Dean's Newsletter

Archive of previous newsletters

Evarts Joint Center at Highland Hospital

April 07, 2005

On March 17th, 2005, the opening of the Evarts Joint Center at Highland Hospital was celebrated, and on Monday, March 21, 2005, the first operation was performed at the Center. This new facility--consisting of a completely renovated unit with 20 new private patient rooms, an on-site physical therapy unit, and two new state-of-the-art operating rooms designed specifically for joint reconstruction--is the first such Center in the state outside of New York City.

The Evarts Joint Center represents a major advance for patients in the region in need of joint reconstruction; it brings together the resources, talent, and focus that are sure to improve their quality of care and clinical outcome. Before expanding on this point, however, it may be helpful to step back and consider, from a broader perspective, how and why it has come to pass that the University of Rochester Medical Center's joint center has been located at Highland Hospital.

Let me take you back to the year 1994. At that time, the health care environment in Rochester was very different than it is now, particularly for Strong Memorial Hospital, Highland Hospital, and the full-time faculty and community-based practitioners who admitted patients to these hospitals. At that time, Strong Memorial Hospital and Highland Hospital were 33% and 10% of the regional market, respectively. Furthermore, there were dark clouds on the horizon. First, major employers, particularly Kodak, announced that to compete internationally, its cost structure would have to be reduced; part of this process would include a reduction in expenditures on health care services for their employees. Second, outside consultants retained by Rochester-area hospitals pronounced that health-care utilization per capita was too high in Rochester and that the community was over-bedded. Third, local insurers, well aware of these factors and mindful of their own business interests, were under pressure to constrain premium increases by capping total expenditures to providers—both hospitals and physicians. Fourth, in an effort to secure an advantage in this challenging health care marketplace, Rochester General Hospital and the Genesee Hospital came together to form the Greater Rochester Health System (GRHS), later named ViaHealth. Fifth, physicians in GRHS formed GRIPA (Greater Rochester Independent Physicians Association), a major purpose of which was to enter into capitated contracts. In such arrangements, an IPA such as GRIPA can retain as profit the difference between the stream of monthly payments coming in, based on the number of patients for whom they assume responsibility, and the cost of providing health care to those patients. There is a great disincentive to refer patients out of the system in such capitated arrangements (e.g., to refer to Strong or Highland physicians). Sixth, adding to the threat posed to physicians were parallel threats directed at the hospitals. Strong Memorial Hospital was viewed as a "high cost" provider (even though, among 86 hospitals in the Council of Teaching Hospitals survey, only 6 were less costly) and local insurers threatened to divert patients to "less costly" hospitals in the community. And finally, Highland Hospital was losing money on the operating line and therefore had difficulty investing in its future in terms of physical plant, people and infrastructure.

In view of the above considerations, especially the joining of Rochester General Hospital and The Genesee Hospital, quiet discussions began in 1994 between Strong Memorial Hospital and Highland Hospital about a closer affiliation. Until then, Highland Hospital had been affiliated with the University of Rochester Medical Center primarily through graduate medical education, much like the other hospitals in town. By the time I arrived as Chair of Ob/Gyn in 1995, formal discussions began regarding a closer affiliation, and task forces were convened in the major clinical areas. These task forces included physicians, nurses, and board members from both Strong Memorial Hospital and Highland Hospital. I remember participating in the Women's Health Task Force, for example, a group that met for an hour every Monday morning at 7 a.m. for the better part of 1995. Ultimately, synthesizing the ideas from all the task forces, it was decided to draw upon the strengths and traditions of both institutions and to respect the marketplace. (1) There will always be patients—and physicians—who prefer a community hospital environment, and there will always be those who prefer a University hospital environment. We should respect these two different preferences and, indeed, accommodate them both. (2) Affiliation between Highland and Strong, each retaining their own identity, would allow the system as a whole to allocate its resources in a focused manner that can best serve the interests of community-based physicians and their patients on the one hand, and University-based physicians and their patients on the other hand. (3) It was decided that the best model for such an affiliation as applied to each medical specialty was to develop system-wide, integrated departments with two sites, one at Strong and one at Highland. (4) In large part as the result of the first three considerations, it was decided that Highland should remain a general medical-surgical hospital—albeit with niche programs that could be emphasized—rather than a single-specialty hospital (e.g., women-and-infants hospital, heart hospital, musculoskeletal hospital, etc.).

