As a veteran internist prepares to close her practice for good in advance of the mandatory transition to ICD-10, she says running a medical office is "not efficient at all" and describes being "overwhelmed by the administrative burden."
Instead of spending the last few months preparing in haste for the transition to ICD-10 on October 1, internist Isabel Hoverman, MD, has been transferring medical charts, selling supplies and tables to other physician offices, and saying goodbye to patients she's taken care of since 1992.
Hoverman, who along with three other physicians is part-owner of Austin, TX-based Austin Internal Medicine Associates, decided to stop seeing patients because the administrative burden was too expensive, too complicated, and took away from patient care.
"This is not me being a dinosaur and refusing to move into the future," says Hoverman, who was chair of the Joint Commission's Board of Commissioners in 2011. "We are so overwhelmed by the administrative burden that we forget to step back and ask, 'Why are we doing this?' "
Isabel Hoverman, MD
Hoverman, who was on Austin Monthly'sBest Austin Doctors roster in 2013, will see her last patient on Friday, September 4, and she anticipates it will be hard because of the emotional connection the patients have to her and the practice.
But, Hoverman says, it will also be a relief.
"How you run a medical office has changed greatly," she says. "It's not efficient at all, especially if you look at all the administrative requirements, and the lack of uniformity in how payments are made. All of that trickles down to how it works out on the front line."
At 70 years old, Hoverman says it would be easy for critics to point to her age as the real reason for closing her practice, but she says it is the combination of administrative red tape and unorganized regulations that pushed the practice to decide to close.
"I don't have a set plan," says Hoverman about what's next. "We have patients who ask, "Where are you going to go?' I'm going home. I think any time you make a big change, you need to stop and take into account what is out there."
Fed up With Red Tape
While ICD-10 was the "last straw" for Hoverman and the other physicians, the decision to close a practice that has a 40-year history was not a reactionary one. The practice began thinking about closing its doors last year.
The hiccups with insurance, varying quality programs, and CMS added to a long list of frustrations that took physicians away from patients. When it was clear the ICD-10 start date would not be delayed this year, the partners approved the closure and aimed for seeing its last patients in early September to avoid any code confusion with its payers. Letters went out to patients in April.
"[ICD-10] is not a problem for me as a physician, but to have this big huge transformation, would be another huge administrative burden," she says.
Austin Internal Medicine Associates does not have an EHR system. The practice does electronic billing and e-prescribing, but implementing an EHR system was not financially feasible, she says. "If we had an EHR that worked, I'd be very excited; I don't think I'd retire."
A. Tomas Garcia III, MD
The frustration physicians feel is real, and Hoverman's absence is something Texas Medical Association (TMA) President, A. Tomas Garcia III, MD, a practicing cardiologist in Houston, fears he will see more of across Texas.
"Doctors may need to walk away, and those patients have to go somewhere," says Garcia. "In the TMA, we think 60%–65% of physicians have an EHR, which means 30% to 40% of doctors are not up to speed, and that gives them the opportunity to quit or go to cash only."
The patients from Austin Internal Medicine Associates have found other physicians, says Hoverman. But Garcia worries about not only the practices that close for good, but also the ones that close for a day or two because they are overwhelmed by the additional details that can cause a delay.
"My concern is access," he says. A few minutes here or there in one physician's office may not be a big deal, but he suspects it's more than one physician office that is not prepared.
Physician and Payer Mistrust
He's right. By and large, physician groups are unprepared for the transition to ICD-10, especially when compared to hospitals. Garcia himself is prepared, but like other physicians, frustrated, too.
"It's going to be awful," Garcia says, referring to ICD-10. "They're using it for research—I get that—but uncouple it from reimbursement. When you couple ICD-10 with reimbursement there are [payers] who will play games."
The Centers for Medicare & Medicaid is giving physicians a one-year reprieve from being financially penalized or audited for submitting the wrong ICD-10 codes (as long as the codes submitted are in the correct family of codes), but it's not clear whether commercial payers will follow suit.
Garcia tells me he has not received any guidance from payers, other than CMS. "I'm ready for ICD-10," he says. "I know I'm not going to get paid, but the payers are going to play games. Why? Because they can."
Garcia is not the only one who says commercial payers have been silent on whether they will work with providers or deny claims submitted incorrectly. Gregory Fuller, MD, a primary care physician at North Hills Family Medicine, a five-physician primary care practice in the Dallas–Fort Worth area, says he doesn't know if payers will follow CMS's lead.
"We've gotten no communication from payers on this," says Fuller. "We're able to champion the grace period with CMS, but we don't have that information from commercial providers."
Fuller, who is prepared for the ICD-10 transition, estimates the payer mix at the practice breaks out to 91% commercial, 8% Medicare, and 1% cash pay. That means any delay in reimbursement would significantly impact the practice's the revenue stream.
"I laugh when these experts say you need to have 3–6 months of operating revenue saved up," says Fuller. "We operate month-to-month. There is not a big pile of money to be used. We have an open line of credit at the bank, and we haven't had to use any, but we aren't going to be very happy if we have to draw money on that to keep us going."
Like Garcia, Fuller is concerned about access to care for patients, especially in rural areas of Texas where some counties have no physicians.
"This has the potential to hamper medical care in the state of Texas, that's the worst case scenario," says Fuller. "Rural practices tend to have more Medicare and Medicaid patients, and they do have a buffer for the first year, but they are the most vulnerable practices, even without ICD-10 looming."
The transition to ICD-10 will no doubt be a bumpy road for most physician practices, but it will also likely exacerbate tensions among an already frustrated group of providers.
As payment models in healthcare shift away from fee-for-service, some provider organizations are changing cardiology compensation contracts to reflect value instead of volume.
This article appears in the July/August 2015 issue of HealthLeaders magazine.
The march toward value-based reimbursement isn't being made with confident steps. That's because most healthcare providers are living in a fee-for-service world. Having a foot in value-based care while still getting paid on volume is a difficult reality, especially within the cardiology service line, because it is heavily weighted on relative value unit generation. But some organizations are facing the challenge head-on by tying a portion of cardiologists' compensation to quality metrics.
Compensation for the specialty traditionally has been based on productivity, and while that still is the foundation of most contracts, some organizations are renegotiating compensation that relies less on RVUs and instead rewards physicians for things that do not generate revenue, such as patient communication, documentation, and professionalism.
Edward Fry, MD
"Our compensation model is still weighted toward fee-for-service and reimbursement based on generation of RVUs, but within that is a significant and growing component of rewarding for nonclinical work," says Edward Fry, MD, chair of the cardiology division and physician director of the cardiology service line at St. Vincent Medical Group, a physician-led multispecialty medical group with more than 600 providers that is part of St. Vincent, a 22-hospital health system based in Indianapolis, which is part of St. Louis–based Ascension Health.
Fry says cardiologists and other specialists have to be willing to accept changes in how they're paid because value-based care reimbursement will not support a volume-based paycheck.
"Everybody sees the handwriting on the wall," says Fry.
Until recently, that handwriting was faint. Value-based care reimbursement was on the horizon, but there were no clear goals and there was no definite end to fee-for-service. The Centers for Medicare & Medicaid Services has funded several value-based pilot programs over the past few years, such as the Hospital Value-Based Purchasing program, the Pioneer ACO program, and the Bundled Payment for Care Initiative, and commercial payers have rolled out their own proprietary value-based programs. But it wasn't until January that the ambiguous future of what a value-based care reimbursement system might look like became clearer. CMS announced an aggressive and ambitious schedule of tying 85% of all Medicare reimbursement to quality by 2016 through its value-based purchasing and readmission-reduction programs.
Fry and others are skeptical of those goals, but they are a signal that healthcare executives cannot and are not ignoring. At some organizations, the first target is transforming cardiology compensation contracts to reflect value instead of volume.
At Spectrum Health Medical Group, a multispecialty physician group that includes 1,100 providers and is part of the Grand Rapids, Michigan–based Spectrum Health, a nonprofit health system that includes 11 hospitals, 170 ambulatory sites, and a health plan, leaders completely abandoned a productivity-based compensation model for its 38 cardiologists and opted instead for a straight salary compensation package, with two opportunities to earn more based on quality metrics.
Not many groups outside of Cleveland Clinic have attempted to pay cardiologists a straight salary, but Spectrum's venture could signal to other cardiologist groups and large health systems that the specialty is ready for a new compensation structure.
"Clearly, you can't live in a value-based world and pay people in fee-for-service," says Darryl Elmouchi, MD, FHRS, division chief of cardiovascular medicine at Spectrum Health Medical Group. "The hard part is we still live primarily in a fee-based world, so we sat with providers, leaders, and asked, 'How are we going to change?' We all agreed that we had to change physician compensation. Cardiology was the tip of the spear."
The medical group's primary care physicians also are working on a transition to the model the cardiologists adopted, which is a straight salary that has a 10% withhold for citizenship, a measure made up of four separate metrics: clinical productivity, program development, scholarly activities, and clinical excellence.
"The clinical productivity metric is not RVU-based," says Elmouchi. "It is essentially, 'Are you doing the things we ask you to do?' A distant outreach clinic is good for patients and the organization, but for the individual provider, it could mean some slow clinic days where they don't have a lot of RVUs, and to judge someone based on that seems counterintuitive to us."
Elmouchi says cardiologists can earn part of the 10% salary that is withheld, so it is not "all or nothing."
Darryl Elmouchi, MD, FHRS
"We have a scoring system," he says. "I meet with everybody in the beginning of the year to hear what their plans are, and then at the end of the year to give them a grade. We hope everyone gets the 10%, but not everyone will."
Spectrum Health Medical Group cardiologists also have an opportunity to earn a bonus of up to 5% if they meet patient satisfaction and other goals. There are six metrics that cardiologists will have to meet to earn the 5% bonus, with each metric weighted to reflect the system's goals. For example, 0.5% is tied to patient satisfaction, which Spectrum Health Medical Group measures with the CG-CAHPS survey, a tool that assesses patient satisfaction in clinic settings.
Another 0.5% is dependent on Spectrum Health meeting its financial goals, which Elmouchi says is less strict.
"If the whole system goes bankrupt, they're not giving us a bonus," says Elmouchi.
Another 0.5% is earned if cardiologists meet the goal of sending a provider note about the patient. This metric is new and is one of several metrics tied to the 5% bonus aimed at improving certain physician behaviors, explains Elmouchi.
"A lot of electronic notes are generated that get sent to a primary care doctor," he says. "We want to have a personal note describing the patient's experience and their plan. The goal is to have 60 notes sent. For many of our providers, that's a very small number, but the whole goal is to change behavior and push people to do that and make it part of their standard work."
Two other bonus metrics that aim to change physician behavior are more heavily weighted, at 1% each: access and patient calls.
"We want to improve access," says Elmouchi. "We put a goal that we would be able to see any patient for any problem within 10 business days. And when patients call with a concern, we want quick providers to have a 48-hour turnaround for those calls."
The metric that is weighted heaviest for the 5% bonus is the departmental budget goal. As long as the cardiology department doesn't exceed its budget, the physicians will receive 1.5% toward their bonus. This metric isn't the only one that is shared. The CG-CAHPS score that makes up 0.5% isn't based on the cardiologists' individual scores; it's based on the department's scores.
