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ROUND-UP PROVIDING NEWS AND INFORMATION FOR THE MEDICAL COMMUNITY SINCE 1955 • May 2016 | Volume 62 | Number 5

Maintaining The Independent Practice of Medicine


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THE STRENGTH TO HEAL and stand by those who stand up for me. Learn the latest treatments and play an important role in the care of Soldiers and their families. As a physician on the U.S. Army Reserve health care team, you’ll continue to practice in your community and serve when needed. You’ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. You’ll make a difference. To learn more, visit healthcare.goarmy.com/ey56 or call the Phoenix Medical Recruiting Center at 602-253-0371.

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Round-up Staff Editor-in-Chief Adam M. Brodsky, MD, MM abrodsky@mcmsonline.com Editor Jay Conyers, PhD jconyers@mcmsonline.com Content Editor Dominique Perkins

Connect with your Society mcmsonline.com facebook.com/MedicalSociety twitter.com/MedicalSociety instagram.com/Medical_Society Letters and electronic correspondence will become the property of Round-up, which assumes permission to publish and edit as necessary. Please refer to our usage statement for more information.

Advertising To obtain information on advertising in Round-up, or to become a Preferred Partner, contact: Barb Spitzock 602-528-7704 bspitzock@mcmsonline.com

Cover photo and member profile photos by: Denny Collins Photography www.dennycollins.com 602-448-2437

MCMS 2016 Board of Directors Officers President Adam M. Brodsky, MD, MM

Send address changes to: Round-up, 326 E. Coronado Rd., Phoenix, AZ 85004

Secretary Ross F. Goldberg, MD

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Treasurer May Mohty, MD President-Elect John L. Couvaras, MD Immediate Past President Ryan R. Stratford, MD, MBA Directors Jay M. Crutchfield, MD Shane M. Daley, MD Tanja L. Gunsberger, DO Kelly Hsu, MD Lee Ann Kelley, MD Marc M. Lato, MD Richard A. Manch, MD, MHA John Middaugh, MD Tabitha G. Moe, MD Constantine G. Moschonas, MD Anita C. Murcko, MD Steven B. Perlmutter, MD, JD Resident Representative Pamela McCloskey, DO Medical Student Representative Kimberly Weidenbach, MEd

MCMS offers: A FREE physician referral service A benefit of membership – we help drive new patients to your office To learn more contact Dixie Harris 602-251-2363 dharris@mcmsonline.com Visit us online at: www.mcmsonline.com

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Postmaster

May 2016 | Volume 62 | Number 5 Round-up (USPS 020-150) is published 12 times per year by the Maricopa County Medical Society, 326 E. Coronado, Phoenix, AZ 85004. Round-up is a publication of the Maricopa County Medical Society (MCMS). Submissions, including advertisements, are welcome for review and approval by our editorial staff at roundup@mcmsonline.com. All solicited and unsolicited written materials and photos submitted to Round-up will be treated as unconditionally and irrevocably assigned to and the property of MCMS and may be used at MCMS’ sole discretion for publication and copyright purposes and use in any publication, website or brochure. MCMS accepts no responsibility for the loss of or damage to material submitted, including photographs or artwork. Submissions will not be returned. The opinions expressed in Round-up are those of the individual authors and not necessarily of MCMS. Round-up reserves the right to refuse certain submissions and advertising and is not liable for the authors’ or advertisers’ claims and/or errors. Round-up considers its sources reliable and verifies as much data as possible, but is not responsible for inaccuracies or content. Readers rely on this information at their own risk and are advised to seek independent legal, financial or other independent advice regarding the content of any submission. No part of this magazine may be reproduced or transmitted in any form or by any means without written permission by the publisher. All rights are reserved.


ROUND-UP

PUBLISHED MONTHLY BY THE MARICOPA COUNTY MEDICAL SOCIETY

May 2016 | Volume 62 | Number 5

7 8 10 14

What’s Inside President’s Page

Maintaining the Independent Practice of Medicine

Creating a Healing Environment Through Space Design

By Sheila Bale

HR’s Daily Dilemma:

21

How to Discourage a Physician By Richard Gunderman, MD

Fixing Health Care on the Front Lines

Maintaining Independent Practice of Medicine: A Q&A session with surgeon Sumer Daiza, MD, F.A.C.S.

28

To Fix Healthcare, Ask The Right Questions By Henry Mintzberg

30

Recruiting Top Talent Away From Your Competitors By Gil Zeimer

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25

Ambiguous Performance:

Patient Safety and Quality Measures in the U.S. Healthcare System By Thomas Esposito

34

Philanthropy In Medicine:

43

Marketplace

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By Richard M.J. Bohmer, MD

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What’s Inside May 2016

B

ack in the day, physicians fresh out of residency had little to think about other than practicing medicine. It was a given they’d hang out their shingle and patients would come pouring in. They could walk into the local bank, quickly secure a business loan, and be out of the gates in little time. I’ve even spoken with a number of our retired physicians who credit the Society with helping them secure their first business loan to open their practice (and many have maintained their Society membership ever since, as a result!). Their biggest assets — their hands and their minds — didn’t require financing, so once they got some space and a license, they could start to practice. Unfortunately, those days are now a thing of the past. Sure, many a physician still goes the route of independence, but the obstacles are now considerably greater. Getting approved by insurance companies has become such a large impediment to practice that many physicians are hiring firms specializing in health plan enrollment. And delays in reimbursement make it challenging to bridge the cash flow gap — from the time of treatment to when payment is actually received — that seems to widen on a daily basis. In addition to assistance with health plan enrollment, many physicians embarking on private practice are hiring firms to help with a laundry list of tasks: what legal structure to go with, and how to structure partnership agreements as new docs join; how to fund the practice — bank loan, private equity, etc; compliance with state and federal regulations. marketing the practice; front office; back office; recruitment of mid-levels; the list goes on and on. Despite the trend of more and more physicians migrating to hospital employment, many physicians are still committed to staying in private practice. And many are thriving. In this issue of Round-up, we pay

tribute to those who remain independent. Here’s to you! For this month’s profile physician, we sat down with Sumer Daiza, MD, a Scottsdale-based plastic surgeon who’s always gone her own way. She prides herself on her commitment to her patients by being there every step of the way, from the initial consultation through post-op follow-ups. We hope you enjoy reading about her. We also have a thought provoking parable from Richard Gunderman, MD, who peers into the mind of a healthcare consultant advising hospital executives in how to transform independent physicians into employees. Richard Bohmer offers some thoughts on what role physicians should play fixing our healthcare system. We also have a perspective piece by Henry Mintzberg, who ponders which questions we should be asking when examining the state of healthcare.

Jay Conyers, PhD EXECUTIVE DIRECTOR

jconyers@msmsonline.com 602.251.2361

Also in this issue, we have some wonderful articles from our local business partners. Newmark Grubb Frank & Knights gives us their insight into optimizing medical office space design and suggests that creating a healing environment should be front and center. Additionally, Arizona Central Credit Union offers some tips on how your human resources department can help you attract better talent. For our June issue, Round-up looks at the erosion of the doctor-patient relationship. We profile a physician — Linh Nguyen, MD — who has built a thriving ‘housecall’ practice out in the west valley. We have some great articles to accompany Dr. Nguyen’s profile, and we hope you enjoy the issue. Until then, stay cool and join me in counting the days until we can (once again) see triple digit highs in our rear view mirrors.

