Health Professionals 
Overview 

By Bob Keaveney
from Physicians Practice, Inc.

A home health aide comes to Helen Rackauskas' house three days a week now, to help care for her 92-year-old husband, who has Alzheimer's disease. But up until the day last spring that she nearly died--it was Palm Sunday, she says--she'd been caring for him by herself, having rejected the idea of outside assistance. "I never wanted anyone in my home," she explains. "That's just the way I am."

Everything changed on April 4. After sitting up all night with chest pain and shortness of breath that she'd attributed, hopefully, to her asthma, after trying unsuccessfully to treat herself with her inhaler and a couple of Bayer aspirin, she drove herself at sunrise to an urgent care center near her house in Springfield, Ill. It was there she learned she was having a heart attack, and soon the 79-year-old was in surgery, undergoing a risky triple-bypass procedure.

The physicians with Prairie Cardiovascular Consultants, who performed the surgery and have treated her ever since, told her son and daughter that her chances of survival were about 25 percent. Helen--a dignified, feisty, plain-spoken Midwesterner who doesn't complain much and doesn't figure to scare easy--was afraid.

She knew that if she survived, her life would never be the same. How would she care for her husband after the surgery? How would her own emotional needs be met? Would she be able to find the time and the strength to do all the difficult rehabilitation work that her doctors would ask of her? And what about the post-surgical pain?

When she arrived at the emergency room at St. John's Hospital in downtown Springfield, she asked to be treated by the only cardiologist she knew of, James Dove. "Everyone says he's the best," she says. Indeed, Dove is one of the country's leading cardiologists, so Helen's request was not a small one. But not only did Dove treat Helen, he and his staff treated her with such kindness, care, and attention that she says she will forever be grateful.

"He's wonderful," she swoons. "I just can't say enough nice things about him and his staff. He just made me feel special: 'You're important.' And when a doctor tells you you're important," she trails off a bit now, her eyes widening. "I've never had a doctor like that. Other doctors aren't like that."

A breed apart

In fact, many doctors are like that, and Dove, president and founder of Springfield-based Prairie Cardiovascular Consultants, says he won't have doctors working for him who aren't like that. Dove launched Prairie Cardiovascular in 1979 with the idea of developing the kind of large and sophisticated cardiology service for the farming communities of central Illinois that the people of Washington, D.C., and New York, were then coming to expect.

Cardiology has undergone radical changes since 1979--clot-busting drugs and angioplasty have been developed, and the number of medications to treat cholesterol and hypertension has exploded, to name a few. Prairie has changed a lot, too. The practice started with only three employees--Dove, his nurse Annie Alms, and his first secretary. It now has 43 physicians and 285 employees at seven permanent locations, and its physicians perform a full range of services. It conducts weekly clinics at community hospitals throughout rural Illinois, and is among the nation's busiest practices in performing cardiac bypass surgeries and angioplasties. 

With St. John's Hospital, its partner in the Prairie Heart Institute, it recently completed construction on a magnificent new facility, complete with operating rooms, a catheterization lab, a high-tech recovery room, and a cardiac rehabilitation center.

But for all the changes, a few things have stayed the same. Annie is still Dove's nurse. (Dove's second, and current, secretary, has "only" been with him about 16 years.) Another constant: Prairie Cardiovascular's devotion to its mission of providing high-quality, personal care with warmth and compassion, an ethic that begins with Dove and flows to every staff member, from physicians to nurses to the billing clerks. 

For example, Helen says the practice sends all of its post-surgical patients home with an oversized teddy bear, instructing them to squeeze it hard to brace themselves against the pain of a coughing spell or jostling in bed. It was a godsend, she says, and she would often encourage other patients in her cardiac rehab sessions to "hug your bear." When she was first discharged, Helen adds, "Annie would call me every day at home just to see how I was doing," recalls Helen. "Sometimes twice a day. Oh, I got so lucky."

