Stakeholder Engagement Governance Model for Engaging Physicians Helen Macfie, Pharm.D., FABC For IHI Leading Population Heath Transformation February, 2017
Strategic Focus & Evolution Two decades of testing & learning
Engaging physician leaders Physicians as Partners same, together BUILDING WILL Shared learning Deep Dives 2012, 2014 Site visits, study teams Leadership Retreats Triple AIM Big names Ambulatory diversification Medical Foundation Sites of care Executive sponsors Population Health Clinical Integration Continued messaging
Physician voice & governance STRATEGIC INVOLVEMENT 1. Physician Society 2. Best Practice Teams 3. Physician Leadership Academy 4. MC*21 Informatics 5. MC*21 Lean Management System 6. Medical Foundation & ACOs 7. Ambulatory Services 8. Clinical Integration & BPCI 9. And Research Newest: Dialysis An Affiliate of Fresenius
Strategic Plan FY 17 Pyramid Key linkages to Population Health A. Develop and implement plan to respond to consumerism B. Advance population health roadmap for alternative payment models A. Implement plans to address Bold Goals for quality & amazing patient experience B. Realize benefits of a fully integrated leadership structure for key ancillary and clinical services C. Identify and implement new metrics to measure population health outcomes and link our community benefit programs A. Expand strategic health plan partnerships and relationships B. Grow and successfully manage MCMF at-risk lives to 250K C. Monitor and evolve Medi-Cal approach D. Advance diversified plan for ambulatory services A. Strengthen connections with independent and group practice physicians B. Grow both divisions of MCMF, maximize capacity for all sites new and existing C. Enhance MemorialCare/IPA physician partnership A. Activate Playing to Win strategies for CHLB B. Activate Playing to Win strategies for SMMC-SC A. Advance programs to foster world-class managers B. Resource the Plan
Physicians as Partners FIVE-YEAR VISION: MemorialCare has leadership and partnership models in place to optimize working relationships and alignment opportunities with our physicians. THREE-YEAR STRATEGY: Optimize our pluralistic model for physician alignment.
Physicians as Partners The power of the Physician Society The Physician Society Growth in Membership 95% of admissions Responsibilities Professional association. Board level. Committed to development and utilization of evidence-based/best practice medicine Lead development of best practice Implement best practice guidelines at the bedside / visit-side Leadership of physician informatics and outcomes 20 Years of Innovation Over 300 Best Practice guidelines Best Practice Teams, multidisciplinary Ambulatory Anesthesia Blood Use Breast Care Antimicrobial Stewardship Cardiac Colorectal Emergency Imaging Neonatology Orthopedics Palliative Care Pediatrics Pulmonary & Critical Care Sepsis Stroke Women s Health Wound Care
MemorialCare s Bold Goals For Safety, by June 2017 Reduce mortality Severe sepsis mortality by >70 % Achieve perfect care Core Measure sets all diagnoses/bundles to > 95% Medication Reconciliation metrics: all 3-90% Reduce harm to Zero Zone Hospital acquired infections (HAI) Achieve 100% hand hygiene compliance Hospital acquired pressure ulcers (HAPU) Patient falls with injury Harm Across the Board by > 80% Promote Population Health NTSV C-Section rate to < 15% Medical Foundation goals to top 10 th percentile Screening breast and colorectal; diabetes care HbA1c < 8, generic prescribing rate, childhood immunizations (combo 10)
History of shared accountability Harm Across the Board 15,668 Bold Goals: Lives Touched 73% Just HEN HAB* *Hospital Engagement Network definition includes Warfarin with INR > 6, Early Elective Delivery, Fall with Injury, Pressure Ulcer 2+, ICU Catheter Associated UTIs and Central Line Blood Stream Infections, Surgical Site Infections, Ventilator Pneumonias, and Pediatric Harm
Cascaded strategic focus Physician Society Strategic Plan A. Develop new communication models for internal campaigns, education and initiatives A. Lead focus on Overdiagnosis & Overtreatment 2.0 B. Build awareness of red pill, blue pill transparency C. Achieve Medication Reconciliation 90% A. Support evolution of new payment models B. Readiness for Physician Value-Based Payment A. Integrate onboarding process for membership B. Sponsor refinements to CVO services C. Foster use of Physician Data A. Foster engagement of younger physicians in new and existing areas of leadership B. Support expansion of clinical Integration C. Activate EMR Optimization A. Launch MemorialCare Experience for staff and physicians
