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SUNDAY, APRIL 3, 2011 SERVING HELENA, MONT., SINCE 1867| |

INDEX

Vol. 67 No. 103 | 406-447-4000

Business 1EClassified 1DMontana 6AMovies 7AMutuals 4EObituaries 7AOpinion 4A

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41 23 23 14 13 12 10 <5Percent doctorturnover at St. James2008-10

Percent doctorturnover at St. Peter's2008-10

Percent doctorturnover atBenefis 2008-10

Percent doctorturnover atBozeman Deaconess2008-10

Percent doctorturnover atBillings Clinic(Fiscal years2009-2011)

Percent doctorturnover atKalispell RegionalMedical Center2008-10

Percent doctorturnover at St. Patrick2008-10

Percent doctorturnover atCommunityHospital 2008-10

‘UNHEALTHY’ | St. Peter’s Hospital’s doctor turnover rate among highest in state

PHYSICIANS | Doctors bemoan ‘controlling’ administration at St. Peter’s Hospital

ADMINISTRATION | Employment, health care trends contribute to ‘negligible’ rate

By SANJAY TALWANI | Independent Record

If you think it’s hard to find a doctor in Helena, you’re not alone.The number of internists who see patients outside the hospital has dropped by half in recent years. Several well-known

doctors have left town, and several more have left their affiliation with St. Peter’s Hospital to work for the VA at FortHarrison. The hospital has seen highly valued specialists come and go, with several longtime players in the medicalindustry here alarmed by what they perceive as an unhealthy turnover rate for doctors, both in specialties and primarycare.

Several doctors also left the Helena Physicians Clinic over the past few years, landing at St. Peter’s, the VA, or out ofthe area. With the pending sale of the clinic to St. Peter’s, the last significant competition to the hospital will disappear.

From 2008 to 2010, St. Peter’s saw 17 doctor resignations (in addition to five retirements) while recruiting 27 newphysicians for its medical staff, which now numbers 101.

Dr. David Lechner, a member of the hospital board of directors and the president of St. Peter’s Medical Group,describes recent turnover as “negligible.” But data from other hospitals around the state show a higher turnover ratehere, and several doctors with long-term experience here say the turnover rate is higher than it should be, and is bad forthe community.

More TURNOVER, page 9A

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Highway deaths fallto lowest level since 1949

By KEN THOMASAssociated Press

WASHINGTON — Highway deathshave fallen to levels not seen since theKorean War, helped by more peoplewearing seat belts, better safety equip-ment in cars and efforts to curb drunk-en driving.

RegionThe PacificNorthwest

region, whichincludes Wash-ington, Oregon,Idaho, Montanaand Alaska, saw

fatalities fall 12percent. More HIGHWAY, page 12A

By EVE BYRONIndependent Record

Consummate news-man Bill Skidmore,known to his friends as“Skid,” died early Satur-day morning after a two-year battle with cancer.

Skidmore, 64, was aquiet man who listened more than he

talked, perhaps due to a tendency tostutter. But to those who took the timeto listen, he was a dry-witted manwhose intense love of reading trans-lated into his writing and conversa-tions.

He started as a reporter at the Hele-na Independent Record in 1971, aftergraduating with a degree in journalismSkidmore

Bill Skidmore, longtimeHelena newsman, dies at 64

More SKIDMORE, page 12A

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Eliza Wiley Independent Record

SUNDAY, APRIL 3, 2011 Page 9A

Doctor turnover is a problem around thestate and the nation, with internal medicinespecialists — those doctors who care forpatients with chronic illnesses — arguably inthe shortest supply. Several trends are con-tributing to the situation: young doctorsheading into specialties; the rise of the use ofinternists as hospitalists (doctors who workexclusively in hospitals, taking care ofpatients and thus relieving outside doctors ofthose duties); and the trend toward moredirect employment of doctors by hospitals,making doctors more able to move from job tojob and city to city, instead of building prac-tices slowly over the long term and staying ina single community for an entire career.

But in Helena, several physicians saythere’s an additional problem — a poor rela-tionship between the doctors and the hospitaladministration, and particularly with hospitalPresident and CEO John Solheim.

While some doctors spoke of positive expe-riences with the administration, others toldthe Independent Record of a wide range ofpractices they say drive doctors out, includingcontrol of patient care by hospital administra-tors, instead of by doctors; an aggressive driveby the hospital to employ more and more doc-tors directly; and a rigid atmosphere in whichdoctors’ suggestions for improvements areignored.

Several doctors contacted by the Indepen-dent Record would not speak directly of theirexperiences in the hospital, or would speakonly on narrowly limited subjects. Severalcited fear of retaliation by the hospital admin-istration; several noted that hospital rules formedical staff prohibit disparaging remarksabout health care delivery. Some said theywould not speak about the quality of healthcare at the hospital because of fear of liability.

“Solheim’s a tough guy, and he never for-gets,” said Randy Sibbitt, a radiologist whosegroup parted ways with the hospital in 2009.

Revolving doorSeveral doctors describe a revolving door of

physicians in Helena.In the past few years, several doctors have

left St. Peter’s for the VA hospital at Fort Har-rison, an attractive place to work with its sin-gle-payer billing, absence of on-call responsi-bilities, regular hours and steady paycheck.