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President’s Page T

he focus of this month’s issue is on maintaining the independent practice of medicine. This may seem like a loaded phrase, for it begs the question: independent of whom, or what? Let me give you some definitions upon which I think we can all agree. Maintaining the independent practice of medicine means that physicians can practice the way they see fit - as opposed to the way other stakeholders see fit. It means that physicians can continue to act as advocates for their patients - as opposed to advocates for their company, employer, or government. It means that physicians can exercise their professional judgment - as opposed to following arbitrary preauthorization guidelines. And it means that physicians can meld their knowledge of medicine with their intimate personal knowledge of their patients to arrive at treatment plans uniquely tailored to their individual patients - as opposed to blindly following standardized care pathways and quality metrics.

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While these definitions may seem obvious, in practice they are difficult to achieve. There are myriad forces which currently hamper our independence. However, if we physicians want to to be treated with the respect we deserve and be able to maintain our ability to practice medicine independently, we must also recognize that we are no different than other professions in that there are bad actors within our own ranks - doctors who game the system for their own personal gain. This behavior gives all of us a bad name. Much less dramatic but much more common and pervasive is the continual “gaming of the system” into which physicians are forced by the obtuse and varying practice and preauthorization rules imposed on them by payors. This unfortunate relationship between payors and providers encourages gaming the system by both sides simply out of necessity and survival. In order to address this issue adequately, however, we need to change the culture of medicine and medical school. Issues relating to


reimbursement must be discussed early on in medical training in an in-depth and honest way, rather than simply being glossed over as unseemly or unfit for discussion with idealistically pure medical students, until physicians find themselves in practice competing in a cat-and-mouse game with payors for which they were never prepared. Is it any wonder that more and more physicians are opting for employed positions; voluntarily sacrificing some of their independence? For many of the current wave of employed physicians, it was exactly this threat of a continual tit-for-tat war of attrition with insurance companies that compelled them to seek employment, rather than be forced to soldier on alone or in a small independent group. The current trend of physician employment is rapid, startling, and concerning. As the percentage of employed physicians grows, and hospitals and networks continue merging, more and more of the nations doctors will be concentrated in the hands of fewer and fewer businesses. Is that what we really want? Whereas large multinational companies such as Starbucks, Google, Facebook, Apple, Coca Cola, and WalMart have indeed achieved huge economies of scale and brand equity, and have been able to either lower prices dramatically or command higher prices successfully; we must ask ourselves: is that really what we want from our personal physicians? Eliminating physician employment is not the answer; our current health care system makes that impossible. Rather, there needs to be a consensus among policymakers that certain principles of independent practice need to be enshrined permanently in our healthcare system. Whether a physician is employed by a large company, in solo practice, or in a

physician-owned group practice, that physician should be shielded as much as possible from outside interests as it relates to patient care. Obviously, the reimbursement method at work brings with it inescapable financial incentives. A fee-for-service model causes an incentive to over-utilize. A capitated model causes an incentive to underutilize. A straight salaried model may have less bias for over or under utilization but causes an incentive for low productivity. As discussed in my previous article, a system that rewards quality may be a proposed ideal, but due to the rudimentary nature of this discipline, is currently unachievable and merely results in gaming the quality indicators thru documentation maneuvers.

Adam Brodsky, MD, MM

MCMS PRESIDENT 2016 abrodsky@msmsonline.com 602.307.0070

This is a difficult and continually evolving topic. It is one that during our medical training we never imagined would have such strong implications for the way we practice. But it is one, which, unfortunately, requires our constant vigilance.

Dr. Brodsky specializes in Interventional Cardiology He joined MCMS in 2005. Contact Information: Heart & Vascular Center of Arizona 1331 N. 7th Street Suite 375 Phoenix, AZ 85006 http://heartcenteraz.com

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Creating a Healing Environment through Space Design BY SHEILA BALE

E

motions play a critical role in our lives, including the lives of our patients and loved ones. A caregivers’ job, in part, includes providing an environment that promotes well-being. But different people require different environments to feel comfortable, especially when feeling under the weather. What type of environment do you want when you don’t feel good? Something like your home that you grew up in, something like your bedroom at home, or something like the school nurse’s office?

not have a personal desk to store items or keep books. While there might be one internal restroom, most of the restroom use is utilizing common area restrooms down the hall, unless of course this is urology or an OBGYN office.

Employed physician space plan emphasizing TI cost reduction as focus

Medical office space layout might seem to be very mundane and typical, just like many homes or offices, but the creativity used in some spaces is surprising. There is a clear difference between the physical space of employed physicians and private practice physicians, both in layout and configuration as well as in the types of sensations created within that environment. Let’s take a closer look at the differences and similarities between employed physicians and private practice physicians. The most obvious difference is that employed physician space takes on a look and feel of an institution utilizing standard materials you might see in a large hospital and, in many cases, it is a layout replicated in numerous offices around town. Since many of the employed physicians and their office managers might manage multiple sites, it is preferable to have the locations designed in a similar fashion. The finishes are all of very standard types that are used in large office buildings and purchased in volume by the hospital systems supplier. These finishes are designed for very high volume use, long life and efficiency. Most often the space is designed around the existing walls and plumbing to reduce costs, not necessarily planned to optimize patient experience or physician efficiency. Employed physician offices have a layout that fits only the main specialty of the practice. They very seldom have room for private physician offices where a physician can escape and do research. Physicians typically have a computer area were they place calls, write prescriptions and perform paperwork. When work is finished they pack up their personal items in a backpack or briefcase and do 10

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Features •

Utilize existing walls to limit build out costs, walls not in alignment

In this example the plan has two break rooms because a second sink installation in the employee café is too costly — an example of the configuration not being ideal.

Restrooms located inconveniently for patients and staff

Patient experience is not logical to needs but based on how to not remove existing walls and reduce costs

Lack of physician research and office space

Successful private physicians, on the other hand, have


a strategy to differentiate themselves in the medical world. They usually accept insurance but also have ancillary businesses that augment their insurance reimbursement. This might be vitamins and supplements, skin treatment and makeup, weight loss, eye frames, massage and chiropractic, etc., in addition to general medicine. Each medical business line needs a special area to display items or apply them to the body. As a patient walks through the space, the theme is carried throughout to reflect the specialty and creativity of the practice. Exam rooms tend to be larger and hallways are wider giving the effect of a slower pace while in the space. There is one private internal restroom and, at a minimum, the lobby and easily visible surfaces tend to be out of natural stone and higher end finishes. The

Medical office space layout might seem to be very mundane and typical, just like many homes or offices, but the creativity used in some spaces is surprising. Private practice physician plan emphasizing patient experience Features • Hallways all in alignment — clear patient flow — eliminates confusion • Interior suite restrooms — increased patient convenience • Main break room with secondary entrance/exit away from main patient flow — provides more privacy for staff • Logical flow for patient experience • Physicians have offices to research and plan

less visible space within the exam rooms might actually have laminate but the first impression will be of natural stone. The other trend of the private physician is certain specialties will bring in all their referrals into a single office. For example, dermatology is now bringing plastic surgery in a specific area to repair any skin cancer removal that needs attention. They also have anesthetists, lasers, and specific creams they create and distribute themselves. Another example is endocrinology: under one roof, they might have a weight loss area, a skin product, full-time lab, kidney dialysis, etc. In many cases, these practices are leasing/purchasing up to 12,000 square feet for one private practice with many symptoms being treated as one-stop shop. Some goods and services are paid for with insurance and some with cash, purely for the convenience. The specialist is treating many symptoms in a single office with one independent person or group orchestrating it all with one theme and mood throughout the office. The independent physician is depending on the convenience and the environment to draw patients back to their care for all symptoms. An illustration of the private physician office layout is above.

