ROOTS

ALL SMILES

A young Yajnik poses for a pic with his wife, Mohua, his sister, parents, and dog, Wolfie. PROUD GRAD

Yajnik with his wife and daughter at his MBA graduation from The University of Western Ontario.

ROOTS

SANJIV YAJNIK

President, Financial Services

CAPITAL ONE

FAMILY TRIP

as told to DIANTÉ MARIGNY illustration by JAKE MEYERS sanjiv yajnik, financial services president at Capital One, grew up in Kolkata, India. After earning his engineering degree, he worked for two multinational shipping companies, posts that allowed him to spend time in more than 60 different countries over 10 years. That led to executive roles overseeing Capital One’s work in Canada and Europe, before relocating to North Texas for his current post. Here, Yajnik talks about his journey.

“Growing up in Kolkata, India, I had the opportunity to work in Shishu Bhavan, Mother Teresa’s orphanage, from first grade through high school graduation. One of the many life lessons I took away from her was the importance of purpose—working toward something much bigger than yourself. Without purpose, everything else will fail. Her purpose in life was to take care of those who were the least capable of taking care of themselves. This has been a huge motivator

Yajnik with his son, Shiv, at Mother Teresa’s orphanage in India, where he once worked. for me personally as a leader, and also in transforming businesses. It has allowed me to keep a long-term perspective and make business decisions that better the lives of our associates, customers, and the community. “One memory that stands out to me growing up is something that happened in the fourth grade. I remember it vividly—it was a Thursday.

I was serving meals at the orphanage’s cafeteria when I tripped and fell, taking down with me one of the boys who lived there. I looked at him and had an epiphany; I realized we were so similar, and yet, I was given a better hand in life. I went home and asked my parents many questions. It impacted me tremendously and made me realize how fortunate I was. I never wanted to take anything in my life for granted.”

CONGENITAL HEART SURGERY DREAM TEAM

System CEOs on COVID-19’s Lasting Impact

Primary Care Physician Roundtable

2021 EDITION

Where to Shine Our Spotlight

COVID-19 still dominates the headlines, but there are other healthcare stories that also need to be told.

Dr. Kristine Guleserian operates on a young patient at Medical City Children’s Hospital.

when covering any beat, journalists must choose between using our limited time covering a major news event that everyone else is reporting on or unearthing important stories or trends that haven’t attracted as much attention. Do we bring something new to our readers and risk that it will get lost in the shuffle, or find a new angle on the big happening of the day?

The last two years as a healthcare reporter have asked this question of me more than ever. I could easily spend every waking second reporting on and writing about COVID-19 and how the pandemic is impacting the medical industry and society at large, but doing so risks missing other important stories about innovation and healthcare trends that may last well beyond our battle with the virus. In this year’s Healthcare Annual, we tried to find the balance between covering new angles on the pandemic and sharing voices that speak to where the health industry is going and how it got here.

In this special report, you’ll hear directly from the CEOs of the region’s largest healthcare systems on how COVID-19 has impacted their organizations (page 86). I also spoke with frontline primary care physicians who shared insights on the difficult challenges they face (page 93). Additionally, you’ll find a report on the future of the rapidly changing hospital (page 88) and a behind-the-scenes look at the first women-led congenital heart program in the country (page 82).

Healthcare is a big focus for us at D Magazine Partners; we launched the region’s only news site that focuses on the business of the industry nine years ago. I hope you’ll sign up for our daily e-newsletters. And, as always, I welcome your feedback and ideas. You can reach me at will. maddox@dmagazine.com.

Will Maddox

Healthcare Editor

HEALTHCARE ANNUAL 2021

CONTENTS 82

BREAKING BARRIERS, ONE HEART AT A TIME

Women are leading the congenital heart surgery program at Medical City Children’s Hospital.

86 88

THE PANDEMIC’S IMPACT ON DFW HEALTHCARE

System CEOs share how battling the disease has forever changed their organizations.

THE HOSPITAL OF TOMORROW

Innovations we can only dream of today may become commonplace within a decade.

93

POWERING AN EVOLUTION IN CARE

Primary care physicians may provide the answer to skyrocketing healthcare costs and other issues.

ASK THE EXPERT

How a North Texas Mental Health Company Grabbed the World’s Attention

AWSTIN GREGG, MBA, LCSW, LCDC, CHIEF EXECUTIVE OFFICER, CONNECTIONS WELLNESS GROUP

What are some of the awards and recognition Connections Wellness has received recently? Our team’s notoriety has come in the form of national accreditations, local licenses, and even distinctions as an advanced clinical teaching institute. We’ve also been recognized as best in class within our county 33 different times, ranging from best mental healthcare practice to best psychiatry practice, and this even includes multiple individual distinctions, several of which we’ll be defending for the third year in a row. These awards are certainly celebrated, but we’re most thankful for our notoriety in public as an expert resource. Recently, we’ve provided expert commentary in multiple articles for World Health News, participated in globally broadcasted podcasts, and have been interviewed countless times by local news stations as we traversed the mental health effects of the pandemic together. The recognition our team gets for our clinical excellence ultimately allows us to serve more people, influence more lives, and pursue our company’s mission & vision with greater nimbleness.

