How Physicians Can Achieve
Success in the Arriving
Population Health Model
Presented to:
University of Virginia Health System
©2013 THE ADVISORY BOARD COMPANY
Presented by:
John A. Deane
CEO, Southwind Division
Lisa Bielamowicz, M.D.
Executive Director & CMO
The Advisory Board Company
September 26 , 2013
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National Trends Driving
Physician Alignment
5
Meet Your Newest Medicare Beneficiaries
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Happy 65th Birthday!
Steven Tyler
Al Gore
Ozzy Osbourne
James Taylor
Terry Bradshaw
Kathy Bates
6
A Population More Predisposed to Comorbidity
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Worsening Case Mix Not Just Due to Aging
Obesity Rate Among U.S. Adults1
Obesity Rate Among U.S. Adults1
1988
2009
No Data
<10%
1) Body Mass Index ≥ 30, or 30 pounds overweight for 5’ 4” person.
10%–14%
15-19%
20-24%
25-30%
>30%
Source: Centers for Disease Control Behavioral Risk Factor Surveillance
System, available at: http://www.cdc.gov/brfss/, accessed May 4, 2011;
Health Care Advisory Board interviews and analysis.
7
Chronic Disease Growth Outpacing Population Growth
Projected Increase in Chronic Disease Cases
2003-2023
62.0%
53.0%
39.0%
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29.0%
41.0%
54.0%
19%: Projected
population
growth, 20032023
31.0%
Source: Milken Institute, available at: http://www.milkeninstitute.org/
pdf/chronic_disease_report.pdf, accessed April 27, 2011; Health Care
Advisory Board interviews and analysis.
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Getting Paid Less to Do Less
New Payment Models Calling Old Imperatives Into Question
Accountable Payment Models
Performance Risk
Cost of Care
Bundled Pricing
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• Bundled Payments for Care
Improvement program
• Commercial bundled
contracts
Utilization Risk
Quality of Care
Pay-for-Performance
• Value-Based Purchasing
• Readmissions penalties
• Quality-based
commercial contracts
Volume of Care
Shared Savings
• Medicare Shared
Savings Program
• Pioneer ACO Program
• Commercial ACO
contracts
Source: Health Care Advisory Board interviews and analysis.
9
Health Care Defects Occurring at an Alarming Rate
Growing Demand for Higher Value
Health Care Quality Defect
Breast cancer
screening (65-69)
Adverse drug events
Hospitalized patients
injured through
negligence
1,000,000
100,000
Defects
per
Million
10,000
1,000
Overall health
care in U.S.
100
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Anesthesia-related
fatality rate
Post-MI
beta-blockers
Hospitalacquired
infections
Airline
baggage
handling
10
U.S. industry
best-in-class
1
1
(69%)
2
(31%)
3
(7%)
4
(.6%)
σ Level
(% Defects)
5
(.002%)
6
(.00003%)
Source: Modified from Buck, CR, General Electric; Health Care
Advisory Board interviews and analysis; Southwind.
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Bridging the Transition Between Payment Paradigms
Mitigating Incentive Disconnect Between FFS, Value Based Payment
Revenue Generated Through Incentive Model
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100%
Total Cost
Accountability
Realizing Returns
Today
Preparing for
Tomorrow
• Can increase FFS rates
• Stabilizes physician
economics
• Improves performance
on key quality and cost
initiatives
• Can increase market
share
• Creates infrastructure
for care coordination,
management
• Builds physician
comfort with
performance focus
Fee for
Service
0%
Time
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Forcing Tighter Ties
Payment Reforms Place Greater Burden on Care Coordination
Strategic Responses to New Payment Methodologies
Pay-forPerformance
Hospital-Physician
Bundling
Episodic
Bundling
SharedSavings Model
• Partner with PCPs
• Invest in chronic
disease management
• Reduce utilization
• Partner with postacute providers
• Standardize care site
transitions
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Degree of
Management
Challenge
• Standardize devices
• Reduce orders and
consults
• Engage active
medical staff
• Standardize care
processes
• Track and analyze
performance
• Leverage physician
incentives
Actions
needed
under all
payment
reforms
Provider Cost Accountability
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Creating a Value-Based Health Care Delivery System
The Strategic Agenda
Michael Porter, Harvard University, 2013
• Organize "Integrated Practice Units" or "IPUs" around patient conditions
• Organize primary and preventative care to serve distinct patient segments
• Measure outcomes & cost
• Offer bundled pricing arrangements
• Integrate delivery across separate facilities
• Expand geographic coverage by excellent providers
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• Build and enable information technology
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This Is Not a Cup of Coffee
Source: Health Care Advisory Board interviews and analysis.
