Invited Perspective 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55
Lessons in Leadership: The Physician Entrepreneur, Reclaiming the Future of Physical Medicine and Rehabilitation Q8
Michael F. Lupinacci, MD The worlds of medicine and business are colliding with a force never before seen in American medicine. As physicians, we embrace our core values of altruism and advocacy while promoting patient-centered care. This is a critically important perspective and truly represents our main identity. Without these values, our patients would be clearly unprotected, because the infrastructure of medicine in the United States has evolved into a complex business model in which the bottom line, meeting the metrics, and facility survival frequently are the overriding measurements of success. Whether you are happy with this relationship or not, you must accept that medicine and business will be linked as partners into the foreseeable future. This combination requires the vision and fortitude of unique leaders. In my opinion, present-day leadership in physical medicine and rehabilitation (PM&R) requires a dramatic amount of toughness, a high emotional IQ, and fearless discipline. My views are influenced through a diversified leadership experience that has included serving as an American Academy of Physical Medicine and Rehabilitation (AAPM&R) President with several years of previous experience on the AAPM&R Board. My day jobs include being medical director of an inpatient rehabilitation facility (IRF), leading a private practice, and providing leadership and point of care service in multiple inpatient settings (IRF, skilled nursing facilities [SNFs], subacute SNFs, and long-term care hospitals) and outpatient settings that include general PM&R, musculoskeletal, pain, and spine care. I also help manage my practice’s interventional ambulatory surgery center. By anyone’s measure, including my own, I’ve been bucking the norm for many years while working in both proprietary and not-for-profit settings. Our “environment of care” right now is under the greatest stress and strain ever encountered in American medicine, and leaders are being challenged. Whether we work in IRFs, SNFs, subacute SNFs, long-term care hospitals, or outpatient settings (or all of them), we have to morph our clinical behaviors to adapt to that particular “silo of post-acute care.” This impacts our job satisfaction and our office policies, practices, and economic viability. For example, there are no consistent admission criteria to determine which patients would be best served at which of these sites. There are no uniform regulatory requirements or outcome measurement tools that fairly compare one silo with another with respect to the efficiency and safety of care delivery. Worse yet, each of these settings has a business need to fill its beds. Patient care is fragmented into nonseamless, autonomous, and differently regulated postacute silos. PM&R leaders must constantly manage under the intense regulations and financial burdens that the Centers for Medicare and Medicaid and Medicare Payment Advisory Commission impose on physicians’ practices and on the care settings in which we work. And in this intense environment, what happens to the welfare of our patients? Our typical Medicare patient is, in one word: vulnerable. She frequently cannot self -advocate, doesn’t understand her care or the system of care, and can be shuffled between institutions. This is happening when these older patients are at their collectively sickest state in the history of rehabilitation medicine (just look at the Case Mix Index [severity of illness measure] increase over the past 5 years). Now comes the mandate to fund the sustainable growth rate fix with savings from postacute care. The pressure for change in the settings in which we deliver care has intensified without a clear roadmap forward—everybody appears to be jockeying for position and trying to figure it out on his o her own. As our patients’ demographics change and the PM&R 1934-1482/14/$36.00 Printed in U.S.A.
M.F.L. Physicians of Rehab Industrial and Spine Med Prism PC, Mechanicsburg, PA. Address correspondence to: M.F.L.; e-mail: [email protected] Disclosure: nothing to disclose Submitted for publication March 5, 2014; accepted March 5, 2014.
ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. -, 1-3, - 2014 http://dx.doi.org/10.1016/j.pmrj.2014.03.002
SCO 5.2.0 DTD PMRJ1224_proof 3 April 2014 6:27 am ce
1
56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 Q1 104 105 106 107 108 109 110
2
111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165
Lupinacci
THE PHYSICIAN ENTREPRENEUR
population grows. there will simply not be a sufficient number of PM&R doctors in the future to provide point-ofservice care under the laws of supply and demand. Our broadest contributions will need to be made as leaders managing systems of care for our patients with disability and pain. There is no doubt that physiatrists are passionate about patient care, but is that enough for the specialty to survive in the future of medicine? Will the future leaders in PM&R drastically and positively alter the impact of our specialty? Many residents are choosing to join hospital organizations, and private practice physicians are following suit. Who wants to endure more insurance, administrative, medical liability, technology, and lifestyle hassles? However, contrary to popular opinion, I do not believe that private practice will completely disappear. I believe the decline of private practice will decrease to approximately 30% of all physiatrists, from its present level of 50%, and then stabilize there as new models of care surface, evolve, and eventually thrive [1]. These new models will be lead by future physiatric leaders who will embrace technology not simply for the advancement of traditional rehabilitation. These leaders will organize new models of care that will emphasize early, personalized disease identification and prevention, and subsequent disability and pain prevention in addition to early treatment. The physiatric goal will ascend to preserving physical functioning and the ability to thrive well into ones 90s and 100s. Personalized care in this model is an elegant concept. It will be complex and must be creatively organized. The process will have its basis in medical innovations in drugs, devices, biologics, genomic analysis, vaccines, digital and mobile health technologies, social media, nutrition, exercise, health (body and mind) maintenance, and telemedicine, all coupled with advanced scheduling, registration, verification, and revenue cycle management [1]. This delivery model will center on a key concept, that being that we must stop viewing practice strategic planning as linear. We have to transition to exponentially extrapolating the business end of practice, assuming quantum leaps in medical technology. It took $2.7 billion to sequence the human genome, and now 10 years later “23andme, Inc” can offer a reasonable personal genomic analysis for $99 (we can debate the merits about this another time). Therefore, genomics and personalized medicine have hit the road in a major way. Our genes predispose us to certain diseases, and epigenetics (the study of heritable changes in gene activity that are not caused by changes in DNA sequence but are heavily influenced by developmental and environmental cues) influences gene expression. Because individual genetic profiles are now inexpensive and easy to obtain, we will likely be able to project the potential early impact of environment on our genetic expression and thus, modify an individual’s health care as necessary to limit the development of disease and subsequent disability. It is simply a matter of time before genomic analysis becomes a much more broadly used standard of affordable care [2].
Personal quantification will continue to evolve. Personal sensors are generating data streams with great potential to manage health and disease [2]. Just take a look at the Fitbit application (www.fitbit.com; Fitbit Inc. San Francisco, CA), PatientsLikeMe website (http://www.patientslikeme.com/about; PatientsLikeMe, Cambridge, MA), and the Scanadu device (http://www.scanadu.com/pr; Scanadu, Moffett Field, CA).The next step is to derive actionable data from these resources. Physiatrists should be well positioned in this marketplace. The challenge for the new-age PM&R physician is that it takes a certain set of skills to conceive of a business, fund the business, and execute on it in a way that makes the business successful over time. For many, after medical school and residency training and accumulating debt, becoming a salaried employee is a pathway that minimizes financial risk and is often too enticing for a young physiatrist to follow rather than embarking on an entrepreneurial adventure [6]. Specialty training has trained our brains to think in silos. The medical entrepreneur must think in systems with a lot of moving parts. Physicians are also typically inexperienced in business practices. Therefore, specialists generally create businesses that impact their specialty and not the general population. Being a medical entrepreneur requires being a team player, delegating decision making control, and managing people. The most successful physician entrepreneurs will develop systems with useful, reproducible, proactive, patient-centered methods and products to motivate and engage patients in their own health care even before they become our patients. Technology will continually reduce the barriers for patients to access health improvement tools [6]. As I see it, the leadership challenge is to create a PM&R future that is not reactive and disease-centric. The new wave of leaders will have the power to imagine and envision a new paradigm. They will embrace technology and use it to promote function preservation and physical vibrancy as much as functional restoration. They will raise the bar of our specialty to emphasize early disease, disability, and pain prevention as much as treatment. They will be leaders of inspired teams that will translate health maintenance innovations into exciting applications that people will seek out. They will be physicians first yet develop the strong business acumen that the environment will demand. They will honor the traditions and values of PM&R and not fear failure. The main challenges will be to leave the present system behind (temporarily) and then look forward through the dense fog of history and present chaos of health care to see a clear vision. These future leaders then must secure the confidence of a few select visionaries, both philosophically and financially, who will be supporters and mentors [5]. So which of you will reject the straight and narrow. and have the creativity for a realistic innovative idea, the skills to raise capital, build and manage a team, and execute a financially sustainable business over time? Which of you will create meaningful health care products and services that promote the prevention of disease, disability, and pain as
SCO 5.2.0 DTD PMRJ1224_proof 3 April 2014 6:27 am ce
166 167 Q2168 Q3169 170 Q4171 172 173 174 175 176 177 178 179 180 181 Q5182 183 184 185 186 187 188 189 190 191 192 193 194 Q6195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220
PM&R
221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275
Vol.
