Tom Shufflebarger, Gary Gause, Jerry Callahan (standing – moderator), John O’Neil, Keith Granger, William Ferniany, PhD
In August, the Birmingham chapter of the Medical Group Management Association (MGMA) held a roundtable discussion for an luncheon audience of 130 practice administrators that featured the chief executives of five Birmingham hospitals, including Gary Gause, President and CEO of Brookwood Medical Center; Keith Granger, President and CEO of Trinity Medical Center; Tom Shufflebarger, Executive Vice-President and COO of Children’s of Alabama; William Ferniany, PhD, CEO of UAB Health System; and John O’Neil, President and CEO of St. Vincent’s Health System.
|A video of the full discussion is available below.
The Birmingham MGMA polled members to compile a list of questions that roundtable moderator Jerry Callahan, CPA of Kassouf & Co, posed to the executives. The Birmingham Medical News, with the help of Integrated Solutions, transcribed the event with some of the highlights here:
Callahan: Two weeks ago, Children’s Hospital moved to the new facility. I’ve asked Tom to lead us off with a brief about the logistics of that.
Shufflebarger: It’s been an exciting month at Children’s. There were years of planning to coordinate the operations in the new building and to organize the move. You plan for a lot of things and a lot of them happened during that day (day of the move). Within the first six hours, we had two traumas, a helicopter trip came in, and a patient family member passed out. We’re glad to have that behind us and now we have the challenge of making the building work, which for us is about getting a return on investment in terms of patient satisfaction and quality improvement.
Callahan: I want to get everyone’s perspective on primary care and the physician shortage.
Ferniany: All you have to do is look at Massachusetts to know that, as the Accountable Care act moves forward, we are not going to have enough primary care physicians, and there are several issues we’re going to have to address in Alabama. We have to decide what to do about physician extenders and scope of practice.
Granger: I think Will is right. We all see the avalanche of activity that’s coming. And not only is there a lack of numbers of primary care physicians, but many who have gone into medicine don’t approach it in the same style that they might have approached it 30 years ago. More physicians want to go part time or have limited hours or shift-like work. Call is becoming an issue for hospitals.
We’re watching what’s happening on the extender front along with the development of another medical school in south Alabama.
Ferniany: In addition the OD school in south Alabama, Auburn is also opening up an OD school and UAB is opening up another primary care medical school, a two year school like we have in Tuscaloosa and Montgomery. Those should help.
O’Neil: I think the extender issue is an opportunity for us. I came from upstate New York where we had a number of extenders and it worked well. They worked alongside our primary care physicians and played a big part in diminishing our primary care gap.
But I agree that primary care is going to be a huge issue when the Affordable Care act kicks in. We need to look at not only new programs, but at additional residency program spots.
And a continuing issue is reimbursement. We need more primary care physicians, but if we keep cutting their reimbursement while asking them to work harder and earn less with higher malpractice costs, we won’t bring people into the profession.
But primary care is a key and we’re looking at it very diligently within the St Vincent’s Health System. We’ve added several new primary care offices within the last two years, but we’re nowhere near ready to see the onslaught of new patients that we’re going to see soon.
Gause: A lot of what we’re doing is consistent with what has already been mentioned. We’ve expanded our Brookwood Primary Care network and we’ll continue to do that because we have a responsibility to ensure that Medicare patients who have traditionally used our facilities have access to a quality primary care physician. As we see more physicians coming out of the Medicare system, which I think is going to be inevitable with the passage of the ACA, the hospitals are going to have to do a little more to step up. That probably means we’re going to be subsidizing primary care practices when we put them in place. Nobody wants to do that but it’s part of being a comprehensive system.
On a macro level, I think you’re going to see less resources available for physician practices, just as there will be for hospitals, and the debate is probably going to rage about how much of the money needs to be devoted to specialty care versus primary care. And it probably will take more of a crisis in primary care for more of those federal funds to be redirected to primary care to, over the long term, recruit more people into primary care.
Callahan: Gary, I’d like to follow up with you here. When we travel the state we find that, while there is a bit of a primary care shortage in Birmingham, rural Alabama is suffering even more. Do you have any initiatives as it relates to increasing availability of primary care in rural Alabama?
Gause: Unfortunately, the program that was in Tuscaloosa for training rural physicians is shut down. That was very disappointing. It was an excellent program.
Also, we have one of the more limited physician extender laws in this state, which affects rural access to care.
And I think hospitals need to work better with the medical community. We’ve got to pool ourselves together. For instance, the hospitals have to continue to better leverage the physicians’ time. Hospitalist inpatient practices have probably helped keep the primary care physician in the office so they can see more patients. But the hospitals have to do even a better job of helping those doctors, giving them better information, whether it’s diagnostics, inpatient stay, or other metrics.
We have to get better information back to the practices. We have to get information and scheduling with these practices so that COPD patients see a doctor within seven days of discharge. That has to be done or else these patients are going to be re-admitted and consume unnecessary resources.
Shufflebarger: One thing that’s different with pediatrics is that over the years in Alabama, we’ve gotten most children insured. So we won’t see a big increase in the demand for primary care.
Callahan: There has been a lot of news on Cooper Green recently. One of our Jefferson County Commissioners said that we need more input from the medical community and called the vote related to Cooper Green as disrespectful. There was a lot of emotion surrounding that. Anyone have any thoughts?
