Physician Burnout

MGMA Alabama Winter ConferenceMarch 7, 2019

Alex Kirkland, MBAVice President, Coker Group

Today’s Agenda

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Evolution of the Healthcare Industry

Understanding Burnout

Engage Physicians to Reduce Burnout

EVOLUTION OF THE HEALTHCARE INDUSTRY

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Industry Paradigm Shifts

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Payers• Risk shifting from payers

to providers (both upside and downside risk based upon outcomes)

• Increasing number of value-based programs (i.e., bundled payments, pay-for-performance, shared savings plans, etc.)

Patients• Consumer-driven, high

deductible health plans with increasing price transparency

VOLUME

VALUE

Providers• Re-tooling operations to

infuse more focus on care management, cost reduction, data utilization and prevention/overall wellness

• Harnessing innovation and entrepreneurialism (particularly for independent providers) to develop clinically integrated networks (CINs) that are private practice or ASC based

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Changing Payment Models

Providers paid a specified amount for each service provided

Incentives for higher quality measured by evidence-based standards

Percentage reimbursement at risk, earned back by high quality outcomes

Single payment for episodes of treatments, shared by hospital and physicians

Percentage of savings from reduced cost of care shared with hospitals and physicians

All services compensated in one payment that manages the patient across the delivery system

Fee-For-Service

Pay-For-Performance

Value-Based Purchasing

Bundled Payments

Shared Savings

Global Payments

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Overarching Payer Goals

CMS Pushing Risk

Obama admin goal of 90% of all Medicare FFS payments tied to

quality or value by2018

Trump admin pursuesvalue-based

programs

Health Care Transformation

Task Force

75% of payments tied to risk-based models

by 2020

Further quality improvements and

cost reductions in the public and private

sectors

Source: Health Care Transformation Task Force: http://hcttf.org/about-us/guiding-principles/

Transition to Value-Base Reimbursement

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In an effort to reduce costs and increase quality of care, the U.S. government began to transition to VBR with the passage of the Affordable Care Act (“ACA”) and Medicare Access and CHIP Reauthorization Act (“MACRA”):

• Established the Medicare Shared Savings Program, which allows for VBR through accountable care organizations (“ACOs”).

• Mandated the initiation of various pilot projects that test alternative payments systems such as the implementation of bundled payments.

ACA

• Established MIPS, which scores providers on various quality and cost-based categories.

• MIPS providers’ performance will be judged against their peers, and they will be eligible for a 4% Medicare Part B payment adjustment increase in 2019, and a 9% increase in 2022.

MACRA

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Transition to Value-Base Reimbursement

To provide more value to their patients, providers will need to align or partner in such a way that promotes team-based care (where a patient’s care is coordinated among various providers), rather than care being given in an independent and fragmented nature (as was common under fee-for-service reimbursement).

Alignment models that promote this type of care are typically those that have achieved “full integration”, such as ACOs, clinically integrated networks (“CINs”), group practice subsidiary (“GPS”) employment models, professional service agreements (“PSAs”) and clinical co-management agreements (“CCMAs”).

Alignment Integration

Last Five-Seven Years

• Consolidation• Creating Critical Mass• Gaining Market Share

Next Five Years

• Gaining efficiencies/reducing costs

• Collaboration/sharing best practices

• Improving quality• Enhancing patient

experience

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As noted on the previous slide, going forward, integration will be the key to achieving success in this new value-based healthcare environment

The Alignment and Clinical Integration Strategy

Adaption to Value-Based Reimbursement

In order for organizations to successfully clinically integrate, physicians need to be front line leaders driving change; thus, physician engagement is imperative

Managing physician engagement requires:

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Analysis of physician referral patterns—both in

and out of network—to

determine potential for

physician reinforcement

Physicians being willing to

participate in new-age healthcare

methods (i.e. evidence-based,

best practice care guidelines,

population health management, etc.)

Transparent reporting that

allows for continuous process

improvements

Real-time data that allows physicians

the ability to compare their

performance against national

and network standards

Establishment of clear goals with the input of physicians

(both qualitative and quantitative in

nature)

Limited Integration

Managed Care Networks (Independent Practice Associations, Physician Hospital Organizations): Loose alliances for contracting purposes

Moderate Integration

Service Line Management: Management of all specialty services within the hospital

MSO/ISO: Ties hospitals to physician’s business

Equity Group Assimilation: Ties entities via legal agreement; joint practice ownership

Joint Ventures: Unites parties under common enterprise; difficult to structure; legal hurdles

Full Integration

Employment*: Strongest alignment; minimizes economic risk for physicians;

Employment “Lite”: Professional services agreements (PSAs) and other similar models (such as the practice management arrangement) through which hospital engages physicians as contractors

