Richard Lewis

Transcript

00:00:05
Rigelhaupt:
It is March 2, 2015. I am in Fredericksburg, Virginia, at the 2300 Fall Hill building, doing an interview with Dr. Richard Lewis. And, to begin, I would like to ask you if you could describe your first interaction with Mary Washington Hospital.

00:00:24
Lewis:
My first interaction in 1984 was, I think, with the medical staff secretary. She had some people to introduce me to, show me around the grounds, get my feet wet, and get a little bit acclimated. It was nice because part of the reason I came to Fredericksburg then was the small-town atmosphere, a community hospital, and it really is a very warm first day that I remember. I had come from Charlottesville, University of Virginia Hospital, which was a great health system. Charlottesville’s not a big town, but it is a big university with hustle and bustle and it was nice to be a little bit quieter and more sedate.

00:01:02
Rigelhaupt:
Did you visit the hospital as you were interviewing for the position in private practice? Did you see it, and did it play a role in your decision to practice medicine here?

00:01:12
Lewis:
That’s funny because I probably did, but I don’t remember. I remember I was living in Charlottesville at the time and so it was only about an hour-and-a-half, an hour-and-forty-five-minute drive. I remember coming to interview with Dr. Cherwek who was in solo cardiology practice at the time. I remember going to his office and interviewing with him there. I remember going to his home and meeting his family. I remember going to La Petite Auberge and having a great French meal. But I really don’t remember him taking me to the hospital. He probably did. It’s funny, because some people get the impression, “Well, all hospitals look alike once you walk through the front door.” A lot of them did have the institutional green wall look: green walls and linoleum on the floor and stuff. So it’s funny that I don’t really actually remember before then.

00:01:56
Rigelhaupt:
Could you describe a little bit about your practice, and what were some of the main things you and Dr. Cherwek were doing, and some of the patients you were seeing as you began practicing cardiology in the region?

00:02:06
Lewis:
It was my first job in private practice. That was a big change. When you come from academic medicine there are always layers of responsibility. You have medical students; you have interns; you have residents; you have attendings; you have junior attendings, senior attendings. So even though you’re thinking you’re taking care of a patient, there’s always somebody backing you up and somebody you can ask questions about. But when you get to private practice, it’s fairly more on your own and more the responsibility of your own. Dr. Cherwek had been in private practice for six years and, as you know, solo practice can be pretty demanding. He was a very demanding person himself, at least on himself. I think part of the reason it took six years to find somebody is because he wanted to make sure he made the right choice. He was very knowledgeable, a very good doctor, and I never really felt like I was alone. He was a very good source of support and encouragement, and knowledge and experience. [03:00] The funny thing about private practice, at least practicing in Fredericksburg at the time, is that it’s not just your medical knowledge, but your feel for the community and what’s going to make you popular early as a physician that other people are going to trust more to come to. It’s always a competitive situation. Back in 1984, it was a kind of interesting situation in Fredericksburg because there was something called the Pratt Clinic, now called the Pratt Medical Center. This was a large multispecialty clinic. I can’t remember how many physicians it had, but they had specialists as well as primary care physicians. The advantage the Pratt Clinic had was that if you were a cardiologist in the Pratt Clinic and patients saw a primary care physician, internist, or a family practitioner in the Pratt Clinic, that they would always feel obligated to refer, if they needed a cardiologist, that patient to the Pratt Medical Center cardiologist. Whereas if you’re on the outside like Dr. Cherwek and I were, it’s almost like you’ve got to—in that kind of situation—you have to generate your own sources of referral and make it obvious that you are practicing at a level of medicine that people are going to want to seek you out. I think in terms of that part of practicing, Dr. Cherwek was helpful, as well. Although I’ve always been a people person and I never have trouble getting along with people. I think I have practiced a relatively warm brand of medicine and it worked well here because it’s a very warm, open community. It didn’t take long for me to feel I had made the right decision by coming to Fredericksburg.

00:04:33
Rigelhaupt:
What do you remember about some of the primary care physicians you worked with, and some of the first referrals that came to your practice?

00:04:43
Lewis:
As I recall, there was different strata. There were some family practitioners that had a very low threshold for seeking help. In that case, you would be practicing what Dr. Cherwek called “cardiology with a little c.” It wouldn’t necessarily be a patient with a heart attack or an arrhythmia, or low blood pressure, or had just passed out. Not a major cardiac problem, but somebody maybe who had blood pressure that wasn’t really well controlled or maybe a cholesterol level that was a little bit high. Some family practitioners and internists would take care of that on their own; others would get a cardiologist involved early on. I guess they were that brand of family practitioner who maybe sometimes you felt like you were hand holding, but you still felt wanted, needed, and it provided a service to the patient. Then there were others that felt like they were maybe just below the strata of a cardiologist. Some of them felt like they could do their own cardiology until they were really getting in trouble, or the patient was really getting in trouble. In some sense, that was a little bit more stressful a consultation because if that kind of physician asked you to help with the managing of their cardiac patient, then you knew that this was more than the ordinary, bread and butter, staple cardiology patient. There was something else going on that maybe was a little bit more potentially stressful and acute and warranted that level of attention. [06:00]

00:06:09
Rigelhaupt:
Part of being a physician in this area in 1984 is doing a lot of rounds in the hospital.

00:06:15
Lewis:
Right.

00:06:16
Rigelhaupt:
What do you remember about some of your first experiences making rounds?

00:06:19
Lewis:
The days were relatively long because Dr. Cherwek and I would round probably seven o’clock in the morning. We’d see all of our own patients and get back to the office by nine o’clock, spend the whole day in the office, and then get back to the hospital at 5:00 in the evening and visit for your rounds. It’s funny, because when you join somebody in practice, you almost feel obligated to mimic or copy what they were doing as kind of your brand, I guess. He thought it was very important and he would see each patient twice a day. Sometimes you’d have to run over in the middle of the day at lunchtime, if you call it lunchtime. We rarely had that much time to have lunch. One of the advantages of where we practiced is our building was 2500 Charles Street. This building, where the hospital used to be, was 2300 Fall Hill Avenue, just a couple blocks away. Very easy to go back and forth by foot, which was good for your heart, obviously. Rounding was the older style of medicine in the hospital, as well, where you had a head nurse on the floor. She was like a mother hen to not just the patients, but to her nurses that she was in charge of. In some sense, I miss that brand of hospital care because there was one person on the floor, on the ward, who really knew something about all thirty patients at that time. Now they kind of work in teams. It’s not like the nurses don’t know what they’re doing or they’re not familiar with their patients. But in terms of when you first start on a floor and you want to ask one person about all your patients before you get started rounding, there was a head nurse. Some of them would have the time to actually round with you. It was kind of a nice system there. It was more of a community hospital at that time. You might say we didn’t have the real sick patients or the potentially unstable patients. We would send them to Charlottesville or Richmond at some point. Although we did have an intensive care unit and we did have patients who had heart attacks, some who had had low blood pressure, or rapid heart rates and arrhythmias, and they were acute cardiac problems we took care of. But since we didn’t have cardiac surgical program here, you had a relatively low threshold for transferring somebody to a university hospital if you felt that was necessary or you were concerned about a patient going in the wrong direction. I guess in that sense, working in the community hospital at that time, there was a little less acuity. But again, then you had more time to spend with patients and I never really felt particularly rushed. Not often did I feel rushed on rounds. If you had a big census in the hospital, you just came in earlier or stayed later. I enjoyed rounding at the hospital because it was a good nursing service and good nursing care. [09:00] And again, that head nurse situation was fun to work with, I thought. The toughest part about working in the community hospital at that time, as opposed to now, is that there was no such thing as a hospitalist. There were no physicians that were dedicated just to working in a hospital. We community physicians had our office practice and our hospital practice and there really wasn’t anybody else. When you finished your rounds in the morning, you might be in your office taking care of patients, but there was always a chance that you would get called by one of the nurses or one of the other physicians about your patient who was in the hospital. Dr. Cherwek and I tried to split that up somewhat. As a practice group, we were able to actually assign a cardiologist to the hospital and they would be responsible for the hospital duties and try to take the pressure off the office cardiologist for the day. But back then, it was just me and Dr. Cherwek and even when it was me and Dr. Snow when we had a three-person group, we really took care of our own patients and had our own hospital practice. Still, we always had that chance of being interrupted during your office day by hospital problems. Of course, at night, it made even a bigger difference because anything that showed up in the emergency room was your responsibility. Now, they can call hospitalists down to the emergency room to help take care of your patients. Even the hospitalists admit the patient and then consult you in the morning. Back then, if it was our patient we would get called in. Even if it was one of the family practitioners’ patients, if they have, for instance, congestive heart failure, and the ER physician said, “I’m admitting Mrs. Smith for congestive heart failure.” They would say, “Well, just call the cardiologist.” Instead of the internist or family practitioner coming to the hospital, the cardiologist would. From that standpoint, nights may have been busier and more stressful than they actually are now. The hospitalist system has really taken some of the pressure off night call. Also, we have protocols now for dealing with problems like low blood pressure or hypertension sometimes, or high potassiums or low potassiums. Some of the problems that people in the hospital have a low threshold for calling you for, we have protocols that are in place now that they can go to and use to treat the patient before actually calling you.

00:11:17
Rigelhaupt:
Do you remember any of your early calls to the emergency department?

00:11:21
Lewis:
I do. At that time it was just Dr. Cherwek and myself. We didn’t want to have to take call every other night, and if somebody was out of town, every night. So we shared call with one of the internal medicine practices in town. But on the other hand, let’s say there were two internists, maybe three: Dr. Marks, Dr. Bigoney, and Dr. Smith. The five of us rotating call, but on the nights that Dr. Smith or Dr. Bigoney or Dr. Marks were on call, either Dr. Cherwek and I would be available for cardiology back up if they had questions about cardiology-specific patients they were concerned about. [12:00] The trade-off for making your call less frequent is that, when you were on call, not only did you have the responsibility for cardiology patients, but you had responsibility for the internal medicine patients of Dr. Marks, Dr. Bigoney, and Dr. Smith. In training, I’d spent a year doing a general internal medicine internship. I did two years of internal medicine residency and then three years of cardiology. I had specialized in cardiology. It had been over three years since I had taken care of general medicine patients, and here I was, now, in a community hospital, taking care of general medicine patients. That took some getting used to. They also covered nursing homes. You would have patients who resided in nursing homes and maybe were elderly and pretty far out of their illnesses and you really didn’t feel like they had that great quality of life. But it didn’t matter at two in the morning whether it was a thirty-year-old with a first heart attack or a ninety-year-old with a bad urinary tract infection; you had to come in and take care of them. That was the difference. That was kind of a wakeup call compared to what I had been doing for three years, which was almost pure cardiology.

00:13:08
Rigelhaupt:
I’m sure it’s impossible to talk about a typical patient because it’s too varied. But what were some of the most common things you were treating patients for when you began practicing here?