How did Connections Wellness go from a single-office company to one of the world’s fastest-growing companies in three years? I think the answer is as simple as prioritizing the things that actually matter, which is undoubtedly your team and those entrusting their care to them each day. I don’t want to oversimplify a complex business scale strategy, but at the heart of it is genuinely caring about those very things. I encourage my team to re-recruit the people they’ve already hired each day. At the heart of what we do is relationships. When these are built on trust, genuineness, authenticity, and held up by individuals truly pursuing the highest degree of quality, growth always follows. I think far too often organizations can put “Benjamins before Benjamin.” When finances become the exclusive tip of the arrow, everything that follows becomes disjointed.

What hallmarks of Connections Wellness’ reputation got the world’s attention? In our business, there is one metric that drives what we do, and it’s our clinical outcomes. It’s our ability to objectively communicate to others that we can truly treat their illnesses. This relentless focus is something our team talks about each day. We design ways to improve it, measure it, and celebrate every decimal point of an increase. One of our core values is “unapologetically pursuing unequivocal excellence.” Our team works relentlessly to embody that value when we contemplate our treatment models. We’re very open about our treatment outcomes for all lines of service. I think this level of transparency, coupled with our objective data, has really aided our ability to capture a very wide audience. We believe people seeking treatment for their illness should know if the provider is capable of treating them without delving through cryptic acronyms or sorting through hundreds of pages of research literature. The level of transparency creates a tremendous amount of accountability—which is exactly our onus to carry—and I believe this is what has gotten the world’s attention.

What is next in the timeline as Connections Wellness is poised to become the largest privately owned mental health company in Dallas-Fort Worth? We’re excited about our growth within Dallas-Fort Worth; we certainly make no secret about it. We’ve built out an incredibly talented team, teamed up with incredible organizations like Vertava Health, and have begun geographically expanding across Dallas-Fort Worth. We’ve opened eight new locations this year, with several more slotted.

Awstin Gregg is a licensed clinical social worker and holds two additional master’s degrees in business. A former hospital CEO and a current professor at TCU and Texas A&M Commerce, he was voted Social Worker of the Year in 2018, Entrepreneur of the Year in 2019, and leads the Denton County’s fastest-growing healthcare organization, Connections Wellness Group, while receiving seven distinguished awards in its first year of operations. Connections Wellness Group is a nationally accredited healthcare practice able to care for any need, from the acute depression to the common cold to everything in between.

Dr. Kristine Guleserian performs heart surgery on a child at Medical City Children’s Hospital.

Breaking Barriers, One Heart at a Time

Women are stepping into leadership at the congenital heart surgery program at Medical City Children’s Hospital.

story by WILL MADDOX

MONDAY MEETINGS WITH THE congenital heart surgery team at Medical City Children’s Hospital are not like those at a typical office. Sure, some of it might look familiar: More than a dozen physicians, surgeons, clinic managers, and other staff gather around 7:30 a.m. to discuss the week ahead. Some of the team calls in virtually; others sit around a conference table. But that’s where the similarities end.

When I visited there in July, several people jumped up to leave the room about halfway through the meeting. They weren’t refilling their coffee or using the restroom. One of their patients needed immediate resuscitation. (The team was successful, and the patient survived). When the doctors returned, they sat back in their seats as if they simply stepped away to grab a snack. Typical, this is not.

At the meeting, what looks like an indecipherable bloody mass of flesh is shown on the screen, but it speaks volumes to the team. They point out malformations and results of past procedures and create a plan for each of the children upstairs in the team’s intensive care unit. Walking past the patient rooms, I am struck by just how small the children look in the full-sized hospital beds. Machines loom large on either side, pumping in fluids and antibiotics, beeping as parents huddle nearby. Laying on their backs, many have patches over their eyes, their chests rising and falling almost imperceptibly.

Meanwhile, downstairs at the meeting, Dr. Kristine Guleserian leads the discussion from the head of the table. She is the first and only woman to lead a congenital heart team in the country, and her comprehensive knowledge of the patients, their families, and the condition of their hearts is on full display as the group discusses each case.

