Tension crackled inside a conference room at Barberton Hospital in early 2015.
Several doctors said they remember about 30 members of the hospital’s medical leadership team gathering to hear Summa Health’s new CEO, Dr. Thomas Malone, lay out his vision for population health, a national trend aimed at squeezing more value out of health care while improving patients’ health.
Dr. Ihsan Haque, a longtime cardiologist, challenged Malone to reach beyond jargon.
“We’ve heard ‘population health’ for six months, but what does it mean? Put some meat on the skeleton,” Haque said.
Malone snapped, according to three people who said they were at the meeting. He told the group that he was now driving the Summa health care bus and physicians had two choices — get on the bus or get off the bus. But the bus was moving forward with or without them.
Malone, through a spokesman, said he doesn’t recall the meeting. But three of those who said they attended recall an awkward pause followed and then another doctor broke the silence: “Could you describe where the bus is going?”
Now some doctors say the Barberton story illustrates the kind of relationship that’s evolved between many local physicians and Malone during the past two years.
“I’ve been here 30 years,” Dr. Haque said during an interview last week. “I’ve built these programs. This is my bus and I’m not getting off.”
Nearly 250 doctors this month signed a letter calling for Malone’s departure. On Thursday, an additional 15 orthopedic specialists from Crystal Clinic signed a no-confidence letter. And Friday Summa’s cardiology department chair confirmed he is sending a letter to the Summa board on behalf of the majority of the heart doctors seeking change.
Malone’s supporters — who include physicians — dismiss the dissenting doctors’ push back against the CEO. They say the critics’ anger is rooted in a clash of cultures as Malone pushes doctors to change the way they’ve done business for years.
So far, Summa’s board appears to be supporting Malone, who said last week that the no-confidence vote has been a learning experience.
Audio: Part 2 of the Akron Beacon Journal interview with Dr. Malone
Malone said he’s working with department heads to make Summa more engaged with physicians.
But many doctors say it’s too late.
Interviews with physicians, nurses and Malone, combined with Beacon Journal reporting in recent years, reveal how Malone, Summa’s 7,000 employees and physicians ended up here.
Malone era begins
Malone arrived at Summa in September 2013 as president of Akron City and St. Thomas hospitals.
The Youngstown-area native, then 57, had spent much of his health administrative career in Michigan, most recently serving as president and chief executive of Harper University and Hutzel Women’s hospital, a 560-bed medical center affiliated with Wayne State University in Detroit.
Before that, he oversaw graduate medical education, physician contracting, medical information technology and other initiatives at the medical center.
Thomas J. Strauss, who had led Summa for nearly 15 years, welcomed Malone, saying he had the experience Summa needed push forward with needed changes.
Under Strauss, Summa had created an accountable care organization (ACO), a concept in population health that brings hospitals, doctors and other health care providers together to manage the care for a group of patients. If patients remain healthier through more coordinated, efficient care, the providers share in the financial benefits.
Summa’s demonstration project involved 25,000 people covered by Medicare, saving $11.8 million in medical costs over an 18-year period. That savings resulted in a $5.8 million government bonus paid to Summa for the care.
Malone — who worked for 18 years as a neonatologist before earning an MBA and going into heath care administration — saw a chance for Summa to expand the concept, possibly creating a statewide network.
But first, big changes needed to be made.
In May 2014, about eight months after Malone arrived, Summa announced it would close Wadsworth-Rittman Hospital and convert St. Thomas Hospital’s emergency department into a primary-care practice.
Although Wadsworth hospital had a positive operating margin in 2013, Malone said at the time it was losing money on inpatient care. Summa would maintain the emergency room and outpatient services, but Wadsworth would no longer serve as a community hospital.
Closing St. Thomas’s ER, Malone said, made sense because it was only 1.8 miles from the ER of Summa’s flagship, Akron City Hospital.
St. Thomas’ emergency medicine services had been losing about $600,000 a year.
In litigation yet to be resolved, representatives from Wadsworth and two townships sued Summa, trying to bring a full-service hospital back to the community.
Summa, the lawsuit said, acquired the Wadsworth hospital in 2008 for $1 through the Wadsworth-Rittman Hospital Association from the Wadsworth-Rittman Area Joint Township Hospital District.
