Advocate for Physician-Led ACOs Shares Secret of Success

The former president of Advocate Physician Partners says it's a slow process to get newly hired physicians smoothly cobbled into an accountable care organization. But "culture is the main determinant" of an ACO's success.

Marty Manning built "one of the nation's leading clinical integration programs," as his new bosses describe it. The former president of Advocate Physician Partners, Manning helped design managed care contracts and other personnel ventures involving 4,000 physicians in nine hospitals within the Advocate Health Care System, based in the Chicago area. In that role, he worked to build consensus among private and employed physicians.

He did the job for eight years, and it was fun, Manning told me. "We had gotten to be a mature and successful organization … and I enjoyed the business incubation in different circumstances." In the process, he saw in accountable care organization development "so much opportunity."

So much that the prospect of more ACO development work effectively prompted Manning to leave his job. In May, he resigned from Advocate Physician Partners and joined Health Directions as executive VP to lead physician integration, clinical integration and especially ACO practices at the healthcare consulting firm based in Oakbrook Terrace, IL. 

He wanted to do something slightly different.

"I feel with the innovations and experimentations going on right now [within ACOs], it's absolutely the right thing for improving outcomes for patients, as well as addressing the cost problems [that are] unavoidable at this point," Manning says.

The process is complex, although the Centers for Medicare & Medicaid Services essentially defines ACOs in the simplest terms, as "groups of doctors, hospitals, and other healthcare providers, who come together voluntarily to give coordinated high quality care to their Medicare patients."

Manning has an easy style, and laughs often in a conversation. From the outset, it's not difficult to see why he is so accomplished at negotiations. Make no mistake, though. This business of physician integration is no easy task.

There are turf battles in the tenuous struggle to find the "right balance" in physician groups. There's the ever-present need for the right physician leaders, and even the need to exert "pressure" to ensure quality. Ultimately, having such a team in place—especially within an accountable care organization—doesn't happen overnight. It can take two years to cobble one together. As Manning says: "It's a journey of several stages, and there are challenges at each stage."

Manning refers to a recent case to illustrate his point. Two hospitals and two physician groups were trying to form an ACO team. "They were coming together for the first time," Manning says. Connecting them meant overcoming "all those cultural challenges, and the history of some differences and animosity. It was getting them to work together and trust one another and forming the ideal governance," explains Manning. That process is still unfolding.

In some ways, timing is vitally important in bringing physicians and hospital groups together. "You don't want to sign up a bunch of doctors and have a lull for six to nine months while you are trying to put your [leadership] board together," Manning says. 

Yet, if the deal-making process occurs too quickly, "there is loss of opportunity to engage physicians in that process," he adds. "There's a sweet spot that we go for. Because we have a lot of content and ideas and experience in our toolkit, we can facilitate those discussions. The physicians can act in a pretty well-informed manner."

While timing is crucial, that "culture" thing, seemingly ever-present in healthcare discussions today, is also critical to establishing an ACO team, Manning says. "I think in the long-term culture is the main determinant of success. Anybody can buy a system or set up measures; it's really the performance all around that matters. In order to get to that performance, you need to create a common language, and common ways of doing things, a common value and common dialogue."

Having physician leadership in a team also is a must, Manning says. That's not easy to arrange, either. "Getting physician engagement is absolutely essential to the long-term success of these things," Manning says. "I am a strong advocate that [the ACO] needs to be physician-led, and facilitated by management. I think engagement starts with selection of who the leaders would be."  Manning suggests that one of the most useful ways to get physicians engaged and develop leaders "is just having leadership retreats—spending in-depth time to really explore issues, not just approving reports.

Having that "engagement" means that executive teams need to ensure that they don't cater to one doctor at the expense of others, Manning says, or become too involved in certain clinical specialties, without examining the whole.

Although physicians obviously have their own specialties and interests, ultimately those interests should be secondary to the overall team goals, he believes. That's certainly easier said than done. "It's important how you get people together and get them focused and directed, because you can easily get into a rabbit's hole of everybody's favorite pet measure," Manning says.

"There may be some obscure thing in which one physician on a committee has that subspecialized area, but a broader strategy and direction of the program is needed. That subspecialized area may not be highly relevant. You have to navigate through that."  Leadership committees should develop specific work plans involving governance and best practices, Manning says.

Even though hospitals may be working with both independent and employed physicians, having a "physician peer pressure [program] can help drive physician performance" regardless of its  employment model, Manning says. Although he didn't go into details of what such a program may look like, Manning suggested that each hospital and physician group agree on one that fits their needs. He hinted at what the "peer model" could do.

"We have more transparency around performance and more sharing across physician practices so there is a dialogue and learning from each other," Manning says.  For employed and independent groups, the peer pressure "increases interdependency, even though they may remain separate entities." Manning calls the collective group of physicians a "group without walls."

He maintains high regard for Advocate Physician Partners and its work with integrated physician practices. During his tenure, they had acquired physician groups, but Manning cautions that the process is slow going. It takes time to blend new physicians into the team that already exists.

"When I was at Advocate Physicians we had this rather mature program and even with that mature program and lots of training tools and resources, it took about two years to bring the performance of the physicians at new sites up to the level of the average of the rest," he says. "It just takes that long transforming the practices and setting up the bare bones." The IT structure and the legal issues are among the obstacles that have to be overcome.

Still, there's good news. Generally, physicians today are much more engaged than "five or 10 years ago, and there is much more widespread acceptance by physicians that things have to change and this time it's for real," Manning explains.

"Unless a physician is retiring in a couple of years, I'm spending much less time convincing physicians the 'why' about [ACOs and integration with hospitals]. It's more about the 'what' to do, and 'how' to do the best job possible."