The ABCs of ACOs
Creating a Culture of
Collaboration with Physicians
Kathleen L. Lewton and Steven V. Seekins
Principals, Lewton,Seekins&Trester
Clark Jensen
Senior Director—Marketing, Intermountain Healthcare
Society for Healthcare Strategy & Market Development
Sept. 14, 2011, Phoenix AZ
FROM: “ACO’s The Final Frontier”
TO:
“Well, maybe not?”

Proposal submitted when ACO’s were THE
ultimate solution . . . . . .
• ACO Watch website
• Second ANNUAL National Accountable Care
Organization Summit
• Newly-minted experts and consultants by the
dozen(s)
• Blogs, op-eds, articles . . . . . . .
And then the winds shifted . . . .


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CMS shared the details
And the big guns (Mayo, Cleveland Clinic,
Geisinger among others) said “maybe not for us”
February survey: 70% of hospital execs cynical
about medical homes and ACOs
• New models will hurt our margins
• And half of MDs don’t know what an ACO even is

BUT even if ACOs don’t turn out to be the ultimate
magic acronym . . . .
Whatever the acronyms, hospitals &
physicians must work as partners

Full physician ENGAGEMENT is the critical
success factor in creating, planning and
executing key initiatives relating to:
• Quality (never events, readmits, hospitalacquired infections)
– Think just about HAND WASHING
• Cost control
• The “total patient experience”
• Patient acquisition (translation: admissions)
Time-Out #1:
Take Your Own Pulse
Self-Assessment of Your
Organization’s Current State of Mind
and Practice
Rate using a 5 high – 1 low scale:
1.
2.
3.
4.
5.
6.
7.
8.
Your hospital/system’s current physician satisfaction level
(your personal opinion)
How well your CEO interacts with physicians
Overall effectiveness of your physician communications
program
Quality of data you have about your physicians (current,
detailed, quant and qualitative, etc.)
Your personal relationships with physician leaders
Depth of physician involvement in planning and decisionmaking
Board/management commitment to physician relationships
as a top priority
Your level of worry about physician engagement
Status Report 9/14/2011
From the hospital POV, we are the
center of the healthcare universe


From the patient’s point of view, things may
be not quite the way we see it
Recent major research effort in “test market”
type city in “mid-US” found the consumer
“my healthcare” word cloud had a different
picture
The patient POV on “healthcare”
DOCTOR
I asked my doctor and he . .
I’d go where my doctor says
my doctor thinks . . . .
At my doctor’s office . . . . . .
With some Rx and outpatient facility references
thrown in for good measure
A quick reality check:

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Doctors “have” the patients (almost all the
time)
Most care (not in-bed care, just care in
general) happens in the doctor’s office (or
wherever the doctor SENDS the patient)
Doctors have the credentials and the
license to treat
• The phrase “Doctor’s orders” isn’t a cliché
And most significantly . . . .

The doctor-patient bond, albeit battered and
tossed around in past few decades, remains
the core of trust in the entire healthcare
endeavor
• Strengthen that bond and all benefit
• Erode that bond, and our entire ‘industry’ suffers
– especially the patients
When hospital leaders think about
ACOs, they focus on “hard goods . . .

Here’s the typical list (from SHSMD
Futurescan) of what a hospital leader would
think about:
•
•
•
•
How MANY doctors do we need
Impact on patient volume
Governance and management capabilities
Capacity to manage total costs across episodes
of care
• Level of incentive alignment between hospital
and physicians
• Ability to be transparent and report publicly
Instead of focusing on the CORE issue:

Can these doctors and this team of board
and hospital leadership work together as
respectful partners?
• Buzz words like “level of incentive alignment”
reduce a relationship to a price tag
• Six “Keys to Lasting PARTNERSHIPS”:
–
–
–
–
–
–
Align physicians with hospital strategy (control)
Sufficient capital ($$)
Practice acquisition (control and $$)
Physician compensation ($$)
Clinical integration via a contracting entity (control)
MANAGE physicians (control)
And what do hospitals think they
have to DO to become an ACO?
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
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Establish a legal entity including joint negotiation
with physicians for contracts
Establish physician membership criteria to ensure
physician’s full commitment
Common set of performance measures . . .
Create management system to track . . .
Establish an incentive system to promote
collaboration and peer pressure to improve
performance . . distribute shared savings
. . . . Drive clinical performance using physician-led
committees
Alternatively . . . .

