A health system executive shares tips for securing a satisfactory cultural fit, communication, pay, and work-life balance for NPs and PAs.
With demand dwarfing the supply of advanced practitioners, it's a good time to be a nurse practitioner or physician assistant. But even though such nonphysician practitioners (NPPs) essentially have their pick of where to work, they're not all satisfied with their current employment.
Nearly 16% of PAs and 19% of NPs expect to change jobs within one year, according to a survey of 1,070 advanced practice clinicians conducted by PracticeMatch, a provider of staffing resources. Overall, one-third of respondents said they'd consider a change.
For insights into how healthcare leaders can set NPP relationships up for success, I spoke with David Taylor, FACHE, FACMPE, corporate vice president of Cox Health in Springfield, MO. The following is an edited transcript.
HealthLeaders Media: Would you agree that recruiting and retaining NPPs is a challenge?
Taylor: Absolutely. Every medical specialty today is using advanced practitioners in some way. In our organization, we're probably using six times as many NPPs as we did 10 years ago. And within primary care, we're moving toward a ratio of three NPs or PAs for every one physician. So that will up the ante as far as supply and demand.
Even with a dozen or more programs in our state that train NPs and PAs, and our own college producing about 30 [NPPs] a year, we can't hire enough.
HLM: With such high demand, is it even possible to be selective for cultural fit? What are the keys to forging long-term relationships with clinicians?
Taylor: It starts with your physicians. They have to buy into it and understand who these people are, what their roles are, and how they can be utilized in the delivery of care. Senior leadership has to also be behind it and understand the value of team-based care.
There's also the aspect of how we communicate with NPs and PAs. We hold three to four forums a year where our NPs and PAs can come together and discuss what's happening nationally in healthcare or within our own system.
HLM: According to the survey, salary and work-life balance were by far the most influential incentives to NPPs. How have you addressed these desires?
Taylor: When it comes to compensation, we treat our advanced practitioners a bit like physicians in that there are bonus plans based on production. And depending on the supply and demand, there may be a sign-on bonus and retention bonuses.
We also find that these clinicians really value flexibility. So we have a lot of part-time roles and options for where people can work, whether it's in a traditional clinic, retail clinic, or even doing telemedicine from home. People might spend two days in one setting and three in another, so there's variety. It's important to have a broad array of things we can fit from a cultural standpoint and an interest standpoint of these individuals.
HLM: You mentioned the importance of physician and leader buy-in into team-based care, but how does an organization go about getting that?
Taylor: We've been blessed to for the most part, have it from the beginning, partly because of the way we use NPs in our residency program.
But we don't mandate or set a strict schedule to roll out adding NPs and PAs across our clinics. Rather, we let it evolve, beginning with early adopters. Then once other physicians see how other practices are doing it or talk to their colleagues, they may come forward wanting to bring it into their practice.
Or we may approach a practice that is starting to reach the point where access is becoming a problem, and we offer adding NPs and PAs as a way to enhance that aspect of the clinic in a particular community.
A primary care physician describes the electronic health records system workflow that works for his practice.
The AMA's time-motion study released last week quantified a major complaint about EHRs, concluding that for every hour physicians spend with patients, they spend another two hours interacting with their electronic medical records systems.
In an editorial accompanying the study in the Annals of Internal Medicine, Susan Hingle, MD, an associate professor of internal medicine at Southern Illinois University School of Medicine, articulated an equally valid, arguably more productive conclusion:
"Now is the time to go beyond complaining about EHRs and other practice hassles and to make needed changes to the healthcare system that will redirect our focus from the computer screen to our patients and help us rediscover the joy of medicine," Hingle wrote.
For insights into how physicians might improve their relationships with EHRs (and therefore, patients), I spoke with Salvatore S. Volpe, MD, a New York-based solo primary care physician. In addition to using an EHR in his practice for the past eight years, Volpe belongs to the board of directors of the New York eHealth Collaborative and serves as chair of the health information technology committee for his state medical society.
He offered the following tips for EHR efficiency:
1. Take a Team Approach
Volpe's office team includes just a medical assistant (MA), a biller, and an occasional RN. But what it lacks in size, this level-3 patient-centered medical home makes up for in strength. The MA in particular plays a key role by documenting patients' chief complaints.
"The medical assistant talks to the patient about the chief complaint, and the patient says whatever she's going to say," Volpe explains. "When I come in, the patient has had a few more minutes to think about it and give me the history of present illness."
Within the chief complaint field, the MA also writes reminders for Volpe, such as, "pneumonia shot due," or "discuss chronic care management."
"Even though I could hit the clinical decision support key and have a lot of that stuff pop up for me, if she cues that up for me in advance, it's one less button I have to hit," Volpe says. "That's where you can use your MAs to make a good product even better."
2. Invest in Prep Time
Reviewing patients' records and test results takes less time overall, Volpe says, if he makes time to review them more than once. Typically, he spends the most time reviewing documents from specialists and other materials over the weekend. During these sessions, he'll make annotations to the progress note to streamline the visit.
"I typically do a little bit every day, but a lot on the weekend," he says. "If I've already reviewed the documents, then it's less than three minutes of review before going into the exam room. But if I do it the same day, it could become five to seven minutes."
3. Ask for Help
Learning to navigate an EHR and develop the muscle memory to find the right buttons at the right time isn't easy, Volpe admits, especially if physicians are using different platforms at the offices and hospitals at which they work.
"If people are having a hard time or feel like they're spending too much time navigating the EHR, if they're employed they should ask for additional training time," Volpe says.
Another practical solution is to ask for a scribe, with the caveat that physicians are still ultimately responsible for their EHRs.
"Scribes are very valuable, but doctors have to realize that having a scribe doesn't mean they don't have to block out a certain amount of time to make sure there wasn't a transcription error by someone who didn't go to medical school," Volpe says. "It will definitely make things faster, but you still have to proofread it."
How healthcare leaders can succeed with value-based care, the Quadruple Aim, and more.
It's been said that the best way to eat an elephant is by taking one bite at a time. But if changes are elephants, today's physicians have herds of them on their proverbial plates.
For insights into managing the challenges of moving toward value-based care and more, I spoke with Gerald A. Maccioli, MD, FCCM, chief quality officer for Sheridan Healthcare.
The following transcript has been lightly edited.
HealthLeaders Media: A common struggle among physicians and executives I've spoken with seems to be determining their pace of transition from fee-for-service (FFS) to value—deciding how much risk to take on and when. Is that consistent with your view?
Maccioli: Absolutely. Right now in clinical practice, whether you're a six-person group in Topeka, Kansas, or you have 5,600 physicians in multiple specialties like I have, you've got one foot in the traditional FFS world—and you have to do all of that reporting and revenue cycle and quality assurance work.
At the same time you have to gear up and create, in many cases, entirely new reporting structures for a value-based world.