Whether employed or private, all physician space has the ability to present a positive mood and healing environment by utilizing the skills of interior designers who work within the framework provided. Because medical finishes are more expensive, the environment needs to balance cost effectiveness with aesthetics. In some cases, employed physicians pay extra design fees themselves for a more individualized environment within the scope of institutional budgets. After all, it’s all about how the patient feels when they walk out the door and how they feel within 24 hours that reflects on the effectiveness of the medical care. Give yourself a head start and make sure the mood is healing while patients are in your space.

SHEILA BALE Sheila Bale is a seasoned office and healthcare real estate professional who specializes in leasing, sales and development of office and healthcare buildings and facilities. As a real estate advisor, Ms. Bale is focused on efficiency, economy, competition and differentiation.

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HR’s Daily Dilemma:

Recruiting Top Talent Away From Your Competitors BY GIL ZEIMER

I

n today’s ultracompetitive market and with the U.S. economy rapidly gaining momentum, the more benefits you can offer your prospective employees the more likely you’ll be able to hire them away from your competition. Don’t you wish there was a way that your HR & Benefits Department could offer your employees an incremental variety of valuable services for no extra cost? Credit unions may be able to help you out. As a Select Employee Group (SEG) partner of an existing credit union, consider the ways that your HR department can work together to discover unique and attractive employee benefits. Here are 10 tips to consider as you work on your recruitment and employee benefit strategy.

Tip #1: Install a Convenient Surcharge-Free ATM

Wouldn’t you love having an ATM right in your workplace? Can you imagine how much time that would save you on a weekly basis? Partnering with a credit union may bring benefits like these to your organization! It really does happen; recently a local Arizona credit union installed an ATM in the community room at Wickenburg Community 14

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Hospital. This not only deepened the credit union’s relationship with the hospital, but also provided the entire Wickenburg community with convenient access to their accounts; providing access for cash withdrawals, deposits, balance checks and fund transfers.

Tip #2: Offer Tax Savings with a Health Savings Checking Account With escalating health care costs, who doesn’t want to save money on their healthcare expenses? Partnering with a Health Savings Account (HSA) provider gives your employees the opportunity to put up to $3,350 into a Health Savings Checking Account to save for future medical expenses. HSAs also offer a special tax-advantaged strategy for paying qualified medical expenses later on. Any adult can have an HSA if they have coverage under an HSA-qualified “high deductible health plan” (HDHP), if they don’t have another health insurance coverage plan through a spouse or partner, if they’re not enrolled in Medicare, and if they’re not claimed as a dependent on someone else’s tax return. Of course, we always recommend that you contact your tax adviser to answer any questions about an HSA.


Tip #3: Help Your Employees Save Time with Direct Deposit

Credit unions let you pay your employees with the convenience of Direct Deposit. This convenient, safe and secure service saves your business time and money on employee payroll processing, and lets you avoid the hassle and expense of cutting individual employee checks. All transactions are processed online through a secure website. You’ll be their hero as well, saving them the trouble of dashing off to their financial institution to deposit their paycheck before closing time. It’s a win-win for you AND your team.

Tip #4: Throw in Extra Vacation Days or Paid Time Off

A well-rested employee is a happy employee, so consider incenting them with extra vacation days or paid time off (PTO) to keep their minds sharp and loving their job. This is a great way to reward employees who are doing a terrific job — without having to pay them a cash bonus. In fact, many firms have successfully incentivized employees by offering “summer” hours, that ask them to work four 10-hour days per week instead of five 8-hour days. In return, they get Fridays off during June, July and August and earn three-day weekends when they need them most during the dog days of summer.

Tip #5: Volunteer Together

Most employees take pride in improving the communities in which they live and work. If you and/or your team want to support a local charity, a shelter, or a church group, think about planning a weekend day when your employees can volunteer together to accomplish a certain task. Have you ever thought about hosting a car wash, a bake sale or an art show as a fundraiser? Whatever you do, do it together with your employees. You can maybe even have a t-shirt design contest for the event – and reward the winner with a vacation day!

Tip #6: Give Your Employees Free Notary Public Services

If you have a home loan, a title deed, a will or a trust to sign, or other important legal documents, why make your employees have to find someone to get it authenticated? By partnering with a local credit union your employees can arrange a free notary public service to get that paperwork signed, sealed and notarized. Each document must be notarized, signed, and stamped in the presence of a notary. Notaries typically charge fees for their services, but free notary services are available through your local credit union. You can even have your documents notarized without a special appointment at a special customer service desk.

Tip #7: Reward Them with Vacation & Travel Discounts

Everyone loves to travel while saving as much as they can while they do it. Many credit unions offer special discount vacation packages to places like Disneyland, Sea World, and San Francisco to the companies they partner with.

You can also qualify for discounts on hotel rooms, fantastic cruises and other exciting destinations, plus extra night free specials when you pre-book a vacation. If you purchase your package through your credit union, a portion of each sale also benefits the Children’s Miracle Network.

Tip #8: Help Your Employees Find Great Vehicles and Auto Loans

Since almost everyone needs a car at one time or another, offering your employees ways to find their new “ride” through known and safe channels can be an added bonus. Many credit unions offer online car buying programs such as AutoSMART. You can access this convenient service from your desktop, laptop, tablet or smartphone and it lets your employees easily research, finance and locate their next new or used vehicle locally. They can even value and post an advertisement to sell their current vehicle while they search for another one to replace it. Plus, they will have access to motorcycles, power sport vehicles, RVs and trailers, power boats, personal watercraft and commercial trucks.

Tip #9: Provide Employees with Retirement and Investment Options

In addition to all of the services listed above, many credit unions offer securities and investment advisory services to help employees achieve their financial goals through companies like Voya Financial Advisors, Inc. These investment companies offer no cost, no obligation initial meetings. They realize that every employee is unique and has different scenarios for retiring, different risk tolerance for investing, and different shortand long-term needs for their retirement plan; whether they choose to buy stocks, bonds, property, annuities, or other investment options.

Tip #10: Offer Your Employees Insurance Options Just about every employee could use insurance benefits as well. That’s why most credit unions offer a range of insurance plans. These typically include auto insurance for your vehicles, homeowners or rental insurance for where your employees live, affordable life insurance coverage options to protect their family, and accidental death and dismemberment insurance in the case of a tragic, unexpected accident.

GIL ZEIMER Gil Zeimer is a freelance copywriter with over 25 years of experience. He specializes in direct response copy writing projects, and created this article for Arizona Central Credit Union. All members of Maricopa County Medical Society receive $200* when they join Arizona Central Credit Union – a full-service financial institution that has served Arizona for over 75 years. They operate ten full-service branches throughout Arizona, and offer access to more than 6500 branches and 50,000 surcharge-free ATMs nationwide. * Please visit joinus.azcentralcu.org for details.

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How to Discourage a Physician BY RICHARD GUNDERMAN, MD

N

ot accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily.

Seated across from me was a handsome man in a well-tailored, three-piece suit, whose thoroughly professional appearance made me — in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets — feel out of place.

Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon, roused by the sound of my own snoring, I started and looked about. That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.” No one else was about, so I reached over, picked it up, 16

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and began to leaf through its pages. It became apparent immediately that it was one of the most remarkable things I had ever read, clearly not meant for my eyes. It seemed to be the product of a healthcare consulting company, presumably the well-dressed man’s employer. Fearing that he would return any moment to retrieve it, I perused it as quickly as possible. My recollection of its contents is naturally somewhat imperfect, but I can reproduce the gist of what it said. “The stresses on today’s hospital executive are enormous. They include a rapidly shifting regulatory environment, downward pressures on reimbursement rates, and seismic shifts in payment mechanisms. Many leaders naturally feel as though they are building a hospital in the midst of an earthquake. With prospects for revenue enhancement highly uncertain, the best strategy for


As a result, the challenge of managing a hospital medical staff continues to resemble herding cats. ensuring a favorable bottom line is to reduce costs. And for the foreseeable future, the most important driver of costs in virtually every hospital will be its medical staff.” It continued: “Though physician compensation accounts for only about 8% of healthcare spending, decisions that physicians strongly influence or make directly — such as what medication to prescribe, whether to perform surgery, and when to admit and discharge a patient from the hospital — have been estimated to account for as much as 80% of the nation’s healthcare budget. To maintain a favorable balance sheet, hospital executives need to gain control of their physicians. Most hospitals have already taken an important step in this direction by

employing a growing proportion of their medical staff. Transforming previously independent physicians into employees has increased hospital influence over their decision making, an effect that has been successfully augmented in many centers by tying physician compensation directly to the execution of hospital strategic initiatives. But physicians have invested many years in learning their craft, they hold their professional autonomy in high esteem, and they take seriously the considerable respect and trust with which many patients still regard them. As a result, the challenge of managing a hospital medical staff continues to resemble herding cats. Merely controlling the purse strings is not enough. To truly seize the reins of medicine, it is necessary to do more, to get into the heads and hearts of physicians. And the way to do this is to show physicians that they are not nearly so important as they think they are. Physicians have long seen the patient-physician relationship as the very center of the healthcare solar system. As we go forward, they must be made to feel that this relationship is not the sun around which everything else orbits, but rather one of the dimmer peripheral planets, a Neptune or perhaps Uranus. How can this goal be achieved? A complete list of proven tactics and strategies is available to our clients, but some of the more notable include the following: Make healthcare incomprehensible to physicians. It is no easy task to baffle the most intelligent people in the

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organization, but it can be done. For example, make physicians increasingly dependent on complex systems outside their domain of expertise, such as information technology and coding and billing software. Ensure that such systems are very costly, so that solo practitioners and small groups, who naturally cannot afford them, must turn to the hospital. And augment their sense of incompetence by making such systems user-unfriendly and unreliable. Where possible, change vendors frequently. Promote a sense of insecurity among the medical staff. A comfortable physician is a confident physician, and a confident physician usually proves difficult to control. To undermine confidence, let it be known that physicians’ jobs are in jeopardy and their compensation is likely to decline. Fire one or more physicians, ensuring that the entire medical staff knows about it. Hire replacements with a minimum of fanfare. Place a significant percentage of compensation “at risk,” so that physicians begin to feel beholden to hospital administration for what they manage to eke out.

fective technique is to ensure that patient-physician relationships are frequently disrupted, so that the hospital remains the one constant. Another is. . . .” I stopped reading as the sound of a door roused me again. The man in the three-piece suit emerged from the office, he and the hospital executive to whom he had been speaking shaking hands and smiling. As he turned, I looked about. Where was “How to Discourage a Doctor?” It was not on the table, nor was it on the chair where I had first found it. Will he think I took it? I wondered. But instead of stopping to look for it, he simply walked out of the office. As I watched him go, one thing became clear: having read that document, I suddenly felt a lot less discouraged.

Transform physicians from decision makers to decision implementers. Convince them that their professional judgment regarding particular patients no longer constitutes a reliable compass.

RICHARD GUNDERMAN, MD Dr. Richard Gunderman is chancellor’s professor of radiology, pediatrics, medical education, philosophy, liberal arts, philanthropy, and medical humanities at Indiana University. He is also president of the Indiana Radiological Society and elected member of the Council Steering Committee of the American College of Radiology.

Refer to such decisions as anecdotal, idiosyncratic, or simply insufficiently evidence-based. Make them feel that their mission is not to balance benefits and risks against their knowledge of particular patients, but instead to apply broad practice guidelines to the care of all patients. Hiring, firing, promotion, and all rewards should be based on conformity to hospital-mandated policies and procedures. Subject physicians to escalating productivity expectations. Borrow terminology and methods from the manufacturing industry to make them think of themselves as production-line workers, then convince them that they are not working sufficiently hard and fast. Show them industry standards and benchmarks in comparison to which their output is subpar. On the off chance that their productivity compares favorably, cite numerous reasons that such benchmarks are biased and move the bar progressively higher. Increase physicians’ responsibility while decreasing their authority. For example, hold physicians responsible for patient satisfaction scores, but ensure that such scores are influenced by a variety of factors over which physicians have little or no control, such as information technology, hospitality of staff members, and parking. The goal of such measures is to induce a state that psychologists refer to as “learned helplessness,” a growing sense among physicians that whatever they do, they cannot meaningfully influence healthcare, which is to say the operations of the hospital. Above all, introduce barriers between physicians and their patients. The more directly physicians and patients feel connected to one another, the greater the threat to the hospital’s control. When physicians think about the work they do, the first image that comes to mind should be the hospital, and when patients realize they need care, they should turn first to the hospital, not a particular physician. One ef18

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Health Care Providers Should Publish WESTGATE HEALTHCARE CAMPUS . . . LEADING BY EXAMPLE. Physician Ratings What excites me most is this campus will significantly enhance the growing health care industry in Glendale. BY ASHISH K. JHA

It’s very important to the quality of life for our City

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arly efforts to publish performance data about our inresidents! doctors andand hospitals the U.S. usually required a strong external force, such as pressure from a state department of health. But that’s changing.

physicians, patients, institutions and the press — is privy to data on performance, physicians will develop a greater sense of accountability to deliver high-quality care. J E R RY W E I E R S For example, if M a AYO physician sees that many people rate R O F G L E N DA L E him as not spending enough time explaining the benefits and side effects of medications, he might take more care in conveying that information to future patients.

Some leading health care systems are now publishing ratings of their physicians on their own websites, not just ceding that activity to consumer outlets. This development may seem small, but if the trend grows, it will drive improvements in the quality of care.

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4. Providers’ own data will affect how other ratings outlets operate. When consumers see that providers 2398 East Camelback Road, Suite 950, Phoenix, Arizona 85016 www.ngkf.com are publishing their own ratings — and in great deSo far, most of this data is modest in scope (such as tail — they will ask themselves: Why use Yelp when patients’ ratings and written reviews of physicians), but the hospital itself gives me more? Why use ProPublithe growing trend toward providers’ publishing their ca if the hospital reports its own surgical complication own ratings is likely to transform health care in four rates? These efforts by providers will spur other ratings important ways. venues to identify metrics that are not currently mea1. Providers will build trust by empowering patients sured and reported. In effect, each ratings outlet will try to shape the quality of care. Patients deserve inforto outdo the other by publishing the information that mation about how well hospitals and doctors perform matters most to patients. In turn, if a provider sees that — and they know it. By starting to share their own perit is being outdone by consumer-oriented competitors, formance data (good and bad), hospitals are building it will have an incentive to improve its own reporting. a loyal patient base. When hospitals openly admit their The culture of transparency in health care is getting strengths and weaknesses, patients are far more likely stronger, prompted in part by patients’ growing financial to trust other information they get from those hospitals contributions to their own care and the easy availability and to stay engaged because they know that they, as of information online. Therefore, the era of performance patients, are influencing quality. data that is hard to find, difficult to understand and not 2. Providers will get to define the terms of transparmeaningful to patients is likely to come to an end. ency. So far, providers have been playing catch-up and are at the mercy of other ratings programs, such as Yelp and ProPublica. When a provider complains about ASHISH K. JHA, MD the methodology those outlets use, it comes across as Dr. Ashish K. Jha is a professor of international health and the disingenuous. If a provider posts its own performance director of the Harvard Global Health Institute. Disclosure: Dr. data, it has more credibility to criticize others’ informaJha BUILD-TO-SUIT serves on the advisory board for PLEASE Amino, aCONTACT: startup that FOR SALES, LEASING OR INFORMATION, tion. It also gets to decide what data is most important uses billing data from doctors and hospitals to build profiles of physicians consumers. — and to share it prominently. And if the data highTRISHA TALBOT, CCIM Managing for Director D:602.952.3880 E:ttalbot@ngkf.com lights deficiencies, the provider has theKATHLEEN chance to adMORGAN, CCIM©Managing Director D:602.952.3815 E:kmorgan@ngkf.com 2015 Harvard Business School Publishing Corp. dress them right out of the box.

