Patient-Centered, Physician-Driven

Though still a work in progress, UnityPoint Health's strategic plan calls for physicians to take the lead on managing populations.

This article first appeared in the November 2016 issue of HealthLeaders magazine.

As healthcare organizations take more responsibility for the quality and cost of the care they provide, they face complex problems that challenge existing norms governing how physicians and executives interact. Some people call that "soft stuff." But talk to anyone whose goal is to change a culture and "soft" is the last word they'd use to describe the task. Culture is at least as important as strategy—you can't execute on the latter without a firm foundation in the former.

Culture, and more specifically, physician culture, has a huge impact on how well health systems are meeting their ultimate goal of healing patients. Nowadays, healing is just half the expected outcome. It increasingly must be done cost-effectively, and no group has more of an impact on cost than physicians.

When you attempt to remake their culture, that's where trust comes in, and in many organizations, such trust can be in short supply, says Kevin Vermeer, president and CEO of UnityPoint Health in West Des Moines, Iowa. UnityPoint has been working to align the incentives of physicians and the organization since 2012, when the system began to move toward a value-oriented strategy. Consolidation of several legacy physician groups into a single unit was one important result of the cooperation Vermeer and his leadership team engendered with the organization's more than 900 employed physicians. The work to accomplish that outcome started with an effort to simplify the way the 17-hospital, four-state health system interacts with its physicians.

"We knew we had to move away from episodic, hospital-centric care, and that we needed to be patient-centric and physician-driven," Vermeer says. "But to do that, we needed physicians and providers in general to take the lead in how we manage a community population across the entire continuum."

But how do you get physicians to do that in the face of declining income, increasing regulation, and general frustration with the evolution of clinical practice into what physicians often see as a never-ending treadmill of checkboxes?

Opportunity knocks once
The rise of competition on both the outpatient side and in primary care provides a sense of urgency for many health systems to better cooperate with their physicians. So does the ratcheting down of admissions and readmissions targets for hospitals. Further pressure comes from the implementation of new payment methodologies that determine reimbursement based on much more than whether the organization delivers a service.

Those are just a few intimidating factors senior leaders and physicians must deal with that can be overwhelming strategically and which can place a huge strain on a health system that employs a big contingent of physicians. UnityPoint leadership decided that by transforming the organization into one that is physician-driven, senior leadership could better align the organization with accountability and value.

Executive leaders should welcome such challenges, because they provide momentum for perhaps a one-shot opportunity to recast the relationship between physicians and executives in ways that should help these two disparate groups work together more harmoniously and, ultimately, provide better healthcare, says Alan Kaplan, MD, CEO of UW Health in Madison, Wisconsin, who served as executive vice president and chief clinical transformation officer at UnityPoint until he took the helm of UW Health in April 2016.

He says that over time, generally, maintaining their business became more demanding for physicians, so something had to give. Often, that something was the relationship between hospitals and physicians—which took the form of physician apathy toward hospital goals. That relationship was something that didn't change just because they suddenly became health system employees.

"What we found was that the discourse between hospitals and physicians, that crevasse, grew," he says.

As the health system tried to evolve from a collection of hospitals to an integrated delivery system over a period of years, working on improving quality, building care teams, and coming up with techniques and services to better coordinate care for its 325,000-member ACO and other value-based structures that evolved later, the person missing from the table was often the physician, Kaplan says.

"We had physicians making less money, and we were asking more of them, so understandably, we saw empty rooms and apathy when a hospital committee meeting was in session," says Kaplan.

The question, says Vermeer, was how to bring physicians to that table in a meaningful way—so they understood the value they could bring to the organization through their participation.

As Vermeer and Kaplan discussed the issue with physician leaders over time, they found that the doctors didn't ask for authority or to be in charge, but that their input be integrated at all levels of governance and management to make decisions about patient-centered care together.

That's where Vermeer says they knew they could make good progress. The commitments from both sides from those early meetings coalesced into a philosophy that can be boiled down to physician-driven, patient-centered, Vermeer says. Concrete steps taken to achieve that vision included consolidating dozens of practices that historically had their own governance and compensation structures into one cohesive group practice that governed all employed physicians across the system. Critically, the physicians themselves would create the model.

The educational component
Physicians usually aren't trained to build governance structures and create expectations for themselves and their peers. UnityPoint decided to address this deficiency by building a physician leadership academy to train and develop employed physician leaders who could drive the transition to a physician-centric, patient-driven philosophy, Vermeer says. That vision continues to be a work in progress, but development of the physician leadership academy was a big step on the journey.

"The idea is that it would augment the skills they learned in medical school," Vermeer says.

