Submission Date: August 14, 2015 American College of Medical Practice Executives Professional Paper Topic and Outline- FOCUS

Transcription

1 Understanding Finances in a Service Line Model Submission Date: August 14, 2015 American College of Medical Practice Executives Professional Paper Topic and Outline- FOCUS

2 Introduction This paper will focus on the topic of how the well-informed healthcare executive can financially manage service line models through the use of established tools and models. The same need to budget, manage to budget, and to provide financial reporting to leadership exists whether in a two person practice in a physician-owned clinic or in a complex service line model in an Academic Health Center. A literature review of source material from both the web as well as printed materials was utilized to define service lines in a healthcare setting and to identify the internal and external forces that encourage healthcare leadership to select a service line model for their organization. Much of the available literature speaks to the service line model in which a hospital selects specific services to market and label as service lines. Increasingly, there is a clarion call in healthcare to completely re-organize the healthcare delivery model into a model that is patient, not provider centric, and is integrated. Nowhere is this seen to be more imperative than in Academic Health Centers (AHCs) where interdisciplinary teams are needed due in large part to the complexity of care. i Some healthcare leaders believe that organizations can leverage service line models to achieve the necessary response to external forces in the healthcare market. The Woodruff Health Sciences Center s Leadership Academy Class of 2015 at Emory University recently published a study of Emory s service lines. ii This study found that AHCs are pushing for better alignment among their constituent hospitals, physician practices, clinical departments, research centers and educational programs as well as across the different disciplines with common interests in disease management. There are over 130 AHCs in the United States and the characteristics which make them unique such as their size, perceived higher quality, and specialized care also put them at risk in this rapidly changing healthcare landscape. iii 1

3 The concept of service lines in healthcare has been identified as a solution for improved collaboration between healthcare providers since the 1990s. iv It is interesting to note that another major development during this same time period was the emergence of HMO s as a way to reduce healthcare costs. In 2008, the Cleveland Clinic organized into an institute structure that puts the patient needs first, ahead of medical practice tradition. v This model created a tiered network with a care delivery system based on patient needs arranged in 27 Institutes. In a presentation at the Society for Healthcare Strategy & Market Development of the American Hospital Association in September 2012, Kurt Salmon Senior Partner Jeffrey R. Hoffman predicted that New care models will expand to meet supply and cost constraints; care delivery will continue to transition to use broader multidisciplinary teams and networks vs. current physician centric model. vi Of special interest is the utilization of service line or product line models in Academic Health Centers. AHCs often rely on public sources of funding which will be challenged to provide continued support with the aging of the baby boomers into Medicare. vii And, there are other fiscal challenges contributing to the on-going competition for federal and state dollars. However, changes in commitments from governmental payer sources are not the only potential threat to AHC revenue streams. Informed consumers of healthcare services will look to cost-effective products and services as will commercial and managed care payers. Per the Blue Ridge Academic Health Group, many AHCs lag behind local and regional community health care organizations in transitioning to value driven models. viii In their Report 18. A Call to Lead, the Group recommended that AHCs accelerate team-based care models and use as a platform for patient-centered, team-based learning and discovery model development. ix This thought is echoed by the Institute of Medicine s Committee on the Roles of Academic Health Centers in the 21 st Century which published Academic Health Centers- Leading Change in the 21 st Century. In this book, the Committee recommends that AHCs design and assess new 2

4 structures and approaches for patient care. x The Committee writes If health care is to produce a different output, the platform for delivering that output needs to be rethought. xi However, identifying or developing this platform for healthcare delivery will not be that easy for AHCs. AHCs are identified as complex adaptive systems which means among other characteristics- there is no single point of control. xii They can t be successfully commanded or controlled. They can be incentivized and they can adapt. According to the Blue Ridge Academic Health Group, one way to incentivize physician leaders is to give them meaningful responsibility over the clinical enterprise xiii Organizations interested in utilizing a service line model may benefit from incorporating physician leadership in service line management. The Association of American Medical Colleges Advisory Panel for Health Care working with Manatt Health Solutions conducted a study of thirteen AHCs that they had identified as leveraging leadership to guide the AHCs into a sustainable future. They noted, as emerging themes in advancing AHCs, new physician leadership and evolution of the practice as well as more efficient operating models to bend the cost curve. xiv What is a Service Line? Service lines are typically called product lines in other industries. xv Hospitals are usually organized in departments that offer specific services just as Colleges of Medicine are arranged in departments by specialty. However, patients seek healthcare for a variety of medical issues during the course of their lifetime. Healthcare, to date, has been viewed as episodic with preventive care being traditionally provided by primary care disciplines. But in reality, patients may require services from multiple product or service lines sometimes even during one hospitalization. Therefore, the organization must identify how to attribute specific patient encounters to a specific service line. This concept will be discussed further in the section entitled 3