Continue (or begin) to work with our
physician partners to create an organization
that . . . .. . . .
The devil is in the details . . . .

But while many hospital leaders are
worrying about the CMS regulations, they
need to first be worrying about how they can
create the FOUNDATION – a true
partnership with physicians – when their
views of the world are so divergent
. . .but the mindset matters

Emphasis now on power and control
• Leading hospital management consultant
advises using a “council” model – employed
MDs serve on councils, with “Board appointed
fiduciary – the hospital CEO – with ultimate
bottom-line accountability and veto power”
• Meanwhile the president of the AMA says
“Oh yes, there will be ACOs and they will be
PHYSICIAN-led”
A quick scan of the current
landscape shows lots of land mines

Hospital trade publication:
• “One of the key goals of the ACO is to better
coordinate care to reduce costs, which means
reducing utilization rate of the most costly
services, which drive up costs BUT are also key
revenue generators for hospitals. . . . Volume
will drop and hospitals will have to reach to a
broader population base to make up for that lost
volume.”
MINDSET MATTERS. The big goal is no longer
how can hospitals make more money, it’s the
health status of a population
Current landscape

Study of hospital physician relations
programs done by SHSMD finds:
• Programs “also referred to as physician SALES
programs”
• Goal: get physicians to send patients to our
hospital
• Use sales plans and metrics
• Only 13% of these programs report to CEO
• List of responsibilities never mentions building or
enhancing sense of partnership and
collaboration
Mindset: SELL TO rather than work with
Current landscape:

Research done by SHSMD and major
agency: “Recurring theme is improving
physician relationships . . . Specifically,
changes needed in the (drum roll)
physician relations function”
• 80% of CEO, consultant respondents say
physician relationships is a major challenge –
half mention “alignment”
• Key disconnect: some see physicians as an
internal audience, others still say “external”
some say both (if they are employed)
An A-Ha! moment: Large urban system,
discussion of “our” doctors focuses
exclusively on employed docs.
Q: What % of your revenues come from
NON-employed physicians?
A: Gee, not really sure.
Reality: 70%
Current landscape:
Same study . . . . Intriguing insights
“Our ability to integrate more physicians into
our employed group and build that group,
without alienating any of the independent
groups in the process . . .”
“We have to find a way to align the physician
groups SO we reduce the amount of
leakage that goes to competitors.”
Mindset: Doctors exist to feed our need for
patients.

And more . . . .

Communications is seen as a panacea . . .
“We have to communicate TO medical staff what
the changes are and GET THEM to understand”
“Get them to understand OUR strategy and OUR
goals”

. . .as is the fabled “alignment”
“If they are employed, WE have to run the group
as best we can. If not employed, it’s economic
alignment . . . there are models where we are
both at risk.”
Some glimmers of insight . . .
“We have to view physicians as partners including
being concerned about their financial welfare”
(CEO)
“We need get physicians to help us design programs
that we deliver. For instance, we could have
cardiac care physicians help design the cardiac
care that the hospital delivers.” (CEO with good
intentions)
Mindset: When asked, respondents had difficulty identifying the
skills and expertise needed to do all of this
And now back to real life . . .

Amidst all the talk of ACOs and alignment:
• Major System X fires its radiology group,
replaces with a contracted group – and
announces it as a fait accompli to the medical
staff . . . who are STILL furious 18 months later
• CEO-no-confidence votes still occur
• “Independent” physicians – who still do admit
patients and generate revenue – more and more
concerned about their role as 2nd class citizens
More real life . . . .

National Healthcare Leadership Survey:
• Hospitals that report having (average scores):
– Administration succession planning 4.67 (of 5)
– Nursing leadership succession planning 4.33
– Medical leadership succession planning 3.54
– Administration 360-degree feedback 3.80
– Nursing leadership 360-degree
3.47
– Medical leadership 360-degree
2.31
One more dose of real life . . . .

