PROVIDER ENGAGEMENT Building a Stronger Work Marriage Lessons in Dyad Leadership Karim Botros MetroHealth Matt Garabrant The Advisory Board Company Fred Neis The Advisory Board Company
Road Map 2 1 2 MetroHealth s New World 3 Applying The Advisory Board Company Partnership Using Data to Support Change
3 Challenges Inherent in Cleveland Market Poverty Has Hit Cleveland Hard 1 Challenging Population Growth 2 34.2% 14.9% 15.4% 4.0% USA Ohio Cleveland USA Cleveland Axis Title -3.8% Cuyahoga County ranks 65 th out of 88 counties in health outcomes in Ohio 2 Ohio ranks 40 th in health outcomes by state 2 1. US Census Bureau Quick Facts (2008 2012) 2. MetroHealth supplied data
4 Living in the Shadow of Giants The Competitive Landscape Total Facilitates 2 Physicians 2 25 10 17 11 1 17 Revenue and FTE s 1 3,500 1,500 3,000 1,700 500 0 CC UHHS MHHS $6.7 Billion CC UHHS MHHS Inpatient Outpatient Employed Affiliated 6,600 $903,153,000 39,000 24,498 $2.9 Billion MetroHealth Cleveland Clinic University Hospitals Total Employees Total Revenue 12.0% Inpatient Market Share 3 Total Beds 2 4,008 3,482 762 14.5% Ambulatory Market Share 4 CC UHHS MHHS Source: 1. 2. HealthLeaders 2015 Market Overview, Cleveland 3. OHA, 2014 4. Truven 2014 Market Estimates and EPIC 2014
5 Despite the Unique Challenges Challenging Payer Mix January September 2015 Self Pay 5.06% Community Perception Perception Reality Commercial 22.66 % 45.39 % Medicaid Public Hospital Medicare 26.89 % Anything PUBLIC has a negative connotation. It suggests FREE which means crowds, long waits, unclean and a lower quality than something you would pay for. Think about it A MetroHealth Survey Respondent Operation Margin 3.2% 2015 YTD Source: MetroHealth Monthly Financial report, September 2015
6 The Catalyst for Change New CEO Positioning MetroHealth for Optimal 10 Year Growth Redefined Mission Driving Transformation - New Campus Engaging Employees Re-branding to sway community perception Changing Strategic Direction: Running towards Population Management
7 What Wasn t Working? MetroHealth Outside Consulting Expenses $12.0 $11.0 $10.0 $9.0 $8.0 $7.0 $6.0 $5.0 $4.0 $3.0 $2.0 $7.8 M $6.9 M 1.1% 1.0% $11.6 M 1.6% $4.9 M 0.6% $3.4 M 0.4% $5.7 M 0.6% FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 (Projected) 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Total Expenses Percentage of Operating Expenses $ 6.7 M MetroHealth s Average Annual Consulting Expenses (2008 2013) yielded varying degrees of success
8 The Accelerator Phase Integrating ABC Services Around Key Strategies 1. Enhance Patient Access Across the System 2. Cost Reduction/ Revenue Maximization 3. Physician Engagement and Alignment 4. Methodology and Culture for Data Driven Decision Making 5. PCU reorganization to Service Line Structure 6. Redefine Acute Care Services 7. ACO for medically intensive population 8. Patient Experience Consulting Sourcing Consulting Technologies Research & Insights Research & Insights Consulting Research & Insights Research & Insights Technologies Technologies Engagement Survey Technologies Technologies Technologies Technologies Technologies
9 Re-Prioritization Around Emerging Strategies Medical Chair Retreat Span of Control Retreat ACO VIP Day Care Management Redesign Care Management Survey & Retreat Enhance Patient Access Patient Experience Redefine Acute Care Services PCU reorganization to Service Line Structure ACO for Medically Intensive Population Cost Reduction/ Revenue Maximization Methodology & Culture for Data Driven Decision Making Physician Engagement & Alignment Clarify & Prioritize Activities Around Emerging Strategic Goals MetroHealth Should Be a Population Health-Focused Service Line Organization
10 Prior to Service Line Model. New Leadership Clarify Strategic Direction and Develop New Structure Address Organizational Fragmentation Create Transparency with Data
