Geoffrey Cole
President, Emerson Hospital

Interviewed December 1, 1995

Concord Oral History Program
Renee Garrelick, Interviewer.

Click here for audio in .mp3 format

Our Oral History Program has the benefit of recollections from senior physicians that mark a certain period of time. Geoffrey Cole has taken us to the next step, the new direction for the next century.

Geoffrey ColeI arrived here at Emerson Hospital in the position of Administrator in August 1994. During these past 15 months I've been spending a lot of time trying to establish a new strategic direction for the hospital bringing the board, medical staff and management together to clearly assess where we are headed as an organization in a very difficult time for hospitals. This is a time when hospital use rate is dropping very quickly, with HMOs now increasingly dominating the scene, with outpatient business increasing but inpatient business declining very rapidly as HMOs find alternatives for inpatient care. We need to find ways in all of this during these tough times to keep the hospitals strong and vital and relevant to the community and in financially good enough shape to survive this heavy surf that we are in right now.

I have been very involved in a number of projects in the last year. Probably the most important has been the development of the strategic planning process that has involved the board of the hospital, leadership of the medical staff and management of the hospital. Among the very first things that we inaugurated was a decision on one of our first goals, which was to decide whether or not to become part of a larger network of hospitals and physician groups. The feeling was and still is that in these days where the large HMOs are increasingly dominating the scene that it is going to be important for hospitals and physician groups to be part of a larger regional network so that they can attain better arrangements with the managed care companies, achieve economies of scale, etc. We spent several months deciding whether or not it did make sense for Emerson to be part of a larger network, and finally did decide that yes, it did. Then we proceeded to look at what our options were with respect to a network. After a great deal of work we decided to go with the Partners Network, which is the network here in New England founded by the Mass General and Brigham and Women's Hospitals, and they are just about to sign that affiliation agreement in the next couple of days, although it has already been announced in the papers.

Our hope here is that we can get and hold large good managed care contracts which will keep this hospital busy, and that we will be able to do some new program development, possibly some jointly with the Mass General and Brigham to bring new technologies and new services out to Emerson, out to Concord, rather than having to send people in town for things. We really believe now with the technology being the way it is, and with the quality of medical staff that we have that we can increasingly be bringing those modalities out here. The arrangement with Mass General and Brigham, the Partners Network, can initially stimulate some of that.

There are a couple of reasons why we chose the Partners Network over others. One reason is the reputation those two hospitals have in the communities, which we think is really excellent. We think it complements Emerson well. The fact is that the Mass General and Brigham, the Partners Network, does not seek to pull patients out of Emerson and bring them downtown. That is not the reason we are putting this network together, it's not to fill beds downtown, but rather to build a regional presence so that all of us can have more clout with managed care companies, the HMOs. We made it very clear that if they had the intention of trying to suck patients downtown to fill their beds that we weren't interested. Clearly that was never part of their vision of what they're doing. Had they shown any interest in that we would have backed out very quickly.

The staff allocation is determined by what health plan you've got, and what hospitals and doctors are included. Most things that people go to hospitals for, about 90% by most records, can be done in hospitals like Emerson. There are very few things that require going downtown. They tend to be quite traumatic when they occur, serious burns, severe multiple traumas, transplants. These things, while they are quite traumatic and quite expensive, are, in fact, extremely rare. The vast majority of things that people go to hospitals for, hip replacement surgery, gall bladder surgery, vascular surgery, pneumonias, infectious diseases are handled exactly the same way, with the same technology, the same nurses, the same equipment, the same everything at a top notch community hospital which Emerson is. We have top notch trained doctors who trained at the same places that the doctors downtown trained, nurses who trained in the same programs. The only difference is that we are not a teaching hospital although we have some small teaching programs, but we are not essentially a teaching hospital and we're not downtown. But being in Boston, we have a very sophisticated community, and we have very sophisticated doctors and nurses, so we are kind of a miniature version minus the teaching of what you would see downtown. We are therefore able to handle most things.