Recruitment/Incubation: Economic assistance for new physicians

ACO/CIN/QC: Participation in an organization focused on improving quality/cost of care for governmental or non-governmental payers; may be driven by practices or hospital/groups

Group (Legal-Only) Merger: Unites parties under common legal entity without an operational merger

Group (Legal and Operational) Merger: Unites parties under common legal entity with full integration of operations

Call Coverage Stipends: Pay for unassigned ED call

Medical Directorships: Specific clinical oversight duties

Clinical Co-Management: Physicians become actively engaged in clinical operations and oversight of applicable service line at the hospital

Typically Physician-to-Physician

Typically Physician-to-Hospital

Either Physician-Physician or Physician-Hospital

Under the VBR paradigm, clinically integrated alignment models such as an ACO, CIN, or QC will become increasingly popular – these, of all the alignment models, require the greatest level of

physician engagement11

Traditional Alignment Models

Market Conditions and Employment

As the healthcare landscape has become exceedingly more complicated, more physicians are shifting from private practice in favor of health system employment (specific contributing factors shown to the right)

In 2016 an American Medical Association study found 47.1% of physicians had ownership stakes in a medical practice, down from 53.2% in 20121

Moreover, as the shift to value becomes even more pronounced, organizations are seeking ways to further align with providers to meet these expectations (and vice versa)

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The adoption of expensive and complex EMRs.

Shift from FFS to FFV calling for more clinical integration and alignment.

Increased regulations and

payer mandates.

Providers are seeking a work/life balance and are

less interested in taking on extra administrative

duties

Source: “Policy Research Perspectives.” American Medical Association. 2017. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/health-policy/PRP-2016-physician-benchmark-survey.pdf. Accessed January 15, 2019.

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Factors Driving Physicians to Employment

Adoption of expensive and complex EHRs Capital investments Learning something new Changing practice patterns

Work/life balance Extra administrative duties Security Generational shift in mindset

Complexity of data collection and reporting Data capture Data performance Data submission strategy

Increased regulations and payer mandates MACRA Commercial risk-models State-based initiatives

Shift from FFS to FFV More clinical integration and

alignment Data reporting Patient cost management

Risk shifted onto providers Carrots and sticks Attribution Unstable markets

More physicians are shifting from private practice in favor of health system employment due to increased levels of required investment, security in uncertain times, and personal decisions.

2017 QPP Outcomes

More than 1 million clinicians participated in the QPP for this year

Almost 100,000 clinicians earned APM participant status

The overall mean score for MIPS-eligible physicians was 74.01 points; the median 83.04

Scores were higher for those participating in MIPS through an APM

Small and rural practice participants earned lower scores

– Rural – mean score 63.08

– Small practices – mean score 43.36

The majority of MIPS participants (93%) received a positive payment adjustment (maximum 1.88%)

71% of clinicians earned a positive payment adjustment and a bonus for exceptional performance

2% of clinicians had a neutral (or no change) adjustment

5% of clinicians received a negative payment adjustment (maximum -4%)

14Source: https://www.beckershospitalreview.com/finance/95-of-physicians-avoid-mips-penalties-12-notes-on-qpp-year-1.html

UNDERSTANDING BURNOUT

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Three Dimensions of Burnout

Three Dimensions of Burnout

Personal Accomplishment

• Measures feelings of competence and successful achievement in one’s work

Depersonalization• Measures an unfeeling

and impersonal response toward recipients of one’s service, care treatment, or instruction

Emotional Exhaustion• Measures feelings of

being emotionally overextended and exhausted by one’s work

“Designed for professionals in the human services, it is appropriate for respondents working in a diverse array of occupations, including nurses,

physicians, health aides, social works, health counsellors, therapists, police, correctional officers, clergy, and other fields focused on helping people live

better lives by offering guidance, preventing harm, and ameliorating physical, emotional or cognitive problems.”

Maslach Burnout Inventory, MBI-Human Services Survey (MBI-HSS)

Source: Maslach Burnout Inventory, Christina Maslach & Susan E. Jackson: https://www.mindgarden.com/314-mbi-human-services-survey

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Address the Issue!

Three Recommendations from JAMA Internal Medicine Study

Support Physicians in Early Stages of Careers• Residents and early

career physicians more at risk compared to middle and late-career physicians

• Proactively addresses physicians that will be responsible for decades of healthcare delivery

Standardize Reporting for Quality and Patient

Safety• Correlate the affects of

physician burnout to its association with patient care deficiencies

• Scale results

Score Physician Depersonalization

• Creates baseline performance scale to help measure future results

• Drives appropriate interventions and helps understand when they should occur

Fixing burnout serves as an opportunity to improve patient satisfaction and the quality of care delivered

Source: HealthLeaders, 9/13/18, Christopher Cheney: https://www.healthleadersmedia.com/clinical-care/physician-burnout-impacts-safety-professionalism-patient-satisfaction