As part of the $1 deal, the lawsuit said Summa agreed to return the assets to the hospital district if it stopped operating a full-service facility with inpatient services there.
The same month Summa announced the closure, Summa restructured its leadership team, increasing the responsibilities of Malone and Dr. Erik Steele, the health system’s chief medical officer, positioning either to take over for Strauss, who would soon announce he planned to retire at the end of 2014.
During the first half of 2014, Summa barely broke even, posting operating income of $713,000 on revenue of $712.5 million, according to a health system financial report.
In 2013, Summa reported operating income of $5.9 million on revenue of $689.1 million for the same six-month period.
In November 2014, the board announced Malone would replace Strauss at the beginning of 2015.
People involved in the search said recently that the board picked Malone over Steele because they believed the nonprofit health system needed to be run more like a business to remain viable.
Different business
Yet running a health system isn’t like running most businesses, experts say.
“If you’re CEO of General Motors, it’s accepted that you’re the boss and everyone works for you,” said Doug Bolon, who teaches health care administration at Ohio University.
In health care, the relationship is different, particularly between a CEO and highly educated doctors who tend to be independent-minded and autonomous.
“If you go in as an administrator and say you’re going to manage the medical staff, it’s not going to work,” Bolon said. “They’re going to need to see you support them before they’ll go in the direction you want to go.”
One of the first things Malone did as CEO was move his office out of Akron City Hospital near downtown and into Summa’s corporate services center about 2.5 miles away near North High School.
The health system’s executive wing had always occupied space within Summa’s flagship hospital. But Malone said he wanted to send a message: Under his leadership, Summa’s focus wasn’t just hospitals.
Akron City doctors and nurses had grown accustomed to having easy access to the CEO. Strauss often stopped to talk to employees in the halls or cafeteria and, once a month, he held a staff meeting where anyone could ask him anything.
Malone and his new leadership team began hammering out a future facility plan, where outpatient services like geriatrics, women’s health, primary care and behavioral health would take emphasis away from surgical procedures.
Closing Wadsworth-Rittman had already made Malone unpopular in come community circles.
Now his plans were starting to open rifts with doctors.
A disagreement over the need for a new hospital facility in northern Summit County led to fallout between Summa and the physician owners of Western Reserve Hospital in Cuyahoga Falls.
As Malone was working to cut hospital capacity, the independent physicians at Western Reserve wanted to break ground a few miles away and break free of Summa, which has a 40 percent ownership stake.
“I think that’s probably caused more of a strain on our relationship than anything else,” Malone said in March 2015, “because they still feel a smaller hospital in the suburbs might be worthwhile.”
A legal battle between Summa and the physician owners over various issues continues.
Dress code questions
Ongoing staff changes at Summa over coming months gained little notice outside the medical community.
Then, in July 2015, Summa imposed a new dress code that affected all employees of the health system, including Akron City, St. Thomas and Barberton hospitals, SummaCare insurance, Summa Physicians Inc. and outpatient facilities.
Among other things, employees were told to have natural-looking hair color, a trimmed beard and no visible piercings, other than a maximum two per ear.
If employees wore skirts or dresses, pantyhose or tights were a must.
And tattoos had to be covered.
A day after news of the dress code started Akron talking, Malone was scheduled to address the Akron Roundtable.
During his speech, Malone told about 300 people that big changes were coming to local health care, not only at Summa, but at Children’s and Akron General.
“We have to change to survive,” he said.
Malone explained population health and talked about the possible need to combine service. Does Akron need two top-level trauma centers, one at Akron City and one at Akron General Cleveland Clinic, he wondered aloud.
When he finished, the audience wanted to know about Summa’s new dress code and why it was needed.
“Have you been to Wal-Mart? People who left the house actually thought they looked good some days,” he said.
Health care institutions need to set a higher bar, he said.
His words drew ire over coming days.
Some were angry that a high-paid health administrator took a shot at Wal-Mart shoppers. Others were angry about the way Malone appeared to be treating Summa employees.
But the issue died after a few weeks and Malone seemed to survive the public controversy unscathed, freeing him to help another Akron executive with bigger problems.
Scott Scarborough, the University of Akron president, had caused an uproar with employee layoffs and a move to rebrand the school as a state polytechnic institution.