In truth, luck had very little to do with it. For its devotion to quality care without ever forgetting the importance of the physician-patient relationship; for its remarkable achievement of building one of the country's largest and most successful cardiology practices despite the challenge of its rural location and an ongoing shortage of cardiologists nationwide; for its use of technology to enhance efficiency, clinical excellence, and patient satisfaction; and for being a great place for physicians to practice and employees to work, Prairie Cardiovascular Consultants is the 2004 Physicians Practice's Practice of the Year Grand Prize Winner.

The Practice of the Year contest, launched two years ago as a way of recognizing practice excellence and offering groups around the country a model for efficiency and practice management innovation, was at its most robust this year. Practices from every part of America entered, and the applications were among the most detailed and sophisticated Physicians Practice had ever received.

And the judges' choice of Prairie Cardiovascular was the most decisive to date. Of the five expert judges, including the heads of the two previous Practice of the Year winners, four put Prairie Cardiovascular at the top of their lists.

"I'm very proud of what's happened," says Dove, in an early-morning interview in his modest third-floor office. He's talking less about the contest recognition than about the growth and success of the group he founded, from which he will retire at the end of the year. Dove has been Prairie Cardiovascular's heart and soul since its beginning, but he credits others with its success: "It's happened because there are phenomenal people here; I've been very fortunate to have partners who are just wonderful to work with. They're very responsible and high-quality. I also have been lucky in terms of the administrative staff--it's a very good staff that helps to carry the ball and really understands the direction of the group."

Recruiting challenge

Springfield is a small state capital about two-thirds of the way to St. Louis from Chicago on Interstate 55 and is surrounded by hundreds of miles of, well, not much.

"We don't have oceans and we don't have mountains," Dove says matter-of-factly, describing one of Prairie's biggest challenges--physician recruitment. In truth, Springfield, a town of about 111,000, offers scant cultural events, no professional sports teams, little nightlife, and no major university (though Southern Illinois University's medical school is based in town). Its major attractions are the scads of Abe Lincoln-related historic sites and the state fairgrounds.

"If I were single, it would be hard to want to come to Springfield," says Marc Shelton, MD, a member of Prairie's executive committee. "I'd want to go to San Diego or someplace glitzy."

The man who will take over for Dove next year, president-elect Frank Mikell, MD, who has been with the group since the mid 1980s, agrees. "If you've lived your entire life in New York or San Francisco, and you just fly into the Springfield area, it's quite a shock," he says. "You think you're lost. A lot of people rule us out on the basis of geography."

But a mere willingness to live in Springfield is hardly enough. Mikell says the group uses physician recruiters sparingly, preferring to identify candidates through "personal contacts," but still throws away about half the resumés it receives. "The first criterion is: Do we think this person has the training to achieve what we want clinically?" Mikell says.

If so, a senior partner conducts a lengthy phone conversation with applicants, explaining Prairie's practice philosophy and style and the nature of its location.

Philosophically, one thing that distinguishes Prairie is its insistence on continuity of care. Elsewhere, cardiologists spend all day performing one function--say, catheterizations--because it's easier to schedule the physicians. At Prairie, each physician does whatever his patient needs at the time.

"If Sally Sue has [a heart attack] and I see her first when she comes in, she's forever identified as my patient," explains Shelton. "So I do the follow-up ... and that kind of continuity of care is vital. That's a plus for patients. ... The downside is that it is harder to schedule. Sally Sue might come in with chest pain [unexpectedly], and I'm going to [see her].

"Whereas in the emergency system, on Tuesday you're doing caths, on Wednesday you're reading echocardiograms," Shelton continues. "The patient may interact with three or four different cardiologists. That works best for the physicians but not the patient. One of the reasons this group has worked so well is because referral physicians know that we're going to treat their patients well. And patients want to come here, when they could go to St. Louis or Chicago, because they get that kind of service here. I think that's the main reason this group has grown."

