SOMOS Community Care serves 1 million Medicare and Medicaid beneficiaries in New York City.
For the past decade, SOMOS Community Carehas risen to the challenges of serving thousands of Medicare and Medicaid beneficiaries in New York City.
For healthcare providers, Medicare beneficiaries pose challenges including multiple chronic conditions. Serving Medicaid beneficiaries can be equally challenging, with relatively low reimbursement rates.
One of the most important factors that has led to SOMOS's success in serving Medicare and Medicaid patients is the way that the physician network has built a Social Care Network model to serve 1 million Medicaid and Medicare patients in predominantly Latino and Asian American communities across New York City, says Chief Medical Officer Yomaris Peña, MD.
"When patients visit one of SOMOS' 2,500 providers, we don't just address their conditions or health at face value," she says. "SOMOS providers pay special attention to social determinants of health, including housing conditions, nutrition, socio-economic status, language barriers, and immigration status, and we connect them to resources to help them mitigate the effects of these factors on their health."
When SOMOS providers work with their patients, they fundamentally understand patient concerns, Peña says.
"When a patient needs to change their diet, SOMOS providers help the patient alter their nutrition without losing their traditional foods," she says. "When a patient needs exercise, providers tell them about the free pool in their neighborhood. When a patient is hesitant to talk about their mental health, providers screen at every appointment and come to them from a place of understanding to help them work through culturally prominent stigmas. We have family offices, embedded in the neighborhoods and communities that they serve, with open-door policies and welcoming atmospheres."
SOMOS has a Social Care Network with a focus on addressing health inequities as well as providing solutions for a broad array of social care needs for those who are chronically sick, hardest to reach, and persistently overlooked, Peña says.
"To break down these systemic inequities and fully address whole-person health needs with a preventative focus, SOMOS engages in community-based public health engagement and education with a trusted workforce that is part of the fabric of the community," she says. "SOMOS establishes partnerships with community-based organizations for the provision of comprehensive social assistance for community members including housing and food assistance."
SOMOS has embraced value-based care to rise to the financial challenges of serving Medicare and Medicaid beneficiaries. SOMOS was founded in 2014 as the only physician-led Performing Provider System in New York State's Delivery System Reform Incentive Payment (DSRIP) program. Advanced value-based care models mean building stronger preventative care services, mental health screenings, and addressing issues such as nutrition and housing so patients have better long-term outcomes, Peña says.
"SOMOS has demonstrated that advanced value-based care models intertwined with culturally competent healthcare is the most efficient way to improve patient outcomes for the Medicaid population, all while saving New York State tax revenue over the course of the five-year DSRIP timeframe," she says. "We have also successfully implemented our accountable care organization model for a decade, ensuring our Medicare population is taken care of and not overlooked."
Culturally competent care is a cornerstone of the SOMOS model of care, Peña says.
"SOMOS's approach to connecting with patients in their own language and shared cultural context has been proven to decrease healthcare costs and to reach New York's goal of reducing hospital admissions and readmissions," she says. "When our patients walk into the waiting room and the exam room, they feel understood, welcomed, and like they can fully express their concerns in the way they are most comfortable. Culturally competent care can be as simple as a doctor advising patients on their carbohydrate intake, for instance, recommending a Dominican patient to limit their plantain intake or suggesting a Mexican patient to reduce their tortilla intake. At its core, it's about truly understanding the patient and meeting them where they are, in a way that builds trust."
Healthcare has reached one of the most challenging inflection points in more than 100 years, Donald Yealy says. And that requires new ways of addressing challenges.
Donald Yealy, MD, chief medical officer and senior vice president of the health services division at University of Pittsburgh Medical Center (UPMC), says 2024 is a challenging year for CMOs.
Yealy says the top challenges include change management, improving healthcare access, and learning from the coronavirus pandemic to prepare for the next existential threat to healthcare.
1. Change management
Yealy says healthcare has reached one of the most challenging inflection points in more than 100 years because of three factors.
The push for consumerism in healthcare that began several years ago is now "unassailable," he says. People seeking healthcare want and will have a much more dominant voice in what that healthcare is and how it is assessed to be helpful or not helpful. In the past, there was much more trust in how, when, and where to get healthcare on the professional side. Now, healthcare is more of a partnership or driven by individual people seeking care. Their expectations and desires have become more important.
Healthcare economics are changing dramatically, he says. Patients want all of the goodness and availability of healthcare, but they want healthcare in a manner that fits their ability to access it from a financial perspective. Decades of growth in expenditures on healthcare are likely over, Yealy says.
There is not a single human endeavor that has continued for an extended period of time without an ability to adapt to new demands and find new ways to do things better, and healthcare is not an exception, he says.
When you put these three factors together coming off a once-in-a-lifetime pandemic, there is tremendous pressure for change, Yealy says.
"As a CMO, I have to get people to understand the need to change, what the change is, and the tools to achieve change," he says. "That is not easy, and change needs to happen in a compressed timeframe. Up until this year, we would think about change in the months-to-years horizon, but healthcare providers do not have months to years to figure this out. We must get better much more quickly, and better in a way that not only we feel is better but also the people we are serving feels is better."
Health systems and hospitals need to take a hard look at what they do and do not do well, Yealy says. Then they need to be willing to let go of things that do not serve the people who come to them for care well.