She and the team work efficiently with input from all directions. Guleserian is the head of the program, but it is not a one-woman show. Pediatric cardiologists, general surgeons, and clinic managers alike chime in to add their perspective, weighing on the imaging, family, mental health, and medical history. It is no coincidence that the group functions so well; Guleserian built the team with moments like this in mind.

GETTING THE BAND BACK TOGETHER

After more than a decade at UT Southwestern and a spell in Miami, Guleserian was hungry to lead and more than capable. Although she is not much more than five feet tall, she looms large in the congenital heart surgery world, serving on leadership in numerous organizations, and is a coveted speaker at conferences. While at UT Southwestern, she made headlines when she performed a heart transplant on what was at the time the world’s smallest patient, a five-pound newborn.

When she arrived at Medical City in September 2019, the hospital invested in assembling her ideal team, a collection of cardiologists who balanced all the qualities she looked for in colleagues— and they just all happened to be women. “It’s like fantasy football. You pick everybody who you would dream about working with, and you change the whole atmosphere,” Guleserian says. “You get rid of the toxic work environment that so many of us have been subjected to, and you build a team with all the best people, the most talented, and the ones who have the best bedside manner and personality.”

Finding a physician who is gifted technically, great with patients, and lacks a disruptive ego is no easy task. But Guleserian is confident that she has found a crew that checks all her boxes. Over the years, she made mental notes of who she would want to work with if she were given the resources to build her own crew and bring in her preferred talent.

Within the last year, Guleserian has recruited four physicians to join her at Medical City Children’s. All of them came from UT Southwestern, though they all were at different stages in their career. Usually, it would take years for the resources to open for such a significant talent acquisition, but Medical City made it happen.

Guleserian’s real-life fantasy line-up includes Dr. Vivian Dimas, the medical director of adult congenital heart disease at Medical City Children’s Hospital who specializes in minimally invasive treatments of complex heart conditions. She is joined by Dr. Carrie Herbert, a pediatric interventional cardiologist who also focuses on minimally invasive procedures. Dr. Poonam Thankavel is a pediatric cardiologist and the medical director of pediatric cardiac imaging specializing in imaging and diagnosis. Dr. Ilana Zeltser is a pediatric cardiologist and the medical director of pediatric electrophysiology and specializes in diagnoses.

Having that many women leaders in a cardiology program is rare, but Guleserian didn’t set out with that intention. “I picked them for their talent,” she says. “They just so happen to have two X chromosomes.”

Guleserian also brought in her surgery partner, Dr. Janier Brenes, from Costa Rica, and the team’s intensive care unit director, Dr. Mark Clay. “It’s always been my dream since I was a medical student to build a team of all the people who I liked to work with. That’s been the vision here—to bring the best of the best who are people you like to work with,” Guleserian says. “They are more than just clinical experts. They have a great bedside manner, personalities, and outside interests that make them multi-dimensional.”

Many of us have experienced that special team or group of colleagues where everything just clicked. Together you did great work, you got along, and you cared about each other. Time, money, families, partners, and other opportunities eventually get in the way. But you stay in touch in case there’s a way to work together again. That’s what Guleserian made happen. “It’s hard to believe how much we’ve done, but it is a case of getting the band back together with a bunch of people who respect each other, like each other, and work well together,” Dimas says.

“I picked them for their talent. They just so happen to have two X chromosomes.”

DR. KRISTINE GULESERIAN

Those who were part of the pediatric cardiology team before Guleserian arrived say they’ve noticed a marked difference in the ambition of the program and the innovation it embraces. “Dr. G thinks outside the box, and she’s a perfectionist, which is absolutely vital in terms of what we’re doing,” says Dr. Jane Kao, a pediatric cardiologist who has been at Medical City since 1995. “She never says it can’t be done. She asks, ‘Why not?’”

Bringing in that many new leaders in a short time isn’t easy in any business setting, but in just six months, the team is already functioning at a high level. Keeping the focus on the patient is critical. “Every person that’s part of this team comes together for

the sake of the patient,” Kao says. “We always put the patient first.” Guleserian believes she is having her cardiology cake and eating it too. “People sometimes ask, ‘If you had to have a technically excellent surgeon or a surgeon with great bedside manner, which would you choose?’ And I always said, ‘Why can’t I have both?’”

OPERATING IN A MAN’S WORLD

Several of the physicians I spoke with shared a similar story. It goes something like this: As women at the top of their field, who often present and speak at conferences, they tend to see the same audience while peering over the podium. Before them could be 100 physicians from all over the world, but only about eight of them would be women.

Interventional cardiology is still a bastion for male physicians. Even though gender parity has improved from a generation ago, women still experience a lingering disparity. At the last in-person conference that Dimas attended, prior to the pandemic, she approached the faculty check-in table. A woman seated behind the table told her, “Vendor check-in is down there.” Dimas says, “I told her, ‘I’m checking in for faculty.’ That [kind of] stuff is still out there.”

