building a magnet physician enterprise€¦ · value maximizers • size of reward is what matters...
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BOSTON | CHICAGO | HOUSTON | MIAMI | SAN FRANCISCO | WASHINGTON, DC
Building a Magnet Physician Enterprise
David Fairchild, MD, MPHDirector, BDC Advisors
Professor of Medicine, UMass Medical School
Arkansas Chapter HFMA Meeting April 11, 2019
Copyright © 2019 BDC Advisors, LLC. All rights reserved.2
Today’s Discussion
1. Context
2. Attributes of a High Performance Physician Enterprise
3. What we are seeing (where med groups fall short)
4. The importance of physician engagement
5. Assessing the organization
Copyright © 2019 BDC Advisors, LLC. All rights reserved.3
Source: Avalere Health, Updated Physician Practice Acquisition Study: National and Regional Changes in Physician Employment, 2012-2016, Physicians Advocacy Institute, March 2018.
Percentage of Hospital-Employed Physicians (U.S) 2012 – 2016
Perc
enta
ge
0
5
10
15
20
25
30
35
40
45
2012 2013 2014 2015 2016
As physicians shift away from independent practice to employed status, an attractive work environment is critical for recruitment and retention
Copyright © 2019 BDC Advisors, LLC. All rights reserved.4
Source: AAMC 2018 Update. The Complexities of Physician Supply and Demand: Projections from 2016 to 2030
Predicted significant shortfalls will increase competition for top physicians
Total Projected Physician Shortfall Range, 2016−2030
“…The 25th to 75th percentile of the shortage projections continues to
reflect a likely range for the
projected adequacy of physician supply. The projected shortfall of
total physicians in 2030 is between 42,600 and
121,300…”
Copyright © 2019 BDC Advisors, LLC. All rights reserved.5
Source: Frieberg, M.W., Chen, P.G., Van Busum, K.R., et al., Factors Affecting Physician Professional Satisfaction and Their Implicationsfor Patient Care, Health Systems, and Health Policy, RAND Corporation, December 2014.
Rand Study Found 4 Elements Associated with Provider Satisfaction
• Providing high quality care
• EHRs: they help improve the quality of care and the tracking of quality, but this comes at a price…provider frustration with “documentation” requirements that take away from dr-pt experience
• “Fair, transparent and aligned” compensation associated with higher satisfaction
• Cumulative burden of external regulations and rules (meaningful use, coding rules, etc)
Physician satisfaction is critical for provider engagementand
Engaged providers will be at the center of high performing physician groups
Copyright © 2019 BDC Advisors, LLC. All rights reserved.
Medscape National Physician Burnout, Depression & Suicide Report 2019
Physician Burnout: a concerning problem, getting worse
Percent of US MDs reporting 1+
symptom of burnout
2011: 46%2014: 54%
Behav Sci (Basel). 2018 Nov; 8(11): 98.
Copyright © 2019 BDC Advisors, LLC. All rights reserved.
After years of medical school and residency, this is the reward…
Medscape National Physician Burnout, Depression & Suicide Report 2019
Copyright © 2019 BDC Advisors, LLC. All rights reserved.
*. https://www.itagroup.com/insights/culture-heart-successful-healthcare-organization
Burnout: the consequences
• While the number of hours in a physician work week has remained stable over time, the rate of burnout among physicians has risen
• What happens to physicians who burnout? - Lower job satisfaction- Disruption of work and personal relationships- Drug abuse- Reduction in the quality of patient care- Turnover- Depression, and even suicide
• Consider the financial impact of losing a provider in your practice:• 1 RN turnover is estimated to cost $58K*• 1 PCP turnover estimated to cost $1.3M*
Copyright © 2019 BDC Advisors, LLC. All rights reserved.9
**Burnout during residency training: a literature review. Ishak WW, Lederer S, Mandili C, Nikravesh R, Seligman L, Vasa M, Ogunyemi D, Bernstein CA. J Grad Med Educ. 2009 Dec; 1(2):236-42.^Williams D, Tricomi G, Gupta J, Janise A. Efficacy of burnout interventions in the medical education pipeline. Acad Psychiatry. 2015;39:47–54*Clinician Burnout: Global Medicine as a Possible Prevention and Treatment Strategy. Iserson, Kenneth V, MD, MBA .Mayo Clinic Proceedings; Rochester Vol. 93, Iss. 1, (Jan 2018): 121^^Interventions for Physician Burnout: A Systematic Review of Systematic Reviews. Int J Prev Med. 2018; 9: 81.
