Future Medical Staff Models: Doing What Works

Executive Retreat

New York City

October 23, 2009

Presented by:

Amy MacNultyMACNULTY CONSULTING, LLC

Healthcare Strategy & Planning

781.405-2298

amy@macnultyconsulting.com

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Agenda

Drivers of Change

Case Studies: What’s Working and Why?

Creating a Culture of Engagement

Beyond First Generation Alignment Strategies

Strategies for Success

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

Leadership

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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How effective is your organization today?

How prepared are you for changing incentives?

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Drivers of Change

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A Roadmap to Reform

Most of President Obama’s Ambitious Healthcare Goals Depend on Bending the Cost Curve

Source: 1) HFMA Regulatory Sound Bites and http://www.whitehouse.gov/issues/health_care/

Reduce Cost Growth

Invest in Prevention

and Wellness

Improve Safety and

Patient Care

Assure Affordable Coverage

Protect Families from

Medical Bankruptcy

Guarantee Choice of Docs and

Health Plans

Maintain Coverage

During Job Transitions

End Barriers for Pre-Existing

Conditions

Catalyst Primary Outcome Secondary Outcome Tertiary Outcome

Causal Relationship Between the President’s Healthcare Goals

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Global payment per enrollee

Global DRG case rate, hospital, and

post-acute care

Global DRG case rate, hospital only

Global fee for primary care

Blended fee-for-service/medical

home fee

Fee-for-service

Co

nti

nu

um

of

Pay

men

t B

un

dlin

g

Continuum of Organization

Independent physician

practices and hospitals

Hospital systems Integrateddelivery systems

Primary care group practices

Outcome

measures

Care

coordination and

intermediate

outcome

measures

Simple process

and structure

measures

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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Organization and Payment Methods

Implications for Hospitals

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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If enacted, the proposed reforms will have a significant impact on how hospitals operate

Key Action Steps

Physician Alignment: Integration

Imperative

Physician

Alignment

Infrastructure

Bundled

Payment

IT

Connectivity

Physician

Consolidation

New physicians

more likely to look

for established

group practice

models

Hospitals without

such structures

may need to tap

into expertise of

systems who

have structure

Physicians want

EMR/IT

connectivity

Hospitals may join

networks to gain

access to IT

infrastructure or to

communicate with

physicians who

are already

―locked in‖ to

another network’s

system

As physician

groups get larger,

they become

targets for

hospital

acquisition by

competing

systems

Hospitals may

need to join

networks to

ensure they aren’t

frozen out of

referral stream

The advent of

bundled payment

will require tighter

alignment with

physicians

Hospitals may

need to join

networks who are

more aligned with

their physicians to

not be excluded

from payment

stream

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Creating a Culture of Engagement

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Alignment: How Ready Are You?

Structural

Readiness

Cultural

Readiness +

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An organizational

personality that will

effectively support

alignment that is

required in today’s

world

What is it?

Assuming hospital physician alignment is as important as ever, are you ready?

Building blocks that

are necessary to

undertake the new

planning

What is it?

Build respect among senior executives

What Management Can Do…

Mentor your directors and managers

Thin line between front-line empowerment and

interference

Collective memory embarrasses elephants

Practice what

you preach

Be role model

Clarify

responsibilities

Promise only

what you can

deliver

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Beyond First Generation

Alignment Strategies

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Healthcare Strategy and Market

Development (SHSMD) survey

of 3,000 members

362 respondents

60+ interviews

ACPE survey of 10,000

members

400+ respondents

15 interviews

Focus: What strategies are being used to

strengthen physician-hospital alignment,

& which strategies are most effective?

