The ABCs of ACOs Creating a Culture of Collaboration with Physicians

The ABCs of ACOsCreating a Culture of

Collaboration with Physicians

Kathleen L. Lewton and Steven V. SeekinsPrincipals, Lewton,Seekins&Trester

Clark JensenSenior Director—Marketing, Intermountain Healthcare

Society for Healthcare Strategy & Market DevelopmentSept. 14, 2011, Phoenix AZ

FROM: “ACO’s The Final Frontier”TO: “Well, maybe not?”

Proposal submitted when ACO’s were THE ultimate solution . . . . . .• ACO Watch website• Second ANNUAL National Accountable Care

Organization Summit• Newly-minted experts and consultants by the

dozen(s)• Blogs, op-eds, articles . . . . . . .

And then the winds shifted . . . .

CMS shared the details And the big guns (Mayo, Cleveland Clinic,

Geisinger among others) said “maybe not for us” February survey: 70% of hospital execs cynical

about medical homes and ACOs• New models will hurt our margins• And half of MDs don’t know what an ACO even is

BUT even if ACOs don’t turn out to be the ultimate magic acronym . . . .

Whatever the acronyms, hospitals & physicians must work as partners

Full physician ENGAGEMENT is the critical success factor in creating, planning and executing key initiatives relating to:• Quality (never events, readmits, hospital-

acquired infections)– Think just about HAND WASHING

• Cost control• The “total patient experience” • Patient acquisition (translation: admissions)

Time-Out #1: Take Your Own Pulse

Self-Assessment of Your Organization’s Current State of Mind

and Practice

Rate using a 5 high – 1 low scale:

1. Your hospital/system’s current physician satisfaction level (your personal opinion)

2. How well your CEO interacts with physicians3. Overall effectiveness of your physician communications

program4. Quality of data you have about your physicians (current,

detailed, quant and qualitative, etc.)5. Your personal relationships with physician leaders6. Depth of physician involvement in planning and decision-

making7. Board/management commitment to physician relationships

as a top priority8. Your level of worry about physician engagement

Status Report 9/14/2011

From the hospital POV, we are the center of the healthcare universe

From the patient’s point of view, things may be not quite the way we see it

Recent major research effort in “test market” type city in “mid-US” found the consumer “my healthcare” word cloud had a different picture

The patient POV on “healthcare”

DOCTOR I asked my doctor and he . . I’d go where my doctor says my doctor thinks . . . . At my doctor’s office . . . . . .

With some Rx and outpatient facility references thrown in for good measure

A quick reality check:

Doctors “have” the patients (almost all the time)

Most care (not in-bed care, just care in general) happens in the doctor’s office (or wherever the doctor SENDS the patient)

Doctors have the credentials and the license to treat• The phrase “Doctor’s orders” isn’t a cliché

And most significantly . . . .

The doctor-patient bond, albeit battered and tossed around in past few decades, remains the core of trust in the entire healthcare endeavor• Strengthen that bond and all benefit• Erode that bond, and our entire ‘industry’ suffers

– especially the patients

When hospital leaders think about ACOs, they focus on “hard goods . . .

Here’s the typical list (from SHSMD Futurescan) of what a hospital leader would think about:• How MANY doctors do we need• Impact on patient volume• Governance and management capabilities• Capacity to manage total costs across episodes

of care• Level of incentive alignment between hospital

and physicians• Ability to be transparent and report publicly

Instead of focusing on the CORE issue:

Can these doctors and this team of board and hospital leadership work together as respectful partners?• Buzz words like “level of incentive alignment”

reduce a relationship to a price tag• Six “Keys to Lasting PARTNERSHIPS”:

– Align physicians with hospital strategy (control)– Sufficient capital ($$)– Practice acquisition (control and $$)– Physician compensation ($$)– Clinical integration via a contracting entity (control)– MANAGE physicians (control)

And what do hospitals think they have to DO to become an ACO?