It's part of why you see a lot of burnout and stress among physicians. It's the volume of change, the velocity of change, and the magnitude of change. MACRA is a prime example. The final rule is expected the first week of November, and in theory, go-live will be January 1, 2017.
HLM: With so many demands on physicians and organizations, how can they begin to set priorities?
Maccioli: It comes down to three items. First is informed leadership. Large organizations need to appoint and empower either a chief quality officer or chief value officer who has an understanding of the legislative and regulatory landscape.
Next, it's got to be someone who has credibility with physicians. And the last thing is that it absolutely takes a commitment of resources.
You need all three. If you have leadership and vision, that's great but you won't accomplish much. If you have all the resources in the world but no leadership and vision, you're going to fail.
HLM: How can physicians and organizations get over the hump in which changes and "improvements" create more strain than noticeable benefit?
Maccioli: I made and hung a sign in my office that says, "Frame every decision with the Quadruple Aim in mind."
Everybody's heard of the Triple Aim—better patient experience, population health, and lower cost. And as a physician, as a patient, and as a citizen I absolutely believe in that. But the Quadruple Aim is when you include what I think is the preeminent variable of workplace satisfaction of the physicians.
That means setting up quality programs that are as seamless as possible for physicians and create as little friction as possible.
You can't take unhappy, disenfranchised people who feel they're overburdened and put upon, and say, "Give us these wonderful results." You have to create an environment where those people who are going to facilitate the change feel empowered and engaged.
HLM:Amid all the talk about stress and struggle, what are the positives? What can physicians get excited about?
Maccioli: There are reams and reams of data of what happens with patients, and a lot of that information has been siloed and segregated.
One of the great things is that we're going to be able to show physicians that the results of the care they are giving and help them find ways to do a better job. I think it will be very empowering to get that kind of longitudinal feedback.
These insights may not have been on point, but they revealed physicians' takes on MACRA, telehealth, and other key challenges.
Physicians' time is precious, so while interviewing, I do my best to stay on topic. But some of the best conversations I have with physicians flow more like a winding river than a highway, with bumps and currents that may not pertain to a particular article but make the ride more memorable.
Here are the highlights from some recent side trips to visit various subjects.
"After all these years, I've gotten back many personal letters from patients, not about what I've done for their cancer, though that's been part of it, but about the things I've done to make people feel better—the kind words, the time," says George Raptis, MD, executive director of Northwell Cancer Institute, in New York.
"The people who write will always note the people who were kind. It's not always providing the cancer care that really endures and makes an impression on patients. It's the caring."
"Telehealth is a good thing," says Charis Eng, MD, PhD, chair and founding director of the Genomic Medicine Institute of the Cleveland Clinic.
Considering that there are only 500 or so practicing physician geneticists in the country—fewer than there are professional astronauts—virtual access makes sense. But while practicing telemedicine within the Cleveland Clinic is relatively seamless, challenges outside the system remain.
"What's wrong with telehealth?" Eng asks. Licensing, for one thing. "I think it will happen one day that there will be a telehealth license that covers physicians nationally," she says.
"And reimbursement is almost nonexistent. The third-party payers absolutely know that telehealth gives access and drives costs down. So these are things that need to be solved and can be solved."
"It's a time of so much instability for all of us, and we don't even know what the rules are yet," says Sarah E. Streett, MD, chair of the American Gastroenterological Association Institute Practice Management and Economics Committee.
Streett, a clinical associate professor of medicine at Stanford Medicine, was referring to MACRA. But this time of instability also presents new opportunities for collaboration to occur.
"It's like you're in the middle of a game and the board keeps moving around," she says. "But my hope—and really the direction that I see—is that as the rules become more fixed, all of the different partners in healthcare really are going to need to collaborate.
"We often have so many layers of committees and not enough opportunities for people to come together, share information, come up with some goals, and actually enact them," she adds.
In recounting the process of creating a new cancer center and changing its model of care, the logistics were not the hardest part, says Randall Oyer, MD, medical director of the oncology program at Lancaster (PA) General Health's Ann B. Barshinger Cancer Institute.
"I don't think any one step was individually challenging. The challenge is to find the time, attention, and focus to get all of the right people to the table at the same time," says Oyer.
"You're essentially creating new teams, new work flows, new imperatives. It takes vision. It takes operational diligence and it takes follow through. It takes ongoing, vigilant communication with the many different people who work in many different parts of the organization."
Still, some organizations, particularly those with an appetite for risk and the skills to manage it, will be ahead of the curve.
I spoke recently with Marci Sindell, chief strategy officer and senior vice president of external affairs for Massachusetts-based Atrius Health, about the lessons the system has learned so far about value-based care and how it will apply to MACRA.
The following transcript has been edited lightly.
HealthLeaders Media: With your longtime experience bearing risk, how well prepared do you feel to comply with MACRA? Will any of your groups qualify as an alternative payment model (APM) in the first reporting year?
Sindell: For Atrius Health being measured on a wide range of quality metrics in payer contracts, [and achieving] compliance with MACRA will not be very difficult. As a Medicare Pioneer ACO since 2012, we have a strong track record of scoring in the 90th percentile nationally in quality. We expect to participate in NextGen, so we will qualify as an APM in the first reporting year.
HLM: How have you so far educated and engaged your employed physicians around the changes coming with MACRA?
Sindell: Our employed physicians have been well educated in population health management over the years, and are very engaged in quality improvement.
Importantly, Atrius Health has built systems to support high achievement for each quality measure. This means being able to identify the population of patients who are included for each measure, doing outreach to ensure that process measures are achieved, and reporting to identify those who are not achieving outcome goals so that additional outreach using defined protocols can improve their health.
HLM: How might MACRA complement (or challenge) your existing initiatives around population health and providing high-quality, high-value care?
Sindell: The volume of work to support 33 or more metrics makes it literally impossible for a physician to do all of this on their own and ensure the process reliability that is needed to achieve high quality.
But patients deserve no less. At Atrius Health, physician leadership has built much of this into our EMR, with physicians supported by medical assistants who do screening, population health managers and case managers for outreach, and nurses, nutritionists, and other clinicians to support treatment.
Finally, we are making joy in practice a top priority and are seeking systematic efficiencies by improving EMR efficiency and offloading population health management tasks from physicians.
This will help primary care physicians use their important cognitive skills to treat the issues that cannot be managed by protocol and to build lifelong personal relationships with their patients.
HLM: What insights do you have to share with other organizations about transitioning toward value?
Sindell: MACRA was designed to have winners and losers as it relates to payment. Physicians with lower documented quality will fund bonuses for others with high quality.
For organizations of any size just starting on this journey, the challenge is to put this in place for 2017 measurement (assuming MACRA stays on schedule), along with infrastructure to report the metrics to CMS to be successful when MACRA kicks in.