Internist Erik Riessen is now in Utah andgastroenterologist James Riegler now prac-tices in California. They did not respond tomessages left at their offices. Tracy Dill, incharge of the hospitalist program at St.Peter’s, has left for St. James Hospital inButte. Shari Marx, internist at St. Peter’s andlater at Helena Physicians Clinic, is now ahospitalist at Bozeman Deaconess. Shedeclined to comment for this story. Cardiolo-gist Blair Erb is in Bozeman. He did not returna call to his office seeking comment. Familypractitioner Bill Schoderbeck left suddenlyand is working in Oregon. He, too, declinedcomment.

Pulmonologist Carl Hallenborg is in Utah;currently St. Peter’s has no permanent pul-monologist on its medical staff. When thehospital opened its clinic on North MontanaAvenue in early 2008, it named four doctorsto its staff. Two of them, Dr. Phil Hess and Dr.Paul Donaldson, are gone. Interventional car-diologist Andrew Carter came from Michiganand joined the hospital in 2007; he’s gone.

Doctors who worked for or at St. Peter’s butwho are now at the VA at Fort Harrison

include internists Scott Falley and ElaineSamuel; and family practitioners DerekWilliams and Trena Bonde.

With the fresh arrival of Dr. Anne Anglim,Helena has just five internists (not countingthose with additional sub-specialties, or thoseat the VA) who see outpatients. That’s onemore than the towns of Hamilton and Dilloneach have, according to data compiled by Dr.Jay Larson, an internist here for about twodecades.

Larson and Dr. Jean Justad have a privatepractice that’s full; they don’t accept newpatients.

“If you have someone with a chronic dis-ease who wants to see a doctor, they’re out ofluck,” Larson said.

Examination of turnoverSolheim and Lechner said turnover at St.

Peter’s is consistent with similar hospitals inthe state and nation. Lechner describedturnover in the past year as “negligible.”Some of it is attributable to the departure ofdoctors at Helena Physicians Clinic who alsowere on St. Peter’s staff.

“If it’s your doctor that’s leaving it feelsheavy,” said Solheim. “But the reality is ourturnover is no greater or less than the othercommunities.”

Data supplied by Montana hospitals alonecannot tell the full story, as lists of medicalstaffs may include doctors with a variety ofroles and differ from hospital to hospital. Yetwhen calculated equally as the number ofdoctors who left during the three-year periodof 2008-10 against the current staffing totals,it gives insight as to the trends occurring athospitals across the state.

From 2008 to 2010, St. Peter’s saw 17 doc-tor resignations (plus five retirements) whilerecruiting 27 new physicians (12 in 2010) forits medical staff, now numbering 101 (includ-ing both hospital-employed and independentdoctors). Counting the retirements, thethree-year loss totals nearly 23 percent of thecurrent number of staff.

Benefis Health System in Great Falls had anear identical rate of turnover: 36 doctors leftactive staff from 2008 to 2010, in addition tosix retirements. The hospital added 52 full-time staff, bringing its current total to 184 (aconservative count of only its active physi-cians, the hospital said). That puts the num-ber of departures about 23 percent of activestaff over the three-year period.

St. James Hospital in Butte has seen a high-er rate of turnover; its CEO resigned in 2008amid what he called long-standing animositybetween doctors and the administration. In2008-10, St. James lost 29 doctors (includinga pair of retirements, and five emergencyroom doctors who were removed when thehospital ended a relationship with an outsidecompany and directly hired its own doctors)out of 70 on active staff, a loss of 41 percent ofthe current total.

Others had greater retention.At Bozeman Deaconess over the same peri-

od, 22 doctors left and one retired as 45 newdoctors came on board to bring the staff totalto 153, for a 14 percent turnover.

Kalispell Regional Medical Center hasundergone rapid expansion, adding 60 physi-cians to staff from 2008 to 2010, bringing itsstaff total to 188. Over that time, 22 doctorsleft the hospital, including six who retired, ora total of less than 12 percent departed.

St. Patrick Hospital in Missoula had stilllower turnover. It has 283 doctors on staff(many of whom are also on the staff of nearby

Community Medical Center.) At St. Patrick,25 doctors left in 2008-09, but just four did soin 2010 — a turnover rate of less than 10 per-cent over three years and just 1.5 percent lastyear. Over that same period the hospitaladded 61 doctors.

At Community, a spokesman said the hos-pital has lost just a few doctors from its staffof about 250 over the past few years for aturnover rate of less than 5 percent.

“The turnover on that has been very, verylittle,” said Larry Fagerhaug, vice president oforganizational development at Community.

At the Billings Clinic — which employs allits physicians directly in its main hospital andvarious clinics — 30 doctors left during thattime while 57 were hired to bring the total to236 — a loss of 13 percent over the three years.

“The board thinks that there’s noturnover,” said Dr. Lee Harrison, a current St.Peter’s hospitalist and a former member ofthe board, who has practiced in the communi-ty for about two decades. “It’s so corrupt andin such a petty way.”

“It’s way greater turnover (in Helena) thanwe ought to be seeing, so I have to think thatthere’s some bad treatment of physicians bythe administration, not just letting them bephysicians,” said Dr. James Crichton, a for-mer chief of staff at St. Peter’s and formermedical director at Blue Cross and Blue Shieldof Montana, now retired.