Establish a legal entity including joint negotiation with physicians for contracts

Establish physician membership criteria to ensure physician’s full commitment

Common set of performance measures . . . Create management system to track . . . Establish an incentive system to promote

collaboration and peer pressure to improve performance . . distribute shared savings

. . . . Drive clinical performance using physician-led committees

Alternatively . . . .

Continue (or begin) to work with our physician partners to create an organization that . . . .. . . .

The devil is in the details . . . .

But while many hospital leaders are worrying about the CMS regulations, they need to first be worrying about how they can create the FOUNDATION – a true partnership with physicians – when their views of the world are so divergent

. . .but the mindset matters

Emphasis now on power and control• Leading hospital management consultant

advises using a “council” model – employed MDs serve on councils, with “Board appointed fiduciary – the hospital CEO – with ultimate bottom-line accountability and veto power”

• Meanwhile the president of the AMA says “Oh yes, there will be ACOs and they will be PHYSICIAN-led”

A quick scan of the current landscape shows lots of land mines

Hospital trade publication:• “One of the key goals of the ACO is to better

coordinate care to reduce costs, which means reducing utilization rate of the most costly services, which drive up costs BUT are also key revenue generators for hospitals. . . . Volume will drop and hospitals will have to reach to a broader population base to make up for that lost volume.”

MINDSET MATTERS. The big goal is no longer how can hospitals make more money, it’s the health status of a population

Current landscape Study of hospital physician relations

programs done by SHSMD finds:• Programs “also referred to as physician SALES

programs” • Goal: get physicians to send patients to our

hospital• Use sales plans and metrics• Only 13% of these programs report to CEO• List of responsibilities never mentions building or

enhancing sense of partnership and collaborationMindset: SELL TO rather than work with

Current landscape: Research done by SHSMD and major

agency: “Recurring theme is improving physician relationships . . . Specifically, changes needed in the (drum roll) physician relations function”• 80% of CEO, consultant respondents say

physician relationships is a major challenge – half mention “alignment”

• Key disconnect: some see physicians as an internal audience, others still say “external” some say both (if they are employed)

An A-Ha! moment: Large urban system, discussion of “our” doctors focuses exclusively on employed docs.

Q: What % of your revenues come from NON-employed physicians?A: Gee, not really sure.

Reality: 70%

Current landscape:

Same study . . . . Intriguing insights“Our ability to integrate more physicians into

our employed group and build that group, without alienating any of the independent groups in the process . . .”

“We have to find a way to align the physician groups SO we reduce the amount of leakage that goes to competitors.”Mindset: Doctors exist to feed our need for patients.

And more . . . . Communications is seen as a panacea . . .

“We have to communicate TO medical staff what the changes are and GET THEM to understand”

“Get them to understand OUR strategy and OUR goals”

. . .as is the fabled “alignment”“If they are employed, WE have to run the group

as best we can. If not employed, it’s economic alignment . . . there are models where we are both at risk.”

Some glimmers of insight . . .

“We have to view physicians as partners including being concerned about their financial welfare” (CEO)

“We need get physicians to help us design programs that we deliver. For instance, we could have cardiac care physicians help design the cardiac care that the hospital delivers.” (CEO with good intentions)

Mindset: When asked, respondents had difficulty identifying the skills and expertise needed to do all of this

And now back to real life . . .

Amidst all the talk of ACOs and alignment:• Major System X fires its radiology group,

replaces with a contracted group – and announces it as a fait accompli to the medical staff . . . who are STILL furious 18 months later

• CEO-no-confidence votes still occur• “Independent” physicians – who still do admit

patients and generate revenue – more and more concerned about their role as 2nd class citizens

More real life . . . .

National Healthcare Leadership Survey:• Hospitals that report having (average scores):

– Administration succession planning 4.67 (of 5)– Nursing leadership succession planning 4.33– Medical leadership succession planning 3.54

– Administration 360-degree feedback 3.80– Nursing leadership 360-degree 3.47– Medical leadership 360-degree 2.31

One more dose of real life . . . .

