Achieving clinical integration through greater physician hospital alignment

1. Future Medical Staff Models:
Doing What Works
Presented by:
Executive Retreat Amy MacNulty
MACNULTY CONSULTING, LLC
New York City Healthcare Strategy & Planning
781.405-2298
October 23, 2009 amy@macnultyconsulting.com

2. Agenda
Drivers of Change
Creating a Culture of Engagement
Beyond First Generation Alignment Strategies
Case Studies: What’s Working and Why?
Strategies for Success
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3. Overview
 Health Reform – not “if” but “when”
 Primary Care/Prevention
 Quality/Efficiency
 IT/EMR
 Bundled payments
 Maximizing Plan A While Moving to Plan B – knowing
where to start How effective is your organization today?
 Leadership How prepared are you for changing incentives?
 Quality
 Information Technology
 Care Coordination
 Case Studies – what’s working and why
 Strategies for Success – what’s the end game
 Specific strategies for L, Q, IT and CC
 Measures and Metrics for each
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4. Drivers of Change
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5. A Roadmap to Reform
Most of President Obama’s Ambitious Healthcare Goals Depend
on Bending the Cost Curve
Causal Relationship Between the President’s Healthcare Goals
Catalyst Primary Outcome Secondary Outcome Tertiary Outcome
Maintain Protect
Coverage Families from
During Job Medical
Reduce Cost Assure Transitions Bankruptcy
Growth Affordable
Coverage End Barriers Guarantee
for Pre- Choice of
Existing Docs and
Conditions Health Plans
Invest in Improve
Prevention Safety and
and Wellness Patient Care
Source: 1) HFMA Regulatory Sound Bites and http://www.whitehouse.gov/issues/health_care/
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6. Organization and Payment Methods
Global payment per
enrollee
Outcome
measures
Global DRG case
Continuum of Payment Bundling
rate, hospital, and
post-acute care
Global DRG case Care
rate, hospital only
coordination and
intermediate
Global fee for outcome
primary care measures
Blended fee-for-
service/medical
home fee Simple process
and structure
measures
Fee-for-service
Independent Primary care Hospital systems Integrated
physician group practices delivery systems
practices and
hospitals
Continuum of Organization
Source: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way, February 2009.
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7. Implications for Hospitals
If enacted, the proposed reforms will have a significant impact on
how hospitals operate
Key Action Steps
 Examine existing processes to identify those that should be re-engineered to take
advantage of EHRs
 Evaluate performance on current quality measures and begin a campaign to
improve them
 Embark on sustained cost reduction efforts
 Use scenario planning when making capital budgeting decisions
 Convene a high level work group to discuss how your organization’s business model
will have to change if these proposals become law
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8. Physician Alignment: Integration
Imperative
Physician
IT Physician Bundled
Alignment
Connectivity Consolidation Payment
Infrastructure
 New physicians  Physicians want  As physician  The advent of
more likely to look EMR/IT groups get larger, bundled payment
for established connectivity they become will require tighter
group practice targets for alignment with
models  Hospitals may join hospital physicians
networks to gain acquisition by
 Hospitals without access to IT competing  Hospitals may
such structures infrastructure or to systems need to join
may need to tap communicate with networks who are
into expertise of physicians who  Hospitals may more aligned with
systems who are already need to join their physicians to
have structure ―locked in‖ to networks to not be excluded
another network’s ensure they aren’t from payment
system frozen out of stream
referral stream
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9. Creating a Culture of Engagement
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10. Alignment: How Ready Are You?
Assuming hospital physician alignment is as important as ever, are
you ready?
Cultural Structural
Readiness + Readiness
What is it? What is it?
An organizational Building blocks that
personality that will are necessary to
effectively support undertake the new
alignment that is planning
required in today’s
world
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11. What Management Can Do…
Practice what
Build respect among senior executives
you preach
Be role model Mentor your directors and managers
Clarify Thin line between front-line empowerment and
responsibilities interference
Promise only
what you can Collective memory embarrasses elephants
deliver
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12. Beyond First Generation
Alignment Strategies
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13. First Generation
Focus: What strategies are being used to
strengthen physician-hospital alignment,
& which strategies are most effective?