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An Absurdly Fragmented Market Offering
Dozens of Businesses, Thousands of Products
Typical Silos in Health Care Delivery
Office Visits
Imaging
Lab Tests
Quite a Lot on the Menu
745
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Emergency
Department
Rehab
Outpatient
Procedures
Long-Term
Care
1) Medicare Severity-Diagnosis Related Group.
2) Healthcare Common Procedure Coding System.
3) Accreditation Council for Graduate Medical Education.
Inpatient
Procedures
Pharmacy
~15,000
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MS-DRGs1
HCPCS2
Codes
ACGME3Accredited
Specialties
Source: Accreditation Council for Graduate Medical Education,
http://www.acgme.org/acWebsite/RRC_sharedDocs/ACGMEAccredited_Specialties_and_Subspecialties.pdf, accessed May 14,
2012; Health Care Advisory Board interviews and analysis.
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In Consumers’ View, Only Two Products
Individual Services Merely Inputs; System’s Role is in Assembly
Health Care Production Model
Inputs
Value-Added Products
Office Visits
Acute Care Episodes
Imaging
Lab
• High-quality, low-cost
treatment of acute illness
• Includes pre-acute, postacute services, readmission
Emergency Care
Inpatient Procedures
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Outpatient Procedures
Health System
• Planning
• Coordination
• Delivery
Longitudinal Management
Rehabilitation
Long-Term Care
Pharmacy
• Ongoing, comprehensive
health management
• Includes chronic disease
care, wellness, prevention
Source: Health Care Advisory Board interviews and analysis.
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Physicians at the Nexus
Physicians Essential to Generating Value from Systemness
Value-Added Processes
Hospitals Integrating Physicians
Care
Delivery
Examples:
• Texas Health Resources acquires Medical Edge
• St. Thomas forms 1,600-strong IPA1 in two years
• MemorialCare acquires 400-physician Nautilus
Payers Integrating Physicians
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Care
Planning
Care
Coordination
Examples:
• UnitedHealth acquires Monarch HealthCare
• Humana acquires Concentra
• WellPoint acquires CareMore
1) Independent Practice Association.
Source: Health Care Advisory Board interviews and analysis.
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Moving Beyond “Us and Them”
True Systemness Requires Demolition of Individual, Group Silos
New Ambition for Hospital-Physician Relations
Collaborative Care Enterprise
”
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Traditional Goal:
Strengthen individual practice
ties to hospital center
Traditional Goal:
Strengthen ties within
medical group/CI1 network
Today’s Goal: Align priorities,
strategies, and efforts of
system leadership with those
of broader physician network
Words Matter
“The language hospital leaders use to describe physician
alignment—‘how do we get them to work with us’—
reveals how deeply rooted this sense of separateness is.”
Health System Executive
1) Clinically integrated.
Source: Health Care Advisory Board interviews and analysis.
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The New Hospital-Physician Compact
Collaborating to Deliver Value to Patients
Patient Demands, System Responsibilities
Timely Access
• Physicians build schedules around
patient needs, connect to other
providers to expand options
• System invests in alternative
access points and needed capacity
Cost-Effective Care
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• Physicians actively work to
reduce cost, unnecessary
utilization
• System encourages use of lowcost care pathways
Principled Referrals
• Referral decisions based on
quality and cost, not habit
• Physicians coordinate with peers
to ensure safe and effective
transitions
Top-Quality Care
• Physicians build and utilize
evidence-based care standards
• Clinical decisions prioritize quality
• All providers accept, respond to
transparent performance data
Open Communication
• Physicians, care teams respond
promptly to patient inquiries
• Providers proactively engage
patients in care management
Unified Care Experience
• Care transitions appear seamless
to patients
• Information is a system asset,
updated and utilized by all to
streamline care experience
Source: Health Care Advisory Board interviews and analysis.