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Fixing Health Care On The Front Lines BY RICHARD M.J. BOHMER, MD

I

n the United States and around the world, there have been plenty of proposals for curing what ails health care. All of them — new organizational forms, alternative payment systems and free-market competition — aim to tackle a universal challenge: improving the quality of health care and reducing, or at least curbing, its soaring cost. But regardless of what happens to the many experiments and reform efforts, the basic structure of the health care system in the United States and most other countries will remain in place for the foreseeable future. General hospitals and independent practices are not going to disappear anytime soon. The only realistic hope for substantially improving care delivery is for the old guard to launch a revolution from within. Existing players must redesign themselves. No single dominant design exists, which is not surprising given that each organization has its own environment, structure and history. An organizational design

that is effective in one setting does not necessarily translate to another. More important than the specific designs are the four common principles on which they are based.

Manage the care

The decisions, tasks and workflows crucial to optimizing patient care must be the organization’s primary focus. Applying evidence to practice requires standardization, not just of operational routines but also of the rules for making clinical decisions and executing tasks. Intermountain provides an example of one approach to standardization. To the extent medical science allows, it specifies how a patient’s health problems are diagnosed and treatments are selected and executed. In contrast to the loosely worded clinical guidelines that have been common in health care, Intermountain’s clinical processes are defined by protocols: detailed mcmsonline.com/round-up

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It expects — even encourages — doctors to deviate from a protocol whenever they think doing so is in the patient’s best interests. descriptions of the sequence of tasks and decisions that lead to the resolution of a patient’s health problem. For instance, its community-acquired-pneumonia protocol lays out how the patient’s history and results of physical examinations and laboratory tests should be used to make a diagnosis. These same data are used to ascertain the severity of the pneumonia using a well-validated calculation. This, in turn, determines where patients should be treated — in an outpatient clinic, on the ward or in the intensive care unit — and the oral or intravenous antibiotic that is most likely to be effective. At Intermountain, each protocol is drafted by a small team of paid clinical experts who review the scientific literature and Intermountain’s own experience. The team defines each variable — symptom, physical ob-

servation or laboratory result — and the expected timeline for the patient’s diagnosis, treatment and recovery. This information is translated into a sequence of yes/no check boxes and specific test and treatment choices laid out to mirror the order in which a doctor usually does his work. A larger team of general practitioners, nurses and information-systems and administrative personnel then ensures that the protocol is workable in practice. Both teams are permanent; they track the scientific literature and the organization’s experience, and make minor adjustments monthly and major revisions every two years. Intermountain limits the work involved by creating protocols only for the roughly 70 conditions that make up more than 90 percent of its caseload. These are predominantly common adult diseases — such as diabetes, hypertension, coronary artery disease and some cancers — for which there are established treatments supported by robust scientific evidence.

Corral variability

More than a quarter of Americans over 65 suffer from four or more interacting diseases, and many have conditions for which there is no definitive treatment. As a result, the overall care they require is highly variable and cannot be standardized. Organizations that deal effectively with this challenge apply a second broad principle: High- and low-variability care must be separated. Intermountain achieves this by allowing doctors to override standardized clinical processes in ambiguous situations. In other words, even though it standardizes as many treatments as possible, it expects — even encourages — doctors to deviate from a protocol whenever they think doing so is in the patient’s best interests.

Reorganize resources

When delivery organizations redesign clinical processes, they must also reconfigure the supporting infrastructure and practices. Intermountain has reconfigured its resources to support its protocols in the following ways:

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The steps in its protocols have been embedded in its electronic-medical-record system. As a result, when a doctor determines that a patient has a moderate case of community-acquired pneumonia, for example, a drop-down menu in the EMR offers a choice of two drug regimens.

2.

To train medical staff members and keep them up to date, educational materials and activities have been developed for each protocol.

3.

The teams responsible for developing protocols create measures that track compliance with and the impact of each one.

4.

Managers’ compensation is determined in part by whether compliance with protocols meets predetermined goals established by Intermountain’s board of directors.

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Learn from everyday care

WHY HEALTH CARE ORGANIZATIONS MUST BE REDESIGNED The explosion of scientific knowledge over the past 30 years has profoundly changed how medical professionals care for patients, but the structures and processes of most health care organizations are legacies of an earlier era. BEFORE: The nature of medicine before scientific advances: •

Disease cause was unexplainable

Disease occurrence and progression were unpredictable

Treatment outcome was uncertain

Patients were heterogeneous and manifested diseases in different ways

Who: Fragmented and independent providers widely distributed in the community; diversified hospitals with the resources to cope with complex health problems When: At the patient’s request Where: In specifically configured health care settings, such as a physician’s office, a hospital ward or a clinic What: Customized diagnosis and treatment based on the individual physician’s judgment AFTER: The nature of medicine after scientific advances: •

Diagnoses are more accurate, treatment choices better specified and treatments more reliable

Progression of disease and common complications and their precipitants are better characterized

Subgroups of patients with the same disease have been defined

Who: Professionals who are not necessarily doctors When: Before complications or exacerbations are manifest Where: Not necessarily during a face-to-face encounter between the patient and the care deliverer; in settings such as the patient’s home, a fitness center or a shopping mall

The structure and processes of hospitals, clinics and practices must be designed to help organizations systematically learn from their daily work. All too often, they are not. That’s because of the traditional separation between the generation and application of medical knowledge: Basic scientists and clinical researchers create the knowledge, which is then taught to practicing doctors and nurses in the continuing education programs that they must take to maintain their licenses. In other words, knowledge flows one way — from research to practice. In fact, valuable new knowledge about the nature of a disease, how to treat it and how to organize the delivery of treatment is often generated by the daily practice of medicine. Some organizations, recognizing that their staff generates large and small insights and innovations that could have a tremendous impact on performance, develop routines for creating, capturing and disseminating such knowledge. For example, when a doctor at Intermountain overrides a protocol, it is taken as a sign of the protocol’s failure to meet the needs of a particular patient. The teams developing the protocols collect the overrides, analyze them for patterns in patient outcomes and incorporate what they learn in their revisions.

The hard work of redesign

While the debates over health care reform continue to rage, a quiet revolution in health care delivery is under way. Organizations are applying these four design principles to improve patient outcomes. The lesson they offer is that no one solution can be imposed from on high: One size will not fit all. Government policies can aid in the transition, but the clinicians and managers who labor in the organizations where patients receive their care must do the hard work of redesign. Health care reform is as much a management as a policy challenge.