Study after study finds that physicians say:• They have less time and no control• Unable to keep up with changes in practice

– “I default to what I learned and feel comfortable with it even if it may not be the most current because I can’t do what I’m not sure I feel good at”

• They are frustrated at best, furious at worst• Concerned about money (NOT what they

planned) but even more concerned about . . . .• Not beingrespected (a core need)

Beware the conventional wisdom

Ownership is inevitable• Accenture – 13% or less will be independent by

2013. • REALLY? How many systems are even at 50%

and it’s almost 2012? – And think about the stats – one Mayo with employed

sure brings up the average• But acting out of that mindset has profound

implications – Some other system wants yourignored independents

More conventional wisdom

Owned = aligned = partner = collaboration = shifts in practice patterns. NOT necessarily.

Most of all, owned = respected. Key to success in ACO is $$

• AMN study of biggest obstacle to ACOs:– Physician alignment 42%– Capital 38%– IT 31%– Evidence-based

protocols 25%

Case in Point:Integrating Independent

Physicians

St. Joseph’s Hospital Health Center, Syracuse

Strategic planning process driven by ad hoc coordinating council of ten physicians (employed and independent) and five administrators

Five ten-physician task forces handled specific subjects and sought physician input via department-by-department advisory meetings – 150 physicians participated

Admins and doctors jointly presented to Board

Time-Out #2: Let’s Talk

Questions, comments, discussion and debate on what you’ve heard so far

Now . . . . On to the ABC’s

Attitudes, Building Bridges, Creating a Culture of Collaboration

“A”Attitudes:

What Makes Physicians Tick

Tick, Tick, TickNot Captain Hook’s alligator - how docs think & feel

Informed insights based on a few decades working side-by-side with physicians in a non-hospital setting)

Doctors by nature are perfectionists, like challenges, like being right, are analytical, like being leaders (in the sense of giving the orders), are competitive, like doing things in ways that are accepted by their peer community

Tick, tick, tick . . . .

Doctors are very very smart and bright individuals, highly educated . . .

AND they want to be loved and respected as people, too

High ego strength is essential for what theydo Huge info seekers, users (from gossip to research

findings) Driven by facts and numbers – data, data, data Truly committed to their patients!

Different tocks . . .

Physicians Doers 1:1 interactions Reactive Immediate results Deciders Value autonomy Independent Patient advocate Identify with specialty

Administrators Planners, designers 1:N interactions Proactive OK w/delayed results Delegators Value collaboration Participate Organization advocate Identify with organization

Doctors are not all alike . . .

Chose medicine for different reasons Huge variation from older to youngest

• “This is NOT what I envisioned” Medical vs. surgical – different mindsets Communications preferences vary wildly Infighting does occur:

• PCP vs. specialist(s)• Specialist vs. specialist (ortho/neuro,

plastics/ENT/head and neck, etc.)

Nor do they think about communications as we do

Study of paired CEOs/physician leaders

Best info source CEO PhysiciansCEO 76% 32%Chief of staff 66 48Thought leader in my specialty 22 52

Best communications tactics?

Tactic CEO PhysiciansLiaison 62 32Advisory boards 36 48Newsletter 28 28Personal mtgs. 94 80CEO letters 60 38

More ticks . . . .

They want to:• Care for patients with the fewest possible

hassles• To improve quality• To make sure their patients are safe• To build the body of medical knowledge• To hear things firsthand and directly

A great summary from UBM Medica:

A cross-section of American physicians appears to resemble a cross-section of middle-to-upper-income Americans• Professionally satisfied but struggling to find time

for work and personal life• In wide agreement that medicine, although

challenging, is a noble profession from which they gain great personal and professional satisfaction

Understanding physician attitudesis the core first step . . .

So disregard everything we just told you and listen to your own physicians• Not a standardized generic survey from some

survey company – YOUR benchmark is your own physician satisfaction

• Use surveys – phone, online, whatever they will do

• And personal interviews (focus groups almost impossible with this audience)

• Get your own “up close and personal” view AND set your own benchmarks to monitor change

AND . . . understand your board and C-suite attitudes, too

Is it “US vs. THEM” or “I’ll grit my teeth” or “I genuinely want to work WITH these doctors, but how?”