This new compensation model was just rolled out in January, and it took about a year to put together.
"If you would have talked to us two years ago about going away from productivity, I wouldn't have guessed it could happen," he says, adding that, so far, he gives the effort a solid B because reengineering work flows to improve things like access takes time.
Success key No. 2: Be willing to change
While the switch from an RVU-based compensation package to one that is straight salary is not well-suited now for every organization, some leaders are taking incremental steps toward linking quality to cardiology compensation.
For example, 85 cardiologists in the St. Vincent Medical Group, which staffs cardiology programs including St. Vincent Heart Center, just renegotiated their compensation contract, and it stipulates that a smaller portion of cardiology compensation will be based on RVU clinical production. Going forward, 80% of cardiologists' compensation will be RVU-based, and 20% will come from management and quality metrics. In previous years, the split was 90/10.
"The portions of compensation directly related to meeting certain quality metrics will grow over time," says Fry, who is also a member of the American College of Cardiology's board of governors. "There is more recognition of the nonclinical work and a better valuation for things cardiologists do other than providing straight clinical services. This is fairly common for what is going on around the country."
The reduction of dependence on RVU generation also reflects a national decrease in RVU production, according to Fry.
"In the past two years, RVU production nationally is down 5%?9% per year, and that's because cardiologists are doing fewer procedures, less testing, all of which is guided by appropriate use," says Fry. "They are also being asked to do more in terms of documentation, compliance, and chronic disease management, so it's a way toward overall patient management."
Cardiologists at St. Vincent may not be paid the same way as those at Spectrum Health, but there are similarities in the way they are measured. Fry says the 50 metrics St. Vincent uses to measure cardiologists' adherence to quality benchmarks is a "mixed bag" of CMS core measures, system metrics such as patient satisfaction, and a scorecard from one of its commercial payers. With the renegotiation of its compensation contract, Fry says there will be a menu of measures that cardiologists will agree to every year.
"There's some dynamic nature to it," says Fry. "The feeling is once you reach near 100% compliance, move on. Stop rewarding the same thing over and over."
St. Vincent also includes quality metrics that are aimed at changing physician behavior. For example, Fry says he wants to incentivize cardiologists to perform percutaneous coronary intervention in a certain way.
"It's not based on the volume of the procedure; it's to shift from femoral catheterization to transradial, for which there is better patient satisfaction, less bleeding, shorter length of stay."
The new goal is to have cardiologists perform at least 25% of PCIs via transradial access, and that percentage likely will increase over time. Directing cardiologists toward procedures or practices that have been proven to reduce length of stay, for example, can have a direct impact on the bottom line, which is a goal of value-based care.
Although St. Vincent does not draw a straight line from care to cost yet, there is some indication that its cardiologists are moving in the right direction. St. Vincent Heart, the hospital staffed by the medical group's cardiologists, has received an annual bonus three years in row from CMS for performing well in the agency's Hospital Value-Based Purchasing program. VBP measures hospitals' quality, process of care, patient experience, outcomes, and efficiency. Through the program, CMS withholds a certain percentage of inpatient payments from each hospital. If the hospital does well, it effectively earns a bonus; if not, then the withheld money is lost. In the first measurement period, October 2012?September 2013, St. Vincent Heart earned a bonus of 0.35%; in the second reporting period, the bonus increased to 0.46%; and the third reporting period shows a bonus of 0.54%. The maximum amount a hospital could earn or be penalized ranges from 1%?1.5%, depending on the year.
Fry says that St. Vincent's cardiologists are open to moving toward a compensation package that is less reliant on clinical productivity because of St. Vincent Heart's success with VBP. The cardiologists were able to earn the bonus, in part, because of the group's long history together, he says. Although they are part of St. Vincent now, the group was independent until 2010 under the name The Care Group, which was a large cardiology practice.
"We've been one unified group for a long period of time, and we haven't been sidetracked with cultural changes, which can take a long time," says Fry. "That's one of the challenges holding cardiology groups back. Until value-based reimbursement becomes part of the vast majority of the primary care base, there will always be a measurement of reimbursement based on clinical productivity for specialists. I think specialists will be slower to transition than primary care."
Steven Nissen, MD
Success key No. 3: Capitalize on culture
The one place that does not have to transition its cardiologists to a new compensation model is the Cleveland Clinic, a nonprofit academic medical center that is known for its straight salary model. With the move toward a value-based reimbursement system, Rob Coulton Jr., MBA, executive director of professional staff affairs, who sits in on all annual performance reviews and oversees the review process, says he knows that the clinic's compensation strategy is a model for other systems.
"To organizations trying to change, I respect how hard that is," he says. "The culture is so strong here. If you are the 132nd cardiologist in the cardiology department, accepting the salary model is quite easy."
Cleveland Clinic has 140 cardiologists on salary, but, says, Steven Nissen, MD, chairman of cardiovascular medicine at the hospital's Heart & Vascular Institute, that doesn't mean that their compensation formula has not evolved.
"We made a decision in 2012 to approach cardiovascular medicine compensation with a far more systematic and metric-based approach, not just a general impression of performance," says Nissen.
Instead of rewarding cardiologists based on seniority, which was the norm, Nissen says the department developed what it calls an IP-3, Individual Physician Performance Profile. It's a detailed collection of nearly 90 metrics on cardiologists' clinical and nonclinical performance.
"There are 38 metrics that we collect on every physician in our department of cardiovascular medicine for clinical performance, and then another 50 or so metrics for nonclinical, academic, national leadership, publications, etc.," says Nissen. "They are highly detailed, and they are provided to each individual and to the chair prior to annual performance reviews."
The metrics are a mix of core measures that CMS uses to rate heart care, and there are also Cleveland Clinic?specific metrics, such as closing patient encounters. Nissen says they were not measuring that initially in performance reviews but noticed that some providers left their patients' records open for several days. That can lead to delays in patient care. With the addition of a metric to close patient encounters the same day a cardiologist sees a patient, Nissen says open records are "virtually eliminated."
Despite the strong culture that exists at Cleveland Clinic, introducing cardiologists to a more comprehensive set of metrics was met with resistance. There was pushback that eventually faded, but Nissen says he had to fight the "ivory tower" mind-set.
"There has been sort of a mentality that's existed at academic medical centers for a long time of 'We're here to do what we want to do, and we're accountable only to ourselves,' " says Nissen. "What we said is, 'We're accountable to each other. Our performance as a group needs to get better as individuals.' "
Nissen says high performers who feared being scrutinized realized they had nothing to worry about, and the low performers got better. In the three years that the detailed scorecard was used for its cardiologists, he says the bottom 10% increased their performance by 19%; the top 10% increased by 4%?6% in overall job performance.
"That means the good people got better, and the people that weren't doing quite as well got a lot better," he says. "That's what we hoped would
be accomplished."
Holding individual cardiologists accountable for their performance has impacted patient care, too. Nissen points to the door-to-balloon-time performance measure for heart attack patients. The current guidelines recommend a benchmark of 90 minutes or less. Nissen says Cleveland Clinic's door-to-balloon time was better than that benchmark last year, but now it is down to 47 minutes.
"That means the patient gets evaluated; you get their EKG, make a decision, get them into the catheterization lab, and get the coronary open," says Nissen. "We pushed those metrics because we are tracking all of this and reporting to each other. I didn't think we could get to 47 minutes, but we did."
Targeting one of the highest-paid specialties with a focused approach on metrics that determine its value to the organization is one way to prepare for value-based reimbursement. The road to get there is not smooth, but it is not vanishing either, says Elmouchi.
"This is a new era; this is how we're all going to do better."
A new model of primary care avoids traditional insurance headaches— has shown how a $45 investment prevented $200,000 of healthcare costs—and is gaining momentum among physicians, patients, and payers.
The number of primary care physicians who want to practice medicine without the pressure of having to see more patients is steadily climbing.
Despite the move to transform the healthcare system to one that rewards value over volume, most reimbursement is still based on how many patients a doctor sees. The constant churn can lead to physician burnout, which the country can't afford because in ten years there will be shortfall of at least 12,500 primary care physicians.
This is neither shocking nor news, but some PCPs are pinning their hopes on the direct primary care (DPC) model as a way to survive healthcare's transformation.
DPC is similar to the concierge model in that patients pay a monthly fee in exchange for more access to their physician. Appointment times are kept without much waiting and patient visits are longer. Patients have 24/7 access to their doctor through phone, email, and text.
But that is where the similarities end. Concierge practices can be expensive with some annual fees reaching $6,000. DPC practices charge a monthly fee, usually a sliding scale depending on the age of the patient. Concierge physicians also accept traditional insurance. A DPC physician does not.
Zubin Damania, MD
No Insurance
The no-insurance rule is a radical idea that has some physicians scratching their heads, but others, such as Zubin Damania, MD, founder of Las Vegas–based TurnTable Health, believe DPC has the ability to improve patient care and physician satisfaction. "We are attracting younger patients," he says, noting that the average age of TurnTable Health's 300 DPC patients is 35 years old. "We have a minimum 30-minute visit."
Damania is also known as ZdoggMD, an alter ego who raps about some of hospital's biggest headaches, such as readmissions. He puts a humorous spin on sobering topics, but he is serious about changing patient health in Las Vegas. "It's some of the worst healthcare in the nation," he says. "Las Vegas tends to attract a transient kind of group. There are amazing physicians here, but it is one of the most challenging environments. I was horrified and terrified and when I came here, but I fell in love with it. There is something about this city… people here want change. Las Vegas is about reinvention."
TurnTable Health is not exclusively a DPC practice. The city's culinary union contracts with TurnTable Health so that its members have a place to go for care. And TurnTable was an option under the [failing] Nevada Health Co-op, which was set up for Nevada's health insurance exchange. The Co-op announced this week that it would cease operations next year due to "market conditions" and it's not clear how that will affect TurnTable, which has 1,500 Co-Op patients.
The mix of health insurance, self-pay patients, and the handful of small businesses that use TurnTable Health for health coverage is a not a one-off idea limited to Las Vegas. Iora Health, based in Cambridge, Massachusetts, and led by founder Rushika Fernandopulle, MD, is deploying its version of healthcare in several states.
Iora and TurnTable are also partners. Damania describes the relationship as supportive. "We provide the building, patient acquisition, and they (Iora) provide the staff, electronic health record, and clinical day to day operations."
Rushika Fernandopulle, MD
Healthcare's 'Lack of Courage'
In addition to the clinic in Las Vega, Iora has clinics in five other states. Fernandopulle is an adamant patient advocate, viewing traditional health insurance as a nonstarter for innovating healthcare practices. But, he's a realist, and rather than keep insurers completely out of the loop of care, he says they have to be part of the solution, but on his terms. For example, instead of submitting codes for care delivered, Iora charges insurers a flat fee.
"I think what we have in healthcare is a lack of courage," says Fernandopulle. "I think there are a lot of us who realize that the payment model for primary care is silly. It doesn't allow us to do the right thing. Every other industry in the world, the sellers of the service decide how they want to get paid and the buyers decide if they want to take it or not."
