NEW CHALLENGES IN INTERNAL MEDICINE
0025-7125/92 $0.00 + .20
THE MUL TISPECIAL TY CLINIC IN A CHANGING ENVIRONMENT Michael C. Tooke, MD
FORMULATING A STRATEGY
In the early 1980s, Ochsner Clinic found itself at a crossroads. During four and one-half decades as a provider of highly specialized medical services ("tertiary care"), the Clinic depended on its position and reputation in the region to stimulate referrals of patients. Those referrals were generated not only by area physicians seeking specialty consultation but also by patients themselves. They came from local communities, the Gulf South region, and, in large numbers, from Latin America. In the last quarter of the twentieth century, however, a variety of developments began to influence the flow of these patients to Ochsner. Local residents were beginning to be directed to competing health care providers through agreements struck with their employers. The surrounding region was becoming increasingly populated with well-trained physicians-many of whom, ironically, had trained at Ochsner-and patients found they did not have to travel to a distant medical center to access competent specialty care. In Latin America, the oil bust, currency instability, and political unrest reduced a once healthy flow of patients to Ochsner to an anemic trickle. The signpost at the crossroads was clear. The Clinic could continue to depend on referrals in an environment that was clearly restricting the ability of patients and doctors to choose Ochsner as a referral center, or it could respond to changes in the health care climate with new approaches that would encourage patients to access Ochsner medical services. ("New approach" is a relative term-in the early 1980s, New Orleans was the only large metropolitan area in the United From the Ochsner Clinic and Ochsner Health Plan, New Orleans, Louisiana THE MEDICAL CLINICS OF NORTH AMERICA VOLUME 76· NUMBER 5· SEPTEMBER 1992
1035
1036
TOOKE
States that had yet to see the introduction of health maintenance organizations and managed care.) After much deliberation, the Clinic adopted a three-pronged strategy. First, the practice would expand to locations away from its heretofore single campus in suburban New Orleans. This ultimately took the form of a metropolitan network of satellite neighborhood clinics and a distant regional multispecialty clinic (in Baton Rouge, 90 miles away). The Clinic thus made its services more convenient to patients. The Clinic recognized that the primary physician, the physician visited first, typically chose the specialist needed for consultative services. Convenient neighborhood clinics would put Ochsner in a position to capture that initial visit, which in turn would lead to specialty referrals. Second, the Clinic developed a health maintenance organization (HMO), Ochsner Health Plan. Selling a prepaid insurance program to local employers guaranteed a population of patients who would use the Clinic for specialty care. The problem of financing health care was thus removed as a potential barrier to a patient's access to the group practice, just as the convenience of location of that health care had been addressed through the neighborhood clinic system. Because the HMO requires that all covered health care be received through the group, this population of patients was bonded to the group practice by its financing mechanism. This made possible more predictable growth and planning for expansion of the Clinic's specialty services. Finally, the Clinic added a new specialty, Family Medicine. Since the Clinic's strategy of response to the changing environment was based on expansion of primary care, it was logical to seek physicians best trained to deliver it. Three years of postgraduate training with an emphasis on broad-based ambulatory care make family physicians uniquely qualified to provide the routine, comprehensive care that complements the specialty services already in place in a multispecialty group. Importantly, these physicians were hired using the same criteria for excellence applied to any other physician invited to join the group. A common theme governed this tripartite strategy: the Clinic undertook all these steps on its own. Neighborhood clinics were designed and built by the institution, not leased from other parties. Primary care physicians were added to the group with full status, and the HMO was a venture of the Clinic in association with Alton Ochsner Medical Foundation. No proprietary hospital companies provided assets. No outside physicians were approached with contracts. And no national HMO corporations were brought in to run the Clinic's health plan. This independent approach, although expensive in terms of resource commitment, allowed the group practice to remain in control of its own destiny to the maximum extent possible. The Ochsner Medical Institutions have remained a physician-driven organization.