Study after study finds that physicians say:
• They have less time and no control
• Unable to keep up with changes in practice
– “I default to what I learned and feel comfortable with it
even if it may not be the most current because I can’t
do what I’m not sure I feel good at”
• They are frustrated at best, furious at worst
• Concerned about money (NOT what they
planned) but even more concerned about . . . .
• Not beingrespected (a core need)
Beware the conventional wisdom

Ownership is inevitable
• Accenture – 13% or less will be independent by
2013.
• REALLY? How many systems are even at 50%
and it’s almost 2012?
– And think about the stats – one Mayo with employed
sure brings up the average
• But acting out of that mindset has profound
implications
– Some other system wants yourignored independents
More conventional wisdom



Owned = aligned = partner = collaboration =
shifts in practice patterns. NOT necessarily.
Most of all, owned = respected.
Key to success in ACO is $$
• AMN study of biggest obstacle to ACOs:
–
–
–
–
Physician alignment
Capital
IT
Evidence-based
protocols
42%
38%
31%
25%
Case in Point:
Integrating Independent Physicians
St. Joseph’s Hospital Health
Center, Syracuse

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Strategic planning process driven by ad hoc
coordinating council of ten physicians
(employed and independent) and five
administrators
Five ten-physician task forces handled
specific subjects and sought physician input
via department-by-department advisory
meetings – 150 physicians participated
Admins and doctors jointly presented to
Board
Time-Out #2:
Let’s Talk
Questions, comments, discussion and
debate on what you’ve heard so far
Now . . . . On to the ABC’s
Attitudes, Building Bridges,
Creating a Culture of Collaboration
“A”
Attitudes:
What Makes Physicians Tick
Tick, Tick, Tick
Not Captain Hook’s alligator - how docs think & feel


Informed insights based on a few decades
working side-by-side with physicians in a
non-hospital setting)
Doctors by nature are perfectionists, like
challenges, like being right, are analytical,
like being leaders (in the sense of giving the
orders), are competitive, like doing things in
ways that are accepted by their peer
community
Tick, tick, tick . . . .
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Doctors are very very smart and bright individuals,
highly educated . . .
AND they want to be loved and respected as
people, too
High ego strength is essential for what theydo
Huge info seekers, users (from gossip to research
findings)
Driven by facts and numbers – data, data, data
Truly committed to their patients!
Different tocks . . .
Physicians
 Doers
 1:1 interactions
 Reactive
 Immediate results
 Deciders
 Value autonomy
 Independent
 Patient advocate
 Identify with specialty
Administrators
 Planners, designers
 1:N interactions
 Proactive
 OK w/delayed results
 Delegators
 Value collaboration
 Participate
 Organization advocate
 Identify with organization
Doctors are not all alike . . .


Chose medicine for different reasons
Huge variation from older to youngest
• “This is NOT what I envisioned”

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Medical vs. surgical – different mindsets
Communications preferences vary wildly
Infighting does occur:
• PCP vs. specialist(s)
• Specialist vs. specialist (ortho/neuro,
plastics/ENT/head and neck, etc.)
Nor do they think about
communications as we do

Study of paired CEOs/physician leaders
Best info source
CEO
Chief of staff
Thought leader in
my specialty
CEO
76%
66
Physicians
32%
48
22
52
Best communications tactics?
Tactic
CEO
Liaison
62
Advisory boards 36
Newsletter
28
Personal mtgs.
94
CEO letters
60
Physicians
32
48
28
80
38
More ticks . . . .

They want to:
• Care for patients with the fewest possible
hassles
• To improve quality
• To make sure their patients are safe
• To build the body of medical knowledge
• To hear things firsthand and directly
A great summary from UBM Medica:

A cross-section of American physicians
appears to resemble a cross-section of
middle-to-upper-income Americans
• Professionally satisfied but struggling to find time
for work and personal life
• In wide agreement that medicine, although
challenging, is a noble profession from which
they gain great personal and professional
satisfaction
Understanding physician attitudes
is the core first step . . .

