Dr. Michael Wagner was director of the internal medicine residency program at St. Mary’s Hospital and a member of the Department of Medicine faculty at the University of Rochester’s School of Medicine years ago when he thought it would be interesting to pursue an MBA at the same time.
While trudging to class one wintry evening, Wagner realized he could direct his career development more effectively if he channeled his time and energy into projects at the hospital rather than pursue another degree. “I said to myself, ‘What are the issues confronting a hospital and how can I help an organization work on those issues?’”
The 53-year-old has always been a problem-solver, analytically oriented and comfortable sifting through a large amount of data and correlating that with clinical information.
“Early on I got that piece, and that was valuable to the organization,” Wagner said. “So as we looked at managed care data and clinical practices of primary care physicians, I could understand how the two were related to each other.”
“We develop practices in the community in order to bring high-level specialty care in collaboration with our referring physicians but not in competition with them.”
A facilitator and clarifier who makes things happen, Wagner believes that “people come to the table sincerely, to do the right thing. My goal is to listen carefully, to understand where they are coming from, how they look at the world, and use that in a way that is a win-win for both parties.”
His skills have proved valuable, particularly at the 550-member, Boston-based Tufts Medical Center Physicians Organization, where he held various positions before becoming president and chief executive in September 2012. Tufts Medical Center, which counts Paul Revere and Samuel Adams among its founders, is a nonprofit academic medical center home to two Boston teaching hospitals, one serving adults, the other children. It is also the principal teaching hospital for Tufts University School of Medicine. Step by step, Wagner has helped pursue a sustainable health care model that is working for Tufts Medical Center — one that is based on operating an efficient organization that depends on strong relationships with the community and a network of partners to provide the health care people need.
Tufts Medical Center is relatively small compared with its competitors in Boston — with 260 to 330 beds occupied on any given day — but it is as big as it wants to be, Wagner said. “We are happy with that bed size because we think in the future world of health care delivery, it will be efficient, relatively smaller tertiary medical centers that have a high degree of expertise in specific areas that can deliver … value to the community.”
Despite demonstrating quality and efficiency that match or exceed its larger competitors, Tufts Medical Center’s reimbursements have historically been less, “so we have to have a very cost-competitive structure,” Wagner said. But so far, the results have been positive. The center’s cost data, reviewed by the University Health System Consortium, is consistently in the top 10 range nationwide, he said. “That means we have figured out how to efficiently take care of patients. At the same time, our quality scores are as good as or better than many of our local competitors. We think that structure is very important going into the future of health care delivery.”
Another important piece of Tufts Medical Center’s philosophy is the relationships it establishes with its employees, other physicians and the community it serves. Wagner understands first-hand the power of those connections. He started his career at Tufts Medical Center as a general internist, a position he held from 1990 to 1992. He returned to the hospital in 1999 as chief of general medicine and held that role until 2003. He left for five years and returned as chief of internal medicine and adult primary care in 2008.
He credits familiarity for his returns. Like the “title song from the Boston-based television show ‘Cheers,’ everybody knows your name,” he said. “That’s how many of us feel about Tufts Medical Center — we know our patients, and they know us.”
That friendly environment extends beyond Tufts Medical Center. “Our physicians understand that in order for us to be successful we have to extend that friendliness to our referring network,” Wagner said. That involves calling people and treating them with respect. It also involves a strategy called Distributed Academic Medical Center, “where we develop practices in the community in order to bring high-level specialty care in collaboration with our referring physicians but not in competition with them,” he said. “This is something that Tufts Medical Center Physicians Organization has done for decades to build strong and respectful physician relationships.”
“If we remain a traditional medical center where all we care about is the admission, we won’t survive.”
“We know that providers in the community have choices,” he added. “For them to stay with us means we must constantly keep an eye on value. I think a lot of primary care doctors and specialty physicians in the community ultimately want respect. They want to be part of a network that is highly effective.”
The efforts have resulted in good relationships with physicians in the community and a good relationship with Tufts Medical Center’s own physicians network, the New England Quality Care Alliance (NEQCA). Last September, Tufts Medical Center, NEQCA and Vanguard Health Systems announced they were forming a joint venture to improve patient health care delivery. Over the years, the NEQCA relationship has gone beyond contracting with insurers to include care management, patient technology implementation, health registries “and a whole culture of physicians working together under a single banner to provide community-based care, population-based care and also integration with academic and tertiary care,” Wagner said.
Strategically, Wagner said, the combination of Tufts Medical Center, the Physicians Organization and NEQCA provides the ability to execute the “triple aim” of accountable care: improving population care, improving health outcomes for individuals and doing both cost effectively.
When it comes to partnering, it isn’t a one-size-fits-all approach, Wagner said, and the organization is always exploring new approaches. Tufts Medical Center negotiated an Alternative Quality Contract with Blue Cross Blue Shield of Massachusetts, which is part of the NEQCA network. The contract focuses on quality and use management to help keep health care spending in check.
“I think this is a fundamental piece,” Wagner said. “We all know that we are going through a transition in health care delivery. The problem is if we do not effectively manage the transition from fee-for-service to payment based on value, we could financially harm the organization. By performing well on risk-based contracts while in this transition phase, we can make the appropriate investments.”