Hospital Perspective Physician Perspective
 Healthcare Strategy and Market  ACPE survey of 10,000
Development (SHSMD) survey members
of 3,000 members
 400+ respondents
 362 respondents
 15 interviews
 60+ interviews
Source: Noblis/AHA, Strategies for Strengthening Physician-Hospital Alignment: A National Study, 2006; ACPE Member Survey 2008
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14. 2005 Noblis National Study Key Findings
Infrastructure Substantive Physician
improvements to
increase efficiency/ involvement in leadership
accessibility of care decision making development
Support for
High quality/safe
physician practice
patient care
growth
Interrelated
Strategies Selective alignment
Information
systems of economic
interests
Communication … Positive Visibility/
accessibility of
Openness… organizational CEO/Senior
Trust…Respect culture Management
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15. Noblis’ 2005 Physician-Hospital Alignment
Study
 Physicians are going to be either collaborative partners or active competitors.
Key  Decreasing physician reimbursement causing physicians to spend more time in office
Alignment and/or competing with the hospital for ancillary services.
Findings
 Of the 10 most effective strategies, half involved employing physicians.
% Respondents Ranking
as Highly Effective
1) Employ intensivists 75%
2) Employ a vice president of medical affairs (or equivalent leader) 74%
3) Employ hospitalists 74%
4) Provide financial support for recruitment to independent practices 72%
Ten 5) Sponsor retreats limited to physician leadership and senior management 70%
Most
6) Have a formal physician relations program with professional staff responsible for 68%
Effective spending time with active medical staff members and their office staffs in an effort to
Alignment strengthen physician-hospital relationships
Strategies 7) Sponsor planning retreats that include board members, physicians, and senior management 68%
8) Actively involve physicians in planning and developing clinical service lines or centers of 66%
excellence
9) Employ primary care physicians 65%
10) Employ some office-based specialists 64%
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16. Balancing a Multidisciplinary Approach to
Alignment
Leadership Quality
Culture Uniform focus on Quality & Safety
Collaborative Physician Leadership & Communication
Communication : Electronic & face-to-face Team Approach: Clinical & Support Staff
Generational diversity Evidence-Based Clinical Practice
Physician -Executive Infrastructure Support
Physician-Physician
Physician Advisory Council
Physician Liaison Program
Alignment
Care Coordination Information Technology
Common Goals for PCP & Specialists High Prevalence & Facilitates Goals
Chronic Care Management EHR, CPOE, eICU
Across Patient Care Settings High Speed Internet Access
Focus on Positive Outcomes Integrated Patient ID system
Infrastructure Support
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17. Alignment Strategies: Degree of Integration
 Model of Integration
 Hybrid, Mixed model aka The ―New‖ Diversity
 Age, generation, primary-specialty-
subspecialty, employment
One of the biggest challenges
 First generation alignment strategies still matter to creating a unified quality
 Physician-BOT- Administration Leadership strategy is the varied physician
staffing models in place at
 Physician Liaison Program many hospitals, particularly
when they include independent
 Physician Strategy Council doctors. ―The independent
medical staff is still a
 Joint Ventures challenge,‖ Lambert said. ―Their
interests are so diverse and the
 Clinical Program leadership hospital is not a central part of
their environment.”
 Getting Ready for Health Reform: Matthew Lambert, M.D., Senior
Bending the Cost Curve Vice President for Clinical
Operations at Elmhurst (Ill.)
Memorial Healthcare, H&HN,
July 14, 2009.
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18. The Alignment Balancing Act:
Maximizing Plan A While Moving
to Plan B
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19. Four Common Elements of an Integrated
Health System
Hospital and medical staff leadership jointly invested
Leadership
in having a dynamic structure and relationship.
Information
Technology High prevalence of information technology facilitates
aligned goals and objectives.