So disregard everything we just told you
and listen to your own physicians
• Not a standardized generic survey from some
survey company – YOUR benchmark is your
own physician satisfaction
• Use surveys – phone, online, whatever they will
do
• And personal interviews (focus groups almost
impossible with this audience)
• Get your own “up close and personal” view AND
set your own benchmarks to monitor change
AND . . . understand your board
and C-suite attitudes, too


Is it “US vs. THEM” or “I’ll grit my teeth”
or “I genuinely want to work WITH these
doctors, but how?”
It’s up to us as the scanners/spanners to
manage attitude adjustment via a continuum
of approaches:
• Facts, data, dose of reality
• Persuasion, offering ways to ease the pain
• Bringing in outside help who can say what you
can’t
• OR . . . .
Time-Out #3:
Let’s Talk
What are you encountering and what
have you done about it, or what do
you want to do about it?
“B”
Building Bridges: From Better
Communications, to Trusted Partners
A great starting point . . . . .

UBM study
“Marketers should focus on connecting to
the emotional satisfaction that physicians
get from being physicians while promise
help crossing the hurdles that get in the
way”
The goal is engagement

This is a fine point, because it goes way
beyond communicating TO or even
communicating WITH – to a desired state of
physicians who genuinely care about the
success of the organization, and an
organization that genuinely values the
physicians
• Not just their clinical expertise – their personal
and professional selves
That “value ME” proposition plays
out in so many ways

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“I still like to be called DR. Jones, at least at
first”
Start conversations with points of
agreement and commonality – not “here’s
the problem we have to fix”
Praise a physician publicly, address
problems face-to-face privately (NOT in
email)
Understand cultural and personal life
sensitivities
To “value ME” begins with knowing ME


Knowing about the doctor’s background,
hobbies, family, goals and worries
John O’Brien, when at Cambridge Hospital
• “I like our doctors. I like going around and
talking with them about all kinds of things. I
keep in touch with them because I want to – it’s
not some strategy.”

Now some call it “physician rounding”
In the final analysis . . . .

It’s all about trust
• 2010 PriceWaterhouseCoopers physician study:
• 23% said they trusted hospitals, 50% said they sometimes
trust, and 20% said “nope.”

The key: find out what YOUR doctors believe and
feel, and go from there
• Lack of trust is best addressed by first acknowledging it,
doing a bit of dissection about what went wrong when and
where, and making commitments to change in ways that
the doctors can see and monitor.
• And always tie efforts to the shared goal: flawless patient
care.
Build communications OUT from a core
of trust, rather than vice versa

Physician communications through the ages
(dark and otherwise)
• The one-way newsletter and the quarterly allstaff meetings
• And don’t forget the SHRIMP at the annual
banquet
• Then on to liaisons (a.k.a. sales reps – a term
physicians came to loathe)
Communications “perfect storm”

The info glut + time crunch +hospitalists
• Too much info from all sources (medical
journals, research studies, pharma messaging,
healthcare reform, hospital administration)
• Just at the point when doctors’ time is eroding
• AND with hospitalists, your key PCP group
doesn’t come in anymore . . . so even signs on
the doctor’s entrance don’t work!!!
• Then ADD email bedlam and you have
CHAOS!
Case in Point:
The System That
COMMUNICATED
Major system that reflects the norm

Monthly newsletter
•
•
•
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Page after page
Key info next to golf outing
And now it’s online
Newsletter created by the CMO at one hospital for “his” physicians
Newsletter “from the desk of” one hospital COO
MD 411 for employed physicians (fizzled out)
Rounding – but only on doctors in system-owned office buildings
Departmental newsletters (virtual meeting, runs to 40 pages)
Update for physician leaders (“we hope they share it”)
Faxes, a glut of emails (“FYI”)
Visits by corporate sales reps
Fliers on doors of ambulatory buildings
Clinical meetings, social events
Intranet “sort of” in the works
Missing emails for 40% of medical staff
The search for magic bullets . . .

Newsletters – just send it out as a PDF
• “All our doctors are online”

Put them on (all of) our email lists
• So we clog up the emailboxes that they don’t like
anyway

National study recommended blogs, twoway digital comms, town hall forums,
physician advisory council – everything
except one-on-one conversations
Even the Advisory Board flinched:

Study which had been expected to produce
clear guidance on the “single best way to
reach physicians” pronounced:
“Ultimately, it’s a question for which no
clear, overarching answer exists, and one
that poses great difficulty for our members.”
What’s missing?

