“One day I was Jewish, the next day I was Advocate.”
The senior cardiologist from NorthShore University HealthSystem who uttered this comment garnered a nervous laugh from everyone. While the ripple effects of the proposed mega-merger between two of the larger health care systems in Chicago, NorthShore University HealthSystem (my employer) and Advocate Health Care, remained unknown, the immediate anxiety among workers was palpable.
“What do you think, Dr. Fisher?”
I had to stop and think for a moment. What does such a merger mean to organization? What does it mean to local workers? What does the merger mean to doctors as a whole in these two systems? What does the merger mean to patients?
I suspect from an organizational standpoint, this was an important and necessary move to maintain viability in the increasingly competitive health care marketplace and one that was carefully planned to position each of the organizations nicely in the dog-eat-dog push for patient populations to manage. Waiting until the prior merger between two other affluent medical systems, Northwestern and Cadence, was strategically important as NorthShore and Advocate attempt to gain approval for the merger from the Federal Trade Commission and Illinois regulators. While these issues are important to the ways of health care business these days, how they will affect health care delivery remains to be seen.
In most ways, I suspect the merger of NorthShore and Advocate to become “Advocate NorthShore Health Partners” reflects a reality – the two systems will function as they have in most areas except for contract negotiations with insurers at first. A huge geographic footprint of metro Chicago is consumed by these two organizations. To that end, the administrators savvy in these skills will be uniquely positioned to retain their jobs, but since both organizations will be culling redundancy to save costs, middle management will feel the first effects if this “partnership” consummates. This will serve both health systems well and “cut costs,” but I suspect that little of this cost savings will seen by patients.
Electronic Medical Records
NorthShore University HealthSystem uses EPIC Systems for it’s entire electronic medical record system solution – both in and outpatient – while Advocate uses Cerner’s Millennium EMR system for its inpatient EMR, Allscripts for its employed-physician group outpatient EMR, and eClinicalWorks for the EMR of it’s “physician partners.” Bruce Smith, Chief Information Officer at Advocate previously explained the rationale for their three-EMR system this way:
“… it gives our independent physicians the option of staying independent. They select if they use the software [and] they work with the vendor. If they choose to leave Advocate Physician Partners, they can do so and take the data with them. It remains under their control, as opposed to the Medical Group, in which everything is in one shared database.”
While this solution worked for a while, the complexities of maintaining three systems makes the Cerner/Allscripts/eClinicalWorks solution at Advocate vulnerable to EPIC Systems’ unified EMR solution. It is also interesting to note that the latest 2014 Medscape EMR Report tabbednationwide EPIC penetration at 23% to Cerner’s 9%. NorthShore University Healthsystem was the metro Chicago’s first EPIC client and while its 4 hospitals are a relative minority compared to Advocate’s more geographically diverse 12-hospital system, its seamless outpatient and inpatient integration of EMR platform may threaten Cerner and Allscripts control of Advocate’s EMR solution. While I suspect change may not come immediately, if a move to consolidate EMR systems occurs, both doctors and patients in one of the systems may seen some dramatic changes going forward as a result.
Physicians
For employed physicians of each system, the effects of this union will be minimal. But for those who are independent, if an EMR system switch is required, many more will find themselves joining a system because of prohibitive costs to make such a change. There will also be renewed efforts to consolidate payment models for physicians system wide if these large health systems unite. As Medicare and Medicaid payments are restricted by CMS in the future, pressure to control expenses for such a large system will be inevitable. Advocate is employing a “budgeted payment model” compared to a “fee-for-service model,” so doctors will be instrumental at working along side the health care system to achieve cost savings while attempting to maintain care quality – not always an easy thing to achieve. Also, in-system referral of patients will be encouraged, if not eventually tacitly mandated, but one advantage to such a large system is that more resources are available. Whether the affluent patient population of NorthShore’s population will want to utilize those resources remains to be seen. But it is interesting to consider the possibilities that might arise as colleagues from one system can unite with colleagues from another health system to provide care.
For individual physicians joining such a large system, the opportunity for a wide range of practice environments exists, but the wide geographic spread of this system makes the possibility of having to practice in multiple locations (especially for specialists who are increasingly viewed as “proceduralists”) a larger reality. Also, geographically-stipulated non-compete clauses in employment contracts will be a concern since the newly-formed “partnership” might mean the physician would have to relocate to another city if they wanted to change practice environments. This is a growing concern for doctors who want to practice in Chicago as health systems consolidate. While this concern might not mean much to the average patient, it might be affect recruitment of specialized physician talent to the Chicago Metro area.
Staffing
For most nurses and technicians, I suspect the effects of consolidation of these two systems will be minimal. More likely, the combined assets of these two large health systems might facilitate some improvements in staffing as the patient population served by these two systems swell. But both systems are plagued by the needs for wide geographic coverage of hospitals. And as competition for trained technical staff continues between large health systems, turnover is likely to be higher in systems that require greater amounts of entropy as staff are shared between hospitals or employees might make a change to a hospital closer to their home, impacting some centers more than others.
Patients
For most patients, the implications of such a mega-merger will be minimal at first. But the current trend of rising out-of-pocket health care costs for patients does not seem to be abating. Mergers are business decisions, not patient care decisions, and the people most likely to benefit from “cost savings” and “efficiencies” (as defined in the press releases of this merger) are more likely the systems themselves. But eventually, these rising out-of-pocket costs swill push a demand more transparency of procedural pricing – first with expensive diagnostic tests (like CT/MRI), then with medical procedures. And while health systems will need to compete with each other, their larger monopoly will keep prices artificially high since competitors will be few.
Patients will also see their doctor staring at computer screens more than ever as EMRs change and incentives for data entry are tied to physician compensation even more in the new managed care environment ahead. Senior doctors’ pushback on these requirements will be tolerated for a while as health care systems wait for them to retire, but younger tech-savvy physicians will consider this form of health care their new norm.
Healthcare.gov problems and rising penalties for those without insurance will kick in in 2015 – how these issues will affect such a large health care system remains to be seen.
Summary
So we’ll see how this works and how many of my predictions come true in the years ahead. One thing’s for certain, health care in Chicago, just as in so many other regions of the country, has forever changed to fewer health care delivery options for both physicians and patients.
-Wes
