Medical Staff Planning and Physician Community Need Assessments

1. Medical Staff Planning and Physician Community Need Assessments November 17, 2004

2. Welcome! Session #3 – 9:30 – 10:00 A.M. Community Need Assessments John Harris

3. Physician Manpower Trends and Issues Future of National Workforce Status of the Regional Physician Workforce Implications for Hospitals and Health Systems

4. The Future of the National Workforce Plethora of recent research on physician supply and demand COGME (2000) Escarce, et. al. (2000) Cooper, et. al. (2003) Solucient (2003) Weiner (2004)

5. COGME

6. COGME

7. COGME

8. Escarce et. al. (2000)

9. Cooper et. al. (2003)

10. Solucient (2003)

11. Weiner (2004)

12. So what is the consensus on the physician workforce of the future?

13. So what is the consensus on the physician workforce of the future?

14. So what is the consensus on the physician workforce of the future?

15. What about the impact of major industry trends?

16. Medical Education Resources National Medical schools continue to train at same rate Regional No reported shrinkage of residency training slots

17. Regional Developments Decentralization of tertiary services to suburbs Shortages of hospital beds Employment of specialists Large single-specialty groups

18. What is happening to the physician supply in our region?

19. Regional Physician Workforce In Perspective Short term – shortages within selected subspecialties likely to continue in next 3-5 years Long term – possibility that the supply of graduates and an improved practice environment may restore balance to physician need/supply

20. Implications for Hospitals and Health Systems Careful and thoughtful strategic planning must be implemented Program and service development often dependent upon physician resources New hospital/physician relationship models Allocation of capital resources between facility, technology, and manpower requirements

21. What are the implications for physicians in our region?

22. HOSPITAL IMPERATIVE:Medical staff planning and community need assessments Medical staff planning and development Quantifies and prioritizes physician resource needs Identifies competitive opportunities in market area Provides process for maintaining continuity and control over resource allocation process Community need assessments Supports innovation in physician relationship models Mitigates regulatory/compliance issues

23. MEDICAL STAFF DEVELOPMENT PLANS

24. Definition of a MSDPWhat is it? Five Year Future Assessment of the Institution’s Need for Physician Manpower Identify Physician Shortages in the Community Meet Key Strategic Initiatives Replace Departing/Retiring Physicians Strengthen Core Programs and Services Add New Business Lines and Ventures Address Competitor Challenges “Right-Size” the Medical Staff PHO/IDS Service Requirements Facilitate Medical Staff Organization/Affairs Balance Politics of Conflicting Interests

25. Importance of a MSDP Strategic Planning Has Changed Driven by Financial Realities Operating Margins Continue to Narrow Capital Investments Growing Larger Debt Capacity is Limited Focus is on Revenue Growth Initiatives New Technology Acquisition Alternative Delivery Models/Sites Service Line Development/Integration High Margin Services are Specialty Driven Need Referral Networks and Physician Loyalty MSDP MUST be Linked to Key Strategy and Financial Parameters

26. Key Issue – Institutional Need vs. Community Need

27. MSDP Process Step 1 – Define Service Area & Profile Demographics Geographic Draw 85% of Annual Admissions/Discharges Use Sub-Areas, if Necessary Population Growth 5-10 Years By Age Cohort (0-14, 15-64 and 65+) Key Demographics Age Distribution Race/Ethnicity Mix Seasonal Factors (Employment/Recreation) Environmental Factors Malpractice Situation Level of Managed Care Penetration

28. MSDP Process Step 2 – Compile Physician Supply (In FTE’s) Develop Initial Inventory Medical Staff Rosters Proprietary Databases (AMI, ABMS) Public Databases (Telephone Directory, MCO Directory) Determine Supply Adjustments Physician Age and Practice Levels (65) Multi-Office Locations (in/out of Service Area) Non-Clinical (AS&T Activity) Finalize Physician Supply