Source: Noblis/AHA, Strategies for Strengthening Physician-Hospital Alignment: A National Study, 2006; ACPE Member Survey 2008

Hospital Perspective Physician Perspective

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First Generation

2005 Noblis National Study Key Findings

High quality/safe

patient care

Substantive

involvement in

decision making

Physician

leadership

development

Support for

physician practice

growth

Selective alignment

of economic

interests

Infrastructure improvements to

increase efficiency/ accessibility of care

Interrelated

Strategies

Visibility/ accessibility of

CEO/Senior Management

Positive

organizational

culture

Information

systems

Communication …

Openness…

Trust…Respect

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Noblis’ 2005 Physician-Hospital Alignment

Study

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%

5) Sponsor retreats limited to physician leadership and senior management 70%

6) Have a formal physician relations program with professional staff responsible for

spending time with active medical staff members and their office staffs in an effort to

strengthen physician-hospital relationships

68%

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

excellence

66%

9) Employ primary care physicians 65%

10) Employ some office-based specialists 64%

Physicians are going to be either collaborative partners or active competitors.

Decreasing physician reimbursement causing physicians to spend more time in office

and/or competing with the hospital for ancillary services.

Of the 10 most effective strategies, half involved employing physicians.

Key

Alignment

Findings

Ten

Most

Effective

Alignment

Strategies

% Respondents Ranking as Highly Effective

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Leadership

Culture

Collaborative

Communication : Electronic & face-to-face

Generational diversity

Physician -Executive

Physician-Physician

Physician Advisory Council

Physician Liaison Program

Quality

Uniform focus on Quality & Safety

Physician Leadership & Communication

Team Approach: Clinical & Support Staff

Evidence-Based Clinical Practice

Infrastructure Support

Care Coordination

Common Goals for PCP & Specialists

Chronic Care Management

Across Patient Care Settings

Focus on Positive Outcomes

Infrastructure Support

Information Technology

High Prevalence & Facilitates Goals

EHR, CPOE, eICU

High Speed Internet Access

Integrated Patient ID system

Alignment

Balancing a Multidisciplinary Approach to

Alignment

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Alignment Strategies: Degree of Integration

Model of Integration

Hybrid, Mixed model aka The ―New‖ Diversity

Age, generation, primary-specialty-

subspecialty, employment

First generation alignment strategies still matter

Physician-BOT- Administration Leadership

Physician Liaison Program

Physician Strategy Council

Joint Ventures

Clinical Program leadership

Getting Ready for Health Reform:

Bending the Cost Curve

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One of the biggest challenges

to creating a unified quality

strategy is the varied physician

staffing models in place at

many hospitals, particularly

when they include independent

doctors. ―The independent

medical staff is still a

challenge,‖ Lambert said. ―Their

interests are so diverse and the

hospital is not a central part of

their environment.”

Matthew Lambert, M.D., Senior

Vice President for Clinical

Operations at Elmhurst (Ill.)

Memorial Healthcare, H&HN,

July 14, 2009.

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The Alignment Balancing Act:

Maximizing Plan A While Moving

to Plan B

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Four Common Elements of an Integrated

Health System

Hospital and medical staff leadership jointly invested

in having a dynamic structure and relationship.

Aligned goals and objectives enable a uniform focus

on quality improvement.

High prevalence of information technology facilitates

aligned goals and objectives.

Patient care coordination across care continuum.

Leadership

Care

Coordination

Quality

Information

Technology

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Together, These Four Elements Create the

Foundation for an Evolved Medical Staff

Quality

Information

Technology

Leadership

Care

Coordination

Hospician: Clinical and Business

Integration*

*Quote from Dr. Joel Reich at ECHN BOT Retreat, April 2009

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Solving the case of the disappearing doctor

Balance between over-

organization & autonomy

Fully aligned goals

Fully aligned incentives

Fully shared risk

Entity contracting for all

Full clinical integration

Referrals within system

Clinical protocols

Integrated information system

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Case Studies – What’s Working

and Why?

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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Geisinger Health System – The Current

“Gold Standard”

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Open and highly integrated delivery system –

hospitals, clinics, health plan, and affiliated rehab

clinic.

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.

22 clinical service lines are co-

led by a physician –

administrator pair.

Each operating unit has its

own quality and budget targets

tied to system objectives.

Overview

StructureMore

Competitive

Less Competitive

Market Competitiveness “Thermometer”

The New Face of Health Care

A new system rewards doctors and hospitals for

taking better care of patients at lower costs.

By: Patricia Barry | Source: From the AARP Bulletin print edition | April 1, 2009

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 fragmented, mainly fee-for-

service and for-profit system

elsewhere is another.

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Geisinger Health System – The Current

“Gold Standard”

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Sources: Paulus, Ron. Davis, Karen. Steele, Glenn. ―Continuous Innovation In Health Care: Implications of The Geisinger Experience.‖ Health

Affairs. Volume 27. Number 5.

Standard EHR

utilized across the

system in all care

settings

Efforts centralized with

significant input from

operational leaders

Personal Health

Navigator

Chronic disease

care optimization

Geisinger ProvenCare

Led by the Board,

innovation in care delivery

is a focused

and collaborative

effort Quality

IT

Leadership

Care

Coordination

Advocate Health System – A Newer

Approach

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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.

Sources: The 2009 Value Report. Advocate Physician Partners. Advocate Physician Partners website.

Provide efficient, effective,

and affordable health care

Improve health outcomes

Overview

Program

Goals More Competitive

Less Competitive

Market Competitiveness “Thermometer”

APP: In their own words…

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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

number of physicians who have employment

relationships with us to be sure that they participate

and drive our quality goals,” said Robert Stein, M.D.,

vice president of medical management at Advocate

Christ Medical Center, Oak Lawn, Ill.

Physicians in the PHO

receive quarterly report

cards updating them on

their performance. An

online tool allows them to

check their performance

in real time. “It’s a rich,

ongoing and accurate

process,” said Michael

McKenna, M.D., vice

president of medical

management at Advocate

Good Samaritan,

Downers Grove, Ill.

The Clinical Integration Program is effective. “Each

year we’ve progressively had more alignment in terms

of providing incentives to physicians for things that

create efficiency in the hospital,” said Advocate Health

Care CMO Lee Sacks, M.D. “Incentives for hospital

management are aligned with where the physicians

are going.”

Advocate Physician Partners: The 2009 Value

Report, Benefits from Clinical Integration

Executive Summary

Pay-for-Performance: Changing the

Reimbursement Paradigm to Improve Quality

and Savings

Beyond Disease Management Beyond Traditional Outreach

Moving Beyond Evidence-Based Medicine to the Evidence-

Based Clinical Practice

Health Care Technology: Why Does It Matter? High Speed Internet Access In The Office

Electronic Data Interchange (EDI)

Electronic Medical Records: Including Computerized

Physician Order Entry (CPOE)

Electronic Intensive Care Unit (eICU®) Usage

Electronic Prescribing

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

Ophthalmology Care—Cataracts and Diabetic Retinopathy

Patient Satisfaction

Preventing Deep Vein Thrombophlebitis (DVT) and Pulmonary

Embolism (PE)

Pharmaceutical Statin (Cholesterol Lowering Medication) Use

Surgical Care Improvement

Additional Innovative Patient Safety Initiatives: Patient Safety

Communication and

Office Patient Safety Assessment

Raising the Bar—The 2009 Advocate Physician

Partners’ Clinical Integration Program

Professional and Community Recognition

Acknowledgements

Source List

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* APP membership requires utilization of technology.

Sources: The 2009 Value Report. Advocate Physician Partners. Advocate Physician Partners website.

Advocate Health System – A Newer

Approach

APP utilizes many

technologies – high

speed internet

access*, EDI*, EMR

and CPOE, eICU*, and

electronic prescribing

Quality standards based

on national benchmarks

(e.g., CMS, AHRQ,

NQF, AMA, etc);

evidence-based

clinical practice

Beyond Disease

Management

Patient Outreach

Program

Worksite Wellness

Provider-led group of

PCPs and specialists;

program offers

infrastructure and

support to its

physician practices

Quality

IT

Leadership

Care

Coordination

Carilion Clinic – A Recent Conversion to a

Traditional Clinic Model

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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.

Sources: Carilion Clinic website. Carryrou, John. ―Nonprofit Hospitals Flex Pricing Power.‖ Wall

Street Journal. August 28, 2008.

Recruited 77 physicians in 50

specialties during first year in

Clinic model

Conversion costs estimated

at $100M

Overview

Major

TransitionMore

Competitive

Less Competitive

Market Competitiveness “Thermometer”

Not-for-profit Not-for-profit

Carilion Clinic Structure – Clinic Model

Carilion Roanoke

Memorial (and

former Roanoke

Community)

Source: Carilion Clinic website. Ownership relationship

Contractual relationship

Franklin Memorial

Hospital

Giles Memorial Hospital

New River Valley

Medical Center

Stonewall Jackson

Hospital

Regional referral

center and teaching

hospital

Carilion Clinic(Board of Governors includes 8

physicians and 3 administrators)

Bedford Memorial

Hospital

300+ Physicians

including

approximately 100

teaching Physicians

VA Tech University

Medical Research

Institute

50% / 50% Joint Venture

Clinical Research Institute

and Medical School

Four other owned

community hospitals

One co-owned

hospital

(with Centra)

One managed

hospitalCarilion Medical

Group

Tazewell Community

Hospital

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Carilion Clinic – A Recent Conversion to a

Traditional Clinic Model

Source: Carilion Clinic website.

Nearly 1,000

Carilion physicians

use its EMR; CPOE

will be fully implemented

by 2010; utilize positive

patient ID system

Goals set at the corporate,

facility, and department

levels; targets include

mortality, patient

flow, medication

reconciliation

With physicians’

common goals

and EMR, Carilion

strives to improve care

coordination and increase

positive outcomes

Led by physician-CEO,

Clinic aims to reduce

unnecessary medical

services, lower

costs, and

improve safety

Quality

IT

Leadership

Care

Coordination

Partners HealthCare – Collaborating with

Two Physician Organizations

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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.

Sources:Epstein, Andrew. ―Models of Medical Staff Redesign: Internal Strategy to Support Programs

and Performance.‖ ACHE Congress. 2008. Partners HealthCare website.

Both Brigham and Women’s

Hospital and Massachusetts

General Hospital have their

own physicians organization

Over 2,500 physicians

More Competitive

Less Competitive

Market Competitiveness “Thermometer”

Overview

Structure

100% adoption of

CPOE and PCP

EMRs; 87% specialty

physicians have EMRs;

currently implementing

systemwide e-prescribing

Clinical experts

recommend guidelines

and standards for all

patient care, in

hospitals and

physician offices

Programs for

target populations:

Identify and

Connect (heart failure)

Health Coaches

(Medicaid patients)

Launched Partners High

Performance Medicine

Initiative in 2003 aims

to provide optimal

patient care

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Quality

IT

Leadership

Care

Coordination

Source: Partners HealthCare website.

Partners HealthCare – Collaborating with

Two Physician Organizations

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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Strategies for Success – What’s

the End Game?

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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Remember the 7 Ss: Tom Peters and Bob Waterman, In

Search of Excellence

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Source : A Strategic Plan for the Physician Enterprise By Dan Beckham, Hospitals and Health Networks, July 14, 2009

StrategyDeeply involve physicians in developing

and executing the strategic plan for their enterprise.

StructureUnify the physicians, incorporate service lines, and forget

“groupness”.

SystemsIdentify financial flows, get real about transparency, align to

clinical and management standards and guidelines.

Shared Values Be principle-driven.

Style Cultivate and support physician leaders.

Staff

Look beyond physicians, augment physicians with physician assistants, transition the front office.

Skills Turn ―I‖ into ―We‖.

―A tangled web of

relationships won't

help your

organization. Put

together a cohesive,

consistent model that

will lead to a

successful physician

enterprise.‖

D. Beckham

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