00:13:18
Lewis:
I guess you could say there were two different categories of patients. There were patients who had been diagnosed or documented with heart disease, or you took care of their first heart problem, like people who had had a heart attack or had had a stroke or had had congestive heart failure. Then there were other patients who were concerned. They didn’t have a diagnosis of a heart problem, but they were concerned, usually on the basis of their family background, that they might be at risk for having a heart problem. You would take care of patients who had high blood pressure, who had diabetes, who had cholesterol problems, maybe are overweight, or cigarette smokers. And maybe you would identify factors that made them at risk for heart disease that they weren’t even aware of. Some of the internists and family practitioners would identify patients in their practice that they were concerned about if things didn’t change. That’s when they would end up with a heart problem that could otherwise be prevented. Some of the primary care docs would take care of that themselves. Some would feel more comfortable having to share that responsibility with a cardiologist. In the hospital, if you were consulted by someone because their patient had a heart attack or an arrhythmia or poorly controlled hypertension, then you would pick up those acute problems in the hospital and after they went home you would follow them. The follow up care would be in the office. Then the other patients that we’re talking about who are stable, who had previously identified heart problems, that you would hopefully keep stable, keep them from having a second heart attack or a second stroke, or keep their blood pressure controlled. Then the people with risk factors, you’d want to do what’s called risk factor modification: help them follow a healthier lifestyle so they don’t maybe travel that road down to heart disease that their parents or their brothers or sisters had. [15:00]

00:15:02
Rigelhaupt:
How would you characterize the medical community, I mean other physicians you worked with. What were some of the strengths of physicians in the region when you began practicing here?

00:15:12
Lewis:
That’s one of the biggest differences since I’ve been practicing here thirty-and-a-half years. I remember when I came on board at Mary Washington Hospital, I was I think medical staff number sixty-three. There were only sixty-two other physicians on the medical staff. What was nice about that was you had this kind of a fraternity. Well, there were women, too—fraternity, sorority, whatever, fraternal organization. At least the doctors knew each other very well. Not only did we know each other on a first name basis, but we knew their spouses and their children. In fact, when I came to practice the first summer in 1984, Dr. Cherwek had a party at his house and invited basically the whole medical staff. We had medical staff there and their significant others and you really got to know people on a personal basis. It was kind of nice. When you got a consult it wasn’t just a professional interaction, it was a personal interaction. I kind of miss some of that because I don’t know all the physicians by first name anymore. That’s how I met Dr. Childress. He was a pediatrician at the time. I met him at Dr. Cherwek’s party for me and it turned out he was a guitar player. He had a small rock-n-roll band, and they had been looking for a keyboard player. He found out I played the keyboard and then Rick and the Arrhythmics was formed, and we went from there. It gave that kind of thing when we had those. Almost every physician that came to town had a party in their honor, and you would meet them. It was fun. After I had my party, then I would go to other parties and be in that position to welcome people to the community and maybe have a little bit of knowledge about the community that I can impart to someone else, rather than just being on the receiving end. Now I think if you look at the roster, there may be over 550 on the active staff, and if you took the consulting and affiliate staff, it’s probably over 800—it’s a big difference. Of course, there was one hospital. Now, we have three hospitals in town, plus imaging centers, a free standing ER, and the whole bit. In fact, that’s one of the reasons I came to Fredericksburg. I grew up on Long Island and my father commuted to New York City. It’s just like the commute here up to D.C., two hours in the morning, two hours in the evening. I said, “That’s one thing I’m going to try to avoid.” I came to a town where I was in walking distance of my office and walking distance of the one hospital I had to work at and that was pretty nice. Of course, that’s changed now. My office has moved from Charles Street down to Massaponax and that’s an eight-mile drive. Then the hospital has moved not that far, but it’s a move across Route 1, which is a very busy, four-lane highway. It makes it more difficult to walk, obviously. Again, it’s that double-edged sword of growth. You have more opportunities, more facilities, and more things that can be done in town as opposed to going out of town. But on the other hand, you have the higher pace of life, the traffic, and may be losing some of that small town atmosphere. That’s how I think the medical practice, or the practice of medicine in Fredericksburg reflected the community as a whole. [18:00] When we came to Fredericksburg, if you had some major shopping to do, major clothing shopping or a major purchase, you just have to go out of town. Now you can do a lot of your shopping here in town, but of course, you have to put up with the Route 3 traffic or Route 17 traffic getting to the stores. It goes both ways.

00:18:20
Rigelhaupt:
How would you characterize the relationship between physicians and the hospital as you began practicing here?

00:18:26
Lewis:
With the relatively small physician community and small administration community, everybody knew each other. I guess in some sense it might have been more of an adversarial relationship than compared to now in that I guess it seemed in some sense you were competing for resources. Of course, administration wanted you to admit their patients to their hospital, but we didn’t really have much choice there. So in that sense, I guess we felt like there wasn’t much of a competitive advantage. If we wanted the hospital to purchase a certain piece of equipment or to change the way they were doing things, we didn’t have as much of maybe a sphere of influence, other than the fact that they were our patients. It seemed like everything was a little bit of a battle in some sense, and we usually came to a mutually satisfactory decision. At that time, the financial aspects of medical practice weren’t so constraining. If you won some and you lost some, it was okay. I think as things evolved and as the financial aspects of medicine become more paramount, especially as you know, the cost of care became more of an issue. It turned out maybe we couldn’t afford to give all care to everybody. We had limited resources and we had to be more careful and more efficient in how we utilized those. I think that’s part of what made the atmosphere between the physicians and the administration more cooperative. If we’ve got one community that we’ve got to take the best care of that we can and if resources are limited, we have to be efficient and that involves the input of both parties.

00:20:17
Rigelhaupt:
Thinking about the first couple of years, and in no specific timeframe but just early in your career here, what were some of the things that you and Dr. Cherwek would have been asking the hospital for, or to invest in, to support cardiology practices?

00:20:34
Lewis:
I think the one thing that he got just before I came here was their first CT scanner. It’s funny, because there are CT scanners on every corner now, almost like Starbuck’s. Back then, this was the only CT scan in town. And even thought it wasn’t specific for cardiac care, he realized it was very important for medical care in general. Of course, our patients don’t just have hearts; they have kidneys, and brains, and legs, and everything else. [21:00] Everything is connected: if you want to take good care of a cardiac patient, then you want to make sure their overall care is good. He recognized that. I had heard that Mary Washington Hospital was considered a Band-Aid station between Washington and Richmond. I think a lot of the physicians at that time wanted to do something about that. They wanted to improve the quality of the care in our hospital. They didn’t want to feel obligated to transfer every sick patient, if they didn’t have to. It’s an expensive piece of equipment, but he was right: It was clearly state-of-the-art. It wasn’t like a boondoggle. It was something that was going to be worthwhile for patient care. Even though the initial investment is there, the return is going to be great. The fact is, obviously, that CT scan worked out very well and I think it gives some credibility between the administration and the physicians when they make a recommendation and it turns out to be the right thing. The next thing after the CT scan was nuclear cardiology. I don’t remember there being a lot of pushback on that. I think it was pretty clear that that was a very important way to assess patients for coronary artery disease and the hospital administration realized the utility and the economic benefit of trying to keep patients in town as much as possible. Of course, in terms of patient experience, they don’t want to feel like they have to travel an hour, an hour-and-a-half, just to get a scan if they can get that in town. Gradually that evolved to the hospital beefing up their diagnostic services, their facilities, and the services they were able to offer, to the benefit of the physicians, the patients, and their hospital system. Everybody has got their own turf to protect, but if you keep the larger system going, I think that helps, as well. I’m trying to think of something we really clashed on that we didn’t get. I guess the biggest thing that we talked about for a while was a cardiac cath program, and then cardiac surgery, and they eventually came along. I think the administration had their hands up a little bit in some sense, but you really don’t want to make that big a leap until the whole system is ready. It’s not just us recruiting a doctor who knows how to do a cardiac cath: obviously, you have to have a cath lab staff and the after care the pre-care. That takes a lot of cooperation between the hospital and physicians in terms of recruiting the right physicians, but also the right nursing and technical personnel and being able to afford the equipment that’s necessary. It is doing requests for proposals for Siemens or whatever other companies might be able to put a cath lab together. You’re talking about a multi-million dollar investment. I guess in some sense, physicians had to evolve to be more businessmen and hospital administrators had to evolve to have some clinician side, too. I think I’ve seen that evolution over the last thirty years. [24:00] We’ll probably eventually talk about this, but now we’ve got an ACO, an Accountable Care Organization, which is really a shared model where the hospital and the hospital facilities and the administrators are just as important as the physicians. The idea of that organization is to foster efficient care and to maintain or improve quality of care, while containing costs and improving the patient experience—what we call the triple aim. So really, if you look at the story of Mary Washington Hospital and medical care in Fredericksburg, I think that it’s a microcosm, or mirrors what’s been going on all over the country. At one point, Medicare came on, and it looked like there was an unending pool of resources, of finance. You just write a prescription, or you order a test and there it was. It seemed like you could afford anything you needed. Not that you would order tests or procedures that weren’t necessary, but you never felt constrained. That wasn’t part of the equation (where you ever considered the cost of what you’re ordering as part of the equation whether it was the right thing to do or not). Now we’ve come to the point where cost has to be a consideration so we can afford to do what’s most important for most people.

00:25:13
Rigelhaupt:
Now, I know part of the story of Mary Washington Hospital after the new hospital is a rapid increase in clinical practices, and you alluded to some of them, cardiac surgery being one of them. But would it be fair to say that the momentum from physicians in the years preceding when the new hospital was really pushing to increase the level of care and new programs, and really trying to ask the hospital to be able to treat a higher acuity patient?

00:25:40
Lewis:
I think it’s kind of the nature of medical practice: we all get trained in what we feel is state-of-the-art when we go through our training programs. When we go into practice, what is so disconcerting is it doesn’t take long for the state-of-the-art to change to the point where either I have to go back to fellowship or back to a medical school or university to learn this new technique or to learn this new procedure. Or I’m going to have to recruit somebody who was trained just like I was a few years ago to bring that service and that technique to our practice and our community. You have this kind of competition with the universities in your area. Universities don’t want to create what is called their own competition, but in a sense that is what they end up doing. They train these physicians in the state-of-the-art. They really don’t have enough capacity or patients to keep them happy on their home turf. They go out of the community, a little bit further out from the university, to bring that technique to a nearby community and there you are. But again, just like with cardiac cath, you can bring a physician who is well-versed and well-trained in cardiac catheterization, but they can’t come here and do that on their own. They need a cath lab to the catheterization. As each practice evolved and wanted to provide the best care that they could in the community without referring patients out all the time—it’s kind of like a self-fulfilling prophecy. [27:00] If you’re going to recruit physicians with these new techniques and the latest and greatest, number one, they have to be reassured that, when they come to those communities, they’re going to be able to practice the art. Then the hospital says, “Well, if I’m going to put this procedure in place, we have to make sure we have the personnel to make the best of it.”

00:27:27
Rigelhaupt:
Just before you started here, Mary Washington became MWH MediCorp with some small for-profit subsidiaries. Did that organizational change have any resonance with you? Was that still something talked about when you started practicing here, or was it just—?