The double standards don’t end at international conferences. Women surgeons and cardiologists are still subjected to assumptions that affect women in multiple professions. “There is that undertone that as women, they will never be as dedicated as men because they are dedicated to their families and can’t give everything to their job,” Dimas says.

Dr. Kristine Guleserian (left, below) became the first woman to lead a congenital heart surgery program in the U.S. when she was named medical director of Medical City Children’s Hospital Heart Center last year. She has since built a cardiac surgery “dream team” whose members include, from left, Dr. Vivian Dimas, medical director of adult congenital heart disease; Dr. Carrie Herbert, pediatric interventional cardiologist; Dr. Jane Kao, pediatric cardiologist, Dr. Poonam Thankevel, medical director of pediatric cardiac imaging; and Dr. Ilana Zeltser, medical director of pediatric electrophysiology. Guleserian once implanted a pacemaker in a baby born at just 32 weeks.

But around the conference table at Medical City Children’s Hospital, floors below the impossibly small infants preparing for or recovering from heart surgery, Guleserian is working to change the paradigm. “We’ve all been subjected to some form of harassment in the workplace,” she says. “What we’re trying to do is set the example and have a zero-tolerance policy.”

In addition to building her dream team, breaking barriers of medical leadership, and performing some of the most complex and delicate surgeries on the planet, Guleserian seeks out mentorship opportunities with young women at all stages of their medical education. She embraces her role and leans into the opportunity. A few years back, before moving to Miami, she invited some medical students over for dinner. As they finished their meal, the students pleaded with her to keep empowering women, building teams, and fearlessly sharing her story. “I said, ‘You know what? From here on, I am going to make a stand. Because if we can make it better for the next generation, then that’s what we need to do.”

The Pandemic’s Impact Eighteen months after COVID-19 on began wreaking havoc, North Texas healthcare CEOs share how DFW their experiences battling the disease have changed their organizations. Health story by WILL MADDOX Systems

COVID-19 BEGAN TAKING HOLD OF THE NATION in the spring of 2020, putting those in the healthcare sector on the front lines of the battle against it. Leaders were called upon to be more agile, innovative, and resilient. As their frontline workers fought to save lives, administrators scrambled to develop and implement policies that would protect patients—and their own personnel. The challenge tested them like nothing had before. For D CEO’s healthcare news site, I recently sat down with system leaders to get their thoughts on the last year-and-a-half—how it forever changed them, their companies, and the industry. Here’s what they had to say.

“It quickly became evident that the COVID-19 pandemic was not a sprint. As the North Texas cases began to multiply over time, the dynamic nature of the situation was going to be more like a marathon. As we moved through the pandemic, we moved through several different phases. Initially, we were in the preparation phase. And then, as we began to see the spike, there was a response phase— and I am proud of how our team stepped up to the challenge there. What we learned was that there were going to be spikes and valleys as we move through this pandemic and that we needed to be prepared to respond in both scenarios. We relied on data science and projection models to the best of our ability. And because we are part of HCA, a nationwide company, we had the visibility to see what was happening in other markets as they spiked, accelerated, and decelerated.”

EROL AKDAMAR

Medical City Healthcare “Back in 2014, when we had our experience with Ebola, we observed the environment moving from science, to social science, to science fiction. We knew that was going to happen with COVID-19 because we’ve seen it happen before. That helped us anticipate how we could deal with some of the lack of information or misinformation picked up in the media and on social media. We’re seeing the same kinds of things now, so we had to put in place a way to vet information and decide whether that would impact how we were caring for patients. What advice were we giving to physicians and employees as well as the public? We had a way to ingest that information daily and then, on a very rapid turnaround basis, get information out about what was truth and what wasn’t. We spent time thinking about the essential institutions for communities.”

BARCLAY BERDAN

Texas Health Resources

“The situation called us to quickly adapt in two big ways. The first was the scientific response: Trying new drugs, expedited trials, and the early authorizations to push out the drug. To go from a new disease to a vaccine within a year is just unheard of. The other part of the speed of response is how services are structured and delivered. We all had to adapt as we got information— whether it was how to cohort patients or what your PPE policy will be. What do you do beyond the walls of the hospital in terms of public health measures? What I learned when I went through Katrina was that during a crisis, there is no time to be hesitant and guarded in your response—you have got to jump in. What has impressed me is people’s willingess to do what has to be done. People get into healthcare to make a difference, and this is a defining moment in our careers.”