Dr. Mark Ibsen, who owns Urgent Care Plusdowntown (and who worked in St. Peter’semergency room until about four years ago),caters to many patents who are without pri-mary care doctors or are unable to see them.An advertisement for his operation invitespatients who are “between doctors.”

“There are a lot of patients who can’t get into see their primary care doctor,” he said. Hedescribed as an example a recent patient whoneeded to see her internist, but couldn’t getan appointment for 3 1/2 months.

Recurring issueThe issue isn’t new. In February 2008, more

than half the doctors on staff wrote the hospi-tal board of directors warning that “The bul-lying and antagonistic attitude of the admin-istration is significantly to blame” for doctordepartures, and called for a meeting with theboard and Solheim.

“Rest assured, these developments are amajor threat to the quality of health care inHelena, and it necessitates that you becomeinformed and involved,” the letter said.

Asked about the letter, Solheim said henever saw the signatures; Lechner said doc-tors were “bullied” into signing it. He attrib-uted the letter to “very specific individualswho were promoting their own agenda.”

Orthopedists Brooke Hunter, John Miche-lotti (a former board member), Peter Hanson,Max Iverson and David Heetderks wereamong those who signed the letter. They saidabout 74 doctors signed it (a significantmajority of the medical staff), although theydidn’t show the names to hospital adminis-trators.

“The hospital expects to be treated by thephysicians as a partner, and expects thephysicians to accept being treated by the hos-pital as a commodity,” the letter quoted adeparted internist as saying.

“I’m fairly certain we could get most ofthose people to sign again,” Harrison said.

That letter led to a few meetings with one ortwo board members, but no significant

“Doctors are losing controlof their individuality and

autonomy that they’ve hadfor years. And the hospitaltends to become the focus

of that because changesoccur in the hospital tolower costs to make itmore favorable for the

business community,because you have two

pressures: You can havedoctors be totally

autonomous and notworry about costs, and the

business side says youhave to control costs. So

part of the hospital leader-ship is to kind of integratethose two, and sometimes

that creates tension.”

John Solheim, CEO, St. Peter’s Hospital

continued from 1A

Turnover: Examining why doctors leave St. Peter’s

More TURNOVER, page 10A

“If you have someone witha chronic disease whowants to see a doctor,

they’re out of luck.”

Dr. Jay Larson, internist, private practice

“So being an employee,and not making individual

decisions as a manager foryour own clinic, that’s a

role that’s difficult forsome to change into. Andthat’s a change for some

physicians.”

Dr. David Lechner, president, St. Peter’s

Medical Group

“It’s time for the communi-ty of Helena to take

responsibility for this. Wetried and it didn’t work.”

Dr. Lee Harrison, hospitalist,St. Peter’s Hospital

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changes in relationsbetween hospital and med-ical staff resulted, Huntersaid. Solheim said neitherside got all they wantedfrom the meetings, but anagreement on recruitmentand retention was reached.

In January 2009 theLewis and Clark CountyBoard of Health launched aTask Force on UniversalHealth Care, which inOctober 2010 released areport on the loss of physi-cians and access to care.

“Residents perceive thatthe hospital is not provid-ing quality services forcommunity members,” thetask force wrote.“Providers attribute, inpart, the high turnover ofprimary care providers todissatisfaction with hospi-tal administration.”

In December, the HelenaPhysicians Clinicannounced its physicianswere giving up hospitaladmitting rights because itcould not pay the costsdemanded by St. Peter’sfor its hospitalist program.The move brought on afresh wave of concernamong patients that theywould not be able to findmedical care in Helena.The clinic, a branch of theGreat Falls Clinic, wasonce the largest local com-petitor to St. Peter’s. InMarch, the hospital beganthe process of buying theclinic building.

Dr. Brian Weitz, who leftthe clinic for Minnesota,said the hospital demandednearly $400,000 a year tosupport the hospitalistprogram — a prohibitivesum for the clinic. Otherproviders in the area arenot charged for the hospi-talists.

In February, Lewis andClark County Commis-sioner Derek Brownaddressed the issue of doc-tor turnover and doctor-administration relations ina talk at the weekly Home-town Helena morning cof-fee gathering, and placedblame directly on Solheim.

“I’ve never come acrossthis situation, in such a bigorganization, where every-thing’s focused on one per-son,” Brown told the Inde-pendent Record. “It’s allabout one person, andeverybody I know thatdeals with him says he’s abully.”

After Brown’s talk andafter he sent an e-mail onthe matter to about 120people, Rick Hays, a mem-ber of the hospital boardand its past chairman,invited Brown to a meeting

that included Solheim,Brown said.

“Solheim looked like hewas being taken to theprincipal’s office,” Brownsaid. “We probably met for45 minutes to an hour andit just ran downhill.”

Numerous complaintsNearly every doctor who

spoke with the Indepen-dent Record said the vastmajority of staff at the hos-pital are dedicated andhard-working and deliverexcellent patient care. Buttheir complaints againstSolheim are numerous andpersonal.

