Experience the Eide Bailly Difference Physician Engagement: Are Physicians a Full Partner in Care Management? ICAHN: 2013 Annual CAH Conference
Learning Objectives Understand distinctions between physician ALIGNMENT and ENGAGEMENT Provide diagnostic tools to assess physician readiness for clinical care coordination/interaction Define clinical care coordination/integration and emerging models and reimbursement scenarios
Goals of Population-Based Models Achieve best possible quality at minimum necessary cost Shift provider s mindsets from the patient in front of them to the population for whom they are responsible Create effective collaborations across settings of care (e.g., PCPs and specialists) Reduce unnecessary hospital admissions/er visits through proactive outbound care Improve wellness and preventative care Source: Objective Health The Road to Population Health: Key Enablers In Implementing Value-Based Models Webinar January 23, 2013 4
Medical Care and Health Care Defined Given only one choice, what would you choose? A doctor/clinic with better health care rankings OR A doctor/clinic with better medical care quality rankings The Merriam Webster dictionary defines health as the state of being free from illness or injury It defines medical care as the science of practice of diagnosis, treatment, and prevention of disease Source: Minnesota Physician Magazine Medical Care and Health Care An Avoidable Conflict E. John English, MD 5
Differentiating Between Health Care and Medical Care Health care is a population-based approach designed to improve everyone s well-being. It s prevention, pure, and simple. It is a public health-centered, top-down approach that traditionally has been the responsibility of the state. Medical care is completely different. It is an individual-based method to restore, maintain, or improve an individual s wellbeing. It is highly personal and is, in fact, usually attained one person at a time. It is a hands-on, bottom-up approach. It is diagnosis- and treatment-centered. At some point in everyone s life, it is desired, demanded, and sought out basically after the preventative measures have failed. Source: Minnesota Physician Magazine Medical Care and Health Care An Avoidable Conflict E. John English, MD 6
Achieving Desired/Achievable Health 7
The Imperative for Change Patients expect quality and seek service Technical competence alone is no longer sufficient for medical/health care success today Employers and payers both demand value Increasing costs are driving employers to shop for value and payers to Pay-for Performance Physicians are a scarce resource The ability to attract, recruit, and retain technically and behaviorally skilled MDs is an extreme challenge Margins are slim and getting slimmer The imperative to deliver quality, service, value, and physician and staff satisfaction, with minimal resources, requires a very sophisticated corporate strategy
What Health Care Leaders Are Saying Demands for efficiency and quality improvement often conflict. - chief operations officer for a hospital Physicians resist initiatives that require additional documentation. - director of ambulatory services for a hospital Assuming the increasing numbers of insured belong to payers that are reimbursing collectively less, I would anticipate that physicians will see increasing value in the security provided by hospital employment. - Vice president of operations/administration for a hospital Source: HealthLeaders/Intelligence
What Health Care Leaders Are Saying Collaboration between hospitals and physicians will be the only way to survive. - service line director for a hospital Physicians may be looking for additional support from hospitals to help with the patient influx. My hospital is willing to consider ways to improve alignment. - medical director for a hospital Less reimbursement and threat of increased or enforced penalties has already led to hospital demands of physician documentation practices. Even the electronic entering of physician orders is meet with tremendous whining of the medical and nursing staff. - chief of staff, health system Source: HealthLeaders/Intelligence
Physician Engagement Successful physician alignment cannot be achieved without effective physician engagement: Is ongoing, continuous, and long term process Involves listening to and deliberating with members of the medical staff; please help us design better processes Uses a variety of strategies to reach all physicians Sees to find common ground among stakeholders What IT S NOT A quick fix to a problem or issue A research tool or survey A forum for debate A publicity method A strategy for educating or persuading people Alignment: coordinated approach to deliver project outcome Engagement: alignment plus PASSIONATE, PRO- ACTIVE
Physician/Hospital Alignment: Key Trends Historical alignment overview Hospital acquire new market share Physician income security and growth working capital and career stability The current physician perspective Security for career and monetary gain, subject to fair market value parameters Larger medical groups are not rushing to hospital employment, but rather seek clinical integration structures under systems of care Institutional investors become a viable capital partner for larger groups, Max Reiboldt, CPA Source: Source: Coker Group Holdings, August 30, 2013 Reported in BECKER S HOSPITAL REVIEW 12
