The Exec: Physician Groups Should Have a Clear Mission

Clarity is crucial to the success of medical groups, the chief medical officer of Monument Health says.

Physician groups should have a clear definition of who they are, says Brad Archer, MD, chief medical officer of Rapid City, South Dakota-based Monument Health.

Archer has been CMO of Monument Health since September 2017. Prior to joining Monument Health, he was chief clinical officer at University of Iowa Health Alliance. His prior experience includes serving as executive medical director of MercyCare Community Physicians.

HealthLeaders recently talked with Archer about a range of topics, including the challenges of serving as CMO of Monument Health, physician group leadership, and value-based care. The following transcript of that conversation has been lightly edited for clarity and brevity.

HealthLeaders: What are the primary challenges of serving as CMO of Monument Health?

Brad Archer: Initially, going back about six years ago when I got here, the biggest challenge was the lack of structure, which led to a lack of engagement from the physician staff. So, we have focused on building our culture starting with building a consistent structure that sought to generate physician input on a regular basis as opposed to an ad hoc basis. We worked on the leadership infrastructure.

We have also created an atmosphere of psychological safety and transparency in terms of error reporting and process improvement.

Our geography is a challenge. We have a large region to cover without any other population centers nearby. There are no other hospitals or health systems to share some of the responsibility that comes with our geography. Our healthcare partners are in places such as Sioux Falls, Billings Clinic, and Denver, which are quite distant from us, so one of our challenges is providing the latest and best care for our patients given that we have distant healthcare partners.

Another challenge we face is that we have a disproportionate government payer mix. So, in addition to the large geography, we have some issues with affordability.

HL: Do you have a high percentage of Medicare and Medicaid patients?

Archer: Yes, and we have a high percentage of government payers in general. For us, that also includes the Indian Health Service, which is a significant component of our tertiary referral base. For the tribes, we are their tertiary facility. Like all government payers, IHS is paying us below our costs to provide services.

HL: How are you rising to the challenge of having government payers that do not cover the totality of your costs?

Archer: It is a challenge, and it got worse with COVID with the increase in supply chain costs and the increase in labor costs. We are having to be careful as we look at our expansion into different service lines. So far, the payer mix has not kept us from launching new service lines, but it is a consideration. Like a lot of places, we are becoming leaner in terms of our efficiency. As we maintain and improve quality, we are looking to do so in a way that is most efficient and financially feasible.

We are getting better with our revenue cycle—connecting our clinical teams to our revenue cycle and finance teams to achieve the best possible financial outcome for patients. We do not want to burden patients with unnecessary medical bills or expenses because we did not get prior authorization or because we did not document in a way that resulted in a reimbursement denial.

Brad Archer, MD, chief medical officer of Monument Health. Photo courtesy of Monument Health.

HL: Your previous experience includes serving as executive medical director of MercyCare Community Physicians. What are the keys to success in physician group leadership?

Archer: You need a clear definition of who you are as a physician group and how you do things. You need to put these definitions in writing. I tell young physicians who are considering joining a physician group to make sure the organization has a clear mission, a committed leadership structure, and an operational structure that reflects the organization's values and leadership structure. Clarity is crucial to a successful medical group.

The CMO of a successful medical group needs to function like an air traffic controller. You need to navigate people to get things done and stick to it.

HL: What are the primary elements of physician engagement?

Archer: It goes back to structure. You need to create a structure that is consistent and has physicians involved on a regular basis. I always say the worst thing you can do with physicians is to try to not bother them much then have ad hoc meetings where you ask their opinion. Under those circumstances, physicians will often feel that they do not get follow-up. The consistency of the governance structure and the inclusion of all the operational decisions within the organization on the physicians' agenda are essential. You do not want to make assumptions or bypass the physician leadership.

There are different ways to conduct physician engagement. At Monument Health, we are fully integrated with our non-physician leadership in a way that provides open dialogue for our decisions with physicians.

HL: What role do physicians play in administrative leadership at Monument Health?

Archer: When I got here, there was a separate physician group and seeking input was primarily on an ad hoc basis. We dissolved that group and chose a fully integrated model. So, we have medical directors at every level of service in a market-based operational structure.

We have the system-level operations structure, then each market has their own unique operational structure. Within those markets, there are physicians who are paired at the director level and the vice president level in every department. So, we have department-specific medical directors who are paired with their department directors, and we have executive medical directors who are paired with the operational vice presidents. These leaders are engaged in all of the decision-making.

HL: You have a large rural population. What are the keys to success in providing value-based care in this kind of an environment?

Archer: With value-based care, you need to change information systems and the workflows to more of a proactive management, where we are focusing on our panel of patients that we are responsible for and trying to predict their needs ahead of time. We need to make sure patients are getting preventative care and not be reactive. In our case, this is particularly challenging because tertiary care is a big part of our value in the region, and it is largely reactive and emergent care. We must do tertiary care well while we shift our focus to managing populations and focusing on population health. Traditionally, our data systems have not supported that type of management as readily as we would like them to.

Things are getting better now. Claims information that we can get from the Centers for Medicare & Medicaid Services and other payers that are promoting value-based contracts is certainly helpful. But we must alter our workflows, particularly in our primary care clinics, in order to accommodate a value-based approach to care.

One of the keys to success is contractual, where you seek to appropriately document and code your patients' conditions. That is a separate component of success that is not inherently part of a general medical education or of a medical practice necessarily.

Another factor is having the appropriate access, which is a challenge for us and many other health systems across the country. Primary care access is not always easy, and in rural areas such as ours it can be even more challenging. In particular, when you are trying to do outreach and to get people to come in, we have some distance to cover to bring people in to see their providers. So, transportation becomes a challenge for us.

HL: What are the primary elements of patient safety at Monument Health?

Archer: First and foremost, it is about promoting a just culture and getting our errors reported, including near misses. These are opportunities for us to learn and improve our processes.

To support a just culture, we have a good quality assurance structure in place. We have the correct technology and data tools to provide opportunities for improvement. We also have promoted the lean methodology.

Related: The Exec: Transparent Leadership Crucial Element in Physician Engagement