00:27:44
Lewis:
You know, not really. I was more focused on our Cardiology Associates of Fredericksburg, our practice, and making it grow and succeed and prosper. One thing that I remember about MediCorp is the name rubbed me the wrong way, in fact, because it seemed to emphasize the business of medicine. Maybe other people felt that way too because it’s not called MediCorp anymore. It’s Mary Washington Healthcare, which from a touchy-feely standpoint is really a much better name. The CEO at the time when I joined was very impressive as an administrator and as a businessperson. It almost seemed like physicians were in charge of making sure the patients got the best care and the administration was in charge of making sure that the hospital was as financially sound as possible. Which is okay, unless the profit motive wasn’t a major motive; that’s all. I think sometimes there were some clashes in that regard. How much of their earnings are they going to retain for business and expansion? Throughout the whole time, I think they were technically a nonprofit organization, but of course part of their expenses are their salaries and their benefits for their administrators. Other than that kind of peripheral relationship, my partner, Dr. Cherwek, was much more aggressive in getting involved in the dealings with the administration and those kinds of things. He earned a reputation for being hard working, a good, strong advocate for the physicians, and a good negotiator. There’s not much I could add to that. I was kind of on the periphery in terms of those issues, like you’re talking about, until more recently when I evolved to become an administrator myself—I’ll find out how the other half lives.

00:29:33
Rigelhaupt:
Soon after you started practicing, mid-1980s, DRGs become part of hospital care. What are your memories of how that changed practice? Did it have an effect on conversations with administrators?

00:29:45
Lewis:
It did more. We always had help in terms of the business side of our practice. Clearly, you go to medical school and you go through training to learn the medical side of practice, the care side and the treatment, and I was well versed in that. [30:00] But to be honest with you, I don’t remember having any kind of formal courses or training in managing a practice, making sure your profit and loss and your balance sheets were all in place so you could maintain that practice, afford to recruit people and personnel, update your equipment, and all that. We always had, initially, I guess you’d call it outsourcing. There were several firms that actually specialized in helping medical practices get through the business part of it. I came in when it was just called the “golden age of medicine”—and it’s kind of a tongue-in-cheek golden age. We’re not talking about the golden age of medicine in terms of the best practice or the best medical care. They’re talking about the golden age in terms of physicians not being as concerned about the bottom line because there was a pure fee-for-service environment. Again, you never really worried about writing a prescription for a drug, whether it was a brand or generic, ordering whatever procedure you felt like the patient needed because either Blue Cross/Blue Shield or Medicare or whatever would pay for it. A lot of the controversy—or it was not the controversy, but the interest in the economics of medicine. There was a disconnect between the people who were utilizing and the cost of medicine. That’s part of how things got out of hand. But right at the beginning, in the early 1980s, you still had the insurance companies and Medicare paying the bill without asking much question, really. We really had the fee-for-service. We really had what we call going from volume to value now, but then it was pure volume. You got reimbursed for whatever you did, so there wasn’t an incentive to necessarily choose the most efficient. You choose whatever you felt was appropriate for the patient and what you felt you were good at. In that sense, it was the golden age of medicine in that you could practice medicine without the concern about the economics involved. When I started, that was just changing and DRGs was a big part of that. But the DRGs, to be honest with you, there was really an effect on the hospital in practice and we were still relatively unaffected by DRG, diagnostic related group. We use the initials. I’m not even sure if that’s what it stands for. But anyway, for us it said that when a patient comes to the hospital with a heart attack, the hospital is only going to get, let’s say it’s $2,000 for an uncomplicated heart attack. But I’m still going to see the patient and bill the patient for my service in the hospital and outside of the hospital, and so that didn’t change. Of course, once the hospital is limited in terms of what they’re going to get reimbursed for that patient, then they want to make sure that they know the physician ordered treatment, which is a big part of that. In fact, even now we talk to, in terms of managing a network, it says that the biggest source of expense is the physician with a pen, even though we don’t really write orders now. [33:00] We type on keyboards and stuff, but the idea is that the orders, most of the procedures, treatments, and medications, start with a physician order. I think the administration got much more interested in the economics of what their physicians in their hospital were doing, and not just the medical care.

00:33:22
Rigelhaupt:
And that was part of my reason for asking, the DRGs did affect hospitals more. Did that start to change the relationship between physicians and the hospital administration?

00:33:32
Lewis:
Right. It did because they’re very closely related. I guess some physicians saw the handwriting on the wall that eventually they’re not going to leave the physician totally out of the equation. But I think in some sense, from an ethical standpoint at least, you want the physician’s decision to be, as little as possible, tied to economics. You really want the physician to make a medical decision based on their interaction with the patient, their medical knowledge, and what they decide is the best treatment for that particular patient. Now, I think that’s become a little bit different. You’ve got to think about the cost, which in a setting of limited resources. You have to do that. It’s just nobody wants to hear the “R word”—the ration word. There are a lot of competing influences in our country right now and that’s why Obamacare is so controversial. Everybody needs health care. It affects everybody. Some of these issues we’ve touched on are paramount.

00:34:29
Rigelhaupt:
Well, another major piece of legislation early in your medical career is in ’86, the Emergency Medical Treatment and Labor Act. Hospitals were going to have to treat people in the emergency department, regardless of their ability to pay.

00:34:42
Lewis:
Right.

00:34:43
Rigelhaupt:
Women in active labor. Now obviously, that had more of an effect on the hospital, but do you remember as a physician recalling discussions with the hospital or in the physician community about what that would mean for this region?

00:34:55
Lewis:
We take a Hippocratic Oath that binds us to treat any patient in need. I think the administration did remind us, and in fact as I recall, a component of our staff privileges is that when you’re called to the emergency room, you care for whoever you’re called for, regardless of their ability to pay and whether it’s your patient or not. Even in an emergency situation and even if it’s a patient that you’ve severed your doctor-patient relationship in the past, you provide emergency care and you’re still obligated to do that. Then once the dust settles, you can transfer the patient to another care facility. EMTALA, I guess you’re referring to, right? I think physicians are used to taking care of whomever. When that really came into the fore was it was the time when the hospital was getting very crowded. We would sometimes be at the point where we didn’t have any beds to admit patients. [36:00] The patients would be in the emergency room and we would call around and see if we could find beds in neighboring hospitals. Of course, you always have to make sure you documented things very well. That was where the administration and the EMTALA came in our interaction: they want to make sure you document that we’re transferring this patient for this reason and not because they don’t have insurance or we don’t want to take care of them, but our beds are full, the ER is overcrowded, and we need to do what we call treat and divert. In that sense, the physicians were part of that documentation process to make sure that we weren’t not following EMTALA rules because that’s a federal statute. You don’t want to cross the feds.

00:36:43
Rigelhaupt:
How do you remember learning about it? Were there staff meetings for the physicians? Did physicians lead them? Did the hospital administration? How would a big law or a change like this be communicated to the physician community?

00:36:57
Lewis:
In a sense, actually, communication was less of an issue than it is now because you had one hospital. Most of the physician practices were in proximity to that hospital and we actually had our staff meetings at lunchtime. I remember it was usually noon to one. We’d have a meeting in the hospital. Lunch would be provided, which is always a good thing. All of us would gather in one of the rooms. We had a medical staff president who would run the meeting, but the administration would always have a segment or report and then they could report on the things in the administrative side, the legal side, or the government side of medicine that they felt were important to us. They would have their forum to provide that and those meetings were very well attended. In fact, all the committee meetings were. Committees had meetings, as well. The department of medicine had their meeting. The medical staff had their meeting and OB/GYN, GI, or whatever. Again, partly because of the proximity of the practices to the hospital and because we practiced in the hospital more, especially the primary care physicians—we didn’t have, again, hospitalists. I think everybody felt invested in going to those meetings and getting the information that was important. The problem is, as the health system has grown, you can’t get 550 physicians in a room anymore. You would be surprised about how poorly attended these staff meetings are. With hospital system and hospitalists in the hospital, most of the primary care and internal medicine physicians are in their own offices and they’re seeing patients all day. If you take them away from their practice to come to a meeting, they’re not seeing patients and there’s an economic issue there. Then they feel, “Well, I’m not even practicing in the hospital, so maybe what’s going on at the hospital isn’t as important to me as it used to be.” That kind of thing. Now that I’m in an administrative position I have to deal with that communication issue. There are a lot of important things going on and the physicians need to know what’s going on. [39:00] We do have more methods of communication now: we have social media; you have email; we have snail mail. But you also have 550 physicians, and some of them prefer this and some of them prefer that. Some don’t have Facebook accounts. Some hate Facebook. They have email, but then they’ve got three different email accounts. It really becomes pretty difficult. We found that—and this is based on my experience as much as anything—is that face-to-face contact is the best. It’s just become logistically more difficult if you can only see a few doctors at a time. They’re spread out. In the alliance [Mary Washington Health Alliance], we have 400 physicians and a hundred practices. It’s hard to make a visit to a hundred practices. We use a combination of things, but the communication has always been important. Back then in the ‘80s when the community was smaller, more homogenous, and more concentrated in one area, it was easier. That’s something that’s gotten more difficult, but not less important.

00:39:54
Rigelhaupt:
So before switching to the early ‘90s, what would you characterize as the most important advances in cardiology, either at the hospital or in combination with your practice and in the region, before the new hospital opened?

00:40:06
Lewis:
Right. Before the new hospital, so we didn’t have cardiac cath yet. I’m just trying to think about what we did have. We had medical cardiology and the advances we had were nuclear stress testing, which we had previously sent patients to MCV and UVA for, and that was the biggest. We had nuclear cardiology. Of course, medications had progressed significantly. We had what we call ACE inhibitors. Beta blockers had become more frequent and more of different kinds. But of course, the medications you could use anywhere. We kept up to date, at least with the patients in our community. Since it was a community hospital, but not a university hospital, our patients still got the benefit of the most up to date medications. We did have forums to educate each other about that. We had peer review sessions where we got together to make sure everybody was on the same page on what was the latest and greatest. But in terms of procedures and surgery, I think until we had cardiac catheterization, it was nuclear cardiology and invasive hemodynamic monitoring of patients with heart attacks and shock. In other words, Swan-Ganz catheter. We were able to put those in in our small intensive care unit. We had echocardiography. When I came, and one of the reasons Dr. Cherwek brought me was there was the Doppler component of echocardiography—echo being the visualization of the heart and Doppler actually following the physiology of the hemodynamics of blood flow through the heart. That we had in the mid-1980s. We had echocardiography, Doppler echocardiography, nuclear medicine, and advances in certain medications, statins and ACE inhibitors. Leading up to the move, I think those were the biggest things there.

00:41:50
Rigelhaupt:
Now, I know you held a number of positions. Or maybe you weren’t formally on the staff, but supervising cardiac rehab and involved with cardiac inpatient services. Did any of those precede the move to the hospital? [42:00]

00:42:04
Lewis:
Cardiac rehab—I think we had that at what was the Amy Guest wing, and that’s where nuclear cardiology was. I think we had the beginnings of cardiac rehab here. Yes. As I recall, I was probably the director almost from the onset of that program. Otherwise, we also had the Fredericksburg Area Medical Society. I was president of that, and that might have been the late-1980s. That used to be very well attended, too, actually. Again, it was a smaller group and the advantage of that was that doctors could get together outside the hospital without administrators present. We concentrated on issues more pertinent to our practices. The meetings were usually held at one of the local restaurants and we had a good meal. But of course now, logistically, you can’t get everybody in one restaurant. Again, it’s an evening meeting and people are busy and they’re pulled in many different directions. That’s something that’s fallen by the wayside, but when I was president of the medical society, it was still a relatively active organization.