29. MSDP Process Step 3 – Estimate Demand of Physicians (In FTE’s) Interview Key Physicians and Senior Management Department/Specialty Needs Referral Patterns/Activity Levels Strategic Initiatives Apply Industry Planning Standards and Methodologies Physician-to-Population Ratios Use Rate Productivity Models National Supply Benchmarks Estimate Demand of Physicians (Use Range)

30. MSDP Process Step 4 – Compare Supply to Need F O R M U L A  

31. MSDP Process Step 5 – Integrate Strategic Plan Initiatives Impact on Service Area Definition Changes in Service Delivery Requirements Technology and Practice Model Shifts Inter/Intra-Organizational Changes

32. MSDP Process Step 6 – Prepare Implementation Plan Clarify Policy and Procedural Issues Establish Priorities To Meet Current Demand To Accommodate Projected Demand Define Physician Retention/Recruitment Packages Hospital Supported and Funded Non-Hospital Related Support Prepare Five Year Budget Estimate Include Performance Metrics Identify Leadership and Coordination Physician Liaison Representative Reporting (Board, Admin, and Medical Staff)

33. Winthrop University Hospital – A Case Study In Medical Staff Planning WUH Background Founded in 1896 – Long Island’s First Non-Profit Hospital Mission Statement – Comprehensive Health Care Services in a Teaching and Research Environment – “Care Without Compromise” 591 Bed University-Affiliated Medical Center(SUNY@Stony Brook School of Medicine) Full Service Medical Center Six Major Institutes (Cancer, Digestive Disorders, Heart, Neurosciences, Lung and Family Care) Level I Trauma Center Major Pediatric Referral Center

34. WUH Background (continued) Voluntary Attending Medical Staff of 1,250 Medical Education Profile 21 Accredited Residency and Fellowship Programs 16 Independently Accredited 5 Integrated 200 Residents and Fellows 150 Full Time Faculty and Clinical Investigators Operational Profile (2002) 32,200 Admissions 45,500 ER Visits 18,000 Surgical Procedures (820 Open Heart) 4,600 Deliveries

35. WUH Strategic Profile Service Area Definition Covers 43 Zip Codes in Nassau, Suffolk and Queens Counties Sub-Divided into Five Core Areas (87% of Discharges) Stable Population of 1.1 Million Physician Inventory of +/- 3,500 Physicians Many with Multiple Offices and Medical Staff Appointments Many Over 65 Years, but Still Practicing Many with Non-Clinical Activities Major Competitor Large Multi-Hospital System (10 Hospitals & 4,000 Beds) Two University-Affiliated Medical Centers Some Medical Staff Overlap Winthrop University Hospital – A Case Study In Medical Staff Planning

36. WUH Objectives for MSDP Develop Physician Resource Requirements for Clinical Departments and Specialties Sustain Strategic Initiatives Maintain Clinical Education Program Balance Interests Between Voluntary and Faculty Physicians Provide Legal Basis to Close Departments/Sections Project Range of Primary Care and Specialty Physicians to Meet Future Community Needs Identify Specific Demand in Each Core Area Build Reliable Physician Supply Database Identify Implementation Strategies, Priorities and Actions Winthrop University Hospital – A Case Study In Medical Staff Planning

37. Results of MSDP Community-Based Physician Demand Primary Care (IM/FP) Practice Patterns in Long Island Market Reflect IM Dominance Net Demand of 30 Physicians in Total Service Area One Core Area need for 60 Physicians Specialists Modest Deficit for Cardiac, Thoracic and ENT Surgeons Nominal Deficit or Excess in Rest of Subspecialties Winthrop University Hospital – A Case Study In Medical Staff Planning

38. Results of MSDP Medical Center Physician Needs Voluntary Attending Staff Generally Sufficient to Meet WUH Needs (Cardiac Surgery Need Due to Recent Defections) Some Specialists are Splitters – Loyalty Issue (Nephrology, Cardiology, Hematology/Oncology, GI) Large Number of Inactive Physicians Faculty Staff Clinical Workloads Indicate Needs in Cardiology, Infectious Diseases and GI Non-Clinical (AS&T) Need Not Quantified Winthrop University Hospital – A Case Study In Medical Staff Planning

