to healthcare providers that are better aligned and have the greatest value proposition As you can see, the economic and non-economic reasons for alignment are very similar. Individual economic tools such as medical directorships, joint ventures, physician service agreements, comanagement agreements, and employment can serve to fulfill the economic alignment but, prior to entering into one of these arrangements, both sides must agree to a goal and define what they consider a successful outcome will look like. Regardless of the number of meetings and the amount of time spent on discussing an alignment of purpose, it is critical that
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the final written product include an outline of this section to ensure that each side has the same expectations. Before you decide which alignment best fits your situation, physicians must stop thinking solely with his/her clinical hat. Defining what you consider to be quality patient care will be the easy part of any negotiation because it will be within your comfort zone. For the hospital, what makes sense for the bottom line will be within their comfort zone. You must learn to speak the same language which means putting on your business hat. The hospital will come to the negotiation with numbers that tell them what your economic value is to their institution. You must know that number from your perspective and be armed with your own data. You also need to be open to reviewing their data. Often, physicians have a skewed view of what their value is to the hospital. On the other side, hospital data is not always accurate. Keep an open mind and KNOW YOUR DATA. Multiple forms of alignment exist. Several of the most common are presented here:
Medical Directorships These positions, which include stipends to oversee specific programs, services, and departments and achieve certain metrics, help incentivize improvements to clinical quality. When appropriately structured, they allow physicians to be paid for their time and expertise and the hospital gains leadership, buy-in, and improved efficiency.
Clinical Co-Management Co-management agreements are contracts where physicians can help manage operating rooms, orthopaedic floors, or the entire orthopaedic service line for a percentage of the profits. • Physicians can sign agreements that allow them to benefit from improved efficiency in Operating Room such as decreased OR times, turnover times, standardizing surgical packs, SCIP, etc. • Physicians can benefit from assisting in management of orthopaedic floor care to decrease medication expenses, standardize postoperative orders, decrease lengths of stay, etc. • Beware of contracts that decrease physician benefits for failure to improve efficiencies. • This structure withstands legal challenges of kickback violations or inappropriate hospital ownership by physicians. Such agreements can allow closer partnerships without the legal ramifications of employment. This relationship improves quality, operations, and program development.
Joint Ventures Take the form of legal partnerships designed to share risk or expertise around specific healthcare functions or services, such as ambulatory surgery. An organization can benefit from physicians’ expertise in these new areas, and may find innovation more attractive if the risk is shared with another party. 2014 Lippincott Williams & Wilkins
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Employment Many hospitals and physicians are considering employment strategies because of the recent elimination of many of the previously permitted economic alignment tools, a desire by physicians to alleviate the administrative burdens and ongoing capital investment associated with running a professional practice, and increasing uncertainty of future payment.
Gain Sharing Physicians can negotiate arrangements in which they can benefit directly from cost saving decisions. Once thought to be illegal, this is becoming more common and many forms of gain sharing exist. Money saved on implants or durable medical equipment can be directed toward additional orthopaedic floor nurses, trauma coordinators, C-arms, OR equipment, etc. Assigning gain to hospital-based services will be significantly easier to negotiate than direct physician or group remuneration. The financial incentives within a contract can vary depending on desires and vision; the incentives can include payments for quality outcomes, serving selected markets, or providing management services. Financial stability is often cited as a reason physicians choose employment over other financial alignments. It will prove very difficult in the future with the payment changes and changes in delivery models to maintain current salaries within a hospital-based practice. But physician employment is more than a business contract. Many of the difficulties that arise surround the noneconomic issues. Sometimes the most contentious part of the agreement between hospital and physician surrounds the issue of control, not finance. Some high level hospital administrators are leery or too proud to relinquish control of hospital services despite numerous examples of improved efficiency and quality with increased physician involvement. Expectations and cultural norms within the hospital environment can prove very difficult to adapt to from a physician that is used too much greater autonomy. Managing and directing employed physicians requires quite a different organizational structure than is typically encountered in hospitals and health systems. A separate, but tightly coordinated and linked, structure is usually needed. The goal is to create the right structures for physicians rather than force physicians to adapt to the hospital’s existing structures. Regardless of type of contracts, physician partnerships need consistent nurturing and cultivation. It is important for hospital administrators and physicians to constantly evaluate the direction and success of any agreement and partnership and to discuss changes needed through open communication. As reimbursements decline and the nation trends toward the development of clinical integration (eg, ACOs), physician–hospital alignment becomes ever more important. This section discusses the importance of physician–hospital cooperation in a community setting as well as the incentives for each stakeholder. It also provides some real examples of these types of relationships. Academic settings and employed models naturally fit into an ACO, but physicians in those 2014 Lippincott Williams & Wilkins
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models can adapt some of the strategies here to promote improved patient care.