In November 2015, Malone was among seven Akron business leaders who signed a full-page add urging the community to give Scarborough more time to fix the school’s financial enrollment problems.
A Summa spokesman at the time said Malone supported the ad because “we know as well as anyone that change can be difficult, but that with change comes great opportunity to make our organizations stronger assets for the people we serve.”
The ad ultimately did no good.
In May 2016, under tremendous pressure, Scarborough resigned as president of the University of Akron.
Few anticipated it then, but soon Malone would face calls for his own resignation.
Building momentum
From the outside, 2016 appeared to start off well for Malone and Summa.
In April, Malone unveiled Summa plans to pump $350 million into its facilities, including construction of a six-story tower on its main campus on the edge of downtown Akron.
The building — facing North Adolph Street, overlooking state Route 8 — will serve as Summa Akron City Hospital’s new main entrance, as well as house a women’s health center and help shift most of the hospital’s inpatient rooms from shared to private.
Summa also announced plans to build a 50,000-square-foot medical office building on its main campus off East Market Street and spend $22 million on additional improvements to make Barberton Hospital a more user-friendly community hospital.
Two months later, the Summa CEO unveiled a new logo to match the upcoming $350 million facility overhaul and to reflect its move toward population health.
Summa had depended on a stout wine-and-teal-striped shield over the word “Summa” for at least 15 years.
Malone was replacing it with by a bright orange, red and blue logo that looks like pieces from a circular puzzle coming together with a subtle “S” for Summa built into white space in between.
“It’s all part of our strategy to transform culture,” Malone said in June.
Some doctors, nurses and staff took a different view. To them, it looked like pieces of the Summa they knew were coming apart.
Summa is a health system made up largely of independent doctors with deep, intergenerational friendships.
Many older doctors had helped teach younger doctors at City Hospital, a sort of farm system for Summa fed by graduates of the Northeast Ohio Medical University in Rootstown.
By December, several doctors said that at least a half-dozen Summa contract negotiations with independent doctors groups — orthopedists, urologists, GI doctors and others — failed over the previous two years.
But none hit Summa’s heart like the failed contract with Summa Emergency Associates, the doctor’s group that had provided ER services at Akron City Hospital for more than 30 years.
Some Summa staff were upset to see longtime colleagues leaving and worried that a group of contract ER doctors — arranged with about two days notice before starting at midnight on New Year’s — might not be able to easily provide care.
Two weeks later, Summa officials said all five of its emergency rooms — Akron City, Green, Barberton, Medina and Wadsworth — remained open during the transition and that wait times and the number of patients seen have returned to levels seen in previous years.
Summa and the leader of the emergency medicine physicians group have blamed each other for the failed contract.
But whatever happened, the crisis appears to have unleashed frustration over Malone’s management of Summa that’s been building among some doctors for two years.
Summa’s board, while not mentioning Malone by name, released a statement last week pointing to what they consider six Summa successes under his leadership.
Among other things, the board highlighted Summa’s two strongest fiscal years of the last decade under Malone’s leadership and its bond ratings.
Fitch Ratings recently reaffirmed Summa’s A- rating, while also upgrading its rating outlook from stable to positive. Moody’s Investors Service also reaffirmed both Summa’s Baa1 rating and stable outlook.
It also pointed to the $350 million facilities plan “that will serve as the cornerstone of our vision to dramatically improve the overall health of our community while simultaneously serving as a major economic boost to the region.”
Yet hospitals, some doctors caution, are fragile ecosystems.
Doctors have power. If enough physicians direct their patients away from a hospital over hurt feelings or belief that better care is available elsewhere, they can hurt a health system’s finances.
Doctors leading the revolt against Malone said last week that it’s unclear if that could happen at Summa.
But some pointed out that it’s happened in Akron before.
In 1987, the Beacon Journal reported the medical staff at St. Thomas Hospital called for the resignation of the long-term administrator there, claiming St. Thomas couldn’t survive under her leadership.
The administrator resigned two days later and a new administrator was brought in. But the damage to St. Thomas’s reputation was done.
St. Thomas in 1989 merged with Akron City Hospital.
A new health system was born.
It was called Summa.
Business writer Betty Lin-Fisher contributed to this report. Amanda Garrett can be reached at 330-996-3725 or agarrett@thebeaconjournal.com