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Executing Strategy in the Accountable Care Era
Tactics for Evolving Primary Care to Support Accountable Care Strategy
Securing
Physician
Alignment
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• Evaluate, secure and
stabilize primary care
base
• “Clinically Integrate”
the network
• Engage physicians in
leadership,
governance
Care
Transformation
• Promote adoption of
evidence-based care
standards with
aggressive quality
targets
• Start medical home
transformation
• Foster seamless data
exchange across sites
of care
Reducing Costs,
Advancing
Quality
Managing Total
Population
Risk
• Align clinical, operational
and financial goals
• Leverage business
intelligence systems to
identify core
competencies
• Manage inappropriate
utilization of high- risk
patients
• Reduce costs through
quality improvement,
care coordination
• Consider value-based
contracts across payers
• Tailor interventions for
population health
management
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Start by Segmenting Medical Staff by Role in ACO
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The Accountable Physician Enterprise
Community
Contractors
Hospital-Based
Non Admitting
Specialists
Proceduralists
Primary
Care
Community-Based
Medical Specialists
Dermatology
Ophthalmology
Radiology
Anesthesiology
Pathology
ED Physicians
General Surgery
Cardiac Surgery
Neurosurgery
Orthopedics
Internal Medicine
Pediatrics
Family Medicine
Hospitalist
Cardiology
Medical Oncology
Endocrinology
OB/GYN
Minimal Relationship
Efficient Procedural Enterprise
Effective Care Management Enterprise
“ACO
Collaborators”
“ACO
Partners”
“ACO
Principals”
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More Than Just Great Clinicians
Ideal Partners Willing to Demonstrate Cultural Compatibility
Four Attributes of the Ideal Physician Partner
Information-Powered
• Supplements personal
experience with communal
knowledge resources
• Actively contributes to expanding
body of knowledge on care
standards, patient records
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Open to Transparency
Value-Conscious
• Acknowledges continuous
cost pressures within system
• Actively works to improve
patient care in cost-effective
manner
System-Oriented
• Understands benefit of full
data transparency
• Instinctively pursues system
goals
• Accepts results as validated,
unbiased, accurate
• Prioritizes system needs over
individual ambitions
• Views release of performance
data as opportunity to
improve
• Trusts that decisions made with
interest of patients, not politics,
in mind
Source: Health Care Advisory Board interviews and analysis.
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Address Physician Concerns About Team-Based Care
Key Responses to Common Physician Pushback
Fear of “Losing” Patients
• Medical Home is a physician-led team of providers
• Key relationship built around maximizing patient-physician interaction
• Physician actively engaged in overall patient care
Protecting “Physician-Required” Tasks
• Best practices are standardized, maximizing physician time
• “Triggers” to engage physician can be built into care processes
• Physician-required tasks are not offloaded to team
Imposition on Physician Time, Productivity
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• Role and goals of physician defines how team is used
• Team extends time available to patient, without requiring additional physician time
Cost of Creating the Care Team
• More efficient visits improve financial performance of practice
• More cost-effective to minimize physician time spent on non-physician
tasks
• Allows team members to operate at the top of their licenses
Source: Innovations Center interviews and analysis.
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Finding the Right Physician Leaders
Best Ambassadors Are Eager, Committed, Humble
Spectrum of Physician Engagement with System Strategy
Least Engaged
Disruptively
Opposed
”
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Most Engaged
Grudgingly
Obedient
Willingly
Cooperative
Great majority of physicians
willing to support system
strategy but need strong
physician leadership
Passionately
Leading
Distractingly
Over-Enthused
Best suited to
spearhead change,
disseminate
system vision
Putting Our Best Foot Forward
“Even today, we still have people within our system who viscerally oppose our ongoing
shift to clinical process management and improvement. Change is hard. However, we
have enough people who “get it”—and are deeply convinced of and committed to it—
that we can move vigorously ahead.”