RICHARD M.J. BOHMER, MD Richard M.J. Bohmer is a physician and professor at Harvard Business School. He is the author of “Designing Care: Aligning the Nature and Management of Health Care.” © 2010 Harvard Business School Publishing From Harvard Business Review Distributed by The New York Times Syndicate

What: Diagnosis and treatment based on highly specified protocols and decision rules; therapies targeting specific patient groups

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MEMBER PROFILE

Maintaining Independent Practice of Medicine: a question and answer session with

Sumer Daiza, MD, F.A.C.S. Article photos by Denny Collins Photography. www.dennycollins.com • (602) 448-2437

BY DOMINIQUE PERKINS

Tell us a little bit about your beginnings. You’re an Arizona native, right? I was born in Michigan but my family moved to Scottsdale when I was 6 months old so I consider myself a native and can’t imagine living anywhere else. I grew up in Scottsdale and went to grade school at Our Lady of Perpetual Help, high school at Xavier College Prep and obtained my undergraduate degree from Arizona State University in 3 years because I wanted to get to medical school as soon as I could. What made you so excited to study medicine? I made the decision to become a doctor at the young age of 3, inspired by my pediatrician, Dr. David Folkestad. I am the only physician in my family so didn’t have anyone’s footsteps to follow, but I always admired Dr. Folkestad and his warm bedside manner and wanted to be just like him! I attended The University of Arizona in Tucson from 1991 to 1995 for medical school because we didn’t have a medical school in Phoenix at the time. mcmsonline.com/round-up

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How did you select your specialty? During my medical school rotations, I was exposed to the various specialties and on the first day of my general surgery rotation decided that I was going to be a surgeon. I did a 5 year general surgery residency at the Phoenix Integrated Surgical Residency program and it was during this time that I was exposed to plastic surgery and became passionate about the field in general: the physical changes I can make that in turn change people’s lives not just physically but emotionally with improved self-confidence and quality of life. I left Arizona for the first time in 2000 to do my plastic surgery residency at the University of North Carolina at Chapel Hill. Because I wanted to perfect my skills, I decided to do a breast, body and facial cosmetic surgery fellowship in Charlotte, North Carolina, with Charlotte Plastic Surgery, at the time the largest group in the country. Although the 8 years of residency were unnecessary for plastic surgery (some do only 5 or 6 years), I have had no regrets and have never looked back. I was fortunate to train with some of the leading experts in plastic surgery and the extra years gave me the knowledge and confidence that have served me well. I am certified by both the American Board of Surgery and the American Board of Plastic Surgery and serve on the Board of Directors of the Arizona Society of Plastic Surgeons. After completing your training, what led you down the path toward private practice? My first job out of fellowship was with a large group in Sacramento, California. I spent two years with the group which was a great experience and a huge benefit in my career but decided that I wanted to be back in the Phoenix area to be with my family and friends and, of course, to be back in the warm and sunny weather. I also enjoy the autonomy that a private practice allows although some of the benefits of the larger group practice were shared overhead and other doctors to cover call if needed. I think these are the biggest challenges to solo practitioners. Leaving the office for long periods of time is a challenge because the overhead doesn’t change, you are not there to be managing day to day details and patients need to be seen. I personally always find it difficult to leave patients behind even though I’ll have a colleague covering for me. After you made the decision to practice privately, where are you now? I returned to Scottsdale in 2006 and started my private practice from scratch. I am the owner and founder of the Plastic Surgery Center of Scottsdale and am fully dedicated to my practice and my patients. I am in a solo practice and focus mostly on cosmetic surgery, specializing in Mommy Makeovers, tummy tucks, breast surgery and facial injections. Tell us more about your practice – philosophy, your team, other providers, etc. One of the advantages of my solo practice is that I run my practice like a boutique or concierge practice where I see every patient from the initial consultation 26

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to the procedure to all of the follow ups. I do not use ancillary staff for patient care as I like to see my patients for every visit. My practice philosophy is to treat every patient like I would treat my family and to make each patient feel like he or she is my only patient. I feel blessed and honored that patients choose me to make these life changing procedures for them and am most comfortable knowing that I have seen them throughout their entire experience and recovery process. All of my patients are given my cell phone number so they are comfortable knowing that I am available to them at all times. I really love what I am doing and am able to build these long lasting relationships with my patients. Many become like family to me as I see them frequently and many have been with me since I started here in 2006. What are the advantages of patients choosing you over some surgeon at a large hospital? See above but also the personalized care and attention they receive in my office. Everyone is given my cell phone number, they see me for every visit and the office phone is answered by a live person from the office 24/7. I don’t use an answering service so patients know who they are talking to whenever they call and don’t have to leave personal information with someone they don’t know. We really try to make each patient feel that he or she is our only one or at least like part of our family. What are the biggest challenges facing physicians who are struggling to maintain independence? The high cost of running a practice with the continued decrease in reimbursements. In your opinion, what are the keys to success for physicians committed to maintaining their independence? (i.e., group consolation, better negotiating with payers, adopting new business models, social media, etc.) Excellent patient care and rapport I think are foremost; more providers in a group with being careful not to be too large where it starts to lose the personal touch; a larger group has better negotiating power with payers; finding the right staff.

DOMINIQUE PERKINS Dominique joined Maricopa County Medical Society’s staff in 2014, and is currently serving as the Communications Coordinator. She has a bachelor’s degree in Communications and Journalism, and over 6 years’ experience as a writer, editor, and social media strategist. Dominique also enjoys helping with Society events, be sure to look for her the next time you attend! Dominique can be reached at dperkins@mcmsonline.com.


MEMBER PROFILE

Dr. Sumer Daiza | On the Personal Side Describe yourself in one word. Centered

What is your favorite food? Sushi/seafood

What is your favorite restaurant in the Valley? Eddie V’s at Scottsdale Quarter

What career would you be doing if you weren’t a physician?

I would own and operate a health and wellness center incorporating fitness, nutrition, yoga, meditation and mindful living

What’s something that most wouldn’t know about you (play the guitar, sing, etc.)? I am a certified yoga instructor

Favorite Arizona sports team (college or pro)? Phoenix Suns

Family?

Dad, Mom and a sister all in town

One thing you would like to do more of? TRAVEL

Favorite activity outside of medicine? Yoga at MODERN YOGA with John Salisbury

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To Fix Health Care, Ask The Right Questions BY HENRY MINTZBERG

F

ixing U.S. health care was never going to be easy, but some persistent myths have made it more difficult than it should be. The first myth is that the system is failing. In reality, it is succeeding, but in an expensive way: Thanks to costly treatments, people are living longer. The problem is that, as a society, the U.S. doesn’t want to pay the premiums or taxes needed to support those treatments. Another myth is that costs can be brought under control by running health care more like a business and encouraging more competition. In America health care is already more commercial and competitive than it is anywhere else. Nonetheless, the costs there are the highest on earth, by far, and the quality of care is extremely uneven. The health care system could benefit, however, by adopting successful practices that are already in use – practices that are informed by good management (even if they don’t conform to caricatures of “competitive” and “businesslike”). Here are a few worth considering: Look to the people on the ground, not outside experts, for ideas for real improvements. Administrators, econ28

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omists and consultants who believe they understand problems conceptually should not be imposing solutions on the clinicians of all kinds who have to deal with problems tangibly. The latter must often take the lead – working with the former – on developing solutions. One dramatic improvement in recent times, which not only cut costs but also improved care, was the introduction of outpatient surgeries. This innovation came from practicing physicians who saw a better way to organize their work, not from administrators trying to cut costs. Build communities that engage people rather than conventional hierarchies that control them. This is not as hard as it sounds if you recognize that health care at its best is a calling, not a business. Why else would physicians, nurses and other caregivers subject themselves to such pressured work, surrounded by so much human misery? Their engagement is profound, but it needs to be supported by their institutions. Consider the Mayo Clinic, where for many years physicians have been paid straight salaries rather than fees for individual services. This practice lowers costs, since it eliminates incentives


Build communities that engage people rather than conventional hierarchies that control them. This is not as hard as it sounds if you recognize that health care at its best is a calling, not a business. to overtreat; creates a sense of shared purpose and commitment to the institution rather than to the treatment; and supports a culture that puts patients’ needs rather than doctors’ convenience at the core. Stop debating the merits of public versus private governance. This debate pits the efficiency of the private sector against the equality of the public sector. What country can ignore either? But more to the point, we need not always choose between the two. A full 70

GOING, GOING,

GONE!

percent of American hospitals, including the most renowned, are neither public nor private. They’re part of the social sector, owned by no one. The same is true of many prominent HMOs, such as Kaiser Permanente. Encourage greater collaboration. What we call our health care system is mostly a collection of treatments for medical problems; we need to build genuine systems that both promote health and treat illness. To do that, we need more cooperation, not more competition. In health care, what we call competition mostly amounts to individualization – with every person, profession and institution looking out for number one. One exception is Kaiser Permanente, which is a genuine system. It devotes considerable effort to keeping its subscribers healthy, catches any problems early and requires that doctors who treat patients with complicated diagnoses work together. If one institution can do this for 9 million people, surely others can do it for the rest of the population. We can get fundamental change in this troubled field by opening our eyes to its pockets of success.