The other thing that we looked at with the Partners Network was their stability. They are in financially good decent shape, a good amount of cash. We are not, I must stress, merging with them. They are not buying us and we are not buying them, so it is not a financial merger, but we are going to be working collaboratively and it is important that we know our partner is in decent shape financially. Emerson is in good shape financially despite the shrinking of healthcare and the shrinking somewhat of our staff here as a result, but fundamentally in good shape. So we wanted to be sure the partner that we were going with was going to be around for a while and not blow away in the first stiff wind.

We did look at Lahey as another option for us and decided after a lot of back and forth because it is not an easy decision, Lahey has a lot to commend it and to recommend it. Lahey has a good reputation in the towns around here but we think in balance not as good as the Mass General and Brigham.

We have staff that has been affiliated with Mass General and we have staff that has been affiliated from time to time or done work at Lahey, but I would say in balance we have more affiliation with Mass General than with any other single place, more than Deaconess, Beth Israel or anywhere else. You'll find the doctors here are on the teaching faculty at probably every one of the downtown hospitals. Some doctor or doctors here are on the staff or teaches at every one of the downtown hospitals, but the preponderant of connection is with Mass General, and in obstetrics and gynecology with Brigham & Women.

Emerson is an independent hospital. We are not merging with them, we're not becoming part of them. We, along with other independent physician groups and hospitals around the area that have chosen to do this, are becoming part of a network, and our relationship with them is a contractual one and nothing more.

Another thing identified in our strategic planning is the increasing medical staff. The number of people being admitted per thousand in the population is going down which is probably a good sign because we are finding ways to keep people healthier and can do things less invasively or as an outpatient or do home care. In order to be able to grow Emerson and keep it strong in an era when use of hospitals is declining and in order to stay strong and busy, we need to build our presence in the towns around here just to keep the volume up so we can keep this hospital strong. The most efficacious way to do that most directly is to bring physicians into the towns where Emerson does not have as much of a presence in order to build that presence. We're lucky in that we don't have very strong competition nearby. We don't have a lot of hospitals close by. Lahey is a good distance away, Nashoba is a quite small hospital to the west, Lowell General is a good hospital but has tended not to be so successful south of about Billerica and Chelmsford, and to the south MetroWest is pretty far away, so we're lucky in that regard. We have a good reputation in many of the towns that we serve, but in some of these towns we don't have much of a presence. People say "Oh, Emerson, I've been there once or twice when my kid fell out of a tree, I've been to your emergency department, but I don't know any doctors in my town that use your hospital, therefore I don't have any permanent relationship to you." So we're trying to build the capability to have that permanent relationship and to build our presence in Chelmsford and Billerica and Westford and Ayer and Harvard and South Sudbury and all the towns outside, and sort of that next ring, outside the core five or six towns right around Concord where we've always had a strong presence. So we're going to be investing a lot of time and money over the next couple of years to bringing in new doctors. Some will be new doctors just getting out of school, and just as many will be doctors who have been in practice for a while and getting situated and helping get a practice going and being successful in a town.

In addition to the primary care physicians, family practice, internal medicine, pediatrics and OB that I just talked about, we're going to be looking to fill some gaps in our specialty care that we have identified. Areas where for no obvious reason we've simply not had enough of a certain kind of physician specialty, and as a result have been sending more of that business downtown than we need to be. One example is vascular surgery, not cardiovascular surgery, but the other kinds of vascular surgeries which can be done very capably in good community hospitals. We have brand new state-of-the-art surgery suites. We're about to rebuild our ICU so it will be refurbished, excellent radiology and lab. We have all the infrastructure to have an excellent vascular surgery. We just don't have any vascular surgeons, so right now we are working on bringing a group out here. That should strengthen the hospital because it will make it possible for us to keep more business here in town and not have to send it away. Similarly, neurosurgery, we're looking to add more staff there. We only have one neurosurgeon, who is very busy. And in OB, we are very aggressively moving to bring in especially female OB/Gyns into town. We are in the middle of interviewing some wonderful candidates right now. That will help us a lot because there is a big and growing demand by women for women OBs, and if we don't meet that demand in a town or towns as sophisticated as these, people will simply go with their feet and go elsewhere. They don't want to go elsewhere, but they will if they can't find the kind of doctor they're looking for.

