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  • Population health on a budget: How one orthopedic surgeon succeeded in Chicago's most impoverished neighborhoods

    Population health on a budget: How one orthopedic surgeon succeeded in Chicago's most impoverished neighborhoods

    Laura Dyrda -  

    Daniel Ivankovich, MD, is one of a kind.

    For years, his physician colleagues thought he was crazy for establishing his practice among the most impoverished Chicago neighborhoods and treating almost exclusively Medicaid patients. He made house calls and was known for his personal style and connection with patients.


    Today, he's being honored for those very attributes.

    Dr. Ivankovich is among 2015's CNN Top 10 Heroes of the Year, sharing company with Jim Withers, MD, a Pittsburgh-based physician who care for the city's homeless; Richard Joyner, who manages Conetoe Family Life Center with 20 plots of land operating community gardens in a North Carolina nutritional desert; and Sean Gobin, who created "Warrior Hike," a nonprofit to help combat veterans cope with their war experiences.


    Dr. Ivankovich co-founded OnePatient Global Health Initiative and currently performs more than 600 surgical procedures per year. His program has benefited more than 100,000 people.


    "I'm a throwback, misplaced from the older generation," says Dr. Ivankovich. "If you talk to surgeons in their 80s, this concept isn't alien to them. This is stuff they did every day. They never asked whether the patient had money; they brought patients in and did the best they could."


    Practice philosophy — Treating the underserved
    Dr. Ivankovich is a second-generation physician; his mother and father's approach to practicing medicine had a huge impact on his practice philosophy. Patients travel from around Chicago and the Midwest to see Dr. Ivankovich after providers in their home communities turned them away due to insurance status. These patients are often in advanced stages of degeneration or injury because they weren't able to receive immediate or preventative care.


    "I see many patients who have gone through 12 physicians over several weeks and then their injury is far more complicated to manage," says Dr. Ivankovich. "They have a broken wrist or hand and were put into a splint, but that didn't fix the problem. Nobody else will treat them and now they've contracted major disabilities."


    This disparity is all too common for Dr. Ivankovich, who grew up on Chicago's North Side and played basketball with young men from around the city, including those living in the city's Public Housing Projects. After an injury sidelined his basketball career, Dr. Ivankovich attended medical school and became an orthopedic surgeon. He trained at both the old Cook County Hospital and Rush University Medical Center and saw the care level differences there as well.


    At Cook County, surgeons performed around a low volume joint replacements per year with hundreds of people on the waiting list; at Rush, the surgeons performed a much higher volume of joint replacements. Rush was adding surgeons while Cook County was doing fewer procedures, yet caring for a population in need.


    Minority patients historically haven't had as good of outcomes in complex procedures like heart and spine surgeries. The expected outcome for the average patient demographic Dr. Ivankovich treats is 18 percent success rate; his practice is at the 85th percentile.


    "It's hard to be around this on a day-to-day basis and not have it totally impact you," says Dr. Ivankovich. "In the city of Chicago, there are a million people living in poverty, but most Chicagoans don't see them. Surgeons choose to practice in suburbia or on the Gold Coast, but if you travel two miles west and three miles south, Chicago is home to the most challenged, marginalized and violent communities in America."


    He opened a clinic at Provident Hospital of Cook County and performed more than 200 surgeries in the first year. At one point in his career, Dr. Ivankovich was the only orthopedic surgeon covering a community of about half-a-million people and on call all day, every day.


    "I'd drive hospital to hospital and PAs would line up with stretchers and we'd treat the patients," says Dr. Ivankovich. "We have gotten those numbers down now, we are doing prevention with many people, but where we are constantly slammed now is patients coming from other communities where doctors aren't doing their part."


    Caring for Medicaid patients
    Every licensed physician has a Medicaid number and can take Medicaid patients. These patients require more paperwork now than in the past — the Affordable Care Act added a layer of paperwork to the Medicaid HMO — and the reimbursements are lower, but treating a few Medicaid patients per month could have a huge affect on the community.


    "There are surgeons who go on medical mission trips one week out of every year, but maybe instead each month they could do a charity case in their own back yard," says Dr. Ivankovich. "Take a few Medicaid patients every month and you can help. I'm not telling people to do thousands of Medicaid patients. I have fun with those cases because they are challenging; I'm interested in the challenging diagnosis and these cases keep me in the game. I'm excited to help people transform their lives every day. But if every physician in the course of their month did one charity case and three to five Medicaid patients, I think things would radically change."