THE MULTISPECIAL TY CLINIC IN A CHANGING ENVIRONMENT
1037
INTERNALIZING THE STRATEGY
In many respects, formulation of the external strategy was the easy part. The Ochsner Clinic, as a large multispecialty clinic, had developed a strong internal culture based on the increasing specialization of its physicians. Although traditional tensions between certain specialties were present, members of the medical staff had universal respect for their colleagues' highly technical expertise. Practicing on the cutting edge of a technological explosion in medical care, Clinic physicians often equated the "best" care with the "most" care. Into that milieu came the primary care physician, distinguished by breadth, rather than depth, of medical knowledge and practicing at sites fairly far removed from "the mother house." Simultaneously, Clinic physicians were asked to examine the "cost effectiveness" and "value" of the services they rendered. Given that change is always stressful, this sea change in the way in which medicine was practiced created a genuine case of culture shock. Managing such change has an essential requirement, support from the top. Success of the primary care/managed care strategy depends on the endorsement of the multispecialty group's leadership. In Ochsner's case, the Medical Director, the group's CEO, provided support that was rock-solid and unwavering. Such backing provided other agents of change in the group with the reassurance needed to develop the strategy. The CEO had to be willing to take a strong position in support of the strategy and had to articulate the rationale for it forcefully and persuasively. Implementation of the strategy required the emergence of physician leaders who devoted themselves to the ultimate success of various components of the strategy. These persons led the practice "off site." They espoused the tenets of managed care. They served the practice as pioneers, establishing new outlooks and approaches to health care. Such physicians must have two important qualifications: willingness to take time away from the actual practice of medicine and solid professional credibility within the group. Nurturing the components of the strategy, especially considering the cultural changes they represent, requires time spent in meetings and on the phone, time spent traveling to gain familiarity with new concepts, and time spent keeping current with a new literature, to give just a few examples. It is difficult for most physicians to separate from patient care, so a commitment to do so looms as an important initial decision for any physician who wants to help stimulate change. Almost paradoxically, the only physicians who are given the opportunity to take time away from practice are those who have gained credibility in the group through their clinical competence. Indeed, it is likely that the most successful managers are also the most successful practitioners. Physicians given responsibility by the group to implement various components of the strategy had to undertake an educational effort that made them, in effect, "specialists," resident experts in their fields. It is
1038
TOOKE
important that the physician manager bring to the group a level of expertise consistent with that of the medical specialties. An important concept to note is that physicians in a highly specialized group practice respond most positively to new knowledge, facts, rational arguments, and logic. They resist arbitrary restrictions on practice, changes instituted merely to save money, and threats. The physician manager, therefore, must be able to communicate the rationale of managed care and its relationship to enhanced quality of medical care. PATIENT CARE IN THE NEW ENVIRONMENT
The actual practice of medicine takes on an added dimension in the new medical environment. Traditionally, physicians in a group practice have worked in a context of interdependence. Fee-for-service practice meant that increased volumes of services rendered enhanced the financial well-being of the group. "Low-producing" physicians were, in effect, subsidized by "high-producing" physicians in order to maintain a full complement of services in the multispecialty group. In a setting that involves a significant amount of prepaid care, however, increased volumes of services rendered actually erode the group's financial position. In fact, when a physician renders a service, he is actually spending the revenue of the others in the group. Therefore, each medical decision has an accompanying financial aspect as well as a quality-of-care component. The interdependence of the members of the group is actually increased. It is essential to the continued strength of the group practice that all members recognize the importance of these new elements in the delivery of health care. EDUCATION IN THE NEW ENVIRONMENT
Most large multispecialty group practices have a role in medical education. At Ochsner, training of postgraduate physicians and medical students is fundamental to the mission of the group practice. Just as breakthroughs in medical science must be passed on to newcomers to the field, so must the transforming forces that influence the delivery of health care be elucidated to young practitioners who will spend their entire careers in what we recognize as a "new" environment. The modern multispecialty group combines all components of medical care, from primary care to tertiary care and from high tech to low tech. It provides services to patients who finance their care through an everincreasing panoply of mechanisms, with differing incentives for all concerned. It is incumbent on physicians in the group practice to expose their trainees to the new realities of health care. Young physicians must be educated to recognize their obligations to utilize wisely a resource for which society is reaching the limits it can afford to pay. Medical residents should understand the costs of the care they render and relate them to the benefits patients receive.