Harrison, who still worksat St. Peter’s, said she quitthe board after it gave Sol-heim a new contract withglowing recommendations.“He’s a bully and he bulliesthe board,” she said.“Being able to bully andintimidate is really impor-tant to him.”

Harrison said she seesnumerous patients who areangry at the hospital —because of doctors leaving,or because of long waits atthe emergency room, forexample.

Among her several com-plaints: Hospital adminis-trators interfere with thecare of patients, evensending e-mails to thepatient case managers,urging them to get patientsout of the hospital, shesaid. (In many cases,Medicare pays a specificamount of money for agiven condition or proce-dure, so the hospital losesmoney if patients stay longand makes money if theyare discharged more quick-ly.)

Lechner strongly deniedthat anyone but doctorsmakes decisions regardingpatients. “Clinical deci-sions stay with the doctor,period,” he said.

Others said the hospitaluses hardball tactics toinfluence doctors’ behaviorand get them out of inde-pendent practices and intodirect employment by thehospital.

Dr. Keith Edwards was apartner of Sibbitt’s, work-ing in Helena from 2005 to2009. Edwards had previ-ously been a colleague ofDr. Dennis Palmer, anotherpartner in the radiologypractice, who invited himto Helena.

“Dennis told me a littleabout the fact that theywere at odds with the hos-pital, but I don’t think I hadan idea of how strained thesituation was,” Edwardssaid in a telephone inter-view from California,where he is a professor atthe medical school at the

University of California-San Diego.

Before working in Hele-na, Edwards had led an 18-doctor radiology groupthat worked with a 425-bed hospital, so he hadsome experience dealingwith hospital administra-tors. Edwards said Solheimmade clear he would doanything to control med-ical practice in the area,including bringing in newhospital-employed doctorsand pitting them againstindependent practices.

“I think what’s probablyled to a lot of people leav-ing, is that John is just sotightly controlling andreally, I think, looks atdoctors as widgets,”Edwards said.

He said the administra-tion did not, for example,welcome the radiologists’input into the equipment itpurchased, which he called“a crazy way” to runthings. He called the rela-tionship with administra-tors “unusually harsh andunusually pejorative.”

“(Solheim’s) not a com-promising kind of guy, anddoctors are not stupid peo-ple. And I think they cancertainly be reasonable andthey can certainly compro-mise and work with people,but I don’t think that Johnever considered doingthat,” Edwards said.“When you’re paying theirpaycheck, you can prettymuch tell people what todo, if you want to, and Ithink that’s the way he ranthe business.”

Iverson, an orthopedistwith 16 years’ experiencein Helena and, before that,20 years in the Los Angelesarea, described the doctor-administration relationshiphere as “poisonous” and“adversarial,” with work-ers, from doctors on down,afraid to speak critically.

“If they say anythingderogatory or corrective, itputs a target on their

back,” he said. “It stiflesconstructive criticism.”

He said he never sawsuch a problem withmorale in his decades inLos Angeles. But there, henoted, there’s plenty ofcompetition among hospi-tals.

“As with most hospitals,establishing the climate,good or bad, frankly boilsdown to the administra-tor,” Iverson said.

Larson has been aninternist in town for a cou-ple decades, including astretch as a hospitalemployee, and now oper-ates an independent prac-tice with Justad. Larson leftthe hospital, he said, whenhe asked the clinic managerpoint-blank what the valueof internal medicine was inthe community. “And hesaid, ‘I don’t know,’ ” hesaid.

Weitz, who as a partnerat the Helena PhysiciansClinic was part of St.Peter’s medical staff, calledthe administration“unprofessional, immoraland disrespectful.”

“It’s a nasty place towork,” he said in a tele-phone interview from Min-nesota. “It’s horrible, real-ly.”

It’s different at his newjob.

“We have a voice, weparticipate in patient caredecisions and managementdecisions,” he said. “Weare treated with respect,and there is no fear.”

Dr. Harnek Singh joinedSt. Peter’s as a hospitalistin 2009 and only lasted oneyear in what he describedas “mental torture.” Now,he commutes more than 60miles to St. James Hospitalin Butte, working for acompany contracted toprovide hospitalist servicesthere.

Dr. Robert McNutt, arheumatologist, practicedin the Cleveland area formany years. In September

2008, he began working forSt. Peter’s, and then in2010 opened MontanaRheumatology on LastChance Gulch — a move hedid not plan to make whenhe first moved here,although he said he enjoysthe new practice immense-ly.

He declined to discusswhy he left hospitalemployment and said thevast majority of health caredelivery at the hospital isexcellent. But he thoughtthe hospital could improveif it considered the sugges-tions of doctors who left.

“It would seem like aboard member ought to beinvolved in an exit-inter-view process,” he said. “Itwould have to be a boardmember, not a member ofthe administration.”

General surgeon Dr. JohnGalt, a former board mem-ber, called St. Peter’s “agreat hospital” but notedproblems.

“The employees, nursesand physicians are com-passionate, well-trainedindividuals who work hardevery day to provideexceptional care to thecommunity,” he said in awritten statement. “Thelargest threat to our abilityto continue to provide thislevel of care is the currenthospital board and admin-istration.”

General surgeon Dr.William Harper describedthe doctors’ relationshipwith the hospital adminis-tration as amateurs tryingto take on professionals atnegotiating.