The success of this affiliation is a story by itself, and the envy of other academic health centers and community hospitals alike. Today, Strong Memorial and Highland Hospitals together comprise 56% of market share. Both hospitals are full and are generating sufficient operating margin to fund needed capital investments, as well as the academic mission. Over the years, several key programs were moved from Strong and/or greatly expanded at Highland. These include gynecologic oncology, obstetrics, bariatric surgery, and geriatrics. To support these programs, Highland's services in anesthesia, critical care and pathology were greatly enhanced.

The successful introduction of these new programs and support services, each in their own way set the stage for a Joint Center at Highland Hospital. The process of planning and executing the construction and organization of the Center took nearly two years to complete, and involved surgeons, nurses, administrators, architects and designers, as well as staff from marketing, physical plant and public relations. All of the individuals I interviewed for this newsletter agreed with the sentiment expressed by Dr. Alan Boyd, director of the new Joint Center, who states that the process was "completely cooperative and smooth." Roger Friedlander, Chair of the University of Rochester Medical Center Board, initiated and developed support for the idea that the Joint Center should be named after Mac Evarts, MD, CEO of the Medical Center. (More on this later.)

What were the driving forces behind consolidation of joint reconstruction services at Highland Hospital? One key element is, quite simply, clinical volume. Several studies have demonstrated that improved clinical outcomes are related to greater patient volumes. Whether measured as shorter length-of-stay, fewer complications, or greater mobility and range of motion after surgery, clinical outcome is directly correlated to volume (Katz et al., J Bone & Joint Surg 2004; 86-A; 1906-16; Losina et al., Arthritis & Rheum 2004; 50:1338-43). Also, the concentration of resources in one unit, along with increased clinical volumes, leads to much greater potential for clinical and translational research. For example, Highland has invested in a data coordinator to develop and maintain a joint reconstruction database to support outcomes research. It is the results of such research that will generate the knowledge needed for continued improvements in the care of patients requiring joint reconstruction in the future. Research also brings visibility and national recognition to Highland and the University. Further, consolidation of resources creates efficiencies. No longer is there a need for duplicative administrative, nursing, and OR staff. Rather, a single physician group works alongside a single professional staff with a collective, single focus—to provide the best care possible for patients requiring joint reconstruction. This environment is optimal for patients, and improves the training of residents and fellows who will be the next generation of joint surgeons. Inherent efficiencies of consolidation are further enhanced by the patient-friendly environment of Highland Hospital.

Who are the physicians who have come together to work in the Evarts Joint Center at Highland Hospital? Dr. Alan Boyd, Director of the Division of Joint Surgery in the Department of Orthopaedics, will head the Center. Until now, his practice was based at Strong. He is doing his first case in the new Center today and will move his entire practice there. Dr. Michael Klotz will serve as Associate Director of the Center. He has an active practice in joint reconstruction and has worked mainly at Park Ridge in the past. Dr. Hubert Riegler has been the Chief of Highland Hospital Orthopaedics; he has been instrumental in the planning of the Center and will be an active participant. Dr. Steven Kates, a Highland Hospital orthopaedist, works closely with nursing home patients who often develop fractures requiring joint replacement or reconstruction. Dr. Martin Gingras and Dr. John Marquardt, Highland Hospital orthopaedists, will also admit their patients to the Evarts Center. A powerful aspect of this team is the collaboration between full-time faculty (Dr. Boyd and Dr. Chris Drinkwater, newly recruited to the Department) and community-based private orthopaedists (Drs Klotz, Riegler, Kates, Marquardt, and Gingras)

