In population health management, the role of physicians has evolved because the care of chronically ill patients requires a coordinated effort between members of a multi-disciplinary team. However, a team approach does not diminish the role of primary care or specialist physicians. Rather, it should engage and support physicians directly to address quality, outcomes and cost. As provider organizations seek to scale their population health and value-based care efforts, effective engagement of primary care and specialty physicians is critical.
Today, physicians are under escalating amounts of clinical, administrative, time, financial, and legal pressure to perform while their businesses are facing decreasing fee-for-service reimbursements. In increasing numbers, physicians are giving up the independence of private/small group practices and seeking employment with larger groups and health systems. This loss of autonomy coupled with administrative and regulatory pressures can lead to a decrease in physician satisfaction. We often speak about patient satisfaction but physician satisfaction is rarely addressed in a systematic fashion. Despite these pressures, most physicians rightfully view themselves as hard working, high-quality individual performers who care about patient outcomes. However, as organizations start to add the numerous requirements of value based care programs onto already over-burdened physicians, is it possible to maintain effective engagement?
Some larger physician groups and health systems are further along in their population health journey. These organizations have established patient-centered medical homes, continue to expand their multi-disciplinary care teams (nurse care managers, pharmacists, social workers, community health workers and non-clinical support staff) and are transitioning from basic registries to more sophisticated population health analytic and workflow tools. These investments have been made to both transform the care delivery process and simultaneously engage and support front line physicians and nurses. However, the majority of physician groups and health systems that I speak with are still fairly early on in their participation in value-based programs (e.g. planning to apply or in program year 1 of a Medicare Shared Savings Accountable Care Organization (ACO), grappling with the looming impact of the now mandatory Comprehensive Care for Joint Replacement (CCJR) bundles, trying to effectively deal with the Readmissions Reduction program, participating in newly formed commercial ACOs or narrow networks, managing their own employees, etc.). In these early adopter settings, it is challenging to deeply invest in FTE’s, clinical programs, and technology.
Both physician and hospital organizations will also need to address the upcoming requirements of the 2015 Medicare and CHIP Reauthorization Act which will require participation in MIPS (Medicare Incentive Based Payment System) or APM’s (Alternative Payment Models). Not participating or performing poorly across these programs could result in a loss of 9% of reimbursement. The successful implementation of these programs is firmly dependent on the participation and performance of physicians.
In my travels and meetings with physician groups and health systems around the US, several best practices seem to be emerging around physician engagement:
Education: Frequent education on a variety of topics is critical. Physicians understand clinical care. However, concepts such as ‘benchmark’, HCC (Medicare’s Hierarchical Condition Category coding), minimum savings rate, discounting, two-sided risk, attribution, utilization management, multi-disciplinary care teams, etc. were not taught in medical school or residency. A mix of mediums such as conference calls, webinars, town halls and smaller group meetings are being employed. I’ve seen organizations with staff that travel from clinic to clinic on a rotating basis (much like a pharmaceutical rep) to provide 1:1 or small group education. Physicians need to clearly understand regulatory and industry changes, the organization’s shared goals, and the personal and professional impact of these changes.
Tools: It’s important to engage physicians with informatics tools to help them improve their performance on the metrics being measured. There are a variety of supporting capabilities which include easy to access longitudinal patient records, shared care plans, and gaps in care at the point-of-care. Physicians do not have time to log into multiple systems or read multiple reports while providing patient care. Analytics must be actionable at the point-of-care. Increasingly, physicians have an expectation that this enriched patient centric information should be available while seeing a patient or working in a patient chart. In contrast, the supporting care team may also need a population level view to help with pre-visit or day of visit planning and coordination.
Compensation: The satisfaction of being considered an efficient and high quality provider fosters engagement and can create healthy competition. However, compensation can also be a powerful adjunctive motivation. The most forward thinking organizations are not only rewarding primary care physicians and specialists, but also members of the care team when pay for performance or shared savings are achieved. Organizations are also putting a certain percentage of base and or bonus compensation at risk for actively participating and or achieving quality or targets.
Culture: Ultimately, creating the right organizational culture can accelerate achievement of meaningful physician engagement. Integrating physicians into governance is very effective as most of the top performing ACOs are organized by physician groups. Equally important is for organizations to provide the necessary multi-disciplinary team support and informatics investments. Physicians are competitive by nature, and will push each other to perform if provided a meaningful, mutually agreed upon set of goals and measures.
Measurement: In my next blog post, I will explore the importance and challenges of measuring physician performance further. I will also discuss how new analytics tools can help with measurement and support discussions between clinical leadership and individual physicians.
We have moved past the uncertainty of value based care programs initiated as part of the Affordable Care Act, and are entering the next phase of healthcare transformation anchored by the 2015 MACRA. While our transition from fee- for-service to value-based care is going to be challenging, it provides a real opportunity to decelerate the unsustainable growth in healthcare spending while improving patient outcomes. Physicians have a critical role in this transformation.
As I speak with physicians around the US, they share different and insightful perspectives on their participation in population health and value-based programs and the engagement of their colleagues. If you would like to discuss how Caradigm can help you with physician engagement, then please send a note here.