Future Medical Staff Models Leaders For Today 10.23.09

1. Future Medical Staff Models: Doing What Works Presented by: Executive Retreat Amy MacNulty MACNULTY CONSULTING, LLC New York City Healthcare Strategy & Planning…
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  • 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
  • 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 2
  • 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 3
  • 4. Drivers of Change 4
  • 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 5
  • 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. 6
  • 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 7
  • 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 8
  • 9. Creating a Culture of Engagement 9
  • 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 10
  • 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 11
  • 12. Beyond First Generation Alignment Strategies 12
  • 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 13
  • 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 14
  • 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% 15
  • 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 16
  • 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. 17
  • 18. The Alignment Balancing Act: Maximizing Plan A While Moving to Plan B 18
  • 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. 19
  • 20. Together, These Four Elements Create the Foundation for an Evolved Medical Staff Leadership Quality Care Information Coordination Technology 20
  • 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 21
  • 22. Case Studies – What’s Working and Why? 22
  • 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. 23
  • 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. 24
  • 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 25
  • 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. 26
  • 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. 27
  • 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.” 28
  • 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 29
  • 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. 30
  • 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. 31
  • 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 32
  • 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. 33
  • 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. 34
  • 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. 35
  • 36. Making it Work for You How ready is your organization to implement these strategies? What are the major opportunities and barriers to implementation
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