Kevin Kerber Interviews Ralph Sacco - June 9, 2017

Dr. Kevin Kerber: Just to start out, our first question for you would be, can you describe your current roles and responsibilities in terms of administrative aspects that impact patient care and care delivery? And what got you interested in those positions?

Dr. Ralph Sacco: So, my roles as chairman of a department at the University of Miami Miller School of Medicine—my clinical administrative roles would be as chairman. I have other research roles, but we’ll put them aside for now. But in terms of the clinical administrative side, being a chairman of a department, I run a pretty large department; I would say almost 65 percent of the revenue for our department does come from clinical revenue. As chair, you have to be a leader in what goes on in your outpatient and inpatient delivery. I have to negotiate with the hospital. And we have, really, two hospitals—University of Miami Hospital, where we provide services, and also a county hospital, Jackson Memorial Hospital, where we provide services.

So as a chair, I think you have to know, at least for your department, what are the clinical services you provide, what are the— what we will call— “programmatic income” that I have to try to negotiate and fight for to make our department whole?

K: Mhm

S: You know especially for neurology departments, you know a lot of our revenue when it’s attached to hospitals, are downstream revenue regarding radiologic imaging, procedures, [laughing] feeding neurosurgeons for the work that they do, and then, I think, when you look on paper, we can be underappreciated in terms of the overall revenue that’s generated directly by a neurologist, in terms of, you know, billing for specific patient care.

K: Mhm

S: So, I think, as a neurologist, and as a chairman, one has to, you know, have these—wear this hat, in terms of negotiating for your department the proper clinical support and revenue. In my department, I have diversified the leadership a little bit. I have a vice chair for clinical affairs, who happens to be my division director for stroke. And then we have other vice chairs, including a vice chair for administration. And she, who has more of a business background, also helps a lot with all the other clinical metrics that we have to accumulate and use when we try to negotiate with the hospital and the medical school for fair reimbursement to our department.

K: Mhm. What got you interested in taking on that role?

S: Well, it’s funny—you know, my first interest, obviously, was- is in research, and—I’m a translational researcher, and as I continue to go up the totem pole in academics—I led a division, and it was a stroke and cortical care division at Columbia, and again, as part of that role, you have to understand the business side of medicine, which is the clinical revenue generation, the profit and loss, the understanding about RVUs and metrics, and, you know, the ability to—to manage budgets. So it was a natural evolution, and then my next step was considering being a chairman, and, you know, I guess I could’ve just said, “Well, I’ll get a vice chair to do all of that,” but I think to really be successful in this, you have to, you know, go in headfirst, and really understand the-the revenue streams and the clinical administrative issues that need to be addressed in a department of neurology. So it kind of comes with the job; if you want to be a chairman, I think you have to understand, you know, that big part of medicine, which is sort of the business side. Not that we have training for all this, and sometimes the training is, you know as you go along.

K: And can you tell me how the—some of the decisions you make impact the care delivered to patients at your institution?

S: So, I mean, I think the bottom line, always, you know, as an organization is, the patient comes first, and we try to do everything we can to improve quality. Nowadays, with reimbursement being driven a bit by quality metrics, I think the patient is very much involved, and the care that we deliver to patients are—have to be quality-specific. With quality metrics, and the new macro-authorization, we’ll apply even more, you know, hopefully incentives for providing better quality. So I think quality is important; you know, we emphasize to our practitioners the importance of the patient, the PQRS measures, but also patient feedback. All of our practitioners receive dashboards, where they can get- see how patients rate them, as well as how—what comments are written about them. We try to educate our practitioners to understand that, and to share best practices—some are better communicators than others—to understand, you know, what- what is important for providing quality care and making sure our patient experiences is outstanding. And some of these kind of fit in with our health system, and programs at the health system, to try to provide, you know, quality-centric, patient-centric care. You know, incentives that we provide, clinical incentives, are also driven by some of the patient feedback. We recently just decided to expand our incentive plan—it was always just RVU-based, and that’s fine. You can generate all these RVUs, but if you’re not providing high-quality, patient-centered care, where patients are happy with your care, then that may not be the best way to measure performance. So we’ve now added—I think it’s about 25 percent of the incentive requires things on PQRS, patient feedback, and some other metrics that do involve the patient in helping come to a decision about whether that person meets all the performance metrics for an incentive.