Ferniany: Cooper Green is not just the issue. The issue is caring for the indigent. We have a fragmented system for caring for the indigent in Jefferson County. The hospitals take care of about 70% of the inpatient care. The bulk of outpatient care is split between the Public Health Department, UAB, Birmingham Healthcare, and Cooper Green. Clinically, Woodlawn does a good bit. The sad fact is that if it stays on the current course, Cooper Green will close.
We will be impacted. Look where Cooper Green patients come from – half from the middle part of the county while the other half come from the western and eastern part. So if Cooper Green closes, the impact would be heavy on St Vincent’s East, probably some on Trinity, on Medical West and Princeton on the west and on UAB in the center of town.
The problem is the county won’t deal with the underlying issue which is if you’re going to close a patient unit, it has to be done in a manner that is best for those patients. We already had a bad experience with this during this first round when they just arbitrarily closed services, making no provisions for where patients could go.
Granger: When I listened to Tom describe all the planning that went into Children’s move, I think that that’s the same sort of thing that’s needed in this situation. Deliberate planning should be put in place so that the changes that are required can be done in a planned manner rather than a crisis mode. I’m afraid we’re going to get into a further crisis mode before this is solved.
Gause: If you looked at this as a case study for health planning, and you turned in this model as your thesis, you would be thrown out of any program you were attending. The Cooper Green system hasn’t evolved since the 1970s. And healthcare was completely different in the 1970s.
Several ideas have been brought forth for the evolution of indigent care in Jefferson County. Right now, they’re not reasonable because of the politics; not because they can’t be executed.
It’s important to eliminate the time people have from the onset of symptoms to when they actually get treated. You all know this. If someone delays coming to your office, they end up going to the emergency room. Only four percent of the emergency room patients at Cooper Green end up being admitted. At Brookwood, it’s nearly 40 percent. So you have a lot of people using the Cooper Green emergency room unnecessarily.
We should take that care out to the community. Put clinics in the communities where those patients live, give them early intervention, treat chronic conditions like diabetes and high blood pressure more aggressively and eliminate the unnecessary admissions that are going on in the hospital.
There will still be inpatient indigent care, but a large portion of that can be dealt with more effectively with urgent care, with primary care, with physician extenders and private practice offices. 70 percent of indigent patients who are treated in hospitals are treated outside Cooper Green, so the existing facilities are already absorbing the lion’s share of the indigent care.
Shufflebarger: What gets lost in the emotion surrounding Cooper Green is the indigent care trust fund. It’s important to keep that fund focused on trying to offset the cost of indigent care. It doesn’t pay for all of it, but if that gets diverted, it just compounds the problem.
O’Neil: What’s interesting about this whole process is that we’ve reinvented ourselves. In Alabama, we have the most efficiently run hospitals in the country. I have the data to prove it. No one’s even the ball park when you look at what it costs us to run our hospitals.
And there is actually more than enough money in the system for Cooper Green. They get $45 million a year. No one hands us a check for $45 million to do anything. So there’s plenty of money. It’s just a matter of re-designing the system to take the best care of patients. So the one issue we all face with reimbursement is not as big an issue for Cooper Green because they’ve got a locked in revenue base that is probably more than enough money to do what they’re doing.
Callahan: We have an interesting question from MGMA members. With physicians employed, are hospitals seeing better practice patterns within patient care? Have hospital costs gone down with these models?
Shufflebarger: I don’t think we’ve seen a big difference between our employee care networks and other referral sources in terms of what happens in the hospitals. We’ve moved to a 99 percent hospitalist model anyway.
Gause: As John said, Alabama hospitals are the most competitive in the country on an adjusted per-patient day. So we’ve done a lot of what can be done to take costs out of the system. Staffing ratios can’t really go down much more. And we all have low costs in our supply chains.
So the next thing that has to happen is we have to change physician behavior. That’s the most difficult thing we have to do. Employment is one way to attempt to do that. But frankly, an employed physician is not any more compelled to change their practice pattern than an independent physician would be. We have to find better data to show them that proves that if they change their practice, not only will their cost go down, but the care will improve.
O’Neil: The four most expensive words in healthcare are massive unexplained clinical variation. We have to stop with the idea that we don’t like cookbook medicine, that I’m an independent physician and I’m going to do it my way no matter what. Those days are going to be gone. As Gary said, we need to find ways to come together and find protocols. Let the physician set the standards, but everyone has to do things pretty much the same way.
Granger: Our focus hasn’t been as much about cost reduction as it has been on driving clinical performance. The standardization of going forward with evidence based medicine has allowed us to move from perhaps a 50th to 70th percentile performance across the country to where in the last year we’ve achieved top ten percentile performance on all the clinical indicators that we’re measuring. We’ve driven down infections by double digits for each of the last three years. We’ve seen pressure ulcers fall to their lowest level in the last month. So we have many things happening and I think it’s because physicians are in fact aligning around the word quality.
Ferniany: As you might suspect, UAB would be the odd person out. We’re 1100 employed physicians. And one of the competitive advantages of UAB is it has complete alignment between the hospital and the physicians. There’s a thing called the academic medical center exception that allows us to support our physicians financially through the hospital and it allows us to be one. So the physicians do as well as the hospital and vice versa.
Thanks to Integrated Solutions, who filmed this event, a video of entire discussion is available here:
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