    For instance, the government wouldn't need to re-design the healthcare system to ensure people in need received care and keep costs in-check. There may be fewer regulations if people were cared for, and fewer disabilities because providers can treat small problems before they become big problems.


    "Diabetes patients suffer disproportionately poorer health and shorter life spans," says Dr. Ivankovich. "I didn't realize how integral musculoskeletal health and orthopedics was to their lives. It really empowered me to know how I was impacting these patients' lives. I had tens of thousands of patients in need of my services in Chicago."


    And caring for this population could give physicians a better outlook on the future as well.


    Orthopedic surgeons are among the highest paid specialists in medicine, yet many report low career satisfaction. The average orthopedic surgeon earns $421,000 per year, according to the Medscape Orthopedist Compensation Report 2015 — the top paid specialty in the report — yet more than half of the surgeons reported dissatisfaction with their income. Nearly 45 percent of orthopedic surgeons reported burn-out in a separate Medscape report.


    "As you're finding a lack of satisfaction in your personal life, look around you," says Dr. Ivankovich. "Maybe there is a poor person, someone who is disabled; reach out and ask if you can help. If you have the power to change someone's life, do it. Research shows people doing good work derive more benefit from the work than the people who are on the receiving end. It makes you feel good. Deep down inside, humans want to do good. But sometimes you have to step outside a screwed up system to do it."


    Population health on a budget
    Population health is a huge buzz word in healthcare today and many providers are tip-toeing around these initiatives, but Dr. Ivankovich and his wife Dr. Karla Ivankovich already incorporate many of these principles into treating their patients. They teach patients about nutrition and exercise.


    "We have relationships with our patients, so we don't want them just coming in when something is bad," says Dr. Ivankovich. "We love the idea of them letting us know what we're doing well and the healthy things they're eating. We work to impact our patients so they are inspired and motivated to educate others in their community."


    Some of their former patients have become members of organic diet programs or formed walking groups with church members or in their neighborhoods.


    "Doing good is like a virus. You plant good seeds in people and send them out into the community and they'll do good things. They aren't dependent on the medical infrastructure," says Dr. Ivankovich. "It starts with one person doing good who can impact 10 people, and those 10 people impact 10 people and all of a sudden there are 100 people doing good. Each of us has a mission to do positive things every day. This transcends gender and race and socioeconomic data; we are all connected through life."


    Any patient that comes in to see Dr. Ivankovich also spends time with Dr. Karla Ivankovich, a psychologist and population health specialist. Dr. Karla Ivankovich conducts a bio-psycho-social evaluation to identify and manage patients with HIV, diabetes, depression, smokers and other issues. Dr. Ivankovich could operate on nearly every patient he sees, but often these patients aren't good candidates for surgery because other underlying issues and comorbidities.


    "The point is the operation doesn't mean the patient is going to feel better," says Dr. Ivankovich. "Part of your maturity as a doctor is to understand that patients need time. The average patient with a joint replacement takes six to eight month before we're able to perform the procedure. They need teeth extractions, diabetes control and to quit smoking. We are using these life-changing surgeries to actually change their lives for the better."


    They see patients each for around 45 minutes to form a relationship and gain the patient's trust. Caring for patients and recovering from surgery has become easier over the years with minimally invasive techniques and outpatient surgeries. These procedures are less costly and help patients resume their normal lives more quickly. The practice also optimizes resources and runs efficiently to keep the doors open.


    And there are patients constantly coming in their doors.


    "At every clinic we have an average attendance rate of well over 95 percent," says Dr. Ivankovich. "That's an amazing statistic. Patients trust us. I'm not sure why, but we have developed a sense of family with our patients. The ultimate compliment that you get paid by the patients is for the patient to say, 'Doc, you are family.' That's the highest level of what you'll obtain."


    The Ivankovichs are invited to family reunions, barbecues, marriages and funerals around Chicago's South and West sides.


    "This is part of what the good old days were when doctors made house calls," says Dr. Ivankovich. "In order to become part of the solution, you have to become part of the problem. We are a family with these people that we've committed our lives to. It's a badge of honor."


    Looking into the future, the Ivankovichs hope to grow their practice in Chicago and spread their model to other large urban areas. They believe in creating a sustainable program and scalable population health model with a small budget.


    "We're taking on private investors and donors to help us provide care and they think we have a great concept," says Dr. Ivankovich. "Population health is inserting the needs of the lowest common denominator. If you can make it work for them, the same principles can work in the affluent populations."


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