"You must have the insight as well as the ability and the discipline to change," he says. "The ability to change is not going to just involve new tools such as artificial intelligence, new diagnostic devices, and molecular personalized medicine. All of those are tools to do the job better, but we need to get our individual providers such as physicians, nurses, and advanced practice providers to embrace them in a much quicker fashion."
During the pandemic, the vaccine program was a great example of how the healthcare sector developed something from the best available data and had it up and running within a year rather than decades.
"This is the model for change—having an idea, testing it quickly, then getting it out to the people we serve," Yealy says.
Donald Yealy, MD, chief medical officer and senior vice president of the health services division at University of Pittsburgh Medical Center (UPMC). Photo courtesy of UPMC.
2. Improving healthcare access
Healthcare providers must recognize the needs of people seeking care and meet them in ways that are most comfortable and efficient for them, Yealy says.
"For older patients who seek care, the traditional approach of coming to a hospital or physician's office is probably still OK," he says. "But for other patients who are younger or face barriers to coming to a healthcare setting, we need to think about all of the different platforms that we can use. It could be through a smartphone or regional locations. We need to make healthcare accessible to everybody, whether they are in a big city or rural area."
While providers can use technology ,such as smartphones and other deployed devices, to reach patients, health systems and hospitals need to look at ways to build care opportunities that are nearby and accessible to people who have a healthcare need, he says.
"There are different ways we can construct our use of healthcare providers and healthcare locations, whether they are formal bricks-and-mortar facilities or something else," Yealy says. "It will be a combination of virtual and electronic methods as well as a different type of footprint for bricks-and-mortar locations."
Health systems must push ahead with a bricks-and-mortar strategy that goes beyond traditional hospitals, he says.
"We need to deploy more micro hospitals, urgent care centers, and other outpatient settings that have a different footprint than we have been used to for decades," he says. "These facilities need to be embedded in communities and to serve basic and acute needs while being connected to other parts of the healthcare delivery system to ensure ongoing wellness."
3. Learning from the pandemic
The healthcare system is on the tail end of the pandemic, Yealy says, and CMOs need to lead the charge to determine what has been learned from the crisis to be ready for the next threat. Providers need to look at the opportunities that were fumbled away during the pandemic, as well as the successes and failures at several levels: individual sites of care, health systems, states, and the nation.
"While we are doing some of this work, it is not well coordinated, he says. "For example, the communication during the pandemic left a lot to be desired. There has been a degradation in the public trust in the government and healthcare providers because people feel that they did not get straight or consistent answers. We need to concentrate on communicating better."
With messaging, people need clarity about a health threat and what their response to the threat should be, he says, while providers need to embrace the fact that a new threat may not be completely understood.
"Substituting a clear message for a truthful message is a dangerous thing," Yealy says. "We can say things that are dramatic and elicit behavioral changes, but if what we say ends up not being true, it is hard to get trust back. We learned from the pandemic that we should not substitute simplistic clarity for truthfulness in our messaging—they both must be present, not one or the other."
The industry learned some hard lessons with regard to the supply chain, he says. For years, health systems and hospitals honed the supply chain to have what was needed immediately available at the best possible price, but not enough thought went into what happens during a disruption in the supply chain.
"At the beginning of the pandemic, there were shortages of personal protective equipment such as masks and gowns; we learned a lesson from that," Yealy says. "Before the pandemic, we thought we managed PPE well because we only had what we needed. We found out that need can change dramatically, and the supply can change as well."
The report, which was published by the New Jersey Health Care Quality Institute, was authored by more than a dozen experts.
A recently published report raises alarm about a primary care physician shortage in New Jersey and calls for the adoption of advanced primary care in The Garden State.
There is a shortage of primary care physicians across the country. The recent report shows that the shortage is not limited to rural areas.
A co-author of the report, which was published by the New Jersey Health Care Quality Institute, says the primary care physician shortage is widespread in New Jersey.
"All of New Jersey has had a shortage of primary care physicians, particularly family physicians and general internists. The report focuses on adult medicine, where we have the biggest shortage of primary care physicians," says Mary Campagnolo, MD, MBA, medical director of value-based programs and payer contracts at Virtua Health's Virtua Medical Group, a board member of the New Jersey Health Care Quality Institute, and a primary care physician.
She cited data from the American Board of Family Medicine, which tracks how many family physicians there are in the states for every 100,000-resident population. "New Jersey and Connecticut have the lowest concentration of family physicians at about 17 per 100,000. Many other states have 50 family physicians per 100,000 of population, so we are understaffed," Campagnolo says.
RWJBarnabas Health, New Jersey's largest integrated healthcare delivery system, is experiencing a shortage of primary care physicians, says Andy Anderson, MD, MBA, chief medical and chief quality officer at the health system.
"Currently, we are actively recruiting between 30 and 40 open positions for primary care physicians," he says. "Over the past five years, we have been trying to recruit the primary care workforce that we need for the future."
One of the main drivers of the primary care physician shortage in New Jersey is low reimbursement rates, the report says. "New Jersey's primary care spending as a percent of total health spending is one of the lowest in the country. … Fee-for-service payment rates for primary care are also low compared to other states. N.J. Medicaid pays primary care rates that are only about 50% of Medicare rates. Commercial primary care payment rates in New Jersey are on average 93% of Medicare rates compared with the U.S. average of 120% of Medicare," the report says.
