Prescription for change

As governor of Oregon, not only has Dr. John Kitzhaber brought Democrats and Republicans together to reform his state's Medicaid program, he brought physicians and lawyers together to advance tort reform.

Kitzhaber's leadership in getting bipartisan passage of legislation dealing with volatile subjects helped put him on top of the roster of 43 men and seven women who were selected by Modern Healthcare and Modern Physician readers and editors as the nation's 50 Most Influential Physician Executives in Healthcare.

This is the ninth year the list has been compiled, and the first time Kitzhaber has been selected (though last year he placed third on Modern Healthcare's ranking of the 100 Most Influential People in Healthcare). The physicians on this list are not only leading their organizations through tough financial times and budgetary uncertainty, but they also are helping to shape and transform the nation's evolving healthcare system from one that rewards volume to one that promotes quality and value.

Kitzhaber provides an excellent example of how this is done. Earlier this month, it was announced that 22 companies had been approved to offer health and dental insurance to Oregon's uninsured under the state's health insurance exchange, which Kitzhaber says is moving ahead “on time and on budget.” But the splashier headlines were made last month, when the governor signed legislation creating a disclose-and-offer process that offers an alternative to contentious and lengthy litigation after a patient has been harmed.

The measure was approved by a 26-3 vote in the state Senate and a 55-1 vote by the state House of Representatives. Kitzhaber, a Democrat got the ball rolling when he presented what he called “the Holy Grail in medical politics,” a letter endorsing the bill approved by both the president of the Oregon Medical Association and the Oregon Trial Lawyers Association.

“That was big,” he says. “Traditionally, this has been a war of sound bites.”

Kitzhaber, a former emergency medicine physician, says the new law accomplishes goals he set, such as “access to justice” and a “framework to say no” to groundless lawsuits, while also creating a better environment to increase patient safety, allowing compensation for people harmed, and lowering healthcare costs by decreasing the amounts spent on legal defense and defensive medicine practices.

“It's a story of engaging as citizens first and not as stakeholders,” he says. “And it worked.”

Oregon also found itself in the national healthcare spotlight last year when it passed bipartisan Medicaid reform. At the time, the state House was split evenly 30-30 between Democrats and Republicans, but the reform bill passed by a 53-7 vote. Boosted by a $1.9 billion federal grant, the state created a network of 15 coordinated-care organizations that are covering 93% of the state's 600,000 Medicaid beneficiaries. This new system is projected to save the state $11 billion over 10 years.

Kitzhaber is a believer in how care coordination can lower costs for patients with multiple chronic conditions, and he likes to use real-life examples to prove his point. One example posted on the Oregon Health Authority website tells of a Medicaid patient in his late 20s who, in 2009, ran up $99,000 in healthcare costs after being treated 40 times in emergency departments for asthma attacks and hospitalized twice for schizophrenia-related issues. A primary-care team started coordinating his care in 2011. Not only was he was kept out of the hospital, but his healthcare bill dropped 90% to less than $12,000.

Kitzhaber's long-term vision is that the less that is spent on healthcare means more resources are available to invest in education, which will result in less money needed for the criminal justice system.

“He understands that the dollars we invest in healthcare are dollars we cannot invest in other areas,” says Dr. Joseph Robertson Jr., president of the Oregon Health & Science University, where Kitzhaber earned his medical degree in 1973.

Robertson says the best example of Kitzhaber's “paradigm-shift type of thinking” was his argument that the state could save money if the coordinated-care organizations bought air conditioners for people who were being repeatedly hospitalized for heat-related illness. Kitzhaber acknowledges that the idea generated criticism, but he won't back away from it. “I'm always amused by the argument that buying an air conditioner is not the government's role, but paying $50,000 for an unnecessary hospitalization is,” Kitzhaber says.

Only one other elected official made this year's ranking of the 50 Most Influential: U.S. Rep. Michael Burgess (R-Texas), who is No. 48 on the list.

Burgess, who represents the northwest suburbs of Dallas, is co-chairman of the Congressional Health Care Caucus and vice chairman of the House Energy and Commerce Committee's subcommittee on health. Among the measures Burgess is working on is a replacement for the Medicare sustainable growth-rate physician payment formula. Burgess says a bipartisan solution could be ready by this summer.

A 24.4% SGR-driven decrease in Medicare payment rates is now scheduled to take effect Jan. 1, 2014, and Burgess says he wants to avoid a repeat of the decade-old practice of Congress passing a last-minute SGR “patch,” or temporary postponement of the payment cuts, which is a ritual he knows has become frustrating for physicians.

“It's beyond irritating,” he says of the always-looming SGR-driven payment cuts. “It robs them of the ability to plan and grow.”

While acknowledging “some will voice reservations about anything that comes out of Congress,” he says support is building for a plan being developed that would replace the SGR formula with a system of predictable payment rates and rewards for delivering high quality and efficient care.

