INTERVIEW

Preserving independent practice

Owen O’Neill, MD Infinite Health Collaborative

Please tell us about Infinite Health Collaborative (i-Health).

We like to say that i-Health is a modern approach to a timeless idea. We’re an independent practice of like-minded physicians representing several unique specialties, including cardiology, colon and rectal conditions, family medicine, orthopedics, and women’s health. All of us believe that independence in health care enables physicians to focus on each patient’s individual goals without limitations, and that’s the inspiration behind i-Health. By empowering patient choice—arming patients with the tools to make their own educated health care decisions—we are earning their trust and keeping health care personal. In a nutshell, we deliver value-based care, enable physician autonomy, and preserve patient choice.

Please tell us about Revo Health and the services it provides for i-Health physician groups.

Revo Health, a management services organization, helps practices develop valuebased care services and provides support across several departments often referred to as “back of house.” These include revenue cycle, finance and accounting, human resources, information technology, quality, marketing, and more. Sharing these resources creates efficiencies and cost savings, fosters collaboration, and consolidates our expertise. Revo takes care of the business side, so physicians can focus on taking care of patients.

What kind of framework for growth and sustainability of independent physician practices does i-Health provide?

There’s power in numbers. By banding together, we preserve our independence and strengthen our voice in the industry. These days, many small practices are getting squeezed out or bought up by large systems, and transition to becoming employed by the system. i-Health is physician-owned and led, however, so every new physician to join becomes a fellow partner and retains ownership stake in the business. Another major advantage for our operating divisions is collaborative learning. Innovative operational initiatives such as developing prospective care bundles and collecting outcomes data takes time to develop. We’ve all experienced different stages of growing pains, so we help each other avoid re-inventing the wheel.

How can independent physicians be the drivers of the industry’s improvement?

We believe patient-physician relationships are the heartbeat of health care, and we intend to keep it that way. Independent physicians have autonomy to guide patients without the limitations of larger systems, and ultimately enable patients to make their own educated health care decisions. Getting back to basics and putting the power back in patient’s hands is how we believe the industry moves forward.

We believe patient-physician “...” relationships are the heartbeat of health care. “...”

What are some examples of how independent physician practice contributes to innovation in the health care industry?

Our independence enables us to mobilize and test new ideas quickly without the red tape of many larger systems. In the past couple of months, for example, OB-GYN specialists from our women’s health operating division launched curbside obstetric care in response to COVID-19, performing routine checkup tests that cannot be done virtually: blood pressure, baby’s heartbeat, position of the baby, and vaccines. Similarly, Twin Cities Orthopedics (TCO) launched virtual care in under seven days, going from zero telemedicine infrastructure to providing over 1,000 virtual care visits per week. The best part is we did so without sacrificing the patient experience. Niney-nine percent of TCO’s virtual care patients say they would recommend this service to family and friends.

What can you tell recent medical school graduates about the opportunities and benefits presented by the independent practice of medicine?

Our model, which centers around the patientphysician relationship, is the original health care model. Many physicians are attracted to independent practice because it reminds them why they got into medicine in the first place. i-Health provides immediate and long-term financial stability, and independence puts you in control of your own destiny. By building a strong reputation, and delivering exceptional care day in and day out, the sky’s the limit to your potential.

What are some of the ways i-Health members encourage patients to be active participants in their health care decisions?

It sounds so simple to do this, but it’s not our job to tell patients what to do. We encourage patients to be in control of their own health, and it’s our job to guide patients to make the best decisions for themselves. We accomplish this by clearly explaining diagnoses, walking them through options, listening to their concerns, and answering their questions. We also use anonymous clinical outcomes data from over one million survey submissions to set realistic expectations. For example, we can tell patients considering a hip replacement that six months after surgery, 97.93% of total hip arthroplasty patients reported little to no pain lying in bed and turning over.

What benefits can i-Health provide to self-insured employers?

It’s amazing how many employers are simply unaware of the freedoms they have when it comes to customizing their benefits plans. For example, they can partner with us tomorrow to give their employees more surgical care options and better outcomes via our TCO EXCEL Surgery & Recovery program, without changing anything else about their existing plan. It’s a simple add-on model, and the best part is it actually reduces costs across the board. In fact, some local employers have already identified i-Health as a preferred tier inside of their health plans, effectively encouraging their employees/patients to consider value-based care options.

New health care legislation is informed by considerable input from health plans, hospitals, and the pharmaceutical industry, but very little from physicians. How can i-Health help address this inequity?

This is a big reason why we were inspired to band together in the first place: to grow our shared voice in the industry. A voice that is focused on patient care and the delivery of innovation in the market. We deliver value-based care, which means we have actual data to prove how we can improve outcomes and patient satisfaction, while also reducing costs. We’re putting the data to good use in these conversations.