DR. FRED CERISE

Parkland Health and Hospital System “When the pandemic started, our organization was already focusing on continual improvement as a pediatric care provider. We have invested further in technology and processes to support our patients and team members during these challenging times. The pandemic accelerated our development of technology and its use. We are leaders in using telemedicine. Prior to the pandemic, we were already partnering with nearly 30 independent school districts and more than 220 schools across North Texas as part of our school-based telehealth programs. As COVID-19 began to spread in the U.S. and across North Texas, we were well-positioned to expand these services, which became vital at a time when many children and families were not able to come on site for care. We rapidly converted 74 clinics that normally see patients in-person to virtual appointments.”

CHRIS DUROVICH

Children’s Health “How do you create a preliminary telehealth visit with the homeless population, or the most vulnerable populations, or a community that doesn’t have the fiber optics and capabilities that technology affords them? COVID was almost a discriminatory virus in the sense that it hit the weakest, so if you had challenges going into COVID, your chances of adverse or difficult outcomes were far greater. It amplified the challenges we have in communities where we’re not offering the healthcare that’s readily available. It made us at JPS look at issues that are corollary to healthcare, such as these people living in a food desert where they have no vehicle to transport them. COVID said, ‘OK, I’m going to show you your societal problems.’ If we don’t learn our proper lessons from COVID, then that’s a huge mistake. COVID points to the frailties of the human and in healthcare.”

ROBERT EARLEY

JPS Health Network “Our organization is comprised of local board members and leadership. We don’t have to raise up the flag to someone at corporate to get approvals—we can make quick decisions when we need to. Our board gave me and our executive team carte blanche to do what we needed to do when we needed to do it: They supported us when we needed to pivot to ensure that our patients were given the best possible care and that our employees were safe. That also was part of that decision to make sure we gave everyone full pay through this pandemic—even our 450 employed physicians, some of whom were at home for a period of time. We did not have any layoffs or staff reductions. That was a big plus for us, and it speaks volumes to our culture and who we are. When we come to work, we leave our personal selves at the door and walk into this organization.”

RICK MERRILL

Cook Children’s Health Care System “The pace, magnitude, and duration of this pandemic were and, frankly, still are, unprecedented. When I think back to the beginning of the pandemic, I am amazed by the sheer number of decisions that had to be made in almost real-time. We would make a decision and communicate that decision based upon the best information at that moment. Often, we would then get different directions from various national and local health officials requiring significant modifications, sometimes the same or the next day. Everybody was doing the best they could with the information they had; however, it was all staggering, at times. This is the closest thing to a prolonged crisis that I have ever dealt with in my healthcare career, and in the case of this pandemic, I’m proud to say that the Methodist Health System family grew even closer and stronger.”

JIM SCOGGIN JR.

Methodist Health System

THE HOSPITAL OF TOMORROW

Innovations we can only dream of today may become commonplace within a decade.

IMAGINE THAT YOU MAKE A TRIP to the hospital for a simple annual check-up. When you arrive, you enter the specialized area where you need care—but it isn’t any part of your human body that needs attention. You have an appointment at the hospital’s implantables clinic, where the technology implanted into your eye—which guided you through the hospital to the clinic—needs a quick tune-up. In this seemingly alternate reality, the line between the repair shop and hospital is as thin as the line between body and machine. This fantastical exercise is closer to reality than it may seem. The hospital model is now being pulled in contradictory directions: Hospitals are expected to provide consumer-focused experiences for patients—similar to those created within the hospitality sector—and protect employees’ mental health and value, all while continuing to operate within the highest safety and cleanliness standards. They need to create welcoming and uplifting spaces with natural lighting and design elements, while ensuring many areas are safe, sterile, and able to support the latest technology. “Hospitals have moved from transactional to an experiential world, which affects operations and design,” says Jeffrey Stouffer, principal, executive vice president, and health group global director at architecture firm HKS. “It drives patient choice and drives a much more competitive market.” Competing goals are already fostering technological advancement to help meet these new market demands, and soon, as new developments roll out, the hospital of the future will become the hospital of today. Several North Texas healthcare experts shared their thoughts on what the hospital of the future might look like—just 10 years down the road.

AI Could Deliver Diagnostics

Technology is eliminating the need for doctors to memorize massive amounts of medical information, and, as a result, their role is changing. “Physicians will become more of a broker of care and will be more high-touch, more relationshipdriven,” says Ashley Dias, associate principal of health at Perkins & Will in Dallas. “AI will support a lot of the information breakdown and diagnosis space.” Technology is also improving accuracy. With robotic surgery and 3-D modeling, the ability to precisely target problems and avoid invasive surgery will make surgeries more successful and infections more rare. “Providers can 3D model hearts and use AI to detect issues beforehand,” says James Griffin, CEO Invene.