Some insurers are taking the plunge with Iora. Tufts Health Plan, which has more than 1 million members, is scheduled to open two Boston-area primary clinics with Iora next month. The clinics are specifically designed for its Medicare and managed Medicaid members.
$45 of Prevention Saves $200,000 of Care
The reason that a model like Iora can take care of older patients, like the ones it will cater to in its newest clinics, and younger ones, like the ones in Las Vegas, is because it steps outside of the diagnostic box where fee-for-service medicine lives.
The protocols are evidenced-based, but since traditional health coverage is not a revenue stream, it is also not a barrier. And physicians employ whatever they need to do for a patient. For example, Damania says his practice gives patients $8 pedometers to start them walking. Fernandopulle once bought a $45 iPod shuffle from eBay for a patient who would leave in the middle of dialysis because of anxiety. The iPod was loaded with the patient's favorite music. The result?
"In six months, zero ER admissions; [the patient] sat through dialysis every time," says Fernandopulle. "This is a $45 iPod that solved $200,000 of healthcare costs. Why does no one else do it? There's no CPT code for 'Buy iPod on eBay,' there's no CPT code for 'Spend an hour to download music on said iPod.' But in our practice, it doesn't matter. It's the right thing to do for that patient. We do it for the patient."
Healthcare systems are using high-tech and high-touch approaches to reach patients where they are and with what they need, but an actively engaged patient remains an elusive partner in care.
This article appears in the July/August 2015 issue of HealthLeaders magazine.
Providing a patient with clinical care that is safe, effective, and costs less all are high-priority issues competing for the attention of leadership at hospitals, health systems, and physician groups. Top organizations are developing new models of care with the patient at the center of this new paradigm, but it is the patient who is a key variable that can sink a system's efforts.
In the April 2014 HealthLeaders Media Intelligence Report, The New Primary Care Model: A Patient-Centered Approach to Care Coordination, 59% of respondents cited patient engagement as one of the most challenging clinical components of primary care redesign. But it can be argued that patient engagement is a sticking point no matter the setting.
At face value, the term patient engagement seems straightforward. For example, patients who come in for their annual wellness exams on time, or patients with a chronic disease like diabetes who are faithfully taking their medication, monitoring their blood sugar, and coming in for regular checkups would be considered engaged patients.
But providers are finding that there is a lot of nuance to defining a truly engaged patient, one who is an active partner in his or her own healthcare. Settling on a definition is difficult, and measuring it is even harder. Those who have successfully engaged patients in their care have done so with a combination of human touch and technology, as well as an understanding that patience is essential when looking for long-term success.
Patient engagement requires a culture of compassion
In 2009, Brenda Jones was 57 years old, weighed nearly 400 pounds, and suspected she had type 2 diabetes. With no insurance, a temporary job in Dallas, and a sick father to take care of, she first turned to the Internet for help because she didn't have a regular primary care doctor—nor the money to see one.
"My urine started smelling sweet," she recalls. "At first it was faint, but then it increasingly got more noticeable, and it was like, 'What is that?' So, I Googled it, and every hit that came up said type 2 diabetes. I went and bought a glucose tester, and my sugar tested 320 mg/dL. I knew a trip to the ER wasn't what I needed. I knew this was going to be long-term care. I needed medicine and guidance."
Jones was like 17% of adults in the United States and 33% of adults living in Dallas at that time: employed without health insurance. But lack of insurance was just one barrier Jones faced. She says her access to affordable and healthy food was limited, she didn't know how to start eating healthier, and making a lifestyle change seemed too hard to do on her own. "It was too much for me to figure out," she says.
Such situations present a challenge for physicians, too, as they try to figure out how to get patients more involved in taking care of their disease outside of a hospital or exam room.
Last year, Jones recounted her struggle with barriers to care in front of a group of physicians who had gathered for the AMA interim meeting in Dallas. But she was a different person than she was in 2009. At 150 pounds and free of diabetes, Jones gave the room full of doctors advice on engaging patients: "Don't overwhelm a patient with information," she told them. "Patients are in crisis mode and can't handle very much."
Jones, who did not have any type of weight-loss surgery, and did not even take action to diet or exercise until 2012, says what kept her engaged and got her motivated to lose weight was the relationship she formed with Christopher Berry, MD, a family practitioner who has worked at three area nonprofit health clinics that care for low-income and uninsured patients. This is the patient population that Berry says he is passionate about working with.
The pair first met at Worth Street Clinic, a facility run by Baylor Scott & White Health, the Dallas-based healthcare system that includes 46 hospitals and 500 outpatient care sites. But, when Berry moved to become to be chief medical officer at a similar clinic, Mission East Dallas, Jones followed him.
"I come from a background of abuse," says Jones. "It's hard for me to trust anybody, and I'd come to trust Dr. Berry. I felt like he knew me. I wanted to go where he went."
Berry says Jones is the kind of engaged patient all physicians want—but rarely get.
"I have less than five 'Brenda' stories," says Berry. "Lifestyle is hard to change. What I've learned is that diabetes, depression, and obesity is a lot like treating addiction, in terms of hitting rock bottom. Doctors treat addiction in a certain way—to be compassionate. That's helped me think differently."
Berry's medical training was also slightly different. He completed the In His Image Family Medicine Residency Program, a Tulsa, Oklahoma–based program that is accredited by the Accreditation Council for Graduate Medical Education. The Christian-based program trains physicians to be compassionate and unafraid to tap into their spiritual side with patients.
Berry is not out to convert patients to Christianity, but he does pray with them, if they want. He did pray with Jones and says that spiritual dimension of care is a big part of their story.
"Addressing things like diabetes and weight was not going to touch what was going on with Brenda," he says. "It transcended into shame, fear, guilt, and judgment. How do you doctor in that space?" When patients learn that he will pray with them, patients' eyes "light up; sometimes they cry," says Berry.
"It's common in this population [low-income and uninsured]," he says. "At the end of a visit, I say, 'Do you have a religious preference? I'm a doctor who will pray with you.' When you work with people who are really in need more than the average person, you exercise elements of your personality that you may not have to exercise in other settings." Berry says the training he received helps him connect with patients in a more human way, which earns their trust and helps engage them in their care.
Establishing a solid relationship with patients is not the only factor that can improve patient engagement, but it helps, says Charles Wiltraut, CEO at Mission East Dallas, where Jones followed Berry in 2012. Wiltraut says Mission East Dallas, a federally qualified health center (FQHC), measures patient engagement through satisfaction surveys it administers to patients when they are in the waiting room.
The clinic designed its own survey to find out what its patients wanted. The patients are asked about how well the staff listens and whether the staff is giving advice on how to stay healthy. Patients drop off their completed—and anonymous—surveys in a secure box at the clinic. The number of patients who participate in the survey is relatively low, but that is likely because their health issue has reached an acute stage and their focus is on feeling better. Still, the surveys are an important tool for Mission East Dallas staff to see how they are treating patients, says Wiltraut.
"We have a mission to create exceptional patient experiences," says Wiltraut. "We're not a Medicaid mill. The culture we have here is we listen to our patients. We do warm transfers out of the room. We make eye contact."
Wiltraut says the clinic's most recent monthly survey of 60 patients shows that 92% report that the staff listens, and 80% report that staff members give advice on staying healthy. Another way he says Mission East Dallas tries to keep patients engaged is by having them on the board of directors. "Fifty-one percent of the board must be users of our facility," he says, referring to rules governing FQHCs. "There is no better way to engage patients than to give them a seat on our board."
The biggest cheerleader Mission East Dallas has is Jones, who was elected president of the clinic's board in January. Berry encouraged her to be on the board in April 2014 because of her dramatic story of engagement and improvement.
Michael Schaffrinna, MD
"I like being in involved with Mission East Dallas because I know how it served me and I am happy to give back," says Jones. "The community needs that center for people like me. Without it, they're wandering around hopeless, trying to get somebody to help them."
FQHCs play an important role in caring for socioeconomically challenged and underserved populations. In 2013, the California Primary Care Association studied claims data from 134,797 adults who received Medi-Cal benefits. Researchers compared two groups of patients within that population: those who used a FQHC to receive healthcare and those who did not. The patients who used services at an FQHC had an 8.2% 30-day readmission rate while non-FQHC users had readmission rate of 13.1%. A non-FQHC patient was also more expensive, costing $656. Patients who were FQHC users cost $414.
Do these metrics point to a more engaged patient population? Yes, says Wiltraut. "It means we are managing care and seeking to be a medical home for individuals and families."
Mission East Dallas also is improving patient outcomes with key populations. For example, in 2012 the clinic was not screening adolescents for obesity; now the screening rate is at least 56%. Its rate of appropriate treatment for asthma increased from 60% in 2012 to 85% in 2013.
Patient engagement requires time and trust
Another organization trying to improve patient engagement through its culture is Yakima-based Community Health of Central Washington, a network of four medical clinics, one dental clinic, a family residency program, and providers who care for seniors in residential facilities as well as hospitalized pediatric patients. Each medical clinic is an FQHC and recognized as a patient-centered medical home by the National Committee for Quality Assurance.
"We have to engage everyone on our staff—nursing, providers, front desk, reception, medical assistants—to look for opportunities where we can improve the interaction with our patients," says Michael Schaffrinna, MD, chief medical officer of CHCW. "The patient engagement challenge is about time. Healthcare teams need enough time to focus on patients and their needs in order to have credibility. It has been shown that when patients know you care, they are more likely to follow care plans."
He says CHCW took last year to define what type of culture the organization wanted to have. Employees were placed into six groups and asked to come up with ideas. From those sessions, four key words emerged that Schaffrinna says are getting pushed out into the organization continuously: helpfulness, encourage, team, and accountable. Staff members receive a coin to acknowledge their demonstration of those attributes with patients. The coin says "roundtuit," referring to the phrase "You got around to it."
"It's acknowledging staff for taking the extra time," says Schaffrinna, who says the coins are a first step to getting nurses, physicians, and other staff engaged in the extra effort it can take to make a patient aware that they are an equal partner in their care. "Mental health issues, overweight patients, chronic disease—these are opportunities we'remissing because we haven't engaged early enough."
CHCW has only just begun handing out the coins, which can be exchanged for a vacation day. Schaffrinna says he is determined to change the culture at the organization, not because its providers aren't doing a good job, but because he thinks they can do better.
"Every one of our locations is a patient-centered medical home," he says. "When an organization gets to that level, they're better than they were, but it's too low of a bar. Engaging a patient is more than giving them information. They have to trust you. If we don't take control of this ourselves and make it better, our patients are going to suffer."
CHCW has made small improvements in its care of the 30,000 patients its providers see annually. The rate of women receiving prenatal care has improved from 78.5% in 2011 to 80.5% in 2013, and the rate of childhood immunizations increased from 72.9% to 84.2% over the same time period.
Patient engagement is activation
Healthcare organizations have a variety of ways to measure patient engagement. They may look at health outcomes over a period of time, or measure patient satisfaction, or encourage and monitor interaction with the organization's online tools. But a researcher at the University of Oregon put a finer point on the definition of engagement and developed a statistically validated and peer-accepted method to measure a patient's activation level.