What can you tell independent physicians who may want to become part of i-Health?

We live and succeed on our own reputation, and often take the road less traveled, which isn’t for everyone. We were founded upon the promise that no matter what, the care of our patients would always come first. It’s in our DNA, and it’s what drives us every single day. The freedom we are granted as an independent practice allows us to be innovative, create meaningful solutions to complex problems, and deliver on that fundamental promise. And, ultimately, it’s how we provide value. If your core motivation as a health care provider aligns with our core principles, and you share our vision for the future of value-based care, then we would love to get to know you better.

The recent government response to cancel “elective” surgeries brings up several important issues. What are your thoughts on this?

On the orthopedics side in particular, we have seen many patients suffering as a result of elective surgery restrictions. We have observed increased opioid drug use and suicide attempts from patients dealing with severe pain and immobility, in addition to prolonged pain leading to poor long-term outcomes. Prolonged waiting causes stress physically, mentally, emotionally, and financially. Treatment for many of these patients was initially categorized as elective or non-essential when the COVID-19 pandemic began.

The good news is that we have developed comprehensive safety protocols that have enabled us to perform more surgeries in a safe, COVID-free environment within ambulatory surgery centers. We are using a clinical risk stratification tool to determine which surgeries can be performed first, we’re testing patients and employees for the virus, we’re screening at entrances, and much more. Our patients and their families have high expectations for their care, and we want our safety standards to exceed those expectations.

Owen O’Neill, MD, is a board-certified orthopedic surgeon with fellowship training and subspecialty certification in sports medicine. He is a board member for both Infinite Health Collaborative and Twin Cities Orthopedics.

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3Restorative Justice from cover reintegrate students sanctioned by suspension back into school. Restorative practices are trauma-informed and can break the cycle of harm, separation,

If the goal of academic medicine is to heal, whether by discovery of new distrust, and more harm. knowledge, caring for those with illnesses, teaching the next generation of healers, or providing accessible and equitable care for Minnesota Not all harmful situations are appropriate for a restorative approach. communities, can academic medicine improve If someone does not acknowledge they committed its ability to heal by incorporating restorative a harm, refuses to participate in a restorative practices into the work? This is the question practice, or if potential participants in a circle wish posed by the Association of American Medical to dispute a sanction and debate the facts of an Colleges (AAMC) who selected the University incident, restorative practices are not appropriate. of Minnesota Medical School as one of seven colleges of medicine across the country to train a cohort of faculty and staff members in restorative Restorative practices can be used to improve culture. A restorative practice does not obviate the need for a sanctioning process and, in fact, could be used in conjunction with sanctioning. justice approaches. What is actually involved in doing a

What is the history of restorative practices restorative circle?

and restorative justice? Many may be familiar with circle processes. Restorative approaches are not new. They are Restorative circles are good for addressing issues deeply rooted in many Indigenous cultures, including the Ojibwe and of culture, including examining the accessibility Navajo people of North America and the Maori people of New Zealand. of a clinic or exploring how to build a better mentoring program. For a The term “restorative justice” emerged in the 1970s in the United States restorative justice circle, there is extensive planning ahead of time. The criminal justice system as a way to bring victims and those causing harm facilitators thoroughly prepare by interviewing the participants beforehand, together to repair harm and rebuild relationships. Eventually, the restorative planning out ways for participants to connect and talk about the impacts, justice processes involved others impacted by the trauma or event, including proposing how to build trust and community, and finally, proposing some families, friends, and the community. Restorative justice then expanded actions for participants in the circle. into other realms, particularly education, to address discipline issues and Once the circle is formed and agreements around the conduct of the circle are established, the facilitators ask a series of questions that each participant answers in turn and uninterrupted. When meeting in person, a circle would involve a talking piece, an object of significance to the group or

CELEBRATING 30 YEARS OF PROVIDING facilitators that is passed between participants and held by those speaking.

CREATIVE PLANNING & DESIGN A talking piece promotes respect and equity of voice. On remote platforms,

SOLUTIONS FOR EFFICIENT, PATIENT- the facilitators establish a way of designating whose turn it is to speak.

CENTERED HEALTHCARE ENVIRONMENTS Participants are encouraged to listen deeply and tell their own stories. Circles are built on a foundation of respect, integrity, fairness, and confidentiality. A concept that resonated with me is that participants should “take the learning, not the stories.” Rounds of questions eventually lead to the understanding of themes and then action items, if desired. Sometimes, circles are designed for exploring the understanding and impact of an external event and not to determine action items.

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Why did the University of Minnesota Medical School do this pilot program?