Burgess says, however, that he has to be more than a healthcare representative and that he must have the answers to issues ranging from the Veterans Affairs Department to federal monetary policy when constituents ask him questions. When asked if he's ever been told to stick to healthcare, Burgess says, “It happens,” but he says there are more times when important healthcare policy decisions are being made and he realizes that he's the only person in the room who has ever written a prescription or counseled a patient.

“It's critical that physicians be involved and stay involved,” Burgess says, adding that he knows most doctors have little time to do anything more than tend to their practice and their families. “It's important that people making the decisions hear from the people who are actually providing the care on the ground.”

Kitzhaber and Burgess are making their first appearances on the ranking of the most influential physician executives, along with nine others.

The other first-timers are Dr. Patrick Conway, the CMS' chief medical officer (No. 10); Dr. Elliott Fisher, director of the Dartmouth Institute for Health Policy & Clinical Practice (No. 15); Dr. Ram Raju, CEO of the Cook County Health and Hospital System, Chicago (No. 23); Atul Gawande, a professor of surgery and professor of healthcare policy and management at Harvard University (No. 38); Dr. John Hensing, CMO at Banner Health, Phoenix (No. 39); Dr. Joe Selby, executive director of the Patient-Centered Outcomes Research Institute (No. 42); Dr. William Conway, chief quality officer for the Henry Ford Health System, Detroit (No. 44); Dr. Richard Bankowitz, CMO at the Premier healthcare alliance, Charlotte, N.C. (No. 45); and Dr. Robert Grossman, CEO of NYU Langone Medical Center, New York (No. 50).

Dr. Gary Gottlieb, president and CEO of Partners HealthCare in Boston, meanwhile, makes his ninth appearance on this year's ranking. He is the only person to have made the list every year since its inception.

“Any influence I have is really a reflection of the system and its people,” Gottlieb says, adding that the Boston area and the state of Massachusetts have exercised influence at a national level as well.

“We have exceptional institutions that have a two-century heritage of providing exceptional care and leadership,” he says. “Massachusetts has been a leader in raising the importance of healthcare coverage as a matter of social justice and as a right and not a privilege.”

He says Partners is working to align physicians and align interests. This includes redesigning all of its primary-care practices into patient-centered medical homes providing physician-led, team-based care. The practices use nurses as care managers for the highest-risk patients, allowing physicians to use their diagnostic and management skills—and “moving away from being traffic cops and travel agents.”

According to Gottlieb, No. 34 on this year's ranking, what the nation has built is an “illness-care system,” and what society now wants is to preserve the gains on the illness side while “building a true healthcare system.” There will be challenges, but Gottlieb is optimistic.

“Incentives that physicians have depended on have been turned upside down,” Gottlieb says. “But as we move forward with new payment schemes toward population health management focused on high-risk patients, the people who need us the most, we have an opportunity to get this right.”

Similar optimism was also expressed by Dr. Kelvin Baggett, senior vice president of clinical operations and chief medical officer for Tenet Healthcare Corp., a 51-hospital system based in Dallas. “We're on a remarkable journey,” Baggett says. “I'm incredibly excited about where healthcare can go.”

Baggett, No. 18 on this year's ranking, describes that journey as moving the healthcare system away from fee-for-service toward fee-for-value and, eventually, to “fee-for-health.” He notes how Tenet's institutions in California's Coachella Valley—Desert Regional Medical Center in Palm Springs and JFK Memorial Hospital in Indio—are working with the Clinton Foundation to improve food offerings in schools and working with local mayors to make more healthy food options available to the area's low-income population.

“Innovation is one of our core values,” Baggett says. And, to that end, Tenet sponsors its annual clinical innovation awards in which hospitals share information on successful projects that can be replicated across the Tenet landscape. This year's submissions involved projects on improving pain management in orthopedic patients, reducing surgical-site infections in spine fusion patients and improving the continuity of palliative care.

Two people behind one of last year's most successful quality-improvement initiatives, the American Board of Internal Medicine Foundation's Choosing Wisely campaign, are on this year's 50 Most Influential list: Dr. Christine Cassel (No. 9), who will soon be stepping down as president and CEO of the ABIM and taking over as CEO of the National Quality Forum; and Dr. Robert Wachter (No. 26), chairman of the ABIM board and associate chairman of the University of California at San Francisco's department of medicine.

The campaign was publicly launched last April with nine medical specialty societies releasing lists of five tests or procedures that are commonly used but not always necessary. The list has grown to include 130 tests and procedures from 42 societies. The ABIM is also working with Consumers Union, publisher of Consumer Reports; AARP; the Leapfrog Group; the National Business Group on Health and other organizations to disseminate the list.

“Most of what happens in healthcare is because a doctor made an order or wrote a prescription,” Cassel says, so it's natural for physicians to be stewards of healthcare resources.

“I was prepared at the beginning to get a lot of pushback from patients and from physicians who are still paid by volume,” she says. “It could have a negative impact on some doctors' revenue or patients could be suspicious about treatment being withheld.”