SERGIO MARCOS ; THIS PAGE JAVIER PARDINA OPENING SPREAD BY

Analytics Will Continue to Drive Innovation

Major hospital systems are connecting with data giants so AI can predict health outcomes, find treatments with the best results, and improve hospital protocols. For example, Medical City Healthcare and its parent company HCA Healthcare, with 185 hospitals across the country, are partnering with Google Cloud to lean on Google’s data analytics availability to make workflows more efficient and give providers treatment guidance. Texas Health Resources and Baylor Scott & White Health are also getting on the big data train, too, partnering with health provider-led data platform Truveta. The new partnership gives Truveta access to depersonalized medical records representing 15 percent of the nation’s patient care. The goal is to eliminate fragmented health data and make conclusions from the millions of patient care visits represented in the partnerships. As these organizations unearth new patterns and develop new protocols, patient care will become guided by amounts of data larger than hospitals could previously imagine. “We have these economies of scale here that serve a huge population of people and a wide cross-section of our nation,” says Dias. “And we have a major powerhouse in the tech-

Flexibility at Hospitals Will Be Paramount nology world that can work that data.”

Stays May Become Much Shorter

Increases in in-home care technology might soon make for shorter hospital stays, bringing doctors and nurses to patients whenever possible. “If technology can get us closer to that, and I think it is, then it is certainly desired by the patient and potentially could save costs as well for systems or payers,” says Dr. Hubert Zajicek, CEO and co-founder of healthcare accelerator Health Wildcatters. Monitoring technology would instantly connect providers to patients, enabling constant updates on vital signs or diagnostics. “The boundaries are blurring between where care is delivered and how care is delivered,” Wingler says. “The lines are getting blurry between home health, home care, and healthcare.”

The hospital of the future may have patient rooms that can convert from low to high acuity—able to serve as a room where patients can visit with family, then quickly transition to an intensive care unit if needed. Under this design, care teams and technology would travel between rooms rather than the patient. Design could also feature elements to address physician burnout, which has been an issue since long before COVID-19. Many hospitals currently do not feature much natural light or offer relaxing spaces for staff to take a breath—elements that will likely shift in years to come. “We can provide for [hospital staff] so that the load they carry doesn’t go beyond their human limits,” says Deborah Wingler, health research lead at HKS.

Wearable and VR Technology Will Rule

The next decade may bring an increase in wearable technology, which could move wayfinding into hospital apps and perhaps even into ocular technology that augments reality and directs patients to their treatment area. They could also connect with physicians and learn about their conditions. Once admitted, patients may be able to visit with loved ones via virtual reality platforms, reducing contagion while providing a welcomed diversion. “That transportation to another environment is a positive distraction and brings stress reduction, which we know is great for improved outcomes,” says Dias of Perkins & Will.

PHYSICIAN ROUNDTABLE

POWERING AN EVOLUTION IN CARE

Primary care physicians may provide the answer to skyrocketing healthcare costs and the depersonalization of medicine.

THE EXPERTS

DR. JEFF BULLARD

MaxHealth Medical Associates

DR. BETH KASSANOFF-PIPER

North Texas Preferred Health Partners

DR. ANGELA MOEMEKA

Mark9 Pediatrics

DR. MARCIAL OQUENDO

TLC Pediatrics of Frisco, Oak Cliff Pediatrics

The medical home has expanded beyond the primary care physician’s office walls, upending the idea of the traditional doctor’s visit for physicians and patients alike. Additionally, the shift to telehealth, the focus on population health management, and medical technology acceleration have all impacted patient flow, finances, and communication. When it comes down to it, primary care physicians, and the proactive and preventive services they provide, hold the key for healthcare cost containment and more personalized care. We recently spoke with four Dallas-Fort Worth primary care physicians about the challenges they face, the changes they’ve seen, and the opportunities ahead.

HOW DID COVID-19 CHANGE YOUR PERSPECTIVE ON YOUR CAREER?

DR. ANGELA MOEMEKA: “I launched my private practice as the Sars-CoV-2 virus was identified and began to spread. Direct patient care and office workflow would need a revamp to preserve access to care. I began to wonder about the stability of private practice as I witnessed well-established practices struggle and even close during the first few months of the pandemic.”

DR. JEFF BULLARD: “With the onset of the pandemic, suddenly the grander ‘we’ came into vision. Every day felt like a population healthcare delivery day. I am a family medicine physician, and COVID reminded me of the importance of my role as a community health connector.”

DR. MARCIAL OQUENDO:

“Doctors today spend more time clicking boxes, looking up billing codes, and chasing metrics than spending time with patients and their families.”