“They go to meetings totalk about how to controlus,” he said of the adminis-tration. “They’ve beengiven instruction, or tips,on how to control the situ-ation.”

He described a three-year process of trying toestablish a payment systemfor specialists to be on call.Although hospitalists now

handle much of what usedto require doctors to be oncall, they still typicallyneed specialists on call forspecific needs. With so fewdoctors in each specialty, itcan be a difficult andexpensive burden, withsome doctors on call everythird or fourth 24-hourperiod. That means stop-ping what they’re doing —sleeping at home, treatingother patients in theiroffices, whatever — andmaking it to the hospitalwithin 20 minutes.

At some hospitals, the“call pay” is several hun-dred dollars to more than athousand dollars per 24-hour period.

A few years ago, the gen-eral surgeons — at thatpoint, three of them —proposed a pay level. Theadministration hired aconsultant to come up witha figure, which Harperdescribed as “insulting” —$100 per day, or just over$4 an hour.

“They basically ignoredus,” Harper said. “Weweren’t asking for theworld.”

It led to a standoffbetween the doctors andhospital. Eventually thesides agreed, for starters,that there should be anoth-er surgeon in town to makecall duties less burden-some, and the hospitalhired one.

Asked about this, hospi-tal spokeswoman PeggyStebbins responded onlythat the board determinedcall coverage payments in2009.

Changing relationshipSolheim denies having an

antagonistic relationshipwith doctors, although heacknowledged that in a bigorganization going throughmany changes, not every-one will be satisfied withadministration decisions.

He said some of the doc-tors’ complaints relate tothe bigger picture of thechanging dynamics ofhealth care and theimpending changes fromhealth care reform, includ-ing a more systemlikeapproach and coordinatedpatient care.

“Doctors are losing con-trol of their individualityand autonomy that they’vehad for years,” he said.“And the hospital tends tobecome the focus of thatbecause changes occur inthe hospital to lower coststo make it more favorablefor the business communi-ty, because you have twopressures: You can havedoctors be totally

SUNDAY, APRIL 3, 2011Page 10A

By SANJAY TALWANIIndependent Record

Until recently, hospitals were placesthat provided facilities and medical staff,where physicians — independent or partof doctor-owned practices — plied theirtrade.

But medical care is more complex thanever, and across the nation, hospitals aredirectly employing more and more doc-tors. Many doctors find that appealing,with a more reliable income and hours, asopposed to the expensive and riskyproposition of a private practice, wheredoctors have to handle every aspect ofthe business from hiring and firing tomalpractice insurance to time-consum-ing billing and paperwork.

“Most physicians want to look for analternative to being in private practice,and our goal is to aggregate that so thatwe can coordinate the care better acrossthe continuum,” said St. Peter’s Presi-dent and CEO John Solheim. The doctorswant good facilities and diagnosticequipment, income guarantees, stabilityand less time on call, he said.

But some doctors are unhappy with thetrend, saying they are giving up their roleas advocates for their patients, insteadbeing pressured by the hospital’s bottomline, cutting short hospital stays (when,for example, Medicare pays a set fee for agiven condition or procedure) or pushingpatients toward expensive tests and pro-cedures that aren’t necessary.

St. Peter’s maintains that it leavespatient care completely up to the doctors,and that many doctors (though not all)prefer hospital employment. Hospitaladministrators say the hospital doesessentially all the recruiting of new doc-tors to the area, often paying them morethan they actually generate in services, inorder to fulfill the hospital’s mission of

providing enough physicians for the area.Still, many say it fundamentally

changes the doctor-patient dynamic.“When a physician is in a town, and is

committed to that community, his cus-tomers, his patients, he’s in there for thelong haul and invested in the thing and heplans to stay there a long time, as mycohort of physicians did,” said Dr. JamesCrichton, a former St. Peter’s chief ofmedical staff who is now retired. “It’s adifferent situation when you’re employedby a hospital and your main customer’sthe hospital.”

When Crichton was chief of staff, hesaid, all the doctors — primary carephysicians and specialists — were some-what dependent on each other, and themedical staff was also autonomous fromhospital administrators. Doctors, not thehospital, were responsible for disciplin-ing their peers, and several in fact did losehospital privileges.

“But if the hospital employs the physi-cian, as long as the guy’s making money,they’re very unlikely to do anything tohim,” he said. “You don’t really have thepeer pressure to work on physician quali-ty.”

Dr. Jay Larson, a longtime localinternist who has previously beenemployed by the hospital, also is a strongadvocate for independent practitioners.

“Right now, (Dr. Jean) Justad and Ihave a great little clinic,” Larson said.“We focus on patients. That’s what it’sall about. That’s what people want. Theywant to feel cared for, they want to makesure the person taking care of them istheir advocate, and is going to recom-mend the best thing for them. … I have noconflict of interest when I order any-thing. If they want to go somewhere elseto get a diagnostic test, it’s fine with me.”

Longtime family practitioner RichardSargent moved into private practice in

December in what he described as an“amicable” separation from St. Peter’s,where he retains his hospital rights.

“When you’re in a small practice, youget to make all the decisions,” he said,calling that both a plus and a minus.“When you’re in a large group … a smallgroup of people makes all the decision foreveryone that’s in the group.”