Excellence in all mission areas of the U of M Medical School is based on integrity, inclusion, and teams being able to work effectively together and with communities. The focus of restorative practices is to build relationships with each other as participants, repair relationships that may have been damaged, and promote healing if relationships were harmed or build community. Restorative practices can be used to improve culture, repair harm around a specific event or action, and reintegrate a person who has been separated from their work or learning environment. The goal of the U of M Medical School’s participation for the pilot program was to explore how restorative practices could be used to improve culture across all mission areas.

Restorative Justice to page 224

David Schultz, MD Chief Executive Officer Nura Pain Clinics Peter Schultz, MD, MPH Medical Director Nura Pain Clinics

R. Scott Stayner, MD, PhD Medical Director Nura Surgery Centers

Our thoughts on chronic pain…

1. Chronic pain doesn’t take holidays.

Although the COVID-19 pandemic has captured the headlines, chronic pain does not relent. According to the CDC, high-impact chronic pain (pain that interferes with work or life most days or every day) affects approximately 20 million U.S. adults.

2. Opioids are a problem.

They can also be part of the solution.

According to the CDC, opioid overdose is now the leading cause of injury-related death in the United States. Yet opioids have a rightful place in treating chronic pain, as some patients achieve life-changing improvement with minimal side effects on long-term opioids. Even at high dosage levels, opioids do not harm the body’s organs, unlike NSAIDS and acetaminophen. And thanks to the micro-dosing capability off ered by implanted spinal drug pumps, many of the most challenging cases can be treated effectively without risk of addiction.

3. There is no silver bullet.

One of the challenges in treating chronic pain is the patient’s sometimes-overwhelming desire for a silver bullet, a “cure” or a magic button to turn off their pain. While that desire is understandable, in complex chronic pain there is rarely a single perfect answer. At Nura, we’ve found that a comprehensive approach which addresses the physical and psychosocial components of chronic pain is the best solution. So in addition to earning national recognition for leadership in implantable pain technology, we offer behavioral counseling, physical therapy and opioid management, all designed to help the most challenging pain patients.

If you have a patient struggling with chronic pain and you’d like to discuss the case, please call our Provider Hotline at 763-537-1000. If the situation is urgent, we will do our very best to see your patient the same or next day.

Edina & Coon Rapids | nuraclinics.com | 763-537-1000

3The Science of Culture from cover

teams in organizations, and attitudes and beliefs direct the energy that drives performance. For healthcare organizations performance translates to organizations. Observations will refer physicians in independent practices clinical quality, the patient experience, economic and financial productivity, and to employed physician groups operated by health systems, with key employee turnover rates, and it affects the quality of the talent the comparisons to independent physicians affiliated organization attracts. with hospitals and health systems. Understandings Employees bring basic human needs and derived from such comparisons are important, wants to the work setting, along with their since most health systems in the U.S. are staffed by personalities, personal and professional work physicians who fit into three categories; employed, histories, and their hopes, aspirations and contracted or independent. The scope of the There is no unified culture expectations for their prospects as a member of definition of organizational culture is narrowed to in most organizations. an organization. These prospects manifest as “leadership culture”. The observations, and related expectations for extrinsic and intrinsic rewards. support provided here derive from administration Leadership’s delivery on the expectations for of the CulturePulse; a proprietary evaluation the extrinsic rewards are the easier parts of tool developed by D.K. Zismer and B.J. Utecht. the equation; extrinsic rewards come in the This tool evaluates the leadership culture of forms of money, advancement, accolades organizations based on the assumption that the principal job of leaders is and recognition. Delivery on the intrinsic rewards is typically more to define, design, deploy and direct the cultures of the organizations they challenging for leadership, but can have the greater influence on the lead. The format provides boards and senior leadership teams an agenda for culture of organizations; intrinsic rewards such as trust, fairness, equity, discussions regarding the leadership culture of their organizations, including security, predictability, appreciation and fidelity to the implied promises how leadership culture affects organizational performance. of missions and values. Individual perceptions of the leadership culture

Culture in organizations is a product of the human condition at of organizations are profoundly affected by the expectations for a work. Leaders are the principal factor in the curation of how that human spectrum of rewards, extrinsic and intrinsic, available as a member of condition forms individual and collective beliefs and attitudes toward the the organization. organization. Attitudes and beliefs affect the behaviors of individuals and Taxonomy of leadership culture Through administration of the CulturePulse to physicians, other clinicians and support staff in physician service organizations, evaluations of leadership culture observations may be drawn that help evaluate and define leadership culture. Some of these observations include the following points. There is no unified culture in most organizations; especially not in health care, including physician services organizations. Healthcare organizations are a tapestry of specialization of personnel and function. Consequently there are multiple sub-cultures within healthcare organizations. The state and status of these sub-cultures is the product of the leadership. Scores on our evaluations of culture in medical groups demonstrate that while staff may have clear perspectives on how the culture of the organization “should be” (and they will freely share their views and perspectives in our survey instrument), their perspectives on the culture of the organization overall is heavily influenced by where they work in the organization, department or division. So, while healthcare organizations are, in fact, collections of multiple subcultures, patients expect to be cared for by a unified team of professionals. Performance of the whole is a product of the multiple sub-cultures cooperating and collaborating together at consistently high levels of performance. Sub-cultures in organizations are susceptible to situational shocks and shifts. Shocks and shifts can come in a number of forms; examples include changes in leadership, internal consolidations of operating divisions and departments, budgetary performance shifts, and introductions of changes in clinical processes and programming. Shocks to one sub-culture can reverberate through others. No sub-culture operates in isolation of the others in healthcare organizations, and no sub-culture should be presumed to be stable, or impervious to shocks and shifts. Boards need to remain in-tune with how organization decisions may affect culture and performance.

