Editor's Note: This is the last in a series of articles examining how physician-health system relationships are changing to more effectively deliver quality healthcare in the 21st century. The first article in the series, in Modern Physician's April 2000 issue (page 54), addressed the elements driving today's changes. The second article, which ran in July (page 54), illustrated how systems are trying to convince doctors that their fate is tied to the system's future. This piece examines how hospitals are improving quality and building their market identity.
Hospitals are showing new interest in working with their medical staffs to create programs that improve quality and convenience for their patients and help extend their "brand" in the community. These hospitals believe their model holds the key to survival.
"We see free enterprise as a tremendous opportunity," says Jay Bohreer, executive director of Swedish Medical Center's Swedish Heart Institute in Seattle. "This is absolutely the best time to be in healthcare. But to succeed in the free market, you have to provide something of value back. That's the only sustainable model."
It's a model the healthcare industry has come to late, and the learning curve is going to be steep.
"My perception of it is, there's probably been a realization that the customers of these hospitals are not just the patients and insurers, but also the physicians," says Bill Gray, M.D., director of the Heart Institute's endovascular care program.
The phrase "All healthcare is local" is uttered so often it may be on the way to becoming the 11th commandment. But in many instances, it's untrue. Patients in rural and suburban markets often must travel great distances for advanced care. Family routines and jobs are disrupted. The patient has to recuperate far from home, separated from extended family and friends.
For physicians, this treatment model is problematic. "Face time" with their patients and their attending specialists is sacrificed. Consultations and follow-ups must be done via long distance. Communication breakdowns occur regularly.
Models such as the one being implemented at Swedish include such elements as:
One community hospital is filling the hole created by faraway specialty treatment centers with a $70 million expansion project. Vassar Brothers Hospital, a 315-bed facility in Poughkeepsie, N.Y., is attempting to capture a potential patient base of 1 million with new advanced cardiac care, including open-heart surgery, and cancer care programs.
The hospital is centrally located 80 miles away from three hubs of medical research and education: New York City; New Haven, Conn., site of Yale University; and the state capital of Albany, home of Albany Medical College and several large medical centers. For advanced cardiac and cancer care, patients in the region had to choose from these three locations, just far enough away from home to make family support and physician-to-physician communication problematic.
The hospital's strategic planners seized the opportunity, counting on community support. They recruited physicians with extensive experience at academic medical centers to direct the new programs. The community, in turn, realized these services would be a tremendous boon to the quality of life in the region and contributed $20 million in two years. The first open-heart surgery at the hospital was performed in April; the cancer center is slated to open by November.
Daniel Aronzon, M.D., the hospital's chief of staff and vice president of medical affairs, says the expansion is already paying dividends for the region's physicians. Today, a surgical patient's referring physician receives a postoperative status fax before the heart surgeon gets out of his scrubs. When patients had to leave the area, Aronzon says, "a lot of times, the patient would show up in the referring physician's office after they were discharged, and the referring physician wouldn't even know what had happened. Communication was very inconsistent."
"The medical staff was part of the genesis of this project," he says, "part of the planning process, part of the implementation process."
Aronzon says 11 of the 12 members of the committee in charge of finding cardiothoracic surgeons were physicians. Half the strategic planning committee is comprised of physicians. The chairman of the board is a practicing physician.
Physicians occupy six seats on the hospital's 40-member board of directors.
"It's not a bunch of administrators sitting there making arbitrary decisions," he says.
Vassar Brothers has just begun to expand its participation in clinical trials through pharmaceutical brokering, serving as a conduit connecting physicians and manufacturers with products entering Phase III trials. Such help in securing new drugs for patients will keep the hospital in the forefront of both research and clinical service, he says.
"It adds prestige. It adds knowledge. And for some patients, it can be lifesaving," Aronzon says. "It's also part of what we're trying to do in partnering between docs and the hospital. It benefits both because the pharmaceutical companies are willing to pay significant sums of money to both parties, and this can be done on an inpatient or outpatient basis."
As an additional incentive, he says, the hospital provides research coordinators to take care of clinical paperwork, saving physicians time.
Luring top talent
Clinical trials also are a mainstay of innovation and building market share at Kalamazoo, Mich.-based Borgess Health Alliance. Sanford Tolchin, M.D., chief medical officer of the integrated system's medical center and its research institute, says the trials program, which began in November 1998, has attracted physicians from leading academic centers who have opted for leadership roles in a community setting rather than the tradeoff between prestige and bureaucracy in academia.
Tolchin says the Borgess Research Institute was the brainchild of system executives and local physician leaders in cardiac care, neurological trauma, and transplant and emergency medicine. The hospital provides administrators, research coordinating assistance, grant and scientific writing expertise, and capital investment in laboratory facilities and equipment.
Five years ago, Tolchin says, Borgess physicians performed 1,500 cardiac interventions and 800 open-heart surgeries a year, not one under a research protocol. Today, Borgess cardiologists perform 2,500 interventions annually, with 300 under research protocols.
"We've attracted world-class cardiologists," Tolchin says. "Not only do we support research efforts, but we're able to provide for our patients technology they previously could have received only at large research institutions."