39. Key Recommendations Selectively Recruit Primary Care Physicians into Underserved Core Areas Develop Program to Enhance Physician Loyalty to WUH Voluntary Staff Too Large and Unwieldy Purge all Inactive Physicians From Roster Establish Minimum Standards (Admissions, Procedures, Meeting Attendance) to Retain Appointment Consider Closing Departments/Sections with Significant Oversupply of Physicians Winthrop University Hospital – A Case Study In Medical Staff Planning

40. Key Recommendations (continued) Use Voluntary Staff to Augment Faculty Needs Improve Integration and Communication Between Voluntary and Faculty Staffs Replace or Strengthen Physician Leadership in Two Clinical Departments Winthrop University Hospital – A Case Study In Medical Staff Planning

41. Additional MSDP Considerations Use Appropriate Legal Support Legal and Regulatory Concerns Antitrust Fraud and Abuse Corporate Practice of Medicine Fee-Splitting Managed Care Contracting

42. Securing Physician Buy-In Is Important Participation in MSDP Process Use Task Force/Steering Committee Representation Physician Surveys and Interviews Frequent, Ongoing Communication Medical Staff Meetings Electronic/Written Updates Information and Data Objectivity Use Industry-Accepted Methods and Standards Independence of MSDP Resources Additional MSDP Considerations

43. Keys to Implementation Success Embrace Key Medical Staff Constituencies Senior Physicians with Peer Respect Younger Practitioners with Long Term Future at Stake Attributes of Loyalty, Wisdom and Objectivity Recognize Process Issues Establish “Ground Rules” Early Innovation Creates Risk Exposure Sound Planning Mitigates Risk Additional MSDP Considerations

44. Keys to Implementation Success (cont.) Assure Proper Organization, Leadership and Oversight Must Start at the Governance Level Function Must be Clearly Defined Within the Organization Must be Adequately Funded Must Have “Rapid Response” Capability Must be Regularly Reviewed and Adjusted Additional MSDP Considerations

45. COMMUNITY NEED ASSESSMENTS

46. What is a community need assessment? One-time determination of community need for a specific physician specialty Supports physician recruitment and remuneration package Provides documentation for regulatory compliance

47. Comparison of MSDP and CNA

48. The process of completing a community need assessment is made up of five steps Define the service area Enumerate physician supply and make appropriate adjustments Estimate physician demand based on planning standards and market forces Calculate deficit or surplus Issue opinion letter or memo to file

49. Define the Service Area Stark II provisions Fewest contiguous zips w/75% of IP business For determining “relocation” of practice Maintaining consistency with hospital’s MSDP service area is preferable, but not required Tertiary or quaternary programs may have unique service areas

50. Determine Physician Supply Start with MSDP data Check for recent practice additions Contact individual practices by phone Multiple practice locations Work effort level AS&T Pending retirements or relocations

51. Numerous adjustments are made to accurately assess physician supply within designated service area

52. Apply DGA Planning Standards Compiled from several sources Weiner (2004) U.S. Supply (Weiner 2004) Solucient (2003) Longshore + Simmons (1995) Specialty board studies Expressed as a range Refined to address subtleties Detailed subspecialty categories Internal medicine/family practice Hospitalists

53. Adjust Planning Standards for Unique Market Forces Apply planning standard (per 100,000 population) to service area population Adjust for variations from national norm Utilization management intensity Demographics Hospitalists Physician extenders Technology

54. Calculate Excess or Deficit of Physicians(Deficit = Community Need)

55. Closing Thoughts One-time determination of community need for a specific physician specialty More narrowly focused than a Medical Staff Development Plan Supports physician recruitment and remuneration package Provides documentation for regulatory compliance