Dr. Brent James
Chief Quality Officer, Intermountain Healthcare
Source: Intermountain Healthcare, “How to Run Your Own Clinical Quality Improvement Training
Program,” available at: http://intermountainhealthcare.org/, accessed May 14, 2012; Health Care
Advisory Board interviews and analysis.
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Building an Effective Ambassador Corps
Small Groups of Leaders Make Large Impact
Attributes of Effective
Physician Ambassadors
Ambassador
Corps
•
•
•
•
•
Respected clinicians
Ethic of trust and stewardship
Effective communicators
Skilled at resolving conflict
Natural problem-solvers
How Much is “Critical Mass”?
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n
Rank-and-File Physicians
Rule of thumb from change
management research: The
number of leaders necessary to
spearhead organizational change
is equal to the square root of n,
where n is the total number of
individuals in an organization
Source: Intermountain Healthcare, “How to Run Your Own Clinical Quality Improvement Training
Program,” available at: http://intermountainhealthcare.org/, accessed May 14, 2012; Health Care
Advisory Board interviews and analysis.
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Funneling Patients Through A Siloed Enterprise
Individual Components Strong But Disconnected
Traditional Clinical Enterprise
Primary Care
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Specialty Service Lines
• Primary care practices serve as feeders
to specialty service lines
• Each practice as individual point of
care, not comprehensive network
• Specialty service lines serve as core
business under FFS1 model
• Care, services streamlined within each
specialty but not across service lines
• Ambulatory space serves as driver of
volumes to inpatient setting, treatment
• Hospital as nexus of clinical enterprise rather
than node on care continuum
Acute Care
Hospital
1) Fee-for-Service.
Source: Health Care Advisory Board interviews and analysis.
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A Week in the Life of a Diabetic
Fragmented Pathways, Poor Coordination Threaten Outcomes
Typical Diabetic Complication Pathway
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Typical
Typical
Failure
Call to PCP
Office
Urgent
Care Visit
Practice
closes early
on Friday,
unable to see
patient
No access to
chart; patient
sent to ED
for wound
care
ED Visit
Med/Surg
Admission
Surgery
Consult
ED unable
to contact
wound care
specialist,
admits
patient
Hospitalist
unclear about
Parkinson’s
medications,
gives wrong
dose
Diagnostics
delayed due to
mental status
changes;
surgeon
refuses to see
patient
Wound Team
Intervention
Clinicians
determine
care plan
without
consulting
outpatient
team
Discharge
LOS two
days longer
than needed
Root Causes of Care Management Breakdowns
Primary care pathways,
providers fractured
across care continuum
Lack of coordination,
interfacing across service
lines, specialties
Lines of control fail to
converge at any
actionable level
Source: Health Care Advisory Board interviews and analysis.
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Patient Problems Often Span Multiple Specialties
Even Simple Problems Require Broad Specialist Collaboration
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Specialists Required to Generate Post-Op Wound Prevention Standards
Surgical Specialists
Guarantee pre-, post-op
care order consistency
Hospitalists, Intensivists
Manage general post-op care
Wound Care Specialist
Supervises wound therapy
pre-, post-discharge
Infectious Disease Specialist
Ensures appropriate antibiotic use
7
Total number of specialists
required for comprehensive
wound care
Source: Health Care Advisory Board interviews and analysis.
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Meeting Clinical Needs Head On
Organizing Quality Around Patient Issues
Quality Committee Characteristics
MissionPoint Quality Committees
• Cardiac – CHF1 and Chest Pain
• Diabetes Mellitus
Nine quality committees
organized around initiatives
rather than specialties
• Respiratory – Asthma/COPD2
• Sepsis
• Preventive Care
• Depression
All physicians required to
spend two hours per month
on a committee
• Joint Pain (including back pain)
• Women/Newborn Health
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• Weight Loss
Physicians not
compensated for time
Case in Brief: MissionPoint Health Partners
• 1,400-physician clinically integrated population management network affiliated
with St. Thomas Health located in Nashville, Tennessee
• Mandates multidisciplinary physician participation on quality committees;18
percent of physicians participate on a committee at any given time
1) Congestive Heart Failure.