We anticipate that smaller, independent physician groups will find it difficult to do this on their own, and that there will be consolidation as physicians strive to be among the MACRA winners. That may not be a bad thing. Competition will drive standards higher and improving health outcomes more consistently is likely to be the result.
Healthcare leaders are developing outpatient strategies that enhance access in an increasingly risk-based environment. This can happen by several means—through acquisitions, partnerships, building new facilities, and often through some combination thereof. From there, the possibilities are almost endless.
This article first appeared in the July/August 2016 issue of HealthLeaders magazine.
To thrive in today's healthcare marketplace, hospital and health system leaders need to think beyond putting "heads in beds."
For some, fulfilling the goal of providing patients with the right care at the right place at the right time means becoming virtually omnipresent in the daily lives of consumers and potential consumers.
Expansion of ambulatory and outpatient care networks makes sense for several reasons, including the desire to improve patient access, strengthen patient-provider relationships, and increase revenue. In fact, 84% of healthcare leaders who responded to the 2015 HealthLeaders Media Ambulatory and Outpatient Care Survey regard the industry's shifting focus from acute to ambulatory care as an opportunity rather than a threat.
This figure is indicative of a changing mindset among health executives about outpatient business, including ambulatory and postacute care.
"Historically, we have viewed ambulatory and postacute care as means to support hospitals," says Scott Nordlund, executive vice president for growth, strategy, and innovation at Trinity Health, a Livonia, Michigan–based not-for-profit with facilities in 21 states and annual operating revenue of about $15.9 billion.
"As we wade into the world of population health and begin to think about networks of care—including outpatient ambulatory networks—in many cases, we're investing as much there as we are in our inpatient facilities. Not everything is necessarily centered around the hospital," he says.
Maintaining network adequacy
Redrawing one's circle of influence can happen by several means—through acquisitions, partnerships, building new facilities, and often through some combination thereof. From there, the possibilities are almost endless, encompassing every type of outpatient care from extensivist clinics to walk-in care to telehealth.
"As we wade into the world of population health and begin to think about networks of care—including outpatient ambulatory networks—in many cases, we're investing as much there as we are in our inpatient facilities. Not everything is necessarily centered around the hospital."
To that end, Trinity Health has recently completed several projects to bolster its outpatient presence, including a network of freestanding emergency departments, an integrated medical fitness facility in Ohio, the acquisition of home health agencies throughout the United States, and more.
And there's more outpatient growth on the horizon, including several physician practice acquisitions in key markets and even conversion of some inpatient hospitals into outpatient destination centers.
Much of Trinity Health's strategy comes down to maintaining network adequacy, says Nordlund. "You have to have sufficient access points across your market and the right kind of levels of care, from the more traditional inpatient space through the outpatient ambulatory as well as postacute spaces in order to care for a population."
Trinity Health is far from alone in its quest to improve population health through outpatient growth. That was among the top factors driving outpatient strategies, cited by 43% of HealthLeaders Media Ambulatory and Outpatient Care Survey respondents.
Other priorities for outpatient expansion included improving quality outcomes (52%), expanding market share (50%), increasing revenue (48%), responding to consumer-driven trends (43%), and reducing costs (39%).
Understanding physician organizations
To achieve these goals, roughly half of the leaders surveyed reported partnering with, acquiring, or establishing physician organizations. But doing so isn't necessarily simple.
"You have to have sufficient access points across your market and the right kind of levels of care, from the more traditional inpatient space through the outpatient ambulatory as well as postacute spaces in order to care for a population."
Nordlund says he learned many lessons throughout Trinity Health's outpatient expansion, but the need to appreciate the uniqueness of each setting is one that stands out. "The expertise that it takes to run and have well-managed acute operations—those skills don't necessarily translate to what it takes to run a network of care," he says. It requires "learning new skills in terms of how to put together real-estate deals, how to acquire physician practices in a meaningful way, and how to aggregate those practices into well-performing networks."
For health systems, the trick is to assess outpatient opportunities in a strategic, proactive manner, rather than a reactive one, says James F. Kravec, MD, FACP, executive vice president and chief clinical officer for Mercy Health Youngstown, an integrated health system employing more than 6,000 and serving four counties in Northeast Ohio. MHY is one of eight regions of Mercy Health, a 23-hospital health system serving Ohio and Kentucky, with assets of $6.1 billion and net operating revenue of $4.5 billion.
"We have found that locally and nationally, many groups are acquired when there was no other option or when there was a need on behalf of the practice," he says. "I think we've found that the best way to acquire a medical group is to focus on when there's a hospital strategic need and making sure you continue on the mission and strategy of the hospital by focusing on what you're focusing on. Don't change it to fit one practice, because that's where you make mistakes."
A common mistake healthcare organizations make is acquiring practices of poor cultural fit, and MHY is no exception. While past mismatches were clear from the beginning, Kravec says in retrospect, the acquisitions proceeded nonetheless.
"This was a very challenging time for the operators and administrators, as the lack of cultural fit bled down to every aspect of the practice, and the relationships did not survive more than a few years," he says.
As a result of three to four successful primary care practice acquisitions in each of the past three years, MHY has more than doubled its number of employed physicians, from 50 in 2012 to 115 in 2016.
Each of these strategic acquisitions has been part ofMercy's overall strategy for population health, amazing patient care, and organizational growth, Kravec says. In particular, the group is striving to increase its percentage of primary care physicians relative to specialists. To date, its physician composition includes 42% primary care physicians and 58% in specialties.
The physician enterprise is steadfast about staying on course. "It's not meant to be one where physicians have no other options, and we're the last people they called. We want to be very strategic in the practices we acquire."
To help ensure acquisitions meet MHY's strategic alignment, market, and access goals, the group uses a matrix that categorizes physician practices by three key elements: critical strategic alignment, compatible cultural fit, and capable performance. Depending on how well practices score in these categories, MHY will rank them by worthiness to pursue, consider, consider exclusively for succession planning, or avoid.
Assessing the objective criteria within these categories is fairly straightforward. Some of the easy questions: How many active charts per FTE? What's the wait time for a new appointment? Is the group aligned with a competitor? What brand and type of EMR does it use, if any?
"The tougher ones are reputation and quality metrics for those that are not in a hospital setting," says Kravec. "If a physician is in a private practice, it's a little harder to find some of this data, so we have to use our best educated knowledge of the practice to fill out the matrix."
Other considerations are related to geographic expansion potential, the ratio of primary care physicians per population in a given area, and the number of retail or open access clinics within a certain radius.
From the first meeting with potential recruited physicians, including those coming out of residency, leadership communicates its goals and expectations for improving population health. The group is focused closely on the same six primary-care quality metrics as Mercy Health at large, which are systolic blood pressure, hemoglobin A1C, neuropathy screening for diabetics, breast cancer screening, colorectal screening, and pneumonia vaccination.
"When practices come on board, they know from the beginning that we're going to focus on population health and hitting our benchmarks for the metrics that we're following," Kravec says.