Physicians may overestimate the health of the culture of the staff in the trenches. Physicians who have viewed CulturePulse scores of the staff in their own organizations, as compared with those of the physicians, have said things like “I guess we’re out of touch” and “we’re in LaLa land”. It is important to remember that while patients’ perspectives of their encounters with their physicians matter, the status of other subcultures encountered by patients matter as well. Inasmuch as patients will believe the physicians in clinical settings are leaders of the organization, including Physician organizations are keen all clinical programming and related services, they observers of how leaders interact. will attribute the condition of the full culture they encounter to the physicians; i.e., “it must be what they want it to be, they’re in charge.”

The factors (individual items on the CulturePulse) that most influence the opinions of the state and status of the people affiliated with one sub-culture may not be influential for others. Here again, the leaders of organizations should presume there is no unified or commonly held perspectives of the state and status of culture in organizations, nor is there a uniform approach to how leaders should address the cultures of the groups they lead.

There is a somewhat pervasive assumption held by students of culture that if the people of the organization understand the mission of the organization and know how they fit with and contribute to the mission, individuals are more likely to hold the status of the culture in high regard. Our results The Science of Culture to page 214 demonstrate that while important, these two can operate independently of individuals’ perceptions of the culture; i.e., one’s understanding the mission and their belief that they contribute meaningfully to that mission may have little bearing on their perceptions of the culture they work in every day. So, when the people of the organization reflect an understanding and belief in the mission, and they understand how they make meaningful contributions to the mission, leaders should not presume that all is well with the individuals’ perceptions of the culture and “where they live” in the organization.

Other repeating patterns of culture in healthcare organizations

Leaders’ abilities and inclinations to hold all to high levels of performance accountability are meaningful to the people of organizations. We typically see a stark “downdraft” in survey scores, across the board on this factor. “Holding all physicians to the same high standards of patient care quality” can be a very strong predictor of how physicians rate the quality of hospital leadership and the overall culture of health system leadership.

Staff in physician organizations are keen observers of how leaders interact to cooperate and collaborate with their peers (other leaders) for the good of the organization, and staff will routinely hold opinions of whether individual leaders behave in the best interests’ of the organization or self interest. The people of the organizations will also hold strong opinions on the whether leaders reflect the values of the organization in their decisionmaking, and leadership behaviors. A common mistake of leaders is creation of a “silo culture”. Extremes here can make those they lead feel stifled and even trapped by their leaders. Healthier cultures foster and encourage cooperation, collaboration and problem solving between departments, and division or clinical specialties.

The people of the organization will hold strong opinions on whether leaders work to ensure “an environment that can be trusted to be fair”. Most individuals in organizations understand that not every decision made by leaders will be pleasing to them, but they do expect leaders will make every decision based upon values of fairness and equity. The predictability of perceived trust, fairness and equity can be strong predictors of individuals’ motivation to perform at the highest levels on behalf of a mission.

How individuals rate the last item on the CulturePulse; i.e., “I believe the culture of the organization is as good as it should be” will predict their response levels to all other items on the evaluation tool. For example, if a respondent rates the state of the culture of the organization at the lowest level on the scale, it is probable they will rate all other items at low levels. Likewise those who rate the last item at high levels will tend to rate all others at high levels on the scale. While such findings may seem to be a statement of the obvious, the key point for trustees here is the breadth of the effect an individuals’ perceptions of the leadership culture can have. To be specific, if an individual rates the leadership culture at a low level they are likely to rate another 20 key leadership culture factors presented in the evaluation tool at low levels. To put this observation in the practical, if 15% of the work force in the physician services organization rate

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AUGUST 2018

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THE INDEPENDENT MEDICAL BUSINESS JOURNAL Volume XXXII, No. 05

Physician/employer direct contracting

Exploring new potential

BY MICK HANNAFIN

With the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.

Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk,

Physician/employer direct contracting to page 124 CAR T-cell therapy

Modifying cells to fight cancer

BY VERONIKA BACHANOVA, MD, PHD

University of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.

CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia.

CAR T-cell therapy to page 144

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