THE MULTISPECIALTY CLINIC IN A CHANGING ENVIRONMENT
1039
Financial arrangements, such as an HMO, which bind patients to a single health care organization, provide an opportunity for medical education that is not available otherwise. In that an HMO member is obligated to utilize a specific group of physicians, a medical resident can participate in true longitudinal, continuous care. The group practice must organize its educational activities to take maximum advantage of this opportunity. RESEARCH IN THE NEW ENVIRONMENT
Medical research represents the third point in the traditional triangular mission of large multispecialty groups. While basic research and innovative therapies can be realized, the changing environment creates opportunities for new areas of investigation. An HMO, for example, has a large "captive" population that assures longitudinal follow-up of patients. Such complete follow-up permits assessment of the safety and effectiveness of therapy. Large group practices with large patient populations have an obligation to evaluate current therapies and investigate new ones, and assess their risks and benefits. FACING THE FUTURE
The dizzying changes of the past decade only presage even more dramatic evolution in health care delivery. Increasing strain will be placed on the budgets of all parties that purchase health care services. The staggering numbers of uninsured and underinsured citizens must be brought into the system and cared for. The right to die and rationing of health care will become real issues to be faced, not headlines from elsewhere. A multispecialty group must be able to evolve along with its environment. And it may be uniquely qualified to do so. As posited by Or. Arnold Relman, former editor of the New England Journal of Medicine, "Group practices, controlled by physicians, provide an environment favorable to the practice of cost-effective medicine and the maintenance of professional standards . . . . Practicing physicians . . . must participate in the effort to generate and apply the new knowledge. This, too, would be facilitated by group practice."l References l. Relman AS: Reforming the Health Care System. N Engl J Med 323: 991-992, 1990
Address reprint requests to Michael C. Tooke, MD Ochsner Clinic 1514 Jefferson Highway New Orleans, LA 70121
0025-7125/92 $0.00 + .20
THE MUL TISPECIAL TY CLINIC IN A CHANGING ENVIRONMENT Michael C. Tooke, MD
FORMULATING A STRATEGY
In the early 1980s, Ochsner Clinic found itself at a crossroads. During four and one-half decades as a provider of highly specialized medical services ("tertiary care"), the Clinic depended on its position and reputation in the region to stimulate referrals of patients. Those referrals were generated not only by area physicians seeking specialty consultation but also by patients themselves. They came from local communities, the Gulf South region, and, in large numbers, from Latin America. In the last quarter of the twentieth century, however, a variety of developments began to influence the flow of these patients to Ochsner. Local residents were beginning to be directed to competing health care providers through agreements struck with their employers. The surrounding region was becoming increasingly populated with well-trained physicians-many of whom, ironically, had trained at Ochsner-and patients found they did not have to travel to a distant medical center to access competent specialty care. In Latin America, the oil bust, currency instability, and political unrest reduced a once healthy flow of patients to Ochsner to an anemic trickle. The signpost at the crossroads was clear. The Clinic could continue to depend on referrals in an environment that was clearly restricting the ability of patients and doctors to choose Ochsner as a referral center, or it could respond to changes in the health care climate with new approaches that would encourage patients to access Ochsner medical services. ("New approach" is a relative term-in the early 1980s, New Orleans was the only large metropolitan area in the United From the Ochsner Clinic and Ochsner Health Plan, New Orleans, Louisiana THE MEDICAL CLINICS OF NORTH AMERICA VOLUME 76· NUMBER 5· SEPTEMBER 1992
1035
1036
TOOKE
States that had yet to see the introduction of health maintenance organizations and managed care.) After much deliberation, the Clinic adopted a three-pronged strategy. First, the practice would expand to locations away from its heretofore single campus in suburban New Orleans. This ultimately took the form of a metropolitan network of satellite neighborhood clinics and a distant regional multispecialty clinic (in Baton Rouge, 90 miles away). The Clinic thus made its services more convenient to patients. The Clinic recognized that the primary physician, the physician visited first, typically chose the specialist needed for consultative services. Convenient neighborhood clinics would put Ochsner in a position to capture that initial visit, which in turn would lead to specialty referrals. Second, the Clinic developed a health maintenance organization (HMO), Ochsner Health Plan. Selling a prepaid insurance program to local employers