WHAT DOES ALIGNMENT MEAN IN A COMMUNITY SETTING? The goal of a physician–community hospital alignment should be to provide high quality and cost-conscious care to the members of the community. The individuals include family members, neighbors, colleagues, and workers. High quality care leads to better outcomes. It means that community physicians commit to providing emergency room coverage so that members of the local and outlying communities can stay close to home to receive their care and follow-up. When physicians assume accountability to their community and take ownership in their institution, patients and staff can sense this dedication. Physicians can also team up with hospital organizations to cosponsor community programs that promote preventative medicine, education, and goodwill. The incentives for improving care delivery are many and exceed financial rewards. More efficient and higher quality care leads to better outcomes. Excellent results and collegiality promote more referrals. Efficient care delivery leads to cost savings for both the physician’s practice and the hospital. It may also allow greater throughput, which can directly have an impact on both the quality of life and revenue stream for physicians. When cost savings are realized, these dollars can be directed toward initiatives that benefit the patient (eg, decreasing staff to patient ratios, increasing the number of physical therapists, investment in operating room technology). Collaborative efforts may also open the doors to physician–hospital partnership in other ventures (eg, developing a fellowship program, co-management agreements, development of centers of excellence). Successes in care delivery and outcomes create beneficial publicity for both the physician and the institution. In these situations, hospitals have many expectations for their physician partners. The 3 As (availability, affability, and ability) will always be central to the relationship. Two more As (accountability and advocacy) should also be included. Hospitals expect prompt, high quality, evidencebased, and cost-conscious care for all individuals regardless of financial status. They hope that physicians will bring their elective patients to that hospital and that physicians will fulfill their coverage needs and enhance their market competitiveness. Hospitals value physician self-governance and accountability and welcome participation in quality assurance committees, medical directorships, and other leadership roles. Hospitals look toward physicians not only to provide direct care to patients, but also indirectly influence care delivery through the education hospital clinical staff (nurses, therapists, physician extenders, other members of the medical staff). Medical staff members are expected to maintain compliance with CMS guidelines and legislation as well as uphold patient confidentiality. Hospitals look to physicians to spearhead and participate in cost savings initiatives and support quality outcome measures such as deep vein thrombosis prophylaxis, reduction in iatrogenic and hospital-associated complications, reduction www.jorthotrauma.com |
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of readmission and “never events,” SCIP, and Hospital Consumer Assessment of Healthcare Providers and Systems Survey. Similarly, the surgeon should have the following expectation of the hospital. The physician expects to have access to the operating room and its staff to perform both elective and emergent cases. The requested equipment must be available and in good condition and cases should start on time. An adequate number of amiable and well trained support staff (eg, social workers, therapists, nurses, nursing assistants, emergency room technicians, traction technicians, transport technicians, and, in some situations, physician extenders) should be employed by the hospital to facilitate prompt and high quality care delivery. Hospitals must also provide the appropriate ancillary resources (eg, magnetic resonance imaging, computed tomography, therapy) and it must be of high quality and accessible in a timely manner. The hospital should also support non-orthopaedic specialties to ensure that physicians have access to well-trained consultants when the patient condition demands their involvement. The infrastructure and technology must be in place to facilitate care delivery both in the hospital and when the physician is off campus (eg, electronic medical record and picture archiving and communication system and offsite access with adequate technical support). Physicians should also look to the institution to provide indigent care to the community and clinical care coordinators who can facilitate appropriate discharge dispositions as well as medication assistance. Hospitals should also provide educational support for local and national continuing medical education opportunities. For physicians taking call, a lounge and call room should be available. Care providers must be included in decisions regarding hospital initiatives, staff support, and capital investment in technology (eg, navigation). When cost savings or successes arise from these collaborative efforts, the monies should be directed toward service reinvestment. A shared vision increases the likelihood of the initiative’s success. The goal of satisfying all of the above expectations is to ensure high levels of patient satisfaction and care outcomes while minimizing the number of complications. The patient– physician relationship continues even after the hospital stay is complete, but the patient’s hospital experience can play a significant role in the perception of their overall care and recovery. Physician–hospital alignments can take many forms. Effective partnership efforts have surrounded the development of orthopaedic trauma call panels, quality assurance panels, implant selection committees, or the development of centers of excellence (eg, joint replacement programs, trauma programs). Other collaborative efforts may arise in the development of order sets for hip fractures, fragility fracture programs, or participating in educational ventures (eg, lectures within the institution or in the community, development of graduate medical education programs). The broad goals of these partnerships are to improve patient experience, decrease
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length of stay, and promote high quality outcomes and judicious resource utilization.
COMMUNICATION Hospital executives and physicians are often challenged to keep the lines of communication open. Often, communication becomes adversarial. To establish productive, efficient communications, the physician must be clear about what they want, understand clearly what they bring to the hospital and its economic and non-economic value. The goal is to create a win-win situation. Take the time to understand the issues the hospital is dealing with, especially the political problems that surface as they begin to choose their preferred partners. Help them solve their political problems and you are more apt to come to a satisfactory solution.