There is also an increased demand for women primary care physicians, but it is most pronounced in OB. I think it is true in internal medicine and you see it in cardiology. We have one female cardiologist who has done exceptionally well. There seems to be a growing demand out there in the world for women. We're even hearing stories of parents who want their daughters to go to female pediatricians. I'm passing no editorial comment on this one way or another or attempting or not attempting to be politically correct, but really observing what we see in the real world and trying to respond to it, if we want stay relevant in this community.

HMOs are inelegant but necessary. They are a little klutzy, that's true, but in an era where employers and individuals want to not be spending as much for healthcare and still want to get a reasonable product, they represent the best effort thus far to rearrange the way healthcare is organized to make it more efficient. The way they do it is typically by making it harder to see specialists, which is not always inappropriate. They're not self-referring directly to a very expensive specialist for something minor that can be handled easily and well by a primary care physician. It can be a more difficult set up for people because it becomes a little harder to navigate your way through the system, little barriers are suddenly erected that make it harder to get where you want to go as a consumer. But as long as people want good care and with price increases as modest as possible and until some other system can be "thunk up," this is what we've got right now.

We have about 850-875 full-time employees, probably about 1200 or 1300 people because we have a lot of part-timers and people who float, per diem and such.

As to purchasing I don't know how much we do locally, but we do a fair amount within the region. We are a heavy buyer of supplies, and we have a kind of multiplier effect on the economy. A hospital and any sizable employer in town is a heavy user of raw materials and resources.

The Boston area is very strong in medical and scientific brainpower and health technology innovation. There is a lot of biotech, and a tremendous number of hospitals. One would argue possibly too many, almost certainly too many hospital beds, particularly downtown. But it is still one of the backbones of the Boston economy, by far the biggest employer when you add up all the hospitals. If you add other biotech related concerns, it is by far the largest sector, which is unusual. There aren't that many towns where healthcare is as dominant as it is in Boston. Philadelphia is another one. There are a couple of cities of our size where that is true, but not very many.

Hospitals are heavily serving old folks in this period of time. The population is aging and we're tailoring our services more and more to a broad set of needs for seniors -- Alzheimer's programs; home care, which is heavily slanted toward seniors; geriatric assessment programs, which allows to make diagnoses for seniors with suspected organic brain disease or depression; and more and more getting involved in what we call case management. Case management is the actual managing of people when they are not sick, but in-between illnesses, through calls to home, through home care visits from time to time, check ups - just seeing how people are tracking, which is to avoid or try to delay admissions to the hospital, trying to keep people healthy.

We do interact with the medical facilities right here in Concord. We provide lab and radiology facilities to the Mediplex skilled nursing facility across the street. We do a tremendous amount of work in the nursing homes around here -- respiratory therapy, physical therapy, some of our doctors do rounds in those nursing homes or act as medical directors for those nursing homes, and of course, lots of patients get referred out of the hospital here to nursing homes for other kinds of long term care or sub-acute care. So we have all kinds of organic interaction with the other healthcare providers around here.

The health industry has become a dominant industry within Concord and around the Concord area. I'm not an expert on the profile of industry in Concord, but there are a number of health related firms around here and a lot along Route 128 in kind of the junction between high tech and biotech and healthcare.