What do we know about preventing burnout?
• Physicians are not equally susceptible to burnout- Age, experience, specialization, gender, and marital status influence the risk of physician burnout**
• Interventions can be effective, but unclear which type of intervention is more effective^:- Individual-directed
♦ Mindfulness techniques, cognitive behavioral therapy, improved communication skills, and stress coping strategies, e.g.
- Organization-directed♦ Scheduling modifications, reducing workload, improving teamwork, changes in professional assessment,
increases in job control, and increased participation in decision-making, e.g.• Alternative interventions?
- Volunteer in underserved areas locally or globally*• In summary…
- “…reaching conclusions about effective interventions for physician burnout is not easy” ^^
Copyright © 2019 BDC Advisors, LLC. All rights reserved.10
A strong supportive culture is more likely to engage providers
• Contributes to the identity and values of the medical group
• Employees feel that they belong- helps recruitment and retention
• Culture is palpable to patients, help strengthen image and brand
Engaged providers will be at the center of ‘magnet’ high performing physician groups
Copyright © 2019 BDC Advisors, LLC. All rights reserved.11
Anatomy of a High Performing Medical Group
A “Magnet” physician enterprise is the nucleus of a high-performing medical group
• The physician enterprise is the nucleus that powers the performance of a medical group
• Typical medical group “assessments” focus only on the outer shell of clinical, financial, and operational metrics
• How healthy is the nucleus?
Magnet Physician Enterprise
withCulture of Physician
Leadership and Engagement
Operational Efficiency
Sustainable Financial
Performance
Outstanding Clinical Quality
Population Health
Competency
Copyright © 2019 BDC Advisors, LLC. All rights reserved.12
Elements of a ‘magnet” high performing medical group
Establishing a culture that will attract and retain providers
• Governance model that includes physicians in decision-making
• Physicians involved in operations- Can be part of a dyad
• Team-based approach to clinical care with each provider working at the top of license
• Support systems that unburden providers of administrative and regulatory “busy work”
Copyright © 2019 BDC Advisors, LLC. All rights reserved.13
Elements of a ‘magnet” high performing medical group
Establishing a culture that will attract and retain providers
• Compensation plan that is fair, transparent, and aligned with the success of the whole medical group
• A collective understanding of how each type of provider contributes to the overall financial performance of the whole
♦ Avoiding the trap of singling out provider groups (PCPs, e.g.) as “losing money”
• Efforts to support provider wellness and a sense of community- Burnout considered a practice issue, not an individual provider responsibility
Goal: engaged providers
Copyright © 2019 BDC Advisors, LLC. All rights reserved.14
Enhanced physician engagement and practice performance are mutually reinforcing
Magnet Physician Enterprise
With Culture of Physician
Leadership and Engagement
Operational Efficiency
Sustainable Financial
Performance
Outstanding Clinical Quality
Population Health
Competency
Magnet Physician Enterprise
withCulture of Physician
Leadership and Engagement
Operational Efficiency
Sustainable Financial
Performance
Outstanding Clinical Quality
Population Health
Competency
Copyright © 2019 BDC Advisors, LLC. All rights reserved.
A practice environment that is supportive of providers sounds like “motherhood and apple pie”…But this gets complicated when transitioning from FFS to Value-based care
• Problems we are seeing- Misalignment of incentives
♦ Physicians paid based on RUVs undermines performance on value-based contracts♦ Misalignment between words and actions Health system ”supports the ACO”, but unwilling to engage in efforts to reduce readmissions,
e.g.
• Health systems trying to succeed in VBC using a FFS platform
• Lack of effective population health infrastructure - Under-investment in the necessary (and expensive) infrastructure for population health- Infrastructure in place but not effective
♦ Decentralized infrastructure with inadequate central control mechanisms
Copyright © 2019 BDC Advisors, LLC. All rights reserved.16
Source: Ian Morrison
Beware the ‘merit badge’ approach to population health management
Copyright © 2019 BDC Advisors, LLC. All rights reserved.17
Is Population Health Management Dead or Alive?
• Reimbursement remains largely FFS
• Hospitals still drive health system economics
• ACOs exiting the MSSP program
• Only 34% of ACOs earned shared savings from Medicare in 2017
Dead? Alive?
Making the Case
• Healthcare cost growth needs to be constrained
• Medicare refreshes ACO program to encourage move to downside risk
• Strong Medicare Advantage growth
• Private equity capital focused on acquiring and expanding risk-bearing physician groups
Copyright © 2019 BDC Advisors, LLC. All rights reserved.18
Source: AMGA:, “Taking risk, 3.0; Medical Groups Are Moving to Risk…Is Anyone Else?