Reimbursement rates for primary care physicians are problematic in New Jersey and at the national level, Anderson says.
"It has gotten a little bit better over the past five years—there has been an incremental increase in reimbursement for primary care, but it is not at the level it needs to be to influence physicians to go into primary care and to build out the workforce that we need for the future," he says.
The low reimbursement rates drive many primary care physicians who are trained in New Jersey to move to other states. Virtua Health works to provide competitive salaries and benefits to retain primary care physician trainees, Campagnolo says.
"We regularly assess the market rates in the Delaware Valley," she says. "Then we try to pay the median salary or higher. That helps to attract and retain primary care physicians. We have a good benefits package that is not always available to primary care physicians in private practices. We have good medical insurance coverage. We have a good retirement account. These strategies have helped us retain our trainees."
RWJBarnabas has pursued multiple strategies to retain its primary care physician trainees, Anderson says.
"We are trying to retain trainees through financial incentives and through partnerships with high-performing practices," he says. "We also have a model called the patient-centered medical home. In that model, the physician is the captain of the ship, but there are other health professionals in the model such as social workers, nutritionists, dieticians, and nurses who are part of providing a comprehensive environment for patient care. That type of a model is attractive for physicians because it is a team-based model."
Campagnolo says chief medical officers in New Jersey and across the country should be concerned about primary care physician shortages.
"If you are the chief medical officer of a health system that has multiple services, the referral source for those services is the primary care physicians. So, if you do not have primary care physicians, you do not have the ability to get patients to any of the other services," she says.
Promoting advanced primary care
The report calls for support of advanced primary care in New Jersey.
The National Academies of Sciences, Engineering, and Medicine (NASEM) define advanced primary care as integrated, accessible, and equitable healthcare provided by interprofessional teams that are focused on most of the health and wellness needs of individuals. Advanced primary care includes preventive care, management of chronic conditions, and a longitudinal perspective on patient health and well-being.
Anderson says RWJBarnabas' patient-centered medical home model for primary care is similar to the advanced primary care approach.
"We are practicing advanced primary care in the patient-centered medical home model of care," he says. "We have a team-based approach to primary care. We have physicians working with other health professionals to provide services focused on prevention, wellness, and chronic disease management. It is a good model in terms of providing better access, better support services, and better continuity for patients. It also provides more expertise in the primary care setting because everyone is working to the top of their license. For example, if you have a dietary expert, they really understand the field and can counsel patients at a high level."
The report makes three recommendations to support advanced primary care in New Jersey:
The state should raise Medicaid FFS primary care payment rates to the level of Medicare and it should direct Medicaid managed care organizations to also pay Medicare rates for primary care.
The state should take an active role in developing and encouraging advanced primary care in New Jersey.
The state should report annually on primary care spending as a percent of total healthcare spending and on the use of alternative payment models that promote value-based care.
To streamline the admissions process for emergency department patients, Tufts Medical Center is using a clinical communication and collaboration platform to improve teamwork between physicians and the hospital's Center of Patient Placement.
Tufts Medicine has focused on improving communication between clinicians and between care teams to increase hospital patient throughput.
Hospital patient throughput is a key metric for hospitals. Weak throughput can lead to boarding in emergency departments and patient safety concerns such as hospital-acquired infections when patient lengths of stay are extended beyond medical necessity.
Patient throughput is a major concern for chief medical officers and other clinical leaders, says Michael Davis, MD, associate chief medical information officer at Tufts Medicine and an internal medicine hospitalist at Tufts Medical Center.
"A big part of the chief medical officer's role is patient safety and quality care," he says. "So, when you have overcrowding of the ED or hospital units, you run the risk of compromising the quality of care you provide to patients, and you run the risk of patient safety events happening such as hospital-acquired infections. If we can streamline patient throughput across the hospital encounter, you are going to avoid the mismatch of supply and demand for beds. Ultimately, across the board, boosting patient throughput should have a beneficial effect on patient safety."
Tufts Medical Center has been concentrating on eliminating waste in the admissions process—specifically eliminating "phone tag" between essential players in the hospital, Davis says. The hospital has targeted an inefficient process for admitting patients from the emergency department.
"In the past, the ED physician was trying to call the medicine provider, the ED physician was trying to talk with the Center for Patient Placement, and the Center for Patient Placement was trying to reach out to the medicine provider," he says.
About a year ago, Tufts Medical Center started to use TigerConnect, a clinical communication and collaboration platform that provides communication on smartphones and desktop computers, to boost teamwork between ED physicians, the Center of Patient Placement, and the medicine physicians who are admitting patients, Davis says.
"Instead of trying to arrange separate conversations, the ED physicians can go into TigerConnect, activate the admissions team, then you have a group conversation on a single thread about the patient," he says. "That has streamlined communication for the admissions process. This is important for us because we are sensitive to overcrowding in the ED—we want to get our admitted patients out of the ED as quickly as possible and up to the medicine floors."
In addition to improving the efficiency of the admissions process, Tufts Medical Center has been using the clinical communication and collaboration platform to improve patient throughput in operating rooms.
The hospital analyzed the patient life cycle of going through the OR, where patients check in, go into preop, have the procedure, then go into postop. They found that process required many different phone calls to be made to all of the people needed to coordinate getting the OR ready and getting the physicians and anesthesiologists to come in to perform the procedure, Davis says.
"There was a lot of waste in that communication process, which contributed to decreased rates of the first case on-time starts for OR cases," he says. "We leveraged an integration between our electronic medical record and TigerConnect. When the OR staff is documenting in the EMR, there are automatic notifications that are sent to TigerConnect alerting the multidisciplinary OR staff about milestones that prompt them to come into the OR. We were able to eliminate wasteful phone calls, without adding any new work for the OR staff."
Combined with internal efforts by the hospital's perioperative team, including a staggered OR start time pilot, the first case on-time start rate has increased by about 70%, Davis says.
To make sure patient discharges are not delayed because of difficulties placing patients at post-acute facilities, Tufts Medical Center relies on case managers to work closely with the hospital's post-acute partners, Davis says.
"The case managers need to know from the medical team when the patient is medically ready for discharge," he says. "There is a lot of communication going on between the physicians and the case managers throughout a patient's entire hospital encounter. A physician may interact with several case managers on different floors, so you must rely on efficient, on-the-go digital communication."
A proposed regulatory strategy for artificial intelligence in healthcare settings is compared to regulatory standards for new drugs.
A trio of experts is proposing companies that produce artificial intelligence (AI) tools in healthcare should be regulated based on their ability to achieve benefits in patient outcomes.
Last year, President Joe Biden issued an executive order to set guidelines for AI policy. The executive order established the U.S. Health and Human Services Department as the lead agency in setting AI policy, including a directive for the agency to set up a task force to create a plan for responsible AI use.
In a recent Viewpoint article published by JAMA, three experts from the University of California San Diego argue that AI in healthcare should be regulated based on the ability of AI tools to generate positive changes in patient outcomes.
"We believe AI regulatory assessments should be grounded in clinical evidence regarding how patients feel, function, or survive in rigorously designed studies, such as randomized clinical trials, which is consistent with regulatory standards applied to new drugs that also require a net clinically meaningful improvement in patient outcomes compared with a placebo," the experts wrote.
Healthcare regulators already have the ability to draft rules based on clinical outcomes, the experts wrote.
"For instance, electronic health records require federal certification under the Health Information Technology for Economic and Clinical Health Act," the experts wrote. "Rule makers can use this avenue to require that any AI tools seeking to integrate or embed within an electronic health record be evaluated with clinical end points. With the clear goal of accessing the healthcare marketplace under regulatory approval, many companies and health centers may be given appropriate incentive to register trials that evaluate the potential of AI tools to improve patient outcomes. This regulatory approach ensures that AI technology is deployed primarily for the benefit of patients. Otherwise, industry may focus on revenue-generating opportunities and not patient outcomes."
AI tools improving patient outcomes
The top clinical leaders at Allegheny Health Network (AHN) and Providence say their health systems are using AI tools that have a positive impact on patient outcomes.
The primary area where AHN is using AI tools to impact patient outcomes is AI technology linked to the health system's electronic medical record, Epic, says Donald Whiting, MD, chief medical officer of AHN and president of Allegheny Clinic.
"We are using AI to look for sepsis risk, look for ICU readmission risk, and predict length of stay," he says. "So, we are using AI to scour the medical record to look for predictors of things where we can intervene."
AHN is also using an AI tool that uses 3D imaging to scan for skin abnormalities, Whiting says.
"This improves skin cancer screenings, and we are using this technology in primary care offices so they can screen patients instead of them having to go to a dermatology office," he says. "The AI compares the images to a set of images in a database for cancer diagnoses and creates a score to quantify risk to determine whether the patient needs to go to a dermatologist or skin cancer expert for further evaluation."
Hoda Asmar, MD, MBA, executive vice president and system chief clinical officer at Providence, says the health system has been making strides to improve patient care and boost efficiency for clinicians. "There is incredible potential for AI to transform the healthcare space, and I'm encouraged by the positive impact we have seen so far at Providence," she says.
One AI tool being utilized at Providence that is improving clinical outcomes for patients is Trial Connect, which is using AI to match patients with more than 2,500 ongoing research trials.
Clinical leader perspective on healthcare AI regulation
Asmar says it is a good idea to regulate healthcare AI tools based on their ability to drive positive patient outcomes.
"It is going to be critical to have a balanced approach toward AI in healthcare where ethical and governance standards are established not to stifle progress but to make sure we are prioritizing the positive impact on patient outcomes," she says. "Providence is committed to developing and deploying AI in ways that best serve and support our clinicians, positively impact patient outcomes, and provide the means to help us give more access to our communities, especially the poor and vulnerable."
Regulating healthcare AI tools is a necessary step in the development of this technology, Whiting says. "There is a fear of anything new, especially something like AI that has potentially unlimited capabilities. Finding the right utilization of AI intelligently and establishing the right guardrails is going to be important."
Insurers or their vendors are charging physician practices and hospitals fees ranging from 2% to 5% of claims payments for electronic funds transfer transactions.
One of the sponsors of legislation that would end fees for healthcare providers' electronic funds transfer (EFT) transactions from insurers is optimistic about the bill's passage.
In November, the No Fees for EFTs Act (H.R. 6487) was introduced in the U.S. House of Representatives. For years, health insurers and their vendors have been charging physician practices and hospitals fees ranging from 2% to 5% of claims payments in EFT transactions.