The power of partnerships
In addition to acquisitions, strategic partnerships can also help health systems expand into the outpatient space; but not all such relationships are created equal, says Nordlund.
"In these spaces, partnerships make a lot of sense," he says. However, "you want to have a very well-defined set of criteria that you think about and use when choosing best-in-class partners that you want to be with, because whether you hold majority or minority share, that relationship becomes part of your reputation."
One partnership that has been an important part of Trinity Health's strategy for consumer engagement and organic growth is its work with Sharecare, a Web-based patient-engagement tool that provides users with its health risk assessment, individualized wellness programs, fitness device data aggregation, facility locators, appointment schedulers, secure messaging with physicians, symptom navigator tools, and more.
"Strategic partnerships are important to our 2020 People-Centered Strategic Plan," Nordlund says. "We are business partners with—and equity investors in—Sharecare because we believe they are well-positioned to help us engage patients and consumers in a way that helps us build the strong, lifelong transformative relationships we need to build in order to deliver truly effective people-centered care."
So far, the results of the initiative have been impressive. Since the first pilot sites went live on Sharecare in October 2015, there have been more than 2 million visits to Sharecare in those pilot markets, Nordlund says, adding that visits to Trinity Health physician profiles and content on Sharecare.com has grown by 83% from February to April 2016. "We are very pleased with the value and intellectual horsepower Sharecare is bringing to our partnership.
"We're moving ahead with strategic opportunities and testing right now, and are looking forward to assessing our metrics after all the levels of our effort are implemented, especially when it comes to integration with our patient portal," Nordlund says.
As with any aspects of the outpatient movement, such relationships require leaders to think differently than they have in the past—when hospitals owned and controlled most parts of the delivery of inpatient care.
When it comes to aligning oneself with others' expertise, and in turn giving up some measure of control, healthcare leaders should consider carefully who their partners are, how they reflect on their organizations, and the plan of action if there is a problem, Nordlund says.
"These are not vendor relationships. These are true partnerships, so it's really important to think through what that means to you well beyond just return on investment," he says.
In other words, while a vendor-buyer relationship is primarily about a sale and purchase of products and/or services, a partner becomes part of the fabric of your organization and affects how services and even care may be delivered, Nordlund says.
"Trinity Health partners with all kinds of organizations in many different ways, and each partnership is unique," he adds. "The major difference with the Sharecare partnership is that we are an equity investor in Sharecare and they have accepted accountability for helping us achieve our long-term goals in consumer engagement."
In some cases, relationships evolve over time.
For example, Henry Ford Health System, a five-hospital integrated nonprofit health system in Detroit with $4.7 billion in annual revenue, is among many organizations that developed early partnerships with CVS MinuteClinic in response to the growing retail health sector. Under its original 2011 contract, Henry Ford provided physician medical directors exclusively to CVS MinuteClinics in Detroit to ove see clinical operations and supervise nurse practitioners.
While Henry Ford still provides the medical directorships, the rules are more flexible so as to benefit both parties. "At one time it was a very exclusive arrangement, but it actually put handcuffs on everybody," says Paul Szilagyi, Henry Ford's vice president of primary care and medical centers.
Those restrictions not only locked Henry Ford physicians in with CVS, but the Henry Ford branding also limited CVS' ability to receive patient referrals from other health systems. Loosening those ties also allowed Henry Ford to create and run its own retail clinics, including QuickCare.
"We view that the future of healthcare is going to be more and more about outpatient services, so we've intentionally been trying to add new outpatient centers and make sure we have a strong outpatient network throughout the region that we serve."
Meanwhile, the two organizations continue to collaborate in significant ways. "We are actively talking with them right now about how we can work together on understanding our populations better to improve adherence to medications and protocols, and then to also bring down the cost of care at the same time," Szilagyi says.
MinuteClinic's recent switch to the Epic EMR system has made population management and care coordination easier for Henry Ford providers, he adds.
Primary care at the center
Outpatient expansion is also a priority for Cleveland-based University Hospitals Health System, an integrated network of 18 hospitals with more than 40 outpatient health centers and primary care physician offices in 15 counties throughout Northeast Ohio.
"We view that the future of healthcare is going to be more and more about outpatient services, so we've intentionally been trying to add new outpatient centers and make sure we have a strong outpatient network throughout the region that we serve," says Paul Tait, University Hospitals' chief strategic planning officer.
And not unlike its fellow Ohioans at Mercy Health, some 70 miles away, University Hospitals regards primary care as the hub to its enterprise.
The system's emphasis on primary care and population health began in 2010 when the team, led by Tait, recognized the need to become a market leader in delivering accountable care. By the end of that year, University Hospitals developed an accountable care organization for its own employees and added a pediatric ACO in 2012. Building on these efforts, the organization has since added a Medicare Shared Savings ACO and entered into ACO contracts with several payers, including Anthem, Cigna, and others.
"So all told, when you add up all the various types of ACOs, we have over 300,000 lives that we manage now," says Tait.
What's more, a total of five hospitals have joined the University Hospitals system within the past two years, which in many cases included the absorption of existing outpatient centers. While some of these facilities help support the growing network, the organization is on the lookout for remaining community need.
"We believe in the importance of outpatient services, so what we've been doing is strengthening the current sites and adding new ones," Tait explains.
For example, Elyria and Parma Medical Centers are two hospitals that became wholly owned parts of the UH system in 2014. Set to open this summer, UH's Broadview Heights Health Center, located south of Cleveland, has been designed to integrate with them by offering on an outpatient basis a range of primary and specialty care physicians (cardiology and orthopedics), laboratory services, diagnostic imaging and radiology services, as well as emergency and urgent care.
A similar 50,300-square-foot ambulatory health center and freestanding emergency department under construction in North Ridgeville, about 20 miles west of Cleveland, will in 2017 support the system's west-side hospitals: Elyria Medical Center and St. John Medical Center.
While the size and shape of each new location may vary, they share a common denominator. "Our whole model is around primary care physicians," says Richard Hanson, president of University Hospitals' community hospitals and ambulatory network. "So we don't build a site until we have a large primary care mix in that location, and then we bring the specialists out to that site where our primary care physicians are already located."
Even still, leaders are careful to assess demand before placing physicians anywhere, particularly for specialists, says Hanson. Some outpatient centers, as a result, include timeshare suites in which each specialty physician might work two days per week, and work out of other centers the remaining days. "That way you're offering services locally but you're also keeping the physician productive in terms of how time is used," he says.
University Hospitals physicians are also grouped strategically to allow them to cross-cover for one another and share evening and weekend call coverage. They all share the same EMR as well, which the team regards as a must for coordination of care.
And as consumer-driven healthcare continues to take hold, patient convenience is also important. "Consumers want convenient access to primary and urgent care," says Tait. "So we try to provide as much care locally as possible, because we recognize that most people don't want to get in the car and travel very far for care if they don't have to."