2) Chronic Obstructive Pulmonary Disorder.
Source: Health Care Advisory Board interviews and analysis.
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Evolving to a New Physician Leadership Bench
New Crop of Leaders Rising To Meet Tomorrow’s Challenges
Traditional Hospital
Physician Leadership
VP of Medical
Affairs
Tomorrow’s Health System Leaders
Chief Clinical Officer
VP of Care Transformation
• Holds management
jurisdiction, authority over
entire clinical enterprise
• Bridges stakeholder
relationships
• Applies systematic analysis
to pilot effective population
health programs
• Tailors offerings, rolls out
stratified risk programs
Chief Medical
Information Officer
• Bridges communications gap
between IT staff, physicians
• Provides guidance on
realities of clinical practice as
IT systems are deployed
Chief Quality Officer
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Chief Medical
Officer
• Roles largely limited to inpatient
quality management, standards
• Legacy of independent medical staff
model, responsible for credentialing
• Limited authority to enact true change
across organization
• Leads transition to
evidence-based practice
• Sets unified quality
standards across care
continuum
Source: Health Care Advisory Board interviews and analysis.
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Patient-Focused Culture Not an Overnight Change
Transforming Personal Relationships, Attitudes Takes Time
Shifting Perspectives
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“Comfort Zone”
New Expectation
Clinical Practice
Model
• Physician makes treatment
decisions unilaterally
• Main responsibility to
advance patient to next
stage of care continuum
• Physician collaborates with
colleagues, adheres to
evidence-based standards
• Responsibility extends to
coordination across entire care
continuum
Understanding
of Success
• Personal financial
performance paramount
• Profit potential proportional
to volume
• Individual success closely
linked to system objectives
• Financial return dependent on
quality, coordination
Relationship to
Hospital
• Physician refers to, practices
at hospital
• Relationship based on
convenience, financial ties
• Physician engages with
hospital as strategic partner
• Relationship based on
common culture, patient focus
Source: Health Care Advisory Board interviews and analysis.
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Tough Decisions Require New Paradigms
Successful Physician Alignment Must Be Redefined
Difficult (But Necessary)
Transformations
Restrict network participation
to culturally-aligned,
performance-focused
physician partners
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Empower physicians with
meaningful influence in
system strategic planning
Restructure reporting
relationships to emphasize
unified, coordinated patient care
over parochial interests
Traditional Goals
•
•
•
•
Physician satisfaction
Network size
Physician “buy-in” to hospital-led strategy
Minimized losses on employed practices
New Measures of Success
• Stronger physician engagement with system
• Network integrity, compatibility with payer
contracting objectives
• Physician contribution to jointly-led strategy
• Physician impact on quality, cost of care
Source: Health Care Advisory Board interviews and analysis.
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Value Proposition of Systemness Broadening
Attracting Physicians to New Model Requires Making Benefits Clear
Traditional Physician
Benefits of Systemness
Additional Value Proposition
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Collaboration with
network peers
Stronger negotiating
position with payers
Affiliation with larger,
respected brand
Access to
investment capital
Efficiency through
shared services
Comprehensive
IT infrastructure
Stronger negotiating
position with payers
Access to
investment capital
Coordination across
care continuum
Patient-focused
care model
Affiliation with larger,
respected brand
Efficiency through
shared services
Source: Health Care Advisory Board interviews and analysis.
33
Three Fundamental Principles
Recalling the Tenets of True Systemness
An End to Factionalism
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Hospital leaders,
physicians must move
beyond “us vs. them”
mentality to one of system
unity, shared purpose
Physician-Oriented
Leadership
System leaders need not
be physicians, but must
have collegial, productive
relationships with
physician partners
Patients at the Center
All stakeholders must
understand that system
value derives from serving
patient needs through highquality, cost-effective care
Source: Health Care Advisory Board interviews and analysis.
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Questions