The legislation was introduced by U.S. Reps. Greg Murphy, MD, (R-NC), Morgan Griffith (R-VA), Marianette Miller-Meeks, MD (R-IA), Ami Bera, MD (D-CA), Kim Schrier, MD (D-WA), and Derek Kilmer (D-WA).
Rep. Murphy says he expects the legislation to be adopted by the House and the U.S. Senate. "I am optimistic about this legislation passing. There is definitely bipartisan support in the House, and it should pass in the Senate."
The next step for the legislation is review in at least one House committee.
The Affordable Care Act mandated that insurance companies be able to provide an electronic payment for medical services by physicians, physician groups, and hospitals. Insurance companies have been charging EFT transaction fees for "value-added services" such as a customer service phone number.
Murphy says the fees are a "ridiculous charge."
"Some physician groups have been charged up to $1 million annually. It is just absolutely absurd. You shouldn't have to pay a fee to get your own money," he says.
The American Medical Association (AMA) helped draft the No Fees for EFTs Act. The AMA says the EFT fees are equivalent to an employer charging a fee for providing employees with electronic direct deposit payments for compensation.
AMA President Jesse Ehrenfeld, MD, MPH, says the EFT fees are an unnecessary burden for physician practices. "Insurers have slashed reimbursement rates, foisted prior authorization requirements on physicians, and created narrow networks. But requiring physicians to pay fees to get paid? This bill would give much needed relief to physician practices and score a victory for common sense," he said in a prepared statement.
Murphy says EFT fees are an existential threat for many physician practices and hospitals.
"I ran a surgical practice for many years. We had five surgeons in a poor area of the country, so our margins were very thin," he says. "If you add a surtax of 2% to 5% on an already thin margin, it further decreases your ability to survive financially. If you don't survive financially, you either close the doors or get acquired by a hospital, which is a more expensive site of care. These fees are a threat to keeping private practices and hospitals in business."
EFT payments were supposed to make claims payments easier, so healthcare providers did not have to process paper checks, which is burdensome and has the possibility of lost checks, the AMA says. The point of EFT transactions was saving money and improving efficiency for payment transactions in the healthcare system—it was not supposed to be a revenue-generator for anyone, the AMA says.
Private equity-backed management services organizations provide independent physician practices with business-savvy talent and access to capital, according to one practice leader who has taken that route.
Private equity-backed management services organizations (MSOs) are helping independent physician practices to remain independent.
Independent physician practices are declining, according to the American Medical Association (AMA). From 2012 to 2022, the proportion of physicians working in private practices fell from 60.1% to 46.7%, the AMA says. Over the same period, the proportion of physicians working in hospitals as employees or contractors rose from 5.6% to 9.6%.
"In 2017, we saw that there were other independent physician practices across the country that were joining these MSOs and we wondered whether we should, too," he says. "As we got further into the weeds, what became apparent to us as a physician-led organization is that joining an MSO would provide us with several abilities."
"We were thinking: How do we stay independent?” he adds. "How do we deliver quality care? How do we keep costs to the system low? And how do we make sure access to our services is expanding? That is what led us to join the GI Alliance."
An MSO serves as the business office of a medical practice, providing such business functions as billing, compliance, information technology, and accounting.
Private equity-backed MSOs provide two primary advantages for independent physician practices, Berggreen says.
Access to higher levels of business talent. "Back in the day, we all had office managers, and they were good at managing an office of five to 10 doctors," he says. "But to run the business functions of an MSO, you need to have people who have a lot of business skills. Even at Arizona Digestive Health, which has 50 doctors, we could not afford that type of talent. Joining the MSO gave us access to that type of talent."
Access to capital. For example, Berggreen says, a large oncology practice in Tennessee recognizes that many patients in rural counties have significant access issues getting to appointments. The oncologists joined an MSO with a private equity backer and used their new access to capital to open clinics in rural areas so their patients can access oncologists without having to make a one- or two-hour drive. The oncologists were able to identify where their rural patients are located, where it makes most sense to put a rural clinic, and how they’re going to staff the clinics with help from the MSO.
With access to business talent and capital that private equity-backed MSOs provide, independent practices can remain independent with few strings attached, Berggreen says.
"At AIMPA, we look at private equity-backed MSOs as part of independent physician practices remaining independent," he says. "But we look at that as a neutral financing mechanism. In this case, private equity firms do not own medical practices. So the clinical decision-making stays separate from the business functions of a practice. The whole concept of these kinds of MSOs is that the business functions remain separate from the clinical operations, and any clinical decision-making remains with the physicians."
Arizona Digestive Health is physician-owned and -led. The CEO, chief medical officer, and chief development officer are all gastroenterologists. The practice's physicians have oversight and direction on every decision that is made without interference from the MSO, Berggreen says.
"With these private equity-backed MSOs, there is no ability for a private equity firm to make decisions or force physicians to do anything from a clinical standpoint," he says.
Prospects for private equity-backed MSOs
Berggreen says the private equity-backed MSO model for independent physician practices is a national trend.
"In 2010, you saw very few of these arrangements," he says. "In recent years, you have been seeing more and more of these arrangements because independent practices love autonomy."
"If there are concerns about getting involved with a private equity firm, the solution is for physicians to stay involved," he adds. "You need to make sure that physicians have an active role in the everyday management of the practice. You need to make sure that physicians are insisting that quality, cost, and access remain the three most important things that inform your business decisions."