THE FUTURE A study conducted with hospitals in Arizona in 2010 looked at the qualities of high-functioning hospitals. Commonly, they were characterized by leaders who managed to “engage and inspire the physicians.” The CEOs were considered “superb communicators” and visionaries and the top physician executives effectively served as bridges between hospital administrators and medical staff. Together, they managed to “convince the physicians to restrain some of their instinctive sense of autonomy for the greater good of the institution and their patients.” The methods for achieving this outcome varied and included everything from paying for physician participation in critical meetings and retreats to responding to physician concerns quickly and publicly. The high-functioning hospitals of the future will be marked by a kind of culture of collaboration—at the macro level, between the medical staff and the hospital administration, and at the micro level, between hospitalists, nurses, and case managers working on a given ward. The hospitals will create an environment in which surgeons recognize that care will be better and safer if they can agree on standard procedures that everyone uses, rather than pushing the hospital to sustain customized procedures, which are incredibly inefficient and error-prone. They will operate as if the doctors, nurses, administrators, and others recognize their complete interdependency in a shared effort to achieve a single, overarching goal: the provision of the highest quality, safest, and most satisfying care to patients at the lowest possible cost. REFERENCES 1. Ziran BH, Barrette-Grischow MK, Marucci K. Economic value of orthopaedic trauma: the (second) bottom line. J Orthop Trauma. 2008;22: 227–233. 2. Vallier HA, Patterson BM, Meehan CJ, et al. Orthopaedic traumatology: the hospital side of the ledger, defining the financial relationship between physicians and hospitals. J Orthop Trauma. 2008;22:221–226. 3. Althausen PL, Coll D, Cvitash M, et al. Economic viability of a community-based level-II orthopaedic trauma system. J Bone Joint Surg Am. 2009;91:227–235.
2014 Lippincott Williams & Wilkins
Hospital Fundamentals Peter L. Althausen, MD, MBA,* Austin D. Hill, MD, MPH,† and Lisa Mead, MBA*
Summary: Under the current system, orthopaedic trauma surgeons must work in some form of hospital setting as our primary service involves treatment of the trauma patient. We must not forget that just as a trauma center cannot exist without our services, we cannot function without their support. As a result, a clear understanding of the balance between physicians and hospitals is paramount. Historical perspective enables physicians and hospital personnel alike to understand the evolution of hospital–physician relationship. This process should be understood upon completion of this chapter. The relationship between physicians and hospitals is becoming increasingly complex and multiple forms of integration exist such as joint ventures, gain sharing, and co-management agreements. For the surgeon to negotiate well, an understanding of hospital governance and the role of the orthopaedic traumatologist is vital to success. An understanding of the value provided by the traumatologist includes all aspects of care including efficiency, availability, cost effectiveness, and research activities. To create effective and sustainable healthcare institutions, physicians and hospitals must be aligned over a sustained period of time. Unfortunately, external forces have eroded the historical basis for the working relationship between physicians and hospitals. Increased competition and reimbursement cuts, coupled with the increasing demands for quality, efficiency, and coordination and the payment changes outlined in healthcare reform, have left many organizations wondering how to best rebuild the relationship. The principal goal for the physician when partnering with a hospital or healthcare entity is to establish a sustainable model of service line management that protects or advances the physician’s ability to make impactful improvements in quality of patient care, decreases in healthcare costs, and improvements in process efficiency through evidence-based practices and protocols. Key Words: governance, hospital/physician alignment, co-management (J Orthop Trauma 2014;28:S18–S24)
HOSPITAL–PHYSICIAN RELATIONSHIPS The inception of the physician–patient relationship, particularly in trauma, occurs in the hospital. Hospitals cannot perform a procedure, run an emergency department, or achieve their healthcare mission without physicians. Physicians typically need hospitals to access the capital and technology that provide the facilities for them to practice Accepted for publication April 9, 2014. From the *Reno Orthopaedic Clinic, Reno, NV; and †Austin Skeletal Trauma Specialists, Austin, TX. The authors report no conflict of interest. Reprints: Peter L. Althausen, MD, MBA, Reno Orthopaedic Clinic, 555 North Arlington Avenue, Reno, NV 89503-4724 (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
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medicine and for the education and training of future physicians. Effective, efficient patient care relies on this mutually dependent relationship. Although the daily dealings of physicians and hospitals appear outwardly cordial, there is often underlying distrust and concern about what motivates each side in their decisionmaking processes. Physicians see themselves as advocates of quality patient care and practice efficiency. They want control over the scope of their practice with minimal barriers between themselves and their patients. The business of the hospital is not foremost on their mind when treating a trauma victim. Often this leads to the 2 sides talking over each other in different languages in an attempt to achieve similar outcomes. Establishing a trinity of mutual beneficence between the hospital, physician, and patient is now the standard of care. With profit margins shrinking due to the increasing costs of healthcare delivery, litigation, and decreasing payer reimbursement, the inefficiency of adversarial relationships will no longer be viable or tolerated. In the beginning, medical staff membership fostered physician autonomy with minimum interference from the hospital. These nonprofit institutions were aligned with the physician’s mission of patient care. In time, the agenda of the increasingly “corporate” hospital included increasing efficiency in order to realize greater gains to the financial bottom line. The alignment surrounding patient care began to diverge. This marriage was one of necessity–each needed the other–but it was not without competing interests and discord. To create effective and sustainable healthcare institutions, physicians and hospitals must be aligned over a sustained period of time. Unfortunately external forces have eroded the historical basis for the working relationship between physicians and hospitals. The market is changing, demonstrating increasing competition and reimbursement cuts, as well as increasing demands for quality, efficiency, and coordination. Coupled with the payment changes outlined in healthcare reform, the current status has left many organizations wondering how to best rebuild the relationship. The principal goal for the physician when partnering with a hospital or healthcare entity is to establish a sustainable model. This includes creation of a service line management system that protects the physician’s ability to make improvements in both the quality of patient care and process efficiency through evidence based practices and protocols.