K: In your administrative role as a chairman, as you moved to that level, can you describe something that was particularly surprising that you experienced when you got to that level? You didn’t expect something to happen, and once you got in that role it was a surprising aspect that you learned about, you know, the business model of it, or anything in that aspect that you didn’t really appreciate was important before you got to that role?

S: So I guess—I mean, I had some good advice from former chairs, which were helpful, so—they were helpful in giving me some advice along the way. In fact, I remember my chair at Columbia University, who will remain nameless [laughs], said to me, “Don’t forget—you’re boarded in neurology and psychiatry; use a lot of psychiatry as chair.” And I think the point of that is, there is always issues regarding, you know, people getting along, personality issues; that part of the job sometimes is less rewarding, especially when there are miscommunication issues and fingers being pointed. Some of that, you know, can be difficult, and sometimes requires even bringing in an external person.

I think early on, another chair actually advised, you know, said to me, “Do you have a coach?” And I said, “No,” and I said, “why, do you think I need a coach?”And then he said, “No, no,” he said, “it’s really good to have a coach, especially as a new chair.” And this person had already been a chair. So, I went to my dean and said, “Do you think I need a coach?” And he said, “No, I don’t think you need a coach, but if you want one, go ahead; we’ll pay for it.” And that was helpful, and I think—where was that helpful? One, for giving me personal advice along the way in some new areas, but two, probably one of the hardest decisions I had to make early on as chair were some changes in leadership—things that I kind of felt like I knew in my gut that I needed to make, but I hesitated and wanted to give people the opportunity to shine, and sometimes bringing in an external person to do a three-sixty and provide some recommendations helped me make those decisions. In retrospect, I think I once said, “Should I have made the decision sooner?”, and I think if I made it too soon, it could’ve been perceived as a kind of non-compassionate, rash decision, not giving people the chance to shine, even though I think I felt in my gut I knew that I was going to have to make this decision. So I waited, tried to get all the evidence in place, tried to get consensus built around before I had to make some tough decisions, and I guess those things you don’t really realize that are going to come with the job. You know, you think people management and personal management and changes will go really easily, and it’s difficult.

The other thing is, you know, sometimes you inherit certain leadership, and as a new leader coming in—and I think one of the things I remember learning from Gunther Grey was, you have to get people on the bus before you drive the bus, and so for me, early on, it was about getting the right people on the bus, and a lot of that did involve external recruiting and making some difficult decisions about changes in leadership for division leaders that had been there before.

K: Mhm. And I’d like to know—are there specific things that made it difficult for you to give high-quality care to the patients at your institution?

S: Difficult…well, I mean, one of the things for us, actually, is an access issue. You know, the biggest thing I deal with, probably on a daily basis, is either an email from the dean, or the CEO, or some other chair—“Can we get this patient in quicker to see you? We just can’t seem to navigate the access system.” Now, when I first got there, access was divided, and departments had their own access system, and at some point, we thought we were doing pretty well, because we had full control of access. Then they decided to centralize access, where, even off the campus, there’s a access group - there’s a certain turnover in that group, where they don’t know the physicians as well, and they don’t know how to navigate among our faculty, so some of quality and sometimes why patients can get discouraged, are often because it’s so hard to get in. So that affects quality, and actually, some of them walk with their feet, because they can’t wait for an appointment. So that was one thing, and how we had to try to get our physicians to be more responsive to add-ons, overbooking, sometimes extra clinics, to try to get these patients in. How do we rationally use advanced practice providers to maybe provide some of the follow-up, and then allow us to take in the new patients, which are of high demand?

