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Partnering to Fill Gaps in Subspecialty Care

Case Study · October 24, 2016

Since 2005, Bridgeport Hospital has built a strong relationship with Yale–New Haven Hospital and Yale University School of Medicine. The partnership allowed us to fill gaps in certain subspecialty fields while integrating the clinical-care culture for providers at the two institutions and ensuring a steady stream of new talent for Bridgeport.

Key Takeaways

  1. Identify subspecialty shortages that the community hospital and its physicians cannot recruit. Develop contracts with the academic center that allow both sides to gain something.

  2. Share resident physicians, clinical fellows, and administrative fellows. Some of the most talented people will prefer the non-academic environment; carefully identify who will prefer it by getting to know them first as trainees.

  3. Foster a collegial relationship with the academic center so that you can attract outside leaders with the prospect of a full integration between the two institutions.

The Challenge

Bridgeport Hospital (BH), a 425-bed major teaching hospital and safety-net provider for Bridgeport, Connecticut, has been part of Yale–New Haven Health (YNHH) since 1995. Our CEO at that time approached YNHH’s leadership to propose a partnership, which YNHH embraced as an opportunity to enhance its regional presence. Despite that initial partnership, a decade later we had a deteriorating physical plant and a persistently slim operating margin (hovering around 1%). We knew we had to make major improvements to meet our community’s needs.

We decided to strengthen our partnership with YNHH by further integrating our hospitals, including some service lines, and by trying to meet subspecialty-care needs that we could not address alone locally. This stronger institutional affiliation had many facets, but in this present case study we focus on how we filled specific gaps in subspecialty care and built a strong leadership team in the process.

Starting in 2005, a committee that focuses on physician succession in primary care expanded its scope to include specialty and subspecialty care. In-depth analyses identified 11 “subspecialties in crisis” that our community physicians could not address and for which our hospital was unable to recruit the requisite clinical staff. These areas included hepatology, radiation therapy, surgical oncology, and others, in addition to gynecologic oncology, where we had already had some success collaborating with Yale Medical Group (YMG). Actively supported by YNHH’s leadership, we created mutually satisfactory contracts with YMG’s subspecialty sections in those areas.

The Goal

It was important to BH and its medical staff that we offer the full spectrum of care to our community. Our goal was to fully integrate our newly contracted YMG subspecialists while maintaining the institutional identity and morale of our existing community physicians.

The Execution

Being part of a health system led by an esteemed academic medical center made many of our physicians concerned that they would get short shrift. We took several steps to allay those concerns while making the arrangement appealing to Yale.

First, we strictly limited our YMG agreements to the identified “subspecialties in crisis.” We communicated with the clinical chairmen, section chiefs, and community practice leaders on a regular basis about our recruitment of subspecialists. Joint recruiting took about a year to complete.

Some BH physicians also worried that Yale might open its own practice in eastern Fairfield County, near Bridgeport. Therefore, in our affiliation contract we outlined a deliberate three-level arbitration process for any expansion of YMG into that region. To make the situation a win for YMG as well, it was allowed to retain its professional fees and expand its geographical reach. Yale was also providing critical patient-care services for our community and essential educational services for our graduate medical education (GME) programs, thereby ensuring that YMG would not sustain financial losses related to the hiring.

We have filled our subspecialty gaps while increasing our physician-leadership ranks, thereby melding the cultures of the two institutions. Consider how we integrated some of our GME programs — in surgery, emergency medicine, and pediatrics. These Yale residents now spend a substantial portion of their time at BH. After completing their training, some graduates return to gain clinical and teaching experience at BH without the pressure of having to do research, as they would at Yale. For example, we hired two fellowship-trained burn surgeons as a result of their rotation experience at BH. We also hired five YNHH clinical and administrative fellows, after they completed their fellowships. We now have a cadre of excellent developing administrative leaders.

Thanks to our joint subspecialty recruiting with YMG and YNHH, we have superb physicians providing the full range of primary and subspecialty care, and our community physicians no longer worry about being overshadowed by YMG. In short, we have built very successful practices that benefit YMG, YNHH, and BH.

The Team

The key team members in this effort have been the senior staff, the clinical chairmen, and the planning staff for the hospital. Finance as well as our legal counsel have also played critical roles.

The Metrics

We track historical subspecialty volume as well as migration to other states using a robust state registry. We discuss the findings at quarterly leadership retreats and act on the results. Two examples: In 2003, our combined inpatient and outpatient gynecologic surgery volume was 260 procedures annually. Within 5 years, the annual volume increased to more than 2000 procedures and has stayed at that level; similarly, our cardiac surgery volumes rose from barely more than 100 per year to just under 200.

Next Steps

The affiliation with YNHH has allowed us to attract gifted physician leaders and administrators. It sounds clichéd, but leadership counts. We have assembled a smart, motivated, cohesive leadership team that has led the transformation in areas beyond the subspecialty recruitment described in this case study, including the chairmen of emergency medicine, psychiatry, and internal medicine — and the chiefs of trauma, geriatrics, gastroenterology, and endocrinology. We are still recruiting for thoracic surgery, urologic oncology, and pediatric gastroenterology — and for those efforts, we will continue to derive value from the structure and process of our committee that focuses on physician succession.

Nevertheless, our subspecialty recruitment effort is not a one-time fix, but a work in progress. Here are the ongoing challenges:

  • Hiring academic physicians is not cheap. Besides recruitment costs, the substantial overhead costs for full-time faculty must be incorporated in the contract.
  • Academic physicians tend to relocate more often than other doctors. For example, our excellent young pediatric gastroenterologist moved on this past summer.
  • We simply don’t have adequate volume to keep some subspecialists sufficiently busy, so they supplement their work in other ways. For example, our ENT oncologist also sees patients at the West Haven VA medical center.

This is not a complete list of our challenges, but many as they are, we have made great strides and are committed to sustaining our progress.

 

This case study originally appeared in NEJM Catalyst on January 29, 2016.

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