Several studies have recently reported that private equity has a negative impact in the healthcare sector. For example, a December 2023 article published by JAMA found that private equity acquisition of hospitals was associated with a 25.4% increase in hospital-acquired conditions, such as falls and central line–associated bloodstream infections.
Private equity-backed MSOs that work with independent practices are an example of how private equity can have a positive impact on healthcare, Berggreen counters.
"There are many examples, such as the Tennessee oncologists, that show private equity-backed MSOs can have a positive impact when physician practices remain independent but have the operational and financial firepower of a well-tuned MSO," he says. "You are going to see more stories and research that show what private equity-backed MSOs can accomplish."
"This model is not that old," he adds. "Most independent practices have joined these MSOs in the past five years. I expect that we are going to see positive data on what we can accomplish with these MSOs."
Patient experience is linked to reimbursement, patient safety, and clinical outcomes.
Executives at a pair of healthcare organizations that earned Pressy Ganey patient experience awards say that following best practices has allowed their institutions to excel in patient experience.
Patient experience is a key performance indicator for health systems and hospitals. It's tied to reimbursement from the Centers for Medicare & Medicaid Services, and it is linked to patient safety and clinical outcomes.
Press Ganey recently announced the winners of their 2023 Pinnacle of Excellence Award for patient experience. The award recognizes health systems, hospitals, and other healthcare providers that demonstrate top performance in patient experience for three years. Nearly 100 organizations earned the honor in 2023.
Executives at two of the award winners, Hoag Orthopedic Institute in California and Dartmouth Health in New Hampshire, recently shared the primary elements of their patient experience success with HealthLeaders.
Steven Barnett, MD, chief medical officer of Hoag Orthopedic Institute, says patient experience needs to be a top concern for CMOs, other top executives, and physicians at hospitals.
"Patient experience reflects on all of us in our practice at the hospital," he says. "All of the doctors at the hospital work in private practice, and the experience our patients have in episodes of care, whether it is a joint replacement surgery, knee ligament reconstruction, or a spinal decompression, directly reflects on us and our practice. As CMO, patient experience is critical to my career."
Brant Oliver, PhD, MS, MPH, system vice president for care experience at The Value Institute at Dartmouth Health and associate professor at Dartmouth College's Geisel School Medicine, says there are three reasons why CMOs should be concerned about patient experience.
"First is the bottom line," he says. "About 12.5% of CMS reimbursement is predicated on patient experience performance. The better we do on patient experience, the better the bottom line will be."
“Secondly," he says, "the better we do on patient experience, the better workforce engagement will be. Working on patient experience can make working as a healthcare professional better. Thirdly, patient experience is connected to quality and safety outcomes. Evidence shows that as safety improves, so does quality and patient experience."
Patient experience best practices
At Hoag Orthopedic Institute, Barnett says, there are seven key components of patient experience at the hospital and the organization's ambulatory surgery centers.
Ensuring that patient navigation through the episode of care, from pre-surgery to surgery to post-op to discharge, is easy and seamless.
Educating patients before surgery to set realistic expectations about care and outcomes. Patients should not be surprised by anything during the episode of care.
Whether it is phone calls or office visits, follow-up is part of the episode of care, and care teams want to make sure patients are achieving what they are expected to achieve.
Staffing with dedicated and competent clinical care professionals is critical. The institute has been successful in maintaining high nurse-to-patient ratios, which promotes responsiveness in care settings.
Offering patient engagement tools and applications that patients can use throughout their care. These resources are easy to access, so any questions that patients have that can't be answered by someone on the phone can be addressed through the tools and applications.
Ensuring the hospital is clean and well-maintained.
Scheduling monthly meetings of the patient experience committee to discuss opportunities for improvement at the hospital and ambulatory surgery centers.
Oliver says there are several important facets of patient experience at Dartmouth Health.
"Effective communication between patients, families, and healthcare professionals is critical," he says. "Another critical area is access. Patients need to able to get access to what they need when they need it in a way that works well for them. Access can mean not just getting in to see a provider but also being able to get a response back when you call in."
"Another part is recognizing feelings and preferences," he adds. "Oftentimes in healthcare, we focus on the right service, the right medication, or the right diagnostic work, and those things are important. But if we do not know the patient's preferences and what they value most, we will miss the target in trying to help them. There also must be a respect for diversity, culture, and different backgrounds. Different people from different cultures have different expectations and different healthcare needs."
"They are frontline-oriented, meaning that if there are issues or concerns about care experience, the frontline people work to address those issues or concerns rapidly," he says. "There is also a high degree of senior leadership empowerment and engagement for patient experience activities. For example, at New London Hospital, the CEO goes on rounding with the patient relations and patient experience manager to speak with patients directly. This may seem like a small thing, but it empowers care experience actions at that site."
Avoid patient experience pitfalls
Barnett and Oliver say there are ways to avoid detracting from patient experience.
"It is important to hire the right people," Barnett says. "People who are not engaged in patient experience do not get hired at Hoag Orthopedic Institute. Patients tell us that our staff is the most caring and friendly staff they have ever experienced at a hospital. You also should never tell patients that you are too busy to do something."
Patient experience should not be approached as a matter of only amenities, Oliver says.
