Q&A With Barbara Paul, MD: How the supply chain can remove barriers and forge a stronger bond

Barbara Paul, MDNamed one of Modern Healthcare’s 50 Most Influential Physician Executives in Healthcare, Barbara R. Paul, MD, is senior vice president and chief medical officer of Community Health Systems Professional Services Corporation (CHS) in Franklin, Tenn. She has served fellow HealthTrust members as a member of HealthTrust’s Physician Advisory Committee.

After graduating from Stanford University School of Medicine and completing her residency in San Francisco, Paul worked full-time in internal medicine practice in northern California for 12 years. In 1999 she moved to Washington, D.C., where she worked for the Medicare program (Centers for Medicare & Medicaid Services). While there, she directed the Physicians’ Regulatory Issues Team and changed a number of policies that were excessively burdensome for practicing physicians. Paul was instrumental in developing Medicare’s first “pay for quality” demonstrations and the hospital quality alliance.

Prior to joining CHS, she was senior vice president and chief medical officer for Beverly Enterprises Inc., a provider of nursing home, hospice and rehabilitative services to the elderly.

In 2006 Paul came to Nashville, Tenn., to work for CHS. The organization includes 135 affiliated acute-care hospitals in 29 states. She became CHS’ chief medical officer in 2007.

“I didn’t set out to have a career in policy or administrative roles—I just identified things I liked doing and followed opportunities that presented themselves,” she says. “I have enjoyed the ability to impact healthcare for patients in a broad way.

“If I can do something that removes a barrier or enhances the doctor/patient relationship, then I’ll feel I have done something good that day.”

She spoke with The Source about the changing dynamic between providers and physicians as a result of healthcare reform, strategies for better physician engagement, and the impact of value-based purchasing.

What impact will the convergence of clinical and financial outcomes have on physicians in the future?

Physician and hospital success will increasingly be linked. Under today’s Value Based Purchasing and Readmissions Reduction programs from Medicare, results are published for each hospital. However, physicians and hospital administrators (and members of the community) know that relative success with these outcomes-based payments tracks back to physician and nursing care—not just hospital operational factors.

Today, more hospital care is provided by hospitalists, or physicians who care only for hospitalized patients. This relatively new care model can enable tighter coordination between hospital operations and physicians, drive quicker improvements and, potentially, better clinical and financial outcomes. As additional payment changes roll out—bundling payment for episodes of care such as hip or knee replacement comes to mind—physicians and hospitals will be finding additional ways to link to succeed.

“If I can do something that removes a barrier or enhances the doctor/patient relationship, then I’ll feel I have done something good that day.”

A different convergence of clinical and financial outcomes is occurring between physicians and their patients. There is increased transparency regarding cost of care, as well as ever-increasing deductibles and copays, causing patients to become more cost-sensitive. More patients have access to the Internet and are reading more news stories about differential healthcare service costs, and they are demonstrating that they can be savvy consumers, too.

Some of this is good—physicians are more thoughtful about ordering MRIs, blood tests or even surgery because their patients are asking more questions. I expect that this kind of conversation between patients and their physicians will just be a given in the future.

How are physicians’ thought processes evolving based on the changing dynamic between providers and physicians (e.g., pay for performance programs, the rise in employed physicians, public reporting of measures that clearly link back to both)?

More and more physicians are seeking employment by a hospital or health system rather than staying in private practice. Ten years ago, some would not have considered being employed, but they’re doing it now to stabilize their practice life.

Some physicians are shifting to a concierge practice, charging each patient an annual retainer fee and reducing their patient load substantially. Other physicians are adding ancillaries or other services to their practices that don’t fall under insurance benefits so they can be paid in cash. Still others have stopped taking new Medicare/Medicaid patients. As the economy improves, surveys suggest that many older physicians, who deferred retirement because of the recession, will retire or substantially reduce patient care duties.

Countering that somewhat gloomy backdrop, fortunately there are also many who are simply rolling up their sleeves. Physicians do understand that healthcare is changing, and we have many among our affiliates who are working closely with administrators, nurses, pharmacists and others to navigate these changes together. It can be an exciting time to develop new programs and make a big impact on the quality of care for one’s community.

What advice would you have for supply chain leaders to best support clinical objectives?

Get physicians and supply chain professionals together early and often. Physicians understand the need to purchase in a cost-effective way. What they ask is to be at the table with supply chain to sort through the choices, to see and get comfortable with any data being used, and to share clinical issues that need to be considered.

Bringing physicians to the table early and keeping the focus on better clinical care will go a long way toward solving many challenges. Physicians are wired to be helpful and need to believe in a project in order to engage in it. We have lots of competing priorities, so if we’re going to engage on a supply chain project, it has to engage us in a way that we know will positively affect people’s lives. If not, we have many more things competing for our time.

It’s important to look at the whole episode of patient care. For example, using a cheaper drug may save the pharmacy department money, but it may require extra staff or procedure-room time. Certain medications may be more expensive, but they may eliminate the need for blood testing. One radiological product may be less expensive than another, but it may require more staff time to mix and use. Looking at patient care holistically will help supply chain leaders get to the clinically and financially appropriate answer.

