WyAMSS Annual Meeting
MHSC
April 25, 2013
Employed Physician Presentation
Keri Chorazewitz
I) Employed Physicians
A. Why Employ Physicians?
1. Response to the implementation of health care reform
2. Over half of all US physicians employed by hospitals now
3. Because of risk based payment systems ramping up hospitals trying to gain
control
B. Cyclical
1. Happened in the 1990’s when hospitals hired most of their physicians
2. Hospitals then divested themselves of most of them
3. Costs hospitals more money to employ the physician versus contract them
4. Increased oversight requirements – regular employee requirements as well as
the medical staff requirements
C. Hospitals lose $150K-$250K over the first 3 years of employing the physician – partially
due to onboarding/building practice.
D. Physicians benefit from the hospital assistance/responsibility for the increasing payor
and regulator demand for transparence, public reporting of date, pay for
performance initiatives. They don’t have to invest in the staff and expensive
technology systems.
E. What are the benefits?
1. Can better monitor and hold accountable for quality outcomes
2. Can better monitor and hold accountable for productivity
3. Can better monitor and hold accountable for behavior
4. Not all about monitoring and accountability – creates environment where
physicians are part of the culture and take ownership in the success of the
organization – they are more a part of the “family” if set up correctly.
F. Pay from private insurance is decreasing, from governmental programs increasing yet
amount decreasing in both – most significantly in governmental programs. Hospital
employment shields them from this to a large degree.
G. Governance of physicians
1. Federal and State laws
2. Regulatory Body (TJC) requirements
3. Medical Staff Bylaws
4. Human Resource Policies
H. What should you consider prior to pursuing employed physicians
1. What is your goal? Multispecialty group or single specialty? Recruit what those
who will help you achieve your strategic goal – and theirs.
2. Why? Hire only individuals who believe they can achieve more of what they
care most about by working together rather than working alone.
3. What are your values? Know what you want and in what order – know what is
non-negotiable.
4. How do you define success? Articulate metrics and how you see them
gauging and guiding the future. Make sure the physician agrees and can
articulate the same goals
5. Who is in charge? Ensure that the Physician Bylaws and organizational
structure support one another. If a physician is out of compliance with any of
the required regulatory expectations, who will address it? Make sure this is a
solid and constant process so everyone is clear who has what role and when.
6. How will you pay them? Reward good behaviors. Set clear contractual
expectations around competency, volume, quality – whatever is of most
importance to your organization and the achievement of strategic goals.
I.
How can you be successful?
1. Create and cultivate expert culture. Physicians thrive in an environment where
they can be driven by their own vision, not an organization’s – therefore
ensuring they are aligned at the outset becomes critical
2. Dialogue, dialogue, dialogue. The suspension of judgement and the ability to
listen to the physician creates meaningful conversations. If the physicians are
provided an environment where they can come to their own understanding
instead of having it forced upon them, they will thrive and so will the
organization.
3. Do not treat employed physicians exactly like other employees. It is essential to
give them a higher level of respect and sense of control. They must feel that
they are given authorship for their work.
4. The organizational mission has to be more than about money. Physicians must
be able to connect their sense of purpose to their work to a higher degree
than any other employee.
II) Joint Commission Education Requirements
A. Our favorite chapter….MS – Medical Staff
1. 46 pages of pure bliss
2. MS 01.01.01 alone represents 36 elements and 6 pages of requirements for
accreditation.
3. Remember that all JC elements are based on requirements set forth in CMS
Conditions for Participation
B. HR – Human Resources
1. All elements in this chapter are relevant to employed physicians when
discussing qualifications, competency, verification, education
2. Some elements are also covered in the credentialing and re-credentialing
processes outlined in the MS chapter.
3. The information on the physicians should be kept in one place – duplication is
not necessary. However, all financial information must remain in a different
folder or location than the rest of the physician information as financials must
be separate at all time.
a. This does not include the contract.
b. This is relevant to tax forms, withholdings, court orders/garnishments, etc.
c. Separation required in order to avoid the appearance that an
employee’s financial situation has any bearing on their performance or
the employer’s view of the performance.
4. Orientation requirements – completion must be documented:
a. Relevant hospital-wide policies and procedures
b. Job specific role in assessing and managing pain
c. Job specific role regarding infection control
d. Sensitivity to cultural diversity
e. Patient rights, ethics
5. Competency requirements – this can be addressed in the delineation checklist
and credentialing process. Should also incorporate peer review and other
OPPE elements
6. Evaluation requirements – this can be addressed in the re-credentialing/OPPE
process, but evidence of evaluation of performance must be present for at a
minimum of once every three years unless clearly defined otherwise for the
organization.
