Hospitals and Group Practices
Medicine’s small business owners BY SUSAN L. DAVIS
I
f physicians have essentially been small business owners, hospitals have been their workshop. Before our eyes, they are cobbling together a new business relationship – with caring the focus. Hospitals and physicians traditionally have been paid for the volume of care they provide, and little had been done to change that. Now the Affordable Care Act focuses on population health and has a payment model that rewards quality and cost savings, while providing incentives for electronic patient information sharing. While no one knows what the final details of health reform will look like, the change from volume- to value-based payment will change the system of care. Improving population health and quality outcomes requires alignment between providers, especially the physician and the hospital. Traditionally independent of each other, these two groups of providers find themselves facing a new world and a new way of working together to
deliver care. There are many models that are being developed across health care in the United States to bring hospitals and physicians closer together. However, the most common of these models include the employment of physicians by hospitals. Employment is not a desired option for every physician, but for those who find it an attractive model, there are many opportunities.
Physicians, hospitals – and patients The independent practice of medicine today can present many challenges to a physician. The increasing cost of the practice, overhead along with decreasing reimbursement, investment requirements in information technology and quality reporting requirements make small, single-specialty practices difficult to maintain. Employment by a health system or hospital provides the small medical practice or independent physician economies of scale, giving them access to information technology systems and providing management
services that will enable the physician to focus on the care of their patients. For hospitals, the employment of physicians is an opportunity to align incentives and develop a continuum of care for the patients. Clearly, the patient is the most important component in examining a hospital/physician employment model. Today we see significant increases in chronic illness such as diabetes and heart failure. The employment model allows for systems to be implemented between the hospital and the physician’s office that will better monitor the patient and coordinate their care. This care coordination will ensure that the patient gets the appropriate care in the best setting to treat and manage their symptoms. These care management systems are proven to improve outcomes and decrease cost.
The challenge
in some cases the trust between the two has not been strong. However, both parties realize that they have to change and that change requires each to give up some independence, change their focus and look at building a relationship that puts the patient and their needs above all others. This is certainly achievable. There are many places across our country where change is happening and it is benefiting the communities the hospital and physicians serve. This is an exciting time to be part of the health-care system. While we cannot predict what will happen with reform, hospitals and physicians are partnering through different models to create systems that will improve care across a continuum for their patients. Together hospitals and physicians are changing the health care landscape and improving the way we work together to deliver care.
While hospital/physician employment may on the surface seem easy, it is not. Physicians have been trained to be independent small business owners. The hospital has been the workshop for the physician and
Susan L. Davis is CEO of St. Vincent’s Medical Center in Bridgeport and St. Vincent’s Health Services. She can be reached at sdavis@stvincents.org.
Treating tweeners, teens and twentysomethings, too BY JANICE KIRKEL
jkirkel@westfairinc.com As Dr. Marcie Schneider puts it, this is a very transitional age group. Not only are their bodies and minds transitioning, so is the responsibility for their medical care. She founded Greenwich Adolescent Medicine in July 2005. But her training and experience in adolescent medicine goes back much farther than that. After completing her pediatric residency at Montefiore Medical Center in the Bronx, she went to North Shore University Hospital in Manhasset where she did her fellowship training in adolescent medicine. There she stayed for 13 years. During that period she was associate chief of the division of adolescent medicine and medical director of the eating disorders program. In 1999, Greenwich Hospital recruited her to start an adolescent medicine program. Six years later, she founded the practice where she remains today. Another doctor, Sara Buchdahl Levine, joined in July 2008. “It’s a relatively small field,” Schneider said. “There are only about 600 or 700 of us in the whole country who are boarded (board certified) in this sub-specialty.” She said being a specialist in adolescent medicine is different than being a pediatrician who says he or she also treats adoles-
cents. Half of what she does, she said, is general well care of adolescents, who are defined as being between the ages of 10 and 25. The American Academy of Pediatrics defines the end of pediatrics as age 22. But the Society for Adolescent Health and Medicine says it’s the end of the 25th year or when a person turns 26. “Most kids between 22 and 25 are floating,” Schneider said. “They’re in grad school, they haven’t settled down.” Her office gets very few new 25-year-olds; most of the older patients started when they were much younger. As for the other half of being a specialist in adolescent medicine, she said that consists of working in the sub-specialities of eating disorders, obesity, gynecological issues, behavioral issues and growth and development. Treatment usually begins with what is known as a HEEADSSS (heads) assessment, a screening acronym for all the areas of a patient’s life that should be examined – home, education or employment, eating, activities, drugs, sex, suicidality, safety and strengths. “A 12-year-old might be asked, ‘Are you going to parties? Are kids your age dating?’ I recently saw a young woman who was thinking of going on birth control pills. Initially she decided not to. Then she called back, reconsidering. We’re trying over time to give kids more responsibility for their
Dr. Karen Browner-Elhanan
health care.” The issue of patient confidentiality and parental involvement is a sticky one, especially since New York state has no minimum age for patient confidentiality. “Sometimes what I do,” said Dr. Karen Browner-Elhanan, the medical director and adolescent specialist at BridgeSpan Medicine in White Plains, “is say to the parent, ‘I’m going to examine your child now, why don’t you have seat in the waiting room and we’ll call you in.” She said she and the two other doctors in her practice, Jody Ross and Patricia Avvocato, try to be more understanding of the lifestyle of an adolescent. “There’s a real
difference in approach to the management of adolescence. And here, an adolescent gets it all under one roof, whether it’s a mental health issue or an eating disorder. It’s a more general approach.” Schneider expressed similar sentiments. “We put in the looking-at-thewhole-person part of it,” she said, “even if we’re dealing with a chronic disease, like diabetes, asthma, or Crohn’s disease. We need to know where they’re going to school, if it’s time for college, what resources they’ll have, anything so they’ll be able to live as happy and healthy a life as they can.” And when it is time for a patient to leave home and go to college, Schneider says she has a role to play there too. “We want to make sure they know what medications they’re on, that they know how to access the health service at school. Also, that they know that they have to give their parent permission to talk to the health service, or else they can’t. Even though they’re not at home anymore, they want Mom and Dad to still be involved.”
16 Week of April 30, 2012 • Fairfield County Business Journal a division of Westfair Business Publications • www.westfaironline.com