A corresponding leadership academy was created for managers and directors, and much of the learning both groups do is not classroom-based—it's through real-world joint projects that can be enacted relatively quickly.

An added benefit is smoother cooperation going forward, as both groups mature through the organization, Vermeer says.

On the physician side, leadership academy students undergo training in financial and quality management, communication, participating in difficult conversations, leading a meeting, and other skills necessary to help bridge disagreements and form a cohesive strategy. More than 100 physicians have graduated from the academy since it was launched in 2010, with the first graduation in 2011, and 60% of those are currently in leadership positions at UnityPoint.

Perhaps the biggest task—and the most successful one so far for both groups—has been re-creating and consolidating the physician organization from eight legacy groups, each with its own compensation structure and governance, into one unified practice.

"At that time we had a collection of contracts with physicians but no governance, management, or committee structure," says Kaplan. "You can't just select some physicians to sit on the board and think you'll be physician-driven. You have to start with an organizational structure."

The ACO and the new physician group were eventually named UnityPoint Clinic. However, in the beginning of the process, they were referred to as "newgroup" to reinforce the idea that groups were not being merged into an existing structure but into a totally new one, with physicians writing the rules of engagement in cooperation with the executive team.

None of the work involved in creating the "newgroup" happened quickly.

"You can't do this without creating physician leaders," says Kaplan.

Taking on history
Every hospital once had a chief medical officer. Now successful organizations not only employ a CMO but also increasingly have a cadre of physician leaders that include a chief medical information officer, chief quality officer, and others from employed physician groups.

Because of the scarcity and demand for these skills, "you can't recruit them readily, and if you can, they don't come cheap," says Kaplan.

Thus the reason for the physician leadership academy, which has both on-site and online training curricula. The first graduates were instrumental in developing the consolidated medical group, starting in 2012.

"We took the 'newgroup' approach with graduates of the leadership academy," says Kaplan, because that removed an impression that some of the big groups would dominate the smaller ones.

"I told them we weren't going to merge them. Instead, we'd take everything we've learned through the physician leadership academy and design a new group [based on what] we learned from experience with the medical groups," he says. "This was the first example of empowering our employed physicians to do something important."

They started with perhaps the most potentially contentious issue: standardizing compensation, progressing through the governance and management structure. In the process, they built 70 National Committee for Quality Assurance—certified patient-centered medical homes within the newgroup's 281 clinic locations. About 40 of those have achieved Level III certification within the first two years. They also agreed to standards and, with executive participation, developed a 24-hour nurse call center, committed to offering patients the ability to make next-day appointments and e-visits.

Perhaps the organization's most impressive accomplishment has been its clinician recruitment record, says Vermeer, who adds that the group added 158 new providers last year and approximately 400 new providers since 2013, with a retention rate of 94%, which includes retirements.

"We are recruiting to small towns in Iowa and downstate Illinois, and yet we have only a 6% attrition rate, which includes retirements," says Kaplan. The newgroup has improved in-network referrals by 11%, even though such referrals can't be incentivized by financial means, he adds. The group has integrated with home health and medication management protocols, all of which helps immeasurably with care transitions, an important factor in ACO performance.

"At the time we started with the strategic planning in 2010," Vermeer says, "we felt like there was a fairly long time horizon before value-based arrangements would represent a preponderance of revenue, which was good, because this is a cultural transformation, which doesn't occur overnight."

He says that glide path was essential, because the organization continues to tinker with exactly what the physician-driven portion really means to the physicians as it matures. It boils down to proving through outcomes that the organization operates differently and more efficiently, to the benefit of patients and payers, not just physicians.

"We thought we were breaking this into digestible pieces, but those actually on the front lines in the transformation told us it was much more like drinking out of a firehose."

"As we've moved along this journey, part of this transformation is the pulling together of the UnityPoint Clinic," Vermeer says. "We're going to be physician-driven as a system, but within that, we've got true physician-led foundational components. Bringing those under a single group governance structure was a big piece."

Not that the transformation hasn't had its hiccups over the years.

"We thought we were breaking this into digestible pieces, but those actually on the front lines in the transformation told us it was much more like drinking out of a firehose," Vermeer says.

The biggest challenge in buying into the patient-centric, physician-driven culture piece revolved around physicians' perception of how the organization operated historically.

"There was a healthy and respectful skepticism about whether leadership that had operated in a hospital-centric way could really make that transition and change how we make decisions such that physicians and providers are at the center of clinical decision-making but their input is heard as a value partner, as part of the system as a whole," Vermeer explains.

The organization continues to work through that skepticism, but through the cross-pollination effort of the two leadership academies collaborating on various projects, Vermeer says some of that historical wariness has been overcome.