Judith Hibbard, DrPH
Judith Hibbard, DrPH, is professor emerita in the department of planning, public policy, and management at the University of Oregon, and serves on the leadership team of Insignia Health as the lead researcher and developer of the Patient Activation Measure. PAM is a 10- or 13-question survey a patient takes to assess his or her knowledge, skills, and confidence in managing his or her health. The results of the questionnaire assess patients on a 0–100 scale and can be used to categorize them as a 1, 2, 3, or 4, with 1 representing the lowest activation level and 4 representing the highest.
According to the description of what PAM 1 means, a patient at this level is likely to feel "disengaged and overwhelmed." As the levels increase, so does a patient's confidence. At a PAM level 2, patients are "becoming aware, but still struggling." At a PAM level 3, patients are actively taking a role in the management of their health, and a PAM level 4 patient has made and kept healthier habits. Hibbard has been studying patient activation for 10 years, and has published many peer-reviewed studies that repeatedly show a patient's activation level is related to health outcomes.
"Patients who are less activated are twice as likely to have a 30-day readmission," says Hibbard. "If you look at a commercially insured population, about 30% are in the bottom two levels of PAM; in the Medicare population, 40% are in the bottom two activation levels; and in the Medicaid population, 50% are in the bottom two categories. Becoming activated is possible for everyone."
Time is a critical element to engaging patients. Whether it is encouraging staff to spend more time with patients to get them engaged, as Schaffrinna suggests, or giving patients more time to become active in their own care, Hibbard says that model of care for which most physicians have been educated and trained does not encourage true patient engagement.
"Most physicians are trained to give patients information, and if the patient doesn't follow through, that's not the doctor's problem," she says. "That model doesn't work. In healthcare, we often ask people to do things that are way beyond their capabilities. People want to have good health, but for some, their motivation is muted because they are overwhelmed and discouraged."
Valerie Overton, DNP, FNP-BC
Hibbard developed PAM to give physicians a starting point for determining how motivated, confident, and knowledgeable their patients are. The tool is gaining traction with healthcare providers. According to Insignia Health, the Portland, Oregon–based company that licenses PAM, there are 140 health systems, hospitals, and physicians who use the tool in the Unites States and United Kingdom.
Minneapolis-based Fairview Health Services, a nonprofit health system that includes seven hospitals and more than 40 primary care and specialty clinics, has been collecting PAM scores on patients who visit the system's primary care clinics since 2010.
Valerie Overton, DNP, FNP-BC, vice president of quality and innovation at Fairview Medical Group, which is part of Fairview Health Services, says the medical group began measuring patient activation because leaders believed it would help capture the value of patients' health.
"We believe that one of the most important moves of the future for primary care is not only an emphasis on the measurement of disease-related outcomes but the measurement of health outcomes," Overton says. "As we move forward as an accountable care organization, we will be able to talk about how much health we produce for dollars spent."
A study of PAM scores collected from 33,163 Fairview Medical Group patients in 2010 found that patients with a PAM level of 1, the lowest, incurred a higher cost ($966) than patients who were PAM level 4, which is the highest level of activation. These patients' healthcare costs were $799. The results proved to Overton that PAM is a valuable tool, but clinicians were reticent to use PAM actively, she says, because it wasn't clear that if patients' PAM levels changed, their clinical outcomes would, too.
"Clinicians are evidenced-based," says Overton. "There's a time investment that it takes for clinicians to interact with patients, and clinicians really want to understand, 'If I'm going to change my approach, it really is going to make a difference.' "
What has not been clear is what a physician can do to improve a patient's activation measure. First, Overton says she had to gain physicians' trust about using PAM with patients. Now, even though definitive clinical outcomes are not yet available, the results of the most recent PAM study have allayed physicians' concerns, says Overton, because researchers found that when PAM levels improve, so does patient health.
Published in March in Health Affairs, a longitudinal study of patients who had their PAM levels taken twice, once in 2010 and again in 2012, showed that 58% of patients did not move between PAM levels, but of the 42% of patients who did either increase or decrease their activation level, their outcomes and costs moved with them. For example, 9% of patients with a baseline of PAM level of 3 or 4 moved to a PAM level of 1 or 2. Those patients' incidence of having higher A1c levels, going to the emergency department, and being obese also increased, as opposed to those who improved their PAM levels.
Fairview Medical Group is engaging with its clinicians now to figure out what interventions are most effective at improving a patient's PAM score. "This study is a turning point for us," says Overton. "We're trying to understand how to help our clinicians embrace certain ways of interacting with patients that are engaging to patients and are likely to improve their engagement. What does it really take to change activation levels? We're looking at patient-facing technologies, patient monitoring, websites related to their disease management, and improving provider interpersonal communication skills and coaching skills."
Overton says the medical group has taken a step in determining how it can improve patients' PAM scores by differentiating how patients are managed. For example, Fairview Medical Group experimented with using health coaches to help depressed patients. She says the group added a health coach to the care management of mildly to moderately depressed patients with a low PAM score. The additional resource was supposed to improve patients' depression, but what the group found was that the combination of depression and low activation was too much for a health coach to handle. Overton says they learned that patients needed more targeted resources.
"We're going back to the drawing board," says Overton. "We're pursuing using more behavioral health counselors for patients with depression and a low activation score, but using health coaches for patients with high activation scores. Our behavioral health resources are scarce, and we want to make sure we get the right patients to the right resources."
The lesson learned, says Overton, is that PAM isn't only useful for physicians and patients, but also for the system. "You can't care manage or case manage everybody. If you're going to deploy scarce resources, PAM can help you figure out which subpopulations to deploy your resources to."
Patient engagement is high-tech and high-touch
Technology and patient engagement go hand in hand at Geisinger Health System, the Danville, Pennsylvania–based integrated health system with nine hospital campuses, a multispecialty group practice, and a health plan. With one of the industry's most mature electronic health record systems, GHS has been able to leverage patient data and technology to help get and keep patients engaged.
Interestingly, the patient engagement strategy at GHS was largely informed by Hibbard's research into patient activation, says Albert Bothe, MD, FACS, executive vice president and chief medical officer for GHS. "Dr. Hibbard's work was a demonstration that effective care wasn't just the skill of the provider," says Bothe. "It correlated the engagement of the patient with the recommended treatment."
Bothe says Geisinger doesn't use the PAM questionnaire, but it did use the concept of helping patients get activated earlier in their treatment by providing them access to websites that explain upcoming procedures. The strategy that began seven years ago has developed into what is now a robust approach to engage patients with a combination of high-tech tools and high-touch providers.
"An engaged patient is a healthier patient for us," says Gregory Moore, MD, PhD, chief emerging technology and informatics officer, and director for the Geisinger Institute for Advanced Application. "If you're a Geisinger patient, you've become used to multiple individuals reaching out to you and in different ways. It's not unusual for a nurse navigator to call and say, 'Hey, I notice you have a couple of open care gaps. You haven't gotten to that eye exam we've scheduled for you. Can we assist in getting you a ride there, or can I make that appointment at a more convenient time for you?' "
Closing those gaps in care is a key way that Geisinger measures patient engagement, and it's also used as provider incentive. Moore says physicians have 20% of their salary "on the line" for meeting quality metrics, one of which is closing care gaps. "You only get credit for closing your patients' care gaps if it is 100%," says Moore. "The metric that matters is not the number of care gaps, but how many times we get to 100% of care gaps closed."
Moore describes the GIAA as think tank and research lab for patient engagement, big data, and big concepts like population health. "We're the ideation part," he says.
The GIAA is made up of three centers: the Center for Clinical Innovation, the Center for Reengineering Healthcare, and the Center for Emerging Technology. The Center for Clinical Innovation is the laboratory for patient engagement pilots that—if they are able to demonstrate better care, cost, and patient satisfaction—are rolled out to GHS.
The Center for Clinical Innovation is where the care gap program was piloted. It gets patients with chronic diseases up to date on their immunizations, routine checkups, and lab tests. That keeps them engaged with the system, both with technology tools that GHS is constantly testing and with providers (because patients have to come into GHS clinics). The data from the pilot showed that from 2010 to 2013 there were not only fewer gaps in patient care, but there was also a $30 million increase in revenue because patients were getting more and necessary care. "That was an unexpected by-product of doing the right thing for the patient," says Moore. "We were focusing on patients with diabetes, hypertension, chronic obstructive pulmonary disease, and figuring out a reliable way to close those gaps in care."
Moore says a care gap is typically identified in the patient's EHR before the patient comes in for the appointment. Depending on the patient's preference, either a phone call, text, or email will outline what to expect, including whether it is time for a foot exam or a vaccine, for example. If it's a foot exam, the patient will be asked to remove shoes in the exam room. It's a small action that reminds the doctor a foot exam is due, though GHS' technology makes the care gap nearly impossible to miss. It is noted in the EHR so that the front desk sees it when the patient checks in, the nurse sees it when rooming the patient, and the physician sees it on the EHR screen in the exam room.
"We've found that the patients themselves are reminding the nurse and alerting their care team," says Moore. "It's about those communications. Everyone is getting information before the visit." The number of gaps that GHS closed during 2010–2013 was 250,000.
Another patient engagement initiative recently rolled out at GHS is the use of OpenNotes, which gives patients and their caregivers access to providers' notes about their care through a secure patient portal. GHS has had a patient portal since 2001. It now has 300,000 registered patients, with a daily log-in rate of 15,000–20,000. The large patient population using the portal made it a natural fit to be one of the first pilot sites for OpenNotes in 2010.
"There was concern among the physicians in allowing patients to read their own notes," says Bothe. "But after the pilot study was done, all the patients who were surveyed and all but one of the physicians wanted to continue allowing access to the notes."
The study Bothe references is from the Annals of Internal Medicine in 2012, which showed that patients appreciated the ability to see their doctors' notes and to add to them to give a more complete picture of their medical history. According to the study, 77%–87% of patients said they felt more in control of their medical care, and they also reported better medication adherence. Bothe says OpenNotes is now in every department, except for mental health (psychiatry/psychology), interventional pain management, and otolaryngology.
GHS patients may be used to technology—touch screens are in every primary care exam room, some waiting rooms have iPads, and the MyGeisinger portal is also a patient app—but Chanin Wendling, director of eHealth for the division of applied research and clinical informatics at GHS, says the technology tools exist to support the patient and provider relationship, not replace it.
"We're not looking to not talk to the patient," she says. "That face-to-face time or time on the phone is still important. I'm not giving anybody a complex cancer diagnosis over a mobile app or secure message through a patient portal, but what I can do is once that doctor has had that conversation, I can reinforce care plans and give patients tools to deal with a life situation where they're going to have to think about their diet or medications."
Wendling says she studies consumer technology trends to find out how GHS can become part of a patient's routine so that it is easier for patients to be engaged with their health. A small weight management study that utilized text messaging showed positive results that Wendling says may provide a clue to patient preferences.
From November 2012 through April 2013, 700 gastroenterology patients who were trying to lose weight enrolled in a program that delivered a text message to them three days a week over 12 weeks. The text messages were motivational tips and reminders to keep weight management "front and center."