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Strategy
Core messages
Coordination
• Matrix PR/communications, marketing, CMO,
medical staff office

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Brevity and repetition
One or two truly CORE channels
• Intranet that works
• Guaranteed “read ONLY this” email from CMO
Case in Point:
Building Trust with Physicians
By Doing, Not Talking
CaroMont Health, Gastonia NC

Six physician-led service line councils
• Three directed by independent physicians, one
co-led by independent and employed physicians


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Councils develop strategic plans on care
delivery, reflecting community needs
No more dueling agendas – employed
physicians and independents working
together AND working with the hospital
“Physicians are in charge of clinical care –
they must lead system redesign.”
“C”
Changing Culture:
Not Just THEM, but US, too
Creating a climate for change

New attitudes for board and hospital
executives
• Alignment is not something we do “to”
physicians
• MD Blogger: “Physicians are not chess pieces
to be set up by administrators. And it is not
necessarily the case that the fiduciary duty of a
hospital administrator is aligned with the patient
responsibility that a physician has. Physicians
must remain patient advocates.”
• And administrators must convince physicians
that they, too, are patient advocates!
So it starts with
defining a shared vision


Alignment discussions often start with
economics (worst place to start, kills a
‘patient advocate’ mentality) or with clinical
activity (also touchy, tromping on
physicians’ turf)
If you start with alignment of purpose –
shared belief, common culture, single
mission, and a commitment that physicians
will be actively involved, then you can move
forward in a partnership style
And re-think our vernacular


Even the word “alignment” has started to
have a negative connotation because it is
felt to imply “you doctors align with us” – so
always be sensitive to the nuances that
might suggest “loss of control”
And always make good use of data
• CIGNA-Dartmouth-Hitchcock ACO pilot found
that giving doctors data specific to them and
helping them compare with others is a good way
to move toward behavior change
When communicating:

Brevity – painful (to us) brevity
• True message management, using terms you’ve
tested with physicians


Delivering messages repetitively through
multiple tested channels
Understand who the real physician leaders
are (doesn’t always necessarily map to
titles, elected or appointed) and build
relationships
To build relationships:



It can begin with “onboarding” – content,
approach and participation at new physician
orientation sets a critical “early tone”
Rounding works (tried and true) in person
(although some really do prefer a quick
phone call)
Drilled down, ongoing physician attitude and
satisfaction research, managed by a joint
team including physicians
More on relationships

Physicians, especially PCPs, tell us they
miss going to the hospital, miss the
collegiality, feel like they’re getting out of
touch, don’t “know” other doctors
• So we can create the opportunities to bring them
back together
• And don’t give up departmental and staff
meetings if some physicians still find them
valuable
Help physicians
prepare for their new roles

They’re being asked to be managers, team
leaders, collaborators
• NOT skill sets taught in medical school or
acquired in private practice

Assist with training opportunities
• Kaiser making “teamwork” skills a priority with
their physicians

Identify, develop and mentor physician
leaders
• An inspiring speaker at a meeting is only the
beginning
Dispel one of the great myths


Heard for years: “The doctors want to RUN
and CONTROL this place.”
Premier Alliance seminal research effort
many years back found differently
• Doctors emphatically said they don’t want
control.
• What they wanted was to be involved, listened
to, consulted – from the beginning.
• “Don’t announce your decision or plans to us –
include us in the discussion from the get-go.”
What’s more . . . .