Today's consumers also want choices, notes Hanson. So in some cases, the system offers urgent care and an emergency room in the same facility. "If it is a true emergency, they can go one avenue, and if it's an urgent-care-type need, they can go the other way and keep the cost down," he says.
To help consumers determine which setting is most appropriate—and get seen as quickly as possible—University Hospitals uses the InQuicker program. The technology allows patients to log in through the website or mobile app, answer a brief series of questions to determine the appropriate site of care, and self-schedule an appointment at the ED or urgent care center that is closest to them or has the shortest wait. Typically, patients who use this technology can be seen within 10 minutes, says Hanson.
InQuicker has benefited University Hospitals as well, through increased urgent-care volumes and fewer nonemergent cases showing up in the ED, Hanson says. Based on registration data dating back to January 2014, 46%–50% of patients who used the program indicated they were new to the facility they visited, and thus represented 552 new patients in 2014, 3,698 new patients in 2015, and 2,159 new patients between January and May 2016.
When an outpatient growth tactic is successful, the volume speaks for itself in indicating the system is offering the right services in the right locations to meet community need, Hanson says. "These are our entry points into our system. So if they're run well, they feed our hospitals and facilities."
The benefit of a large health system with various facilities throughout the region, Tait says, is that patients have the ability to get most care closer to home, and on an outpatient basis when that makes the most sense. For instance, while UH's main campus provides high-level tertiary care for complex cases, oncology patients are able to access much of their care close to home at the UH Seidman Cancer Center's outpatient locations.
In general, UH outpatient facilities often service patients who, at some point, will be seen in a UH inpatient facility, Hanson adds. And while adding an outpatient location does boost system net revenue and market share in areas previously lacking access, lag time to break even can vary considerably by project.
Meanwhile in Detroit, Henry Ford Health System has designed much of its ambulatory strategy around a concept its leaders have dubbed radical convenience.
"We started as a hospital, but we were fast in moving from inpatient care to outpatient care with our vast ambulatory network in this Detroit market," says Szilagyi. "We're constantly looking for new ways to appeal to a more outpatient or ambulatory type of care that is delivered in new ways. It revolves around the idea of access."
That access is available in three ways, which the system's leaders refer to as call, click, or come in.
These catchphrases aren't just about marketing, however. With about 70% of its payer contracts involving risk, Henry Ford is especially attuned to managing population health. And a key part of that strategy is offering care that's not just convenient but also affordable.
"When we first started this adventure, there were only two ways to get into the Henry Ford Health System," he says. "You booked a visit in a clinic or you came in through the emergency room. What we've done is created more opportunities for patients to access the system."
As the "call, click, or come in" terminology implies, some forms of patient care are just a phone call away, via Henry Ford's 24-hour nurse hotline or its cold and flu hotline, both of which are available for free to established patients. For needs that can't be fully satisfied by phone but don't necessarily require an in-person visit, Henry Ford offers virtual visits through its partnership with Teladoc.
And when "coming in" is warranted, patients have plenty of options, including same-day appointments at primary care clinics, three freestanding emergency rooms, four urgent care clinics, and five walk-in clinics located throughout the city.
Henry Ford's newest addition to this array of access points is its QuickCare Clinic, which opened last summer in downtown Detroit. The 2,000-square-foot facility offers retail-focused care that is broader in scope than a typical CVS MinuteClinic, Szilagyi says. Nonroutine services offered include acupuncture, massage, and travel medicine.
While insured patients can go to any of these sites for an office-visit copay, pricing is standardized and posted on a menu board for those paying out of pocket.
In addition to its affordability, Henry Ford utilizes self-scheduling technology to save patients time. Similar to the InQuicker program offered by University Hospitals, Henry Ford holds a partnership with vendor Clockwise.MD. "It's like call-ahead seating so you can reserve your spot in line," Szilagyi says.
Henry Ford was among the first healthcare organizations in Michigan to use Clockwise.MD, Szilagyi says. And with very little promotion, almost 25% of the system's walk-in patients are now using the service. "It's been phenomenally successful," he says.
The other benefit of the technology, which informs patients of the wait time at each nearby site, is that it helps distribute workload throughout the facilities. "It reduces the big waves that roll in at 3:30 when school lets out or at 5 when people get out of work."
As for the financial success of the care sites themselves, leaders will be happy if the QuickCare Clinic breaks even. They expect a learning curve in determining what patients want in terms of the new endeavor, but volume is already on a steady increase.
Overall, the success factors for any Henry Ford site include its abilities to attract new patients to the system and connect care to the people in the system. "Our goal is to help increase the value of care to our patients from multiple perspectives," he says.
"For example, consider somebody who just never bothered establishing a relationship with a health system or primary care provider. If we can meet their needs at a local level, at a low-acuity point, as their needs progress over time and they establish a relationship with us, we hope that they'll think Henry Ford when they need a higher level of care," Szilagyi says.
Knowing your audience
Despite the growth of the retail health segment of the outpatient market, providers face challenges to offer the scope of services patients want within the constraints of the model, which was built around the idea of handling low-acuity, acute medical needs, typically with a staff of nurse practitioners.
Now that major retailers, including Walgreens healthcare clinics, are expanding services to help consumers manage chronic conditions, healthcare leaders must reassess what it means for their system to offer the right care at the right place at the right time.
For Henry Ford, that's somewhat a work in progress. "Clearly, we're working on refining the model and understanding patients' needs a little bit better. Our plan is to actually produce more of these QuickCare Clinics, as we understand the appropriate locations to place them," Szilagyi says.
Though careful not to overgeneralize, he notes that young professionals represent the main demographic drawn to the downtown QuickCare. And while these millennials are less interested in having a relationship with a primary care physician, the system has learned, they are also interested in a place to get care quickly and conveniently near home or work, which the QuickCare site is for many of them.
As a result, staff at the clinic don't push patients without a primary care physician to get one. "That's one of the things we found that's a little bit different for us," Szilagyi says. "With a strong brand name like Henry Ford, people don't think of us as a small retail clinic. So what we're doing is adding PCP services to the site."
Although it can be difficult to achieve direct ROI on PCPs in a retail setting, the same can be true of primary care in general, he says, referring back to Henry Ford's deep investment in value-based care. "In risk contracts, we're taking care of the whole patient."
No model can be one-size-fits-all, Szilagyi says. "To be able to offer a variety of access points in a variety of ways is a key initiative for us."
Tackling financial hurdles to population health
Another strategy some systems have used to provide an array of health services within the communities they serve is with the concept of medical plazas.
Though the definition may vary throughout the industry, for Novant Health—a nonprofit integrated healthcare system serving 4 million patients annually throughout Virginia, North Carolina, South Carolina, and Georgia—a medical plaza can be any collection of services that are provided in a patient-centric and convenient manner in a specific geography.