"When providers have the patient in the office, they talk about all of these strategies and get the patient pumped up, but then the patient doesn't come back for three months or six months and maybe didn't remember all the things that were said, or had trouble keeping their motivation up," says Wendling. "These text messages would come and be a little kick in the butt."
The pilot program results showed that patients who participated in the text messaging pilot lost 0.5 body mass index more than patients who didn't participate. "Going from a 50 to a 49.5 BMI may not be a huge difference, but you have to start somewhere, and the text messaging program is cheap," says Wendling. "It's not a huge cost to the system, and it's good for people who are obese, have diabetes, and high blood pressure. There are a lot of people you can touch with this program."
The text messaging program for weight management was made available across the system in 2013. That coincides with another text messaging program that has had a high adoption rate among patients. Wendling says GHS began enrolling patients in its appointment reminder via text program in October 2013 as patients came into clinics. She estimates it took a year and a half for all patients to receive information about the program because some patients only come in once a year.
"We have over 200,000 that have signed up," she says. "We consider our active patient population to be about 550,000, so that adoption is tremendous. That clearly states people want a text message reminder."
Wendling says paying attention to how patients want to be communicated with is an important step in understanding how to engage them in their care. She wants to figure out how to work healthcare into patients' normal, daily routine.
"Patient engagement is all about the patient taking action," says Wendling. "In order for the patient to take action, in my view, you have to work with them in a space they're comfortable with. I'm not trying to get the patient to do something they wouldn't normally do. I'm trying to weave our health system into how they live their life."
Patient engagement is personal care coordination
The dynamic technology solutions at GHS are not only for large integrated health systems. North Atlanta Primary Care, a patient-centered medical home with seven locations in the metro Atlanta area, also uses technology to close gaps in care, but its real secret to patient engagement, says founder Thomas Bat, MD, is physician assistants.
"We would not be here without PAs," says Bat, who initially used a PA in 1989 to fill in temporarily during a busy flu season. The PA he hired had 25 years of experience and proved to be invaluable, so Bat kept him and has since hired
14 others.
Bat sees PAs as an integral part of providing team-based care to the 550 patients NAPC providers see daily. "Every patient has a care plan," he says. "My office managers have a spreadsheet of every patient seen, and every day they use it to look for gaps in patients with chronic disease, then they develop a daily call sheet."
Though NAPC has a portal with 100,000 patients who could get their information about a missing exam or checkup through a secure message, Bat says the PAs get a list of 10–20 people to call per day. The patients respond better, he says.
"We find that when a PA calls to follow up with a patient, 85% will make an appointment within the next week," says Bat. "Patients like it when they talk to someone who is educated."
Dawn Morton-Rias, EdD, PA-C
The education track for PAs is often cited as one of the reasons they work well as midlevel providers, or physician extenders, the term Dawn Morton-Rias, EdD, PA-C, CEO of the National Commission on the Certification of Physician Assistants, prefers.
"While PAs have a very scientific approach, we have formal education on interviewing and patient engagement—how to gather medical history, ask open-ended questions, how to make eye contact, body language," she says. "You have classroom instruction long before you get out to the clinical practice."
The use of PAs in family medicine, specialty practices, and emergency medicine has grown considerably since 1975, when the NCCPA certified the first PAs. Since 2009 alone, PAs have increased in from 74,777 to 101,977 in 2014.
PAs, along with nurse practitioners, are providers who can free up time for a physician to see more complicated cases. PAs practice under the supervision of a doctor and can examine, diagnose, treat, order tests, and develop treatment plans. Bat says using PAs to their full extent allows his practice to give patients the time they need to understand their health condition, which can be complicated because 70% of NAPC patients have a chronic disease.
"We shoot for a 1:1 ratio of PA to doctor because they can exchange patients," says Bat. "If they're unsure about a next step, they can say, 'Hey doc, can you jump in on this patient while I do your refills?' It keeps the flow going."
Technology is also a part of NAPC's patient engagement strategy. Its patient portal has 100,000 registered users, which Bat says encourages compliance with patients who use it. Despite being an early adopter of electronic health records—NAPC won the Nicholas Davies Award from HIMSS in 2004—Bat says portals have their limitations, and are not the primary answer to the question of how to better engage patients.
"Portals are good and bad," he says. "Some patients love it. The technology allows patients to go more in depth with education and articles I can put out on the portal for them, and that's where it's positive. But the above-60 crowd, who has much of the chronic disease, does not use it as much as younger patients. They want one-on-one time. My goal is to have an app that fits in with patients' lives."
The tug-of-war between giving a patient more time or more technology is a struggle that most healthcare providers continue to have; however, as some organizations have found, it is a combination of both that has the best chance of getting a patient to be an active healthcare partner.
As hospitals and health systems continue to grapple with patients who have significant health issues but little motivation, Bothe says it is important to remember that health literacy is a significant challenge.
"How readily patients can have a conversation with their provider is a two-way street," he says. "If a provider recognizes a patient has limited fluency with medical terms, the provider needs to change the vocabulary and the pacing of explanations."
It is also the tone a provider strikes with a patient. Empathy is what Jones valued with Berry so much that she followed him from one clinic to another. That five-year relationship led to an extreme turnaround in her health. Remarkably, Berry did not ever ask Jones about her weight. Should he have? Jones says yes, probably, but she was relieved he didn't because it was embarrassing. Berry says more doctors need to recognize the delicate balance of knowing when to talk to a patient and when to listen.
"It gets back to that need for us doctors to be sensitive, to not be seen as accusers or judges to people who may already feel ashamed," says Berry.
And though Jones is no longer under Berry's care because she doesn't have diabetes and because he's also moved on to help another Dallas clinic become a FQHC, they still keep in touch.
"I miss him terribly as my doctor," says Jones. "I miss him praying with me. I had been able to talk to Dr. Berry about not just physical stuff, but hurts in my heart. He always took his time with me. I still feel that the doctors at Mission East treat all of me—the physical, emotional, and spiritual."
Reprint HLR0815-2
This article appears in the July/August 2015 issue of HealthLeaders magazine.
Improving cost, quality, and outcomes is not accomplished only from the C-suite, it requires strong leadership from within operating rooms and physician offices.
Developing capable physician leaders is one of the many priorities healthcare executives name as a component to delivering a better patient experience, as well as improving costs and outcomes.
Hospitals, healthcare systems, physician groups, and insurers realize the value of having a physician champion in their corner, especially with the massive paradigm shift in healthcare right now. A strong physician leader—formal or informal—can impact process improvements, from reducing readmissions to perking up patient satisfaction scores.
Ali Rahimi, MD, director of performance improvement development and cardiovascular quality at Atlanta-based Southeast Permanente Medical Group, teaches a four-day performance improvement course that is open to anyone in a management position at a multi-specialty practice that is the contracted physician arm for Kaiser Permanente (KP) of Georgia.
"It's important to teach our young physicians the complexity of the healthcare system," he says.
A Broad Perspective
Rahimi is 41-years old, and is a fellowship-trained cardiologist, but before going to medical school, he received his master's degree in health policy and management. That education opened his eyes to the intricacies of health system performance and helped set him on a course toward becoming a physician leader who wants to develop leadership capabilities in other physicians, too.
"I wanted to get a public health perspective," says Rahimi. "I knew the medical degree wouldn't prepare me for that. I think having that public health experience gave me the underpinnings of having a better voice and being an active participant in the science of performance management."
To be a physician leader, it's not necessary to earn an additional master's degree, though many of today's disruptors and innovators have MBAs.
Rahimi says an important part of the class is the variety of participants. They include physicians, hospital case managers, operations directors, front office managers, and pharmacy techs among others.
"In order to improve performance, you have to bring everyone in; it's not filled with doctors," says Rahimi. "You have to teach them the science of process improvement, such as how to look at data. It gives them a new perspective on how they can solve a problem. That's how we go about getting better."
Once the four-day class is over, the "graduates," as Rahimi calls them, return to their departments tasked with working on performance improvement project. The course is offered twice a year and is spread out over four months—one session per month. So far, the class has graduated 35 management team members over the last three years. Rahimi says this year's next class will have 29 health system leaders attending—its biggest class ever.
Generational Hurdles
One challenge that remains, even for a large, integrated health delivery system like KP of Georgia is the generational divide between younger and older physicians.
"It's hard; it's difficult," says Rahimi. "It's like coming from two different countries."
To bridge that gap, Rahimi recommends that physicians of all ages get involved in their medical associations and local societies because it is a neutral forum.
"You have to understand where older physicians are coming from," he says. "What are our shared goals and perspectives? Having physicians in larger practices who have a sense of the challenges in the smaller practices is one way to bridge the divide, and [another] way we minimize it is we need physicians to be active in organized medicine."
Ali Rahimi, MD
According to a survey of 20,000 physicians in 2014 by the nonprofit Physicians Foundation, 58% of physicians in the U.S. are under 45, and of that group, 66% are employed by a hospital or medical group. The trend toward employed physicians is expected to continue growing, but it's not clear if physician satisfaction grows with employment, too.
Some physicians find shelter from administrative burdens and declining reimbursements in an employed model, which relieves the hassle of being a business-owner. But employee status can introduce a new set of frustrations, such as lack of control over patient care.
It seems the variable is dependent on the business model of the organization where a physician works. Rahimi says he intentionally sought out employment within KP of Georgia because he saw healthcare transformation on the horizon and the organization's structure supports value-based care.
"I see 14 cardiology patients a day, and I spend 30 minutes with each patient," says Rahimi. "In private cardiology practice, it's more like 25 to 30 patients a day. I'm in the minority, not everyone has this benefit, but with a system this big, there are challenges."
Physician leadership is a strategic focal point for all organizations. For example, within particular hospital service lines, physician leadership is a growing concern, says Katy Reed, a consultant with ECG in Seattle.
"The governance piece is important," she says. "A lot of organizations contend that physician involvement in the cardiovascular service line key, but they have to be interested in wearing multiple hats."
Identifying which hat a physician needs to wear may be an important issue, but so is realizing that the onus isn't entirely on the physician. Rahimi says healthcare organizations—big or small—have to realize the importance of bringing in a physician as an equal partner.
"We are just one component," he say, ticking off the other healthcare stakeholders such as lab, imaging, medical records, and hospitals that all are touch points of patient care. "That's the concern physicians have: The ownership of the risk should be shared by everyone. We recognize it's not just the physicians. It's a system issue, and we need to get better at process management."
Leaders of five New Jersey hospital and health systems are pushing to fundamentally change the state's mental health system, which they believe is in crisis.
Three of New Jersey's counties—Camden, Burlington, and Gloucester have a need for mental health services that outpaces the availability of providers, a 2013 community health assessment revealed. The news wasn't too surprising, especially for area hospitals that have seen a significant increase in behavioral health patients who are using the emergency department for help.
Russell Micoli
"Hospitals are carrying an inordinate burden," says Russell Micoli, vice president of ambulatory services at Kennedy Health System, an integrated health system with three hospitals, outpatient care, physician networks, and more than 4,000 employees. Its service area includes the same southern New Jersey counties that were included in the 2013 community health needs assessment.