Wise, veteran CEO: “You can say no to
physicians. I’ve done it. You just have to
make it clear that you understand their
viewpoint, that it was clearly considered,
and tell them the reasons why you can’t do
what they recommended.”
Case in Point:
The Intermountain Experience
Up Close and Personal
Clark Jensen
Senior Director—Marketing
Intermountain Healthcare
Mission, Vision, Values:
“Engaging Physicians” is built in
 Intermountain’s vision/aspiration is to provide
Extraordinary Care in All Its Dimensions
 Six “Dimensions of Care” are pillars supporting this
vision
 “Engaging Physicians” is one of the six
Dimensions of Care
Our mission has always been excellence in the delivery of care—
not just the management of hospitals. Therefore, we have
always needed to work closely and collaboratively with
physicians.
Some history . . .
1975-1994: Physicians involved in governance;
councils; early quality improvement studies (QUE
studies)
 1986: Arrival of Brent James, MD
1994: Medical Group formed
 Clinics acquired; physicians recruited
1998: Clinical Programs established
2008: Charles Sorenson, MD, becomes CEO
2011: Shared Accountability
Today
Medical Group:
Headcount
Medical Group:
Clinics
Physicians
818
Clinics
165
Midlevels
182
InstaCares
24
Employees
3,267
WorkMeds
9
Total Headcount
4,267
Total Clinics
198
Plus: 3,500 independent “affiliated” physicians credentialed at
our 23 hospitals.
SelectHealth health plans have 4,900 physicians on panels
(including the Medical Group physicians).
Intermountain Medical Group:
How we pay physicians
Productivity (Relative Value Units): 85%
System/Quality goals: 15%
Medical Group contributes to system margin
Physician relations principles
Partners: Can’t affect quality/cost without physicians.
They must be partners:
 Governance: Physicians on Board (literally)
 Leadership: Physician CEO; physicians in
other key leadership positions
 Clinical Programs: Medical directors oversee physician
relations and delivery of care
 SelectHealth: Continual outreach
 Medical Group: Most physicians are employed, but we
refer out to some highly aligned specialists
Engaging physicians in clinical
quality improvement
 Dr. Brent James and the Intermountain Institute for
Healthcare Delivery Research
 Advanced Training Program
 Advocacy for evidence-based medicine,
comparative effectiveness research
 Quality Improvement Conference (new in 2011)
 Board of Trustees establishes annual clinical
quality improvement goals
Engaging physicians in clinical
quality improvement
Clinical Programs:









Cardiovascular
Oncology
Women & Newborns
Primary Care
Surgical Services
Pediatric Specialties
Intensive Medicine
Behavioral Health
Patient Safety
Engaging physicians in clinical
quality improvement
Techniques for engaging physicians:






Peer-to-peer (physician-to-physician)
Teamwork
Show them the data
They decide
Outcomes speak for themselves
They explain departures from protocols
Engaging physicians in clinical
quality improvement
Example: Elective inductions prior to 39 weeks
Timing of Elective Inductions
Elective Inductions < 39 Weeks
Elective Inductions
Timing of Elective Inductions
35%
Elective Inductions < 39 Weeks
30%
25%
20%
15%
10%
5%
0%
Over $1.7 million of savings in
2009 and 2010
Engaging physicians in clinical
quality improvement
Example: Orthopedic Devices
 Difficulties
 Supply Chain negotiations
The Future:
Shared Accountability
Goals:
 Better quality (for our patients)
 Better health (for populations we serve)
 Bending the cost curve
The Future:
Shared Accountability
Aligning incentives:
 By helping plan members manage health and by focusing on
most effective care (address problems of overuse, underuse,
and misuse), we believe we can generate significant costsavings
 Physicians will share in those savings and earn more by
supporting this effort.
 Rewards for providing best care, not most care
The Future:
Shared Accountability
Example: Changes to Medical Group compensation
 Today: Physicians earn bonus partly on basis of global
quality goals
 E.g., 70% of diabetic patient population with HbA1c ≤ 7).
 Tomorrow (2012): Physicians earn bonus on
basis of goals specific to their patients
The Future:
Shared Accountability
Incentives, not penalties
 Doctor knows best: Physicians are the key to
making Shared Accountability work
 As always, you can’t deliver best care—or any
care—without them
 Physicians have the highest credibility,
especially with patients/consumers
 See studies by Robert Wood Johnson
Foundation and others
Time-Out #4:
Let’s Talk
How can we use our marketing and
communications skills of research and
relationship building to advance the
process
And in Closing: Check It Out
1. The Handy-Dandy Checklist to help
you plan your next steps – will be
posted 9/19 on www.lstllc.com
2. klewton@lstllc.com 917 734 5376
sseekins@lstllc.com 818 378 6664