"Like many other fields, patient experience has evolved over time and in some health systems it is positioned as part of a communications department, HR department, or marketing department," he says. "In these health systems, patient experience efforts may be focused on improving the food in the cafeteria or having better televisions in patient rooms. Those things are helpful, but they do not target the main drivers of experience such as trust, confidence, communication, and responsiveness. So, one pitfall is to go after 'shiny things' rather than the practices that we need to focus on to optimize the care experience."
Another main patient experience pitfall is the belief that focusing just on doing the right technical things will provide a good experience, Oliver says.
"Technical prowess is necessary but not sufficient," he says. "It is critical to communicate well with people in addition to doing the right technical things in clinical encounters. It is also critical to focus on the things that are important to patients and families as opposed to the things in guidelines that we have to do."
Team-based care has many benefits for patients and healthcare providers.
Health systems and hospitals should be doubling down on team-based care, a pair of chief medical officers say.
In a recent position paper, the American College of Physicians stressed the importance of physician-led care teams. Team-based care models have been linked to good patient health outcomes and better healthcare-professional collaboration.
Healthcare has reached a level of complexity that calls for a team-based approach to care, says Brad Archer, MD, CMO of Monument Health.
"The complexity of navigating an increasingly technologically advanced medical system requires more than an individual physician or traditional doctor-nurse team can provide," he says.
Team-based care takes the doctor-nurse dyad to the next level, effectively engaging a variety of healthcare professionals, including advanced practice providers, social workers, clinical pharmacists, therapists, and back-office staff, says William Agel, MD, MPH, CMO of Cape Cod Hospital and Cape Cod Healthcare.
"Healthcare is the ultimate team sport," he says. "There are many benefits of team-based care. For the patient, they get the broad and deep talents of a group of professionals working together to get them well and keep them well. For providers, team-based care allows for the distribution of tasks and complementary skillsets that reduces administrative burdens, lowers burnout rates, and improves job satisfaction as everyone works at the top of their licenses."
CMOs need to be focused on team-based care, Archer says.
"Ultimately, CMOs are charged with allocating increasingly scarce resources for patients over increasingly more complex technological offerings," Archer says. "We have talked for years about providing the right care to the right patient at the right time. In most cases, there is no individual who has the capacity and the breadth of knowledge to focus holistically on patients. So the CMO must rely on teams to provide care."
Care team leadership
In most cases, care teams should be physician-led, Archer and Agel say.
That's the case at Monument Health. The health system participates in a Medicare accountable care organization and other value-based care arrangements, which use attribution to physicians for looking at data, so physician-led care teams make sense, Archer says.
Physician-led care teams also fit well with patients' perceptions of who is in charge of their healthcare, he says.
"Ultimately, we want a captain of the ship in place to help guide care, and physicians are well-suited to that role," Archer says. "The coordination of care needs prioritization. Physicians are the best trained healthcare professionals to be able to know how to prioritize care coordination needs."
Care teams should be led by the individual most qualified to attain a positive outcome for the patient, Agel says.
"In most cases, that is going to be a physician, who is the person with the most training and the most authority to diagnose and treat a problem," he says.
There are circumstances where a nurse or an advanced practice provider, such as a nurse practitioner or physician assistant, can take on the responsibility of leading a care team, Archer and Agel say.
"For nurse practitioners or physician assistants to lead care teams, there needs to be clear and concise guidelines," Archer says. "You should also have a patient population that has been pre-selected. The goal should be to gain adherence to the guidelines for the betterment of the patient's health. Those situations lend themselves well to having advanced practice providers leading teams. However, when there is diagnostic uncertainty or multiple problems that are contributing to a patient's overall health, it is best to have a physician leading the care team."
An advanced practice provider or nurse may have a particular area of expertise, such as coordinating the care of a patient or navigating a patient's experience through diagnosis, that makes them good candidates to lead a care team, Agel says.
"An advanced practice provider may know the patient perfectly well in the primary care setting and know the patient better than the physician does," he says. "In that case, the advanced practice provider is probably better able to guide the care of the patient, with the help of every member of the team including the physician."
Team-based care at Monument Health and Cape Cod Healthcare
The approach to team-based care at Monument Health is focused on three principles, Archer says.
The health system has embraced a culture of team-based care that is supported by participation in a Medicare accountable care organization as well as the need to manage the health system's own self-insured employee population.
Monument Health care teams define roles based on team members functioning at the top of their licenses.
Care teams address workflows and the needs of the patient outside of the care team. For example, care teams play a key role in addressing the social needs of patients and have a master list of resources that they can make available to patients.
Cape Cod Healthcare also deploys teams across the continuum of care, Agel says.
On the outpatient side, the health system's patients have a medical home in the primary care physician space that features a team-based approach to care. In another example, there is multidisciplinary care for cancer patients.
"On the inpatient side, our obstetricians and nurse midwives work side-by-side with our pediatricians, nurses, and social workers to provide wrap-around care and support for families," Agel says. "Our general cardiologists work with our interventional cardiologists, nurses, and advanced practice providers in a heart-team approach to optimize the care of our cardiac patients. Our surgeons, surgical subspecialists, emergency department staff, hospitalists, physical therapists, and nurses provide care for our trauma patients."
Deviating from physician credentialing best practices puts healthcare organizations at risk for claims of negligence.
Although physician credentialing may seem like a tedious administrative task, poor executions can result in serious consequences such as fines, delays in claim reimbursement, exclusion from federal programs, and harm to patients.