Quality
Aligned goals and objectives enable a uniform focus
on quality improvement.
Care
Coordination
Patient care coordination across care continuum.
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20. Together, These Four Elements Create the
Foundation for an Evolved Medical Staff
Leadership Quality
Care Information
Coordination Technology
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21. Hospician: Clinical and Business
Integration*
Solving the case of the disappearing doctor
 Fully aligned goals
 Fully aligned incentives
 Fully shared risk
 Entity contracting for all
 Full clinical integration
 Referrals within system Balance between over-
organization & autonomy
 Clinical protocols
 Integrated information system
*Quote from Dr. Joel Reich at ECHN BOT Retreat, April 2009
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22. Case Studies – What’s Working
and Why?
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23. Successful Integration Models
 There is no one model that guarantees
success in hospital-physician integration.
 Examples will show a diversity of
models used by organizations that have achieved
longevity and fame/eminence in the industry.
 In most cases, the model has evolved over time to meet
changing needs.
 By and large, the tighter the economic integration of the
model, the more flexibility in negotiating in the managed
care arena and the greater chance for survival in a highly
competitive market with strong payers and strong players.
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24. Geisinger Health System – The Current
“Gold Standard”
Overview Open and highly integrated delivery system –
hospitals, clinics, health plan, and affiliated rehab
clinic.
Market
Structure  22 clinical service lines are co- Competitiveness
“Thermometer”
led by a physician – More
Competitive
administrator pair.
 Each operating unit has its
own quality and budget targets
tied to system objectives. Less
Competitive
Sources: Paulus, Ron. Davis, Karen. Steele, Glenn. ―Continuous Innovation In Health Care: Implications of The Geisinger Experience.‖ Health
Affairs. Volume 27. Number 5. Betbeze, Philip. ―Bundling by Decree.‖ HealthLeaders Magazine. June 11, 2009.
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25. Could it be done at the
national level?
Making these principles work in
integrated systems like
Geisinger and others which
typically are nonprofit, pay their
doctors' salaries and have the
flexibility to divert resources into
areas such as primary care
where they’re most needed is
one thing. Translating them to
The New Face of Health Care
the fragmented, mainly fee-for-
service and for-profit system A new system rewards doctors and hospitals for
elsewhere is another. taking better care of patients at lower costs.
By: Patricia Barry | Source: From the AARP Bulletin print edition | April 1, 2009
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26. Geisinger Health System – The Current
“Gold Standard”
Led by the Board, Efforts centralized with
innovation in care delivery significant input from
is a focused operational leaders
and collaborative
effort Leadership Quality
 Personal Health Care Standard EHR
Navigator Coordination IT utilized across the
 Chronic disease system in all care
care optimization settings
 Geisinger ProvenCare
Sources: Paulus, Ron. Davis, Karen. Steele, Glenn. ―Continuous Innovation In Health Care: Implications of The Geisinger Experience.‖ Health
Affairs. Volume 27. Number 5.
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27. Advocate Health System – A Newer
Approach
Overview Through a joint venture between more than 3,200
physicians, the eight system hospitals, and in
collaboration with local health plans, Advocate
Physician Partners (APP) has developed its
Clinical Integration Program.
Market
Program  Provide efficient, effective,
Competitiveness
“Thermometer”
Goals and affordable health care
More
Competitive
 Improve health outcomes
Less
Competitive
Sources: The 2009 Value Report. Advocate Physician Partners. Advocate Physician Partners website.
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28. APP: In their own words…
Advocate Health Care in Oak Brook, Ill., has a large physician hospital organization with a focus on quality
metrics. About 3,200 of the system’s 5,000 physicians are members of Advocate Physician Partners.
Through the Clinical Integration Program, the PHO has established contractual relationships with some
payers that link incentives to quality metrics.
