From Private Practice to an Integrated Health System: Playing to Your Strengths

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Logan Briggs
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1 From Private Practice to an Integrated Health System: Playing to Your Strengths Mark Schickendantz, MD Director, Cleveland Clinic Center for Sports Health Associate Professor of Surgery, Cleveland Clinic Lerner College of Medicine Head Team Physician, Cleveland Indians

3 Why Integrated Health Care Delivery Systems (IDS)? Current US healthcare system is: Fragmented Complex Expensive Highly variable quality The goal of an IDS is: Delivery of high quality, cost effective care Address the health care needs of the community

4 Volume vs. Value Current volume-based payment system (fee for service) rewards more work Supports fragmentation; inhibits integration Value-based payment systems (pay for performance) rewards quality work Supports integration; coordinated, patient centered care

5 Health Care Delivery Models Approximately 850 IDS s presently in the US Most are evolving along this continuum

6 What is an IDS? A network of organizations that provides a coordinated continuum of services to a defined population and is willing to be held fiscally and clinically accountable for the outcomes and health status of the populations served American Journal of Managed Care 2013 Patient centered Improved patient experience Increased communication, information sharing Address community health care needs

7 Integrated System Acute Care Acuity Community-Based Care Hospital Family Health & Surgery Center Urgent Care Inpatient Rehab Wellness / Fitness Center Home Physician Clinics Retail Pharmacy Diagnostic / Imaging Center Skilled Nursing Facility Outpatient Rehab Home Care Recovery and Rehab Care

9 What are the keys to success? It s not size or specific structure that matters. Rather, it is.. An organizational commitment to, and a culture of, continuous quality improvement that is most closely linked to better performance as measured by clinical quality, patient satisfaction, organizational learning and financial performance Shortell, 2005, Med Care Res Rev

10 In order to be successful, Integrated Health Care Systems must: Attract the best qualified medical, scientific, and support staff Excel in specialized medical care supported by comprehensive research and education Develop, apply, evaluate and share new technology Excel in service Provide efficient access to affordable medical care Ensure that quality underlies every decision The Cleveland Clinic Way

11 What are the barriers to success? 3 General Categories: Operational Governance Cultural All have the potential to de-rail the process

12 Operational Barriers Multispecialty groups are difficult to form due to income disparity of various specialties. There is a lack of payment methodologies that promote group function. Competition exists between hospitals and physician groups. Hospitals have different business cultures than physician groups. A lack of consistent quality performance measures exists for hospitals and physicians. Different information systems exist. Some physicians cannot see the value in integration.

13 Governance Barriers There are usually two forms of governance within hospitals that have competing priorities and cultures the hospital board and the medical staff leadership. Hospital board members typically lack a health care background or clinical expertise and are not prepared to evaluate quality issues. Because of its loose structure and emphasis on individual physician interests, medical staff governance is not well suited to promoting collective responsibility for quality and operational efficiency. Commonly, medical staff leaders cannot render decisions on important policy and organizational matters in a timely manner because they require support of all or most of the physicians.

14 Cultural Barriers A high degree of competition in the local health care market creates unfavorable conditions for hospital and physician alignment. Physician practices do not typically engage in formal, long-term strategic planning, and small practices do not usually participate in continuous quality improvement. Hospital leaders work in meetings, but physicians value time spent in direct patient care.

18 What About Quality IDS s have demonstrated improved quality of care: Lower: admission rates Length of stay Adverse outcomes Improved: Chronic disease management DM, HTN, CHF Higher: use of EBM use of preventative care Newhouse; Int J Integ Care 2003 Rittenhouse; Med Care Res Rev 2010 Ramalho; J Manged Care Pharm 2010

19 What About Cost There is a positive correlation between integration and high performance on quality measures However, no correlation between high performance on quality measures and financial performance has been demonstrated Utilization of services has been lower in some systems (appropriate?) Integration has not been shown to reduce the cost of services Weeks, 2010; McCarty 2009

20 Medscape 2015 Physician Survey

21 Current Employment Trends

22 AAOS Department of Research and Scientific Affairs: Orthopaedic Practice in the U.S American Academy of Orthopaedic Surgeons. Rosemont IL.

23 AAOS Department of Research and Scientific Affairs: Orthopaedic Practice in the U.S American Academy of Orthopaedic Surgeons. Rosemont IL.

24 Salary: Employed vs. Self Employed 27.5 %

25 AAOS Department of Research and Scientific Affairs: Orthopaedic Practice in the U.S American Academy of Orthopaedic Surgeons. Rosemont IL.

26 Play to your Strengths to Avoid Dissatisfaction

27 Your Potential Strengths Clinical and surgical excellence Academic expertise/leadership Political/Organizational skills Clinical and basic science research Team/event physician participation Innovation Community service Business acumen

28 Private/Small Group Practice Advantages Business Ownership Autonomy Control Schedule Vacation Meeting Income potential Ancillary ownership PT Imaging ASC

29 Private/Small Group Disadvantages Limited resources, time and incentive for research Limited resources, time and incentive for education Financial responsibility Malpractice cost/exposure Time commitment to running the practice/business

Integrated Health System Advantages Availability of other medical specialists Support for academic activities Support for research activities

30 Integrated Health System Advantages Availability of other medical specialists Support for academic activities Support for research activities Personnel Financial Time Resources Focus on practicing medicine, not running a business Malpractice coverage/legal protection Financial security

31 Final Thoughts Current economic and political climate supports the development of IDS s Integrated Delivery Systems are growing in size and number Physicians are trending toward employment models of practice, even though self employed physicians in general take home more salary An honest assessment of your strengths is required in order to make a solid decision regarding the best situation for you as an individual practitioner

32 Ultrasound*of*the*Ankle*and*Foot* Thank You!

ACOs: California Style

ACOs: California Style ACO Congress John E. Jenrette, M.D. Chief Executive Officer Sharp Community Medical Group November 2, 2011 California Style California Style A CO California Style California Style