11 A New Structure MetroHealth s Population Health Service Lines Requires a Dyad Structure The Best of Both Worlds Administrative Leader Optimizes the Business Business Strategy/Growth Planning Clinical Operations Management P&L Accountability Coordination with hospital functions Staff Management Physician Leader Leads Clinical Transformation Spearhead clinical strategy, develops, implements and refines new care models Acts as change agent, advocating for clinical initiatives to physician peers Tackles challenges such as care variation reduction, Attributes of High-Performing Dyads Role Definition Accountability Authority Team Player
12 Why a Dyad? Demonstrated Value Driving Increased Utilization Benefits of Dyad Leadership Hospitals Using Dyads In Leadership Roles More than the sum of it s Parts Physician Leadership Hardwired into critical areas and decisions Uses Leaders at Top of License Reduces Leader Burnout Provides Continuity 2014 Physician Leadership Survey (n=100) CQO CMO System VPMA CMIO CMO Facility Department Chair Medical Director Service Line Leader 14% 15% 21% 21% 21% 25% 32% 46% 88% Physician leaders agreed that dyads improve leadership performance and accountability
Road Map 13 1 2 MetroHealth s New World 3 Applying The Advisory Board Partnership Using Data to Support Change
14 Defining our Service Line Partnership Main Initiatives Within the ABC/MetroHealth Partnership Service Line Design and Leadership Change Service Line Strategic Planning Ongoing Service Line Performance Management Best practices for defining service line purview Leading examples of dyad leadership and service line org models On-site facilitation with MetroHealth physician leaders Service Line Market Opportunity Assessments Service line development support Strategic Planning templates to support service line dyads Performance metrics spanning fee-forservice and population health goals Framework for continually evaluating performance and market opportunity
15 Combining the Best of The Advisory Board Offerings Leveraging Expertise and Services from Multiple Areas Research Programs Cardiovascular Roundtable Oncology Roundtable Market Innovations Center Service Line Strategy Advisor Talent Development Performance Technologies Crimson Market Advantage Crimson Continuum of Care Crimson Population Risk Management Crimson Medical Group Advantage Surgery Profitability Compass Best-Practice Research Market-Leading Data Intelligence Coordinated, comprehensive support for service line design and implementation
Organizing Service Lines Around Patient-Centered Care Better Positions Services to Consumers and Enables Strategic Oversight 16 Diagnostics Service Line in Brief Prevention & Wellness Follow-Up Patient-Centered Care Pathway Medical Management Surgical Services Organizational model that enables strategic oversight of high-growth, high-profit business units Organizes services in patientcentered manner Designed to track performance, pursue growth, and coordinate care Aligned with procedural rather than medical specialists Assigns capital and marketing dollars Common Hospital Service Lines Rehab & Therapy Cardiovascular Neurosciences Cardiology Orthopedics Surgical Services Women s Services Source: Service Line Strategy Advisor research and analysis
17 Designing Leadership to Manage Population Health Enables Care Coordination, Reduces Unnecessary Variation z 3 Foundational Elements of Service Line Model 1 Leadership 2 Discrete Budget 3 Strategic Plan Leaders tasked with designing goals and strategies for success Create culture capable of implementing change Dyad model common structure, where administrator works in tandem with physician leader Allocated budget for investment and growth Spending prioritized across multiple areas including capital technology investment, facility expansion, marketing, etc. Unified plan for the service line outlining vision, priorities, profitability and growth targets, and near-term strategies to achieve growth Leverage Structure to Achieve Emerging Population Health Management Mandates Closely align with physicians Provide coordinated cross-continuum care Increase market capture through access, earlier patient identification Control total costs Ensure multidisciplinary care delivery Enhance patient satisfaction Source: Service Line Strategy Advisor research and analysis.
