Physician-Hospital Integration in the 21 st Century Hoyt J.
Burdick, MD, FACHE
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Physician-Hospital Integration in the 21 st Century Background
and perspectives Economic integration and alignment Employment
doesnt assure engagement Dual track physicians
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Physician Hospital Integration: It shouldnt be that difficult
Hospital-Employed Physicians: How Medical Staffs are Coping with
the New Reality Janice Dinner, Esq., Associate General Counsel,
Banner Health Karen Owens, Esq., Partner, Coppersmith Schermer
&Brockleman PLC American Health Lawyers Association 2013
Meeting
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PEJ - Physician Executive Journal of Medical Management
May-June 2014 The management of medical care has become too
important to leave to doctors, who, after all, are not managers to
begin with. FORTUNE Magazine, 1970
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Let your doctor do his job and you do yours.
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Physician Manager - Leader Source: Changing Demographics,
Competencies and Physician Leadership Peter Angood, MD,
presentation, July 27, 2013
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2008 - Noblis Be willing to share leadership and work
collaboratively with one another Understand what our patients need
from us Clarify what changes in the patient care process are needed
Make changes in our behaviors that get in the way Be willing to
deal with each other as true partners Encourage the community to
use our local physician and hospital services Physician-Hospital
Relationship: What Does True Alignment Mean?
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Noblis, 2008 - Joel Reich, MD
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Economic Integration
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Motivation to Engage
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Hospital Board Administration Human Resources
Policies/Procedures Organized Medical Staff Bylaws Peer Review/Due
Process
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Peer Review Review by ones peers within a hospital is not only
time consuming, unpaid work, it is also likely to generate bad
feelings and result in unpopularity. Scappatura v. Baptist
Hospital, Arizona, 1978 Until 1986, physicians performing peer
review still faced potential extremely serious federal liability,
particularly under the anti-trust laws. Health Care Quality
Improvement Act - adequate fair hearing - qualified good faith
immunity
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Employment Law Hospitals resisted claims that physicians were
their employees simply by virtue of being medical staff members.
Most courts found that simple medical staff membership did not
equate to an employment relationship because physicians operated
with too much autonomy to satisfy legal standards for employment.
Diggs v. Harris Hosp. Methodist, Inc., 1988 St. Lukes Health System
v. State, 1994
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Tort Law Under the traditional model, hospitals typically could
not be held directly liable for physician negligence. - Ostensible
agency plaintiff led to believe that the physician was controlled
by the hospital - Negligent credentialing hospital failed to
adequately credential or oversee the quality of the physician
through the peer review process.
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Self-governing Medical Staff
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CMS, in its Conditions for Medicare Participation, requires
hospitals to delegate peer review responsibilities to the medical
staff (42 C.F.R. 482.12) and these requirements are incorporated
into Joint Commission Medical Staff Standards. - Revisions to Final
Rule May 12, 2014 - Hospital Governing body to consult periodically
with medical staff - Enables unified medical staff for
multi-hospital systems
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Physician Employment Trends Hospitals are employing more
physicians: what it means for the rest of us The Incidental
Economist Contemplating health care with a focus on research, an
eye on reform
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Demise of independent physician practice The changing health
care environment, and what it means for health IT Posted on August
15, 2012 by Robert RowleyAugust 15, 2012Robert Rowley
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AMA Principles for Physician Employment Physicians paramount
responsibility to his or her patients (duty to employer - beware of
divided loyalty) Free exercise of professional judgment in voting,
speaking and advocating for patient care interests, the profession,
health care in the community and the independent exercise of
medical judgment Patient welfare trumps economic or employer
interests Treatment and referral decisions must be based on the
best interests of the patient without
restrictions/incentives/penalties Medical directors are practicing
medicine
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AMA Principles for Peer Review All physicians should promote
and be subject to an effective program of peer review Identical for
all physicians regardless of employment status Conducted
independently without interference from any human resource
activities of the employer By physician peers not lay
administrators Accorded due process protections for independent
exercise of medical judgment No link between employment and medical
staff membership or privileges (clean sweep clauses)
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Dual Track Peer Review Controlled by Bylaws Determined by peers
Reviewed by Committee Subject to due process and appeals rights
Traditionally slow and methodical Peer review information that is
confidential with limited discoverability Employer Performance
Evaluations Controlled by contract Determined by supervisor
Reviewed by HR Subject to HR policy May be swift and decisive
Performance information may be reviewed and shared with less
protection from discovery
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Sharing Information? Sharing peer review information with
hospital administration may jeopardize peer review confidentiality
and immunity under state law. Does a CEO/CMO participate in peer
review as an administrator or as an employer? Physician rights of
confidentiality, due process and contractual rights under bylaws?
Medical Staff action vs. Employer action?
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If hospitals employ most physicians over the long term, will
the organized medical staff change or even cease to exist? What
state and federal regulations would have to be dismantled? CMS
conditions of participation that assume a separate medical staff,
HCQIA and state codes Will the Joint Commission need to rewrite its
medical staff chapter? (again) Physician-Hospital Integration in
the 21 st Century
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Background and perspectives Economic integration and alignment
Employment doesnt assure engagement Dual track physicians