Professionalism and Accountability
The Vital Link To Quality of Care
Christine K. Cassel, MD
Building the Bridge: Maintaining Quality in the Face of Change
University of Texas System Clinical Safety and Effectiveness Conference
September 21, 2012
Key Aims for US Health Care
Affordability
Are
all
three
possible?
Access
Quality
NOT without physician engagement and leadership.
Knights, Knaves and Pawns
Julian Le Grand, British economist, on different
underlying frameworks for social policy:
 The Question: How not to undermine socially
positive motivations, while affecting behavior
with external incentives?
 LeGrand – citizens of post-war England.
 We apply these concepts to 21st Century
US physicians.
Source: Jain, SH and Cassel, CK. Societal Perceptions of Physicians: Knights, Knaves or
Pawns? JAMA 2010; 304(9): 1009-1010
What motivates physicians?
Professionalism
(intrinsic)
Knights?
Knaves?
Pawns?
Regulation
(extrinsic)
Financial
(extrinsic)
WILL P4P STRATEGY WORK?
The Roles and Expectations of a Physician:
Complicated and Complex
Society
Patient
Consumer
Professional
Citizen
Healer
Comforter
Provider
Physician
Scientist/
Expert
Evidence,
community
Customer
Team
Leader
Hospital,
clinic,
practice
Pharma,
EMRs, etc.
Contractor
Insurance/
Medicare
Complexity science at work
Outcome is measurable?
How to measure physician quality/performance
 For payment
 For “meaningful use” of HIT
 For public reporting
• “Physician Compare”
• “Consumer Reports”
 For improvement strategies
 For licensure
 For Maintenance of Certification
Can these be aligned?
Results to Date
 Medical malpractice system
• Does not compensate most victims of medical negligence
• Does not lead to better care overall
 Pay-for-Performance
• No consistent results for physicians
• Better on metrics linked to payment, not overall quality
• Missing complexity, teams, systems
 Public Reporting of Scores
• Data too granular, limited meaning for patients
• Peer comparisons more effective for improvement
IMPACT = Professionalism and Accountability
Specialty Certification/MOC
Choosing Wisely
24 Member Boards
Certify more than 750,000 physicians
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Allergy & Immunology
Anesthesiology
Colon/Rectal Surgery
Dermatology
Emergency Medicine
Family Medicine
Internal Medicine (250,000)
Medical Genetics
Neurological Surgery
Nuclear Medicine
Obstetrics & Gynecology
Ophthalmology
Orthopedic Surgery
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Otolaryngology
Pathology
Pediatrics
Physical Medicine
& Rehabilitation
Plastic Surgery
Preventive Medicine
Psychiatry & Neurology
Radiology
Surgery
Thoracic Surgery
Urology
Maintenance of Certification
 Based on principles of adult learning
 Designed to ensure that physicians keep current
and practice high quality medicine
• Employs active learning with feedback
• Performance assessment and improvement
 Knowledge exam every 6-10 years
 Performance/knowledge self-assessment more
frequently (1-3 years)
Performance Assessment Tools:
1. Internet based data collection/analysis (PIMS)
2. Registry based reporting?
3. Practice based data collection
Examples of ABIM Condition Specific PIMS
Asthma
Diabetes
Cancer Screening
Hepatitis C
Care of the Vulnerable Elderly
HIV
Chronic Kidney Disease
Hypertension
Chronic Obstructive Pulmonary
Disease
Osteoporosis
Colonoscopy
Preventive Cardiology
Professionalism: Why do they do it?
Ann Intern Med 2006; 144:29-36
25%
Pr
of
es
si
on
al
im
U
pd
ag
Q
ua
at
e
e
lit
kn
y
pa
ow
tie
le
dg
nt
Pe
e
rs
ca
on
re
al
or
pr
sa
ef
fe
er
ty
en
R
ce
eq
or
ui
re
in
d
t..
fo
.
Pr
re
of
m
es
pl
oy
si
on
m
en
al
t
ad
va
nc
Pa
em
ti e
en
nt
t
sa
tis
fa
M
ct
on
io
n
et
ar
y
be
ne
fit
s
0%
Note: Includes those completed or enrolled in MOC. A greater proportion of those who have completed IM MOC
(33%) rather than enrolled in IM MOC (20%) did so because it was required for employment.
4%
4%
30%
23%
42%
42%
43%
45%
49%
60%
61%
60%
34%
22%
18%
10%
10%
19%
20%
20%
30%
SS/AQ certificate (Subspecialists)
36%
40%
IM certificate (Subspecialists)
45%
50%
51%
60%
55%
70%
59%
IM certificate (Internists)
Studies Linking Certification/MOC and Quality
15% less mortality in myocardial infarction
Acad Med, 2000, Vol. 75, pp. 1193-98
40% less mortality in colon resection
Surgery, 2002, Vol. 132, pp. 663-70
Higher rates of preventive service
(Mammography, A1c monitoring, flu vaccination)
JAMA, 2005, Vol. 294, pp. 473-81
Higher rates of prescription of aspirin and beta
blocker after MI
JGIM, 2006, Vol. 21, pp. 238-44
Decreased risk of disciplinary action
Ann Intern Med, 2008, Vol. 148, pp. 86976
Higher scores on IM MOC associated with better
Medicare quality indicators for diabetes and
mammography screening
Arch Intern Med, 20008, Vol. 168 (13),
pp. 1396-1403
Higher rates on quality measures from RAND's
Quality Assessment Tools
Arch Intern Med, 2010, Vol. 170, pp.