18 Purview Expands as Cases Shift out of Hospital Care Setting Spectrum Hospital Inpatient Department Hospital Outpatient Department Freestanding Outpatient Center MetroHealth Facilities: MetroHealth Medical Center Length of Stay: More than 24 hours Billing Codes: MS-DRG Sample Service Offerings: Obstetric delivery Hysterectomy Inpatient psychiatric admission MetroHealth Facilities: Outpatient Plaza Length of Stay: Less than 24 hours Billing Codes: CPT Sample Service Offerings: Antenatal testing Artificial insemination / in vitro fertilization Endometrial ablation MetroHealth Facilities: 16 Health and Surgery Centers Length of stay: Less than 24 hours Billing Codes: CPT Sample Service Offerings: Psychotherapy Oral function / speech therapy Vision exam More Complex Care Less Complex Care
19 Evaluating Performance Through Two Lenses Methodology for Assessing Service Line Performance Evaluating Service Line Performance Market Position Market Share Measures reach of service line and capture of procedure volumes Volume and Financial Performance Measures hospital volume trends and per case profitability Future Demand Identifies future market opportunity Care Continuum Management Access and Service Excellence Measures patient and physician loyalty through accessible, convenient services Clinical Performance Measures quality of care during acute episode Episodic Value Measures ability to manage care across the continuum Fee-for-Service Payment Model Risk-Based Payment Model
20 Supporting Performance Across the Continuum The Advisory Board Service Line Assessments Snapshot Pre-Acute Acute Acute Post-Acute Post-Acute Scope of Services Early detection (i.e. PHQ-9 depression screening) Social support services Medication management Psychotherapy Inpatient mental health care Electroconvulsive therapy Rehab Community therapy Case management Access and Service Excellence Percent of behavioral health revenue from loyal PCPs 2 : 74% Percent of revenue from loyal physicians 3 : 100% Discharge rate to psychiatric unit: 7% Discharge rate to home health: 7% Clinical Performance Hospital acquired conditions (per 1000): 2.08 (10.88) Complication rate: 0.55% (0.35%) Average LOS: 6.33 days (7.12) Mortality rate: 0.90% (0.49%) Return-to-home: 80% Episode Value Readmissions rate of all patients: 11.51% (11.83%) Readmissions rate of patients discharged to home: 8.07% (11.38%) Readmissions rate of patients transferred to psych unit: 52.63% (15.42%) Readmissions rate of patients discharged to home health: 8.42% (11.73%) Source: MetroHealth Family Care Service Line Assessment, May 2015
Road Map 21 1 2 MetroHealth s New World Applying The Advisory Board Partnership 3 Using Data to Support Change
22 Not Seeing the Forest for the Trees MetroHealth Awash in Points of Data Direct Costs ICU LOS ALOS Readmissions Discharges Observation Patients Surgical Site Infection Rate Employee Engagement Regrettable Staff Turnover CORE Measures Call Center Abandonment Rate Time to first appointment Patient Satisfaction Budget Variation Referrals by Procedure Documentation Compliance Inpatient Market Share Outpatient Market Share
23 Lacking a Holistic View of Performance Quality Department Finance Department National Quality Measures FY 14 Revenue Cost Profitability Operating Room OR Turnover Ambulatory Measures Access
24 Considerations for Metric Selection z Meaningfulness Reliability Collection Feasibility Description: Selected metrics should align with service line and hospital-wide organizational goals Rational: Misalignment may stunt service line or organizational growth Inadequate resources or support allocated Description: Data should be accurate, clearly defined and measure what s intended Rational: Absence in trustworthy data resulted in skepticism of performance variances promotes inaction Description: Process should be manageable and repeatable given institution resources Rational: Laborious manual calculations not productive use of resources Electronic sources that can t be queried do not yield trustworthy metrics Description: z Communicability Definition and rationale should be easy to understand Rational: Lack of clarity and relevance hinders decision-making Description Scientific Support Metrics should be rooted in evidence based literature Rational: Questions or controversy over clinical validity encourages physician resistance
25 A Comprehensive Measure of Performance Market Position Finance Experience Clinical Performance Operations Service Line Profitability Satisfaction Public Reporting Total volumes Volumes of key procedures Patient geographic origin Surgeries per OR Payer mix Revenues Contribution margin per case Cost per discharge Staff turnover Patient satisfaction Specialist satisfaction Employee satisfaction JCAHO 2 patient safety metrics Never Events Mortality rates ALOS 1 Share of Continuum Episode Value Service Quality Evidence- Based Care Outmigration of complex, niche downstream services Patient referral origin Referring physician loyalty Readmissions rates Variation from Medicare cost-perdischarge benchmark for 30, 60, 90-day episode Time to first available specialist appointment Patient likelihood to recommend Use of observation status Ratio of ICD 3 and PCI 4 patients that do not meet guideline criteria 1) Average length of stay. 2) Joint Commission on Accreditation of Healthcare Organizations. 3) Implantable Cardioverter Defibrillator. 4) Percutaneous Coronary Intervention. Source: Marketing and Planning Leadership Council interviews and analysis.