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In the second of two installments, emergency medicine elder statesmen Ricardo Martinez and Lynn Massingale continue their discussion on the changing role of hospitals and the future of Accountable Care Organizations.

Ricardo Martinez: CMO, North Highland Company; Assist. Professor of EM, Emory

Lynn Massingale: Executive Chairman and former CEO, TeamHealth

Ricardo Martinez: A CEO of a large hospital system recently told me that he has a very hard time getting physicians to come to meetings and participate. And yet, many of the hospitals were started by physicians. How did it get this way? And where do we have to go to fix it? Or do we have to fix it? At many hospitals right now, the medical staff and administration have very uneasy relationships. And those of us in emergency medicine sometimes get stuck in the middle trying to bridge the gap. Clearly if we’re going to get paid for performance, our current organizational structure will have to change.

Lynn Massingale: It seems to us – and we work in a lot of hospitals in a lot of states – that there is a wide range of [physician participation]. We see still some traditional situations where physicians on the medical staff are still coming to medical staff meetings, and they’re still serving on committees, and they’re still doing all the things they always did, and taking a call without being paid for it. On the other hand, we are seeing more and more places where that’s not true, where physicians have decided to have an exclusively out-patient practice. And they have decided to not be involved in the hospital. And in fact, if they’re going to have to take call, they’re demanding to be paid for it. And of course, as you know, in many places are being paid for it.

So while I’m not a fatalist, I don’t believe we’re going to turn back the clock and convince all doctors that they need to be actively engaged in the hospital. The exception is hospital-based doctors or the doctors whose practice is primarily limited to the hospital. And for those hospitals who want to try to lure the private medical staff back and keep them engaged in the hospital, we, the ER, need to do all we can on our part to make that work. The phone call from the ER needs to be a competent call. They need to know that if we ask them to come in, that it’s a reasonable request. The general surgeon needs to have some confidence if he’s getting called he really needs to come in. Otherwise it’s just going to make him crazy. On the other hand, at TeamHealth, we’re moving into a model that accepts that some doctors don’t want to take call. We’ve actually just acquired a company that provides surgicalists and laborists and orthopedicists – if there is such a word. But the physicians in those specialties only want to work at the hospital. And we think those doctors will be engaged in the hospital. I’ve thrown in the towel on cajoling an ophthalmologist who really doesn’t want to take call into taking call. Thank God for the few that will.

Martinez: If you’re going to get paid for performance and you’re going to be sharing some risk, then what’s the model that has to evolve? From my perspective, you’re going to see the rise of physician leadership with some sort of shared governance model. Inter-dependence, rather than independence, is going to occur. It’s going to be harder and harder to be a successful independent physician if the insurance or the payers begin to group patients. But how do you have shared incentives that are aligned properly?

Massingale: Well, hospitals can employ the docs. But ultimately they can’t treat them unfairly or they won’t work. They’re just too many opportunities for doctors. So whether they’re employed, affiliated with the ACO, affiliated with the hospital, or they’re contracted like most ED groups are; ultimately all those groups have to figure out how to work together in a way that’s fair. But there’ll be some blood on the floor between here and fair as we try to get that right. Just like there was in the early 90’s when a lot of PHO’s formed around the country. We spent a lot of time fighting over how to divide up the money, and not enough time on how we were going to work together the day after the wedding. Perhaps we’ll all be smarter this time around.

Martinez: Physicians are trained to be independent, to have great faith in their decision-making process. But that doesn’t translate into team work and systems thinking very easily. We have to go back and retrain our physicians in many ways in order to be leaders of teams; to be able to cooperate and collaborate effectively. I believe that you’ll see growth of the healthcare IT, that we’ll be able to develop better clinical pathways that are data driven. Variation in healthcare is one of the issues that we struggle with. We have too much debt, fat and data at this point. We have to find a good way to present data to physicians that will help them take care of patients and remove some of the variation. We did it with trauma, STEMI and stroke. And I think we’re going to see it for sepsis and a lot of other things. How about emergency medicine? What do you see as some of the biggest opportunities for emergency medicine or some of the biggest changes for emergency medicine in the next five to ten-years?

Massingale: When I think about that, I go from one extreme to the other. In the mid 90s, I remember all the dire predictions of how ER visits were going to go down. And in one institution where we worked, they literally filled in a hole they had dug for a new expansion on the hospital because they were convinced that the volumes were going to go to pot. And so on the one hand you could argue that with all the cost containment efforts that might come down, ED volumes might go down as well. On the other hand, 20 or 30 or 50 million previously uninsured patients have something now that they didn’t have before. I believe there’s a lot of pent up demand in those patients. And I don’t believe there’s a place for those patients to go. There’s no primary care capacity to absorb that many patients. So arguably they have to come to the ER. And then finally you just have the aging of the population. So I believe that for the intermediate term that ED volumes are going up.
And that has a lot of ramifications: workforce ramifications, process ramifications, and all the things that impact how we actually deliver those services. On the other hand, there are people, like the urgent care companies of the world, the retail pharmacies, and free-standing ERs, who would like to have that not happen. But our view is that those other places are not going to be sufficiently successful to cause a net decline in ED visits. We believe there’ll be a net increase.

Martinez: I agree. Simply because there are things that go way beyond healthcare reform. We have a shortage of providers. We have an aging population. We have people who want access but who may only have Medicaid or low quality health insurance. But I think we’re going to see that there will be a continued need for acute care. The healthcare debates are mostly about chronic care. But medical homes aren’t well suited for acute care.
Years ago I used to get flown off by helicopter to oil rigs. I went out on ambulances. Now we have telemedicine. I think that we’ll continue to have a strong need for our skills as good diagnosticians. But where we run into trouble is that we are moving toward huge workups and a lot of testing. In terms of value to the system, we need to use our leadership skills to move more toward diagnosing and making decisions without a lot of unnecessary testing. That’s going to require leadership skills to build things like clinical pathways and protocols.
So those are the opportunities that we have in front of us. I think that the emergency department can very well be not only the central access point for the hospital but can extend its skills to some of these outlying facilities or outlying offices.

Massingale: At the risk of being provocative, I do believe that emergency physicians err when they say: “We don’t want the non-critically ill patients in the ER.” We should be spending our time trying to find solutions for where these patients should be.
Martinez: We have to be very careful when we talk about things getting backed up, that we’re not part of the problem. We need to use our skills wisely and be a good team leader. I’m amazed when I meet emergency who don’t play well with mid-level practitioners because they, “may take my job.” I find it amazing perspective to talk about some patients “wasting your time”. Why can’t you let someone else take their time and see those patients?
So the bottom line is that we have to lead by saying what our role is, how we can add value, and how we plan to act on that opportunity. And we need to be proactive. If we don’t, then we’re going to have other people explaining to us how emergency medicine should work. It’s tempting, but you can’t be all things to all people. We need to have a clear vision and share those goals.

Massingale: I think there’s room for lots of opinion. But I do believe that if we are recalcitrant about figuring out these solutions, someone will be forced to figure them out for us. I just think we’re better off being at the table instead of being obstinate.

Martinez: My last comment is this. I think the best days of emergency medicine are ahead. I truly do. I think we’ve got the right skills and we’re positioned in the right place in the healthcare system to make a huge difference. No one knows more about acute care. And we have an opportunity to really help those in need and start the process early.

So, emergency medicine should look for ways to take a leadership role in the changes of healthcare. There’s a lot of people who need access to care. And if anybody has systems thinking, the ability to deal with multiple types of patients, the ability to figure out very complex problems, the ability to move the system in the right position for our patients because they’re great patient advocates, it’s emergency medicine.

Massingale: I think that’s right. And one other thing. I generally assume that most hospital leaders have their hearts and their heads in the right place; and that they’re capable people, motivated to do the right thing. There are exceptions in their ranks and there are exceptions in doctor ranks. But I think most people in healthcare are there for the right reasons. But I do not think that everyone is trying to help the hospitals succeed. Emergency physicians have a unique ability to be in the room with hospital leaders, helping those institutions to be as successful as they can or should be. So I agree, I think it can be a terrific time. There’s going to be a lot of change. I think if you’re totally opposed to change, it’s going to be the toughest time in your life. But if you’re fairly open-minded about it, it can be a great time.

 

 

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