1442-49
Higher rates of chronic and preventive care
Health Serv Res, 2010, Vol. 45, pp.
1912-33
IM MOC scores associated with better diabetes care
Acad Med, 2012, Vol. 87(2), pp. 157-63
ABIM Research Partnerships
Diabetes PIM Composite Measure and Standard
Mean = 71.23 (SD = 11.90)
Decision
Consistency = .98
20.0
17.5
15.0
P
e 12.5
r
c 10.0
e
n
t 7.5
5.0
Standard = 48.51
4% of physicians did
not meet the standard
2.5
0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95100
N = 957
Reliability of
Composite = .91
Total number of Points
 Opportunities for Alignment:
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Health Plans
CMS – Value Based Purchasing
JCAHO
MOL
 Goals:
• Reduce burden of redundant measurement
• Enhance clinical relevance
• Foster improvement
Michael Porter’s Value Framework –
Ideas Whose Time Has Come
 Fundamental question – What are we trying to do?
• Clinicians and other stakeholders need shared
overarching goal
• Otherwise, interactions devolve into gamesmanship
with goal of protecting each stakeholders’ interests
Our shared goal should be improvement of value as
defined by the outcomes that matter to patients and costs
over meaningful episodes of care
• Traditional concepts of quality put focus on clinicians’ reliability in
performing processes
• Value framework puts focus on patients’outcomes, and motivates
problem-solving, learning, and improvement through collaboration.
From Thomas H. Lee, July 28, 2012
The Value Framework as a Path Forward
Atul Gawande Tactics
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Recognition that medicine is so complex that
no human being can be in control of
everything
• The risk that obvious things can be
overlooked is real
 Core values of checklist
• Humility
• Discipline
• Teamwork
• Linguistic -- We need to use the same
language
• Standardization
• Allocation of roles
We ask care redesign teams to
determine the pause points where we
can reduce waste, harm, and chaos
From Thomas H. Lee, July 28, 2012
The Value Framework as a Path Forward
John Bohmer Operations
 Teams that have responsibility for improvement
of value – forever
 Data on outcomes and costs collected as routine
part of care
 Incentives (financial and otherwise) for
improvement
 A leader who thinks constantly about improving
performance
 Formal and informal interactions among team
members
From Thomas H. Lee, July 28, 2012
The Value Framework as a Path Forward
Daniel Pink, Drive
Motivating people who solve complex problems:
• Physicians
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Diagnostic accuracy
Complex factors – patients’ priorities?
Decisions in the context of uncertainty
Payment linked targets work best for routine
repetitive work
Salary and group targets work best for complex
work
Pink, Daniel H. Drive: The Surprising Truth About What Motivates
Us. New York, NY: Riverhead Books, 2009.
P4P could…
Enhance Professionalism
Damage Professionalism
Keys:
• Physician trust in measures and standards
• Organizational culture
The Choosing Wisely Campaign
Choosing Wisely is an initiative of the
ABIM Foundation to help physicians and
patients engage in conversations about
the overuse of tests and procedures and
support physician efforts to help patients
make smart and effective care choices.
Why stewardship? Why now?
 Health care expenditures are increasing at
unsustainable rates
•
Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011
 There is waste in the health care system—some say as
much as 30%
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Jack Wennberg, Dartmouth Center for the Evaluative Clinical Sciences.
 One third of all physicians acquiesce to patient
requests for tests and procedures—even when they
know they are not necessary
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Campbell EG, et al. Professionalism in medicine: results of a national survey of
physicians. Ann Intern Med. 2007; 147(11):795-802
 Physician decisions account for 80% of all health care
expenditures
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Crosson FJ. Change the microenvironment. Modern Healthcare and The
Commonwealth Fund [Internet]. 2009; Apr 27
From: Eliminating Waste in US Health Care
Donald M. Berwick, MD, MPP; Andrew D. Hackbarth, MPhil
JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362
Call to the Profession: Where are the
Health Care Cost Savings?
Deficit pressures are making cost
control inevitable. It will only be
successful if physicians stop
looking to others to find solutions
and focus on approaches that
improve the care for patients with
chronic illnesses.
