Building a Magnet Physician Enterprise€¦ · value maximizers • Size of reward is what matters • People are predictably irrational. • Decisions affected by present bias, loss

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


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

Presenter

Presentation Notes

http://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/2016-PAI-Physician-Employment-Study-Final.pdf


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…”


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.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6262585/


After years of medical school and residency, this is the reward…

Medscape National Physician Burnout, Depression & Suicide Report 2019


*. 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*

https://www.itagroup.com/insights/culture-heart-successful-healthcare-organization


**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” ^^

https://search.proquest.com/indexinglinkhandler/sng/au/Iserson,+Kenneth+V,+MD,+MBA/$N;jsessionid=D994788A1D49580EF7A687B8AE815165.i-0729722f2a3f11ca4

https://search.proquest.com/pubidlinkhandler/sng/pubtitle/Mayo+Clinic+Proceedings/$N/48850/OpenView/1985859457/$B/5B7431D89ED34431PQ/1;jsessionid=D994788A1D49580EF7A687B8AE815165.i-0729722f2a3f11ca4

https://search.proquest.com/indexingvolumeissuelinkhandler/48850/Mayo+Clinic+Proceedings/02018Y01Y01$23Jan+2018$3b++Vol.+93+$281$29/93/1;jsessionid=D994788A1D49580EF7A687B8AE815165.i-0729722f2a3f11ca4

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6151971/


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


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


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”


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


Enhanced physician engagement and practice performance are mutually reinforcing


With Culture of Physician




Performance


Population Health

Competency


withCulture of Physician




Performance


Population Health

Competency


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


Source: Ian Morrison

Beware the ‘merit badge’ approach to population health management


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


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.


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.


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/


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


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


CARE TEAMOptimization

Assessment of medical group performance:5 elements of a “magnet” physician enterprise

23

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


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

[email protected]

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Building a Magnet Physician Enterprise€¦ · value maximizers • Size of reward is what matters • People are predictably irrational. • Decisions affected by present bias, loss