Disrupting and Leading in Emergency Medicine
The Leadership Forum recently interviewed Dominic Bagnoli, MD, Chairman and CEO of Emergency Medicine Physicians (EMP), a physician-owned, leading employer of residency-trained, board-certified emergency physicians across the United States. EMP provides Emergency Department (ED) management and staffing solutions to more than 60 hospitals in 16 states, and is an athenahealth client.
Here’s what Dr. Bagnoli shared about the current state of emergency care, how it’s changed over the past few decades, and EMP’s approach to managing an ED patient population.
Tell us about EMP’s mission and evolution into the ED leader it is today.
When we were founded in 1992, our mission was to provide high-quality, board-certified emergency care with high patient satisfaction. Our commitment, then and now, was to physician ownership — so all of our doctors would have a personal stake in the mission. When we talk about this ownership model I like to ask people, “When’s the last time you washed a rental car?” We all know ownership has real value and believe that when the doctor has a stake in outcomes, they are more engaged in the success of the organization and the patient experience. This model has served us well and allowed us to gain market share to become one of the five or six largest ED companies in the country.
Last year we celebrated our 20th anniversary. We described those 20 years as the first half of our mission and focused discussion with our physicians around what the next 20 years would look like. As part of that, we changed our mission statement — after much heated debate — to something very simple: “To care for patients.” Some asked, “Is that enough for a mission statement?” But what else is there? With so many things in motion — the changes happening with the Affordable Care Act, hospital consolidation, etc., we find that if we always focus on what’s best for the patient we will do well.
What are the biggest challenges and changes facing emergency medicine, and how are you taking them on?
The biggest change is that we used to think of the care we delivered only within the four walls of our facility. Now, we need to think holistically about the patient’s care experience. Traditionally, EDs managed that first hour of care, handling the acute patient, providing appropriate treatment in a cost-effective way, and that was it. The approach of ED doctors was, “I’m just taking care of this one issue and then I’ve done my job.”
We are aligning our doctors to be a complete solution to unscheduled care. It’s no surprise that the traditional view was that emergency care was expensive and part of the problem of spiraling costs. At EMP, we are making our doctors accountable for helping manage chronic disease and preventing unnecessary re-admissions.
One example is our “familiar faces” program, which focuses on patients often derogatorily referred to as “frequent fliers” because of how often they use the emergency room. Rather than vilify them, we decided to focus on understanding them. We identified the 20 most frequent patients at each facility over a 12-month period and concentrated on providing them more effective holistic care. Here’s what we found: most are insured, and most have chronic disease that’s either under-managed or under-cared for. We determined why they kept coming in and what resources they needed to get them the care they needed beyond our four walls.
How is the shift from fee-for-service to fee-for-value payment playing into how your model is evolving?
I think we’re getting ahead of that curve, and were years ago when we started paying doctors based on patient satisfaction. All the things we’re doing now to re-think the role of the ED is part of the final evolution of the model, going from a straight fee-for-service environment — where we get paid for a procedure and just move on to the next patient — to a model where we view ourselves as being at the center of coordinating a patient’s care.
The reality is that ED is the first entry point to the health system for many patients, so our role in ensuring they get the right care in the right places is critical if we’re going to manage care and costs. We’re already operating in that mode as best practice, but as soon as we can realign the payment system, then we can begin to really wring cost out of it. Our doctors get that this is a long-term shift, that the changes we make today with smoking campaigns or focusing on containing re-admittance, is positioning them well for where health care is going.
How did your model and vision for being coordinators of care influence your approach to IT?
We knew we needed to have technology systems that allow our doctors to communicate with primary care physicians, the hospital — wherever our patients go — and to share data efficiently across the continuum. So we naturally gravitated toward the cloud and toward athenahealth, knowing their model and vision is fully aligned with ours. It was really an easy choice to go to the cloud, like asking, “Gee, do we want a cellphone or are we OK with just a landline?” I honestly believe we’ll be looking back at how health care data is handled by most organizations today as we do with other technology developments and say, “Can you believe we used to rely on paper or siloed software that couldn’t exchange data beyond the four walls of our system?”
Do you view EMP as a disruptor in the ED space?
There’s no question that we are a disruptor. Back in the 1980s, EDs got pushed out of many hospitals because they were seen as a loss leader that was difficult to staff and run. Hospitals couldn’t manage it. Now there’s a movement by hospitals to take back control and employ ED doctors again because they need to “align” the physicians, which is code for getting the doctors do what they want them to do, so the hospital can secure market share. If there was ever a time when you needed ED docs to behave differently it’s arguably now. And what’s the best way to do that, employ them? No. Every study shows that’s not how you get doctors to do the right thing. In any other business context you would provide them incentive, give them ownership and the tools they need to be successful. Why wouldn’t you do the same for the ED?
As a leader, what are some of your tried and true mantras that you use to reinforce your mission and culture with physicians and staff?
Wow, there are so many that we created a book called The DNA of EMP that captures them all, and we give it to all our new hires. One mantra that’s been a favorite for a long time is the old saying, “He who chases two rabbits catches none.” As I’ve asked physicians to do more and get on board with supporting chronic care, I’ve gotten a lot of grief about chasing too many rabbits. But conditions have changed. It’s still the same one rabbit, but it’s no longer contained by our four walls. So we need more ways to chase it.
Dominic Bagnoli, MD, is Chairman and CEO of Emergency Medicine Physicians (EMP), a physician-owned, leading employer of residency-trained, board-certified emergency physicians.
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