Governance and the Academic Medical Group

Transcription

1 Governance and the Academic Medical Group What are the models and what works? A summary of the proceedings from the Association of American Medical Colleges (AAMC) Group on Faculty Practice (GFP) Annual Symposium, Denver, Colorado, November 4, 2011 Paul A. Taheri, M.D., M.B.A. President and CEO and Professor of Surgery University of Vermont Medical Group Chair, AAMC Group on Faculty Practice Mark A. Kelley, M.D. Executive Vice President-Chief Medical Officer/CEO Henry Ford Medical Group David Bjorkman, M.D., M.S.P.H. Executive Medical Director University of Utah Medical Group Nicholas H. Benson, M.D., M.B.A. Vice Dean ECU Physicians The Brody School of Medicine at East Carolina University Association of American Medical Colleges

2 Introduction Health care reform, while still in the nascent stage, is affecting virtually all aspects of the health care delivery system. The specific role of the academic physician and of physician led group practices at academic medical centers in tomorrow s health care system is highly variable, but virtually all stakeholders concur with the basic notion that physician participation, integration, leadership, and governance is critical to moving the system forward. Surprisingly, little is known about the precise number, size, and composition of physician groups and how they are governed. The reason for this lack of basic descriptive information on practices is that the definitions of a physician group are multifaceted and not always clear. For example, physicians can be independent practitioners, participate in a physician hospital organization (PHO), employed by a health system, contracted, share expenses with other physicians yet remain independent business entities, be a member of a designated group practice, and other business arrangements. Moreover, those physicians who are members of a discrete practice group frequently have difficulty in precisely determining the oversight, governance, and decision rights that rest within the physician group. Yet, every physician group (whether two physicians or a thousand) must have effective governance that creates an efficient environment for delivering care, obtaining payment for that care, managing interactions with external regulatory bodies, and performing other vital functions. As a result of this information deficit, the Group on Faculty Practice (GFP) Steering Committee decided to devote the entire 2011 annual meeting to better understand the structures, designs, and functions of the various governance structures that exist across a wide-range of academic clinical delivery systems. Since no credible repository of information exists, the Association of American Medical Colleges (AAMC) GFP decided that this type of information is vital to the operation and leadership of large faculty practices, and that we should begin to create the proper forum for this critical information exchange. These practices differ from physician practices in the community in that they are integral parts of institutions that are committed not only to the clinical mission, but also to the missions of research and teaching. From a professional society standpoint, the GFP is a group within the AAMC that represents practices that are strongly tied to medical schools, thereby including representatives from approximately 130 practice plans. Its stated mission is to advance the clinical mission of academic medical centers through the development of policies and models that embrace the fundamental importance of the faculty practice in health care delivery, clinical care, medical education, and basic and clinical research. The purpose of this publication is to capture the key themes and concepts regarding practice governance from our most recent meeting of the GFP in Denver, November, Association of American Medical Colleges 2011

3 Selecting the Presenters The GFP Steering Committee identified the three key types of physician practices that exist within the AAMC membership. They were defined as follows: Non-university integrated physician practice Practices that have full physician integration into the organizational leadership and health system operations. Wholly owned university practice All major constituents of the enterprise, including the faculty practice, Dean, and hospital CEO all report to the same individual within the university. University-based federated practice The departments of the group are closely associated to one another and loosely affiliated with a hospital entity. The GFP Steering Committee then selected institutions for which practice groups would meet the aforementioned criteria and identified the following: for the non-university integrated physician practice Henry Ford Medical Group Detroit, MI; the wholly owned university practice University of Utah Medical Group - Salt Lake City, UT; and the university-based federated practice ECU Physicians, of Brody School of Medicine at East Carolina University Greenville, NC. Upon acceptance of the invitation to present, each of the practice leaders was provided a structured outline intended to provide consistent direction and content to their presentations. The outline consisted of a series of basic questions surrounding the mission, size, clinical revenue, and governance of their practice. The topic of governance was then expanded to discuss who is in charge of the practice, which decisions are really made by the practice, the process and flow of the decisions within the practice, and some assessment of the success of each model. While this information was self-reported, it nonetheless defined a framework for learning about key attributes of success/failure from our peers. It also provided a platform for a focused discussion. Key Practice Attributes The Henry Ford Medical Group, part of the Henry Ford Health System in Detroit, is a fully integrated group of 1300 employed physicians with over $750M in annual revenue. This is the nation s third largest academic medical group and is similar in organization to the Mayo and Cleveland Clinics. Since the inception of the Henry Ford Health System in 1915, the medical group has had a defined leadership role. Its number one priority is to take great care of patients, followed by: recruiting and retaining the best; a commitment to the academic mission; and using resources wisely. The University of Utah Medical Group is fully owned by the larger University and has approximately 1200 clinical physicians and annual revenue of approximately $320M. The group was formed by the Senior Vice President for Health Sciences/CEO of University of Utah Health Care in 2001 to allow for coordination of finances, contracting, clinical operations, quality, and information technology (IT). Each department is still responsible for its own billing, collections, and physician recruitment. 3 Association of American Medical Colleges 2011