DR. MARCIAL OQUENDO, Oak Cliff Pediatrics

“COVID humbled me and everyone into understanding that there is no such thing as a ‘sure thing.’ Right as the COVID pandemic started, I was in the midst of a major transition in my career, going from employee physician to business owner and entrepreneur. For the first few months after the lockdown began, I realized that opening a traditional office was not going to be a good idea. So, I branched out and formed coalitions and mutually beneficial partnerships with other doctors that needed someone to keep things afloat during the trying times.”

DR. BETH KASSANOFF-PIPER:

“The pandemic gave me a new appreciation for my work team, especially my nurse and my partners, and their ability to adapt to change. COVID-19 reinforced how important it is to have a solid connection with patients so they know they can rely on my guidance in confusing times.”

WHAT CHALLENGES DID YOU FACE IN SHIFTING TO REMOTE VISITS? BULLARD: “The biggest challenges were around establishing new workflows, combining in-person with virtual visit scheduling and staffing assignments. We wanted our patients to have a great experience. They were stressed, and most were also experiencing telehealth for the first time.” OQUENDO: “During 2020, I went from 100 percent inperson practice to 100 percent telemedicine at the beginning of the lockdown to now a hybrid of mostly in-person visits but with a strong telehealth component. I have found that it is a great way to keep open communications with patients, even if it’s a ‘last patient of the day,’ last-minute appointment, or a ‘mother has a quick question.’”

KASSANOFF-PIPER: “I was concerned that both the patients and I would find telehealth to be inferior to in-person visits, but I was very pleasantly surprised at the outcome. Being able to see my patients, even if not in person, made assessing their health, and especially their mental health, much easier than just hearing them on a phone call.” MOEMEKA: “We did begin offering virtual well-child visits, but many families preferred to wait it out, not wanting to risk taking children outside the home. We began to incorporate synchronous and asynchronous methodologies into our practice. I worked with our billing company to understand the coding and payment processes for these visits. Texas Medicaid led the way in paying for telemedicine visits in a very expansive sense.”

HOW HAS THE PANDEMIC CHANGED CHRONIC DISEASE MANAGEMENT?

OQUENDO: “Chronic condition management via telemedicine has its pros and cons. We can continue to see the patient on a regular basis for a quick check-up and status update without them having to make a visit. However, telemedicine can limit a physician’s ability to pick up on subtle nuances that can only be seen in person— things as simple as moles or skin color, new tattoos, cutting behaviors, and scars that the

“Value-based care has been the theme for decades; the new shift is to value-based payments.”

DR. ANGELA MOEMEKA, Mark9 Pediatrics

trained eye would notice and would dig into.”

KASSANOFF-PIPER: “I stress the importance of preventive healthcare. Many patients missed their routine screenings for breast and colon cancer during the pandemic, and I continue to work with those patients to get them caught up.” MOEMEKA: “In pediatrics, ADHD and asthma are the primary chronic diseases. These are all easily done remotely. New tools have also emerged to allow virtual chronic disease management to thrive, the most notable being remote patient monitoring devices. In asthma, for example, digital inhalers allow patients to track symptoms and inhaler use then share this information with their physician via portals.” BULLARD: “Physicians will typically recommend home blood pressure, blood sugar, and weight monitoring for our hypertensive, diabetic, and heart failure patients, respectively, but I believe we likely placed more value on those measurements that took place in our offices. During COVID, that shifted. As a result, we recognized the value of upping our game on home management and monitoring efforts, including increasing the time spent on disease state education with patients, coaching on the ideal way to measure and record home collected data, and helping patients navigate app selection for managing weight, diet, and exercise.”

HOW DO YOU SEE TECHNOLOGY IMPACTING YOUR PRACTICE IN THE FUTURE?

KASSANOFF-PIPER: “The greatest advantage I have seen so far is in patients who can share their glucose readings with me remotely, so we can catch up on their progress several times weekly, if necessary, rather than waiting longer periods to make adjustments. This is already improving patient outcomes.” MOEMEKA: “I see the increase in wearable devices increasing health literacy for my patients and families. It eases discussions on disease management and gives a common objective language for symptoms. For example, a child using a digital inhaler can say their asthma has been worse than usual over the past two weeks but can now also show me their tracked inhaler usage each day, which tells a measurable story.” BULLARD: “I see a day in the near future when doctors and patients will be discussing the patients’ progress in their lifestyle app, reviewing data from their remote monitoring blood pressure device, and having a group video visit that includes the doctor, the patient, a spouse or caregiver, and a care team member such as a dietician or a specialist.” OQUENDO: “I believe in the not-too-distant future people will have their own digital-firstaid-kit, with digital otoscope that can send pictures to the pediatricians to check for ear infections, inexpensive Bluetooth stethoscope adapters for phones through which parents can stream of a child’s breathing by following a simple interface app on the screen, and thermometers that can share today’s temperature trends so doctors can look for improvement.”

