Episode 32 – December 2021: MH Medical Group President Aileen Mickey
Over the past six months, Aileen Mickey, MD, MHA, has been leading the development of the MaineHealth Medical Group, Northern New England’s largest multi-specialty medical group. Aileen joins us to discuss her vision for the group and priorities for the year to come.
Mike: And I'm Mike Clark. Julie and I are practicing physicians and liaisons with the MaineHealth ACO.
Julie: In this special episode, we feature just one segment, a Meaty Topic interview with Dr. Aileen Mickey, president of MaineHealth's new systemwide multi-specialty medical group.
Mike: Yes, so there's a lot to digest, so let's dig right in.
Julie: This past summer, Dr. Aileen Mickey moved from the Seattle area to Maine to help build and lead the new MaineHealth Medical Group, the largest medical group in northern New England.
Mike: Yes, you know, Julie, bringing together providers from all of the MaineHealth local health systems and all areas of practice is no small undertaking. But, fortunately, Aileen took some time out recently to talk to our producer, Paul Santomenna, shedding some light on the philosophy behind the medical group and its priorities for the year to come.
Paul: So what prompted your interest in heading across the country and starting a new medical group in Maine?
Aileen: Well, I'm very interested in how we deliver care to patients in an efficient manner, where it's really seamless for the patient and we deliver very high-quality care across multiple specialties, and we make it easy for the patient to access that care. When I finished my training in pulmonary critical care, I went into private practice for about 10 years, and that was a different setting where you had multiple private practice physicians going to different hospitals and caring for patients. And the care always seemed somewhat disjointed to me, where maybe things got missed or tests were ordered too frequently, and standards weren't necessarily followed because you had so many different cooks in the kitchen, so many people involved in the care. And you couldn't really build care pathways or look at best practices or follow clinical guidelines for care across that kind of system. So, I left private practice and I became employed at a medical group outside of Seattle. And there, the care was still a little bit disjointed because there were, 350, about employed providers, but they were all working in their little silos and we had all the specialties in primary care, but they weren't working together as a cohesive unit. And so my work there was really to build that medical group and align it so that we were all working as partners, that the patient could move through the continuum of care. We shared information, we followed clinical practice guidelines, and ultimately, really, it's the patient outcomes that you're looking for. How do the patients do? And when you have an aligned medical group, patients do better. So I really loved that work of bringing physicians and APPs and other clinicians and staff together to work as a team to take care of patients, and looking at different models of care that improve care and also don't burn out our providers. And I really enjoy the strategic aspect as well, of looking at where it is a medical group wants to go, you know, different models of reimbursement, value-based care, all of those kinds of things. So, when the opportunity came up at MaineHealth to align this medical group, I just saw it as something that was perfect for me. This is what floats my boat. It gets me up in the morning. And MaineHealth is unique because we cover so much of the state of Maine that you can impact so many lives. It's just absolutely amazing. And I also thought that MaineHealth really had a true commitment to the community more than I'd ever seen. And I came from a public health, or a public hospital district where we did have a community-based hospital. But still, MaineHealth really dedicates itself to the community and providing care there, which I really like. So it was the combination of the challenge of aligning such a large medical group over a big geographic area caring for so many lives in the state of Maine, and then the commitment of MaineHealth to the community and the vision that I really liked.
Paul: So, you know, technically a medical group can be described as basically just an entity that employs providers, but you know, that's pretty limited. Talk to me about how you define a medical group to begin.
Aileen: Yeah, so I think that that's how medical groups started, right? In the late 1990s and early 2000s, hospitals started employing physicians and many reasons for that. But there were a lot of financial pressures on physicians in private practice that they just couldn't meet anymore. And a lot of regulatory burden that they couldn't meet anymore. And so physicians started coming to hospital systems and asking to be employed. And so the initial models were just what you describe. A medical group is just a way to employ physicians, keep them in the area, keep them coming to the hospital so that you can provide care to your patients in your community. But I think as medical groups grew, what hospitals and health systems realized is that a medical group is so much more than that. It is a culture of practice. It is a partnership between physicians and providers in multiple specialties where everyone is working together toward that common goal, which is to improve patient outcomes, to improve patient health. That's really what you want to do. And by aligning a medical group, you can create so much more. You can create clinical care pathways so that a patient with diabetes who is seen by endocrine can go back to their primary care physician and get excellent care by their primary care physician because everyone is following the same clinical pathways and best practice, and you can really improve outcomes. You can also look at different models of care. How do you work in the office together as a team? How do you utilize other really important pieces of the care team like APPs and pharmacists, your medical assistance, your RNs, your front office staff, to work as a team so that care becomes efficient and providers don't burn out, as opposed to everyone working in their little silo on a fee-for-service treadmill? So I think the medical group provides that. And ultimately, when you're looking at reimbursement models that we're moving toward, we're moving toward value-based care. We're moving toward pay-for-performance and pay-for-outcomes and getting reimbursed for how well we're taking care of patients. In order to do that, we have to be aligned. We have to be working together as a system and also the ability to provide care across different venues of care, inpatient, home care, ambulatory, and across a geographic area, so that if a patient walks into a primary care clinic in Franklin or in Portland, they're going to be treated the same. They're going to have the same level of quality of care, and that's extremely important. So a medical group is so much more. It's really a way to deliver care that improves outcomes for patients, that meets the community need, that gets us toward our vision of working together to make our communities the healthiest in America, and also takes care of the care team. So the care team isn't burned out, and doing all of this in a way that's financially responsible so that we can leverage new options for reimbursement, like value-based care.
