After dominating the news media for months, health reform discussions are now emerging in hospital and health system management meetings and board room discussions. Perhaps the area of greatest interest and anxiety relates to Section 3022—delineating the implementation deadline (Jan. 1, 2012) for a shared savings program under the construct of accountable care organizations.
The concept of ACOs was articulated in MedPAC's 2009 report to Congress: "The defining characteristic of ACOs is that a set of physicians and hospitals accept joint responsibility for the quality of care and the cost of care received by the ACO's panel of patients."
Has your management team and board already addressed this elephant in the room? How do you align the hospital and physicians in a manner to achieve the two principal goals of the ACO process: improving quality while at the same time decreasing cost? Early discussions and planning tend to focus on ACO organization, negotiating ownership agreements, new organization formation, collaborative management structures, and models for managing bundled payment.
While such negotiation is clearly necessary to meet the requirements of ACOs under the Patient Protection and Accountable Care Act, it won't be sufficient to make the necessary fundamental change in alignment between your hospital and medical staff which will allow for success of such models.
In working with healthcare leaders across the country, I've witnessed first-hand the complexity of attaining true physician alignment and integration. Many legitimate leadership initiatives have been inadvertently sabotaged by failing to recognize and address the professional and personal challenges facing physicians. If leadership can collaboratively address these physician challenges, we may be able to move beyond overt or covert hostility to a common vision.
Challenges facing physicians
Is it all about the money? Physician incomes in many specialties have decreased over the past two decades despite increased workload. Now, health reform initiatives have suggested that physicians will be paid for measured quality rather than for quantity of services as we move forward.
With PPACA's vision of bundled payment, which envisions pilot projects by 2013, physicians are increasingly anxious not only about direct income, but also whether they will be able to maintain the traditional private practice, or whether we are destined to become employees of some larger organization.
Autonomy and decreasing scope of authority
Many physicians, myself included, were trained in an era of physician autonomy. The "captain of the ship" analogy was considered legitimate. Let me provide a comparison, however. As a newly licensed private pilot, I had the autonomy to get into my airplane, select a destination, and fly there without permission from anyone (as long as the weather was good). Later, as my skills improved, I wanted to be less constrained by limitations of visibility, so I attained an "instrument rating." This rating increased my ability to fly not only where I wanted, but also when I wanted. But it also came with new obligations. I no longer had the same level of autonomy. I had to participate in a larger team, involving filing a flight plan, communicating with air traffic control and requesting clearances for flight plan changes. However, the constraints on my autonomy were more than offset by my additional aviation freedom.
When discussing alignment with your physicians, there will be a need to address standardization of evidence-based practice guidelines, elimination of utilization of unnecessary resources and other constraints on autonomy. Leadership must be able to articulate the benefits of organizational change to physicians or such initiatives will be passively if not actively resisted.
Technology and information overload
The arena of information technology results in frustration for many physicians. Hospitals must transition to electronic medical records or face financial sanctions. It is generally agreed that clinical information is far more legible, orderly, and secure in an EMR setting. Yet many hospital leaders are mystified by physician resistance to technology.
However, consider the practical aspects from a physician perspective. As EMRs capture data from numerous sources the sheer volume of information becomes overwhelming. Busy physicians acknowledge that they have limited time to review even the majority of the information in the EMR and "hope" that they are aware of all significant issues. The problem is compounded by an unarticulated anxiety about external review. Physicians, in an EMR environment, while recognizing that they cannot review the entire record concurrently, are aware of the potential medical-legal liability of missing any critical element of care. Internal stress builds. Add to this the recent explosion of the "denial industry," with reviewers challenging medical necessity of admissions, appropriateness of diagnoses, etc., and you can see why the physician may see the EMR as a problem, not a solution.
Measurement and profiling
The vast majority of practicing physicians exert the necessary effort to remain clinically competent, despite the explosion of clinical information necessary to master any specialty. Additionally, most are compassionate and committed to patient care, believing that they provide high quality care. It is difficult to reconcile the historical high self-image and community image of any given physician with the statistical fact that under any measurement system, 50% of physicians will profile as "below average." A physician profiling in the bottom quartile for quality might well look for others to blame—including hospital management.
Collaborative Alignment
Physician alignment requires substantially greater effort than simply structuring legal entities, management structures and payment models. Collegial alignment requires a collaborative effort to address many of the personal and professional issues facing physicians as described above. The aviation analogy used above to describe the trade-off of my partial loss of autonomy to gain greater freedom in my piloting experience illustrates the value of creatively addressing needs.
The aviation industry provides other excellent analogies to the clinical setting. For example, one area of emphasis for any pilot is situational awareness. Richard Haines and Courtney Flateu, in "Night Flying," a book about both the beauty and challenge of night-time flight, describe situational awareness as "one's ability to remain aware of everything that is happening at the same time and to integrate that sense of awareness into what one is doing at the moment."
In the technology paragraph above, I described information overload for physicians. While we physicians or pilots like to "do it ourselves," there is a strong case for using infrastructure to assist in maintaining situational awareness. On the aviation side, an instrument pilot is grateful when Air Traffic Control provides information about an embedded thunderstorm in one's path, accompanied by vectors for avoiding a potentially threatening situation. A related aviation concept is the attempt to decrease pilot workload in order to allow full utilization of critical thinking skills.
Building a better model for physician alignment
As hospital and health system leaders attempt to facilitate the development of ACOs, true physician alignment will require solutions to existing problems. Consider the following specific goals:
- Decreasing physician workload
- Increasing physician situational awareness
- Improving defensibility of care
These goals are achievable. Many hospitals are implementing clinical integration infrastructure models specifically to assist physicians, as members of the care management team, to provide higher quality care efficiently. A clinical integration specialist, typically an experienced med-surg, ICU or ED nurse with additional training in patient safety, quality, documentation, medical necessity and other areas of expertise, can provide the medical record surveillance necessary to improve physician situational awareness.
For example, if a note from a dietician suggests the possibility of severe protein malnutrition, the CIS brings that information to the attention of the treating physician for appropriate documentation and treatment. The same individual, identifying a documented diagnosis which appears unsubstantiated in the clinical record, may ask the physician to document his or her clinical judgment in arriving at the diagnosis. This process also decreases the medical malpractice and audit risk inherent to inadequate documentation.
A CIS—using new IT tools to assist in mining clinical information, recognizing high risk clinical patterns and initiating interventions at the optimal time—becomes a key communication linkage between the treating physician and the rest of the clinical team, providing the necessary 'situational awareness' to efficiently enhance the quality of patient care.
Perhaps the most important aspect of the evolution of the practice of medicine is the recognition that the envisioned collaborative, team-oriented clinical approach necessary for ACOs will only be attained if hospital and health system leaders address real, existing, professional and personal challenges facing members of their medical staffs.
Paul Weygandt, MD, JD, is Vice President of Physician Services at J.A. Thomas & Associates. He may be reached at paul.weygandt@JATHOMAS.COM