HOW WILL A SHIFT TO VALUE-BASED CARE IMPACT YOUR PRACTICE? BULLARD: “We are champing at the bit for this type of change. The impact of COVID was that it shined a bright light on so many of the things that are wrong with the way care is delivered. The disconnect between what works and what’s valuable to the doctor-patient relationship and those that make decisions about how the business of healthcare will operate is unfortunate; I think the shift to value-based care can narrow that gap.” OQUENDO: “The reality is that the current system is designed for big players; more than half of the physicians in Texas are employed and not independent. The incentive to include small groups or solo practices has not yet been felt. New models will have to emerge to bridge that gap while also navigating the legal barriers that keep offices from gaining any leverage in the value-based contracting model.” MOEMEKA: “As a general pediatrician, value-based care has been the theme for decades. The new shift is to value-based payments. For my practice, this means streamlining population health management—not only understanding the who, what, and when of gaps in care but also linking with community partners to address the why.”

KASSANOFF-PIPER: “I work hard in my practice to provide care tailored to each patient’s specific situation and to create that unique relationship with patients that encourages them to work with me toward better health. This, in turn, leads to better management of their chronic health conditions and, ultimately, better care overall, which is recognized in valuebased care payments.”

“We could do a much better job dealing with the health of our communities if we focused on proactive versus reactive care.”

DR. JEFF BULLARD, MaxHealth Medical Associates

HOW DO YOU INCORPORATE MENTAL HEALTH AND WHOLEPERSON HEALTH INTO YOUR PRACTICE?

OQUENDO: “A combination of different interactions is how we achieve a true wholeperson health approach. Rarely before have we had a window inside a patient’s home. This is important in getting the whole picture, especially as socioeconomic determinants of health are directly linked to your home, your internet access, and living conditions. Mental health has been the biggest sequelae from this pandemic, particularly in teens and young adults. Telemedicine for mental health is going to stay and will be the main form of accessing therapy and treatment moving forward.” MOEMEKA: “I take into consideration the family background and psychosocial environment affecting my patients. It is difficult to care for my patients otherwise. A 2-year-old doesn’t just walk into my office alone and leave with antibiotics for their ear infection. Instead, that 2-yearold comes in with a parent who is tired from not sleeping for several nights due to their child’s ear pain and irritability, and possibly a parent who is worried about missing another day of work to care for a febrile child who cannot return to daycare. Similarly, an 11-yearold with chronic abdominal pain may be challenged by the transition to middle school and manifesting symptoms of anxiety and stress.”

KASSANOFF-PIPER: “It is so important to understand the whole person, including their home environment and their stressors. I get to know my patients very well and ask detailed questions about these factors and their mental health so that I can give advice that fits them specifically. Many patients will not bring up the subject unless directly questioned. A large number of my patients have had increased anxiety and depression through the pandemic, and not all realize how great that impact is on their health.” BULLARD: “We have taken an integrative approach to care, including fully integrated mental health. In 2007, we started a brain health center, which now includes a counselor and psychologist, treatments for difficult-to-treat depression patients, and a full suite of assessment and treatments for the most common mental health and cognitive issues our patients face.”

WHAT AREA OF MEDICINE IS NOT GETTING ENOUGH ATTENTION, AND WHY?

OQUENDO: “Physician burnout. Doctors today spend more time clicking boxes, looking up billing codes, and chasing metrics than spending time with patients and their families. Primary care and preventive medicine have become a numbers game and all about economy of scale, when it should be the other way around. Making doctors become computer clerks and having them spend several hours a day entering data into templates—for insurance companies to decide what gets reimbursed and what doesn’t—will only lead to more burnout, with worse outcomes for both the medical community and patients.” MOEMEKA: “Health equity for children does not get the attention it needs, mainly because people see children as primarily healthy. We know hundreds of millions of children are uninsured and underinsured, lacking access to the basic care that’s needed to maintain health. We know trauma impacts children in ways that lead to chronic disease and morbidity as adults. We know the first 1,000 days of a child’s life are critical for brain growth and development. These facts all float around us as health inequities that do not get the policy focus needed to effect change.”

KASSANOFF-PIPER: “Doctors must address patients’ anxiety and depression, as well as underlying circumstances, such as their work and home responsibilities, what help they have at home, and whether they can afford medications, to help them achieve better health.” BULLARD: “We could do a much better job of dealing with the health of our communities if we focused on proactive versus reactive care. We do what we are paid to do; as a result, we primarily see patients when they are already sick. Suppose we could instead spend our energies understanding a patient’s daily behavior or situational challenges that impact their health, and work with them before they develop a chronic disease. That could help bend the cost curve. To do this, we must invest more in primary care.”