How do you leverage initiatives from both a clinical and supply chain perspective to positively impact both patient care and your organization’s bottom line?

We have two specific physician advisory groups who assist us on a number of topics, including supply chain questions—a Cardiac Excellence Group and an Orthopedic Excellence Group. For each, we invite about 25 physicians from affiliated hospitals to participate. We tee up questions about new technology that might be getting a lot of buzz, or ask what they are seeing as promising changes in their fields. We have found that physicians help us anticipate upcoming technology and better understand where a certain device or product fits in—and if it fits in.

With our orthopedic group, for example, we discussed a new piece of equipment being promoted as providing superior joint replacement results. In talking to orthopedists, however, we found it probably has no clinical benefit that would make its purchase worthwhile—what we were seeing was primarily a marketing differentiator, not a clinical differentiator.

Physicians are very good at keeping each other up-to-date regarding the science and literature—they keep each other on their toes, and this is an expected part of their communication style. By teeing up an issue to several physicians, the peer-to-peer discussions give the company a better analysis than if we hired a single specialist to take a look at something. And, it’s interesting to see that dynamic at work.

What’s the best way to garner such input from physicians?

It’s important to speak to physicians using their language. If the goal of a project is cost-efficiency with either the same or better clinical care, the way to engage physicians is with clinical language. They will engage in the financial discussion if you first look at the clinical picture. They need to believe that the device—or the procedure or process—will improve the quality of patient care or at least won’t degrade it.

Supply chain professionals might want to find a few physicians who could coach them on how to put a topic on the table in a way that resonates with other physicians. Every hospital has some physicians who are especially wonderful communicators and congenial people. Find one or two who see the big picture quickly, would like to lead and can help frame discussions in a way that resonates with fellow colleagues. Ask, and I think you’ll be pleased with their response.

“By teeing up an issue to several physicians, the peer-to-peer discussions give the company a better analysis than if we hired a single specialist to take a look at something.”

If you start with a focus of, “I’ve come up with six ways to cut a million dollars out of our budget,” physicians may not be interested. However, if you start with, “I’ve come up with six steps that I think will improve or maintain the quality of our care, and allow us to be more efficient—and I would value your input,” they’re generally game to discuss it. They have to believe that the issue at hand won’t degrade patient care quality before they will engage.

How are your facilities instituting quality metrics to support the shift toward value-based purchasing?

CHS-affiliated hospitals track many quality metrics. Some are already being used in Medicare’s Value Based Purchasing program; with others, leadership uses them to track and improve other aspects of quality of care. There are many categories of these measures—clinical process of care measures (e.g., did the patient with a heart attack receive an aspirin?), outcomes measures (readmissions, mortality, hospital-acquired complications, the patient’s experience), and structural measures (are we meeting The Joint Commission’s requirements regarding our facility?).

Many of these metrics are publicly reported on the Medicare website, and some are used in payment differentials. While each hospital has its own quality improvement activities, there are programs that we feel are so important, we launch them across all hospitals. Our “Community Cares” program, assisted by the Studer Group, has been in place for a handful of years. We are seeing many improvements as a result of this program—because of the focus on creating great places for employees to work, physicians to practice medicine and patients to receive care. Hospital employees are engaged—90 percent of them answered their facility’s annual survey, and 85 percent are satisfied/very satisfied. Likewise with affiliated physicians—in the annual survey, 89 percent of them are satisfied/very satisfied with the hospital.

We are happy to see these results improving each year, and leadership is continuously focused on the on-the-ground improvements that make them happen.

What impact will new delivery care models like ACOs or bundled payments have on your organization?

Our leadership is tracking and studying what is happening with early ACOs and believes these models will change and mature. Our approach is to work on building the infrastructure that one needs to succeed in the evolving environment, regardless of the final details. This infrastructure includes working to network hospitals with each other, to develop true partnership and integration between the hospitals and their affiliated physicians, and to continue to demonstrate superior quality. And, our strategic alliance with Cleveland Clinic is very exciting. We are already learning from each other, and the work we are doing to enhance quality provides another piece of the infrastructure I am describing. We believe we are pulling together the right pieces to meet future methods of payment.

What keeps you up at night?

I sleep very well! Seriously, practicing physicians today are dealing with stresses unlike any other that we have seen in our lifetimes. There are many demands that take them away from direct patient care. Besides being accountable for the experience and clinical quality of patient care, they’re being asked to be responsible for complex reporting and coding, implement electronic health records, publicly report quality measurements, manage online reputations and websites, respond to increasing numbers of payer audits, and navigate through the changes coming under healthcare reform. Those practicing physicians are likely the ones having trouble sleeping.

Administrators and supply chain professionals who find ways to remove barriers—and provide the kinds of resources and support that help physicians with a more stable and efficient place to practice medicine—will in fact find the kinds of physician partners they need.

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