Re-admissions are one example. By reducing re-admissions and meeting other significant quality goals, Tufts Medical Center has been able to gain some additional reimbursement that it is investing in health information technology infrastructure to help achieve the “triple aim” goal, Wagner said.
Tufts Medical Center’s agreements with other insurance providers have followed a more traditional path, Wagner said, since not everyone is able to enter into a risk-based contract. “We are interested in moving ahead with a contract structure that allows us to take measured risk, focus on quality and be able to manage utilization in a reasonable way,” he said.
Tufts Medical Center’s approach is due partly to its small size and its reliance on referrals from outside its community, Wagner said. “The number of patients we have that would be able to be in a shared savings program is just over the threshold. So we haven’t seen a shared savings program opportunity for Tufts Medical Center.”
A shared savings contract is one type of risk-based contract that gives a physician practice a percentage of savings if the cost of the care it provides is less than what it budgeted. Risk-based contracts make sense with large pools of beneficiaries.
Wagner said Tufts Medical Center officials are evaluating whether the concept of a bundled payment option proposed by the Center for Medicare and Medicaid Innovation would work for them. The concept would allow the center to suggest a single price for managing care starting when the patient enters the hospital through 90 days after the patient has been discharged.
Then, assuming there are savings, Tufts Medical Center would have additional revenue to invest in other areas. The center needs to “move its care beyond the four walls of the organization,” which is why this bundling option makes sense, Wagner said. “If we remain a traditional medical center where all we care about is the admission, we won’t survive.” The bundling project would allow Tufts Medical Center to expand its reach, and at the same time, help it to defray some of the cost.
Technology and People Challenges
Under debate is what approach will work best to sharing data: a big database that acts as a repository and allows you to sync your data with it or multiple point-to-point systems that require the right interfaces. Currently, Tufts Medical Center uses the latter. “I am sending that information from my hospital-centric system to your electronic medical record and you can consume it,” Wagner said.
However, patients today can interact with multiple providers, each with their own health IT system, which requires data sharing. Tufts Medical Center is completing an implementation of a single electronic medical record (EMR) for the majority of its ambulatory clinics. However, several clinics require specialized EMRs due to their unique care and management requirements. The tension between a single system and multiple systems optimized for specific clinical areas creates data integration challenges, Wagner said. In a perfect world, a single system shared by Tufts Medical Center and all the physicians in its network would be nice, but the reality is “we will have multiple different systems.”
Health information exchanges, which allow organizations to share health-related data electronically, will go a long way to establishing standards, including how data is structured in a way that itcan be distributed and consumed. “These point-to-point solutions have been figured out in banking and finance, why not in health care?” he said. “Fortunately, that is changing.”
“Health care is ripe for that disruptive change. I think there will be some 23-year-old who will come up with some major initiative and it will blow the socks off of everybody.”
Making sure the right technology is in place and teaching doctors how to use and incorporate it in their jobs are important pieces of the puzzle. And because Tufts Medical Center is a teaching hospital, Wagner has the opportunity to do this every day. He likes to remind medical students not to forget the basics of clinical evaluations, even though much patient health data is readily available electronically.
“I worry that students and residents will take shortcuts,” he said. “They look at a prior problem list or medicine list and take it as truth. That’s a concern.”
More change is anticipated, and Wagner thinks that today’s young doctors will help usher it in with new ideas.
“Some of our students and young residents will be part of a disruptive change that will occur in the way we manage patient flow data and how we manage the care of the case,” Wagner said. “Health care is ripe for that disruptive change. I think there will be some 23-year-old who will come up with some major initiative and it will blow the socks off of everybody.”
Leading by Example
Wagner, who enjoys spending time with his wife and four kids, said it was his older brother — also a doctor — who helped convince him to pursue a career in medicine. “He said, ‘Be a doctor and you will have doors that will open for you your entire life.’” Wagner remembers his parents dealing with life-threatening illnesses when he was a child. “Medicine helped extend their lives by decades,”he said. “Surgical interventions and ongoing medical care really were a testimony to modern medicine and the impact it has on people living long, productive lives.”
Wagner also credits his own drive and other early mentors who influenced his leadership style. One such mentor was Edmund Pellegrino, former president of Catholic University and founder of the Center for Clinical Bioethics at Georgetown University, when Wagner was attending medical school at Georgetown.
“Pellegrino was the consummate internist,” Wagner said. “In a lecture, he would talk about medicine, ethics and then he would quote Cicero. And I said, ‘I want to be like him.’”
During his career, Wagner said he interacted with many general internists who have been great role models “because they can speak broadly and they think deeply about issues. It was a natural fit for me.”
For instance, a chief resident he worked with taught him to be a good listener. “Because half of leadership is just listening, a quarter is just reflecting that back and the other quarter is really having a strategic vision of where you want to go.”
In the future, Wagner said, there is a lot more that he wants to accomplish. He sees a lot of potential in further developing patient-related medical home initiatives, which coordinate patient care through a primary care physician. He also is interested in improving the concept of care integration, which helps manage patients as they move from the emergency department to the inpatient unit and back home.
“By working as a shared collective, we can arrive at the best solution for our patients and organization.”
Wagner said he likes where he is — on the provider side, helping solve problems. “I feel that everyone who participates in the conversation is coming with their minds and hearts in the right place,” he said. “By working as a shared collective, we can arrive at the best solution for our patients and organization.”