And that can be good for patient care,he said, since the hospital-employeddoctors may do things in a more consis-tent manner.

Solheim, Dr. David Lechner, a memberof the hospital board of directors and thepresident of St. Peter’s Medical Group,and others maintain that the “integrated”model, in which the hospital supplies afacility and all the services within it, isnot only here to stay, but improves careand lowers costs, making more efficientuse of staffing and resources with moretimely and efficient access to medicalrecords.

Dr. Jeffrey Martin, for example, arrivedin July to work for the independent groupof orthopedists (Helena Orthopedic Clin-ic), but moved over to St. Peter’s MedicalGroup and direct employment by thehospital in March.

Martin switched from the clinic to thehospital because of business issues, hesaid. Also, he wanted to be part of a big-ger and multispecialty group.

The hospital’s purpose in hiring him(and another orthopedist, who alsomoved from the clinic to the hospital)wasn’t to dilute or compete with theexisting practice, he said, but rather tobring in specialists the town needs — andthat requires investment and risk.

“Practices are finding less and lessreason (to hire new partners),” he said.“And the hospital’s saying, ‘We’ll takethe risk.’”

Hospital employment also makes doc-

tors more mobile, for better or worse.Crichton blames the doctors to someextent.

“You get disgruntled about something(and) instead of saying, ‘Well, I’m com-mitted to this thing, I’m going to see if Ican make it better somehow,’ you say,‘Hell, I’ll just go,’” Crichton said. “It’slack of commitment, but we have a soci-ety where lack of commitment is foundjust about everywhere you want tolook.”

Urologist Dr. Tim Grossman left hislocal practice in 2008, but recentlyreturned to Helena — as a hospitalemployee.

“For several years, St Peter’s Hospitaland its affiliated medical group has suf-fered because of the lack of stability ofits physician work force. The loss of somany high-quality experienced doctorshas served to damage the reputation ofthe group and the local health care sys-tem as a whole. I, in part, contributed tothis problem, having closed my inde-pendent practice for a period of time.Now, I hope to be a part of the solution,”he wrote in an e-mail.

He said grumblings about the hospitalseem to swell periodically.

“It is a complex organization, withcomplex problems,” he continued.“However, the ongoing criticism regard-ing this particular issue, I feel reallyassumes two things incorrectly. First,(that) the administration up to the boardlevel doesn’t consider physician turnovera serious problem, which must be fixed.Second, (that) this organization is staticand incapable of change. We have newleadership in this group. Individuals whohave worked in health systems which areand have been extremely successful. Iremain optimistic their ideas and experi-ence will eventually produce results butit is going to take time.”

Some doctor turnover reflects national trend

Turnover: Doctors outline their complaints against administrationcontinued from 9A

More TURNOVER, page 11A

Eliza Wiley Independent Record

autonomous and not worryabout costs, and the busi-ness side says you have tocontrol costs. So part ofthe hospital leadership isto kind of integrate thosetwo, and sometimes thatcreates tension.”

Moreover, hospital-employed doctors do notnecessarily make manage-rial decisions as theywould for their own clinicor practice, Lechner said.“So being an employee,and not making individualdecisions as a manager foryour own clinic, that’s arole that’s difficult forsome to change into,” hesaid. “And that’s a changefor some physicians.”

Solheim said employ-ment of physicians isn’t atool to control doctors, butrather a tool for retention.Without direct employ-ment, the hospital wouldhave 50 percent fewerphysicians, he said. And,Lechner added, employ-ment by the hospital is notfor everyone, although alot of doctors prefer it toavoid the headaches of pri-vate practice and focus onpatient care.

“Our goal is not toemploy every physician,and employing physiciansis not an easy gig,” Sol-heim said.

Solheim and Lechneralso note that over the pastdecade, the hospital hastripled its revenues andexpanded services whilealso merging five separatemedical groups into St.Peter’s Medical Group. Arethere growing pains?Absolutely, Solheim said.

Joe Seifert is a lawyerwho has represented doc-tors and other formeremployees against thehospital, including fightsover noncompete clausesthe doctors used to have toaccept for employment —clauses he called “dracon-ian.” But he said theadministration and boardwork hard to examine andimprove hospital opera-tions, and that’s notalways an easy road.

“The CEO demands agreat deal from the man-agers. And the managersdemand a great deal fromthose who respond tothem,” he said. “They’re avictim sometimes of theirown desire to improvetheir operation.”

Some of the departeddoctors, too — radiationoncologist Robert Pfefferand family practitionerCheryl Cavalli — relatedpositive experiences inHelena.

Pfeffer said he liked theadministration and thatdecisions kept patient careas the highest priority.

“They said if you thinkthat’s going to improvequality of care, we’ll getit,” Pfeffer said of oneexpensive equipment pur-chase. “They really didbend over backwards tokeep me happy. They letme go up to Great Falls touse the cyber-knife (anadvanced surgery tool

used at Benefis HealthSystem). They didn’t haveto do that; they could havesaid, ‘You’re our employ-ee.’ (Instead) they said‘Look, we want you toget professional satisfac-tion.’ ”

In June, Pfeffer left, hesaid, because he just was-n’t busy enough and got anoffer for a more rewardingposition in Spokane.