4 ECU Physicians, a component of the Brody School of Medicine, has over 350 physicians and annual revenue of approximately $167M. It prescribes to a more federated model of a practice in that less clinical activity is centrally managed, though functions such as compliance, risk management, third party billing, and clinical information technology are centrally administered. The School of Medicine does not own the teaching hospital or health system. The practice serves as the safety net provider for the community s indigent and government-insured patients. Practice Practice President reporting structure Practice Board leadership Key decisions over past year Key practice committees Henry Ford Medical Group Reports to Health System CEO At large-physicians, department chairs, Group CEO and COO, and Main Campus Hospital CEO Compensation process, contracting, joint strategic planning with Health System, myriad of clinical initiatives Professional standards, finance, clinical practice, education, quality council University of Utah Medical Group Reports to Senior Vice President for Health Sciences/CEO of University of Utah Health Care Department chairs, appointed and elected physicians, Hospital CEO, SVP is chair Joint strategic planning, EMR and billing system selection, contracting strategies, capital improvements and expansion within group Executive committee, operations, quality, finance, contracting, IT ECU Physicians Reports to the Dean Dean is chair; physicians, department chairs, Vice Chancellor for Health Science, basic science chair Creation of Cancer Center, new clinic leases, dealing with departments that are in financial deficit, payer contracting, new program review, advocacy and reform Finance, space, quality, practice management, HR, and credentials In the various presentations and ensuing discussions, several key issues were identified and discussed. These included defining integration, working to achieve trust and transparency, the role of other stakeholders such as departmental chairs, and communication techniques or tools to help support the practice leadership in communicating the key elements of change in the practice. While this list is not comprehensive, it does begin to identify the wide array of issues facing practice leaders across the country. 4 Association of American Medical Colleges 2011

5 Conclusions Our day did not close with an attempt to provide a definitive answer to which system has the best practice governance. Rather, we concluded the day with a richer understanding of how different and yet how similar our practice characteristics actually are. We determined that virtually all practices have numerous important opportunities that will allow physicians to participate in the governance of their respective practice. Practice boards and leadership are dealing with many but not all of the critical issues facing any enterprise such as capital allocations, revenue, program review, and quality. The issue of integration has at least two distinct facets: the extent to which the practice is itself integrated so that it operates consistently across departments in terms of various functions and decision-making; and at least as challenging, the extent to which the practice shares clinical, financial, cultural, and operational integration with the larger hospital and health system that is its primary teaching and practice site. The latter was described by one presenter as being the elephant in the room, and by another as the biggest chasm in academic medicine. While physician-hospital integration was not the focus of this effort, it is recognized that it is worthy of serious discussion at a future time. It also is evident that the establishment of an effective governance structure takes a long time, should evolve in response to dynamic changes in the healthcare and regulatory environment, and requires a consistent and sustained effort that may require a cultural shift in the organization. For example, it has taken almost a century of work for the Henry Ford Medical Group to become one of the more organized and operationally mature medical groups in the country. Another key issue that was discussed was communication. All participants agreed that the ability to clearly and effectively communicate to individual faculty currently are sub-optimal. Several tools are being deployed by the various groups to improve the situation, including a monthly newsletter, faculty meetings (which receive modest attention at best), and direct communication at the board level with expectations that the chairs will communicate to the faculty at large. Despite these efforts, there was a general belief among participants that ensuring effective communication across the faculty is exceedingly difficult and involves participation by the department chairs in disseminating information; in particular, there was discussion about whether chairs should be the main conduit for informing faculty, or whether other methods work better. Embedded in this are questions about which information is essential for faculty to understand versus which is optional. Communication with faculty can also help bring clarity to discussions about how pressures for clinical productivity compete with the need to safeguard time for training and research. Interaction with faculty is a vital way to identify and develop future leaders for the organization, making an effective communication plan even more important to the overall group and its governance. In summary, academic medical groups are complex organizations that have a wide array of reporting structures which evolved based upon their history, goals, endowments, and competencies. While many issues were not addressed, a few key themes regarding the establishment and maintenance of a successful practice emerged: Be patient; it takes decades to develop a solid mature governance process. Physicians from across the practice must be involved in decision making. Physicians can and do make key strategic decisions that impact the larger organization. Effective physician communication remains exceedingly difficult across all practices. Physicians must take a leadership role within their practice. Effective working committees with engaged faculty members are important. Collaboration with school of medicine and hospital partners on clinical strategic decisions are vital. 5 Association of American Medical Colleges 2011

6 This meeting provided an initial, organized forum to begin a candid discussion about the governance and leadership of various types of academic practices. It illuminated many of the opportunities and pitfalls, and provided a feeling of collective unity and commitment in achieving optimal outcomes related to the management of our practices. While many challenges lie ahead for our respective leadership, we are confident that academic physicians have the drive, commitment, and passion to optimize our clinical and operational outcomes for our institutions, the patients they care for, and the students they train. Links to the Meeting Presentations Henry Ford Medical Group University of Utah Medical Group ECU Physicians Group on Faculty Practice Steering Committee Chair Paul A. Taheri, M.D., M.B.A. President and CEO University of Vermont Medical Group Immediate Past-Chair Lisa Anastos Executive Vice President, Clinical Practice and Business Development University of Chicago Medical Center Chair-Elect Scott Hofferber Executive Director University Physicians University of Missouri-Columbia School of Medicine At-Large Members Dayle Benson, M.H.A. Executive Director University of Utah Medical Group University of Utah School of Medicine James J. Potyraj, M.H.S.A. Executive Director MCV Physicians Associate Dean Virginia Commonwealth University School of Medicine Lawrence Dusty Sanders, M.D., M.B.A Associate Dean for Clinical Affairs Morehouse School of Medicine Craig H. Syrop, M.D. Associate Vice President for University of Iowa Physicians University of Iowa Roy J. and Lucille A. Carver College of Medicine Council of Deans (COD) Liaison Harold Paz, M.D. Senior Vice President for Health Affairs Dean, College of Medicine CEO Penn State Milton S. Hersey Medical Center Pennsylvania State University College of Medicine Bruce Elliott, M.D. Senior Associate Dean, Clinical Affairs Medical University of South Carolina * Members of the Steering Committee were important contributors to the GFP Symposium and provided vital support to the production of these proceedings 6 Association of American Medical Colleges 2011