That patient-first philosophy is etched in everything Prairie does, and physician recruiting is no exception, says Mikell. "People understand when they come here that we have a certain practice philosophy," and those who aren't comfortable with it aren't hired, he explains.

Physicians are king

Dove is an Ohio native who moved to Springfield after he completed his residency in the late '70s because he and his wife were looking for someplace nice, safe, and simple to raise their children. It's a decision he says he's never regretted. Indeed, many of the physicians who come to Prairie are mid-career doctors or those with young kids whose priorities are different from many of their single or childless colleagues. They tend to be "in a family way," says Shelton.

"It's definitely a family kind of a culture," he says. "In our hallways, a lot of the talk is about, 'How are your kids? How's the football team? How's soccer practice going?'"

But what Shelton says he likes best about Prairie is the physician-centric management philosophy, including the autonomy the doctors have to structure their offices their own way, provided they follow the group's strict clinical guidelines. Many of the group's doctors are "academic refugees," escaping a "communistic environment" in which incentives to make more money by working harder don't really exist, and where resentments grow when some doctors work more than others.

In an academic setting "the overhead is humongous," he says. "And when it's all said and done, you might be bringing in 15 percent to 20 percent of billing. In a private practice, I'm doing the same quality of medicine and we get great results, and I don't have to put up with the [same degree of overhead]. So on the production side, there's a big plus."

There's not much reason at Prairie for physicians to resent one another's workloads, since they are generally free to work a little less provided they're willing to make a little less, Shelton says. That's one of the reasons they remain a tight-knit group.

At Prairie, the physician is king. As chief executive officer, Gregory Timmers is the group's highest-ranking administrator, but he has no illusions about being in charge. On the contrary, he speaks proudly of the low turnover on its physician-only board of directors because it helps maintain physician oversight and control.

"Some groups struggle with whether low board turnover is good or bad, but if you encourage rapid turnover, you inevitably and overwhelmingly empower nonphysicians like Ed [Brooks, Prairie's chief financial officer] and myself, because we're the only ones who'll have the knowledge, the background, and the institutional memory to run the place," Timmers says. "Better to maintain longevity and consistency of governance; that's the way we elected to go. And because they've been so committed to living by our mission statement, we've been fortunate in the 25 years we've been in existence that we've never had to reverse a decision or had any big regrets."

So Springfield may not have oceans, mountains, or Broadway, but it has crucial advantages and makes the most of each one in its recruiting. Among them are physician control and autonomy, a warm and inviting place to work and raise a family, a relatively low cost-of-living, a reputation for clinical excellence, high volumes of varied procedures, and an opportunity to conduct research, rare in private practice, at a Prairie-created research institute across the street from St. John's Hospital.

Prairie maintains "an incredibly flat organizational structure," says Timmers, "so physicians know they have ready access to all of us. Our group is organized as if it's 43 individual private physician practices--each physician has his or her own dedicated staff, which they hire themselves. We've created an office structure for them; the commitment within their three- or four-person teams is high. Our business cards list the physician's name in the center and in the bottom corners are the names of the physician's nurse and administrative assistant. That is the team--and that's what leverages the practice, because the patient is going to relate to that team."

Administrators provide support and guidance, not marching orders. "Our goal is to make each individual practice function as easily as possible, so the docs spend their time being docs. That's why there isn't as much conflict as you would expect in a practice of this size. In our case, conflict between the physicians and the management has never been an issue--because if you asked our physicians they'd tell you that they've never felt they couldn't practice medicine the way they want."

EMR pays off

That is, unless a physician is failing to meet the clinical guidelines set down by the American College of Cardiology. In that case, the doctor will be alerted to the deficiency by the group's new electronic medical record so it can be corrected. That's one of the best aspects of the system it purchased in 2001 from Medinformatix, which includes an integrated EMR and practice management system, says Dove.

