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The End of Us vs. Them

Philip Betbeze, for HealthLeaders Media, April 13, 2012
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Who's in control?
Many conversations with healthcare senior leaders begin or end with some version of the statement, "If only we could get our physicians to ..." This thinking is not suited to the types of seismic changes facing healthcare today that require not only the physician's cooperation, but also his or her financial commitment. It also suggests a paternalistic view of the relationships between hospitals and physicians.

The biggest change that has to occur is finding new ways for hospital and health system leaders to cooperate with physicians. A second and no less important driver is simple economics. Physicians who in the past have seen themselves as being in competition with the hospital are now finding that reimbursement rule changes are making it more difficult to remain independent, says Wasserman.

In fact, he predicts that at some point in the next two years, about 50% of primary care physicians will be employed by hospitals, and "specialists will follow behind in a couple of years."

One might think that hospitals and health systems will be able to leverage physicians into following the protocols necessary for achieving performance targets in the hospitals' commercial contracts, not to mention avoiding penalties and sharing in incentives offered by CMS under healthcare reform. But employment does not ensure that doctors will be willing partners in improving care. An important hurdle is encouraging and requiring physicians to agree to hold themselves to certain standards.

"If you don't develop a genuine way to make physicians feel just as important as the hospital, it's hard to make the progress that needs to occur," Wasserman says.

That means giving leadership roles to physicians, who are expected to set their own standards by which the hospital will hold them accountable. But both sides have to give up some control, says Trinity's Murphy.

"We believe strongly that only collaboration will be successful in the future, so we all have to give up a certain amount of control."

Governance for good relationships
Many hospitals and health systems have found a degree of success in improving quality and safety through new governance structures that set standards for every physician in the group.

The traditional medical staff structure, for example, is not one that works to facilitate coordination of care, says Wasserman. It's too big and unwieldy. He encourages his clients to develop smaller work groups that are designed to address a particular challenge "instead of having one system where every doc has his head under a single tent," he says.

Though hospitals are required by the Joint Commission and other accrediting and certification bodies to have a formal medical staff organization, Wasserman suggests limiting its official duties to those required by law: credentialing and review of inpatient quality measures.

And don't make the mistake of assigning your "high-revenue" physicians or the heads of very large practices to lead these efforts, he says. Leaders of quality and safety committees should have an economic stake, but if you really want a meaningful leader, "you have to find someone who has that understanding of the patient process and factors that drive quality care," he says.

Wasserman suggests looking for key physician leaders on the primary care side who care about their patient loads and understand the interrelationships.

"The degrees don't matter as much as their willingness to get engaged in some really definitive activity," he says. "It's not easy, but they're out there. Sometimes, young physicians are the best."

He cautions hospitals that giving up some authority is difficult, but that physicians will generally hold themselves to higher standards anyway, if given enough leeway.

"Often it's the hospital that won't give up authority," he says. "Sometimes giving up a little authority is the best way to get movement, and they'll see right through it if it isn't genuine."

Trinity's Murphy sees a lot of advantages of focusing on chronic disease because such patients need high levels of care, and because poor coordination of their care is one major reason healthcare can sometimes be expensive, and it relates to the quality of care received. As more evidence comes out regarding how the patchwork care coordination such patient populations receive increases the cost of care and hurts quality, Murphy says clinicians feel a professional responsibility, outside of economic incentives, to improve.

"Providers have really started examining the fact that we are incredibly expensive, and they know we can get better outcomes," he says. "They can do that by agreeing as clinicians on guidelines for clinical care."

Not only that, says Murphy, but the technological solutions to guiding patients through the care process are getting better and better.

"In some ways, technology is driving this," he says. "Now you have help in managing patients in a proactive way, with disease registry programs, by knowing what populations are at higher risk, where they are, and how to approach them. We didn't really have those clusters of attribution in the past. We didn't have the data to manage them better before."

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