There will be a number of changes internally at Emerson in the future. We just opened a hospital-based skilled nursing unit that we are calling a transitional care unit which is already getting full, and it has only been open about two weeks. Again this is kind of an attempt to get ahead of the curve. We're seeing more and more care moving out of what is called acute care to lower levels of care. A big question is how to keep costs down and get people off more expensive acute care beds and on to something less expensive at the earliest appropriate time. The most logical way to do that well is to have those beds right in the hospital so patients don't have to go into an ambulance only to be driven a half mile away to a sub-acute unit in a skilled nursing facility and only stay there 10 days and have to go home again. It is just feasible to have it all happen here to accomplish the same step down but without all the inconveniences of having to get driven around. That unit is up and running on Wheeler 6. They had a wonderful opening last week, and it seems to be doing well already.

Our home care is growing at about 30% a year which is incredible. Our biggest challenge there is just finding good RNs who we can employ. We're also looking now at starting radiation therapy for cancer patients at Emerson which would be a historic step forward for us. This is something being made possible by our affiliation with the Mass General and the Brigham. We're going to be working through them to get their license for one of the machines transferred out here, which is something we really could not have pulled off if we had not had that affiliation with them. That's one of the first kind of tangible fruits of our affiliation and actually a rather unexpected one. With the radiation therapy we will able to manage virtually all cancers extremely well right here which will be wonderful for families and patients. We've just recruited two superb young oncologists, top notch, both in their early 30s and both of them so busy, and we will probably have to recruit two more and that is a nice problem to have -- being so busy that we have to expand more. A lot is going on right now.

We're going to be renovating our surgery day care, our same day surgery area this year. We're also going to be renovating and completely remodeling our ICUs, as I mentioned before. They are 22 years old and just worn out. They're serviceable but they've served their useful life, and we will give them a gracious burial and rebuild a state-of-the-art facility.

The four-bed rooms are almost gone. We're now down to one as of last month. We're going to be pushing for more single rooms. We've turned almost all of our fours into twos or ones, and now the next step will be turning as many of our twos into ones as we can. I think that will be a nice step forward in terms of patient satisfaction, a simple thing that we can do. Maybe it's the silver lining in our hospital census dropping because we are more able to do that now. All hospitals are less busy because of HMOs, but at least we can make sure the people that are here have quality rooms.

People, by the way, when they do get here tend to be sicker than they used to be. If you're less sick, these HMOs and other folks are finding ways to keep you out, so by the time you end up here, you need to be here. There are very few kind of borderline admissions any longer. It used to be, even when I started 15 years ago, because insurance companies would pay for it incredibly, you'd see families requesting that perhaps grandma could stay a few more days even though she could go home and that would be done. That is simply never done any longer anywhere in the United States because no one will pay for it. If grandma does that, grandma is going to be stuck with the bill, and grandma will probably not pay the bill and the hospital will be stuck. It just isn't done. That is unfortunate that hospitals can't play that kind of social role as broadly as they used to, but we can't afford it any longer. Society as a whole has said we can't afford it any longer. Employers, the people who buy this health insurance and the government that buys Medicare for people have said, forget it, we're not going to do that.

The suburban hospitals, of course, are easier to get to. The best of the suburban hospital is to be able to give a more personal, more intimate, high-touch care than the downtown hospitals can. That's because of the downtown hospitals' teaching mission, because of their size and because of the fact that they are usually packed into dense downtown areas. Again for 90% of the things, suburban hospitals, non-teaching hospitals, do just as capably, and all things being equal, we think that we can convince people that they would rather be at a place that's got a homey feel to it than a typical university hospital would have. A lot of people feel that way. A lot of people that are dedicated for instance to Emerson, are dedicated exactly for that reason. We can give a sort of higher quality, personal care. For a variety of structural reasons, we're able to do that. We're not more virtuous than downtown hospitals; we're different. We don't have two missions. Downtown hospitals have to teach. We have a more focused mission which is patient care so it makes it easier.

We're even looking now potentially, although it would be a severe financial hit for us, into eliminating the fee for parking. We figure our advantage is that we are accessible and why put any barriers up to people coming. That will be a big hit to our bottom line, but we're continuing to look at it right now.

Text mounted 1 December 1995; audio mounted 23 June 2012 RCWH