“One of our advantages is that we can call on a Physicians in the PHO
number of physicians who have employment receive quarterly report
relationships with us to be sure that they participate cards updating them on
and drive our quality goals,” said Robert Stein, M.D., their performance. An
vice president of medical management at Advocate online tool allows them to
Christ Medical Center, Oak Lawn, Ill. check their performance
in real time. “It’s a rich,
ongoing and accurate
The Clinical Integration Program is effective. “Each process,” said Michael
year we’ve progressively had more alignment in terms McKenna, M.D., vice
of providing incentives to physicians for things that president of medical
create efficiency in the hospital,” said Advocate Health management at Advocate
Care CMO Lee Sacks, M.D. “Incentives for hospital Good Samaritan,
management are aligned with where the physicians Downers Grove, Ill.
are going.”
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29. Advocate Physician Partners: The 2009 Value
Report, Benefits from Clinical Integration
 Featured Clinical Integration Initiatives
 Generic Prescribing Initiative
 Smoking Cessation Education Program
 Depression Screening for the Chronically Ill
 Asthma Outcomes
 Diabetic Care Outcomes
 Coronary Artery Disease and Congestive Heart Failure Outcomes
 Childhood Immunization Initiative
 Additional Clinical Integration Initiatives
 Board Certification
 Cancer Care Improvement
 Effective Use of Hospital Resources
 Clinical Laboratory Standardization
 Obstetrics Risk Reduction and Post Partum Care
 Community Acquired Pneumonia Management
 Physician Education Roundtable Meetings
 Hospitalist Program Participation
 Executive Summary  Ophthalmology Care—Cataracts and Diabetic Retinopathy
 Pay-for-Performance: Changing the  Patient Satisfaction
 Preventing Deep Vein Thrombophlebitis (DVT) and Pulmonary
Reimbursement Paradigm to Improve Quality Embolism (PE)
and Savings  Pharmaceutical Statin (Cholesterol Lowering Medication) Use
 Surgical Care Improvement
 Beyond Disease Management  Additional Innovative Patient Safety Initiatives: Patient Safety
 Beyond Traditional Outreach
Communication and
 Moving Beyond Evidence-Based Medicine to the Evidence-
 Office Patient Safety Assessment
Based Clinical Practice
 Health Care Technology: Why Does It Matter?  Raising the Bar—The 2009 Advocate Physician
 High Speed Internet Access In The Office Partners’ Clinical Integration Program
 Electronic Data Interchange (EDI)
 Electronic Medical Records: Including Computerized  Professional and Community Recognition
Physician Order Entry (CPOE)
 Electronic Intensive Care Unit (eICU®) Usage  Acknowledgements
 Electronic Prescribing
 Source List
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30. Advocate Health System – A Newer
Approach
Provider-led group of Quality standards based
PCPs and specialists; on national benchmarks
program offers (e.g., CMS, AHRQ,
infrastructure and NQF, AMA, etc);
support to its Leadership Quality evidence-based
physician practices clinical practice
 Beyond Disease Care APP utilizes many
Management Coordination IT technologies – high
 Patient Outreach speed internet
Program access*, EDI*, EMR
 Worksite Wellness and CPOE, eICU*, and
electronic prescribing
* APP membership requires utilization of technology.
Sources: The 2009 Value Report. Advocate Physician Partners. Advocate Physician Partners website.
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31. Carilion Clinic – A Recent Conversion to a
Traditional Clinic Model
Overview The Carilion Health System transformed itself in
June 2006 into the Carilion Clinic, modeling itself
on Clinics such as Mayo that are physician-
driven and focused on leading edge training,
research, and patient care.
Market
Competitiveness
Major  Recruited 77 physicians in 50 More
“Thermometer”
Transition specialties during first year in
Competitive
Clinic model
 Conversion costs estimated
at $100M Less
Competitive
Sources: Carilion Clinic website. Carryrou, John. ―Nonprofit Hospitals Flex Pricing Power.‖ Wall
Street Journal. August 28, 2008.