The second thing is, you know, quality also depends on the staff, and I think we had to make sure that it’s not just the faculty, because many times, they are very happy with the faculty, but it’s also the staff—the check-in person, the check-out person, the cleanliness and friendliness of the facility. Some of those things are sometimes beyond our control, even though we are a practice-based clinic. So we had to try to envelop all of that when we think about quality, from the person who answers the phone when you’re starting to make that first call for a clinic appointment, to the check-out person, to follow-up when they call for issues later on; how to make sure our physicians and our staff are always trying to accommodate, you know, patients’ needs.

Another area for quality for us is feedback to the referring docs. That is still a very difficult problem in the ivory tower that exists in academic medical centers; it’s still a problem. One of our most successful neurosurgeons who came on to the University of Miami is loved by all the practitioners; he gets on the phone and calls everybody back, now- as soon as he operates or sees them. Busy neurologists sometimes don’t do that as well, even though our electronic health records send out these faxes; we just don’t have all the time in the system to call the referring docs, and that can sometimes compromise quality and handoff between us and referring doctors; that’s an issue.

K: In terms of difficulty with access, are there structural or policy things that you think are restricting access, things in the design of the care delivery system that you think would improve the access?

S: So, for us, again, access is now driven by central systems, but we have a default where we have—in the department, we had to build what we call a “neurology core,” where, if the central axis can’t do it, they then default to us. And we find that that core program, that is fully under the control of our department, is able to maneuver physicians’ schedules more adequately. So, I mean, I think like anything, everybody has to be flexible, our physicians have to be flexible. At our place, for whatever reason—I don’t know if it’s a south Florida phenomenon, but we have a very high no-show rate, as high as 25 percent. And when you have a no-show rate that high, the only way to deal with it, like airlines, is to overbook. Nobody likes to be overbooked. And trying to at least educate our clinicians to recognizing that, you know, if on average, one out of four aren’t gonna show up, then their time will be there for you to see that poor patient who needs to be seen quickly, and get them in the system faster.

So those are policies that we have to put into place, and some physicians are more willing to go with those policies of overbooking verse [sic] not. We created fast-track programs, where there, the patient will not know what doctor they’re gonna see, but they know they’re gonna see a doctor in a fast-track epilepsy or fast-track movement disorder or fast-track stroke clinic. And a group of doctors then man that with our fellows and residents. Patients, though, wanna know who their doctor is, and sometimes they wanna know, “Oh, well, my doctor has referred me to Dr. X, and I want to see Dr. X.” Well, Dr. X has a three-month waiting list. We work as a team. We want to get you into the University of Miami Miller School of Medicine group, and you will be seen by our experts, who will help you, and get you in sooner. But getting that across to both providers—referring providers—and patients is sometimes tricky. And those are, I think, are policy shifts that we need to be thinking about; Of getting into the system, as opposed to getting in to, say, a specific doctor that may have been the doctor that somebody happened to mention to you.

K: Mhm. So on the flipside of the challenge with access, what would you think of are things that are going exceptionally well at this time point that- that weren’t happening ten years ago, or something more like that, that is actually—you feel is resulting in better care for the patients, even better outcomes, or anything like that? Are there structural policy things done at the department level that you’re seeing actually have a real-world impact?

S: To me, one of the most important things that we can provide for patients with complex conditions, complex neurological conditions, are multidisciplinary clinics. And we have a few of them; I’d love to do more of them. There are clear challenges of how to make them work in a business sense. Our, for example, comprehensive ALS program works really well, but we use philanthropic dollars to then support the, you know, physical therapists to be there and see the patients—someone who deals with chest PT, or respiratory therapists, the social worker. Our Parkinson’s disease foundation partially funded clinic has a social worker that’s attached to it. In our Alzheimer’s memory program, we decided it was important [sic] a psychiatrist there, so we provide free space for that psychiatrist to see and bill for patients in our setting, where an Alzheimer’s patient may be there; going across departmental lines, they can still get their own E&M billing, but we give them free space to make it more convenient for our patients.