And that’s a problemwith Helena, he said — it’san awkward size. There’ssome work for specialists,but not enough people tokeep many specialists asbusy as they might like.

Interviewed from herPueblo, Colo., office, Cav-alli described Lechner as aCarroll College classmateand said, “I just don’tthink there’s a betterhuman on earth.” Shecame to Helena and left forpersonal, not professionalreasons, she said, but sheloved it here.

“The administration ofSt. Peter’s was doing allthey could to help us pro-vide good care,” she said.“I could get involved in asmany community eventsas I wanted and thathelped me build my prac-tice.”

Cavalli is aware of criti-cisms from the communi-ty, she said, but attributesit in part to “the ‘medi-cine’s-better-somewhere-else’ people.”

“That’s what I picked upfrom the community,” shesaid. “And I just don’tthink that was the case.”

Quality of careIt’s unclear whether

doctor-hospital animositynegatively affects thequality of care patientsreceive, but manyobservers think so.

“People who work at thehospital tell me that thequality of medicine’s lowerthan it was,” Crichtonsaid. “Several physicianshave told me that. And I’vehad nurses tell me that.”

Mountain-Pacific Quali-ty Health, which contractswith the state and federalgovernments on Medicareand Medicaid issues, givesawards annually. For thepast three years, St.Peter’s has failed to land inthe top tier of thatstatewide recognition. In2010, nine Montana hospi-tals (among 12 thatapplied), including bothbig and small facilities,earned the top honor, the“Quality AchievementAward,” while St. Peter’searned the next-bestrecognition, the “Com-mitment to QualityAward.” Two hospitalsthat applied received noaward.

In 2009, 14 hospitalsapplied for recognition andseven earned the tophonor; St. Peter’s and fourothers landed in the sec-ond tier, with two earningno award. St. Peter’s wasin the second tier in 2008also.

Solheim defended thehospital’s performance,noting that it at least

received some recognitionfrom Mountain-Pacificwhere other hospitals didnot; and that some of thewinning hospitals are big-ger than St. Peter’s, offer-ing more services.

“A lot of times we fallout because we don’t havean appropriate number ofcases,” he said. “It’s stillan award.”

Among the nine hospi-tals that won the topaward in 2010, six are larg-er than St. Peter’s (BillingsClinic; Bozeman Dea-coness; Community Med-ical Center in Missoula;Kalispell Regional MedicalCenter; and St. VincentHealthcare in Billings) andthree are smaller (ClarkFork Valley Hospital inPlains; Community Med-ical Center in Anaconda;and the HealthCenter inKalispell).

HealthGrades, a nationalorganization, rates 5,000hospitals, using Medicarepatient records from fiscalyears 1999-2009 relatedto 26 procedures and con-ditions. Most of Montana’slarger hospitals were ratedin six or seven broad cate-gories (cardiac, orthope-dic, and so on) and then infurther sub-categories.HealthGrades reportswhether hospitals were at,above or below nationalaverages in the sub-cate-gories.

St. Peter’s scored the“below average” tag in allseven subcategories withinthree of the main cate-gories: orthopedic, criticalcare and pulmonary pro-cedures. No other Mon-tana hospital was labeledbelow average in a majori-ty of subcategories in morethan one of the main cate-gories.

Solheim dismissed thoseconclusions also, sayingthe data is old and thatHealthGrades ratings arewidely debated.

“We don’t have thedepth in specialty that a lotof places do that mightaffect that data,” he said.

He said St. Peter’s hasan 83 percent market sharein Helena; if you removedata on services St. Peter’sdoesn’t provide, like cer-tain advanced cardiologyand neurosurgery proce-dures, the figure rises to90 percent, he said.

“The facts speak forthemselves,” Solheim said.“People do come herebecause we have goodcare, good facilities, goodpeople and good doctors.”

As for costs, EricSchindler, former chair-man of the St. Peter’sboard and now CEO ofMontana Unified SchoolTrust, which buys healthcoverage for school dis-tricts, said St. Peter’s isamong the more inexpen-sive hospitals in the state— charging about 93 per-cent of the average of thestate’s nine biggest hospi-tals (adjusted to the mix ofcases from each hospital).

“I think they run a goodoperation and they’rekeeping the costs low,” he

said. “I think John Sol-heim’s done a really goodjob. … They have a finebalance to watch betweenmission and margin.”

Finding a remedyThe hospital CEO

answers to the 16-memberboard of directors (one ofwhom is Solheim), butseveral doctors said theboard doesn’t have suffi-cient independence fromthe administration.

Three positions on theboard are held bywhichever doctors serve asthe medical chief of staff(now Cancer TreatmentCenter director Dr.Thomas Weiner), the vice-chief of staff (now pedia-trician Dr. Tom Strizich),and the president of St.Peter’s Medical Group(now Lechner), the hospi-tal said. The other boardmembers, including anadditional independentdoctor (now pathologist

Dr. Maria Braman) arenominated by a committeeof three board membersnamed by the board chair-man, currently attorneyThomas Harlen.

Hays, the board’s imme-diate past chairman, saidhe has never felt any lackof independence from Sol-heim or the rest of theadministration, and saidthey always have candiddiscussions.