00:43:19
Rigelhaupt:
And I know local medical societies don’t necessarily follow the AMA, I mean, not lined up perfectly.

00:43:28
Lewis:
Right.

00:43:30
Rigelhaupt:
Do you remember any instances, while you were president of the medical society, where the physician community had any distinct disagreements with the hospital?

00:43:38
Lewis:
It’s been a while. I remember my year wasn’t that tumultuous. I remember I didn’t envy physicians in other years where there were some issues like that. To be honest, I can’t recall what they were. Hopefully, you’ll interview people who remember better or were more in the middle of the fight, but I just don’t remember.

00:43:57
Rigelhaupt:
What’s your earliest memory of discussion that this new hospital might be built? I imagine the physician community was consulted before things leaked to the public.

00:44:08
Lewis:
Everybody who had a potential dog in the fight got brought into that, and some of the physicians did. I don’t think the controversy was whether we needed more space. We clearly had outgrown our hospital. The emergency room was eternally overcrowded. One thing I remember especially is when a census got high—and again, with EMTALA—we wanted to resist sending patients elsewhere. We actually had patients in beds in the halls. They would put a bed in the hallway, put one of those curtains around it, and that’s where the patient got their care until a bed opened up. Clearly, we needed more space. The question basically was can we expand on our present site or not? [45:00] If we did, what would be the cost of that versus starting all over somewhere else? It really became as much of an economic decision as anything else, a logistical decision, and I think the right decision was made. The other alternative was you can expand on the present campus, develop a new campus, or keep this hospital and build a second hospital at some distance to take the stress off of your first hospital. The decision was made to have a bigger hospital. It turned out that the campus they moved to wasn’t that far. Logistically moving from one hospital to the new hospital when it was opened wasn’t impossible. That site turned out to have a lot of room for expansion and that probably went into the decision. It’s funny, because as a member of the community and living right in that area, I don’t remember there being that much land in one place. But I guess it was up on a hill and there was a lot of trees, and all the roads went around it, not through it. I wasn’t even aware. Clearly, it was a good move. In fact, I ended up writing a song about it twenty years later.

00:46:21
Rigelhaupt:
Do you remember any water cooler talk with other physicians? If there was any initial controversy about should this new hospital really be built?

00:46:31
Lewis:
It was mainly the cost because they knew that bonds were going to have to be issued. It was going to have to be financed. The question was whether the financial health of the medical system could handle that and if the bonds would have a reasonable rating and be popular enough. But in general, I think given the prospect of having a totally brand new facility with everything up to date and everything brand new. If you look at the history of medical care in Fredericksburg, it usually involved moving from one facility to another. It was like it was tradition. I think the physicians felt that if the finances were there and they were looking forward to moving to a new place.

00:47:13
Rigelhaupt:
That was probably, if there was reservations, I think it was $300 million in bonds, which probably in today’s dollars doesn’t seem like a lot.

00:47:23
Lewis:
No.

00:47:24
Rigelhaupt:
But certainly, in the early ‘90s, that was a lot of money.

00:47:27
Lewis:
Right. And it turned out that they were able to use this facility where we are today. It’s pretty well occupied now and that turned out to be a good move, as well.

00:47:39
Rigelhaupt:
Do you remember any conversations or being consulted about what kind of space and design of either rooms, maybe ICU, cardiac labs that this new facility would have?

00:47:53
Lewis:
I think we looked at the designs. [48:00] One thing, from the cardiology standpoint, if possible, was we wanted all the cardiac related services to be on one floor. That would involve everything from if we did cardiac surgery, to cardiac cath, to step-down, to the patient treatment floors, and all the imaging—the echocardiography, the stress testing, et cetera. If it was possible, that was one of our wishes. We thought that in terms of in intensive care, it would be nice to have separate coronary care unit from medical intensive care and from surgical intensive care unit. We wanted to make sure that the ER was large enough and flexible enough and could handle acute cardiac care and manage it temporarily there until the patient went to the cath lab, cardiac surgery, the cardiac floor or the intensive care unit. There were a lot of issues, cardiac related. A lot of us who’d practiced in the old hospital had some opinions in that regard because we had been working in this facility, which I think was built in 1957. Not me myself, but there were doctors on the staff that had been working there for quite a while and had an idea of what was working and here’s an opportunity to prove it. That was 1993, and that was around the time we decided to add—I don’t remember, did we do cardiac cath in the old hospital? You might know that better than I. I don’t remember. I don’t think so. The move coincided with adding cardiac cath, which was a huge advancement, obviously, in cardiology care in Fredericksburg. Then, of course, cardiac surgery was close behind that.

00:49:43
Rigelhaupt:
So taking something like cardiac catheterization involves highly skilled physicians.

00:49:50
Lewis:
Right.

00:49:50
Rigelhaupt:
Because you’ve described a team behind it.

00:49:52
Lewis:
Right.

00:49:53
Rigelhaupt:
What were some of the processes to not only have a physician who could do those procedures, but to have nurses, skilled technicians, and to bring the hospital along so that you could practice that well?

00:50:06
Lewis:
As I recall, there were committees devoted to the cardiac cath initiative. Both our group and Dr. Vranian’s group, which I think was still Pratt Medical Center at that time, had recruited physicians to do cardiac cath. In fact, I think they may have had a couple before we did. But in any case, those physicians were instrumental, also, in helping us and telling us what they needed. In general, you spend a year recruiting somebody before they actually start practicing. As I recall, during that recruitment year, we had input from the physicians who would be coming to Fredericksburg to do that procedure. The hospitals have their networking, too. They have networks with administrators and their nurses and nursing staffs and interact with hospitals that have been doing cardiac cath. [51:00] The cardiac cath procedure had been around a long time. Let’s see, I was in medical school from 1974 to 1978, and clearly, cardiac cath was a common procedure back then. Angioplasty was when I was at UVA, ’81 to ’84, so it was early-‘80s, when you could actually put a catheter in when a patient was having a heart attack, find the clot, bust it open, and reestablish blood flow. Of course, the sooner you do that, the better the patient does and the smaller the heart attacks. That was clearly a procedure that we wanted to try to get here in Fredericksburg, rather than having to put somebody on an ambulance and send them an hour by ambulance or fifteen minutes by helicopter someplace else.

00:51:54
Rigelhaupt:
In the stage either before the hospital opened, or even in the first year it was open, what were the initial discussions of the possibly of adding cardiac surgery?

00:52:08
Lewis:
I think once we got cardiac cath going, as I recall, in the early stages of angioplasty, it was a requirement that you have surgical backup. Boy, it’s twenty years ago now and I’m a little bit fuzzy here. I think you could do cardiac cath, and if you identified somebody that had a blockage that needed a stent or an angioplasty, you would have to transfer them to another hospital. It was standard of care at that time if you were going to do an intervention—try to put a balloon and try to open a blocked artery or put a stent in the artery—that you had to have a cardiac surgical team on backup in case something went wrong. I’m pretty sure we had cardiac catheterization at the time we were moving. When we got to the new hospital and we wanted to add interventional cardiology, then we had to say, “If we want to do interventional, then we need to do cardiac surgery as well.” That was a huge decision.

00:53:15
Rigelhaupt:
Was it controversial among physicians to begin cardiac surgery?

00:53:23
Lewis:
I think the only question was whether we had enough volume to keep a surgeon busy. The problem is that you really want enough volume to keep two surgeons busy because you can’t recruit one surgeon and expect them to operate five days a week and take call 365 days a year. And of course, you want the right person. You want somebody who has the personality, the ego strength—whatever you want to call it—to start a program from scratch. [54:00] You can imagine, if you’re operating on the first person ever in a cardiac surgery program, you know that case better go well because the reputation you develop at the onset is really going to carry you through. So I think we wanted cardiac surgery. The question was, was the community ready for it? Could we support a cardiac surgery program? Did we have the volume for it? Was somebody going to recruit a really good surgeon to do that? I think the process was well carried out, well thought out, and we certainly got an excellent surgeon and that made a big difference. Of course, he brought a lot of his team with him, perfusionists and physician’s assistants. It was kind of like—what do they call that?—a turnkey operation? He starts out and he brings a lot of his personnel with him. Of course, he was involved in putting the program itself together. He has the advantage of this is the equipment he would like and this is the way he wants the OR set up. It was all done well and done the right way. The program did get off to an excellent start and has done very well since.

00:55:17
Rigelhaupt:
Were you involved with the process of recruiting Dr. Armitage?

00:55:21
Lewis:
Let’s see. I know I interviewed all his potential partners afterwards and I think all the cardiologists had an opportunity to meet Dr. Armitage. He was so impressive that, to be honest with you, I don’t remember interviewing anybody else. It’s kind of like, “This is the guy. I hope he wants to come because we certainly want him.” Then he also was able to recruit Dr. Quentin Mcmanus, who at the time had been practicing at Inova Fairfax for a long time. I guess you could say he was getting to the end of his career, but he certainly was still a very effective surgeon. I think it worked out to be the perfect person to partner with Dr. Armitage because he didn’t need the volume that Dr. Armitage might necessarily have wanted. We had to go through the COPN process, the Certificate of Public Need. We had to demonstrate to the local health board, then regional board, and the state board of health that we were ready and had the volume to support that program.

00:56:26
Rigelhaupt:
Were you involved at all on working on the COPN?

00:56:29
Lewis:
I went to the local board meetings and the regional board meetings. I didn’t go to the state meeting. I also helped get my patients to write letters of support. It was really a community-wide effort to get that done. Fortunately, we had a lot of local business leaders who supported it. We had, I guess it was Homer Hite and Joe Wilson. There were some very prominent local community leaders who were behind the program and had spoken for it, as well [57:00].

00:57:01
Rigelhaupt:
Was that probably one of the most important programs, in terms of raising the level of clinical care that the hospital could offer?

00:57:12
Lewis:
I think so. In fact, remember that I said that when I came here the characterization of Mary Washington as a Band-Aid station on the way from Washington to Richmond. When you have your own cardiac surgery program and do it well, that goes right out the window. There’s no question that, I guess you could say that you’ve arrived. Of course, since then it enables you to have the visibility to attract other specialists, medical specialists and surgical specialists, to add other services. But I think you’re right: cardiac surgery you can think of as a lynchpin in letting the community know that your hospital has arrived to a certain level. Then that can support bringing on other similar programs. That was a big deal.

00:57:57
Rigelhaupt:
Do you recall a distinct difference in terms of your patients that could stay in the area and be treated? Did you end up seeing a higher acuity patient in the hospital because there were these programs now, particularly cardiac programs, starting at the hospital?