5 Reporting. A service line must be able to be accountable for the services that is encompassed within its parameters, efficient in care delivery, material to the parent organization, and identifiable. E. Preston Gee proffers that SLM (service line management) gets the enterprise closer to the individual than any other managerial model xvi Accountability is more readily understood and managed to by all individuals participating in the service line model including the patient. How the physicians group themselves to deliver care is significant. For example, Dr. Toby Cosgrove argues in The Cleveland Clinic Way that the physician-run group practice provides better and cheaper care. xvii The Cleveland Clinic model utilizes Institutes which are disease oriented and provide all the services required to cover the full cycle of care for each medical condition. And, of note, the Cleveland Clinic has gone beyond identifying a few significant service lines to reorganizing the entire organization into Institutes. Physician leadership is critical to move toward a data-driven approach and to enhance buy in from other medical staff. xviii This type of governance also ensures accountability within the service line. Efficiencies are gained in the service line model when there are fluid handoffs between specialists working in a patient centric approach. With fewer mistakes and increased patient satisfaction, clinical outcomes are improved which has a financial impact in the new world of pay for performance. In the literature, there are definitely two schools of thought when identifying the right number of service lines per organization for the most efficient delivery of care. Gee recommends the more traditional view of narrowing down the number of service lines to a manageable few (no more than four) while others support categorizing all activity into Institutes or service lines. xix This traditional view is echoed in the Edgewater blog from 2010 in Implementing Healthcare Service Lines where the post states that Service Lines are typically limited to a handful of well defined, mutually exclusive categories xx The opposing view is best represented by Dr. Toby Cosgrove s reorganization of all of the Cleveland Clinic s services 4

6 from a department-based model to Institutes which were defined around disease or organ systems. xxi Service line activity should also be material to the organization in terms of income. xxii In the more traditional view of service or product lines, these lines such as Cancer, Orthopedic, or Cardiac, were developed to support growth in the market or to maintain market position. Gee posits in the current healthcare environment that service lines are the solution to the demands of Accountable Care Act and the focus on population health. He states this time is definitely the best of times for a managerial framework that aligns progressive organizations with their most important stakeholder: the consumer. xxiii Gee also states that focusing on individual patterns and behavior will achieve the most meaningful empirical results for population health management. The intersection of consumerism and population health management is where the service line strategy will dominate the marketplace. xxiv A service line should also be easily identifiable. In a Medaxiom blog from 2012, Suzette Jaskie states Successful service lines have a clearly defined scope of operation. xxv This clarity of purpose is from many perspectives- clinical, operational, financial, and from governance. Financial service line management also benefits from clear definitions. Service line activity should be mutually exclusive- clinically and organizationally discrete xxvi It is critically important to avoid any hidden cross-subsidization between different service lines. Otherwise, the financial data will not be valid and could possibly inflate real performance. The organization must develop rules so that services are only attributed once but the rules need to be flexible enough to group the services differently if needed. To group services into various categories, a marker or identifier could be attached to the encounter, provider, or patient. For example, the grouper could be a diagnosis code or procedure code. However, a single patient encounter could potentially be grouped into multiple service lines so the organization needs to set pre-determined 5