For the $3.8 billion system, these collections often co-locate a small (30–50 bed) acute care hospital with a variety of ambulatory services such as primary care and specialty offices, imaging, labs, and more, typically not far from existing shopping areas or greenways.
For example, Novant Health Clemmons Medical Center, its 13th medical center, opened in April 2013 as a two-story, 35,000-square-foot facility offering emergency, imaging, laboratory, and surgery services. In December 2014, Novant added a primary and specialty care medical office building to the campus, and further developments are underway.
"The real key is moving away from the concept of a big downtown megahospital into integrated healthcare delivery centers," says Stephen Motew, MD, senior vice president for physician services for Novant Health's greater Winston-Salem area, and a practicing vascular surgeon.
"The importance of this is not only patient centricity and ease of access, but it also allows us to offer lower-cost venues of care," he says. "When we set up things inside hospitals, they tend to be more expensive, and we are really trying to touch on all aspects of patient-centric thinking, which includes affordability."
And like many health systems, Novant's outpatient growth strategy ties directly to its approach toward population health and value-based care.
"If we define this as improving the value delivered to patients—high quality in a more affordable fashion—it's the right thing to do and our payers are supporting this, and the government payers and the patients as consumers are needing this," Motew says. "What we feel is a key factor that drives up cost for the large general population is the inability to access appropriate levels of care."
Quite often, the right level of care is, indeed, found in the outpatient setting, and perhaps of rather low acuity. To address minor health matters quickly, patients can also visit a Novant Health Express Care, several of which are located in strip-mall-type settings throughout the system's markets.
On the more serious end of the acuity spectrum, Novant is also among the growing number of systems developing extensivist clinics at its community-based hospitals to help patients who would traditionally require an inpatient stay from being admitted. A patient with a skin infection, for example, would visit the clinic during the day to have wound treatment and antibiotics monitored. If all is well at the end of the day, these would-be inpatients leave to go sleep in their own homes and return for more hospital-level care in the morning.
"It's a big patient pleaser," Motew says. "It's very effective clinically and tends to avoid the more expensive long-term hospital stay."
"We are seeing appropriate growth that matches our expansion. As we expand our number of providers and access to them, we see a direct correlation in growth in encounters, which has been consistent in the last two to three years."
As a result of these measures, Novant is ahead of its financial goals, according to Motew, with the caveat that a lack of standardized reporting makes outpatient market share difficult to measure.
"That being said, we are seeing appropriate growth that matches our expansion. As we expand our number of providers and access to them, we see a direct correlation in growth in encounters, which has been consistent in the last two to three years."
Nonetheless, Novant is in company with many other systems challenged by the industry's drawn-out transition from fee-for-service to value-based care. "The contribution margins in general for outpatient care compared to acute care are much less in the fee-for-service realm," Motew says. "So we're sort of straddling that chasm between fee-for-service and value, and as our value-based payments increase, we're expecting to see a better matching of that of [outpatient revenue] compared to acute care revenues."
Not being able to predict exactly when payer models will sync up with emerging ways of delivering care poses strategic risks, he says. "For the most part, we're still 85%–90% fee-for-service, yet we're trying to move quickly. So the real challenge is the timing of this. How fast or how slow should we go?"
In the meantime, consumer demand doesn't wait. "We have to be able to respond quickly to consumers, as they're driving a large portion of this. They're telling us what they want, so that's not a challenge, but it's one of our goals."
The business of health
If there's one thing today's consumers consistently say they want, it's one-stop shopping. The outpatient endeavors of Main Line Health, a 1,387-bed health system with $1.4 billion in annual operating revenue based in Bryn Mawr, Pennsylvania, epitomize that concept and more.
"Main Line Health has a long-standing commitment to bring resources into the neighborhoods where our patients live, and to take services that don't need to be in a hospital setting out into the community," says Lydia Hammer, MPH, the system's senior vice president of marketing and business development.
"We have to be able to respond quickly to consumers, as they're driving a large portion of this. They're telling us what they want, so that's not a challenge, but it's one of our goals."
This commitment is reflected in a new vision statement the system is writing as part of its strategic plan. "We don't believe we are just in the hospital business, nor do we believe we're just in the healthcare services business," Hammer says. "We believe we're in the health business, which means our obligation is to help our communities stay healthy; but then if they need us at times of illness or injury, we are here for them."
In carrying out that vision, Main Line Health has opened four major health centers in the greater Philadelphia region. One of the more recent examples is Main Line Health Center at Exton Square, which opened in January 2014. The 32,000-square-foot, state-of-the-art, patient-centered outpatient facility located at the upscale Exton Square Mall features primary and specialty care along with laboratory, imaging, and radiology services, plus evening and weekend hours and complimentary valet parking.
Overall, these outpatient facilities are highly utilized and gaining new patients daily, Hammer says. "For instance, within the first year, the urgent care component of our Exton office grew to see approximately 30 patients a day." The urgent care center within the Main Line Health Center site in Broomall opened in May, and in just over two weeks the site was already seeing an average of 19 patients a day.
Once patients enter the system through these sites, they frequently become long-term patients in other parts of the system, whether through follow-up with Main Line Health specialists or by connecting with primary care physicians to become their regular source of care, she says.
And set to open in winter 2016 is a fifth center in Concordville. The new center under construction will fill three stories and 135,000 square feet. The expansive space will not only include physician offices and high-tech ancillary services but also a medically supervised fitness center and pool, an urgent care center, and café where only heart-healthy food is served.
"A unique element of the Fitness & Wellness Center is that members will have individual and group programming to meet their specific medical needs, such as diabetes, obesity, heart disease, and orthopedic issues," says Hammer.
So far, Main Line's foray into the fitness space is garnering enthusiasm, with more than 1,300 Fitness & Wellness Center memberships sold as of March, well ahead of target, and a surplus of physicians eager to be part of the fitness center's medical advisory board.
If the venture is a success, Main Line will consider adding more fitness centers where community needs dictate, Hammer says. The organization will evaluate its results based on both improvements in patients' health status—which bodes well for the industry's movement toward population health—and old-fashioned utilization data.
Ultimately, "as patients appreciate that Main Line Health is their partner in maintaining their health, we will have a greater impact on the communities we serve," Hammer says.
In addition to facing many of the other outpatient-growth challenges illuminated by systems throughout the country, Hammer points out that long-term patient loyalty is not guaranteed, at least not in Philadelphia.
"It's a pretty heavily resourced market. There are a lot of doctors. There are a lot of outpatient centers. You can get an x-ray pretty much on any corner. So we have to provide a better product, and that means we have to be easier to do business with and demonstrate the high quality of our services," she says. "We have to always provide outstanding quality and have people feel like we exceeded their expectations."
While new data confirms that the stability of the physician workforce is as precarious as ever, a multi-specialty group's CMO explains how reducing burnout is an achievable goal.