Paul: No small task there. I know you've studied a little bit what makes a high-performing medical group, there's been some work done on that. Can you talk about what you think makes a high-performing medical group?
Aileen: Yeah. So, I think the first thing is the development of culture. You really have to have a culture where everyone in the medical group feels part of the group. They're dedicated to what's best for the whole medical group, and they can look past their particular specialty or a particular situation to say how do I do things that are better for the group. So again, we can deliver that care and keep the patient in the forefront. And that sounds like, it may sound like a simple thing, it's not, it's really, the development of culture is a huge part of having a high-performing medical group because if you feel that you're part of the group and your partner, no matter who you are, is the primary care physician or the neurosurgeon or the orthopedic surgeon or the pulmonologist, and you're all working together. That's very, very powerful. The second piece is really quality of care and having a culture around excellence so that it is driven by the providers in the medical group to say that we are going to provide the highest quality of care and we're going to set our bar very high. So it's a culture of excellence that is very, very important. And the development of those care pathways and the other part of a high-performing medical group is taking care of the care team and the providers. And part of that is making sure that things like compensation are equitable so that we don't have 200 different compensation models, so that people feel like they're being compensated fairly. Their benefits are fair. So again, you can build that culture. And then you have the whole piece around how you manage the financial portion of the medical group. So how do you contract with payers? How do you move into value-based care? Do you have the support systems that you need, such as clinical analytics? So all of that infrastructure that you need in a medical group to make it high performing, so that you have each member of the medical group working up to the level of their license and doing what needs to be done. So, I think those are the biggest components of a high-performing medical group.
Paul: And I know, too, that you're very interested in the make-up of the management team and the governance of the medical group. Can you talk about that a little bit as well?
Aileen: Yeah, and that's a good point. Governance and management are extremely important. So, from a governance standpoint, what MaineHealth Medical Group did is form its own board. So we have a medical group board that reports up to the system board. And I think that's very, very important because the needs and the focus and the strategy of the medical group is unique. It supports all of the work that's done in the system, but it needs to be looked at specifically as the medical group, just as some of the local health systems still have their own boards to look at issues specific to it. So we have a MaineHealth Medical Group board that consists of practicing clinicians, which I think is important because you really need the voices of folks who are doing the work to address the issues. And then that board, just like other boards of health systems, has components of committees that are very important, like the finance committee, the quality committee, academic integration, etc. So the board is important, but I think what is even more important is the management team of the medical group. So the board sits on top and oversees all of the work that the medical group is doing. I'm accountable to the board to make sure that I'm doing my work. And then you have boots on the ground in the practices, doing operations and taking care of patients. But you need a management team that can look across the system, across the entire medical group, and make sure that when we're making decisions, we are thinking about how they affect the entire group and not just a specialty or a particular practice. And so one of the first things that we did when I arrived was form that management team, which consists of myself. Steve Kasabian, who's the COO. Jeff Kirby, who's the CFO of the medical group. Ken Lombard, who is our SVP of medical affairs for the medical group, and then representatives of operational and clinical dyads from across the system. And we've met, I think, three times now with the management team to start looking across the medical group and doing all the work that entails bringing everyone together and getting them to work as a team.
Paul: And that kind of sparks a question about who is in the medical group, I mean, you talk about bringing everybody together, we're talking about more than a thousand providers, 200 plus practices, spread across all these existing kind of local medical groups. So who now is in the medical group?
Aileen: Yeah, and it's a good question, it's one that keeps coming up, and it will likely change a little bit over time as we add more folks. So I think initially it was set up so that any practicing clinician, so physician or APP is part of the medical group, in addition to the operational folks and all of the staff that support the practice. So medical assistants, RNs, PSRs, all of those folks are part of the medical group. And then questions continue to come up about other clinicians, such as psychologists who are practicing clinicians. I consider them part of the medical group. They're practicing clinicians, taking care of patients in our practices. They should be part of the medical group. So I think the membership may change a little bit as I learn more about the system and identify more of the clinicians that are practicing. But really, what it encompasses is those folks who are touching our practice or touching our patients in our ambulatory practices, and our providers who are touching our patients on the inpatient side. So our ED physicians, our hospital, our hospitalists are part of the medical group. Again, it's folks who are employed by MaineHealth and so not contracted services like spectrum or others.