Physician/Hospital Alignment: Key Trends Payers are becoming investors in physician practice Clinically integrated networks (CIN) (e.g., ACOs) Greater interest in consolidations: size matters The current hospital perspective Integrated delivery system development will continue; more economic partnering A pluralistic approach to alignment to include PSAs, co-management, clinically integrated networks, etc. Source: Source: Coker Group Holdings, August 30, 2013 Reported in BECKER S HOSPITAL REVIEW 13
Physician/Hospital Alignment: Key Trends Many health systems have completed Stage I organizational alignment now moving to Stage II ACA driven clinical integration through ACOs and CINs Compensation designs are including care management, enhance quality, and cost control metrics (in addition to traditional professional volume incentives) Governance/leadership structures are moving toward DYAD model (lead MD/DO and Adm); function like partners, not adversaries Hospital hospital consolidations will continue; smaller entities will be re-purposed Source: Source: Coker Group Holdings, August 30, 2013 Reported in BECKER S HOSPITAL REVIEW 14
Physician/Hospital Alignment: Key Trends The Future 2013 PPACA will have extensions and implementation changes as politics continue to play out Clinical care integration (Stage II above) will become the alignment norm Physician pay plans will continue to move from fee for volume to fee for value Measuring value outcomes for care delivery processes will increase with fee bundling, shared savings, and capitation reimbursement changes Summary Industry evolution will focus on physician/hospital alignment and clinical integration Source: Source: Coker Group Holdings, August 30, 2013 Reported in BECKER S HOSPITAL REVIEW 15
Signs of Troubled Physician Engagement 1. Lack of confidence and trust between physicians and hospital Why? Perception that Administration does not focus on assigned projects, team initiatives or cultural improvements. 2. Too many changes made without physician input Failure to solicit, incorporate or recognize operational and process flow initiatives may impact a physicians preferred practice style. 3. No physician champions: often, it takes a licensed colleague to persuade another colleague, especially if behavioral change is desired Source: Becker s Hospital Review, August 20, 2013: Author-Molly Gamble 16
Signs of Troubled Physician Engagement 4. Physicians do not receive meaningful feedback Feedback data on own performance of patient experience data is missing 60-75% of time. 5. Leaders do not create shared levels of accountability across the entire organization (?) input on charge nurse or unit manager s performance; physicians may desire input on performance metrics and goals. 6. Little evidence-based best practice data Physicians are driven by data, without it, desired clinical, quality or operational outcomes are not likely. Source: Becker s Hospital Review, August 20, 2013: Author-Molly Gamble 17
Signs of Troubled Physician Engagement 7. Lack of recognition and rewards Go to physicians with BOTH problem AND solution(s) and acknowledge their role in implemented solutions 8. Lack of adherence to agreed-upon standards Walk the talk of threatened accountability; if C-suite get by, physicians follow similarity 9. Not managing disruptive behavior Recognize the vast majority of cooperative physicians by defining, correcting ANY disruptive behavior (training needed!). 10. Lack of an aligned vision across organization No road-map will lead to wherever you end up. Set expectations and feedback mechanisms for physician behaviors. Source: Becker s Hospital Review, August 20, 2013: Author-Molly Gamble 18
Tools for Assessing Physician Engagement Readiness for Change Assessment Tool: abbreviated tool to access physician s readiness Focus Groups: structured focus groups designed to gain understanding to physicians attitudes, beliefs and behaviors about CIS and CPOE and begin to educate physicians about what is possible Interviews: individual and group interviews with medical staff members Clinical Systems Survey: paper or web-based detailed questionnaire on attitudes, beliefs and behaviors about computerized physician order entry Source: Dr. Scott Cullen, Accenture
Tools for Assessing Physician Engagement Hospital/Medical Staff Relationship Scorecard: summary assessment grid evaluating overall state of relationships between medical staff and hospital or system and its leadership Medical Management Survey: detailed questionnaire about knowledge, attitudes and behaviors regarding medical management and resource utilization Accelerated Solutions Environment: Cap Gemini Ernst & Young setting dedicated to rapid of solutions for organizations Source: Dr. Scott Cullen, Accenture
The Point If you only ask opinion, you foreclose future participation then and there Doctors often feel that once they provide you a resolution according to their opinion, it s your job to fix the problem and their involvement is no longer necessary. It s critical how you phrase the question. Rather than say, What do you think? say, What can we do together to pursue an objective we both agree would be in our mutual best interest? Source: Dr. Joseph Bujak, Kootenai Medical Center
A Physician Engagement Framework Find common ground and shared purpose. Find the opportunities for the mutual exchange of value. A Partnershi p Respect physician s time. Provide good data and respectful feedback.