strongly as treatment and by doing so forever change the course of PM&R?
UNCITED REFERENCES 3,4.
REFERENCES 1. Myers A. The future of private practice. Medical Practice Insider, November 21, 2014. 2013. Available at: http://www.medicalpracticeinsider .com/blog/future-private-practice. Accessed February 25, 2014.
-,
Iss.
-,
2014
3
2. Kennealy P. For physician entrepreneurs: FutureMed - a future glimpse 276 of medicine. The Entrepreneurial MD, November 12, 2013. Available at: 277 http://www.entrepreneurialmd.com/index/for-physician-entrepreneurs278 futuremed-a-future-glimpse-of-me.html. Accessed February 9, 2014. 279 3. Parkinson J. Why aren’t there more physician entrepreneurs? Healthcare 280 Finance News, November 18, 2013. Available at: http://www.health carefinancenews.com/blog/why-arent-there-more-physician-entrepreneurs. 281 Accessed February 25, 2014. 282 4. Fogg BJ. BJ Fogg’s Behavior Model. Available at: http://www. 283 Q7 behaviormodel.org/. Accessed February 9, 2014. 284 5. Connor EJ, Fiol CM. Reclaiming Your Future: Entrepreneurial Thinking 285 in Health Care. Tampa, FL: American College of Physician Executives; 2002. 286
287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330
SCO 5.2.0 DTD PMRJ1224_proof 3 April 2014 6:27 am ce
Lessons in Leadership: The Physician Entrepreneur, Reclaiming the Future of Physical Medicine and Rehabilitation Q8
Michael F. Lupinacci, MD The worlds of medicine and business are colliding with a force never before seen in American medicine. As physicians, we embrace our core values of altruism and advocacy while promoting patient-centered care. This is a critically important perspective and truly represents our main identity. Without these values, our patients would be clearly unprotected, because the infrastructure of medicine in the United States has evolved into a complex business model in which the bottom line, meeting the metrics, and facility survival frequently are the overriding measurements of success. Whether you are happy with this relationship or not, you must accept that medicine and business will be linked as partners into the foreseeable future. This combination requires the vision and fortitude of unique leaders. In my opinion, present-day leadership in physical medicine and rehabilitation (PM&R) requires a dramatic amount of toughness, a high emotional IQ, and fearless discipline. My views are influenced through a diversified leadership experience that has included serving as an American Academy of Physical Medicine and Rehabilitation (AAPM&R) President with several years of previous experience on the AAPM&R Board. My day jobs include being medical director of an inpatient rehabilitation facility (IRF), leading a private practice, and providing leadership and point of care service in multiple inpatient settings (IRF, skilled nursing facilities [SNFs], subacute SNFs, and long-term care hospitals) and outpatient settings that include general PM&R, musculoskeletal, pain, and spine care. I also help manage my practice’s interventional ambulatory surgery center. By anyone’s measure, including my own, I’ve been bucking the norm for many years while working in both proprietary and not-for-profit settings. Our “environment of care” right now is under the greatest stress and strain ever encountered in American medicine, and leaders are being challenged. Whether we work in IRFs, SNFs, subacute SNFs, long-term care hospitals, or outpatient settings (or all of them), we have to morph our clinical behaviors to adapt to that particular “silo of post-acute care.” This impacts our job satisfaction and our office policies, practices, and economic viability. For example, there are no consistent admission criteria to determine which patients would be best served at which of these sites. There are no uniform regulatory requirements or outcome measurement tools that fairly compare one silo with another with respect to the efficiency and safety of care delivery. Worse yet, each of these settings has a business need to fill its beds. Patient care is fragmented into nonseamless, autonomous, and differently regulated postacute silos. PM&R leaders must constantly manage under the intense regulations and financial burdens that the Centers for Medicare and Medicaid and Medicare Payment Advisory Commission impose on physicians’ practices and on the care settings in which we work. And in this intense environment, what happens to the welfare of our patients? Our typical Medicare patient is, in one word: vulnerable. She frequently cannot self -advocate, doesn’t understand her care or the system of care, and can be shuffled between institutions. This is happening when these older patients are at their collectively sickest state in the history of rehabilitation medicine (just look at the Case Mix Index [severity of illness measure] increase over the past 5 years). Now comes the mandate to fund the sustainable growth rate fix with savings from postacute care. The pressure for change in the settings in which we deliver care has intensified without a clear roadmap forward—everybody appears to be jockeying for position and trying to figure it out on his o her own. As our patients’ demographics change and the PM&R 1934-1482/14/$36.00 Printed in U.S.A.