Physician burnout is threatening to engulf the provider workforce, a Mayo Clinic study published this month suggests.
By analyzing physician surveys in conjunction with payroll records, investigators found that for every point increase in the seven-point scale of emotional exhaustion, one of three domains measured by the Maslach Burnout Inventory, there was a 40% greater likelihood a physician would cut back his or her work hours over the next 24 months.
They found a similar relationship for every one-point decrease in the five-point scale measuring professional satisfaction.
And contrary to stereotypes, this trend was not linked to a greater proportion of women physicians or younger physicians reducing professional work effort, Tait Shanafelt, MD, professor of medicine at Mayo Clinic and lead author of the study, told me. "Rather, it was primarily due to an increased proportion of men, particularly male physicians over age 55, reducing professional work effort."
The Cost of Ignoring Alarms
Compounded with a predicted physician shortage and not counting the 89% of respondents to a 2015 Cejka Search survey wanting to change jobs, cut back, or leave medicine, these findings obviously aren't good news for healthcare leaders.
"These results have important repercussions for healthcare organizations seeking to maintain a productive and engaged physician workforce," says Shanafelt. "Burnout is, in large part, a system issue. Organizational efforts to address the problem must address the drivers of burnout, including problems with excessive workload, inefficiency in the practice environment, loss of flexibility and control over work, and barriers to healthy work-life integration."
It's not uncommon, however, for leaders to regard burnout as an emotional issue rather than a business one, according to Karen Weiner, MD, chief medical officer at Oregon Medical Group. This mindset is seemingly unique to healthcare.
"In any other industry, if we were to pull together the CEOs and say, 'you are burning out your primary revenue generators faster than you can replace them,' it would be an all-hands-on-deck emergency situation where every technology, every innovation is focused on sustainability models for that valuable and limited resource," says Weiner. "In medicine, that's where CEOs and leadership needs to be."
The Mayo study may help leaders get there. "If you want to quantify your risk for losing physicians in the coming year, run the Maslach Burnout Inventory on your physicians. You can translate that to an ROI if you want to, if you need to, to direct resources toward improving burnout."
The cost to replace a physician, Weiner notes, ranges from $250,000 to $500,000.
An Outdated Culture
As a physician and leader, Weiner knows first-hand how this exercise can impact an organization. In 2013, when she was on the board of directors and practicing full-time at Oregon Medical Group, morale was at an all-time low.
"We were at a crisis point where we had a lot of angry, frustrated physicians," Weiner says. Perhaps not surprisingly, the MBI revealed that 58% of the group's physicians were experiencing burnout.
"We had implemented our electronic medical record [system], and that really highlighted all of the dysfunction we had in our group. The culture that we had developed over the decades prior had worked well [until] then, but the environment was changing and our culture wasn't conducive to being able to meet the needs of the changing market."
With that impetus to change, the physician-owned group took several measures to update its culture, including articulating a new vision and generating the group's first physician compact, which stated "the new rules of engagement," Weiner says.
"In retrospect, the biggest deficit in our group was lack of community, that we did not have the collaboration that we needed to get anything done," she says.
But once the physicians jointly agreed on the group's new vision, which is to collaborate to provide the highest quality of patient-centered care, their unity became more powerful than the problem. "Once collaboration was in place, everything [else] was doable," Weiner says.
When the group conducted follow-up burnout surveys two years later, the incidence of burnout had dropped significantly, she notes, but there was more work to be done.
"In our progress, we've achieved collaboration and we're trying to remove barriers to providing care because that's always a frustration to physicians and it's not good for patient care. So removing the waste in the system makes everybody's work more rewarding," she says. "It's ongoing. It's small, incremental improvements."
Part-Time Is Better Than No-Time
It's important to note, though, that some of these adjustments involve the very consequence that the Mayo study illuminated: Giving depleted physicians the ability to work less. As of today, Oregon Medical Group has several physicians who work one day per week in the walk-in clinic or jobshare as part of a primary care team.
"An organization has to understand that it has to be flexible—not just flexible—but they have to develop models that work to salvage people," Weiner says. "That resource is so valuable that we have to make it work. And that's what we've done. We have quite a few physicians that would have been gone otherwise that are contributing to care in the community."
Shanafelt agrees that having a part-time physician is better than a physician leaving medicine altogether. "Organizations that provide physicians the flexibility to adjust work-effort to preserve meaning and satisfaction may have a competitive advantage in recruiting and retaining physicians," he adds.
"There is a societal imperative, however, to provide physicians a better option than choosing between reducing clinical work or burning out. Large numbers of physicians reducing their professional effort due to burnout would exacerbate the already substantial projected U.S. physician workforce shortage as well as impact continuity of care for patients," Shanafelt says.
The elephant in the room is the idea of offloading non-physician work to others, specifically, APRNs.
In addition to the cultural changes required to implement team-based care, there are practical ones, especially regarding standardization. "You can't offload work from physicians unless that work is standardized," says Weiner, "because you have to be able to know what work you're giving away and making sure that work is getting done."
And you can't standardize work without physician engagement, Weiner adds. And you can't create physician engagement without collaboration.
And without leadership committed to understanding how physicians are balancing their work and life responsibilities, you can't get the fight against burnout even started.
The 'work before the work' builds trust between clinicians and patients, allows more leeway to get difficult conversations right.
As part of their quest to deliver a better patient experience, healthcare providers have been placing greater emphasis on clinicians' communication skills.
The result has been better awareness and training, but there's still work to be done.
"We still have large gaps to close," says William Maples, MD, executive director and chief experience officer of the Institute for Healthcare Excellence and the chief medical officer at Professional Research Consultants.
Prior to launching the IHE, Maples was senior vice president and chief quality officer at Mission Health in Asheville, NC, and spent 25 years as a practicing oncologist and quality leader at the Mayo Clinic in Jacksonville, FL.
"From the perspective of a profession that faces delivering difficult news frequently, I would say that even in situations where there's an opportunity to practice, time and again there are barriers that make it difficult actually executing conversations, especially those involving end of life or palliative care, for a variety of reasons," he says.
The following transcript has been lightly edited.
HealthLeaders Media: What are the fundamental communication skills most important to talking about difficult subjects?
Maples: There are several competencies involved, including finding the right setting to have the talk and recognizing and responding to the emotion in the room.
One of the most critical steps is the "work before the work."
Often there is some lead time to prepare a family and patient in terms of what news may be evolving. And the way you do that prework can make the actual conversation much more productive, helpful, thoughtful, compassionate, and empathetic.
HLM: Which training methods are most effective in helping clinicians improve their communication skills?
Maples: While some online programs can be helpful, they're really not sufficient.
Even if they incorporate some skills-based practice, the online experience is far short of an in-person, skills-based curriculum in which physicians work with physicians and learn from one another.
By far and away, the most effective is an experiential learning model where there's some time for reflection on the importance of getting this conversation right.