-Ezekiel J. Emanuel, MD, PhD
Medicine's Ethical Responsibility for Health
Care Reform — The Top Five List
“A Top 5 list also has the advantage that if we
restrict ourselves to the most egregious causes
of waste, we can demonstrate to a skeptical
public that we are genuinely protecting patients’
interests and not simply ‘rationing’ health care,
regardless of the benefit, for cost-cutting
purposes.”
Howard Brody, MD, PhD
New England Journal of Medicine
The “Top 5 Lists”
 Funded by an ABIM Foundation grant, the
National Physicians Alliance conceived and
piloted the concept through its Good
Stewardship Working Group
 Developed lists of top five activities in family
medicine, internal medicine, and pediatrics
where the quality of care could be improved
 Published in Archives of Internal Medicine
 Subsequent research published
in Archives found a cost savings of more than
$5 billion could be realized if the
recommendations were put in to practice.
First Nine Specialty Societies Developed Lists of Five
Things Patients and Physicians Should Question
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American Academy of Allergy Asthma & Immunology
American Academy of Family Physicians
American College of Cardiology
American College of Physicians
American College of Radiology
American Gastroenterological Association
American Society of Nephrology
American Society of Nuclear Cardiology
American Society of Clinical Oncology
New Societies Joining Choosing Wisely
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American Academy of Hospice and
Palliative Medicine
American Academy of Neurology
American Academy of
Ophthalmology
American Academy of Orthopaedic
Surgeons
American Academy of
Otolaryngology-Head and Neck
Surgery
American Academy of Pediatrics
American College of Obstetricians
and Gynecologists
American College of Rheumatology
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American College of Surgeons
American Geriatrics Society
American Society for Clinical
Pathology
American Society of
Echocardiography
American Urological Association
Society of Cardiovascular Computed
Tomography
Society of Hospital Medicine
Society of Nuclear Medicine and
Molecular Imaging
Society of Thoracic Surgeons
Society of Vascular Medicine
Consumer Reports
 Consumer Reports is a partner in
Choosing Wisely and will support the effort
by creating patient-friendly materials based
on the society recommendations and
engaging a coalition of consumer
communication partners to disseminate
content and messages about appropriate
use to the communities they serve.
 Tools and resources can be found at:
www.consumerhealthchoices.org.
Choosing Wisely
Consumer Groups
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AARP
Alliance Health
Consumer Reports
Midwest Business Group on Health
National Business Coalition on Health
National Business Group on Health
National Center for Farmworker Health
National Partnership for Women and Families
Pacific Business Group on Health
Leapfrog Group
SEIU
The Wikipedia Community (through a dedicated
Wikipedian-in-Residence)
In the Media
Physician Response
From the Blogosphere…
From cardiologist John Mandrola: “That our thought leaders are now proclaiming–and social media
is amplifying– the values of clinical judgment and targeted thoughtful diagnostic and therapeutic
interventions represents a monumental sea change. Malcolm Gladwell writes about small yet obvious
ideas that come to stick. I think Choosing Wisely has a chance. I hope it sticks like super glue.”
Internist Eric Larson noted: “The Choosing Wisely initiative is remarkable
because doctors’ professional advocacy groups are making recommendations that
are often counter to their own economic interests. By recognizing elimination of
unnecessary care as a matter of professional ethics, medical professionals in a
broad range of specialties may be signaling that we’re reaching a tipping point
toward solving America’s health care cost crisis.”
Dr. James Salwitz: “At its base, the Choosing Wisely Campaign is simple. What is the data?
What really helps? What hurts? How can we work together to educate everyone about the best
care? However, the concept of making decisions in this way is revolutionary. Without government
or insurance control, it gives information so that patients and physicians can together make
quality personal decisions, while maintaining medical freedom. With this kind of initiative, we, the
patients, the doctors, the people, can seize control of health care in this new Century.”
What’s Next?
 Roll out of communication skills modules to help
physicians talk with their patients about
appropriate care (Drexel University)
 Catalyze others to use the information
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Office practices
Health systems
Residency and medical training programs
Additional specialty societies
Consumer Groups
Elements of Success/Potential for Impact
1. Right Message
2. Right Messengers
3. Right Time
Academic Health Centers:
Value Framework and Missions
 Learning and improvement are core to our cultures
 To fulfill our responsibilities to our communities, we have
obligation to do all we can to make health care coverage
for all affordable.
• But cost reduction alone is insufficient strategic orientation
 Substantial opportunities to organize and improve care
for patients drawn to academic medical centers.
• Vulnerable populations
• High risk/complex patients
 Themes are attractive to a generation of outstanding,
idealistic students and trainees.
From Thomas H. Lee, July 28, 2012
The Value Framework as a Path Forward
The Moral Test
“This is the threshold we have now come to, but
not yet crossed: the threshold from the care we
have, to the care we need. We can do this– we
who give care. And nobody else can … The buck
has stopped; it has stopped with you.”
Don Berwick
“The Moral Test”
2011 IHI National Forum keynote
Key Aims for US Health Care
Affordability
All
three
are
possible.
Access
Quality
WITH physician engagement and leadership.