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.”