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32. Carilion Clinic Structure – Clinic Model
Not-for-profit Not-for-profit
Carilion Clinic 50% / 50% Joint Venture VA Tech University
(Board of Governors includes 8 Medical Research
physicians and 3 administrators) Institute
Clinical Research Institute
and Medical School
Carilion Roanoke
Memorial (and Four other owned One co-owned
One managed Carilion Medical
former Roanoke community hospitals hospital
hospital Group
Community) (with Centra)
 Regional referral  Franklin Memorial  Bedford Memorial  Tazewell Community  300+ Physicians
center and teaching Hospital Hospital Hospital including
hospital approximately 100
 Giles Memorial Hospital
teaching Physicians
 New River Valley
Medical Center
 Stonewall Jackson
Hospital
Source: Carilion Clinic website. Ownership relationship
Contractual relationship
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33. Carilion Clinic – A Recent Conversion to a
Traditional Clinic Model
Led by physician-CEO, Goals set at the corporate,
Clinic aims to reduce facility, and department
unnecessary medical levels; targets include
services, lower mortality, patient
costs, and Leadership Quality flow, medication
improve safety reconciliation
With physicians’ Care Nearly 1,000
common goals Coordination IT Carilion physicians
and EMR, Carilion use its EMR; CPOE
strives to improve care will be fully implemented
coordination and increase by 2010; utilize positive
positive outcomes patient ID system
Source: Carilion Clinic website.
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34. Partners HealthCare – Collaborating with
Two Physician Organizations
Overview Highly integrated delivery system encompassing
primary care and specialty physicians, community
hospitals, two academic medical centers,
specialty facilities, community health centers, and
other health-related entities.
Market
Competitiveness
“Thermometer”
Structure  Both Brigham and Women’s More
Competitive
Hospital and Massachusetts
General Hospital have their
own physicians organization
 Over 2,500 physicians
Less
Competitive
Sources:Epstein, Andrew. ―Models of Medical Staff Redesign: Internal Strategy to Support Programs
and Performance.‖ ACHE Congress. 2008. Partners HealthCare website.
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35. Partners HealthCare – Collaborating with
Two Physician Organizations
Launched Partners High Clinical experts
Performance Medicine recommend guidelines
Initiative in 2003 aims and standards for all
to provide optimal patient care, in
patient care Leadership Quality hospitals and
physician offices
Programs for Care 100% adoption of
Coordination
target populations: IT CPOE and PCP
 Identify and EMRs; 87% specialty
Connect (heart failure) physicians have EMRs;
 Health Coaches currently implementing
(Medicaid patients) systemwide e-prescribing
Source: Partners HealthCare website.
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36. Making it Work for You
How ready is your organization to implement
these strategies?
What are the major opportunities and barriers to
implementation?
What do you think the impact of the economic
crisis and/or health reform will have on
implementing alignment strategies?
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37. Strategies for Success – What’s
the End Game?
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38. What more can we do to…
 Involve physicians and increase trust in hospital?
 Develop physician leadership and engage in governance?
 Increase effective communication among and between
physicians and hospital leadership?
 Engage physicians in strategic planning and thinking?
 Enhance physician liaison activities?
 Further enable hospital based physicians to effectively
manage patient care?
 Link additional care providers, e.g., HIE, etc.?
 Increase collaboration in quality initiatives?
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39. Remember the 7 Ss: Tom Peters and Bob Waterman, In
Search of Excellence
Deeply involve physicians in developing
Strategy and executing the strategic plan for their enterprise.
Unify the physicians, incorporate service lines, and forget
Structure “groupness”.
Identify financial flows, get real about transparency, align to
Systems clinical and management standards and guidelines.
Shared Values Be principle-driven. ―A tangled web of
relationships won't
help your
Style Cultivate and support physician leaders.
organization. Put
together a cohesive,
Look beyond physicians, augment
consistent model that
Staff physicians with physician assistants,
transition the front office. will lead to a
successful physician
Skills Turn ―I‖ into ―We‖. enterprise.‖
D. Beckham
Source : A Strategic Plan for the Physician Enterprise By Dan Beckham, Hospitals and Health Networks, July 14, 2009
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