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Strategy
May 29, 2018
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Executive Summary

How can hospitals and health systems generate a return on their investment in their physician enterprises? According to themost recent figures, from the American Medical Association, over 25% of U.S. physicians practiced in groups wholly or partly owned by hospitals in 2016 and another 7% were direct hospital employees. Yet, according to the Medical Group Management Association, hospitals’ multi-specialty physician groups lost almost $196,000 per employed physician. As a result, some larger health systems’ physician operations are generating nine-figure operating losses, which are major contributors to thedeterioration in hospital earnings. It is time for hospitals or health systems to rethink their strategy for their physician enterprises.

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How can hospitals and health systems generate a return on their investment in their physician enterprises? According to the most recent figures , from the American Medical Association, over 25% of U.S. physicians practiced in groups wholly or partly owned by hospitals in 2016 and another 7% were direct hospital employees. Yet, according to the Medical Group Management Association, hospitals’ multi-specialty physician groups lost almost $196,000 per employed physician.

As a result, some larger health systems’ physician operations are generating nine-figure operating losses, which are major contributors to the deterioration in hospital earnings . It is time for hospitals or health systems to rethink their strategy for their physician enterprises.

Let’s first revisit why independent physicians were receptive to becoming employees and why hospitals and health systems felt the need to hire them.

Self-reflection exercises can help family CEOs clarify whether they value their firms’ long-term success more than “being the boss”—even if success means sharing the glory with other managers. In our experience a candid evaluation of one’s priorities is crucial—managers are often oblivious to the fact that their own desire for control may be inhibiting the growth and success of their organizations.

In addition, family executives—and especially owners—should understand that introducing new managerial capabilities within the firm does not necessarily entail a loss of control. It is more likely to create a different role for them—but not necessarily fewer responsibilities.

It’s unwise to teach leaders that strategy and basic management are unrelated.

That is what happened at Moleskine, based in Milan, Italy. Launched in 1997 by three friends, Moleskine went from being a niche notebook producer to a market leader in the space of a few years. Its success created a dilemma for its founders: While it was clear that the company had tremendous potential to grow further, they also recognized the pressing need to professionalize its operations. The founders searched for a private equity firm that could provide the necessary capital and expertise and help them find a new CEO. Eventually, they chose Syntegra Capital and Arrigo Berni, an experienced chief executive who had held leadership roles at family-owned producers of luxury products. Berni brought new rigor to strategy development and operations and at the same time crafted a role for the founders that made the most of their commercial and design expertise. Thanks to this successful partnership—and an IPO in 2013—Moleskine was able to deepen its competitive advantage and develop new growth opportunities globally.

Good management practices require capabilities (such as numeracy and analytical skills) that may be lacking in a firm’s workforce, especially in emerging economies. Indeed, our data shows that the average management score is significantly higher at firms with better-educated employees. Being located near a leading university or business school is also strongly associated with better management scores. Superior performance is likelier when executive education can be had nearby, it seems. While to some extent the availability of skills is shaped by a firm’s specific context, managers can play a critical role by recognizing the importance of employees’ basic skills and providing internal training programs.

Even when top managers correctly perceive what needs to be done, are motivated to make changes, and have the right skills, the adoption of core management processes can be a challenge. Videojet, a subsidiary acquired by Danaher, provides a case in point. In 2005, Videojet launched a new internal initiative that required the engineering and sales teams to collaborate on developing an innovative printer. The Videojet executives decided to use core DBS managerial processes—which up to that point had been used almost exclusively within manufacturing—to structure regular debriefing and problem-solving sessions between the two teams.