III) Legal Precedent
A. Credentialing Doctor with Questionable Qualifications – Minnesota High Court
amednews.com 10-15-07
1. High court recognized that patients can sue hospitals for allegedly granting
privileges to doctors with questionable credentials – 25 other states do this as
well.
2. Peer Review Statute for confidentiality is an obstacle, but it does not preclude
a claim
3. Physicians worry it will chip away at peer review confidentiality as hospitals will
find it difficult to fight back without disclosing credentialing details
4. Could make physicians reluctant to get involved in peer review
5. AMA and MN Medical Assn filed a friend- of the court brief in the case.
6. Even if peer review not discoverable, belief remains that allows plaintiffs to go
find any public dirt and claim because of it the hospital “should have known”
the physician posed a threat
7. Facilities may make it tougher to obtain privileges
8. Facilities may raise medical liability insurance requirements for physicians
9. Plaintiff lawyers believe it reinforces hospital obligation to adhere to
acceptable credentialing standards and ensure patient safety
10. Wyoming is one of 28 states that have upheld negligent credentialing claims.
11. “Questionable Credentials” has not yet been fully defined.
B. Bipolar Physician has ADA Standing to Sue for Medical Staff Privileges
Med Law 05-05-08
1. Determined in Haas v. Wyoming Valley Healthcare System (Pennsylvania) –
physician had standing under Title III of ADA and Section 5.04 of Rehabilitation
Act to sue for privileges.
2. Case Facts:
a. Physician diagnosed with BPD in 1994 during residency – treatment
ensued
b. 2000 Privileged with Wyoming Valley Health System
c. 2001 Suffered episode during surgery which resulted in his taking a leave
of absence and seeking additional treatment
d. Came back and application granted on condition he use “co-surgeon”
during operations – wanted this stipulation removed
e. Court agreed that MD posed threat to patient care and co-surgeon
was acceptable, thus not discriminatory
f.
Therefore, Trial Court rejected jury decision that originally awarded Dr.
$250,000 and entered judgment on behalf of hospital
3. In this scenario, had something gone wrong during the surgery, the patient
might have sued for the hospital having him on staff knowing the “risk”. Would
THIS jury (who was on the side of the physician saying the hospital was wrong
for making him have a co surgeon) have sided with the plaintiff or the hospital?
4. We will never know… but it does cause you to ask: what exactly are
“Questionable Credentials” and at what point does it become discriminatory
NOT to credential?
C. Defining “Disruptive Physician”
1. All hospitals struggle with this definition.
2. TJC requires, via LD.3.10, the definition and ability to address.
3. Challenge for organizations who want to protect high performing physicians
yet provide acceptable hospital practice environments.
4. Wyoming Supreme Court in Guier v. Teton County Hospital District affirmed the
termination of the physician privileges
5. Case Facts:
a. Potential yet not defined connection between the behavior and safe
practice
b. No adverse quality outcomes
c. Prior history of disruptive conduct
d. Most recent renewal was placed on probation – conditions set
regarding conduct
e. After reappointment at least 6 more incidents
f.
Staff petition refusing to work with the physician
6. MEC reviewed situation and summarily suspended physician privileges.
7. Physician exercised due process and suspension upheld
8. Physician pursued court action to reverse the decision
9. A trial court affirmed the decision to suspend privileges
10. Wyoming Supreme Court agreed
11. Of interest, the physician did not contest the allegations of disruptive behavior
in his claim; he just said he did not receive appropriate notice according to the
disruptive physician policy.
12. Court stated that the bylaws carried more weight than the policy re: process
and due process, those requirements were met, and therefore suspension
upheld and claim dismissed
13. What do we learn:
Policies are easier to change, but the bylaws hold more weight – regarding
disruptive physicians – and specifically regarding any action taken for or
against physician privileging
IV.
Closing
A. There are tremendous benefits from employing physicians, if you are organized,
physician friendly and clear about organizational strategic plan.
B. Credentialing physicians – employed or otherwise – is a complex process with a
myriad of things to consider.
C. Weigh your findings about a physician’s past very carefully as it will likely be the
stance of the patient that you put them at risk if you credential or hire them knowing
of a past that does not show resolution.
D. Equally important is the awareness of your responsibility to not discriminating against
an individual because of their past or present issues that may or may not impact their
competency to practice medicine – when in doubt – consult counsel.
E. Employing them does not increase or decrease organizational risk if the physician
causes harm or is alleged to cause harm.
F. Strict attention to quality expectations, engagement of physicians in changing
processes and ensuring that the focus is patient-centric will increase physician success
and the improvement of patient outcomes.