So, I think the future—especially as we care for populations, as opposed to, hopefully, fee for service—is to provide patient-friendly service that is multidisciplinary. That’s where service lines, I think, have grown up in hospitals, but in our own university, I think our most successful clinics have been when we can create multidisciplinary clinics, but a lot of times, the business case for that is tricky. I think the quality is better; patients love it, because they’re feeling—getting all this attention across these different disciplines. The business plan for them is not easy, and right now, unfortunately, the business plan does usually require either philanthropic or research or some other hospital underwriting to make it work.

K: Can you give an example of a particularly difficult decision that you had to make regarding care delivery?

S: …I don’t know if it’s difficult, but I think I was late to making the transition to moving towards a neurohospitalist program. And, so for example, like most academic medical centers, many of our subspecialists rotated at our county hospital. Our movement disorder guy would do, you know, a couple weeks as attending; our stroke service was separate, epilepsy was separate, you know—but various subspecialists would rotate there, and there was this tug-of-war, a little bit, between providing all the care you need to on the inpatient side, yet still having to run to take care of your outpatient activity during those weeks when you’re on service. So probably a little slow to the change, we decided to just kick off, actually, this year, and starting at a more neurohospitalist-oriented program where, now, instead of all the subspecialists rotating across our department for a few weeks a year, I’ve concentrated more of the inpatient care in a cadre of about five to six people. Three of them happen to be stroke-related people; a lot of inpatient work is stroke, but it’s still separate from the stroke service. But I think it’s a program that many are starting to do. I think the advantages of the program are then—when you really have people who are dedicated to the inpatient program, I think we don’t have—we have people who are dedicated to the quality, they work closer with the hospital staff, they’re very key educators working with the residents. They aren’t totally distracted by what’s waiting for them that afternoon in outpatient, so they really can, I think, give the inpatient service its true due needs, and meet those needs.

So I think I was a little slow to come to that; other chairs, I think, have moved this way. I think we as an organization, the American Academy of Neurology, and others, need to start developing the careers of young people in the neurohospitalist kind of program. I call it a neurohospitalist—I think it’s still an academic, important program that just provides a lot of teaching to residents, and provides kind of, I think, high-quality care for our inpatients.

K: What made that a difficult decision?

S: Well, so, one, you know, some of the faculty really felt like, well, were they being carved away from this kind of close interaction with residents? Two, there was some financial support via the hospital towards their salaries that was coming from the hospital that now I had to take away, and then now give to the neurohospitalist group. Three, that meant they’d have to pick up a little bit more outpatient work. So it’s a tricky decision, and for us right now, even—I think it’s still not clear I’ll be a success, since we’re in the midst of starting this, but I think it’s something that was required for us to really concentrate the care in a really busy county hospital, where the hospital really felt they could then count on, I think, this cadre of physicians. And I think, in the end, it will improve access, because now my subspecialists will open up some more outpatient time. So I hope it will work, but it’s a difficult decision that we had the backing of our executive committee to move forward with. I hope it’s a decision that works for my residents, because now the residents may have less at least inpatient access to some of these wonderful teachers in subspecialty areas, but hopefully they’ll still get that access when they rotate through in the outpatient subspecialty specific electives.

K: Okay. All right, no, that’s excellent. So then, the last question—so, if you could wave a wand and change one thing in one of your kind of administrative roles that you think would be the thing that would be the most likely to actually help patients and improve health, what would it be?

S: Wave a wand…there are no wands we can wave!

K: [laughs]

S: That’s a tough question. I think, I guess, the biggest thing is, how to make sure the powers that be—usually CEOs, chief operating officers of hospitals—are fully aware of what we bring to the table, neurologists and the care of patients. How to—as you know, the Academy of Neurology—how to convince others of the value of neurology. Our patients understand our value, I believe, and I think it’s important that other administrators understand the value. So I wish we could wave the wand to then make it clearer that CEOs and hospital executives will provide the adequate compensation to support the high-quality patient-centered care that neurologists do provide.

K: Excellent. Thank you very much.

S: Thank you.

K: We really appreciate your time; it was great speaking with you, and—learned a lot, fantastic.

S: Great.

K: Thank you.

S: Thank you very much, thank you.