7 rules on attribution and allocation which allows both Operations and Finance to look at the data from the same perspective. Financial Pressures In 2005, Dr. Mike Magee asked an intriguing question, What have we gotten for our money? xxvii He posited that the debate around healthcare for the past few decades was focused on cost and not necessarily value. In recent years, the shift is on value- defining it and measuring it. Value can now be defined simply as value = quality/cost. The aftershocks of a major recession and austerity measures are being felt in the healthcare industry as a slowing of the rate of health spending. xxviii It is a dangerous trap to continue thinking in the current paradigm of increased revenues resulting from increased volumes. Healthcare reform has certainly accelerated the transition from volume to value. xxix CMS, through its numerous sponsored demonstration projects to incentivize the delivery of value versus volume, has the attention of healthcare leaders. Also, Health Insurance Exchange participants who purchase insurance will want to understand the value of what they are receiving in exchange for their payments. In some states, health care exchanges may narrow local provider networks to lower cost providers. This could result in excluding traditionally higher cost healthcare organizations like AHCs. xxx Both employees and employers, as a result of higher costs in both premiums and out of pocket responsibility, are now focused on the value question. Physician- based organizations by necessity are also focusing on value as traditional fee for service reimbursement models are shifting towards more global reimbursement opportunities such as episodes of care and bundled payments. These models are following along the same path as the MS-DRG and Outpatient Prospective Payment Systems (OPPS) which govern hospital reimbursement. The payment reform world is currently in transition- providers can actually lose 6

8 revenue through improving care. xxxi But, healthcare executives must understand and manage to their true costs of doing business. In such a way, their practices will be better suited to anticipate the migration away from volume. xxxii Financial Management Healthcare executives can borrow from clinical practice the effective use of evidenced base processes and data analytics for financial management. xxxiii There are current and wellestablished financial management tools that can assist in supporting leadership to successfully manage service lines. Revenue and collection reports, operating or income statements, balance sheets, and cost reports are still necessary for financial management in the service line model. Each organization needs to determine at what level this activity is tracked and budgeted. For example, core expenses which are activities which support all service lines within an organization may be tracked outside of the service line budgets and profit/loss statements. Instead this activity, may be tracked and recorded centrally or it may be tracked and allocated via a pre-approved formula to the service line. Another concept that needs to be decided by the organization is how to track and budget for downstream revenue. xxxiv Forecasted profit and loss statements (P&Ls) can be developed for each service line and combined to view the expected financial result in total for the organization. xxxv The experienced financial manager can then run scenarios based on key business drivers. These factors could include the number of provider FTE s, number of admissions or outpatient visits, payer mix, revenue per encounter, etc. In short, these are the same key drivers that a practice manager would focus on in an organization that does not employ a service line model. Statistical information is similarly identified such as cost per unit, cost per encounter, or cost per provider. Revenue, which is the expected collections from patient activity, and Expense are the key components to 7

9 the profit and loss statement. Physician compensation is a significant factor in the expense category; and therefore, a physician compensation model that supports the accountable and collaborative nature of healthcare delivery utilized in the service line model must be developed. The Matching Principle of accrual accounting matches expense to the revenue the expense helped create. If this relationship cannot easily be determined, then a systematic method of allocating costs is allowed. xxxvi Fixed costs remain constant within a range of activity such as rent or malpractice insurance. Variable costs change in direct proportion to volume such as supplies. xxxvii It is vital that all direct overheads are appropriately identified and allocated to the correct service line(s) while indirect costs such as core functions may be shared across service lines (for example, Human Resource management, Procurement, Housekeeping). In a 2011 Oracle white paper, William Bercik stated that overhead has been identified as the fastest growing category of total costs for hospitals. xxxviii In order to control costs, the healthcare executive must be vigilant in the identification of all factors contributing to costs and then appropriately allocate those costs. There are four main cost allocation models for healthcare organizations. xxxix These are RCC, RVU, Hybrid, and ABC. The RCC model is the ratio of cost to charge. It is the most commonly used model. The RVU or relative value unit model is more complex and requires more maintenance than the RCC model. However, it is a more reliable cost predictor as it allows for something other than charges to be used. The Hybrid or 80/20 model is a compromise between the RCC and RVU models. Many organizations employ a hybrid model in which RVU s are only calculated for charge items that comprise 80% of the total patient revenue. The organization then employs the RCC model for the remaining 20% of charge items. ABC stands for activity based costing. This model is considered the most advanced methodology in which the more accurate service line cost is derived when cost drivers are established based on a cause/effect relationship between the commencement of a cost and its true origin. xl At a micro costing level, each cost driver must have separate measures so that charge items which do not benefit from a resource are 8