Thus, the published trials so far with DPP4 inhibitors suggest that the increased risk of HF seen with certain class members does not represent a class effect. In the coming years two CV outcome trials with linagliptin will be reported, i.e., the CAROLINA® trial [ adidas Adidas Tubular Shadow W Maroon/ Maroon/ Off White sKpoxH
, 118 ] (linagliptin vs sulphonylurea) in 2019 and the CArdiovascular Safety Renal Microvascular outcomE study with LINAgliptin (CARMELINA®) (linagliptin vs placebo) in 2018 [ Balenciaga Race Runner Sneakers with Metallic Leather and Satin Gr IT 36 0OQSNmb
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GLP-1 receptor agonists are indicated to reduce glucose in T2DM and belong to the incretin class of drugs. Apart from glucose-lowering effects, they also have a number of non-glycemic effects including reducing appetite (and inducing weight loss), modestly reducing BP and increasing pulse rate. Two sufficiently powered CV outcomes trials within this drug class have thus far reported; the Evaluation of LIXisenatide in Acute Coronary Syndrome (ELIXA) trial and the Liraglutide Effect and Action in Diabetes: Evaluation of cardiovascular outcome Results—a long term evaluation (LEADER) trial [ SOPHIA WEBSTER Heels T1oMy
, 33 ]. The ELIXA trial (Table Walking Cradles Terrace Wedge Available in Extended Sizes Online Only vaQOzLOD
) included 6068 T2DM patients with recent acute coronary syndrome (< 180days) and reported a neutral effect on both the primary outcome (composite of CV death, non-fatal stroke, non-fatal MI and hospitalization for unstable angina) and on hospitalization for HF (HR 0.96 (95% CI, 0.75 to 1.23)) (Fig. 4 a, b) [ 31 ]. In this large trial, only a slightly increased heart rate was observed with lixisenatide, with mean 0.4bpm (95% CI 0.1, 0.6), a result potentially influenced by the high use of β-blockers in the study population (85 and 84% at baseline in the placebo and lixisenatide groups, respectively). The LEADER trial (Table 3 ) followed 9340 T2DM patients with established CVD (approximately 80%) or more than one CV risk factor (approximately 20%) for a median time of 3.8years, and reported significantly decreased risk for the primary outcome (composite of CV death, non-fatal stroke and non-fatal MI) with liraglutide as compared to placebo (HR 0.87 (95% CI 0.78, 0.97)). This result was driven by a 22% relative reduction in CV death (HR 0.78 (95% CI 0.66, 0.93)), whereas non-fatal MI and non-fatal stroke were not significantly affected. Fourteen % of the study population had prevalent HF, and the drug had no impact on hospitalization for HF (HR 0.87 (95% CI 0.73, 1.05) Fig. 4 a, b)) despite the slightly increased heart rate seen with liraglutide of 3bpm relative to placebo. Lately, smaller studies have suggested potentially adverse effects on cardiac function of liraglutide: the Effects of Liraglutide on Clinical Stability Among Patients With Advanced Heart Failure and Reduced Ejection Fraction: A Randomized Clinical Trial (FIGHT) trial [ 134 ] randomized 300 adults (60% with T2DM) with acute decompensated HFrEF to 1.8μg liraglutide or placebo. After 6months, there was a numerically increased risk for death and hospitalization for HF (which were parts of a hierarchical primary endpoint together with NT-proBNP levels) with liraglutide, and this finding was accompanied by increased LV diastolic and systolic volumes. In this study, there was no difference in the change of heart rate, but there were more cases of arrhythmia with liraglutide reported as safety events (17 vs 11% in liraglutide and placebo). These findings were in line with the Effect of Liraglutide on Left Ventricular Function in Chronic Heart Failure Patients With and Without Type 2 Diabetes Mellitus (LIVE) study [ 135 ] including 241 patients with chronic HFrEF (approximately 30% had T2DM) where no impact on systolic function by echocardiography was seen, but a significantly increased heart rate with 6bpm with liraglutide vs 1bpm with placebo, p  < 0.001. The mechanisms behind the increased heart rate and further effects on myocardial function with GLP-1 receptor analogues remain to be elucidated [ 136 , 137 , 138 ].

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