M.F.L. Physicians of Rehab Industrial and Spine Med Prism PC, Mechanicsburg, PA. Address correspondence to: M.F.L.; e-mail: [email protected] Disclosure: nothing to disclose Submitted for publication March 5, 2014; accepted March 5, 2014.
ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. -, 1-3, - 2014 http://dx.doi.org/10.1016/j.pmrj.2014.03.002
SCO 5.2.0 DTD PMRJ1224_proof 3 April 2014 6:27 am ce
1
56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 Q1 104 105 106 107 108 109 110
2
111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165
Lupinacci
THE PHYSICIAN ENTREPRENEUR
population grows. there will simply not be a sufficient number of PM&R doctors in the future to provide point-ofservice care under the laws of supply and demand. Our broadest contributions will need to be made as leaders managing systems of care for our patients with disability and pain. There is no doubt that physiatrists are passionate about patient care, but is that enough for the specialty to survive in the future of medicine? Will the future leaders in PM&R drastically and positively alter the impact of our specialty? Many residents are choosing to join hospital organizations, and private practice physicians are following suit. Who wants to endure more insurance, administrative, medical liability, technology, and lifestyle hassles? However, contrary to popular opinion, I do not believe that private practice will completely disappear. I believe the decline of private practice will decrease to approximately 30% of all physiatrists, from its present level of 50%, and then stabilize there as new models of care surface, evolve, and eventually thrive [1]. These new models will be lead by future physiatric leaders who will embrace technology not simply for the advancement of traditional rehabilitation. These leaders will organize new models of care that will emphasize early, personalized disease identification and prevention, and subsequent disability and pain prevention in addition to early treatment. The physiatric goal will ascend to preserving physical functioning and the ability to thrive well into ones 90s and 100s. Personalized care in this model is an elegant concept. It will be complex and must be creatively organized. The process will have its basis in medical innovations in drugs, devices, biologics, genomic analysis, vaccines, digital and mobile health technologies, social media, nutrition, exercise, health (body and mind) maintenance, and telemedicine, all coupled with advanced scheduling, registration, verification, and revenue cycle management [1]. This delivery model will center on a key concept, that being that we must stop viewing practice strategic planning as linear. We have to transition to exponentially extrapolating the business end of practice, assuming quantum leaps in medical technology. It took $2.7 billion to sequence the human genome, and now 10 years later “23andme, Inc” can offer a reasonable personal genomic analysis for $99 (we can debate the merits about this another time). Therefore, genomics and personalized medicine have hit the road in a major way. Our genes predispose us to certain diseases, and epigenetics (the study of heritable changes in gene activity that are not caused by changes in DNA sequence but are heavily influenced by developmental and environmental cues) influences gene expression. Because individual genetic profiles are now inexpensive and easy to obtain, we will likely be able to project the potential early impact of environment on our genetic expression and thus, modify an individual’s health care as necessary to limit the development of disease and subsequent disability. It is simply a matter of time before genomic analysis becomes a much more broadly used standard of affordable care [2].