10 not allocated any costs from that resource. This approach is rarely utilized by U.S. healthcare organizations because it is so complex and labor-intensive. However, it could be very beneficial to invest in a cost model application that could provide this level of sophistication in cost allocation. Budgeting Building a budget is key to successful service line financial planning. There are various budget models available to the healthcare executive and examples of these various budget types may be found in the Medical Group Management Association s (MGMA) Medical Practice Management Body of Knowledge Review on Financial Management chapter 1. xli A basic question in budget development is when to use static or fixed budgets versus flexible budgets. Static budgets assume no change in volume. A flexible, or performance budget, can be revised for changes in activity. Ernest J. Pavlock s Financial Management for Medical Groups provides an in-depth study of the requirements for flexible budgeting. xlii A flexible budget can become a performance reporting tool so that actual expenses can be compared to the budget s prediction of expenses. Zero based budgeting as opposed to incremental or traditional budgets is probably better for the start- up years of service line models as every budgeted item must be justified. AHCs often utilize mission based budgeting which identifies both revenue and expense by the missions of the medical school- clinical, education, research, and sometimes, community. This allocation in turn enables management to better understand the contributions of all the activities that make up the mission of the AHC. xliii A particular challenge in mission based budgeting is how to define the activities that make up the different mission buckets and then the allocation of that activity. For example, how is faculty effort allocated while clinical care delivery is happening concurrently with bedside teaching of medical students and residents? How are costs 9

11 calculated for attending physicians loss of clinical productivity while teaching? Budgeting for service lines in AHCs must take into consideration the needs of the education and research missions as well as the more obvious, clinical mission. Activity based budgeting is a form of budgeting that is often used by large non-healthcare companies that looks at the costs of every activity that is performed within the organization. This approach is similar to activity based costing which is also based on the relationship between cost and activity. However, this type of budgeting is as complicated as activity based costing and requires special software and training of staff- both Finance and Operations. While the outcome of utilizing activity based budgeting will provide an organization much needed insight into its true costs, this method requires significant attention to detail, focus, and constant evaluation of all processes. Finally, the service line executive must evaluate actual performance to the budget. Variance explanations must be frequent and regular. Financial analysis must be nimble- information needs to be gathered and analyzed quickly with constant feedback to leadership so necessary adjustments can occur. MGMA s Medical Practice Management Body of Knowledge Review on Financial Management chapter 4 provides an excellent discussion on how to manage to improve financial performance. xliv The experienced healthcare executive will conduct internal comparisons, ratio analysis, and benchmarking. According to Ernest J. Pavlock, benchmarking is searching for and implementing the industry s best operating practices that lead to exceptional performance. xlv When there are no competitive, cooperative, or collaborative benchmarking data available, a healthcare organization can proceed to collect internal data to measure its own performance and to develop performance targets to monitor until such external benchmarking data becomes available. xlvi External benchmarks can also be found by looking to similar activities in other industries or partnering with other healthcare organizations in similar stages of development. 10

12 Most importantly, the action of reviewing actual financial metrics against budgeted numbers will identify opportunities for improvement. Organizations that develop budgeted numbers through the use of external benchmarks instead of relying on incremental budgeting are better positioned to survive financial challenges of the competitive marketplace. Reporting U.S. healthcare organizations should also look to service line strategies being utilized by international healthcare organizations. Monitor, an independent regulator for the National Health Service (NHS) Foundation Trusts in the United Kingdom published an interesting document on financial data for service line reporting. This document defines the structures and provides tools to support service line reporting in the third in a series of documents entitled Service-line Management: an approach to hospital management. xlvii The third guide provides a seven step approach to implementing service line reporting. While not all requirements are the same for U.S. healthcare organizations, this guide is intriguing in its focus on structure and profitability. All service line reporting is based upon the concept of how to allocate an activity, the cost of that activity, and the revenue generated from that activity to a specific service line. Organizations will have to make difficult decisions as they develop rules for attribution and allocation. The organization will need to determine if the activity will be maintained at the patient record level, how will direct and indirect costs be accounted for or distributed to the specific activity, how will technical or professional components of activity be identified and allocated, and when will reports run and data reviews be conducted. These data reviews can be conducted retrospectively, prospectively, and in real time. Retrospective reviews require reliable and accurate coding data that can be pulled into report queries which then reveal what activities were charged during the course of an encounter, 11