"Because of the failures of the mental health system, people really only have one place to go—the ED—it's no eject, no reject," Micoli explains.
Kennedy Health is one of four hospitals in a newly formed alliance that has vowed to work together to improve mental health for southern New Jersey residents. The group is called the South Jersey Behavioral Health Innovation Collaborative, and includes Cooper University Health Care, Inspira Health Network,Lourdes Health System, Virtua, and Kennedy Health. What's different about this collaborative is that it is an effort being led by the CEOs of all five systems.
"These hospitals are coming together in a way that we have not seen in our state before," says Mary Ditri, director of professional practice for the New Jersey Hospital Association, which is also part of the collaborative. "The CEOS have taken the bull by the horns. Hospitals have to do a community needs assessment, but these hospitals came together as a group to do theirs because the state system is not working in our area."
High Utilization
Ditri says New Jersey Hospital Association data showed a significant increase in patients with mental health needs using emergency departments statewide. In 2010, behavioral health patient volume in the ED was 14.35%; in 2014, it rose to 17.31%. In 2014, that represents 534,517 behavioral health patients showing up in a New Jersey ED. Statewide, there are a total of 1,425 beds. In Camden, Burlington, and Gloucester counties, the scenario is similar, says Micoli, who is chairman of the collaborative.
"On average, a patient could wait anywhere from 12 to 72 hours," he says. "There was a day at our Cherry Hill [hospital] campus where we had 25–30 referrals for two beds. That means there were 20 plus patients waiting for hours for a bed to open up."
One problem the collaborative is aimed at solving is the arduous and time-consuming process for involuntary commitments. The rules for committing a patient involuntarily vary from state to state, and the rules are meant, in part, to intervene when patients are a danger to themselves or others. Micoli says the process can involve up to four different people: a certified screener, a psychiatrist, a doctor, and a judge.
Mary Ditri
"It's really inefficient, and you have a family who is in crisis," he says. "We are working now on a waiver that would allow an ED physician to complete the commitment papers, once the patient has been seen by a certified screener."
Any deviation from the process requires a change in state regulations, but Ditri says the mental health situation in New Jersey has gotten so bad that legislators are paying attention.
Progress
"They are listening to hospital providers," she says. "They just came from roundtables where they toured the state, and we are bringing in thought leaders from across the country. The models we are looking at focus on patient throughput. We all agree that the majority of patients who come into the ED don't need to be there."
Some of the leaders the collaborative is listening to include Scott Zeller, MD, chief of psychiatric emergency services at the John George Psychiatric Hospital that is part of the Oakland, CA-based Alameda Health System.
Zeller developed what is known as the Alameda Model, which routes behavioral health patients from the ED to a regional psychiatric emergency service facility that is suited specifically for psychiatric patients. Zeller's model has received a lot of attention in behavioral health circles because it has demonstrated a reduction in patients waiting for an inpatient bed. Zeller also found that only 24.8% of patients ultimately needed a bed.
Micoli also believes the approach of just adding more beds will not solve southern New Jersey's problem.
"We have a mental health system that developed its deep end first—inpatient and crisis screening, but there is more opportunity in developing alternative services in the community," he says. "Those community-based services are just not there to help folks stay out of the hospital."
The collaborative is also getting help from the Camden Coalition of Healthcare Providers (CCHP), a Medicaid ACO led by Jeffrey Brenner, MD. Micoli says Brenner's work in identifying "superutilizers" of the ED is helping hospitals in the collaborative understand the data needed to identify patient flow.
"Our goal will be to create a geospatial map that tells us where patients are moving," says Micoli.
The collaborative was initially set up to last for one year, but Micoli and Ditri expect that it will last longer. The work the hospitals are putting in will net results this year, however. Ditri says recommendations from the collaborative will come out later this year, in three different tiers:
Local level changes with minimal regulatory or administrative requirements
Applying for a new state waiver to change the involuntary commitment process
Larger system reforms with long-term goals
It is significant that the mental health needs of a community have captured the attention of hospital CEOs. Physicians, nurses, and families are familiar with the gaps in service and care for these patients. The CEOs of five major hospitals are working together to improve access and care for these patients. They have committed time and money to attempt to change state policy while also assessing changes needed at their own facilities. In raising the profile for mental health services, they are also raising the stakes, says Micoli.
"The CEOs want to see a change in their EDs. This effort is looking for meaningful but sustainable change. We want results," he says.
A rural healthcare organization makes a physician its CEO and partners her with a former CEO to add the credibility of a physician's voice to its conversations about quality of care and patient experience.
This is the second in an occasional series of conversations with physicians who also lead hospitals, health systems, and other provider organizations. In this installment, I talked with Deborah Agnew, MD, FAAP, andKelley Evans, who will co-lead a new model of leadership at a rural organization in Montana.
Billings Clinic, one of the largest healthcare systems in Montana, recently appointed Deborah Agnew, MD, FAAP, to be one half of the new CEO/CAO dyad leadership model at two of its sites: Beartooth Billings Clinic and Stillwater Billings Clinic. Both sites of care are rural integrated healthcare organizations, which bring together physician offices, an emergency department, and a 10-bed critical access hospital under one roof.
Agnew's new role is CEO; Kelley Evans, who will be CAO (chief administrative officer), has served as CEO at one of the sites—Beartooth Billings Clinics—for more than two decades.
The new leadership model and partnership between Evans and Agnew is only one month old. They both told me they are committed to developing a strong relationship that will empower patients and strengthen rural healthcare.
HealthLeaders: What prompted the change in developing a leadership model that establishes a physician as CEO and co-partner of two Billings Clinic hospital sites?
Agnew: I think it was a long time coming to this level, but it has been foundational.Eight years ago, the clinic really stepped back and looked at our structure and strategy goals and recommended that if we wanted to have physicians at the table, we needed to give them dedicated administrative time and compensation.
They created the division chief council—a department manager and a department chair. I was chief of primary care, and my partner was a director of women and children's services. That was established with the goal of fortifying the dyad model. This opportunity came up in the spring when they decided they'd bring together a longstanding partner with experience, Kelley Evans, and partner her with me.
We are equal in terms of accountability for success. We also really needed to spread out the cost for two facilities. I would say that we've taken the lead from Mayo Clinic—they endorse this model, and we've learned a lot from them. It's another force.
Evans: I've been at Beartooth for 25 years. For the first 10 years, we were a nonaffiliated organization, but when things became more complex, more challenging, the board chose Billings Clinic because of its reputation for quality. [Editor's note: last month Trinity Health announced that it had signed a Letter of Intent between Trinity Health and the Billings Clinic RegionalCare Hospital Partners Joint Venture in which Trinity Health will become part of Billings Clinic RegionalCare.]
Deborah Agnew, MD, FAAP
In 2010, we opened new replacement facility, and with the integrated model, we started looking at how to get it to be physician-led. We did an experiment, creating administrative time for a physician, but immediately the result was diminished revenues in the clinic. Billings Clinic became aware that Beartooth was struggling to find a balance. The opportunity came when the CEO of Stillwater made a decision to retire.
HealthLeaders: Dr. Agnew, what has been your approach to developing your skills as a physician leader?
Agnew: When I was chosen to be the chief of primary care eight years ago, foundational to that was the commitment by the organization to prepare me. During the first three to four years it meant getting a lot of extra training, and there is a lot available. I learned about finance, strategy, bargaining, physician recruitment, EMRs, and process improvement methodologies.
I'd go away for a week and come back and put it into practice. My willingness to take this job was entirely dependent on who my partner would be, and Kelly [Evans] was the clincher for me. I found someone equally willing to try. I also feel like I don't have full accountability. It's shared. We get to be experts together. That's a new thing, because all roads lead to one person. Sometimes I step forward, sometimes Kelly will step forward. I hope we can prove this is very successful. Having many, many lenses into how you tackle things is healthy. This was a unique opportunity to step into this role with the right partner.
HealthLeaders: Kelley, as a longtime CEO, what kind of progress do you feel has to be made in the next six months?
Evans: We need the credibility of a physician's voice when we are talking about quality and patient experience. It's an incredibly close relationship that physicians build with staff who are impressed and awed by a physician's presence. They are the leaders of your organization, with or without a title, and the temple of quality is set by the physicians. I've seen it.
For rural organizations, they are the silent leaders. They can create incredible moments of greatness when a life is saved in the rural ED. That's what I see as the two key things we will be looking at: patient experience and the relationship staff have with physicians.
HealthLeaders: What kind of structure are you setting up to determine how to co-lead at two different physical locations?
Kelley Evans
Agnew: We have accountability for these two organizations, but there are bridges being built with Billings Clinic. We are both affiliated with Billings Clinic, and they have a clear set of goals: quality and patient experience. All three organizations are in sync; our role, our job, and our goal is figuring out the best practice at the regional, system, and local levels.We have intentionally spent a fair amount of time together in both organizations. We want the leaders to see us together; we want to meet together. We've spent more time at Stillwater because they lost their leader. It's important for us to be there to reassure them that things will be okay.
There's no sense of loss at Beartooth at all. We've been putting out a lot of fires, and it's great because it gets you down in the weeds quickly, which is where you need to be. We are embarking on something very powerful, and we are deeply committed to culture being a driving force.
Evans: We both feel a lot of pressure in this first six months. Everyone is looking to see what will happen. Fortunately, we're both coming into this with both organizations doing well financially. One of the most important things for Deborah is for her to establish a relationship with both boards, and both of us adjust to the culture.
They are dramatically different cultures. To make good leadership decisions, that piece has to come together quickly. After 25 years, I don't want to be stale, I like new ideas, innovation, and change, and it seemed the right solution at the right time. I'm delighted.
More than half of the providers participating in CMS's Independence at Home demonstration project received bonus payments for improving cost and quality of the frailest, sickest Medicare patients by keeping them out of the hospital.
In 2012, the Centers for Medicare & Medicaid Services announced an ambitious project, Independence At Home, to tame the rising costs of caring for one of the costliest patient populations: the frail elderly. Now, three years later, results from 17 providers are in, and they are positive. More than half (53%) have been given bonuses ranging from $275,000 to $2.9 million for shrinking Medicare costs and improving patient care.
MedStar Washington (D.C.) Hospital Center, a 926-bed hospital that is one of ten within the $4.6 billion nonprofit MedStar Health system, will share a $1.8 million bonus payment from CMS with two other providers, Penn Medicine and Virginia Commonwealth University Medical Center. The three providers form the Mid-Atlantic Consortium (MAC), which received the second-highest bonus awarded. The payment will be split three ways, based on the proportion of patients each provider had, says K. Eric De Jonge, MD, co-founder of the Medical House Call program at MedStar Washington.
K. Eric De Jonge, MD
"The consortium was formed to apply to be an Independence At Home site. We accepted the results as a team," says De Jonge, who estimates that his site saw 60% of the 400 patients studied.
The MAC was able to reduce Medicare costs by 20% for frail elderly by providing all the care the patients needed at home instead of at the hospital. Instead of spending the projected $5,076 per beneficiary per month, the MAC providers spent $4,060.