Clinical Integration Defined Clinical delivery of care, technology, and operations are interactive processes, with technology being the enabler. Clinical processes should really be our primary focus, above and beyond technology. Patient satisfaction AND clinical care coordination are both the goal and achievement for EVERY episode of care!
Care Coordination Physician led health care teams Patient assessments Defined clinical care plans Data shared between providers Medication reconciliation at every step Informed patients fully engaged in care decisions Patient navigators/case management-nurse teams handling transitions in care Care team providing follow up and education on red flags
Clinical Care Management Operationalized Developing evidence based care practices Deciding factors why should a physician pursue common care practices? Improve clinical outcomes; achieve more consistency in outcomes across the practice Reduce cost, removing unnecessary variability of clinical practice Maximize opportunity for reimbursement Better position for negotiations with payers(s) Position for participation within an accountable care organization
Clinical Care Management Operationalized Developing evidence based care practices Suggested approach to clinical care management Utilize an incremental approach that focuses initially on one (two at most) clinical specialty that represents high volume, high cost and or significant revenue for the practice Establish a work team consisting of the physicians and other clinicians (involved with care delivery of that specialty). Review and analyze existing information related to two or three high volume procedures (ambulatory and or acute care initially): administrative and clinical care practices
Clinical Care Management Operationalized Developing evidence based care practices Suggested approach to clinical care management Look for opportunities to develop consistency in the care practice that results in: reduced variability, reduce cost, improved clinical outcome Identify a desired care practice using existing experiences as well as evidence based third party data Model the clinical and financial impact to the overall practice if the desired care practice was implemented across the practice Develop an approach for deployment of new care practice across the specialty practice Present recommendation and deployment methodology to broader physicians (targeted specialty) for review and approval
The Major Problems in Care Coordination Include Electronic systems that can t talk to each other Poor communication about patients among health care providers Lack of access to patient information Redundant data capture and communication efforts Lost or forgotten orders and missing results Inefficient scheduling Complicated and time-consuming point-of-service collections Mismatched claims for same-patient treatments from ordering provider and facility Improper coding resulting in denials and resubmissions Source: Athena Health Whitepaper: Making Care Coordination Work: A Sustainable Model to Benefit the Whole Community, February 2012
Care Coordination Benefits With an effective model for care coordination in place, health systems can benefit from Increased referrals/order Improved revenue and hospital utilization Lower cost of IT infrastructure Improved margins Increased patient satisfaction Greater visibility into and understanding of referral patterns Increased market share Simplified, streamlined go-to-market strategy to coordinate care with community physicians Incremental acquisitions replaced by more effective physician outreach Source: Athena Health Whitepaper: Making Care Coordination Work: A Sustainable Model to Benefit the Whole Community, February 2012
Fast-Track Start 0-3 months Physicians largely resistant to change Limited physician-hospital collaboration Traditional medical directorships, but no real teambased care or co-management of clinical services 3-6 months Several service-line co-management arrangements in place Physician-centric hospital-sponsored medical group structure functioning Joint physician-hospital planning committee in place Source: Becker s Hospital Review
Fast-Track Start 6-12 months Additional service-line co-management arrangements crafted Pluralistic physician-hospital governance structure in place Task force to start work on the design of the ultimate CIO 12-18 months The CIO is fully operational, but the clinical model continues to evolve Initial VBP payer contracts are being negotiated 18 months and beyond The ability to deliver superior performance; quality/cost quantitative metrics in place Capable of managing full risk for a population or product Source: Becker s Hospital Review
Past Consumer Model of Health Care Acute Care Primary Care Patient Specialty Care Post Acute Care
Past Consumer Model of Health Care Centered on the consumer This means the consumer has the ultimate responsibility not the providers or the payers Problems Comprehensive understanding of complex medical issues required Consumer typically sheltered from financial responsibility Patient must aggregate and share clinical information with providers in order to maintain care continuum