13 admission, or procedure. The rate limiting factor in retrospective reviews is the accuracy of the coding data. Prospective reviews can also be conducted which are more like the pro forma in a business plan. A series of what if questions can be identified and then data queries can be run based on historical information. Different scenario(s) can be developed based on the response to these questions and tweaking key components such as the number of patients treated, the frequency of the visits, or changes in care protocols. A real time review provides immediate data as care is being provided or has recently been provided once the patient discharges from the facility. Volume and cost data should be available during the course of treatment or very soon after discharge. Revenue data can be interpolated based on payer source and contract terms. Service Line leaders should not have to wait until the following month to understand the financial repercussion of care decisions and revenue cycle performance. Real time, validated reporting should provide the data that the financial analysts need to feed back to leadership. Challenges in service line financial reporting are numerous. As stated earlier, patient care is not comprised of a series of linear transactions provided by only one specialty. For example, a patient may have been admitted for a specific diagnosis and then another problem is detected during the course of that admission which requires consultation by another specialty or even a procedure. Organizational decisions need to be made to avoid double or multiple counting of one transaction or activity. Each transaction (based on whatever that is- a case, an episode, a surgery, an admission, a visit) is only counted once. Organizations may decide to re-allocate previously allocated activities if it has been determined that the real influence on care or actual costs are better managed in another service line. Changes in provider or patient allocation after a decision regarding allocation has been made can affect the validity of data reporting. Report writers and data analysts have to be included or informed of any change in allocation strategy. Healthcare delivery by its nature is complicated and there is value in reviewing any transaction to determine if the transaction has a one to one relationship to one service line or instead relates to 12

14 multiple service lines. If the organization has determined that patients will be allocated to service lines based on diagnosis, the question becomes what about the secondary diagnosis or diagnoses other than the primary diagnosis? What happens to the care delivered to support those diagnoses? How can reporting reveal the complexity of these transactions? Monitor posits that all costs and revenue including research and teaching must be allocated by service line to the contribution margin or EBITDA (earnings before interest, taxes, depreciation, and amortization) level. xlviii Again, how could this data be captured and then reported? Service line management requires vast amounts of data. Obviously a data warehouse can serve as the foundation for analytics. Support systems for cost accounting requires data from the organization s general ledger system as well as patient accounting system(s). Sufficient querying tools are required especially if real time or near real time review is desired. Leveraging multiple systems demand that the organization invests in data governance and ensures that there is data definition integrity. Reporting tools must be intuitive, flexible, and even adaptable. Service line financial management will only succeed with input from Operations as well as Accounting, Finance, Contracting and other end-users. Business Intelligence or BI supports the complex nature of service line financial management through tools and techniques that transforms the raw transactional data into meaningful data for analysis. Each organization must identify which metrics to be monitored and published through the use of scorecards, dashboards, on-demand reports, standard reporting packages or ad hoc reporting. The Emory System identified five major categories for service line metrics: revenue positivity, quality outcomes, provider outcomes, research productivity and educational excellence. xlix Examples of possible service line metrics to monitor include total discharges, number of surgeries or tests, market share, outpatient volumes compared to inpatient volumes, complication rates, mortality indices, net revenue, contribution margin (net revenue minus direct costs), net operating income for nonprofits or EBDITA for-profits, HCAHPS (Hospital Consumer Assessment of 13

15 Healthcare Providers and Systems), total operating costs per procedure, total operating cost per FTE physician, total physician cost per FTE physician, shared savings payouts based on attainment of quality measures, E & M coding curve distribution, bad debt expense, etc. Most if not all of the metrics from the above list are already being tracked by the healthcare organization. An important next step is to ensure that those metrics normally tracked by the organization to ensure financial success are not lost in the excitement of creating a service line structure. Conclusion The practice or service line executive can leverage established tools, systems, and financial management models to successfully manage the organization s service lines. Partnering with physician leadership is critically important to lead the organization into the service line structure. The savvy executive will also partner with the organization s Finance, IT, and Analytics leaders to develop the internal controls and reports to monitor financial performance of the service lines. Creating a new platform for healthcare delivery requires bold organizational restructuring. Financial management must remain constant and steady through these organization and governance changes. Service lines or service line-like structures are viewed as acceptable models to breakdown specialty silos and to promote clinical integration. The question now for an organization is to decide how rapidly to deploy a service line structure or how far to take the re-organization. Will the organization deploy a handful of service lines or re-structure all activity into service lines? Community integrated health networks as well as Academic Health Centers will need to rethink structure and governance to be as nimble as possible and responsive to the ever-changing landscape of healthcare delivery in the United States. 14

