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Nudging Physicians Toward Accountability

 |  By gshaw@healthleadersmedia.com  
   January 11, 2012

This article appears in the December 2011 issue of HealthLeaders magazine.

Ellis M. Knight, MD, MBA, went into medicine as an idealist. And, added the senior vice president of ambulatory services at Palmetto Health in Columbia, SC, he still is.

But about five years ago he began to question whether his practice of medicine was measuring up to the expectations, desires, and motivations he had when he entered medical school.

The answer: not so much. It was “crushing,” he said at the HealthLeaders Media Rounds event, The Real Value of ACOs, hosted by Norton Healthcare in Louisville, KY.

“I went into a career in medicine because I wanted to help people, [but] a lot of what I was doing every day wasn’t helping people. I was doing a lot of stuff, seeing a lot of patients, putting people through a lot of tests and procedures, a lot of stays in the hospital, but when you asked at the end of the day how much good I did for people today, what did all this activity result in? My honest assessment was not as much as I’d like.”

Knight thought the answer to this lacking might lie in a system of accountable care. To his surprise, he discovered many of his colleagues felt the same way. In the summer of 2009, Knight sent an e-mail to physician colleagues and asked them what they thought about starting an ACO. The positive response was overwhelming. Ultimately there were well over 100 physicians on the e-mail chain.

The Palmetto Health Quality Collaborative was created in 2010 to align the acute care hospital system with the medical staff and community physicians to improve the quality and coordination of care. All physicians who are members in good standing with Palmetto Health are eligible to participate—including employed, contract, and community physicians.

“Integration at several levels is something that we worked on a lot at Palmetto Health Collaborative,” Knight said.

To succeed, accountable care–type organizations should consider focus on culture as well as clinical and economic integration.

Cultural integration, Knight said, is not only the most important aspect, but also the most difficult to achieve.

Knight harkens back to that e-mail—it was exciting, he said, because it shows that even physicians who are practicing independent of each other have a common vision. Common motivation helps form the bedrock of a common mission and vision for an ACO and is the foundation for establishing trust and breaking down barriers between key players.

“The piece that is really essential to accountable care is to bring physicians and healthcare systems together in a way that they’ve never been before,” Knight said. “To really bring physicians into your business model requires a lot more than a contract and a paycheck.”

And integration needs to be more than clinical: Physicians must also be an integral part of the business model, he said. And that means more than compensation and employment, he added, but bringing together physicians who don’t all work for the same organization.  

“Systems and physicians that don’t have employer-employee relationships [can] come together and economically integrate in ways that previously would have been frowned on, that would have raised issues with regard to antitrust.”

In addition to advice about what organizations should do to succeed, Knight offered the audience a list of four traps to avoid.

For starters, he said, don’t think it will be easy. “It is changing a culture that has been longstanding and well-entrenched, and that is never easy.

“Also, don’t think that there’s a standard way to do this. There is no evidence-based best practice out there that you can pull out of the literature and say, ‘Aha, here it is.’” Collaboration with other organizations that are also experimenting with the model can help.

Don’t wait until things have gotten so bad that there has to be a political or legislative solution. If that happens, “things could get real ugly real fast,” he said. “We have got to act, and we’ve got to act quickly.”
Finally, Knight said, don’t think it’s not worth it. “I believe healthcare is a calling. I believe that those of us who chose this as a profession did so because we had some very noble aspirations, and I think developing accountable care organizations can be a way that we can realize those dreams and create an environment where we can find true fulfillment and also provide the kind of care and the kind of services that out patients deserve.”


This article appears in the December 2011 issue of HealthLeaders magazine.

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