Healthcare Reform Aim Better health for populations Better care for individuals Lower growth in healthcare expenditures Provider
Future (Current) Consumer Model Acute Care Patient Primary Care Physicians Care Management Team Specialty Care Post- Acute Care
The Changing Delivery Model Focus is on centering patient care management on primary care practices Develop IT infrastructure to allow sharing of information Tier patients into chronic categories and develop care plans Identify acute episodes and coordinate them Emphasis on evidence based medicine and clinical decision support Integration of mental health Preventive care becoming major focus
The Changing Delivery Model Changes in the Acute Care model Transition to outpatient medicine Changes in observation care Managing patient length of stays Inpatient medicine subjected to increasing scrutiny: HACs, quality metrics, readmissions Increase in hospitalist practice of medicine Managing the transition to post-acute Community hospitals becoming teaching facilities
The Changing Delivery Model Post-acute care standardizing and shifting toward home Increasing data on widely varying practices of post-acute care Search by payers for best practices in post-acute care Post-acute care becoming vendors in new models Manage the patient at home where possible
Patient Centered Medical Home Numerous projects funded around patient centered medical home by the CMS Innovation Center Projects on-going in numerous states with commercial payers
Patient Centered Medical Home Sometimes referred to as Advanced Primary Care (APC) practices Programs pay additional fees to help cover care coordination, improved access, patient education, and preventive services Target chronically ill individuals or special needs populations
Patient Centered Medical Home As defined for CMS demonstration physicians that are eligible for a patient centered medical home Internal Medicine General Practice Family Practice Geriatrics Excludes Radiology, Pathology, Anesthesiology, Dermatology, Ophthalmology, Emergency Medicine, Chiropractic, Psychiatry, and Surgery
Patient Centered Medical Home Advanced Primary Care Practice Demonstration and FQHC APC Demonstration Medical Homes broken into 2 tiers Tier 1 Physician led health care team Integrated care plan Medication reconciliation Use of evidence based medicine and clinical decision support Health assessment 7 day per week / 24 hour phone triage
Patient Centered Medical Home Tier 2 Meets Tier 1 requirements Also uses Electronic Health Records and coordination of care and follow for IP and OP care Choose from selected other measures
Current Payment Model Patient Purchaser Payer Provider
Payment Reform Payers moving from paying for procedures to population care Payment on population care means Per Beneficiary Per Year (PBPY) Cost/Payments Centered around primary care Seeks to pay for quality care and a healthier population instead of a massive, fragmented health care industry competing for market share in procedures
Payment Reform Two Major Trends Payers experimenting with different payment methodologies Focus on paying for outcomes in acute care and management in primary care Preference among payers to pay providers like they are paid globally Patients paying more for their care, but adjusted for income levels Increase in deductibles and coinsurances Push from ACA to make insurance affordable
Payment Models Changing Fee for Service Global Payments (ACOs) Medical Home Payments Bundled Payments Value Based Purchasing
Patients Paying More
Patient Centered Medical Home Payments for PCMH vary by program but include: Per member per month payments Shared savings arrangements Payment for performance
Value Based Purchasing Payers insisting on payment increases in the future tied to quality Patient Experience Quality Outcomes Clinical Care Guidelines Cost of Care
Bundled (Episodic) Care Payments Industry already has bundled payments DRGs and APCs Expansions in the definition of bundles largely driven by CMS and CMMI Employers are looking to purchase bundles Wal-mart and Lowe s
Global Payments (ACOs) About 10% of Traditional Medicare beneficiaries assigned to ACOs Medicare Advantage plans have numerous global payment arrangements expanding Medicaid in many states working on global payment initiatives Commercial payers most interested in global payments
Takeaways Alignment is good: ENGAGEMENT is great Attachment: Ready for Clinical Integration? Emerging Care Models: PCMH and Care Transitions Payers shifting to Value and Patients paying larger percentage Plan your transition potentially 2 years Start talking to Payers: Payment Models must change with Care Models
Questions Presented by: Perry R Hanson, MHA Director of Health Care Organizational Consulting 612-253-6697 phanson@eidebailly.com Ryan White Senior Manager 224-612-1330 rwhite@eidebailly.com