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Is Burnout Always What it Seems?Alarming Levels of Burnout Observed Among Residents

Source: MedPage Today, 9/18/18, Molly Walker: https://www.medpagetoday.org/primarycare/generalprimarycare/75169

45%Burnout Rate

Of 3,600 second-year residents surveyed, 45% reported burnout

JAMA Study

1 in 7Career Choice Regret

1 in 7 residents said they would “definitely not” or “probably not” choose to become a physician again

Second JAMA Study• Found “substantial variability” in criteria used to define burnout• Varied use of MBI surveys, number of questions, and definition frequency• Casts doubt on the generalizability of any one study

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Approaches for Clinician-Supportive Organizations

Source: Healthcare Executive, Jan/Feb 2019, Maggie Van Dyke, Battling Clinician Burnout; Fighting the Epidemic From Within

Establish an infrastructure• Dedicated staff to build a culture that engages and supports clinicians

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Measure and pinpoint priorities for improvement• Specialty and circumstance drivers

Address the administrative burden• Fewer clicks and documentation support

Train front-line managers to be transformational leaders• Physician leadership training curriculum

Help clinicians pursue meaningful work• Drastically lower levels of burnout observed from studies

Build better care teams• Elevate the care team to top of license

Promote an ethical practice environment• Help address conflicts of ethical quandaries

Address work-life balance• Utilize float pools to soften inflexible work schedules

Provide Wellness Resources• Support groups and wellness programs

ENGAGE PHYSICIANS TO REDUCE BURNOUT

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Drivers of Physician Engagement

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Decision Making Roles

Results of Reimbursement

Voice in Operational Strategy

Physician Leadership Opportunities

• Involve physicians in decision making that affects outcomes, their clinical practice methodology, and overall administrative functions

• These decisions may include designing compensation incentives, developing quality metrics, creating care processes, driving process improvement, etc.

• As MACRA/MIPS becomes increasingly more important to the Physicians’ total reimbursement, it is likely that they will be more willing to participate in activities that drive success under these systems

• Thus, organizations should be transparent about reimbursement rates, payment adjustments, and the transition process

• Physicians who link their economic future to a practice’s performance want a say in its strategy and execution, and more importantly, are the key driving force behind achieving many economic goals

• As such, organizations should be responsive to physician input and make actions/decisions that reflect physicians’ priorities

Relationships with Other Providers and Organizations

• Again, a key function of driving engagement is simply putting physician constituents in leadership positions

• Thus, organizations should identify physician champions to lead projects and reward/compensate them for their time.

• Further, they should foster development of leadership skills and provide opportunities to network with leadership

• Finally, a key function for integration is the sharing of resources and creating economies of scale across disparate practices, service lines, providers, etc. (i.e. aggregating patients, technology or support needs, specialty services, etc.)

• This will also create a more collaborative continuum of care within the organization

Engagement Assessment Tool

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1Physician Connectedness

Physician is employed (3), affiliated via a professional contract (2), or independent (1). (Choose One)

2Physician Loyalty• I am willing to put in a

great deal of effort in order to help this organization succeed.

• I would recommend this organization to a colleague as a great place to practice.

3Quality of Staff Relationships• I have good working

relationships with clinicians in the practice/ organization.

• I trust and believe in the work/abilities of my fellow physicians in the practice/organization.

4Communication• This organization is open

and responsive to my input.

• Clinical leaders serving my practice area effectively communicate difficult messages that my colleagues and I need to hear.

• I am kept informed of the organization’s strategic plans and direction.

5Professional Development

• I am interested in physician leadership opportunities at this organization.

• This organization supports my professional development.

6Operational Support• I receive the necessary

assistance from clinical support staff to succeed in my practice.

• I receive the operational and business support services (IT, billing, coding, scheduling) to succeed in my practice.

• I trust and believe in the work/abilities of the administrative staff.

Engagement Assessment Tool

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7Clinical Practice• I get the information I

need to assess my productivity and care quality.

• I have the right amount of autonomy in managing my clinical decisions.

• This organization recognizes providers for excellent work.

8Executive Engagement• The actions of this

organization’s executive team reflect the goals and priorities of participating providers.

• Members of this organization’s executive team are easily accessible to me for contact.

9Support of External Demands• I have a good work-life

balance outside of the demands of my job.

• My co-workers, colleagues, and management are supportive and understanding of priorities I have outside of work.

10Patient Care and Experience

• This organization makes patient safety a priority.

• Patients receive excellent service and clinical care at this organization.

• I look forward to interacting with and caring for my patients on a daily basis.

11Compensation

• I believe my compensation and benefits package justifies my work.

12Future Outlook• I am likely to be

practicing or aligned with this organization three years from now.

• This organization is well-prepared to meet the challenges of the next decade.