“We probably have moredoctor representation onthe board than most of ourcounterparts across thestate, just because wethink that’s important,” hesaid.

But some doctors thinkthere’s not enough inde-pendence.

Edwards, the radiologistnow in California, said hewent to the hospital boardwith complaints but thatSolheim “hoodwinks” theboard.

Larson, the longtime

internist, said the boardshould have more over-sight and direction overSolheim. “That’s the wayit’s supposed to work,” hesaid.

Orthopedist Iverson saidthe board “does not applyas much oversight as itshould” with respect toSolheim.

The board’s meetingsand the meetings’ minutesare not public.

Some doctors said that,in a sense, board membersare ultimately answerableto the community —friends and neighbors ofboard members, and thepatients themselves whoseek care there.

“It’s time for the com-munity of Helena to takeresponsibility for this,”Harrison said. “We triedand it didn’t work.”

Sanjay Talwani: 447-4086 or sanjay.talwani@helenair.com.

SUNDAY, APRIL 3, 2011 Page 11A

By SANJAY TALWANIIndependent Record

Hospital care in the not-so-distant future could start in yourhome, with scales and pillboxesconnected to the hospital’s elec-tronic medical records system.

If you have, say, hypertension,and then suddenly gain fivepounds in just a few days, ordon’t take your pills, the systemwould contact you, or maybeyour doctor or a nurse, to try andget things right before it leads toa trip to the hospital.

“What an amazing opportuni-ty to make a difference in thisperson’s chronic disease man-agement,” said St. Peter’s Med-ical Group President Dr. DavidLechner.

It’s not here yet, and it couldcost $8,000 to $10,000 for the“wired” home, say hospitaladministrators. But that’s alsoabout what a hospital stay mightcost.

Such a health care concept —combining personal responsibil-ity, technology and a hospital’sdiverse array of services — may

be closer than it appears, and it’spart of the vision of St. Peter’sHospital.

Lechner and St. Peter’s Presi-dent and CEO John Solheim saysuch investments in the hospitalinformation systems will helpkeep costs down, all in the con-text of major transformations inthe industry brought on by thefederal health care reform billpassed by Congress and signedinto law by President Obama lastyear.

“I don’t think we’ve totallyseen the depth of the cost-sav-ings yet, but the vision is, andthe goal is, to coordinate exactlyfor that — to prevent hospital-izations, and you have to investin that infrastructure to get itdone,” said Solheim.

Solheim said the hospital hasbeen successful so far in reduc-ing overall hospital costs by $1million a year each of the pastthree or four years, bringing St.Peter’s costs into the lowest 25percent of hospitals in the stateand the nation.

He points to recognition of thehospital as one of the most

“wired” in the nation and saidit’s spent $8 million so far on acomprehensive, integrated EMR(electronic medical records) sys-tem, with another $8 million yetto go for full implementation.

“In the old, old days, you hadpaper charts. In a group our size,trying to track down a paperchart is a full-time effort forseveral FTEs (full-time employ-ees) and things (would) still fallthrough the cracks,” said Lechn-er. “That doesn’t happen any-more.”

And, an EMR is a top tool inthe ongoing quest to recruit doc-tors to Helena — a must-haveelement for young doctors.

“There’s not a resident in theUnited States who’s now trainedon a paper chart. Every one ofthem has Velcro-ed to their beltsome form of electronic media,”said Lechner. “It’s a bit of alearning curve for the doctors,particularly the doctors whohave been here for a bit. But thedoctors coming in now, theirlearning curve is pretty brief.”

The integration of recordswould connect inpatient, outpa-

tient and post-acute care, savingmoney while improving care,Lechner and Solheim said. Adoctor in an emergency roomcan now see the results of testsfrom an hour ago or a year ago,massively cutting down onexpensive duplication of labwork, MRIs and more.

Another trend, one that thehospital embraces, is more directemployment of doctors. Thelarge, integrated organization isable to use resources efficiently,they say. For example, anexpensive doctor visit could beavoided when a less expensiverespiratory therapist, nurse orpharmacist might do. Still,“rightsizing” staff, making surethe personnel is there for busytimes without having idle peopleduring slow times, remains a toppriority.

The move to electronicrecords will also further empow-er patients, they said, as thehospital looks toward a “patientportal,” available in as soon assix months. That’s analogous toonline banking, where patientscan check lab results, make

appointments and more. “It’ll be an adjustment for

people,” Solheim said. “Somepeople like the online approach,some people don’t.”

As for other elements of thefuture of St. Peter’s, no majornew expansion or construction isplanned, although it does plan todevelop a heart and vascularcenter and a women’s healthinstitute over the next few years.

Meanwhile, the struggle tokeep big-time doctors in a smallmarket remains. With room foronly a few doctors in each spe-cialty, there’s a lot of on-callduty for some, compared to in alarger market where a group ofeight or more specialists mightrotate through the duty. On theother hand, if the communitygets too many specialists, theywon’t have as much work as theywould want.

The hospital has landed somespecialists that are rare in smallmarkets, like a spine surgeonand a pediatric orthopedist inthe past few years.

“We have a lot of services forthis size facility,” Solheim said.

St. Peter’s looks ahead to wired, integrated future

Turnover: Administration defends hospital practices, performancecontinued from 10A

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