"The system has both administrative benefits and clinical benefits," says Dove. "The practice can evaluate whether physicians are remaining on task with recommendations of the ACC because the system has those standards preloaded [and can be easily updated]. So when physicians document what they do, the system prompts them to perform whatever recommended tasks have not been done, and allows practice evaluators to compare physicians' actions against the recommended actions."

Staff and physicians agree that training and deployment of the system was no easy task--virtually all 285 employees had to learn a new way of doing something, from scheduling to billing to medical documentation. Some of the physicians, Dove admits, were at first resistant to change, but "sometimes leadership is about getting people to go where they need to go, but don't necessarily want to go."

Today, the group couldn't be more thrilled with the results. In administration, scheduling has become almost indescribably simpler. "In our practice, the nurse and secretary in each physician's office handle the clinic schedules for that physician," according to Prairie's Practice of the Year application. "The benefit of the new system was immediate since they could now print and track schedules electronically."

Another important benefit of the new system was that it enabled the group to bring its billing and collections in-house, canceling its contract with an outside service. The group's leaders figured the new system would allow it to capture and bill for more charges. They also believe that the practice's compassion-infused mission extends to billing: by having its own billing staff they'd be improving patient satisfaction, allowing patients to deal directly with the practice instead of some third party.

This was a calculated risk. In addition to the cost of the system itself, the plan to bring billing in-house would require the addition of 23 full-time-equivalent billing staffers, almost all at once. Even so, the group's gamble paid off.

Even factoring in the new staff, "the new billing system managed to virtually pay for itself by increasing collections 5 percent. This was made possible by unlimited access to billing and collection information that is now available through reports created in Medinformatix," the practice wrote in its application. Yet even with the increased collections, "billing complaints from patients have decreased."

Claims submission, check posting, and the processing of Medicare explanation-of-benefits forms are all done electronically now, saving the practice time and money. The system can process about 1,200 patients' EOB forms in a few seconds, and it deposits about 8,000 checks per month in an electronic lockbox. The electronic check-processing has allowed Prairie to slash its check-processing fees 70 percent.

"You can access on the computer every check a patient sends us the same day we receive it," says Brooks, the CFO. "You can search by people's names, dollar amount, by date. The hard part of implementing the new system was all the training. But when you looked at all the efficiencies it brought, with all the outsourcing we were doing before ... it was absolutely worth it."

Like a family

Dove's impending departure has left many at Prairie with mixed emotions. In their typically meticulous fashion, the physician leaders have been planning for his retirement for close to five years, and Mikell was chosen as his replacement after a lengthy deliberation, in part because his long tenure is reassuring.

Even so, no one is quite sure what Prairie will be like without Dove, and they're not entirely eager to find out.

"I've known Jim for a long time, and I have a deep respect for him, and a deep love," says Mikell. He says he must be "crazy" to even want to follow such a legend, but he will consider himself a transition president, helping to ease the practice into life after Dove. "The group has really been like a closely held family, and Dr. Dove has been such an integral part of that. No one will ever serve as long as he has, or in the same way."

As for Helen Rackauskas, she was a faithful attendee of her three-day-a-week cardiac rehab sessions, took long walks on her "off" days, and went to most of the optional education classes the practice and hospital sponsor--some of them twice. It wasn't easy leaving her husband at home. "But I tried to do everything they asked me to do, because I want to get well," she says. "I have to do it for my own health, or I won't make it."

Helen says she made new friends, which she desperately needed, during her recovery. She and other Prairie patients were carefully put through their paces at the rehab facility, and over time they bonded. When the sessions ended and the patients "graduated," they hugged and cried and wished one another well.

"We became a family after so many weeks," she recalls. "It was, 'How many bypasses did you have? Does your back hurt? How do you lie in bed?' We became like a little support group, and that was so good. We were like a little family, and it was hard to leave one another."

To learn more about Physicians Practice's Practice of the Year contest, visit www.PhysiciansPractice.com.