HISTORICAL PERSPECTIVE The interdependence of the hospital physician relationship began late in a 19th century America experiencing significant population increases and industrialization. J Orthop Trauma Volume 28, Number 7 Supplement, July 2014
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Historically, only the poor or isolated received medical care in institutions and physicians tended the middle or upper class patients in their homes. As medical practices grew in their sophistication and complexity, there was a shift toward the professionalization of healthcare and the development of a competitive market for medical services that increasingly took place in hospitals. During the late 19th century and early 20th century, control over clinical decision making was left to the physicians. Physician autonomy and control received institutional endorsement in 1912 when the American College of Surgeons (ACS) formed to pursue standardization in medical treatment. Hospitals felt compelled to adhere to their requirements in hopes of avoiding external regulation. The ACS requirements included the development of formal medical staff structures, committees, meetings, and policies to supervise standards within the hospital. The oversight of clinical affairs was assigned to physicians to be clearly separated from the administrative part of the organization. All hospitals before the 1920s operated without much money. Hospitals needed paying patients to help finance the growing costs of providing medical care in their facilities. Much as they do today, physicians controlled the fate, technologically and economically, of the facilities because they brought in paying patient. Hospitals began opening their medical staffs to community physicians resulting in the majority of physicians having hospital privileges by the 1930s. Physicians were given access to hospitals and their support staffs to take care of their patients without having to deal with operational issues. This access was in exchange for donating services where needed, such as taking call in the emergency room or participating on hospital committees. The following decades saw the emergence of the hospital administrator to manage the institution’s growing operations and financial issues. Power was shared between the founders or trustees of the hospital, the administrator, and physicians. Conflicts–such as the expansion of hospital outpatient departments, the addition of nonphysician managers to run specialized services, and hospital hiring physicians– began to arise. There remained a lack of clarity of the medical staff’s role and authority because there was no formal decision-making structure for physicians. This further disintegrated the relationship as administrators lacked a clear party to deal with as problems arose. The passage of Medicare and Medicaid in 1965 widened access to health insurance coverage, and further established divergent paths for physicians and hospitals. Medicare Parts A and B separated payments for hospitals and physicians. This, along with increasing regulation in healthcare, further drove wedges in the physician–hospital relationship. Legal rulings during this time established hospital liability for contractual relationships with physicians and assigned responsibility for their behavior inside the institution, extended antitrust enforcement to healthcare, and abandoned rate regulations of hospitals. These served to change dynamics within the relationship but were only the beginning. A new Medicare prospective payment system using diagnosis-related groups was passed in 1983. Hospitals now focused on cost management in their dealings with 2014 Lippincott Williams & Wilkins
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physicians—reviving old physician complaints about diminished clinical autonomy and the corporate practice of medicine. Purchasing of physician practices, sponsored primary care networks, and employment of primary care physicians came and went in the 1990s and then came back in recent years. Although they seem to have learned from some of their employment mishaps in the 1990s, there is no solid evidence that hospitals have yet learned how to make physician employment profitable. Hospitals have pursued growth of those service lines, including orthopaedics, that generated significant revenues and margins for the hospital while physicians began to build or acquire their own imaging equipment or ambulatory surgery centers. This stripped away ancillary services that contributed significant hospital profits, reported by the National Hospital Association as 75% of hospital profits by 2008. Hospitals, feeling threatened by this competition, began creating physician joint ventures that helped retain some of their profitable outpatient volume and keep physicians from leaving the hospital campus. The changes in physician income growth potential and the continuation of diverging philosophies within the physician–hospital relationship have affected the hospital bottom line in other ways. The formerly voluntary compact with hospitals under which physicians traded medical staff privileges for covering medical service after hours and on weekends creates demands that are particularly acute for surgical specialists. Physicians now expect stipends for covering call, dramatically increasing hospital costs. All of these changes converged as the first nationwide healthcare reform became a reality. The survival of physician practices and hospitals are now more entwined than ever.