00:58:13
Lewis:
The acuity level of our cardiac patients, I think, clearly did go up. Before it was an outpatient who had coronary disease and was symptomatic. Before we had cardiac cath, obviously, we’d have to send them for just about everything. Initially, when I first started, we even had to send them out of town for nuclear stress tests. Then I was able to able to do my nuclear stress tests, but if that was abnormal, then I’d have to send them out for the cardiac cath. Once we were doing diagnostic cath, I could at least have the diagnostic cath done in Fredericksburg. I’d still have to send them out to have the angioplasty done. But now that you had cardiac surgery, we could do the whole diagnosis, the stress test, the cath, the intervention, and the OR cardiac surgery. Those patients who potentially could have complications, that previously had the complications in Richmond, or Charlottesville, or Washington, D.C., had their complications here in Fredericksburg. Clearly, yes.

00:59:03
Rigelhaupt:
Thinking back to before the new hospital opened, what do you remember of your last walk-through? What it was like to be in this brand new building that, probably in a matter of weeks if not days, was going to be a functioning hospital? And what it was like to walk through a building that was just waiting for patients?

00:59:22
Lewis:
It’s funny. I remember walking through that building, and actually getting physically ill. There was a syndrome called new building syndrome, and I really got it. I don’t know if it was everything being new, or the smell, or the trepidation that maybe we hadn’t made the right decision, or has the physician community grown up enough to really support this kind of institution? It’s funny, because I really got queasy and lightheaded walking through that building. I said, “God, I hope we made the right decision.” It was much, much better when the hospital was open and functioning and there were people in the hall. The hustle and bustle made it a lot better. [01:00:00] It really turned out to be a beautiful facility, both internally and externally. It was a source of pride when we were recruiting physicians and when we had people coming in from other institutions, even academic institutions, to give talks or seminars. Everybody always remarked about what a beautiful hospital it was and that was really nice. Not only had we made the right decision, but it had been done well. It’s really stood the test of time in the hospital. It’s hard to believe it’s, what, twenty-two years old now? Really, it looks great. It’s really held up very well. I mean, we’ve had some expansion, but not that much.

01:00:39
Rigelhaupt:
What do you remember about the first time you made rounds in the new hospital?

01:00:43
Lewis:
I really was facing, “Where is this? Where is that?” Even the phone numbers were different. I remember we all carried around cheat sheets and these little laminated cards. They did a good job. We had a card, for instance, for all the new numbers for pharmacy and lab and different floors. We even had to learn where the patients were, because obviously, we had many more wards here in the new hospital than we had in the old hospital. There was a lot of that newness and freshness. Part of it was exciting; part of it was a little bit intimidating. For a while there, it was much less efficient, so we had to leave a little bit more time for rounds. It’s funny, because one thing we didn’t do that we probably should have done from the beginning is we never made all the wards uniform. We really should have taken the opportunity to do that, in retrospect. Although, maybe peds is different from OB/GYN and cardiology is different from medical. But it would have been nice if all the like forms were in the same place on each floor and, you know, all the turntables that had these things. Every nursing staff set up their nursing station, their patient care areas, and their reception areas in their own way. But it might have been nice if there were guidelines from one floor to the other. This particular form would be in this place and in the same place each floor, but we never did that. Eventually I learned everything.

01:02:12
Rigelhaupt:
Part of running a hospital involves three groups, and I think now probably nursing more. But certainly in the early ‘90s and when you began practicing here, it was the medical staff, the hospital administration, and the board. Do you have a sense that there was consensus, coordination, that the board and the administration and medical staff were on board together with the idea of a new hospital?

01:02:43
Lewis:
I remember more of that from the videos that were made in celebrating the twentieth anniversary of the hospital because there were a lot of interviews with board members from back then. [01:03:00] I think that probably was something that united the medical staff and administration and the board, to some extent. Once the decision was made, I think everybody did get along behind it. Like I say, we had a lot of board members who were very passionate about supporting that initiative with the local board of health, the regional board of health, and the state. I think that was probably uniting. It’s funny, because Dr. Cherwek had a lot more interaction with board members than I did because he was much more politically oriented than I was. Of course, that’s changed now. I work with the board very closely, and for a volunteer group, they are really very committed. I’ve been impressed with how knowledgeable they are about health care matters and health care news and affairs and issues.

01:03:52
Rigelhaupt:
Soon after the new hospital opened, within a couple of years, there was a change in senior leadership. Bill Jacobs resigned, and Fred Rankin became president of the health care organization. The hospital became the system. What do you remember about the transition from Bill Jacobs to Fred Rankin?

01:04:13
Lewis:
I think from our group standpoint, it was a positive transition. It seemed like Bill Jacobs and Mike Cherwek were always butting heads. Both were very strong personalities and it was tough for either one to give very much. At least from the Cardiology Associates perspective, we looked at it as an opportunity to start over, and maybe with someone who maybe would be a little bit easier to work with. Not that Bill Jacobs wasn’t a very effective administrator; he was. It’s just that he just always seemed like he had his turf to protect. Whereas with Mr. Rankin, I think his father is a physician. He came from a medical background and we thought maybe that would smoothe the edges a little bit. At least personally, we’ve had a great relationship all along. I think he was a very effective administrator. When you talk about the medical staff, the administration of the board, for a CEO of a hospital, you’ve got many disparate groups you’ve got to get along with, get cooperation with, and work with—from medical staff, from the hospital associates, the community, and the board. You’ve got a lot of people to answer to and I think he did a very good job with that. Not an easy job, but I think it was very well done.

01:05:33
Rigelhaupt:
One of the things that could potentially happen as more and more clinical practices start, both at the hospital and through private physician groups practicing at the hospital, is the potential for crossover, that some physicians do similar procedures. As the clinical practices were on an upswing—that’s exactly the right term—but increasing the level of care, do you remember any tension between, say, a radiologist wanting to this, and cardiologists feeling like, no, this is ours? [01:06:00] And I just threw those out there as names, but how that played out after the new hospital opened.

01:06:15
Lewis:
We call it a turf battle, but yes. It’s interesting that you mention radiology, because even actually before the new hospital, there was—I don’t know if you’d call it a clash, but at least controversy— an issue in terms of who was responsible for reading nuclear cardiac scans, for instance. Both groups, Dr. Vranian’s groups and ours, did have cardiologists who were trained in nuclear medicine and who did read cardiac nuclear scans. In fact, Dr. Kauffman read CAF’s scans, and Dr. Vranian’s nuclear trained physician read his. But in the hospital, those scans were read by radiologists, and they still are. The radiology group does have a preferred provider relationship with the hospital. There’s only one radiology group in town, and whether it’s Mary Washington Hospital, or Stafford Hospital, or the freestanding ER, the outpatient surgery center, that one radiology group really takes care of all of the radiology needs of the community. Obviously, there are plusses and minuses when you have one group. For us, from a cardiology standpoint, it seemed like they had a lot of power and influence in that regard. Whenever you talk about which group does what, or who wins the turf battle, you try to at least get it down to what’s best for the patient and make a quality issue of it. The radiologists always had that trump card that they are in the hospital 24/7 and whenever a study is done, they have someone right there to read it. Where if we had to talk about a nuclear cardiologist who has a practice, who might be out of town, or who might not be in the hospital and you want a reading right away, the radiologists always had that trump card: they always have a nuclear trained radiologist in the hospital available to do that, no matter what time of day or night the study is done. Then the next potential turf battle was with interventional radiology versus interventional cardiology. In other words, all these things that are now able to be done through the vascular approach, as opposed to doing an incision. For instance, an abdominal aortic aneurysm used to only be treated with open surgery, and actually a very big open procedure, which was done either by a vascular surgeon or a general surgeon who was trained to do abdominal surgery. Now there’s a procedure where you can actually cover the injured part of the aorta with a stent and that can be done all through vascular access. [01:09:00] Interventional radiologists have been trained to do that, but cardiologists have been trained to do that. In fact, cardiac surgeons now are trained to do that. So the question is, who does that in the hospital? Let’s see, also stenting of the renal arteries, for instance. As all these new physicians get trained in more extensive training programs, everybody comes here to Mary Washington, to Fredericksburg, with a skillset that overlaps with other skillsets and other specialties. I guess with each procedure, we try to work that out as amicably as possible and in a way that ends up with a procedure that’s most efficient, available, and cost-effective for the community. As far as I know, with the stent grafts for aneurysms, it’s now like a joint procedure between interventional radiology and the general surgeons who are versed in that. Dr. D’Addio actually is a member of VIVA, Virginia Interventional and Vascular Associates, which is a combined vascular surgery/interventional radiology group and that that’s the way that they’ve attacked that problem. There are also, as far as I know, vascular surgeons outside of VIVA who do the procedure, as well. There’s carotid stenting, now: instead of just doing an open procedure to relieve a blockage in the carotid artery, it can be done with a stent. I know there are cardiologists who do that and there are interventional radiologists who do that. I guess it’s an evolving thing. Now it’s even becoming a potential merger of services or overlapping of services between cardiologists and cardiac surgeons. You’ve got these new procedures now to actually repair aortic valves and mitral valves that are done transvascular rather than with an open-heart procedure. At least for now, this is going to be a cooperative venture between the cardiologists who have been trained in the procedures and our surgeon, Dr. John Cardone, who had training when he came through before he came to Fredericksburg. It will even be done in a type of what’s called a hybrid OR, which is a room that is feasible for surgery as well as advanced cardiac catheterization. In that sense, it’s kind of better than have a turf battle: you agree to work together on something. And maybe that’s not always possible. At least for this latest procedure, hopefully it will work out that way. It looks like it is, for now.

01:11:45
Rigelhaupt:
Thinking about turf battles, do you remember an instance in which the hospital or hospital administration played a mediating role, that tried to work with physicians to work out a plan to try to coordinate? [01:12:00] Again, to think about that potential for the hospital administration to play a role in making a plan.

01:12:10
Lewis:
The only one I’m familiar with is the one we’ve just vetted out, which is this TAVR, transvascular aortic valve replacement. Actually, the administration played a key role because they are the ones who really got the committee together, identified the most appropriate personnel to be on that committee, in the administration, cardiac surgery, the surgeon and perfusionist, and interventional cardiology. The administration also had contacts with other programs, for instance MCV, to use their cooperation in terms of a program that already had an active TAVR system going and maybe help us come along in terms of education. It also involves working with Siemens, or whatever manufacture makes the valves. It’s a big venture. I think in that sense, the administration has the advantage of being able to bring all those groups together and they did a very good job with this TAVR program. It’s a very expensive program and it had to be done in a way that was well organized and with a well thought out business plan that could be sold to the board, who made the ultimate decision to go ahead. There were early ones that Dr. Cherwek spearheaded, and I really don’t remember enough details to tell you about, but there would be other people who were closer to the battle scene could do well. But again, it’s going to happen. It’s just the nature of the human body that each piece isn’t isolated. Everything is connected. If you have an area of expertise in one area of the body, it’s going to overlap with someone else’s and so you’ve just got to be able to get along.

01:13:59
Rigelhaupt:
What are some of the clinical practices that the new hospital made possible? Cardiac surgery would be one. Are there other things that you would point to that are significant clinical practices that are now available in this region and that are available in that hospital because it had been built?