Personal quantification will continue to evolve. Personal sensors are generating data streams with great potential to manage health and disease [2]. Just take a look at the Fitbit application (www.fitbit.com; Fitbit Inc. San Francisco, CA), PatientsLikeMe website (http://www.patientslikeme.com/about; PatientsLikeMe, Cambridge, MA), and the Scanadu device (http://www.scanadu.com/pr; Scanadu, Moffett Field, CA).The next step is to derive actionable data from these resources. Physiatrists should be well positioned in this marketplace. The challenge for the new-age PM&R physician is that it takes a certain set of skills to conceive of a business, fund the business, and execute on it in a way that makes the business successful over time. For many, after medical school and residency training and accumulating debt, becoming a salaried employee is a pathway that minimizes financial risk and is often too enticing for a young physiatrist to follow rather than embarking on an entrepreneurial adventure [6]. Specialty training has trained our brains to think in silos. The medical entrepreneur must think in systems with a lot of moving parts. Physicians are also typically inexperienced in business practices. Therefore, specialists generally create businesses that impact their specialty and not the general population. Being a medical entrepreneur requires being a team player, delegating decision making control, and managing people. The most successful physician entrepreneurs will develop systems with useful, reproducible, proactive, patient-centered methods and products to motivate and engage patients in their own health care even before they become our patients. Technology will continually reduce the barriers for patients to access health improvement tools [6]. As I see it, the leadership challenge is to create a PM&R future that is not reactive and disease-centric. The new wave of leaders will have the power to imagine and envision a new paradigm. They will embrace technology and use it to promote function preservation and physical vibrancy as much as functional restoration. They will raise the bar of our specialty to emphasize early disease, disability, and pain prevention as much as treatment. They will be leaders of inspired teams that will translate health maintenance innovations into exciting applications that people will seek out. They will be physicians first yet develop the strong business acumen that the environment will demand. They will honor the traditions and values of PM&R and not fear failure. The main challenges will be to leave the present system behind (temporarily) and then look forward through the dense fog of history and present chaos of health care to see a clear vision. These future leaders then must secure the confidence of a few select visionaries, both philosophically and financially, who will be supporters and mentors [5]. So which of you will reject the straight and narrow. and have the creativity for a realistic innovative idea, the skills to raise capital, build and manage a team, and execute a financially sustainable business over time? Which of you will create meaningful health care products and services that promote the prevention of disease, disability, and pain as
SCO 5.2.0 DTD PMRJ1224_proof 3 April 2014 6:27 am ce
166 167 Q2168 Q3169 170 Q4171 172 173 174 175 176 177 178 179 180 181 Q5182 183 184 185 186 187 188 189 190 191 192 193 194 Q6195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220
PM&R
221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275
Vol.
strongly as treatment and by doing so forever change the course of PM&R?
UNCITED REFERENCES 3,4.
REFERENCES 1. Myers A. The future of private practice. Medical Practice Insider, November 21, 2014. 2013. Available at: http://www.medicalpracticeinsider .com/blog/future-private-practice. Accessed February 25, 2014.
-,
Iss.
-,
2014
3
2. Kennealy P. For physician entrepreneurs: FutureMed - a future glimpse 276 of medicine. The Entrepreneurial MD, November 12, 2013. Available at: 277 http://www.entrepreneurialmd.com/index/for-physician-entrepreneurs278 futuremed-a-future-glimpse-of-me.html. Accessed February 9, 2014. 279 3. Parkinson J. Why aren’t there more physician entrepreneurs? Healthcare 280 Finance News, November 18, 2013. Available at: http://www.health carefinancenews.com/blog/why-arent-there-more-physician-entrepreneurs. 281 Accessed February 25, 2014. 282 4. Fogg BJ. BJ Fogg’s Behavior Model. Available at: http://www. 283 Q7 behaviormodel.org/. Accessed February 9, 2014. 284 5. Connor EJ, Fiol CM. Reclaiming Your Future: Entrepreneurial Thinking 285 in Health Care. Tampa, FL: American College of Physician Executives; 2002. 286
287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330
SCO 5.2.0 DTD PMRJ1224_proof 3 April 2014 6:27 am ce