GOVERNANCE In the United States, community hospitals are categorized by state/local government entities and as not-for-profit or for-profit. Each acute care hospital is required to achieve and maintain compliance with local, state, and federal requirements. Additionally, if the hospital accepts Medicare and/or Medicaid funds, the Centers for Medicare and Medicaid Services (CMS) requires additional certifications through the Medicare conditions of participation. This oversight is usually performed by an approved entity such as The Joint Commission. In 2010, community hospitals were categorized into 3 ownerships: 1. State/local government: 21.4% 2. Not-for-profit: 58.3% 3. For-profit: 20.3%
NOT-FOR-PROFIT HOSPITAL ORGANIZATIONAL STRUCTURE The board of directors is primarily responsible for strategic orientation, fiduciary duty, public accountability, and advocacy. The board is comprised of a combination of senior management from the hospital and community leaders and at least 1 member of the hospital medical staff. The chief www.jorthotrauma.com |
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executive officer (CEO) reports directly to the board and is responsible for the senior management staff. The CEO also attends the board and medical staff meetings and provides leadership on the implementation of strategic initiatives. The primary function of the chief medical officer (CMO) is to establish and maintain healthy collaborative relations between the medical staff and the hospital. The chief quality officer may report to the CMO or CEO and this position holds overall management responsibility and accountability for quality and safety programs. The chief operating officer ensures compliance with regulatory bodies and organizational processes. The chief nursing office provides leadership and direction for all aspects of nursing. The chief financial officer is responsible for the overall financial operations of the hospital (Fig. 1). Their job duties and responsibilities include: CEO • Provide strategic leadership • Establish long-term goals • Promote inpatient services • Organize lines of authority • Promote favorable customer relationships • Coordinate service issues of the medical staff • Oversee operations and assume responsibility for all unit and department functions • Provide program and service evaluation • Implement the operational budget • Attend governing body meetings and medical staff meetings • Supervise leadership staff • Ensure compliance with regulatory bodies Chief operating officer • Design and implement organizational processes • Direct the development of short- and long-term goals • Develop policies and procedures • Oversee quality assurance standards • Ensure compliance with the The Joint Commission, CMS, and other regulators • Supervise assigned staff Chief financial officer • Provide financial information for decision making • Focus on cost management, revenue enhancement, and benchmarking comparisons
FIGURE 1. Example of nonprofit hospital organizational structure.
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• • • •
Ensure the functioning of the revenue cycle Negotiate contracts with other facilities Prepare budgets and forecasting Present monthly financial information CMO • Establish and maintain a positive working relationship between the hospital and the medical staff • Provide leadership for quality improvement activities • Distribute data and advice to improve quality • Facilitate standardizing and implementing best practices • Support the implementation of the electronic medical record • Organize and attend medical staff meetings • Attend meetings of senior management • Provide physician leadership Chief nursing office • Ensure the continuous and timely availability of nurses • Implement findings of current research into nursing policies and procedures • Participate in designing improved patient care systems • Support organizationwide performance improvement projects • Direct and implement appropriate cost containment measures • Provide subordinates with overall administrative direction • Manage overall responsibility and authority for nursing functions Hospitals utilize committees to vet many decisions. These committees are often led by or report to one of the leadership positions. Hospitals have vertical chains of command and budgets that are in place well in advance which can prove frustrating for physicians when requests are made that require a quick decision. As you can see in Figure 2, multiple offices and committees must be involved in the decision-making process to hire additional staff such as a physician assistant (Fig. 2).
ROLE OF THE ORTHOPAEDIC TRAUMATOLOGIST Orthopaedic trauma care is, in general, a high volume, high hospital utilization surgical service. Hospital administrators understand that they need surgeons and surgeon leadership to drive hospital profits. The insightful hospital administrators will engage the orthopaedic traumatologist and attempt to develop collaborative relationships to improve operational performances and outcomes which, in turn, improve national benchmarks. Hospitals are under increasing scrutiny from federal funding sources to meet performance metrics in order to qualify for reimbursement and, on occasion, bonuses. The business-trained orthopaedic traumatologist can favorably participate in this equation to the benefit of both physician practices and hospital reimbursement. The orthopaedic traumatologist is frequently advised from their administration that “trauma is losing proposition.” Recent objective data suggest hospitals with orthopaedic trauma systems are actually profitable when the service is looked upon as an individual profit center. Utilization of 2014 Lippincott Williams & Wilkins
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FIGURE 2. Example of hiring process for physician assistant.
radiology and laboratory services, days in the hospital and intensive care unit, surgical volume, and implant charges can all contribute to high margins for the hospital’s bottom line.1–3 Equally importantly for the graduate trauma fellow is their role as physician leader. These fellowship graduates should assume an active role in quality assurance including Surgical Care Improvement Project (SCIP) protocols, CMS measurements, and patient safety metrics. These physicians should advocate for resources necessary for the care of the trauma patient including orthopaedic trauma operating rooms, operative fixation implants, hospital floor traction equipment, midlevel providers, and the like. All of the ACS requirements for accreditation of orthopaedic trauma care are clearly defined in the ACS Resource Manual (2010). There is a strong possibility that orthopaedic trauma site visits will soon be part of the general trauma surgical service accreditation process. Newly trained fellowship leaders will assume even more responsibility for continued care of these trauma services than did their predecessors. Another key element in the leadership arena for the orthopaedic trauma fellow graduate is the understanding of service line profitability. The orthopaedic trauma service will be reviewed frequently by the administration to be sure the program is in line with their strategic plan. Areas of service line improvement could include cost containment programs, implant discount strategies, early discharge, and monitoring of quality measures. For example, is a return trip to the operating room a routine step in the management of the orthopaedic fracture or is it a complication to be reviewed by the quality assurance committee? Only orthopaedic leadership can make that determination; no business executive has the experience or skill set to offer an opinion regarding these types of clinical issues. Finally, in orthopaedic trauma practice models where established private practices have long-term relationships with their trauma hospitals, some type of co-management agreement may be explored. Certain private businesses have learned effective operational plans that could be used to help hospitals manage ineffective departments and share in the savings. For example, it is well known that privately managed, physician-owned outpatient surgery centers frequently provide more efficient care, with better margins, and superior outcomes. One of the advantages of these small, effective outpatient centers is the “boutique,” patient-focused care they are able to provide by motivated employees. Patient satisfaction and Hospital Care Assurance Program scores are generally better and employee morale is much higher resulting in less frequent turnover and lower training costs. With 2014 Lippincott Williams & Wilkins