01:14:19
Lewis:
Neurosurgery is a specialty we have now that we didn’t before. We are a trauma center, a Level II, trauma center now. We weren’t able to do that without having a trauma service and having an SICU [Surgical Intensive Care Unit] that was developed enough to handle trauma. The fact that Interstate 95 runs right by the hospital is important, I think, to have a trauma service. These patients, the sooner they’re taken care of, the better their outcomes. Trauma, neurosurgery, and cardiac surgery. Even interventional cardiology, being able to do what’s called primary coronary stent placement for STEMIs and taking care of cardiac cases immediately, right from the ER to the cath lab. [01:15:00] I think the new hospital has facilitated that. Primary stenting for heart attacks. And I’m trying to think of all our others. GI—some other procedures in GI and endocrine. Pulmonology probably could have been done in the previous hospital. It’s just that when you have a more modern hospital with all these other services, especially cardiac surgery backup, I think everybody feels a little bit more comfortable doing more advanced, aggressive techniques, knowing that there’s all that support around.

01:15:52
Rigelhaupt:
So part of what the new hospital represents is that there’s no way you could call Mary Washington Hospital a Band-Aid station anymore?

01:16:01
Lewis:
Right.

01:16:02
Rigelhaupt:
And part of what has happened over the last twenty years is that it has become a regional medical center.

01:16:07
Lewis:
Correct.

01:16:08
Rigelhaupt:
And there’s very few things that can’t be treated here.

01:16:11
Lewis:
Right.

01:16:11
Rigelhaupt:
Thinking back on the years that you knew this hospital was going to be built, was there a sense among the physician community at that point that this really was going to transition from a community hospital to a regional medical center? It could have ended up being slightly more beds, a little bit bigger, and a newer, more modern facility, but still largely a community hospital, and there has been a transition into a regional medical center. Did you have a sense that that was talked about, planned, and was something—?

01:16:45
Lewis:
No. In fact, I came here, again, partly because I wanted to practice in a community hospital. I appreciated the one hospital system because I had friends that had gone to other places and had to rotate to two, three, or four other hospitals, and logistically it’s a nightmare. I would certainly be behind making this the best community hospital we could be. In terms of a regional medical center, as far as I can recall, that’s something that came from the administration on down, to be honest with you. I didn’t talk to every physician about it. Would I have been happy the other way or not? I don’t know. Again, I’m a non-invasive cardiologist. I don’t do cardiac catheterization myself. We had very good relations with some very good groups in Richmond, who helped us out when we needed it for procedures and techniques that we didn’t have here in Fredericksburg, and that worked well for us. I think with primary angioplasty: in other words, treating heart attack patients right away with techniques to open their arteries right away, we know that is the best way to treat a heart attack. [01:18:00] I’m certainly glad that we have that technique here. Now at this point it’s nice to say that, the only thing I have to send you out of town for, almost, is a transplant, a kidney or heart transplant. I mean, we don’t do transplant medicine. I doubt we ever will. We do almost everything else. If you had asked me would that be the case when I came here thirty years ago? No. Not only wouldn’t I have said it’s going to happen, but I wouldn’t even have said that’s something I wanted to see. In fact, I was concerned when we decided we were going to be a Level II trauma center because that takes a huge commitment. You’ve got to have a number of trauma surgeons available because they’re going to be probably working twenty-four hours at a time and they can only work so many shifts. If they’re not doing trauma surgery, what are you going to keep them busy doing? A lot of trauma patients aren’t well insured. Is it economically the right thing to do? Are we doing it more for the prestige than the economics of it? Again, in terms of the question, I would have been perfectly happy, I think, with a very well run, progressive, state-of-the-art community hospital. I didn’t come here to be part of a regional medical center. But that being said, given that this direction we’ve done and taken, I think we’ve done very well with that and I’m very proud of the health system we’re working with. Clearly now, I’m in another role within the health system. In terms of being an accountable care organization, I’m glad we can provide all those services. Now we have more control over the cost effectiveness of care of our patients because we can provide almost everything, which means they don’t have to go out of town where I don’t have control, or our health system doesn’t have control over the procedures that are being done and the medications that are being ordered. The costs being monitored are taken care of. Would I have predicted it? No. Am I glad it’s turned out that way? I’m fine now, yes.

01:20:02
Rigelhaupt:
It sounds like there was the potential for some very serious disagreements between physicians and medical staff and the administration in this growth from community hospital to a regional medical center. And yet, it seems like there’s also, as history has turned out, to be a fair amount of coordination now.

01:20:21
Lewis:
Right.

01:20:21
Rigelhaupt:
And some evidence of it in terms of where you’re a medical director, now.

01:20:24
Lewis:
Yes.

01:20:25
Rigelhaupt:
Thinking about the intervening years between the period of when it begins the growth to a regional medical center, to where you are now, with an IPN and Health Alliance, what are some of the things you would point to that kept some of the disagreements at bay, that allowed there to be a culture of coordination, of agreement? Those are my terms. You don’t necessarily need to agree with them.

01:20:50
Lewis:
Right, right, right. That’s okay.

01:20:50
Rigelhaupt:
That made something like the Health Alliance a possibility.

01:20:54
Lewis:
I would start at the top. I think Mr. Rankin was the CEO for just about all that time, right? [01:21:00] From 1993 to he just retired last year, to 2014, so basically those twenty-two years. I think he had the respect of all the groups you’d need to be concerned about with those major decisions—the board, the hospital, the medical staff. Maybe there were a couple of instances where there was a major decision made that really, I think was not well thought out. Even in retrospect, Mr. Rankin thought maybe he could have done it differently. But I can probably count those on one hand. I think in general, nobody ever is going to make all the right decisions. But he always, if he came to the realization that he didn’t make the right decision, he would always own up to it and do whatever he could to smoothe everything over and straighten things out. From a situation that really maybe not have been one of mutual trust, I think he was able to build trust over the years. Most physicians, if you interviewed them, I think they would say they did respect him. He had not necessarily self-interest, but the interest of the health system in mind. I think that helped a lot. All the major initiatives that were undertaken weren’t undertaken behind closed doors in a dark room, with the lights turned down and the telephones turned off. There was a lot of transparency. Things were generally done by committee and there was always physician representation on the committees. We’ve always been included in decisions. Obviously, the board itself I think has two physicians, at least, on it. There are several physicians in very high positions of the administration: Dr. Bigoney, Dr. Mandell. Before then, Dr. J. Thomas, “Tom,” Ryan, was the executive clinical vice president for a long time and I think he jockeyed well between administration and medical staff. I think the medical staff just felt they had been part of all the decisions. They’ve had opportunity for input and I think it’s turned out that most of those decisions that were made were the right ones. Certainly we’ve been through some rough spots, some of it not our doing: some of it was external in terms of economics. But here we are. We’re a growing health system. We take very good care of our patients, most of whom stay in this area to get their care. We’ve maintained independence, which is not an easy thing these days and is very highly valued by our medical staff. [01:24:00] In fact, you mentioned the alliance to the ACO. I think a lot of the impetus to the development of this accountable care organization is that we feel that this is the best opportunity for us to maintain that independence. I guess we’re in this cradle of the country here. The Civil War has gone through here and the Revolutionary War. I guess we got the fife and drum set here so that we kind of value that independence. We’ve done very well as an independent health system, but there are a lot of competing forces to the north, east, and south, and west, whether it’s Inova to the north, Sentara and HCA now in our own back yard, or Charlottesville and UVA, or Carilion, or Novant. They’re out there. They’re large and they’re doing well and they’re well capitalized. If we weren’t strong, we wouldn’t be independent. A lot of what we do now in terms of decisions and cooperation and health care decisions, as well, is trying to go on the route we’re going now because we think it’s a good one.

01:25:06
Rigelhaupt:
We’ll be trying to lead up to the independence and where you are now, but I want to go backward a little bit to try to lead there. One of the things I’ve heard a lot about in the interviews is a sense of values, and a sense of core values among the organization. You weren’t ever an employee as a private physician practicing in the hospital.

01:25:29
Lewis:
Right.

01:25:29
Rigelhaupt:
Thinking back to when you started, was there a sense of core values at the hospital? And how did that influence or be communicated to the medical staff?

01:25:43
Lewis:
If there was one core value, I think that we’ve heard over and over enough to say that this is really actionable and something that people believe in, it’s that if you have a difficult decision, just think about, initially, what’s best for the patient. I think whether it’s the administration, the board, the medical staff, or the associates, I think people feel that if you do what’s best for the patient and what’s best for patient care, that it turns out to be the right decision. There can be other peripheral decisions in terms of economics, in terms of making it viable enough to stay in business and be able to provide that care. But I think in terms of whether it’s turf battles, or investments in equipment, or hiring associates and FTEs, in general, I think in terms of a core value, I think putting the patient first is what I would say. The mission of the Mary Washington Healthcare is to improve the health status of the members of our community. The mission statement is focused on the care of our community. If there was a core value I would say that everything centers around, that that’s the one I would say.

01:26:58
Rigelhaupt:
So thinking about patient care and the mission as a pivot point, with things pivoting around that. [01:27:00] What are some of the things you would point to that have allowed the mission and that core value of patient care to stay so central, when you’ve described physician staff going from sixty-plus to, as you said, probably 800-plus? And I imagine a similar sense of proportional growth among the nursing staff.

01:27:32
Lewis:
And the number of practices, and like I say, services offered.

01:27:37
Rigelhaupt:
So how does that happen that you can say that it’s been consistent, when there’s such a period of growth, and for potential to lose focus on that?

01:27:47
Lewis:
I think we’ve been fortunate to have very good leadership. We’ve already talked about Mr. Rankin. The nurses who have been promoted through the system and into positions of leadership have been excellent. [01:28:00] And even all the community-based programs and the Community Foundation. I don’t know if you’ve talked to Xavier Richardson, but he’s been a very effective leader in that position for probably longer than I’ve been here. There has always been a good community relationship. I think the hospital system has the support of the community and the support of the chamber of commerce and the businesses here. I guess it’s like kind of everybody is pointing in the right direction and there’s a lot of community support. Like I said, the communication has been a problem as the region has grown and the number of participants has grown, but I think the leaders are trying to, as best they can, keep their fingers on the pulse of their respective constituents. They do the best they can in terms of communicating and they hopefully are speaking for as many of those constituents as possible. We have an excellent committee structure. We bring the right people together when committees are making decisions so people feel included and I don’t think anybody feels excluded. I think if anybody feels like they have something to say or want to have a voice in something, there’s a channel or a method of communication to get that said. I think we’ve had responsible people in responsible positions and have been very fortunate in that regard.

01:29:25
Rigelhaupt:
So this is kind of a long question, but I think may tie into where you were just describing in terms of the development of the Health Alliance and the accountable care organization, and connects to some of the things you just mentioned in terms of community benefit and the mission. Part of the history of acute care hospitals, even not-for-profit hospitals in the U.S., is that there tends not to be as much of a focus on primary care, health care, or public health. They’re acute care centers.

01:29:53
Lewis:
Right.

01:29:53
Rigelhaupt:
And they’re very expensive, difficult places to treat chronic conditions.

01:29:58
Lewis:
Right.

01:30:00
Rigelhaupt:
And, so generally speaking, hospitals have not put a lot of focus on primary care, and yet, some of the things you described, the mission, the community benefit, have really been part of the mission of this organization. Why do you think that has come to develop the way that it has?