Preventing Anxiety and Readmissions
For Arnold Goldberger, an 88-year-old retired physicist, the MedStar program has given him peace of mind. He helps take care of his wife, 87-year-old Avriel Goldberger, who has two chronic medical conditions, which is a requirement of the Independence at Home program.
"Prior to the House Call program, I was calling and making routine appointments in northern Virginia, going to a waiting room full of people," he says. "Now, a nurse comes once a month, takes our vital signs, checks in with the doctor, and you see the same nurse every time."
The nurse who visits the Goldbergers is part of a 10-person team that includes physicians, NPs, social workers, and an LPN and business manager. At each house call, which the Goldbergers try to schedule around lunch so they can visit with the nurse or doctor, vital signs are taken and medications are reconciled.
"They don't take our word for it," says Goldberger. "They say, 'Take out the bottles.' They are very thorough and they never rush you, like they do at the hospital."
Last year, MedStar published results from the House Call program showing that it cost less to provide care at home than at hospitals or physicians' offices. MedStar's study focused on the total population of its House Call program while the CMS demonstration project studied the sickest subgroup.
"Independence At Home examined the more expensive subgroup … in our study, we showed a 17% reduction overall, but it was averaged out," says De Jonge. "You can save a lot more money in the high-cost subgroup because before, patients were getting subpar care. They had to use 911 because they didn't have good access to urgent care, and they ended up in the ED, and because they are so sick and medically needy, they ended up in the hospital."
Arnold Goldberger's experience backs up De Jonge's claim. Earlier this year, his wife slipped and sprained her ankle. Within an hour, Goldberger talked to two nurses, his wife's ankle was x-rayed, and the diagnosis was "nothing serious."
"Compare that to going through 911, an ambulance ride, and an ER visit where other patients would have priority and we'd sit around for God knows long," says Goldberger. "Instead, it was one phone call and the whole process was set in motion."
Keeping patients out of the ED was one of six quality measures each Independence at Home site had to meet in order to receive a portion of Medicare's shared savings. The bonus depends on how many measures were met. MedStar says each provider in the MAC met all six:
Reduce 30-day readmissions
Provider follow-up within 48 hours of hospital admission
Medication reconciliation within 48 hours of hospital discharge
Advance care directives documented
Reduce ED admissions for treatable chronic conditions
Reduce hospital admissions for treatable chronic conditions
Who Gets Shared Savings?
After divvying up the $1.8 million among the MAC participants, De Jonge says he isn't sure what will fall to the individuals on the care team.
"If I have anything to say about it, I'd like to have compensation significantly enhanced for all providers on the team to attract more people to this work," says De Jonge.
Pay for providers who treat the frail elderly is a significant challenge.
"PCPs and geriatricians are some of the lowest-paid doctors and have a rigorous work schedule," says De Jonge. "It's not that everyone has to be paid the same, but the savings payments allow us to compensate PCPs, NPs, and social workers for the value of their work. You create a level playing field."
With concrete results and cash in hand from providing care at home, MedStar is now looking to scale the model across the MAC region. De Jonge says they will focus on the population that they know best—the frail elderly—but the demonstration project shows that it could also be applied to Medicare Advantage plans.
It may be time for GI practices to step out of the procedure-heavy comfort zone to prepare for value-based reimbursement and an aging population.
This article first appeared in the June 2015 issue of HealthLeaders magazine.
When Katie Couric underwent a colonoscopy on live television in 2000 as host of the Today show, she not only heightened awareness of the important role colonoscopies play in detecting colon cancer, but she actually boosted the rate of colonoscopies among men and women. Jay Monahan, Couric's husband, died from colon cancer at age 42, and the experience led to Couric's efforts to raise awareness about screening for the disease. The strategy worked and subsequently ushered in a boon to GI practices.
While there are other less-invasive screening tests available for colon cancer, such as the fecal occult blood test (FOBT) or fecal immunochemical test (FIT), which can be done at home annually, colonoscopies are regarded as the gold standard and are the most commonly used screening test to detect polyps that can turn into colon cancer.
"Gastroenterology started gaining traction because of the volumes from the 'Couric effect,' " says Yousif A-Rahim, MD, PhD, chief medical officer for Nashville-based Covenant Surgical Partners, owner and operator of 28 ambulatory surgical centers, most of which are GI-focused, across the country. "We've enjoyed a relatively sanguine era since 2000."
Insurance coverage for colonoscopies, from private payers and Medicare, also helped improve colonoscopy volumes at GI practices. A-Rahim says that at the GI ASCs that Covenant runs, colonoscopies and endoscopies are the "bread and butter" of its revenue streams. Still, technological advances, a mature market—after all, Couric's TV colonoscopy was 15 years ago—and reimbursement reductions are pressures that all GI practices are
facing today.
Some providers, such as Covenant, remain focused on the procedural mainstays of their specialty, but other gastroenterology providers are preparing for a fee-for-value transition by partnering with insurance companies and focusing on specific populations to improve readmission rates.
Success key No. 1: Optimize efficiency
As CMO at Covenant Surgical Partners, A-Rahim has a broad view of the landscape that GI practices are operating in today. He is part of the executive team that is involved in acquiring new practices, but it was only seven years ago that he was on the other side of the negotiating table with Covenant. In 2013, A-Rahim sold the majority of shares of his GI practice, Pacific Endoscopy in Oahu, Hawaii, to the firm.
Specialists, such as GI physicians, have not been immune to the economic realities of running a private practice. There has been a greater focus on primary care physicians leaving private practice for hospital-based employment, but specialists are also looking for some economic cover, which corporate partners such as Covenant and Nashville-based AMSURG can provide.
"With Covenant coming on board, we were able to expand," says A-Rahim. "Pacific Endoscopy now is three different entities, with a fourth center that is under agreement."
Among the primary benefits of becoming a Covenant partner, says A-Rahim, is the standardization of back-end office tasks that take a physician away from seeing patients. HR, payroll, collections, dealing with insurance companies, and recruiting new physicians are all tasks taken over by Covenant's professional arm.
"The majority of doctors are not entrepreneurs," says A-Rahim. "I was a clinician, and the CEO and cofounder of Pacific Endoscopy, and I took on the business development, but suddenly, I don't have to do that anymore. I have someone who is highly specialized and that's all they do."
Each practice that's acquired sells a majority share to Covenant and it, in addition to the practical matters it offloads from physician and staff, also provides pathology laboratory management and anesthesia services.
But prior to partnering with Covenant, Pacific Endoscopy was already optimizing its efficiency to keep patient visits under two hours, which is "tremendous," according to A-Rahim.
"There is a lot of work that goes into it," he says. "We are completely paperless, and before a patient is admitted, we have their history, insurance is verified, and they are registered."
A-Rahim says risk stratifying patients is another way Pacific Endoscopy optimizes its throughput. If a patient is advanced in age, then that person will likely be scheduled for a colonoscopy in the morning so he or she isn't fasting through the afternoon. He estimates that of the 13,000 patients Pacific Endoscopy sees annually, 70% are there for colonoscopies and 30% for endoscopies.
"It's also based on their comorbidities," says A-Rahim. "Before a patient is admitted, we have their history and we can tell if the procedure is likely to be complicated, so we can set aside the amount of time a physician would need with that patient."
Covenant's anesthesia services are the real "magic" that improved efficiency at Pacific Endoscopy, according to A-Rahim. That's because Covenant uses propofol for moderate or conscious sedation of patients who are getting a colonoscopy or endoscopy. A-Rahim says patients are easily arousable because propofol leaves their system quicker, impacting their recovery time.
"Traditionally, we could only do two procedures an hour; now we can actually do three, sometimes four," says A-Rahim, who estimates that the use of propofol has also improved Pacific Endoscopy's overall practice efficiency by 30% because it eliminated the use of nurses who were in the exam room to monitor patients under conscious sedation.
"At Pacific Endoscopy, we had two RNs in the room who were paid between $85,000 and $90,000 a year, and those RNs are used somewhere else; they're not in the room anymore," he says.
The two RNs have been replaced with one certified registered nurse anesthetist, who administers propofol and monitors the patient. The CRNA's salary is about $200,000. A-Rahim says there is partial reimbursement for the CRNA's services, which helps offset the cost, though it's the increase in volume that makes up for the increased expense of using propofol. He also says patients prefer it.
"Our patients love it," says A-Rahim. "You feel great, you're not nauseous, you're not throwing up. When we used conscious sedation, it took 30 minutes to two hours for patients to be semi-recovered to walk; with propofol it's 15 minutes. That's huge because we can take more patients."
Success key No. 2: Value-based care
While the outlook for colonoscopies remains stable, some GI practices are looking to other nonprocedural endeavors that will prepare them for a future under value-based care.
For example, Illinois Gastroenterology Group, an independent group with 45 GI physicians, 16 offices, and seven ASCs serving the Chicago suburbs, recently partnered with BlueCross BlueShield of Illinois to pilot a care model for patients with inflammatory bowel disease, which includes Crohn's disease and ulcerative colitis.
"It was clear to me that we needed to move our gastroenterological community away from a fee-for-service type [of] arrangement … and begin a value-based initiative," says Lawrence Kosinski, MD, MBA, FACG, AGAF managing partner at IGG. "Over half the money that GI physicians receive and live off of emanates from the performance of colonoscopies for colorectal cancer screening and surveillance, so we looked to the next big category of care provided by GI physicians, and that is patients that have inflammatory bowel disease."
BCBSIL announced that it was piloting its specialty intensive medical home with IGG in October 2014. The name of the care model sounds similar to the NCQA's patient-centered medical home initiative but is not part of NCQA, though Walter Hollinger, MD, medical director of strategic operations at BCBSIL, says the aim is similar—to coordinate care for patients, but at a specialty group practice.
"We realized that for Crohn's patients, they, for the most part, have a primary care-like relationship with their gastroenterologist, so it seemed reasonable to take what we had developed for the intensive medical home and apply it."
"The reason we call it intensive is that patients enrolled in the program have had a significant level of medical complexity, severity of illness, and likelihood of having a significant medical event in the near future," says Hollinger.
BCBSIL has three years of experience with its intensive medical home model. It was first rolled out to large primary care groups across Illinois. The partnership with IGG is the insurer's first foray into seeing if it will work for specialists, too.
"We realized that for Crohn's patients, they, for the most part, have a primary care-like relationship with their gastroenterologist, so it seemed reasonable to take what we had developed for the intensive medical home and apply it," Hollinger says.
The partnership between IGG and BCBSIL was a natural fit, according to Kosinski, who says 70% of IGG's patients either have Medicare or BCBSIL.
"It made absolutely the best sense to me that BCBSIL was the best place to go."
"[Payers] are not the evil empire. They never were the evil empire; it's just that we didn't have any communication with them. But I see a lot of positives moving forward."
The two sides acknowledge the inherent tension that exists between providers and payers, but the economic climate in healthcare has changed the dynamic.
"They are not the evil empire," quips Kosinski, referring to the historically frosty relationship that doctors and insurance companies have. "They never were the evil empire; it's just that we didn't have any communication with them. But I see a lot of positives moving forward."