A spectacular aspect of the new Center, as noted above, is its naming for C. McCollister Evarts, M.D. Dr. Evarts is an alumnus of the School of Medicine and Dentistry and of our Orthopaedics residency program, the founding Chair of Orthopaedics as an independent Department here, and a pioneer in total hip replacement surgery. Many of the orthopaedists who were trained by Dr. Evarts traveled from cities around the country to join us in honoring him at the opening of the Center. There were a series of warm and heart-felt testimonials. Dr. Evarts, and his wife Nancy, were clearly touched by these sentiments expressed by long-standing friends and colleagues. A flavor of these comments can be gleaned from the following:

Virginia Cornyn, Chair, Highland Hospital Board of Trustees: "The opening of the Evarts Joint Center is one very positive example of the 'win-win' that has come about for both Highland and Strong Memorial Hospitals due to their affiliation. This collaboration is the reason we are celebrating the revitalization and renaissance of Highland Hospital. Moving this important orthopaedic program to Highland will provide patients with the high tech and high touch level of care they most desire. Naming the wing for Dr. Mac Evarts celebrates not only his many successes in orthopaedics, as a provider and as a teacher, but also his leadership and ability to find the best fit for patients, doctors and the system."

Roger Friedlander, Past Chair, University of Rochester Medical Center Board of Trustees: "I feel that it is most important to honor those individuals who are the 'super-stars' in their particular fields of endeavor. Dr. Mac Evarts certainly is an illustrious member of this category and justly deserves the recognition brought about through his work in orthopaedic surgery in addition to all of his other accomplishments. That's why the Evarts Joint Center is a natural fit!"

Randy Rosier, MD, PhD, Chair, Department of Orthopaedics: "On a personal note, Dr. Evarts has been a career hero-figure to me ever since I was a medical student. As you can imagine, I was practically speechless at the honor of being invited to join his outstanding faculty after completion of my training. How fitting that the Joint Center, a cutting-edge example of excellence in the tetrad of patient care, education, research, and community outreach, is being dedicated to Dr. Evarts, who has contributed so powerfully in all of these spheres. This model brings together the best features of both the academic health center and the community hospital environments. It's almost like a subspecialty hospital within a hospital. The collaboration of part-time and full-time faculty in this endeavor underscores Dr. Evarts commitment to team building for the benefit of our patients, and will undoubtedly serve as a paradigm for other major academic health centers."

Hubert Riegler, M.D., Chief of Orthopaedics at Highland Hospital: "Highland Hospital is very unique, in that it represents the best of a small community hospital combined with the full support of one of the prime university medical centers in the Northeast. The physicians at Highland Hospital have shown a great deal of loyalty to the facility and the administration has been extremely receptive to novel programs such as bariatric surgery and the geriatric fracture program. What does the future have in store for Highland Hospital? With a commitment of Highland's medical staff and the support of the University of Rochester, I am sure that we will be very successful. All of us, and in particular those of us working in the field of Orthopaedics, feel a great deal of pride that the Joint Center has been named for Dr. Mac Evarts. Five of his students are practicing here at Highland and his leadership, his integrity and his skills will continue to guide the Joint Center to a very high level o success"

Well, I just heard from Dr. Boyd. He finished his first case, a total hip replacement in a patient with advanced osteoarthritis, and it went very smoothly. Two weeks after opening, all of the beds in the Evarts Joint Center are full. What an amazing story!

In closing, there is no better summary of this success story than the one given by Steve Goldstein, President of Highland and Strong Memorial Hospitals: "This is all about a Board and medical staff who had the wisdom to form an affiliation for the right reasons, an employee base who bought into the vision and a University who followed through with programs and services that achieved what the Board and medical staff wanted for the institution in the first place."
With my best regards,

David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry