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7 Ways to Achieve Clinical Integration Through Strategic Physician Engagement

Posted by Matthew Smith on Aug 19, 2015 12:11:58 PM

By William K. Faber, M.D., MHCM, Vice President, The Camden Group

Physician Engagement, The Camden GroupNew payment models make it more important than ever for hospitals to collaborate with physicians. From readmission penalties to bundled payments to Accountable Care Organizations ("ACOs"), providers have a growing economic incentive to pool resources, share information, coordinate care and services, and cooperate on quality improvement. 

But while the incentives are strong, the obstacles to clinical integration are daunting. Hospital-physician collaboration is operationally complex. Although physician employment can smooth out some of the bumps, practice acquisition is expensive. While a handful of large health systems have devoted extensive resources to launching clinical integration initiatives, most smaller organizations are still sorting out their options.

How can hospitals integrate with physicians without creating political and financial problems? The solution is to focus on building mutually beneficial relationships and use existing resources wisely.

The following practical approach will help healthcare leaders achieve clinical integration by engaging physicians, strategizing collaborative programs and making targeted investments.

1. Understand Physician Motivation

Convincing physicians to collaborate more closely with a hospital can be challenging. Physicians are trained as autonomous decision makers. Perfectionism and the need for control can make it difficult to weave physicians into an integrated organization. But there is a positive side to the medical personality: No doctor wants to be an outlier.

Engage physicians by presenting data on their patient outcomes. Most physicians will discover at least a few areas in which their performance falls short of their peers.

Talk to doctors about their patients’ flu vaccination rates, medication reconciliation rates, performance on diabetes control measures, etc. This is easiest for hospitals that have access to physician claims data through a physician-hospital organization ("PHO") or that offer physicians a subsidized electronic medical record ("EMR") with built-in Clinical Quality Measure ("CQM") templates that facilitate reporting.

Most physicians do not track and evaluate their own performance, let alone measure their performance against peers. Relevant patient statistics will earn physicians’ attention and generate interest in working more closely with hospital staff to improve outcomes.

It is also important to educate physicians on the evolving healthcare market. Explain how payers are creating incentives for clinical integration though bundled or global payments and per patient/per month care coordination fees. As physicians become more aware of these payment trends, many will embrace the opportunity to increase their salary by partnering with the hospital.

2. Create True Physician Governance

To gain the most under new payment models, physicians and hospitals have to play nice in the sandbox. The key is establishing a governance body that allows physicians to guide the development of care strategies and clinical protocols. Physician-led governance will create physician awareness and support for clinical integration initiatives and make a positive impact on the overall success of the program. Make sure the clinical integration governance committee includes physicians from solo practices and small partnerships as well as large groups. Include representatives from a range of specialties.

Most important, the governance body should include physicians who are critical or even negative about the clinical integration initiative. Often these “difficult” physicians simply want to be heard and provide their input. Making these physicians feel included will go a long way toward smoothing the transition to integration.

3. Focus on Quality, Not Finances

Physicians are concerned about productivity and payment, but concentrating exclusively on financial metrics will disenchant many providers. Focus instead on clinical quality and performance improvement. After all, this is the main reason physicians entered medicine — to provide quality care to the patients they serve.

The clinical integration committee should establish quality benchmarks and treatment protocols that define performance standards. Benchmarks can be based on evidence-based standards and care plans developed by national quality organizations and disease associations. Micromanaging clinical decisions will be unpopular, so care protocols should be broad guidelines that allow room for individual judgment.

To choose initial improvement goals, review admission and inpatient reports to identify areas of low quality and high cost. For which conditions does the hospital see the greatest number of admissions? Which conditions have the longest length of stay? Physicians using an EMR may be able to report on certain quality measures. For example, what is the percentage of hypertensive patients with adequate blood pressure control? How many heart disease patients have an up-to-date lipid profile?

Begin the clinical integration outreach with physicians in specialties linked to poorer outcomes and higher costs. Another logical starting point is primary care. Family practice physicians and internists often have the greatest impact on chronic disease management.

4. Concentrate on Care Coordination

One of the biggest opportunities in clinical integration is better coordination of care. Focus on high- and medium-risk patients who are responsible for the highest costs or who will likely increase costs in the near future. Target care transitions between the hospital and admitting specialists or primary care physicians. Involve physical therapy, home health providers and long-term care facilities in clinical coordination planning.

Physicians need to ensure that discharged patients complete follow-up visits. The hospital can assist by sponsoring a care coordination team for the entire organization to help manage follow-up appointments, referrals and home health services. To help guide care coordination, stratify hospital discharges by risk of readmission, complication or care plan non-compliance.

5. Use Technology to Get Providers Talking

Clinical integration is nearly impossible without an EMR system, but many medical practices are not far along in EMR adoption. Most practices cite expense as the main obstacle.

To overcome the cost hurdle, consider subsidizing EMR systems for practices that agree to join the integrated organization. Relaxation of the Stark laws allows hospitals to subsidize as much as 85 percent of the purchase and support costs of an EMR system. Subsidy agreements can require physicians to report quality measures and meet quality performance thresholds.

However, do not expect physicians to acquire the same EMR system as the hospital. Many small practices can do very well with free and low-cost alternative systems. The hospital should build interfaces for exchanging information with the EMR systems used by the majority of integrated physicians.

Many physicians who have implemented EMRs have participated in the Medicare and Medicaid EHR Incentive Program. As part of demonstrating Meaningful Use under the program, these physicians have already begun tracking clinical quality measures. Clinically integrated organizations should use the EMR to create aggregated quality reports and share them with physicians. Weekly or monthly reports can track disease management data such as HbA1c levels, cholesterol, blood pressure and preventive screenings. Giving physicians the chance to view quality performance metrics will engage both their competitive personalities and their collaborative spirit.

6. Build Financial Incentives

Clinical integration will require physicians to invest time and money into patient education, technology and additional staff. The problem is that methods of compensating providers for care coordination are still being developed and tested by payers. Given the costs being shouldered by physicians, financial incentives are critical.

Regardless of how incentives are distributed, hospital leaders should reward physicians either for controlling costs, achieving quality benchmarks or both. Focus on achieving care management quality metrics early on, since reduced costs tend to follow well-managed patients. Establish and re-assess these performance targets annually.

One important note: Make sure primary care physicians get a piece of the pie. Although surgical specialists might be responsible for most of the hospital’s costs and revenue, primary care doctors have the most frequent patient contact and are also responsible for most of the work of chronic disease management.

7. Invest Early for Healthy Returns

Even hospitals without the resources of a large medical system can achieve clinical integration by focusing on strategic investment and engaging community physicians through quality improvement. Hospital leaders need to allow physicians to establish the quality benchmarks and evidence-based protocols for the organization’s costliest conditions. Leaders can then concentrate on linking doctors through technology, assisting with care coordination, and negotiating with payers on bundled payments or pay-for-performance incentives.


Dr. Faber is a vice president with The Camden Group. As a physician executive, he specializes in the development of accountable care organizations and clinically integrated networks, physician engagement, and health information technology. Prior to joining The Camden Group, Dr. Faber served as Senior Vice President of the Rochester General Health System in New York, where he guided the development of the system’s clinical integration program and assisted more than 150 providers at 44 sites through the conversion process from paper records to an electronic health records system. He may be reached at wfaber@thecamdengroup.com or 312-775-1703.

 

Topics: Clinical Integration, Population Health, William K. Faber MD, Physician Engagement, Governance, Care Coordination

Ten Key Governance Best Practices for Your ACO or CI Program

Posted by Matthew Smith on Jul 21, 2014 12:48:00 PM
By Daniel J. Marino,
President/CEO, Health Directions

ACO, Clinical Integration, GovernanceA board’s most valuable resource is its time.”  That single sentence, from a renowned expert on board and governance matters, serves as the wellspring for some important guiding principles for governance of your accountable care organization (ACO) or clinical integration program.

Following are some best practices your organization can adopt to ensure optimal effectiveness of governance functions and your organization’s overall success in achieving its strategic objectives.

 

1. Screening Tool for Prospective Governance Members

Most population health management-type organizations are comprised of multiple stakeholder groups, some of whom have little history of working together or knowledge of the capabilities and potential conflicts of leadership. In some cases, these stakeholders have historically thought of themselves as competitors to one another. An important exercise for any board is to work through a process for objectively and consistently screening potential board members to ensure suitability. Such a screening process probably should involve some sort of screening for conflicts of interest, but at its simplest level should at least make sure the prospective governance member is available to attend governance meetings at scheduled times.

2. Position Descriptions for Board and Committee Chairpersons and Rank and File Members

Position descriptions are not just for management. A succinct statement of the purpose and expectations of both Board/Committee chairpersons as well as “rank-and-file” Board and Committee members can be remarkably helpful, particularly in underscoring the importance of leaving members’ legacy “stakeholder” organizational interests at the door and acting in the best interests of the enterprise. This is an important first step in building a common culture and preparing for the future, rather than preserving the past.

3. Cycled Performance Review of Board and Committee Chairs and Rank and File Members

Once formal position descriptions for Board/Committee chairpersons and rank-and-file members are developed and approved by the Board, it is easy to use these tools – specifically the duties – as the basis for formal performance evaluation and feedback. It is recommended that Board and Committee chairs be formally reviewed once a year, and that a cycled approach be used for rank-and-file Board/Committee members such that these members are reviewed at least once every two or three years. Performance feedback should be sought from fellow Board/Committee members. An objective third party might be engaged to consolidate (and de-identify) peer feedback, and then review results with the reviewee.

4. Formal Orientation for New Governance Members

It is important to have a steady rotation of new Board and Committee members to ensure all stakeholder represented in Board and committee decision-making, and in building a “bench” of physician leaders knowledgeable of and committed to the organization’s strategies. One effective means of doing this is to have formal orientation governance sessions with the incoming class of governance members. Depending upon the size of your governance, these orientation sessions might be conducted once or twice a year. They should be scheduled at times that are convenient for incoming governance members to attend (e.g. early morning or dinner meeting times). Attendance at an orientation could be a requirement before a candidate is officially seated on the Board or a Committee.

5. Governance Compensation

Some organizations routinely compensate physicians for their attendance and participation in committee work. Other organizations fiercely resist the practice. Regardless of whether you chose to compensate or not, the Board may wish to proactively evaluate the merits of, and formally adopt a policy related to, governance compensation, rather than just respond reactively when asked.

6. Charters & Annual Work Plans

It is typical for a Board, as one of its first orders of business, to develop a governance organization structure that creates a select few committees to do a “deeper dive” into policy matters and oversight activities. While each committee typically reports to the Board, there is often significant interaction among the committees as well. For these reasons, it behooves the Board to clearly articulate the role and expectations of its committees. This can take two forms: first, a “charter” outlining the general roles and responsibilities of each committee, and second, an annual “work plan” outlining what specific activities the committee is to undertake in a particular year. To illustrate, it would be typical for the “charter” of a quality committee to specify that committee as the governance entity in which program measures are to be developed. The “annual work plan” might include a directive from the Board that, this year, it expects the quality committee to develop measures related to cardiology, oncology and orthopedics. Committee charters should be reviewed and changes approved by the Board on annual basis, presumably at the same time that annual Committee work plan assignments are approved.

7. Board and Committee Self Review Process

Boards and committees are collections of individual members, but are also entities unto themselves. Just as individuals’ performance should be reviewed on a periodic basis, it is recommended that Boards and Committees do a collective self-review once a year, perhaps as part of an annual retreat process or in a special executive session.

8. Planning vs. Monitoring

As noted above, a board or committee’s most valuable resource is its time. The role of governance is to set strategy and the role of management is to implement strategy. It would be a revealing exercise to review the agendas of your board over the past year, identifying the proportion of meeting time and content spent on monitoring and looking over the shoulders of management vs. developing strategy and setting policy. How much time was spent looking forward vs. looking backwards at operations?  Ideally, at least 70 percent of Board time should be spent setting strategy, formulating goals and crafting policy. To expedite monitoring functions, it is suggested that the Board develop high-level dashboard reports on critical indicators and other management-by-exception practices.

9. Pro Forma Agenda and Annual Master Calendar of Agenda Items

To help ensure the Board spends adequate time on strategy while still attending to its duties to monitor operations, it can be instructive to develop an annual calendar of agenda items as a planning guide for board activities. This will help ensure that nothing “falls through the cracks” while balancing activities throughout the year.

10. Mix of Routine and Extended Meetings

At least once a year, the board should hold a meeting of extended length to review past year accomplishments conduct a self-review of governance effectiveness and update strategy to chart the way forward for the next year or planning cycle. This type of extended meeting, typically a board retreat, can be followed by a similar extended meeting of key committees – perhaps a month or two following the board retreat – at which committees can assimilate the strategy updates of the board and assess the impacts on committee activities.


Daniel J. Marino, CIN, Clinically Integrated Networks; As President/CEO of Health Directions, Daniel J. Marino shapes strategic initiatives for healthcare organizations and senior health care leaders in key areas such as population health management, clinical integration, physician alignment, and Health IT. With a broad background in all aspects of practice management and hospital/ physician alignment, Dan is nationally recognized as a strategic leader in Accountable Care Organizations and clinical integration development. He frequently speaks at national conferences and regularly authors articles for the nation’s top healthcare industry publications related to current transformations in healthcare delivery. Dan may be reached via email at dmarino@healthdirections.com or by phone at 312-396-5400.

Topics: Accountable Care, ACO, Accountable Care Organization, Clinical Integration, Clinically Integrated Network, Governance, Daniel J. Marino

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