personal physician investment, great care is exercised in the management and outcomes of these surgical procedures. As the federal government shifts from a passive payer of service to a purchaser of value, new stresses have been put on both physicians and hospitals to drive new healthcare delivery models. According to CMS, 13% of the national healthcare budget is related to orthopaedics which makes it a target to generate savings. With the Patient Protection and Affordable Care Act has come accountable care organizations (ACOs), bundled payments, meaningful use, Physician Quality Reporting System, and Hospital Consumer Assessment of Healthcare Providers and Systems Survey, thereby requiring hospitals and physicians to work more closely together. Collaborative partnerships require the use of a variety of tools and strategies simultaneously. Given that the success of the hospital depends on physician alignment, and the changing environment makes alignment a prudent idea for physicians, it is incumbent on hospital administrators and physicians to support a collaborative tenor for their relationship. Although the organizational structure of hospitals and doctors are misaligned their incentives will now be dependent on alignment. All of the forces coming to bear on hospitals–high patient censuses, nursing shortages, pressures to improve quality and safety, the successful implementation of computerized order entry and other technologies–cannot possibly succeed if the hospital and physicians continue to operate as 2 separate islands. The successful medical center of the future will be marked by high levels of collaboration, a sense of shared mission, and recognition by both parties that 1 cannot possibly succeed without the other. In some settings, this sort of collaboration is facilitated by organizational structures that link the medical staff and the hospital, such as academic medical centers or clinically integrated systems such as Kaiser Permanente. Others need to explore the tools that are available to create synergy and a shared mission.
ALIGNMENT As hospital care has become more complex and sophisticated, both outcomes and efficiency are increasingly linked to the quality of teamwork, not only between various types of physicians but between physicians and the other healthcare professionals. Trauma surgeon presence and immersion in their practice environments creates fertile soil for alignment of incentives with the hospital and for the creation of high-functioning teams involving the trauma surgeon. Physicians need to become comfortable with the precepts of systems thinking. In some cases, the financial www.jorthotrauma.com |
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incentives between trauma surgeons and the hospital are already aligned when support from the institution, such as call stipends, directorships, or subsidization for indigent care, make up the difference between the dollars they can generate through professional fees for direct care and the cost of their presence. The presence of these support payments creates an alignment of incentives. According to data from the National Hospital Association, physicians who receive 30% of their income from their hospitals can be counted on to enthusiastically participate in, if not lead, hospital-based quality or cost reduction initiatives. Alignment can occur in 3 areas: • Clinical activity: defined as the correlation of the patient care approach, expectations of quality and service, and consolidation of activity in the diagnosis, treatment, and rehabilitation of patients • Economic: defined as the correlation of physician and hospital financial returns • Alignment of purpose: defined as the correlation of vision, values, and energies and a common culture Alignment in 1 area is not enough to be successful in the future environment. The future post-healthcare reform environment requires much greater integration of the continuum which in turn requires alignment on all 3 factors. Reasons hospitals should align: • Financial incentives • Recruitment and retention of medical staff • Aligned providers to create ACOs • Service line stability • Preparation for future quality and incentive reforms • Economic pressures will drive patients to healthcare providers that are better aligned and have the greatest value proposition Reasons surgeons should align: • Financial incentives • Quality of life • Infrastructure support • Powerful base that can leverage scale when negotiating with commercial payers • Access to ACOs or primary care providers • Access to data • Improve surgical experience • Seat at the table so accurate and clinically relevant metrics for evaluating outcomes are establish • Preparation for future quality and incentive reforms • Economic pressures will drive patients to healthcare providers that are better aligned and have the greatest value proposition As you can see, the economic and non-economic reasons for alignment are very similar. Individual economic tools such as medical directorships, joint ventures, physician service agreements, comanagement agreements, and employment can serve to fulfill the economic alignment but, prior to entering into one of these arrangements, both sides must agree to a goal and define what they consider a successful outcome will look like. Regardless of the number of meetings and the amount of time spent on discussing an alignment of purpose, it is critical that
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the final written product include an outline of this section to ensure that each side has the same expectations. Before you decide which alignment best fits your situation, physicians must stop thinking solely with his/her clinical hat. Defining what you consider to be quality patient care will be the easy part of any negotiation because it will be within your comfort zone. For the hospital, what makes sense for the bottom line will be within their comfort zone. You must learn to speak the same language which means putting on your business hat. The hospital will come to the negotiation with numbers that tell them what your economic value is to their institution. You must know that number from your perspective and be armed with your own data. You also need to be open to reviewing their data. Often, physicians have a skewed view of what their value is to the hospital. On the other side, hospital data is not always accurate. Keep an open mind and KNOW YOUR DATA. Multiple forms of alignment exist. Several of the most common are presented here:
Medical Directorships These positions, which include stipends to oversee specific programs, services, and departments and achieve certain metrics, help incentivize improvements to clinical quality. When appropriately structured, they allow physicians to be paid for their time and expertise and the hospital gains leadership, buy-in, and improved efficiency.