01:30:23
Lewis:
I think you’re right. The focus on population health—there is this pie graph that is very instructive in that regard. Like you say, the acute care that’s done in the hospital only represents ten percent of the influence that our health care system has on sickness and mortality in a community; thirty percent is genetic, which we don’t have a lot to do with that; but forty percent is behavioral. Forty percent is risk factors, and whether people exercise and eat right and don’t smoke. Early on when we were talking about thirty years ago, and you were in the setting when the hospital’s focus, though, was building as many beds as possible, filling them as much as possible, and keeping patients in those beds as long as possible. You think about that and I think the evolution of health care in our community mimics the evolution of health care in our country because it’s just not a good way to deliver health care. It’s kind of like rewarding you for having sicker patients and rewarding you for doing more things to people, whether they’re the right thing or not. That turned out to be very expensive and inefficient care. Then finally it was realized that we cannot go on this same course. The cost of medical care in this country is eating up a larger and larger portion of our GNP, and if you draw that out, Medicare will be bankrupt, just like Social Security. Clearly, something had to be done and it looks like people who really knew what they were talking about have been heard. And you’re right: the investment in population health over the long term gives you much more dividends because you can treat those portions of the population heath that, over the long term, really are what is involved in most of your spending in most of your illness and disease. Then an accountable care organization, like the [Mary Washington] Health Alliance, is a perfect system to get that done. The problem is if the hospital was not aligned with a health care system and ACO, they would be destroying themselves. If they made their community healthier and in less need of the hospital, and did more things as an outpatient, then they would be destroying their own source of income and prosperity. It takes an alliance, it takes an agreement, and it takes cooperation between the hospital, the facilities, the physicians, the outpatients, and especially primary care. It’s funny you mentioned primary care because it has been kind of the weak sister of the health care system all along, at least in our country. [01:33:00] Other countries have recognized the value of primary care. But finally, I think we’re getting around to that in terms of PCMH, patient centered medical homes. All these initiatives to center care around one physician that knows the patient well, and not only knows the patient, but knows the community, knows the family, and knows all the community support systems. I think the health care system can funnel the resources to support that, as well as all these acute care things that we’ve been concentrating on before. Again, yes, I think the directions that health care in the Fredericksburg community is moving mimics what the country as a whole has realized they need to do. Hopefully, in our more concentrated setting, we don’t have to be as beholden to the politics of it, which I think is really kind of holding other communities back in terms of red states and blue states, Medicaid expansion, and all those things. Our health care system has to put up with that because Virginia is a state that has chosen not to expand Medicaid, which is a major financial influence on the hospital. As you know, Obamacare was dependent in part on the fact that we’re not going to pay hospitals as much for taking care of uninsured patients because more of your population is going to be insured. Well, in the states that didn’t expand Medicaid, you don’t have as much of a growth in the insured population and we’re having to deal with that. At least when the hospital is working within a system that understands that as well we can use cost efficiencies as much as hospitals to even thrive and prosper within the system that’s kind of maybe putting some influences on us in other directions. It gives us the best chance to survive and maintain independence. It certainly, from a population health standpoint, is the right thing to do.

01:34:57
Rigelhaupt:
So part of what I want to do is try to tie some of that to the history of the organization, because I think, and correct me if I’m wrong in my hypothesizing here. Some of this has been practiced, perhaps in a less organized form. That the Community Benefit Fund, started as the Community Service Fund, became the Community Benefit Fund, giving grants to public health organizations outside the hospital, has been a part of a practice of the organization for decades. But at the same time, there was always unreimbursed care.

01:35:38
Lewis:
Correct.

01:35:40
Rigelhaupt:
There are always important technologies coming for cardiologists and other specialists, and the foundation could have always made the case that these dollars are better spent supporting the latest technology for surgeons; could have always made the case that this is important to provide those dollars for the unreimbursed care that the hospital is always going to face. [01:36:00] And yet, there has been consistent funding of health care organizations outside Mary Washington Healthcare. Why do you think it happened that way? And how do you think some of that has influenced the development of something like the Health Alliance?

01:36:22
Lewis:
What that enables us to do—well, let me back up a little bit. We’ve kind of been dependent on those outside organizations at least until recently. A lot of those things you were mentioning that are beneficial for care were not reimbursed. Things like care coordination: you never got reimbursed for care coordination; for making sure that when a patient went home from the hospital, that they understood their medications; that their appointments were made with their follow up physician in a timely fashion; that even after they were home, that somebody would call them and make sure they didn’t have any problem with the medications and they didn’t have side-effects; their access to their physicians and their medications was there. All these things that are so important to keep people from bouncing back in the hospital, heretofore, was not reimbursed. The hospital may have had interest in it if it was medical care. But on the other hand, if the patient bounced back to the hospital, well that’s just another admission they’re going to get reimbursed for. Now you see that if a patient bounces back too quick, they may not get reimbursed. Thirty day readmissions is a big focus of reimbursement, now. The incentives are becoming more aligned between the kind of initiatives you were talking about. We may not, hopefully, have to rely as much on these outside philanthropic organizations because now we’re going to a system where we’re going to be maybe given a global fee to take care of a segment of the population and we can do what we feel is most appropriate to take care of them. If we keep them out of the hospital and if we do care coordination; if we have people who can’t get to their doctor because they don’t have transportation, find them transportation; if they have wheelchairs but they can’t get out of the house because of the stairs, we can build them a wheelchair ramp—all the things we know that are relatively low tech that do have big payoffs in terms of medical care and patient experience. Part of that is an accountable care organization having partners with the community benefit programs you were talking about. We want to be able to identify the needs of the patients and link them up with the community resources that are available. Then, the hospital foundation, they can still, assist with the big ticket items. If they still want to help us purchase the latest and greatest equipment and technique, that’s fine. I think in the day-to-day care of patients, we can do a much better job and a lot of that involves just the knowledge of what’s available, who the volunteers are out there that are willing to help, and just matching the need up with the resource. [01:39:00] That’s a big part of population health. It’s low tech. It’s not expensive. But it’s effective and it also improves the patient experience. This is one of the three triple aims.

01:39:11
Rigelhaupt:
Are there things you can point to that you’ve witnessed, or you’ve heard other physicians talk about, that have become models that you’re trying to build on with a more coordinated way with the Health Alliance, that you’ve seen the way another practice does things? Like, say something like the Moss Clinic, which is literally next door to the hospital.

01:39:38
Lewis:
Right.

01:39:39
Rigelhaupt:
That you’re trying to build on some of the things that have been practiced, less formal organizational structure?

01:39:46
Lewis:
We were very fortunate we’ve had Moss Clinic and doctors like Tim Powell and the Christian Health Center. Basically, patients realize that whether they have the means or not, whether they’re insured or not, that the care is there and there are providers there who are happy to provide it in a very nurturing fashion. Again, the Alliance will hopefully be able to emulate that—or any kind of accountable care organization. They’re going to be able to have the funds available to focus on those with the most need, and help maintain the people that are healthy and help maintain their good health so that they don’t become more consumers of health care resources in the future. It really works both ways. You’re able to focus more of your resources on patients who are in need now. The problem is, if they don’t get that need, they only become worse. They have risk factors that aren’t being addressed. They’ve got conditions that they’re not seeing their doctor for because they can’t afford to. I mean, it’s so much more cost effective to treat the hypertension and get people to quit smoking instead of waiting until they have the heart attack and put a $10,000 stent in. That’s the advantage of a practice like Tim Powell and the Moss Clinic: patients don’t feel like they have to put everything off. They don’t have to choose between buying medicines and putting food on the table. I’m not trying to say we’ve got Nirvana here, but at least if the system is aimed toward reimbursing for value rather than volume, it at least gives you a fighting chance of at least applying whatever resources are there, whatever the limits that they’re are, at least in the most effective ways. I think in terms of that providing care regardless of whether people are insured or not is a good thing. Obamacare goes a long way. I don’t want to get too political about this, but Obamacare, at least a version of Obamacare, should help other organizations, as well as our own, accomplish that. I don’t feel like the insurance-based system is the best health care system, but if at least we’re stuck with that, we’ve got to make it more equitable and more available. [01:42:00] It shouldn’t matter whether you have a job or not. Access to decent, basic health care is a right, not a privilege. It’s not a privilege of the people who are richer, or who are employed, or live in certain parts of the country rather than others. I think hopefully, as we move from volume to value, to coordinated care, and to accountable care organizations, we can accomplish more of that.

01:42:25
Rigelhaupt:
Do you think that there is a reflection, again, in a less formal way, in terms of access to health care in the physician community participating in something like the Moss Clinic, and the hospital donating the land, doing a large endowment, fundraising, to make sure, again, that it wasn’t something that was hidden away? In terms of physical coordination, it’s right on the hospital campus, in the middle of it.

01:42:54
Lewis:
Right, right, right. I think they realized that it’s part of their mission, again, to improve the health status of the members of our community, all the members of our community. Access is such an important part. I think a lot of the people who are opposed to Medicaid expansion, for instance, say, “Yeah, we can insure all these people, but then who are they going to get the care from?” Are there practices that are seeing Medicaid patients, et cetera? But with efforts like the Moss Clinic, then you’re providing that access. That’s going to be a problem in general because there’s a relative dearth of primary care physicians. When you talk about access, it’s purely primary care access for most of the population. We certainly maximize the efficiency of our established primary care practices. We utilize mid-level providers, nurse practitioners, physicians’ assistants, community volunteers, or whatever kind of health background you have. You’re right: at the Moss Clinic you’ve got physicians who are otherwise retired who are using their time to deliver that care. There are even commercial establishments getting into it. Even you talk about Target and Walmart, Minute Clinics, whatever. At least, even the simple access to care is available, hopefully in an affordable fashion. If established practices feel like primary care is a source of competition, well then, that’s a stimulus to more physicians being trained in primary care recruitment, et cetera. In general, primary care physicians have been undervalued. The fact that maybe that’s been recognized now, hopefully physicians in training will be more encouraged to go into primary care services because that’s really what we need.

01:44:47
Rigelhaupt:
Another model of something like the IPN would be something like Kaiser, or Mayo Clinic in some ways or the Cleveland Clinic —

01:44:57
Lewis:
Right, right.

01:45:02
Rigelhaupt:
And I know that it was a clear decision to have an open system here, to build on the private practices. But are there things that the hospital and Mary Washington Healthcare has supported that more closely emulate some of those? Are there things you’re doing as medical director that you’ve drawn on some of the parts that you like about the other systems, to implement them within the ACO and IPN that is here?