But Wachter believes he knows why there hasn't been a backlash. “There was so much hunger for physician leadership on stewardship of resources and reduction of waste,” he says. “People were ready for the right message from the right messengers.”

In addition to his coining of the term “hospitalist” for physicians who provide general medical care for hospitalized patients, Wachter also was one of the first high-profile physicians to take his message to social media. Although he says he's on Facebook mostly to check in on his kids, he's been writing his “Wachter's World” online blog since September 2007 and he's been on Twitter since January 2011 (715 tweets, 3,256 followers).

Cassel will be moving over to lead the NQF after her term at the ABIM expires in July. After 10 years of helping decide what it takes to be a board-certified internist, Cassel says she's looking forward to broadening her horizons and working with consumers, purchasers and other stakeholders to disseminate evidence on what works in healthcare.

“In the marketplace of healthcare, we want people to be more transparent about the care they're providing,” she says. “That's where NQF comes in.”

While others are studying the evidence, Dr. Joe Selby, who heads the PCORI, is busy working to produce it.

Selby leads an independent not-for-profit organization created by the Patient Protection and Affordable Care Act to “fund research that will provide patients, their caregivers and clinicians with the evidence-based information needed to make better-informed healthcare decisions.”

Selby says PCORI is identifying evidence on what works well and what doesn't in treating illness for particular subgroups of patients. Examples of this type of PCORI-funded research include studying patient and caregiver preferences between dialysis for kidney-failure patients performed in the home and in a clinic; developing decision aids for parents receiving genetic information about their child's rare disease; and examining why treatment adherence declines among diabetic adolescents.

Patients and clinicians can use this evidence to guide a course of treatment that is tailored to patients' outcome preferences. “I think there is no doubt in my mind that shared decisionmaking is here to stay,” Selby says. “We're providing that last bit of evidence to help make choices.”

Evidence is needed. Dr. Susan Turney, president and CEO of the MGMA-ACMPE, says her organization's 22,500 members (who lead 13,600 medical practices) are looking for answers on technology, staffing, integration and if their practices will be able to stay independent. “I always get asked, 'What's the one thing that keeps your members up at night?' But it's really not one thing,” Turney says. “When I ask them, they say there are 50 things.”

Turney, No. 32 on this year's ranking, says there is no one-size-fits-all solution to these problems, so the MGMA-ACMPE has been providing medical groups with information on implementing technology as well as on forging formal and informal integration relationships with hospitals, nursing homes and pharmacies. “We get them what they need to make that happen,” she says.

According to Dr. Richard Bankowitz, of the Premier healthcare alliance and purchasing network, what organizations need in order to improve is motivation, data and coaching. Bankowitz explains that Premier, which has 2,800 member hospitals, uses collaboration and economies of scale to advance its quality goals.

He says that to participate in Premier collaboratives, hospitals must be transparent in their data—everyone can see how everyone is doing. The goal is to learn from top performers, but—simultaneously—no one wants to see their name at the bottom.

According to Bankowitz, the scores for a hospital in Alabama were at the bottom in a sepsis-reduction collaborative. That provided the motivation for change, and—a little more than a year later—the hospital is now among the top performers. Bankowitz also notes how Premier's QUEST improvement collaborative was launched in 2008 and now has 333 hospitals across more than 40 states sharing information on mortality, cost, patient harm, readmissions and patient experience. According to the data, collaborative hospitals have avoided nearly 92,000 deaths and saved $9.1 billion.

“We're fixing healthcare from the inside,” he says. “We're a private-sector, provider-driven organization, and it's been great to see providers step up and identify what they want to measure and set targets on their own.”

Dr. Peter Pronovost, senior vice president for patient safety and quality at John Hopkins Medicine in Baltimore, also advocates making quality improvement an inside job and says external forces—such as pay-for-performance programs—have had low impact on quality gains.

In contrast, successful programs—such as the implementation of surgical checklists—have been driven by clinicians, he says. Previously, doctors “didn't own the problem” of poor quality healthcare, but now, Pronovost says there is “growing recognition that physicians must step up.”

Pronovost, No. 5 on this year's 50 Most Influential ranking, says healthcare quality suffered from the “bystander effect,” where people cared about the problem but thought someone else was working on it. At Johns Hopkins, Pronovost says a structured accountability format has been developed where, if quality measures aren't met, corrective action is taken. He says this approach is common for financial performance, but basically unheard of for quality. He adds that, if hospitals had quality committees that functioned like finance committees, “we would transform healthcare in this country.”

One problem is a lack of outcomes measures for gauging quality, and Pronovost says people are naively assuming “we have this outcome-measure tree in the backyard” producing fruit few are using. But, as more clinicians and providers get involved, he says the science of healthcare quality is improving—only now there needs to be a “common book of truth” that everyone follows.

“There are no common rules, so we have organizations making up their own rules,” Pronovost says. “You can go to any community and half their hospitals are on somebody's Top 10 list.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks