Shifting Perspectives: My Path Toward Achieving Physician Alignment

In healthcare, every physician, every group, every hospital, and every health system claims to be patient centric. Some succeed more than others. I’ve been practicing long enough to understand that as physicians working in different practice settings, the lens through which we view patient care and the organization around us inevitably changes. Different models of care lead to different lenses, and those lenses can have a profound impact on patient care and outcomes.

When I finished my training in internal medicine in 1999, I started my career in a traditional practice setting. I saw patients in my office. I followed them to the hospital, to the nursing home, and back to the office. While my patients loved this doctor-patient connection, this was clearly not the most efficient way to practice and deliver care. This experience gave me exposure to different care settings and the different capabilities of those settings. However, ultimately my lens was the ambulatory care setting, and I was concerned with volume-driven reimbursement and the increasing regulations governing the practice of medicine.

In 2008, I became the medical director for a hospitalist group in a large teaching community hospital. We were concerned about care delivery in the inpatient setting from admission to discharge, including observation, medical consultation, and teaching services. My lens changed. The team and I were focused on improving length of stay, quality core measures and readmissions. For the most part, we met our goals.

I recall during my first year in this position I negotiated a deal with the emergency department (ED) director: the hospitalist would have 30 minutes from the time of the ED call for an admission to evaluate the patient and determine disposition. While I considered this deal a win for the hospitalists, it is clear that my lens was very inpatient focused, not patient focused.

As a hospitalist, I had little knowledge or care for the ED’s Left Without Being Seen (LWBS) rates. If anything, I thought to myself, higher is better, because if more people left the ED, it meant my hospitalists would have to deal with fewer admissions.

Eventually, I had a rude wakeup call concerning this issue from an ED provider. He told me to imagine a busy emergency department with, say 100,000 visits and an LWBS of 2 percent. If the admit rate was 20 percent, that meant 400 potential hospitalist patients were leaving each year. If the average charges were around $9,000 per patient per admission, that was $3.6 million a year in lost revenue. The focus of many hospitalists is too narrow. That was quite a wakeup call. It became clear that our incentives and goals were not aligned.

Eventually, my lens changed again. I joined the ranks of hospital administration as a vice president for hospital medicine and care coordination. Now my goal was to reduce readmissions, improve transition of care, and deliver care in the most efficient way. I looked for ways to succeed under bundled payment systems. Through this lens, it became clear to me that many hospital initiatives succeeded or failed based on the quality and commitment of the physician leadership involved. I would sit around the table with the hospitalists and the ED providers, and it was obvious we needed our physician leaders to collaborate in order to be successful. Too often, however, instead of working together, they would be pointing fingers.

Then, my lens changed yet again. In 2015, I joined US Acute Care Solutions as the Chief Medical Officer for Integrated Acute Care. For the first time, hospitalists and ED providers were under the same umbrella. Not only were they both providers in the same hospital, but they were part of the same group, a group which gave all its physicians an ownership stake in the company. That meant the people I sat around the table with weren’t just my colleagues, they were truly my partners.

Suddenly our decisions became about what was going to produce better outcomes for patients, because better outcomes for patients would help us to grow this model of integrated acute care delivery throughout the health system, and thus grow our business. Finally: alignment.

Rather than point fingers, all of us involved work together to figure out what’s best for the patient. This model truly shapes the lens through which physicians operate, and thus it incentivizes behaviors you wouldn’t otherwise see. The ED physician now has a clear stake in writing better transition orders, or spending an extra 15 minutes to talk about palliative care, or arranging proper follow up with primary care physicians. Meanwhile, hospitalists work harder in the morning to get their discharges out, knowing that if they don’t, the admissions will back up and the ED will start falling behind.

I look back more than a decade ago on that deal I made with the ED director that I thought was a “win,” and I know it wasn’t a win, at least not for the patients. Now, our integrated acute team solves problems together, establishes admission criteria that we all agree to, and treatment protocol that we all built together. Through this new lens, I see one team with one focus: to provide safe and efficient patient care across the acute care continuum.

Ultimately, I believe our Integrated Acute Care model is the future of healthcare, because it’s the model that best aligns the physician leadership to continually seek ways to improve patient care. Our program has already begun to prove this, with incredible results. If you’re interested in learning more or partnering with us, don’t hesitate to reach out.