guaranteed a population of patients who would use the Clinic for specialty care. The problem of financing health care was thus removed as a potential barrier to a patient's access to the group practice, just as the convenience of location of that health care had been addressed through the neighborhood clinic system. Because the HMO requires that all covered health care be received through the group, this population of patients was bonded to the group practice by its financing mechanism. This made possible more predictable growth and planning for expansion of the Clinic's specialty services. Finally, the Clinic added a new specialty, Family Medicine. Since the Clinic's strategy of response to the changing environment was based on expansion of primary care, it was logical to seek physicians best trained to deliver it. Three years of postgraduate training with an emphasis on broad-based ambulatory care make family physicians uniquely qualified to provide the routine, comprehensive care that complements the specialty services already in place in a multispecialty group. Importantly, these physicians were hired using the same criteria for excellence applied to any other physician invited to join the group. A common theme governed this tripartite strategy: the Clinic undertook all these steps on its own. Neighborhood clinics were designed and built by the institution, not leased from other parties. Primary care physicians were added to the group with full status, and the HMO was a venture of the Clinic in association with Alton Ochsner Medical Foundation. No proprietary hospital companies provided assets. No outside physicians were approached with contracts. And no national HMO corporations were brought in to run the Clinic's health plan. This independent approach, although expensive in terms of resource commitment, allowed the group practice to remain in control of its own destiny to the maximum extent possible. The Ochsner Medical Institutions have remained a physician-driven organization.
THE MULTISPECIAL TY CLINIC IN A CHANGING ENVIRONMENT
1037
INTERNALIZING THE STRATEGY
In many respects, formulation of the external strategy was the easy part. The Ochsner Clinic, as a large multispecialty clinic, had developed a strong internal culture based on the increasing specialization of its physicians. Although traditional tensions between certain specialties were present, members of the medical staff had universal respect for their colleagues' highly technical expertise. Practicing on the cutting edge of a technological explosion in medical care, Clinic physicians often equated the "best" care with the "most" care. Into that milieu came the primary care physician, distinguished by breadth, rather than depth, of medical knowledge and practicing at sites fairly far removed from "the mother house." Simultaneously, Clinic physicians were asked to examine the "cost effectiveness" and "value" of the services they rendered. Given that change is always stressful, this sea change in the way in which medicine was practiced created a genuine case of culture shock. Managing such change has an essential requirement, support from the top. Success of the primary care/managed care strategy depends on the endorsement of the multispecialty group's leadership. In Ochsner's case, the Medical Director, the group's CEO, provided support that was rock-solid and unwavering. Such backing provided other agents of change in the group with the reassurance needed to develop the strategy. The CEO had to be willing to take a strong position in support of the strategy and had to articulate the rationale for it forcefully and persuasively. Implementation of the strategy required the emergence of physician leaders who devoted themselves to the ultimate success of various components of the strategy. These persons led the practice "off site." They espoused the tenets of managed care. They served the practice as pioneers, establishing new outlooks and approaches to health care. Such physicians must have two important qualifications: willingness to take time away from the actual practice of medicine and solid professional credibility within the group. Nurturing the components of the strategy, especially considering the cultural changes they represent, requires time spent in meetings and on the phone, time spent traveling to gain familiarity with new concepts, and time spent keeping current with a new literature, to give just a few examples. It is difficult for most physicians to separate from patient care, so a commitment to do so looms as an important initial decision for any physician who wants to help stimulate change. Almost paradoxically, the only physicians who are given the opportunity to take time away from practice are those who have gained credibility in the group through their clinical competence. Indeed, it is likely that the most successful managers are also the most successful practitioners. Physicians given responsibility by the group to implement various components of the strategy had to undertake an educational effort that made them, in effect, "specialists," resident experts in their fields. It is
1038