01:45:29
Lewis:
The problem with—not a problem. But with Kaiser, you still have to belong to Kaiser. It’s really an insured population. It’s just that they can keep their costs down because they’re efficient and they have certain protocols. Basically, that’s what the alliance has. In terms of emulating a Mayo Clinic or what Kaiser does is, first of all, you encourage generic drug utilization. In other words, you’re using medications that have the same treatment effect, but cost less than brand medications. What we do is we educate. If you ask a physician to use more generic drugs, their first reaction is, “Well, I know about that. I know generics are worthwhile to use because they are effective and less expensive.” But the advantage of a health care system or an ACO with information technology is you can actually gather the data showing that physician that, “Well, you may think you’re doing well in generic prescribing, but you’re actually only prescribing sixty percent generic medications, whereas your peers are prescribing seventy-five percent.” Then you can say, “And these are the medications that you’re prescribing, brand medications, that we think you could, if you agree, generic substitutes would be appropriate.” That kind of thing. Again, care protocols: if you have a patient with hypertension, these are the most cost-effective medications to use initially. Don’t forget to make sure that they’re restricting salt and that they’re exercising regularly. All things that we know are not expensive, but work and have multiple benefits. It is treatment protocols, best practices, education, and that kind of thing. Kaiser has nurses. The other thing we would have is a help line. We use Health Link, which is already established, so that physicians and patients can call and get whatever information they need. Hopefully, if a patient has a question about whether they need to go to the emergency room or not, they can talk to a nurse on Health Link and say, “I know this is bothering me. I’m not really sure I need to go to the emergency room.” Then the nurse would have a protocol to go through, depending on what the complaint was, and say, “No, I think you’re right. I think maybe you don’t need to go to the emergency room this time. Let me call this practice, the on-call physician, and get an appointment for you, 8:00 tomorrow morning.” It is that kind of thing. The patient is getting the right care, in the right place, and at the right time, and you’re saving the health system money because you’re talking about an office visit in a primary care physician’s office, rather than a very expensive ER visit. [01:48:00] That achieves the triple aim as well because the patient is getting good care, you’re saving the health system money, and the patient feels better about seeing a doctor in the office, rather than going to the emergency room and waiting whatever time they have to do.

01:48:19
Rigelhaupt:
The Health Alliance, and I want to go back to one of the things that we talked about, the question of trust and coordination between hospital administration and physicians.

01:48:29
Lewis:
Right.

01:48:31
Rigelhaupt:
I asked some questions about some of the things that the hospital administration has done to win trust in the physician community. But also, I think it goes the other way in terms of where you are now, with the health care organization owning the majority of the Health Alliance—

01:48:47
Lewis:
Right.

01:48:46
Rigelhaupt:
—and the majority of the board members being physicians.

01:48:50
Lewis:
Right.

01:48:51
Rigelhaupt:
What are some of the things the physician community has done to win the trust of the health care organization that there’s that kind of structure? And I know there are safeguards in place in terms of the health system, but still, the board is dominated by physicians, medical director—

01:49:09
Lewis:
Right, right.

01:49:10
Rigelhaupt:
—and yet, the health care organization owns the majority of it.

01:49:13
Lewis:
I think the Alliance is a great demonstration of the fact that yes, maybe the community has evolved from a little bit of antagonism or mistrust between administration and medical staff to a much more trusting, cooperative environment. When the alliance was put together, one of the impetuses was that both the hospital and the physicians wanted to remain independent. Was it Benjamin Franklin who said we either hang together or we hang separately? I think it realizes that together, we would have much better opportunity to achieve that. Yet, it was decided early on that the organization would be physician led and physician governed and the hospital was very much in support of that. I think they realized that if you’re going to have a cost efficient health care system, the doctors have to be a part of that because they’re the ones that are actually delivering the care—again, the pen being the source of most of the expenses. Yes, there’s a sixteen-member board, and twelve are physicians, and four are representatives of the hospital. At this point, two of those hospital representatives are physicians, Dr. Bigoney and Dr. McDermott, and actually fourteen out of the sixteen in our governing board, board of managers, are physicians. Yes, the hospital, technically, Mary Washington Hospital owns eighty-three percent, but the goal is to have a fifty-fifty ownership. To their credit and if you want to talk about trust, basically that means that the hospital really did most of the capitalization to get this organization going. Over time, hopefully, more and more physicians will feel that they want to be owners of this, as well. Right now you can join as a participant and pay certain dues or as an owner and buy a share. The more shares the physicians buy, they actually buy them from whatever shares the hospital owns. I think over time, you’ll see the eighty-three percent creep down gradually to fifty-fifty. That won’t be an issue you can point to, but whether it is or it isn’t, I don’t think anybody thinks of it as influencing the way the organization is functioning now. I go to as many committee meetings as anybody, from the board of managers on down, and I’ve never seen the hospital push their agenda because of, “You know, we own 82 percent of this organization, you’re going to do this.” Never, ever, ever. That’s a credit to the leaders on both sides. It’s incredible that the community has gotten this ACO together, and both sides really want it to work, and I’m sure the community does, the more they find out about it, and I think it’s going to do well. Like you say, it’s just an example or a demonstration of how far the trust issue between the hospital and the medical staff has evolved. [01:52:00]

01:52:08
Rigelhaupt:
And that’s mainly where my question was aimed is that could you have imagined, as you began your medical career here, that there would be this organization, that a hospital would capitalize it in the way that it had, the physicians would be fourteen to sixteen—.

01:52:26
Lewis:
Right, right.

01:52:27
Rigelhaupt:
—and be certainly a medical model for the community?

01:52:33
Lewis:
No, no. Clearly at the beginning, it was us versus them. The administration was tolerated and we knew we needed them because we needed the hospital to be successful so we’d have a place to put our patients, but that was about it. They probably felt the same way. Their hospital is their primary concern, and yes, they’ve got to coddle the physicians because they need their patients, but the least they need to do to get that cooperation, the better. They did have a monopoly. It was the only hospital in town, although over time we an opportunity to send our patients elsewhere. But clearly, yes, when I first came here, there was more of an adversarial relationship. I’m medical director of this organization, so clearly I have a dog in the fight. But even so, I don’t think there could be a better expression of the cooperation you’ve seen. Like you say, the hospital has capitalized it, and yet, in terms of voting rights, they have less. Rarely does it seem to be us versus them on any issue, anyhow. It’s how we can work together to accomplish whatever issue we’re trying to solve.

01:53:40
Rigelhaupt:
And let me ask how you think that compares to your last stop before you began practicing here, which is an academic medical center where there is a lot of coordination. [01:54:00] There is a system in which physicians and the hospital align. That may not be the right word, but—

01:54:02
Lewis:
I know what you’re getting at, but they have it a little bit easier than that. They own the physicians, too. They are paying the faculty’s salaries and they’re paying the residents’ salaries. The other thing is they have resident physicians in the hospital all the time and manning everything. I think maybe they’ve come to even a more cooperative atmosphere, but at least their substrate for accomplishing that is a little bit easier than ours is. In fact, the other ACOs, where they employ their physicians, I think they’ve got it a little bit easier, too. On the other hand, if we’re able to accomplish that without employee physicians, I think that’s even better because we’re doing it because we want to, not because we have to.

01:54:38
Rigelhaupt:
And that’s part of what I was asking, that there are different models of doing this.

01:54:42
Lewis:
Yes.

01:54:42
Rigelhaupt:
And this seems to be more open and less adversarial, but can be done.

01:54:48
Lewis:
Right. I think more difficult and I’m really impressed because I really wasn’t involved with the initial selling and promoting of the organization. I was on the other end. I was sitting on my practice and the group going around the community came to us and told us about this. I was initially somewhat skeptical because I had had all that history, and not all of it good, in terms of relationship with the administration. I had to be convinced that, “Boy, they really mean it.” They sold me. I think we’ve been growing faster than predicted. We had our 5,500 covered lives in Mary Washington Hospital associates and their dependents in the initial year. We were projected to have maybe 6,000 this year and 8,000 in the third year. We’ve signed a contract with Medicare MSSP [Medicare Shared Savings Program] that is 17,600 lives. We’re very close to a contract with Aetna and another 10,000 lives. That’s seventeen-six, plus five, twenty-two six, plus ten—over 30,000. This May or April, we’ll be in existence two years. The hospital put their money where their mouth is; we put our actions where ours is, and so far it’s working.

01:56:07
Rigelhaupt:
So I think that’s always a nice place to wind down in the sense that this is a long-term play. The accountable care organization and the IPN and the Health Alliance, in the same way that the hospital was a long-term play.

01:56:20
Lewis:
Yes, that’s right.

01:56:20
Rigelhaupt:
There was some skepticism that there’s a new venture being started. And I didn’t ask all my specific questions, but I think that’s okay. And so, the way I’d like to end it is to actually ask two questions.

01:56:36
Lewis:
Okay.

01:56:37
Rigelhaupt:
And try to combine it into one. Is there anything that I should have asked that I didn’t, and is there anything you would like to add?

01:56:45
Lewis:
That you didn’t ask? No, that was pretty thorough, actually. Anything you’d like to add? My perspective is a little bit unique. I was practicing cardiology and not that politically involved. [01:57:00] Yes, I did have some directorships and some administrative responsibility, but it was basically patient care with the focus being taking the best care of patients that I could and fostering the growth of Cardiology Associates of Fredericksburg. I was actually winding down in terms of my actual practice. Thirty years is a long time. I’m getting tired: I stopped taking night calls, stopped working weekends, and stopped working holidays. Even then, I said, “Nah. I really should start thinking about packing it up.” Then this IPN came along, this integrated provider network, the ACO, the alliance—whatever you want to call it. They were looking for a medical director. To be honest with you, it wasn’t my idea: it was my practice manager, Atique Pappa. He said, “Rick, you know, you really should think seriously about that. I think you’re perfect for it.” I said, “Oh, God.” Then I was thinking, “I’m trying to wind down and he wants to put all these new responsibilities on my shoulders.” But he turned out to be right in that I have, obviously, a medical background and the experience. I know the nuts and bolts of medical care. I know almost all the physicians, like I say, not all on a first-name basis, but I’m familiar with most of the physicians. I worked very closely with a very good portion of them for long time. I don’t have any skeletons in my closet. I’ve been very fortunate. I’ve had good relationships with almost all of them. The administration, yes, especially the last few years, I worked more and more closely with them. I know them very well and we’ve gotten along well. I like being in the spotlight. I don’t mind getting up in front of a group. I said, “Well, you know. And here we go.” So now it’s like instead of winding down, I’m winding up. That was Rick Lewis, act one. This is Rick Lewis, act two. But it’s funny because it just reflects the whole change in medical care in this country, in general and locally. I think that’s what’s very interesting about your project: if you look at the evolution of Mary Washington Hospital and Mary Washington Healthcare, from MediCorp to Mary Washington Healthcare, from a community hospital to a regional health system, and from a very volume based health care delivery system to one that’s moving toward a value based, it’s a very difficult maneuver. There are maybe winners and losers, or like the burning platform. If you’re going to decrease utilization, you’re also decreasing revenue until we can fully get into a value system. It’s not easy, but it’s kind of a fun journey, and that I can be part of this is very exciting. Instead of just taking care of two or 3,000 patients in my practice, I’m having some responsibility for over 30,000. It’s really very exciting. I feel rejuvenated. I think it’s the right direction for health care in America and I’m just happy to be a part of it. I think Fredericksburg is doing the right thing.

01:59:57
Rigelhaupt:
I think that’s a great place to end.

01:59:59
Lewis:
Good. Okay.

02:00:00
Rigelhaupt:
Thank you.

02:00:01
Lewis:
You’re welcome.
[End of interview]