Paul: Ok, good, that helps to clarify a bit. So you've got the group set up, you have a management team, you have providers and support staff, so what's next? What are all these folks going to be doing together in the next year? What are the priorities?
Aileen: Yeah. So, I think initially what we've been working through are a lot of process issues, right, now that we're coming together as a medical group. Things that were done locally in the local health systems, we now need to look at across the medical group as a system. So a good example is, we're into our fiscal year 2022 budget. Things come up that weren't in the budget, particularly around FTEs for providers. So, normally what would have happened before the medical group is the local health system looked at that and tried to figure out, do we hire somebody or not to fill this need? Now we look at it from the local health system, but also from the medical group standpoint and built a process to evaluate these off-cycle FTE requests to make sure that we're meeting needs, but we're also looking across the medical group and identifying opportunities. So if a local health system needs part of an orthopedic surgeon, how can we hire one and share them and meet multiple needs? So, a lot of the early work has been process work like that, figuring out how do we even deal with these things? Some of it's also been around how we look at the finances of the medical group, what's in the budget of the medical group, what's in the budget of the local health system, what financial reports do we generate so that we can look at the medical group as a whole every month and we can see how it's doing from a financial standpoint. So that's the process stuff and that will go on. That's going to take a good year to really work through processes around the medical group and then the development of infrastructure. So, infrastructure exists to a different degree in all of the local health systems. For instance, analytics is a good example, where I think we have more robust analytics in Portland and we need to spread that across the whole medical group. So how do we build that infrastructure for what we need in the medical group? But I think the biggest piece of work is the development of the culture that I talked about. First, the culture of the management team, working together, actually as a team. So when we put this management team together, some of these folks that never met each other, and now they're a team that's looking across the medical group. So how do you develop that grittiness in that culture and that team feeling of we are the leaders of the medical group, understanding that those folks are still embedded in their local health system and have local health system responsibilities? So development of the culture of the management team and then of the physicians and providers. So a lot of that work will be done through things like specialty councils, where we have specialties that don't have a service line and we want to bring clinicians together from across the system to talk about the needs of that specialty. Because right now we have a board and a management team that has geographic representation. So we have a physician and operational leaders from the different local health systems. But what we don't have is a focus on who's looking at primary care across the medical group or urology across the medical group. And that's where development of a specialty council that has clinicians and operational folks from across the system to look specifically at issues around primary care is really helpful. And that's helpful to build culture because now you have primary care providers thinking, oh, wow, I'm not alone over here. I'm part of this bigger system, and there are lots of other primary care providers that I can talk to and learn from. And the same thing with other specialties. So, I think that's the biggest piece of work is the development of that culture, using different mechanisms like development of specialty councils. And then I think the other giant piece of work is really developing a cohesive, proactive recruitment plan for the medical group. The biggest expense of the medical group is obviously providers, right, which is the biggest expense of any medical group. And right now, when we look at recruitment of those providers, we're looking at them in different silos. So what do we need for clinicians who are going to see patients based on population growth of the area? What does this service line need? What do we need for academics and teaching, which is part of our mission? And that's all done separately and requested separately. And what that doesn't allow us to do is have that overall vision of where is the medical group going and how is the medical group supporting what the system lays out to be priorities. So at a system level, there's work being done on developing a system strategy and then the medical group can take guidance from that and then develop that recruitment plan, so tying all of those pieces of work together and coming out with a coherent plan so that as we plan for the 2023 budget, we have what we need in there to move forward with things like primary care growth or service line growth or meeting clinical needs or having enough folks to teach our residents, and nurse practitioners, and everyone else. So I think that will be a very large piece of work early in the year before we get to the 23 budget process.
Paul: Ok, great, I realize we need to ask one more question, which is to talk about the relationship between the medical group and the ACO. So let me pose that.
Aileen: Yeah, so I think the medical group and the ACO obviously are incredibly tightly connected, right? Because the ACO is going to make sure that we are getting contracts with our payers, organizing all of that quality work that's going on those pay-for-performance pieces of all of the contracts, the heat map that the ACO does so we know where to focus our work in the medical group. And I think that the role of the ACO is going to continue to be extremely important to the medical group, and we work together on trying to move us into value-based care. I mean, I think that's really where the work with the medical group and the ACO is hand in hand. How do we really get to value-based care and switch our reimbursement model and leverage the size of our system and the size of our medical group with the payers to say this is where we want to go, and this is what we need to succeed, from a reimbursement standpoint. So, I think the ACO and the medical group together is incredibly powerful.
Julie: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page MaineHealthACO.org/BACON. And if you have questions, comments, or suggestions, as always, we'd love to hear from you. Please email us at firstname.lastname@example.org. That's email@example.com.
Mike: BACON is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thanks for joining us. We'll see you next month.
Julie: See you next month.