The success of the research initiative also has reduced some of the existing antagonism characteristic of hospital-physician relationships, he says, and shows signs of encouraging further collaborative efforts between the hospital and private practices.
If the Vassar Brothers expansion was the result of astute physicians and executives taking advantage of an obvious existing opportunity, the work done at the Swedish Heart Institute, which opened in 1997, has focused on patient and physician convenience in a region where cardiac care already is plentiful.
While it may seem counterintuitive, Bohreer says the Swedish initiative has not suffered from the late start. While the other programs in the greater King County area have had substantial investments in intensive inpatient procedures such as open-heart surgery, Swedish planners took the opposite approach by focusing on disease management delivered in hospitals and offices close to patients' suburban homes. The managing physician partners of the program's affiliated medical groups vetted its clinical and administrative objectives.
"They were instrumental in setting and validating our business plan, our market strategies, and rolling forward. It was pretty much a physician-driven enterprise," Bohreer says. "We wanted to focus on wellness. You go where the patients are. You need a more regionally oriented approach."
Thus far, Bohreer says the Heart Institute has struck agreements with six regional hospitals and their affiliated cardiology groups and is negotiating with two more. It has also established 11 cardiac catheterization labs in the SHI network and is the regional home of the Dean Ornish program, which focuses on rigorous changes in diet, exercise and stress management to arrest and even reverse heart disease without surgery. "The Ornish program does typify our commitment to aggressive medical management," Bohreer says. "At the same time, we're not neglecting tertiary care. We just built a $90 million acute-care tower last year."
Bohreer says the judicious mix of close-to-home disease prevention and top-drawer technology appeals to patients and physicians in SHI's partnering groups.
To ensure consumer confidence, Bohreer says the clinical care paths at all SHI affiliates are identical to what is delivered at the main campus, with protocols developed by regional councils of physicians and administrators. Patient load has quadrupled since the program began, Bohreer says.
The ongoing direction of the program is also evaluated via the partnership model, Bohreer says. The executive council overseeing the alliance includes an administrator and a physician from each hospital.
For patients, the regional alliance provides uniform educational efforts as well as consistent care pathways, Gray says. He contends physicians in the partnering groups benefit by aligning with a system that was already well known for providing top-quality care and still is striving to improve outcomes.
While building a brand regionally, if not nationally, is sometimes considered a crucial part of increasing market share, physicians and executives at Long Beach, Calif.-based Memorial Health Services have learned another of the most salient lessons in the new healthcare market -- sometimes you win a round because your competitor didn't adapt as well as you did.
One of Memorial's five member hospitals, Long Beach Memorial Medical Center, picked up 48,000 new patients in one fell swoop earlier this year when physicians in two groups switched affiliation to Memorial from the Catholic Healthcare West-owned Long Beach Community Medical Center. CHW, which bought a faltering Community in October 1998, tried to consolidate its Long Beach operations by moving Community's cardiac surgery program and other hallmarks of tertiary care to its larger downtown hospital.
Rather than achieve efficiencies, however, CHW earned the wrath of physicians and residents of eastern Long Beach for whom Community had been the neighborhood hospital for 75 years. Physicians said splitting patient loads between two campuses in congested Long Beach added hours to the workday. Residents believed the consolidation was an ill-disguised gutting of their hospital for the benefit of a bigger institution in a bad part of town they would never choose to patronize. In June, CHW announced plans to close Community.
Memorial executives realize such windfalls aren't the norm. The hallmark of Memorial's campaign, called MemorialCare, encompasses an IT infrastructure that gives physicians access to patient information from remote locations and patients access to the system's quality report cards and physician information.
The MemorialCare concept, which derives from physician-driven clinical protocols, was started in October 1996 by a committee of 40 physicians who were convinced patients would respond to local doctors' efforts to build a better system more favorably than they would to the financially based consolidations sweeping the region at that time.
"Aligning physicians the way we did was not seen as a smart thing to do," says David Lagrew, M.D., MemorialCare information infrastructure chairman, of the days when much of the Southern California market was a veritable bazaar of PPMs and hospital-based practices, which Memorial shunned. "But I think it's been shown you don't buy efficiency when you buy a practice, and you also don't buy a doc's enduring loyalty. I believe our focus on collaboration with physicians and the convenience of the integrated information system appeals to physicians."
For Lagrew, the MemorialCare concept should, as it matures, lead to a golden loop of better data and outcomes, which attracts more, and more savvy, patients to physicians who have joined both the organization's clinical quality and marketing efforts.
The concept is showing growth in the ultracompetitive Southern California market. Adjusted discharges at the five MemorialCare hospitals have risen 18% since 1997.
"Bricks and mortar and ad campaigns are fine," Lagrew says, "but it comes down to perceived quality. We're clearly in the infancy of measuring quality outcomes. It's not a very precise science yet."
Richard Keck, vice president for business development at Swedish Medical Center, agrees that the information-rich approach MemorialCare has used to grow will be necessary for any system that wishes to thrive in the future.
"Right now, the negotiations are all about price," he says, "and that doesn't serve anybody's interest in the long term. A cohort of more sophisticated consumers is emerging, and as we move toward more defined contribution plans as the norm, you're going to see more people asking more questions about price and quality."
Greg Goth is a Redondo Beach, Calif.-based healthcare writer.