It’s up to us as the scanners/spanners to manage attitude adjustment via a continuum of approaches:• Facts, data, dose of reality• Persuasion, offering ways to ease the pain• Bringing in outside help who can say what you

can’t• OR . . . .


What are you encountering and what have you done about it, or what do

you want to do about it?

“B”Building Bridges: From Better

Communications, to Trusted Partners

A great starting point . . . . .

UBM study

“Marketers should focus on connecting to the emotional satisfaction that physicians get from being physicians while promise help crossing the hurdles that get in the way”

The goal is engagement

This is a fine point, because it goes way beyond communicating TO or even communicating WITH – to a desired state of physicians who genuinely care about the success of the organization, and an organization that genuinely values the physicians• Not just their clinical expertise – their personal

and professional selves

That “value ME” proposition plays out in so many ways

“I still like to be called DR. Jones, at least at first”

Start conversations with points of agreement and commonality – not “here’s the problem we have to fix”

Praise a physician publicly, address problems face-to-face privately (NOT in email)

Understand cultural and personal life sensitivities

To “value ME” begins with knowing ME

Knowing about the doctor’s background, hobbies, family, goals and worries

John O’Brien, when at Cambridge Hospital• “I like our doctors. I like going around and

talking with them about all kinds of things. I keep in touch with them because I want to – it’s not some strategy.”

Now some call it “physician rounding”

In the final analysis . . . . It’s all about trust

• 2010 PriceWaterhouseCoopers physician study: • 23% said they trusted hospitals, 50% said they sometimes

trust, and 20% said “nope.” The key: find out what YOUR doctors believe and

feel, and go from there• Lack of trust is best addressed by first acknowledging it,

doing a bit of dissection about what went wrong when and where, and making commitments to change in ways that the doctors can see and monitor.

• And always tie efforts to the shared goal: flawless patient care.

Build communications OUT from a core of trust, rather than vice versa

Physician communications through the ages (dark and otherwise)• The one-way newsletter and the quarterly all-

staff meetings• And don’t forget the SHRIMP at the annual

banquet• Then on to liaisons (a.k.a. sales reps – a term

physicians came to loathe)

Communications “perfect storm”

The info glut + time crunch +hospitalists • Too much info from all sources (medical

journals, research studies, pharma messaging, healthcare reform, hospital administration)

• Just at the point when doctors’ time is eroding• AND with hospitalists, your key PCP group

doesn’t come in anymore . . . so even signs on the doctor’s entrance don’t work!!!

• Then ADD email bedlam and you haveCHAOS!

Case in Point:The System That

COMMUNICATED

Major system that reflects the norm

Monthly newsletter• Page after page• Key info next to golf outing• And now it’s online

Newsletter created by the CMO at one hospital for “his” physicians Newsletter “from the desk of” one hospital COO MD 411 for employed physicians (fizzled out) Rounding – but only on doctors in system-owned office buildings Departmental newsletters (virtual meeting, runs to 40 pages) Update for physician leaders (“we hope they share it”) Faxes, a glut of emails (“FYI”) Visits by corporate sales reps Fliers on doors of ambulatory buildings Clinical meetings, social events Intranet “sort of” in the works Missing emails for 40% of medical staff

The search for magic bullets . . .

Newsletters – just send it out as a PDF • “All our doctors are online”

Put them on (all of) our email lists• So we clog up the emailboxes that they don’t like

anyway National study recommended blogs, two-

way digital comms, town hall forums, physician advisory council – everything except one-on-one conversations

Even the Advisory Board flinched:

Study which had been expected to produce clear guidance on the “single best way to reach physicians” pronounced:

“Ultimately, it’s a question for which no clear, overarching answer exists, and one that poses great difficulty for our members.”