Clinical Co-Management Co-management agreements are contracts where physicians can help manage operating rooms, orthopaedic floors, or the entire orthopaedic service line for a percentage of the profits. • Physicians can sign agreements that allow them to benefit from improved efficiency in Operating Room such as decreased OR times, turnover times, standardizing surgical packs, SCIP, etc. • Physicians can benefit from assisting in management of orthopaedic floor care to decrease medication expenses, standardize postoperative orders, decrease lengths of stay, etc. • Beware of contracts that decrease physician benefits for failure to improve efficiencies. • This structure withstands legal challenges of kickback violations or inappropriate hospital ownership by physicians. Such agreements can allow closer partnerships without the legal ramifications of employment. This relationship improves quality, operations, and program development.
Joint Ventures Take the form of legal partnerships designed to share risk or expertise around specific healthcare functions or services, such as ambulatory surgery. An organization can benefit from physicians’ expertise in these new areas, and may find innovation more attractive if the risk is shared with another party. 2014 Lippincott Williams & Wilkins
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Employment Many hospitals and physicians are considering employment strategies because of the recent elimination of many of the previously permitted economic alignment tools, a desire by physicians to alleviate the administrative burdens and ongoing capital investment associated with running a professional practice, and increasing uncertainty of future payment.
Gain Sharing Physicians can negotiate arrangements in which they can benefit directly from cost saving decisions. Once thought to be illegal, this is becoming more common and many forms of gain sharing exist. Money saved on implants or durable medical equipment can be directed toward additional orthopaedic floor nurses, trauma coordinators, C-arms, OR equipment, etc. Assigning gain to hospital-based services will be significantly easier to negotiate than direct physician or group remuneration. The financial incentives within a contract can vary depending on desires and vision; the incentives can include payments for quality outcomes, serving selected markets, or providing management services. Financial stability is often cited as a reason physicians choose employment over other financial alignments. It will prove very difficult in the future with the payment changes and changes in delivery models to maintain current salaries within a hospital-based practice. But physician employment is more than a business contract. Many of the difficulties that arise surround the noneconomic issues. Sometimes the most contentious part of the agreement between hospital and physician surrounds the issue of control, not finance. Some high level hospital administrators are leery or too proud to relinquish control of hospital services despite numerous examples of improved efficiency and quality with increased physician involvement. Expectations and cultural norms within the hospital environment can prove very difficult to adapt to from a physician that is used too much greater autonomy. Managing and directing employed physicians requires quite a different organizational structure than is typically encountered in hospitals and health systems. A separate, but tightly coordinated and linked, structure is usually needed. The goal is to create the right structures for physicians rather than force physicians to adapt to the hospital’s existing structures. Regardless of type of contracts, physician partnerships need consistent nurturing and cultivation. It is important for hospital administrators and physicians to constantly evaluate the direction and success of any agreement and partnership and to discuss changes needed through open communication. As reimbursements decline and the nation trends toward the development of clinical integration (eg, ACOs), physician–hospital alignment becomes ever more important. This section discusses the importance of physician–hospital cooperation in a community setting as well as the incentives for each stakeholder. It also provides some real examples of these types of relationships. Academic settings and employed models naturally fit into an ACO, but physicians in those 2014 Lippincott Williams & Wilkins
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models can adapt some of the strategies here to promote improved patient care.
WHAT DOES ALIGNMENT MEAN IN A COMMUNITY SETTING? The goal of a physician–community hospital alignment should be to provide high quality and cost-conscious care to the members of the community. The individuals include family members, neighbors, colleagues, and workers. High quality care leads to better outcomes. It means that community physicians commit to providing emergency room coverage so that members of the local and outlying communities can stay close to home to receive their care and follow-up. When physicians assume accountability to their community and take ownership in their institution, patients and staff can sense this dedication. Physicians can also team up with hospital organizations to cosponsor community programs that promote preventative medicine, education, and goodwill. The incentives for improving care delivery are many and exceed financial rewards. More efficient and higher quality care leads to better outcomes. Excellent results and collegiality promote more referrals. Efficient care delivery leads to cost savings for both the physician’s practice and the hospital. It may also allow greater throughput, which can directly have an impact on both the quality of life and revenue stream for physicians. When cost savings are realized, these dollars can be directed toward initiatives that benefit the patient (eg, decreasing staff to patient ratios, increasing the number of physical therapists, investment in operating room technology). Collaborative efforts may also open the doors to physician–hospital partnership in other ventures (eg, developing a fellowship program, co-management agreements, development of centers of excellence). Successes in care delivery and outcomes create beneficial publicity for both the physician and the institution. In these situations, hospitals have many expectations for their physician partners. The 3 As (availability, affability, and ability) will always be central to the relationship. Two more As (accountability and advocacy) should also be included. Hospitals expect prompt, high quality, evidencebased, and cost-conscious care for all individuals regardless of financial status. They hope that physicians will bring their elective patients to that hospital and that physicians will fulfill their coverage needs and enhance their market competitiveness. Hospitals value physician self-governance and accountability and welcome participation in quality assurance committees, medical directorships, and other leadership roles. Hospitals look toward physicians not only to provide direct care to patients, but also indirectly influence care delivery through the education hospital clinical staff (nurses, therapists, physician extenders, other members of the medical staff). Medical staff members are expected to maintain compliance with CMS guidelines and legislation as well as uphold patient confidentiality. Hospitals look to physicians to spearhead and participate in cost savings initiatives and support quality outcome measures such as deep vein thrombosis prophylaxis, reduction in iatrogenic and hospital-associated complications, reduction www.jorthotrauma.com |