16 i Institute of Medicine of the National Academies- Committee on the Roles of Academic Health Centers in the 21 st Century, Academic Health Centers- Leading Change in the 21 st Century, ed. Linda T. Kohn (Washington, D.C.: The National Academies Press, 2004) 69. ii Woodruff Leadership Academy Class of 2015, At Your Service: How to Create and Sustain Effective, Patient-Centered Service Lines Across the Entire Woodruff Health Sciences Center (Atlanta, GA: Emory University s Woodruff Health Sciences Center, June 2015) Web, 13 August iii Howard Peterson and Gordon Alexander, Jr., MD, Integration without Merger: New Alignment Structure Helps Academic Medical Centers Adapt to Widespread Change (Becker s Hospital Review, April 25, 2013) Web, 13 August iv Toby Cosgrove, The Cleveland Clinic Way (New York, NY: McGraw Hill Education, 2014) 39. v ---, A Healthcare Model for the 21 st Century: A Vision from Dr. Delos M. Cosgrove, Group Practice Journal 60.3 (March 2011) 14, Web, 25 June vi Jeffrey R. Hoffman, Clinical Integration: Steps Following Physician Alignment (Kurt Salmon.Com, September 2012) 6, Web, 25 June vii Institute of Medicine 99. viii The Blue Ridge Academic Group, Report 18. A call to lead: The case for accelerating academic health center transformation. (Atlanta, GA: Emory University s Robert W. Woodruff Health Sciences Center 2014) 4, Web, 18 May ix Blue Ridge 2. x Institute of Medicine 121. xi Institute of Medicine 65. xii Blue Ridge 13. xiii Blue Ridge 26. xiv Advisory Panel for Health Care, Advancing the Academic Health System for the Future: Profiles in Academic Health System Leadership (Association of American Medical Colleges, November 2013) Web, 13 August xv William Bercik, Achieving Clinical and Operational Excellence; How to Establish Healthcare Service Line Costs (Oracle Corporation, June 2011) 6, Web, 18 May xvi E. Preston Gee, The Service Line Solution: Consumer-Focused Strategies for the Accountable Care Era (Danvers, MA: HCPro, 2014) 4. xvii Cosgrove, The Cleveland Clinic Way, xviii Gee

17 xix Gee 47. xx MDepaloewt, Implementing Healthcare Service Lines- Inherent Data Management Challenges and How to Overcome Them (EdgewaterBlog. Edgewater, 3 May 2010) Web, 25 June xxi Cosgrove, A Healthcare Model, xxii Monitor, Service Line Management: an approach to hospital management (Gov.UK. Monitor, 12 March 2014) 9, Web, 18 May xxiii Gee xiii. xxiv Gee xxv Suzette Jaskie, Creating value in organization structure- The service line approach Part 2 of 5: Clearly Defining the Scope of Operation (Medaxiom Blog. Medaxiom, 7 May 2012) Web, 25 June xxvi Monitor 9. xxvii Mike Magee, Health Politics: Power, Populism and Health (Bronxville, New York: Spencer Books, 2005) 469. xxviii Blue Ridge 5. xxix Hoffman 8. xxx Blue Ridge 7. xxxi Institute of Medicine 76. xxxii Hoffman 7. xxxiii Institute of Medicine 142. xxxiv Woodruff 10. xxxv Edgewatertech, Strategic Finance for Service Lines: Finding Opportunities for Growth (Edgewater Blog, Edgewater, 20 Oct. 2010) Web, 25 June xxxvi Jim Heffernan, Healthcare Finance 101 (Massmed, Massachusetts General Hospital and Physicians Organization in conjunction with HFMA Massachusetts-Rhode Island Chapter, 10 April 2013)5, Web, May xxxvii Heffernan 19. xxxviii Bercik 5. xxxix Bercik 4. 16

18 xl Bercik 4. xli Medical Group Management Association, Medical Practice Management- Body of Knowledge Review Second Edition volume 2 Financial Management (Englewood, CO: Medical Group Management Association, 2009) xlii Ernest J. Pavlock, Financial Management for Medical Groups: A Resource for New and Experienced Managers (Englewood, CO: MGMA Center for Research, 2000) xliii Institute of Medicine 106. xliv Medical Group Management Association xlv Pavlock 493. xlvi Pavlock 496. xlvii Monitor. xlviii Monitor 9. xlix Woodruff