HENRY MINTZBERG Henry Mintzberg is the faculty director of the International Masters for Health Leadership program at McGill University. From Harvard Business Review © 2011 Harvard Business Publishing Distributed by The New York Times Syndicate

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Student Scholarship Essay Ambiguous Performance: Patient Safety and Quality Measures in the U.S. Healthcare System The Maricopa County Medical Society has teamed up with longtime supporter MICA Foundation to co-sponsor a scholarship for local medical students to write about emerging topics in healthcare. Thomas Esposito is our second of four total essay winners who will receive a $2,500 reward. BY THOMAS ESPOSITO

W

e have seen dramatic changes to the implementation, delivery, and execution of healthcare in the U.S. over the past two decades. The Institute of Medicine published two major reports in 1999 and 2001 that released data on patient safety and the problems and limitations of the U.S. healthcare system, respectively. These reports, among others, greatly increased public awareness of preventable medical errors and the need to restructure the healthcare system to improve clinical outcomes1. One solution that emerged was the development and implementation of patient safety and quality measurement programs by the Centers for Medicaid and Medicare Services (CMS) on cost reduction and improved patient outcomes. These programs manifest today as the Physician Quality Reporting System (PQRS), Meaningful Use (MU), resource use, and the recently passed Merit-Based Incentive Payment System (MIPS) to name a few. With the implementation of all these performance measuring systems, the questions begs, do physicians really know how they are being assessed in terms of patient safety and quality measures? The answer to this question is complex and multi-dimensional; simply put I believe the most accurate, if still frustratingly ambiguous answer might be characterized as “yes, but no.� On one side, agencies such as the CMS lay out clear guidelines and objectives for their incentive programs so that physicians will know exactly how their performance is being 30

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measured. In fact, the MIPS program will combine all of the current quality measures into one reporting system that can potentially alleviate the problem of abiding by different guidelines from different reporting systems. However, the measures assessed within each program will still exist and what constitutes a well performing physician is constantly changing through the enactment of new legislation (MIPS) and modification of existing guidelines within each program. For instance, MU stages have undergone numerous modifications since their inception and many providers are struggling to keep up with the rapid revisions. The CMS released the final rules regarding stage 3 with modification to previous MU stages in October 2015. However, one month prior to this announcement, the American Hospital Association stated that over 60% of hospitals and 90% of physicians have yet to attest to Stage 22. Furthermore, CMS released a report in February 2015 that stated 75% of all eligible professionals had yet to attest to any stage of MU by the end of 2014, resulting in 250,000 providers being penalized3. Additionally, private insurance companies have followed suit and adopted their own methodologies for evaluating physician performance and adjusting reimbursement for services based off the quality of care delivered4. Numerous, independent agencies also evaluate hospitals on a yearly basis, publishing comparison rankings based on measures that they deem most vital in assessing the overall quality of care delivered. In 2013, St. Mary Mercy


Hospital in Livonia, Michigan simultaneously received a rating as one of America’s top 50 hospitals by Healthgrades and a poor rating from Consumer Reports with associated reductions in reimbursements by CMS5. These examples suggest that health systems, along with their providers, may not fully understand how their performance is being assessed. This could be a result of a lack of standardization for which performance measures should be used and which should not, possibly due to the continuous controversy surrounding the use of certain performance measures in assessing the quality of physician care. But undergirding these seemingly contradictory assessments, there’s a more fundamental question that must be addressed: do all of these performance measures provide an accurate assessment of the U.S. healthcare system today? Research has shown that some of these measures do lead to better health care outcomes while other studies illuminate potential problems with the utilization of incentivized programs in improving physician performance. A 2014 meta-analysis of 236 studies on the use of health information technology (HIT) and MU revealed that there is strong evidence supporting the use of clinical decision support and computerized provider order entry in order to achieve more successful health outcomes. A limitation of this meta-analysis is that the studies included rarely evaluated other measures of MU and the authors concluded that it is still unclear why some HIT implementations are reported as successful while others are not6. There is a growing body of evidence that supports the role of performance based measures

in improving clinical outcomes, such as those seen in MU, but this analysis is in direct opposition to the view of many physicians who feel that HIT and MU use has led to worse patient care according to survey results released in 2014 by Medical Economics7. One possible cause for this discrepancy is the misalignment between efficacy as defined by the terms of the performance studies and the translation of those terms in real-world practice. Efficacy studies are evaluated under more ideal circumstances with multiple exclusion criteria and highly experienced providers while effectiveness studies use a normal clinical setting with almost no exclusion criteria and providers representative of the general work pool8. One major factor that is out of physician control, and can have implications on their performance ratings and thus CMS reimbursements, is patient determinants of health. A 2010 study published in the JAMA concluded that for primary care providers (PCPs) working within the same academic health system, lower quality rankings were associated with PCPs who served higher proportions of underserved, non-English speaking, and minority patients. Furthermore, when the authors accounted for differences in visit frequency and patient profile factors, 36% of physicians were reclassified into a different quality quartile9. PCPs also share the care of a patient with numerous specialists who must each fulfill their role in order to maximize clinical outcomes. Should physicians be penalized for “lower quality of care” when they are taking on the burden of patient populations that tend to be poorer, sicker, and have worse health outcomes than

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other populations? Identifying uncontrollable factors and patient predispositions will have major implications on selecting performance measures that more accurately assess provider performance. I believe that current research has demonstrated that some measures are an accurate assessment of healthcare while other measures may not be, or have yet to be proven as, an accurate assessment of healthcare in the U.S. Removing performance measures that have not proven to be effective in improving outcomes is paramount because these measures may result in loss of productivity and increases in unnecessary and unexpected costs due to implementation of such systems10. One performance measure that I believe should be removed is the MU Stage 2 requirement to use electronic messaging within a certified electronic health record (CEHR) until all CEHR vendors can optimize this technology. As a former medical assistant (MA) of a urology clinic, I had first-hand experience witnessing the frustration that patients faced in communicating to their physicians within the CEHR because the system was not very user friendly. In turn, the clinic’s MAs spent increased time on the phone explaining how to use the system, which resulted in less attention paid to patients in the clinic and a slower workflow with physician backup. However, vendors are not fully to blame for sub-optimal usability. Continuing modifications to the MU program have resulted in CEHR vendors shifting their focus on ensuring that their platforms meet CMS requirements to be considered a CEHR, thus leaving less time to work on modifying these systems based of off physician and patient input. One quality measure that may be of use to physicians would be a requirement to provide more simplistic discharge or office visit summary information to all patients. Although an objective similar to this idea exists now under MU Stage 1, it only states that a clinical summary be provided to patients after each visit. The CEHR used in my former clinic printed out numerous pages of irrelevant and complex information in shockingly small font to patients, which served as a summary of their office visit. A patient presenting with urinary frequency may receive summary papers on BPH even if their urinary frequency was derived from a UTI because the CEHR printed out all information on urinary frequency etiologies. These patients would often call our clinic back after their visit stating that they felt confused about information received because it did not line up with their physician’s verbalized plan of action. Of course this would require collaboration between providers, CEHR vendors, and the CMS as well as research studies aimed at determining if there is sufficient evidence justifying the use of such a quality measure in improving patient outcomes. The United States health system is moving into an era of evaluating and compensating providers based off the clinical outcomes of their patients. Research to date suggests mixed results on incorporating pay-for-performance models into healthcare and much controversy surrounds the topic as a whole. One widely accepted