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of readmission and “never events,” SCIP, and Hospital Consumer Assessment of Healthcare Providers and Systems Survey. Similarly, the surgeon should have the following expectation of the hospital. The physician expects to have access to the operating room and its staff to perform both elective and emergent cases. The requested equipment must be available and in good condition and cases should start on time. An adequate number of amiable and well trained support staff (eg, social workers, therapists, nurses, nursing assistants, emergency room technicians, traction technicians, transport technicians, and, in some situations, physician extenders) should be employed by the hospital to facilitate prompt and high quality care delivery. Hospitals must also provide the appropriate ancillary resources (eg, magnetic resonance imaging, computed tomography, therapy) and it must be of high quality and accessible in a timely manner. The hospital should also support non-orthopaedic specialties to ensure that physicians have access to well-trained consultants when the patient condition demands their involvement. The infrastructure and technology must be in place to facilitate care delivery both in the hospital and when the physician is off campus (eg, electronic medical record and picture archiving and communication system and offsite access with adequate technical support). Physicians should also look to the institution to provide indigent care to the community and clinical care coordinators who can facilitate appropriate discharge dispositions as well as medication assistance. Hospitals should also provide educational support for local and national continuing medical education opportunities. For physicians taking call, a lounge and call room should be available. Care providers must be included in decisions regarding hospital initiatives, staff support, and capital investment in technology (eg, navigation). When cost savings or successes arise from these collaborative efforts, the monies should be directed toward service reinvestment. A shared vision increases the likelihood of the initiative’s success. The goal of satisfying all of the above expectations is to ensure high levels of patient satisfaction and care outcomes while minimizing the number of complications. The patient– physician relationship continues even after the hospital stay is complete, but the patient’s hospital experience can play a significant role in the perception of their overall care and recovery. Physician–hospital alignments can take many forms. Effective partnership efforts have surrounded the development of orthopaedic trauma call panels, quality assurance panels, implant selection committees, or the development of centers of excellence (eg, joint replacement programs, trauma programs). Other collaborative efforts may arise in the development of order sets for hip fractures, fragility fracture programs, or participating in educational ventures (eg, lectures within the institution or in the community, development of graduate medical education programs). The broad goals of these partnerships are to improve patient experience, decrease
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length of stay, and promote high quality outcomes and judicious resource utilization.
COMMUNICATION Hospital executives and physicians are often challenged to keep the lines of communication open. Often, communication becomes adversarial. To establish productive, efficient communications, the physician must be clear about what they want, understand clearly what they bring to the hospital and its economic and non-economic value. The goal is to create a win-win situation. Take the time to understand the issues the hospital is dealing with, especially the political problems that surface as they begin to choose their preferred partners. Help them solve their political problems and you are more apt to come to a satisfactory solution.
THE FUTURE A study conducted with hospitals in Arizona in 2010 looked at the qualities of high-functioning hospitals. Commonly, they were characterized by leaders who managed to “engage and inspire the physicians.” The CEOs were considered “superb communicators” and visionaries and the top physician executives effectively served as bridges between hospital administrators and medical staff. Together, they managed to “convince the physicians to restrain some of their instinctive sense of autonomy for the greater good of the institution and their patients.” The methods for achieving this outcome varied and included everything from paying for physician participation in critical meetings and retreats to responding to physician concerns quickly and publicly. The high-functioning hospitals of the future will be marked by a kind of culture of collaboration—at the macro level, between the medical staff and the hospital administration, and at the micro level, between hospitalists, nurses, and case managers working on a given ward. The hospitals will create an environment in which surgeons recognize that care will be better and safer if they can agree on standard procedures that everyone uses, rather than pushing the hospital to sustain customized procedures, which are incredibly inefficient and error-prone. They will operate as if the doctors, nurses, administrators, and others recognize their complete interdependency in a shared effort to achieve a single, overarching goal: the provision of the highest quality, safest, and most satisfying care to patients at the lowest possible cost. REFERENCES 1. Ziran BH, Barrette-Grischow MK, Marucci K. Economic value of orthopaedic trauma: the (second) bottom line. J Orthop Trauma. 2008;22: 227–233. 2. Vallier HA, Patterson BM, Meehan CJ, et al. Orthopaedic traumatology: the hospital side of the ledger, defining the financial relationship between physicians and hospitals. J Orthop Trauma. 2008;22:221–226. 3. Althausen PL, Coll D, Cvitash M, et al. Economic viability of a community-based level-II orthopaedic trauma system. J Bone Joint Surg Am. 2009;91:227–235.
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