For BCBSIL, the strategy to partner with specialists, particularly large groups that are key providers, keeps the risk environment competitive. Some hospitals and health systems are considering developing their own health plans in order to capitalize on the move toward value-based care. If patients are insured by the hospital they're staying in, then controlling costs, or at least knowing the cost of care, becomes, theoretically, easier.
Traditional payer-developed care models tailored for its providers could be a win-win situation, explains Hollinger.
"These arrangements would allow primary care physicians and specialists who don't want to be affiliated with a very large local hospital system to maintain their independence and provide the care in the way they feel is most appropriate for their patients," says Hollinger.
The reason that BCBSIL decided to experiment with gastroenterology first has more to do with Kosinski's goal of reducing the cost of care and improving patient outcomes. He is the one who approached BCBSIL back in 2012. He says he was looking for data on the total cost of care for his patients with Crohn's disease.
"It was mind-blowing to me," says Kosinski. "Over half the money the payer spent was going to the treatment of complications of this illness. GI physicians were only receiving three-and-one-half cents on the dollar of what the payer was spending, yet we are the experts that are supposed to be managing this illness."
Crohn's disease complications are serious and often require hospitalization. Patients often become so used to dealing with the illness that they don't realize they are deteriorating, and so try to fix the issue on their own. "The complications are fistulas, bowel obstructions, abscesses, serious infections—and there is no easy way to handle those once they occur," says Kosinski.
By combing through the patient data IGG received from BCBSIL, he says he found that only one-third of the Crohn's disease patients who went to the hospital for complications had seen a provider 30 days prior to that admission. It pointed to a lack of patient engagement, says Kosinski, who then developed a Web-based app that pings Crohn's disease patients in between visits. In his initial study group of 50 patients, their hospitalizations went from 17% to 5%. The data convinced BCBSIL that Kosinski was onto something, and now there are 185 Crohn's disease patients enrolled in the specialty intensive medical home. The goal is to enroll 500.
Hollinger says based on the experience BCBSIL has had with its primary care intensive medical homes, he expects the cost of care to also decrease.
"We were able to demonstrate fairly consistently that for our initial very large primary care practices, we did see an improvement in the per member per month in overall medical costs with a reduction of about 7%," says Hollinger.
In real dollars, Hollinger says BCBSIL was able to reduce the total per member per month cost by $95.
BCBSIL contracts with and pays nurse care managers, who are key players in its specialty intensive medical home model. At a practice as large as IGG's, with multiple locations, Kosinski says BCBSIL's financial contribution to support a nurse care manager doesn't cover all the patients, but he believes it's a first step to getting "boats rowing in the same direction."
"We have six part-time nurse care managers and a chief nurse care manager," says Kosinski. So even though we are being paid for one full-time nurse care manager from BCBSIL, we are incurring significant expense, but that's okay. We appreciate the fact that we have our major payer to help us build the appropriate infrastructure for value-based care."
Success key No. 3: Prepare for population health
Other GI practices are focusing on nonprocedural services, too, but instead of looking at patient populations with a common disease they are looking at an age demographic. At the University of Michigan Health System, an integrated academic health system with three hospitals, 40 outpatient locations, more than 120 clinics, and a $3.3 billion operating budget, that population is seniors.
The Geriatrics Center is a multi-specialty geriatric facility that is designed to be a one-stop shop, of sorts, for seniors. Gastroenterology was added to the roster of specialties, which include rheumatology, neurology, endocrinology, nephrology, hepatology, palliative care, and psychiatry.
"Going to a regular GI clinic, the physicians just looked at swallowing without noticing social issues or geriatric syndromes. We were trying to get those patients in to balance GI treatment with other comorbidities."
"If you talk to an 80- or 85-year-old patient, they often have more than one health problem, and they're seeing many different specialists," says Jeffrey Halter, MD, director of the Geriatrics Center at UMHS. "As we developed the clinic, it seemed we could make it easier on patients and families to have a more coordinated approach to care."
The GI clinic is provided twice a week, on Monday and Thursday afternoons. Karen Hall, MD, PhD, who started the GI clinic but has since moved on to serve as director for the Acute Care for Elders unit, a joint operation between UMHS and St. Joseph Mercy Ann Arbor, says the clinic helped identify underlying issues that are inherent in older patients, but that traditional GI doctors may miss.
"Going to a regular GI clinic, the physicians just looked at swallowing without noticing social issues or geriatric syndromes," says Hall. "We were trying to get those patients in to balance GI treatment with other comorbidities."
Demand for the GI clinic grew, says Hall. The clinic started out as just a half day with one provider, but within a year, there was enough need to expand the clinic to an additional half day and grow by two providers.
Jocelyn Wiggins, BM, BCh, associate division chief for the division of geriatric and palliative medicine at UMHS, and medical director for the Geriatrics Center Clinics, says the current three-month wait for an appointment at the center's GI clinic shows how much need exists in the geriatric population.
"There are a lot of things about gastroenterology disease that becomes common with age," says Wiggins, "for example, chronic constipation, diverticulitis, impaction—and managing these early prevents complications later."
Though Hall is no longer seeing patients at the half-day GI clinic, she still does the follow-up appointments for patients discharged from the hospital, and Wiggins says the rate of 30-day readmission for the population is remarkably lower.
"The national readmission rate is 20%, our institution is 19%, [and] for people who get seen in our clinic, it is 11%. Care coordination is key."
For an industry that is transitioning to population-based healthcare, reducing health disparities is essential for achieving the triple aim of better cost, quality, and outcomes.
Despite a landmark report published by the Institute of Medicine more than 10 years ago, Unequal Treatment: Confronting Racial/Ethnic Disparities in Health Care, which highlighted the effects of racial and ethnic healthcare disparities in the U.S., there has been little progress in improving health outcomes equitably.
According to the CDC's 2013 report on disparities and inequalities in healthcare, there were many disturbing trends that showed a disproportionate share of poor health outcomes for basically anyone who is not white. Out of all the statistics, I picked the one that I thought would get most healthcare executives to sit up and take notice: preventable hospital readmissions. From 2001–2009, the rates of preventable hospital visits were higher for non-Hispanic blacks and Hispanics when compared with those of non-Hispanic whites.
Frank Astor, MD, MBA, FACS
For an industry that is transitioning to population-based healthcare, reducing health disparities is an issue that not only deserves attention, but is essential for achieving the triple aim of better cost, quality, and outcomes.
"It's the issue no one really wants to discuss, says Frank Astor, MD, MBA, FACS, chief medical officer of Naples, FL–based NCH Healthcare System, which includes two hospitals and more than 500 affiliated physicians. "It's very complex, but it is essential if we're going to do holistic population health." Prior to joining NCH, Astor was the medical director for Blue Cross Blue Shield Puerto Rico.
Equal or Equitable?
One issue that holds physicians back is understanding the difference between providing equal care and equitable care. The distinction is not just semantics, explains Marcus McKinney, MD, D.Min, vice president of Community Health Equity and Health Policy at Saint Frances Care, a Hartford, Connecticut–based integrated health system that includes three hospitals, more than 900 affiliated doctors, and community clinics.
"We constantly hear, 'We treat everyone equally!'" says McKinney. "But if you treat every single human being equally, you're not giving equitable care to someone who has no job, for example. If a patient is diabetic and has a family history of diabetes, a doctor will take that into account. We have to do the same thing for social determinants."
Treating patients equitably means understanding what patients' needs are in order to get an outcome that is equal. For the patient with no job that McKinney references, it means developing a care plan that positions that patient to get the same outcome as the patient who is employed.
McKinney understands the concept well because Saint Francis Care has been at the forefront of reducing health disparities in its community. The system began focusing on the issue six years ago, and has since developed the Curtis D. Robinson Center for Health Equity, a program that has eight full-time employees and is housed within the Urban League of Greater Hartford.
"We know that what drives two-thirds of our underserved patients is social determinants," says McKinney. "Our strategic plan has to look under the hood and see that we're making a difference."
Marcus McKinney, MD
Disparities Leadership Training
McKinney will get a big boost to his vision. He is one of two physicians at Saint Francis Care that was selected to join the Disparities Leadership Program, a year-long executive program at the Boston–based Disparities Solution Center at Massachusetts General Hospital. The other physician joining McKinney is Luis Diez-Morales, MD, medical director for both the Curtis D. Robinson Center for Health Equity and ambulatory care at Saint Francis Care.
"There has to be more education on equality versus equity," says Diez-Morales. "Some [physicians] have a problem with the idea that equality is not the same as equity. I have seen a few light bulbs go on, and some go out."
The program that McKinney and Diez-Morales were selected for is in its eighth year, and Aswita Tan-McGrory, deputy director of the center, says this year's class is the largest ever.
"We have 60 participants," she says. "We have a huge alumni base—121 organizations, 252 participants. Our program is focused on helping executives achieve equity in their organization. People know it's the right thing to do, but don't have the right tools. We provide content expertise and a framework for organizations to move this forward."
Executives who are chosen for the Disparities Leadership Program are put in groups ranging in size to work on projects that the participating organizations have chosen. The structure of the program is virtual and in-person. Throughout the year, the participants meet with peers and are assigned a facilitator.
"Part our structure is giving hands-on access to faculty members and peer support," says Tan-McGrory. "This is more than learning about disparities, it's also about how to sell this to leadership in an elevator pitch."
McKinney and Diez-Morales are working on a project that integrates health equity across Saint Francis Care, beyond the Curtis D. Robinson Center for Health Disparities. Diez-Morales says the center gave the system a solid foundation, but now it needs to be hardwired in other parts of Saint Francis Care. Their project will focus on the system's large hospital-based primary care clinic that sees 80,000 patients annually.
"We have to start with our own staff," says Diez-Morales. "There are about 35 total healthcare providers working there, and we have between 40–50 residents who rotate with us throughout the year."
Luis Diez-Morales, MD
A Matter of Trust
What Diez-Morales and McKinney already know is that identifying the needs of patients comes first. A successful prostate screening initiative started six years ago put them in front of black men, a group of patients that the CDC report identified as being at risk for missing important medical screenings, diabetes, preventable hospitalizations, and other diseases. The two physicians have gone to churches and even barbershops in Hartford to hear patients' concerns about getting screened and seeing a doctor, generally.
"Forty men all jumped into talking about how complicated it is to talk to doctors," says McKinney. "They want it to be simpler. We try to simplify it in the form of a relationship."
The doctors also said it was clear that the men didn't trust their PCPs.
"The majority of men who came [for screening] had a primary care provider, had a relationship with a physician, but they felt something was lacking," says Diez-Morales. "It's very eye-opening to hear a patient say, 'I have a doctor, but I don't know if I trust that doctor.' "
That prostate screening initiative reached more than 7,000 patients; 40 were diagnosed with prostate cancer. That screening program still continues today; McKinney and Diez-Morales are still going to churches and barbershops, making inroads with the community because it takes a long-term commitment to establish trust and break down barriers that prevent patients from getting healthier.
"We have to be teachable," says McKinney.
"A physician who has been entrusted for 10, 20, 30 years doesn't like to hear that the way he or she has been doing it needs to be changed. That is the resistance we find, and we need dedicated attention to that. The statistics are not getting better for population health."