view is that our health system spends a disproportionate amount of money on health services in return for sub-optimal clinical outcomes. How we fix this problem will continue to be an issue of intense debate and will require open communication and receptiveness by all parties involved in the U.S. healthcare system. References Hughes, R. G. (2008). Patient safety and quality: An evidencebased handbook for nurses. Retrieved April 20, 2016, from http://www.ncbi.nlm.nih.gov/books/NBK2677/

1.

2. CMS releases final meaningful use rules. (2015, October 7). Retrieved April 15, 2016, from http://news.aha.org/article/151007-cms-releasesfinal-meaningful-use-rules-

Mazzolini, C. (2015, February 12). Meaningful use penalties: CMS releases physician reimbursement reduction details, latest attestation numbers. Retrieved April 20, 2016, from http://medicaleconomics.modernmedicine.com/medical-economics/news/ meaningful-use-penalties-cms-releases-physician-reimbursement-reduction-details-latest-attestation-number?page=full

3.

4. Chen, P. W. (2010, September 30). Paying Doctors for Patient Performance. Retrieved April 20, 2016, from http://www.nytimes. com/2010/10/01/health/01chen.html?_r=0 5. Rau, J. (2013, March 18). Hospital Ratings Are In The Eye Of The Beholder. Retrieved April 29, 2016, from http://khn.org/news/expanding-number-of-groups-offer-hospital-ratings/

Jones, S. S., Rudin, R. S., et al. (2014). Health Information Technology: An Updated Systematic Review With a Focus on Meaningful Use. Annals of Internal Medicine, 160(1), 48-54. doi:10.7326/M13-1531

6.

Verdon, D. R. (2014, February 10). Physician outcry on EHR functionality, cost will shake the health information technology sector. Retrieved April 18, 2016, from http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/ehr/physician-outcry-ehr-functionality-cost-will-shake-health-informa

7.

8. Singal, A. G., Higgins, P., & Waljee, A. K. (2014). A Primer on Effectiveness and Efficacy Trials. Clinical and Translational Gastroenterology. doi:0.1038/ctg.2013.13.

Hong, C. S., Atlas, S. J., et al. (2010). Relationship Between Patient Panel Characteristics and Primary Care Physician Clinical Performance Rankings. The Journal of the American Medical Association, 304(10), 1107-1113. doi:10.1001/jama.2010.1287

9.

10. Mcdonald, C. J., Callaghan, F. M., et al. (2014). Use of Internist’s Free Time by Ambulatory Care Electronic Medical Record Systems. Journal of the American Medical Association Internal Medicine, 174(11), 1860-1863. doi:10.1001/jamainternmed.2014.4506

THOMAS ESPOSITO Thomas Esposito is a first year osteopathic medical student at A.T. Still University-School of Osteopathic Medicine in Arizona. He is originally from Wheaton, IL and received his Bachelor of Science degree in Neurobiology from the University of WisconsinMadison in 2014. Thomas’s inspiration for this essay was derived from previous experience in healthcare and the desire to discuss the rapidly evolving health care system. Thomas plans to specialize in family medicine, internal medicine, or pediatrics.

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PHIL ANTHROPY IN MEDICINE EVENT

Jenny Weaver and Jay Conyers

Steven Perlmutter, MD and Mark Coltvet

W

e are so grateful to everyone who turned out for our second Philanthropy in Medicine Panel! Held April 28, in the Society courtyard, MCMS members and guests enjoyed an uplifting and informative evening of inspiring presentations and great conversation. We had three wonderful presenters: Lin Sue Cooney, formerly of Chanel 12 News, served as our gracious master of ceremonies, and shared some of her experiences at Hospice of the Valley; Dr. Richard Averitte told us about his experience founding and working with the Arizona Skin Cancer Foundation; and Sister Adele O’Sullivan shared her experience working with Circle the City. The event was made possible by our long-time Preferred Partner, Arizona Central Credit Union, who has served Arizona for more than 75 years! The delicious appetizers were provided by Tasteful Event Serving, and photographer Denny Collins documented the event. The full photo album can be viewed on the Society’s facebook page. We encourage you to drop by online and share a few photos and tag yourself and your friends! We are looking forward to more exciting events in the fall, and hope you will take the opportunity to join us then!

Leland Fairbanks, MD and Richard Averitte, MD

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Guests enjoyed drinks and appetizers before the program began.

Veeve Holtz

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John Middaugh, MD; Diane Petitti, MD; and Jonathan Weisbuch, MD


PHIL ANTHROPY IN MEDICINE EVENT

John Milligan, MD talking with Sister Adele O’Sullivan

Sameeha Khalid, Matt Potter, Hilary Park, Sister Adele O’Sullivan, Benjamin Berthet, Suneun Kim

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Marlie Averitte and Sarah Belden, DO

Eric Hoang

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Barb Spitzock


PHIL ANTHROPY IN MEDICINE EVENT

Richard Averitte, MD, spoke about his experience founding the Arizona Skin Cancer Foundation.

Sister Adele O’Sullivan spoke about her work with Circle the City.

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Robert Guyette, MD, DMD, enjoying the program.

Catherine Lee, and Anita Murcko, MD

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PHIL ANTHROPY IN MEDICINE EVENT

There was a brief Q&A period following the presentations.

Mary Ellen Bradshaw, MD, and Jonathan Weisbuch, MD

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PHIL ANTHROPY IN MEDICINE EVENT

A special thank you to Lin Sue Cooney for serving as out master of ceremonies.

As a thank you for their participation, each speaker was presented with a Cosanti wind chime.


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Space is For Sale or Lease. Enjoys monument signage and easy patient access. Contact Autumn, Ensemble Real Estate Solutions, 602-385-2854 MEDICAL SPACE AVAILABLE IN THIS HIGHLY VISIBLE MEDICAL CENTER AT IRONWOOD AND SOUTHERN Join SimonMed, urgent care, general dentistry, lab and federally funded healthcare clinic in medically underserved Pinal County. Adjacent to Banner Goldfield Medical Center. Contact Marina Hammersmith, CCIM, Ensemble Real Estate Solutions, 602-954-8414 MEDICAL OFFICE SPACE AVAILABLE AT GILBERT HEALTH CENTER AND AHWATUKEE FOOTHILLS HEALTH CENTER. Move-in ready suites with up to 8,422 SF medical space available. Excellent freeway access. Contact Tracy, Marina, or Autumn at 602-277-8558 for leasing information. BEAUTIFUL MEDICAL OFFICE has shared space available for partial lease in desirable NW Peoria location. Located adjacent to the Honor Heath facility on Happy Valley Pkwy. This office is an impeccable 1323 sq feet, with 4 treatment rooms. Rates and terms customizable to number of days/week and number of rooms needed. Contact 623-282-4642


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