Use Case: Best Practice Teams Addressing the opioid epidemic AMBULATORY & INPATIENT Identification of patients at risk EMR automation (Smart Set) Developing consistency in CURES 2.0 use, Controlled Substance Agreements, and Urine Drug Screens Embedding provider education (EHR Best Practice Alert) Participation in advocacy and collaboratives Data warehouse, push reports 5.6% patients with MME>90 (for at least 1 day over 3 months) Excluding cancer, palliative care Site Medical Directors, individual physician reports
Medical Foundation Creating pluralistic options INTEGRATING CARE DELIVERY & OVERSIGHT Medical Group and IPA Foundation model Primary care (31 offices) chassis and specialist network Partnerships UC Irvine Health Ambulatory Services Revenue diversification & strategic partnerships Joint venture opportunities Site neutral payment advocacy And ACOs R Us 0-93K in one year, 261K total Bold Goal 500K by 2021
Medical Foundation structure Physician voice in governance
Use Case: Ease of access Site neutral care in the right setting MOVING CARE SLOWLY BUT SURELY Case for change & advocacy Building ambulatory capacity Shared savings opportunities
Healthcare Value VALUE If Value = Quality Cost, what happens when we provide lots of services that don t help patients? Cost goes up Quality remains unchanged (at best) or worsens (harm), and Value declines
Use Case: Overdiagnosis Making people sick in the pursuit of health PHYSICIAN SOCIETY BOARD Stewards of precious resources Definition: The diagnosis of a condition or abnormality which will, if left alone, never cause symptoms, complications, or shortened life Understanding absolute Number Needed to Treat, or Harm, vs relative
How to Overdiagnose? 1. First, change the rules H. Gilbert Gil Welch, M.D. Author of Overdiagnosed 2. Improve technologies to see more 3. Look harder 4. Stumble onto incidental findings
How Medical Literature Overinflates Benefits 75% Reduction in Mortality!...? RRR: Relative Risk Reduction the relative reduction in adverse outcome with a given treatment Odds Ratio (OR) and Risk Ratio (RR): fractional relationship of an exposure to an outcome ARR: The absolute reduction in likelihood of the adverse outcome NNT: How many patients you have to treat to achieve the desired outcome, or to avoid the undesired outcome/harm (NNTB, NNTH) POEMs: Patient-Oriented Endpoints that Matter Assume: Mortality in Control Group 4% Mortality in Treatment Group 1% RRR = 75% (4%-1%) 4% OR: 0.2424 RR: 0.25 ARR = 3% (4% - 1%) NNT = 33.3 1 ARR = 1 0.03 Will diagnosis/treatment help me avoid suffering or death?
PREVNAR - The CAPiTa Trial TAKE A CLOSER LOOK 84,500 patients in the Netherlands Exclusion: Prior pneumococcal vaccination Mean follow-up for VT-CAP or VT- IPD was ~ 4 years Relative Risk Reduction (RRR) for VT-CAP (reported) 45.56% Absolute Risk Reduction (ARR not reported) 0.097% No difference in mortality (7.1%) NNT to prevent one case of pneumonia in 4 years: 1,030 (also not reported)
How most studies are presented Pulling the wool over our eyes POEMs: Patient-Oriented Endpoints that Matter Relative Risk Reduction Surrogate Measure Odds Ratio Blood pressure lowering Risk Ratio Relative Risk Ratio Measures that Matter Heart attack, Heart Failure, Stroke, Kidney Failure, Death What truly matters: NNTB, Heart NNTH, attack, POEMs, Stroke, Death and $/POEM LDL Cholesterol Lowering Blood Sugar or HbA1c Heart Attack, Kidney Failure, Vision loss, Limb loss, Death
How to inform yourself www.thennt.com
Overdiagnosis successes Physician Society roadmap ADVOCACY & ACTION Broad discussions across physician, leadership, employers, payors and other leadership groups about Overdiagnosis and Number Needed to Test or Treat to obtain benefit Increasing focus on POEMs Patient-Oriented Endpoints that Matter Implemented Choosing Wisely analytics & alerts Leveraging analytics for more sophisticated alerts Advocating with organizations promulgating P4P measures That promote overdiagnosis and overtreatment Requiring our research be published Hope for precision medicine www.thennt.com
Key lessons? LESSONS LEARNED Benefits of ensuring physicians have voice in ALL governance and leadership focus Physicians as Partners strategy resonates Resourcing and activating the commitment