Payment models are continuing on a steady march toward risk-based payments but reimbursement remains strongly fee for service.
Copyright © 2019 BDC Advisors, LLC. All rights reserved.19
Source: Moody’s
The Business Case for Population Health Management
For many health systems, a value-based, population health strategy may enable a
brighter financial future than one focused purely on FFS.
Copyright © 2019 BDC Advisors, LLC. All rights reserved.20
In the transition to value-based care, it is essential to stay within the ‘Sweet Spot’.
Value Capture in Population Health
Valu
e-Ba
sed
Cont
ract
ing
Fully Integrated Population Health
ManagerPopulation Health Transformation
T0
Full Financial Risk
Cost of care exceeds global payments resulting in negative margins
Value created accrues predominantly to the payer
Highest Value Creation and Capture
FFS & Gain Share
Source: https://www.bdcadvisors.com/finding-the-sweet-spot-in-value-based-contracts/
Copyright © 2019 BDC Advisors, LLC. All rights reserved.21
When provider engagement breaks down, so does population health management efficacy
Provider frustration can lead to lack of engagement with existing population health infrastructure, for example:
• Information and services “pushed” to providers is not what they need- Inaccurate or outdated- Not actionable
• Incoming data is not where they need it- Entered into care management database, e.g. (not presented in the EMR where providers “live”)
• Or not provided when they want it- Point of care reminders are optimal…reminders at any other time become ‘noise’
• Providers must ”pull” available data- Only engaged and motivated providers will use pop health data
Copyright © 2019 BDC Advisors, LLC. All rights reserved.
The science of motivation predicts that downside risk will create greater engagement than the opportunity for shared savings
Information
Standard Economics
Behavioral Economics
• If people know what to do, they will do it.
• Education is what matters
• People are perfectly rational expected value maximizers
• Size of reward is what matters
• People are predictably irrational.
• Decisions affected by present bias, loss framing, emotions, social context, inertia
• Incentive delivery and design are critical
• Fear of losses more motivating than potential gains
Copyright © 2019 BDC Advisors, LLC. All rights reserved.
CARE TEAMOptimization
Assessment of medical group performance:5 elements of a “magnet” physician enterprise
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PRACTICE SCHEDULE
StandardizationPATIENT ACCESS
EnhancementINFRASTRUCTURE
Development
1) Care Team duties, including assessment of physician time allocation, (particularly in academic settings)
2) Benchmark staffing levels3) Are all staff working at “top-
of-license”?4) Is there a MA / RN “Float
Pool” or other vehicle to cover staff shortfalls?
5) Care protocols used for common ailments?
1) Scheduling guidelines and workflow
2) Clinician availability policies, including cancellation and bump policies
3) Standardization of practice schedule templates and visit types
4) Strategic patient bookings, overbooking strategies
5) Practice communication, use of “huddles”, etc
1) Use of patient access technology (direct scheduling, online patient portal, wait list management, reminders, etc.)
2) Protocols for walk-ins3) Check-in process4) Chart preparation
procedures5) Phone tree and other
patient communication protocols
1) Administrative structures, physician roles, dyads?
2) Are there staff incentives to meet patient visit and satisfaction goals?
3) Availability of timely, reliable, and actionable data reports
4) Status of EHR usability5) Availability of EHR
mentoring, tutorials and best practices
PROVIDERENVIRONMENT
Alignment
1) Degree of alignment between provider incentives and contracts (FFS and VBC)
2) Comp model that is fair, transparent, and impactful
3) Provider satisfaction4) Practice approach to
preventing provider burnout 5) Physician leadership and
provider voice in governance
Copyright © 2019 BDC Advisors, LLC. All rights reserved.24
Engagement: a key ingredient of ‘magnet’ high performing medical groups
• Anticipate that recruitment and retention of physicians and other providers is going to get more difficult
• The upside of downside risk: engagement
• Whether in FFS or VBC environment, medical group success depends on active participation of physicians and the provider team
• Is your organization a ‘magnet’ physician enterprise?
• What gaps should you work on?
BOSTON | CHICAGO | HOUSTON | MIAMI | SAN FRANCISCO | WASHINGTON, DC
Thank you!
David Fairchild, MD, MPHDirector, BDC Advisors
david.fairchild@bdcadvisors.com
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