Credentialing lapses can expose healthcare organizations to malpractice suits and accreditation problems. Deviating from physician credentialing best practices—obtaining, assessing, and verifying a clinician's credentials—puts healthcare organizations at risk for claims of negligence.
Verisys, a SaaS platform specializing in provider data management, provider credentialing, and compliance, has identified eight common physician credentialing weaknesses.
1. Relying on limited staff and administration: Credentialing includes verifying a clinician's education, medical training, residency, licenses, and certifications issued by a board in the physician's area of specialty. Health systems or hospitals may not allocate adequate resources or staff to complete the medical credentialing process, which can result in lost revenue and overworked staff who are more likely to make mistakes.
2. Incomplete physician enrollment applications: The average physician enrollment application requires a vast amount of information and data. Failing to accurately fill out the application in its entirety causes delays in reimbursement and denial of claims.
3. Allowing physicians to treat patients before credentialing is completed: Courts have ruled that hospitals can be held liable when a physician falsifies credentials or begins practicing before credentialing has been completed.
4. Not updating and verifying information: Physicians need to renew their licenses and credentials on a regular basis, according to the laws of the state in which they practice. Initial credentialing and recredentialing ensures that physicians are up to date with their board certifications and licenses. When hospitals fail to stay on top of recredentialing, it could lead to physicians and facilities performing services they are not certified or licensed to perform, which can lead to malpractice lawsuits.
5. Covering up prior adverse action: Failing to disclose an adverse action is a serious oversight by any physician, but it is also the responsibility of a healthcare organization to conduct screenings for prior disciplinary actions with a thorough background check. Healthcare organizations should verify credentials against an array of databases such as the Office of Inspector General exclusion list.
6. Failing to report adverse actions: Physicians are required to report adverse actions such as license revocation; exclusion from third-party programs; and suspension or voluntary relinquishment of medical staff membership or clinical privileges. Healthcare organizations can be held accountable for a physician's omission.
7. Failing to report adverse actions to the National Practitioners Data Bank (NPDB): Physicians and healthcare organizations that fail to report adverse actions to the NPDB withhold critical information needed to complete medical credentialing. The NPDB requires reporting of the following actions: medical malpractice payments, federal and state licensure and certification actions, adverse clinical privileges actions, adverse professional society membership actions, negative actions or findings by private accreditation organizations and peer review organizations, healthcare-related criminal convictions and civil judgments, and exclusions from participation in a federal or state healthcare program such as Medicare and Medicaid exclusions.
8. Failing to take peer review activity seriously: Information provided in a peer review or investigation should be taken seriously and be evaluated as part of the credentialing process. Peer references can inform the capabilities and competencies of a physician that cannot be determined from simply checking education, training, or license status.
Chief medical officer perspective
Physician credentialing is an essential function at health systems and hospitals, and CMOs should be engaged in the process, says Andy Anderson, MD, MBA, executive vice president and chief medical and quality officer at RWJBarnabas Health.
"Having a rigorous process and procedure around physician credentialing ensures the highest levels of quality, safety, and service in the healthcare environment," he says. "The credentialing process is essentially a crosscheck on training and past work experience to support the granting of privileges to practice in specific areas in the healthcare setting. A CMO has to be someone who monitors, shepherds, and supports that process to ensure that the highest level of quality, safety, and service is attained."
RWJBarnabas ensures that the health system has adequate resources and staffing for physician credentialing, Anderson says.
"We maintain a staffing model that ensures the work gets done at the highest levels of service and quality," he says. "We monitor areas such as turnaround time, and we also get feedback directly from our physicians on the credentialing experience. We have a talented group of subject matter experts in our medical staff office who oversee the credentialing process. We make sure they are fully supported."
RWJBarnabas ensures that physician enrollment applications are complete and that credentialing information is updated and verified, Anderson says.
The health system has a software system that makes sure every element of the process is completed and all requirements are met, he says. Additionally, RWJBarnabas has a quality control process for physician credentialing that goes back and audits and crosschecks to make sure that everything is completed and accurate. The medical staff leadership reviews and approves applications once they are complete and accurate.
At RWJBarnabas, it is nearly impossible for physicians to treat patients before credentialing is complete, Anderson says. Physicians are not activated in the electronic health record to be able to practice until the credentialing process is completed and approved by the leadership of the medical staff, he says.
The health system takes great care in handling adverse actions such as license revocation as part of the credentialing process, Anderson says.
"Any issues such as a history of license revocation are taken into full consideration as part of the assessment of an application to our medical staff," he says. "For physicians who are already on the medical staff, we follow all state laws and regulations, and we report all adverse actions to the New Jersey licensing boards. We take these issues seriously. We also want to be fair with the physicians; but in the end, we must protect our patients and the public."
Peer review as part of the physician credentialing process is also taken seriously. Anderson says.
If there is an issue that has been raised about a patient care case, typically a hospital CMO will conduct fact-finding and determine whether a peer review is necessary, he says. An independent peer is brought in to look at the patient care case and provide unbiased input, so the health system can understand why the physician chose to behave in a certain way. If a patient care case raises serious issues, it can adversely affect a physician's credentialing, he says.
Donald Yealy, MD, chief medical officer and senior vice president of the health services division at University of Pittsburgh Medical Center (UPMC). Photo courtesy of UPMC.