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Develop a shared mission and vision. Develop a philosophy of mutual benefit and shared vision. Strive to be extremely transparent from upper management down. Solicit meaningful physician input early and often, and then act on it. Engage physicians in balancing business and clinical priorities. Set realistic goals together, and go for early wins.

Nurture physician leaders. Identify, mentor, and educate physician leaders. Invest in physician leaders. Reward physicians in ways they value. Attend a leadership conference together or hire a coach to complete

leadership training on-site. Get to know physicians on a personal level—meet one-on-one.

Approaches to Improving Physician Engagement

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Communicate effectively. Ask questions and ensure that any grievances are quickly addressed. Use multiple forms of communication, multiple times. Manage physicians by walking around—listen and learn. Determine the motivation behind physicians and work to create

incentives that match.

Capture and share data. Implement processes that help determine what data is to be collected

and how. Use data as the platform for discussions on improving care and

lowering costs. Foster trusting relationships by sharing data frequently and broadly. Encourage physicians to use data to make decisions.

Approaches to Improving Physician Engagement

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Develop metrics and hold physicians accountable. • Ensure that physicians are a part of creating the metrics (quality, cost,

patient satisfaction, etc.).• Make metrics specific to each individual specialty and/or sub-specialty

(depending upon the size of the organization). • Utilize physicians to meet with colleagues that fail to meet these

measures. • Tie certain incentives to these metrics (i.e. compensation, service line

improvement initiatives, medical directorships, etc.).

Work toward clinical integration. • Regardless of the format in which you pursue clinical integration, establish

a collaborative method of delivering care. • Involve as many physicians as possible (employed, community, etc.). • Determine a method that best meets your needs – not all organizations

should immediately pursue an ACO or CIN.

Approaches to Improving Physician Engagement

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Physicians drive a majority of quality and cost performance.

Physician engagement holds providers and staff accountable for performance when it comes to clinical and service quality, productivity, and financial viability.

If the organizations seeks to clinically integrate, it will be imperative for physicians to help develop and adamantly support such. Moreover, a fully engaged provider base will be more easily transitioned to clinical integration.

The organization suffers when physicians don’t actively participate in improvement and strategic planning initiatives.

Engaged Physician Leaders are Critical

Cultivate Physician Leaders, Mentors and Champions

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• A person who commands a group, organization, or is followed by others.

• Behaves in a manner that makes others want to follow the direction they’re headed and to achieve the organization’s goals.

• Counsels followers to become leaders themselves.

Leader• Provides one or more mentees

with advice, exposure, inspiration, and lessons learned from the mentor’s own experiences.

• Connects mentees to their networks and fosters professional development.

Mentor• An active, vocal, and enthusiastic

supporter of an individual, a cause, or a project.

• Usually a senior level person in the organization capable of removing certain barriers or overcoming obstacles to ensure success of a cause or project.

• Do not have to have appointed or voted upon, can simply be an advocate.

Champion

A successful organization has all three spread throughout the various components of the organization.

Measuring Physician Engagement

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Assess and measure how the organization’s framework is set up to

engage physicians (compensation

structure, professional development,

workplace culture, etc.).

Publish and share reports on physician engagement at least annually across the

organization.

Implement easy to use systems that fully

support how physicians work (i.e. EHRs, order management tracking,

patient scheduling, etc.).

Assess and survey physicians on

engagement using the assessment tool at least

annually.

Spectrum of Physician Engagement and Alignment

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Physician engagement is crucial to determining the next steps for provider/organization alignment

Overall, we expect many organizations to begin considering contemporary alignment models, such as an ACO or CIN as a second step to their previous alignment structure (i.e. PSA, employment, etc.)

Essentially, there are four “starting points” for transitioning your provider base to a clinically integrated model

Aligned and Engaged

•This is the best starting point for your organization and should provide you with a relatively easy transition

•Still, there are likely significant infrastructure and operational considerations prior to fully integrating

Aligned and Unengaged

•While this is still a good starting point as likely your providers share similar management, etc., there needs to be significant focus on why engagement remains low

•Before proceeding, the organization should seek to improve their provider engagement, ensuring there isn’t a larger systemic issue

Independent and Engaged

•Alignment is not necessary for clinical integration – in fact, there are various models for clinical integration that incorporate physician only or hospital to community provider organizations

•The engagement will be critical for gaining trust amongst the independent providers, especially when it comes to sharing data

Independent and Unengaged

•While this is not the ideal position to be in, it does provide significant opportunities for the organization to “start from scratch” and begin building a highly collaborative clinically integrated model

•However, as with the others, this will take significant investments of time and resources to effectuate

Alex Kirkland, MBAVice PresidentCoker Group Holdings, LLCT: 615-418-9040akirkland@cokergroup.com

linkedin.com/in/alex-Kirkland@AlexKirkland_CG

Contact Information

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