What’s missing?

Strategy Core messages Coordination

• Matrix PR/communications, marketing, CMO, medical staff office

Brevity and repetition One or two truly CORE channels

• Intranet that works• Guaranteed “read ONLY this” email from CMO

Case in Point:Building Trust with Physicians

By Doing, Not Talking

CaroMont Health, Gastonia NC

Six physician-led service line councils• Three directed by independent physicians, one

co-led by independent and employed physicians Councils develop strategic plans on care

delivery, reflecting community needs No more dueling agendas – employed

physicians and independents working together AND working with the hospital

“Physicians are in charge of clinical care – they must lead system redesign.”

“C”Changing Culture:

Not Just THEM, but US, too

Creating a climate for change New attitudes for board and hospital

executives• Alignment is not something we do “to”

physicians• MD Blogger: “Physicians are not chess pieces

to be set up by administrators. And it is not necessarily the case that the fiduciary duty of a hospital administrator is aligned with the patient responsibility that a physician has. Physicians must remain patient advocates.”

• And administrators must convince physicians that they, too, are patient advocates!

So it starts with defining a shared vision

Alignment discussions often start with economics (worst place to start, kills a ‘patient advocate’ mentality) or with clinical activity (also touchy, tromping on physicians’ turf)

If you start with alignment of purpose – shared belief, common culture, single mission, and a commitment that physicians will be actively involved, then you can move forward in a partnership style

And re-think our vernacular

Even the word “alignment” has started to have a negative connotation because it is felt to imply “you doctors align with us” – so always be sensitive to the nuances that might suggest “loss of control”

And always make good use of data• CIGNA-Dartmouth-Hitchcock ACO pilot found

that giving doctors data specific to them and helping them compare with others is a good way to move toward behavior change

When communicating:

Brevity – painful (to us) brevity• True message management, using terms you’ve

tested with physicians Delivering messages repetitively through

multiple tested channels Understand who the real physician leaders

are (doesn’t always necessarily map to titles, elected or appointed) and build relationships

To build relationships:

It can begin with “onboarding” – content, approach and participation at new physician orientation sets a critical “early tone”

Rounding works (tried and true) in person (although some really do prefer a quick phone call)

Drilled down, ongoing physician attitude and satisfaction research, managed by a joint team including physicians

More on relationships

Physicians, especially PCPs, tell us they miss going to the hospital, miss the collegiality, feel like they’re getting out of touch, don’t “know” other doctors• So we can create the opportunities to bring them

back together• And don’t give up departmental and staff

meetings if some physicians still find them valuable

Help physicians prepare for their new roles

They’re being asked to be managers, team leaders, collaborators• NOT skill sets taught in medical school or

acquired in private practice Assist with training opportunities

• Kaiser making “teamwork” skills a priority with their physicians

Identify, develop and mentor physician leaders• An inspiring speaker at a meeting is only the

beginning

Dispel one of the great myths

Heard for years: “The doctors want to RUN and CONTROL this place.”

Premier Alliance seminal research effort many years back found differently• Doctors emphatically said they don’t want

control. • What they wanted was to be involved, listened

to, consulted – from the beginning.• “Don’t announce your decision or plans to us –

include us in the discussion from the get-go.”

What’s more . . . .

Wise, veteran CEO: “You can say no to physicians. I’ve done it. You just have to make it clear that you understand their viewpoint, that it was clearly considered, and tell them the reasons why you can’t do what they recommended.”

Case in Point:The Intermountain Experience

Up Close and Personal

Clark JensenSenior Director—MarketingIntermountain Healthcare

Mission, Vision, Values:“Engaging Physicians” is built in

Intermountain’s vision/aspiration is to provide Extraordinary Care in All Its Dimensions Six “Dimensions of Care” are pillars supporting this vision “Engaging Physicians” is one of the six Dimensions of Care

Our mission has always been excellence in the delivery of care—not just the management of hospitals. Therefore, we have always needed to work closely and collaboratively with physicians.