TOOKE
important that the physician manager bring to the group a level of expertise consistent with that of the medical specialties. An important concept to note is that physicians in a highly specialized group practice respond most positively to new knowledge, facts, rational arguments, and logic. They resist arbitrary restrictions on practice, changes instituted merely to save money, and threats. The physician manager, therefore, must be able to communicate the rationale of managed care and its relationship to enhanced quality of medical care. PATIENT CARE IN THE NEW ENVIRONMENT
The actual practice of medicine takes on an added dimension in the new medical environment. Traditionally, physicians in a group practice have worked in a context of interdependence. Fee-for-service practice meant that increased volumes of services rendered enhanced the financial well-being of the group. "Low-producing" physicians were, in effect, subsidized by "high-producing" physicians in order to maintain a full complement of services in the multispecialty group. In a setting that involves a significant amount of prepaid care, however, increased volumes of services rendered actually erode the group's financial position. In fact, when a physician renders a service, he is actually spending the revenue of the others in the group. Therefore, each medical decision has an accompanying financial aspect as well as a quality-of-care component. The interdependence of the members of the group is actually increased. It is essential to the continued strength of the group practice that all members recognize the importance of these new elements in the delivery of health care. EDUCATION IN THE NEW ENVIRONMENT
Most large multispecialty group practices have a role in medical education. At Ochsner, training of postgraduate physicians and medical students is fundamental to the mission of the group practice. Just as breakthroughs in medical science must be passed on to newcomers to the field, so must the transforming forces that influence the delivery of health care be elucidated to young practitioners who will spend their entire careers in what we recognize as a "new" environment. The modern multispecialty group combines all components of medical care, from primary care to tertiary care and from high tech to low tech. It provides services to patients who finance their care through an everincreasing panoply of mechanisms, with differing incentives for all concerned. It is incumbent on physicians in the group practice to expose their trainees to the new realities of health care. Young physicians must be educated to recognize their obligations to utilize wisely a resource for which society is reaching the limits it can afford to pay. Medical residents should understand the costs of the care they render and relate them to the benefits patients receive.
THE MULTISPECIALTY CLINIC IN A CHANGING ENVIRONMENT
1039
Financial arrangements, such as an HMO, which bind patients to a single health care organization, provide an opportunity for medical education that is not available otherwise. In that an HMO member is obligated to utilize a specific group of physicians, a medical resident can participate in true longitudinal, continuous care. The group practice must organize its educational activities to take maximum advantage of this opportunity. RESEARCH IN THE NEW ENVIRONMENT
Medical research represents the third point in the traditional triangular mission of large multispecialty groups. While basic research and innovative therapies can be realized, the changing environment creates opportunities for new areas of investigation. An HMO, for example, has a large "captive" population that assures longitudinal follow-up of patients. Such complete follow-up permits assessment of the safety and effectiveness of therapy. Large group practices with large patient populations have an obligation to evaluate current therapies and investigate new ones, and assess their risks and benefits. FACING THE FUTURE
The dizzying changes of the past decade only presage even more dramatic evolution in health care delivery. Increasing strain will be placed on the budgets of all parties that purchase health care services. The staggering numbers of uninsured and underinsured citizens must be brought into the system and cared for. The right to die and rationing of health care will become real issues to be faced, not headlines from elsewhere. A multispecialty group must be able to evolve along with its environment. And it may be uniquely qualified to do so. As posited by Or. Arnold Relman, former editor of the New England Journal of Medicine, "Group practices, controlled by physicians, provide an environment favorable to the practice of cost-effective medicine and the maintenance of professional standards . . . . Practicing physicians . . . must participate in the effort to generate and apply the new knowledge. This, too, would be facilitated by group practice."l References l. Relman AS: Reforming the Health Care System. N Engl J Med 323: 991-992, 1990
Address reprint requests to Michael C. Tooke, MD Ochsner Clinic 1514 Jefferson Highway New Orleans, LA 70121