Some history . . .

1975-1994: Physicians involved in governance; councils; early quality improvement studies (QUE studies)

1986: Arrival of Brent James, MD

1994: Medical Group formed Clinics acquired; physicians recruited

1998: Clinical Programs established2008: Charles Sorenson, MD, becomes CEO2011: Shared Accountability

Today

Medical Group:Headcount

Physicians 818

Midlevels 182

Employees 3,267

Total Headcount 4,267

Medical Group:Clinics

Clinics 165

InstaCares 24

WorkMeds 9

Total Clinics 198

Plus: 3,500 independent “affiliated” physicians credentialed at our 23 hospitals.

SelectHealth health plans have 4,900 physicians on panels (including the Medical Group physicians).

Intermountain Medical Group:How we pay physicians

Productivity (Relative Value Units): 85%System/Quality goals: 15%

Medical Group contributes to system margin

Physician relations principles

Partners: Can’t affect quality/cost without physicians. They must be partners:

Governance: Physicians on Board (literally) Leadership: Physician CEO; physicians in

other key leadership positions Clinical Programs: Medical directors oversee

physician relations and delivery of care SelectHealth: Continual outreach Medical Group: Most physicians are employed,

but we refer out to some highly aligned specialists

Engaging physicians in clinical quality improvement

Dr. Brent James and the Intermountain Institute for Healthcare Delivery Research

Advanced Training Program Advocacy for evidence-based medicine,

comparative effectiveness research

Quality Improvement Conference (new in 2011) Board of Trustees establishes annual clinical quality improvement goals


Clinical Programs: Cardiovascular Oncology Women & Newborns Primary Care Surgical Services Pediatric Specialties Intensive Medicine Behavioral Health Patient Safety


Techniques for engaging physicians: Peer-to-peer (physician-to-physician) Teamwork Show them the data They decide Outcomes speak for themselves They explain departures from protocols


Example: Elective inductions prior to 39 weeks

Timing of Elective InductionsElective Inductions < 39 Weeks

Elective Inductions

Timing of Elective InductionsJa

n-99

Jul-9

9Ja

n-00

Jul-0

0Ja

n-01

Jul-0

1Ja

n-02

Jul-0

2Ja

n-03

Jul-0

3Ja

n-04

Jul-0

4Ja

n-05

Jul-0

5Ja

n-06

Jul-0

6Ja

n-07

Jul-0

7Ja

n-08

Jul-0

8Ja

n-09

Jul-0

9Ja

n-10

Jul-1

0

0%

5%

10%

15%

20%

25%

30%

35%

Over $1.7 million of savings in 2009 and 2010

Elective Inductions < 39 Weeks


Example: Orthopedic Devices Difficulties Supply Chain negotiations

The Future:Shared Accountability

Goals: Better quality (for our patients) Better health (for populations we serve) Bending the cost curve


Aligning incentives: By helping plan members manage health and by focusing on most effective care (address problems of overuse, underuse, and misuse), we believe we can generate significant cost- savings Physicians will share in those savings and earn more by supporting this effort. Rewards for providing best care, not most care


Example: Changes to Medical Group compensation Today: Physicians earn bonus partly on basis of global quality goals

E.g., 70% of diabetic patient population with HbA1c ≤ 7). Tomorrow (2012): Physicians earn bonus on basis of goals specific to their patients


Incentives, not penalties Doctor knows best: Physicians are the key to

making Shared Accountability work As always, you can’t deliver best care—or any

care—without them Physicians have the highest credibility,

especially with patients/consumers See studies by Robert Wood Johnson

Foundation and others


How can we use our marketing and communications skills of research and

relationship building to advance the process

And in Closing: Check It Out

1. The Handy-Dandy Checklist to help you plan your next steps – will be posted 9/19 on www.lstllc.com

2. [email protected] 917 734 [email protected] 818 378 6664

mailto:[email protected]

mailto:[email protected]

Documents

The ABCs of ACOs Creating a Culture of Collaboration with Physicians