HLM: Surely in real life, clinicians don't always get it right. How can they recover from important conversations that don't proceed as hoped?
Maples: There's not a moment in a caregiver's day that something couldn't go wrong.
The risk doesn't just surround having a difficult conversation or delivering bad news, but around everything a clinician does every moment of every day.
One needs to incorporate all of the practices that help clinicians recover when things go wrong or are misinterpreted, and they have lots of chances to practice building resilience to come back and have a correcting conversation or take a correcting action.
Ultimately, it comes back to the work before the work. [That means] having an emotional, psychological bank account filled up so that there's room for forgiveness, there's room for self-awareness on the clinician's part, and there's an opportunity to revisit that conversation with the patient and family.
To be honest, if you've done your work before you actually have the conversation, patients will give you not only a second opportunity, but a third and fourth, as they know that you really care.
HLM: What can healthcare leaders do to support clinicians' development in handling difficult conversations?
Maples: Administration and leadership need to understand what the ramifications are if we don't get this right.
That includes consequences from the errors we create to lack of partnership with patients to deficiencies in safety, efficiency, outcomes, and ultimately the culture of the organization.
The second thing is to recognize that there is a return on investment that comes from creating trust within the medical team, reducing turnover rates, reducing malpractice claims, increasing patient satisfaction, you name it.
The health system has appointed a director of physician communication to bolster patient satisfaction scores.
Patient satisfaction matters, not just to patients, but inevitably to healthcare organizations' bottom lines as momentum builds toward publicizing scores and linking them to reimbursement.
At the core of most patient dissatisfaction are problems related to communication, says Kelley Dillon, director of physician communication and peer support at Henry Ford Health System, a recently created role aimed at helping clinicians become better communicators.
In fact, the system's entire department of physician communication and support is just a few months old.
Calling herself a "department of one," Dillon says she is building a team that will help Henry Ford build on its early success with communications training for clinic service representatives and medical assistants.
"These are our first-impression folks when you walk into a clinic," Dillon says. "Their scores have gone up and are continuing to sustain because of all our ongoing checking and accountability measures, such as mystery shopping and auditing, to make sure they're doing what they're taught and they're being recognized for it."
Henry Ford still has work to do, however, in improving its overall patient satisfaction scores and the likelihood that patients will recommend the organization.
One of the primary teaching tools being used at Henry Ford is a physician shadowing program, in which Dillon or another trained individual sits as a "fly on the wall" during a patient visit and marks down "yes/no" observations about a standard set of physician behaviors, such as whether the physician apologized for any delay.
The physician then receives a confidential report and private coaching referred to as a "shadow summary conversation."
Most often, this meeting is enlightening to physicians, whose good intentions don't always translate to the patient through their behavior. Physicians tend to think clinically and ask closed-ended questions, Dillon notes, whereas patients tend to speak in open-ended ways.
Part of what makes these conversations effective is that they occur no more than a few days after the patient encounter, when it's still fresh in the physician's and the shadower's mind, says Dillon. "I can say, 'if you do that more consistently, it could move this question here that they're rating you poorly on.'"
Creating Physician Partners
With a solid background in leader development and experience handling patient complaints, Dillon's feedback is generally well received by physicians. But to maintain the program's credibility, she wants more physicians coaching one another.
"By the end of the year, my next step is to get a cadre of internal senior staff physicians who have consistently scored high and see if I can get some of them to be certified as peer coaches to work with consistently low-scoring physicians on sharing best practices," Dillon says.
A key challenge in finding these physician partners, however, is in creating stipends to compensate them for lost clinic time. "Their time is money," she says. "So I have to figure out a way to incentivize them to help me because I really believe the answers are internal. I don't think we need to go out and purchase programs."
Speaking of money, as of this year, Henry Ford's senior staff physicians now have 15% of their bonus tied to whether they reach their communication targets based on patient perception.
"That has never happened before at Henry Ford," Dillon notes. [The bonus has] made it impossible to ignore."
An expert in determining payment packages and executive incentives discusses how to factor the many variables that influence how to pay practicing physicians for administrative work.
Hospitals and health systems increasingly recognize the need and benefits of physicians serving in leadership roles—and the importance of providing those physician leaders with support and resources to succeed.
Sure, the physicians stand to gain skills, prestige, and the opportunity to help more patients through a medical directorship than they can through episodic care.
But if physicians are going to commit to these extra responsibilities and he held accountable for results, shouldn't they be paid for that work? And if so, how much?
Of course, there are numerous factors to consider when compensating physicians serving in leadership or medical directorship positions, and no standard blueprint for organizations to follow.
Challenges may include regulatory issues, accounting for various ratios of clinical and administrative work, and more. Nonetheless, organizations have to look at the big picture in aligning physician executive incentives with organizational goals.
In an a webcast recorded for HealthLeaders Media, David Taylor, FACHE, FACMPE, corporate vice president of Cox Health in Springfield, Missouri, discusses these topics and more.
He followed up with me to answer additional questions. The following transcript of our conversation has been lightly edited.
HLM: Is it outdated to still be talking about work relative value units (WRVUs) when determining physician compensation? How do you factor quality into compensation for physician leaders?
David Taylor: First, for leadership roles, you would not see physicians paid based on WRVUs. This would only be utilized for a physician's clinical compensation.
Despite the industry's shift toward value, WRVU is the basis for most physician compensation plans today. It best approximates work effort and recognizes physicians for their level of production.
For purposes of determining a factor for quality, I would determine a range of what a comp rate per WRVU would be from a fair market value perspective, and then settle on a value within that range.
Let's say we agree with the physician on a rate of no more than $50/WRVU for her clinical work. Then for pay-for-performance, the plan would call for a withhold of 10% of the $50.
This $5 being withheld would be placed into a pool that would be paid out only if the physician achieves certain predetermined measures/goals as they relate to quality or other incentives that help meet the larger organizational goals.
HLM: How do you handle compensation for various specialists who want to be paid for their time lost from practice?
DT: The two don't equate. The administrative rates, per the published data and defined by the market, have reflected lower compensation for most administrative roles as compared to what can be earned by providing patient care.
A physician in a leadership role should take on the position for reasons besides just compensation, which may include the honor, having an interest in seeking a new challenge/experience, or to earn an income to augment an already full-time clinic practice.
Also, note that different specialties can or will command different hourly rates. It is common when looking at a department head or chair of a department to pay differentiating rates based on specialty.
HLM: Do you see compensation committees that approve or reject compensation plans for individual physicians include other physicians?
DT: For the purpose of designing a compensation methodology and creating your group's culture, you should have a compensation committee that includes physicians. This group can help set the parameters as it relates to the group's needs and overall goals.
However, when reviewing the compensation plan from a legal perspective and compliance, there may be physicians that attend the committee meeting, but typically would not vote.
For more on compensation methodologies for physician leaders, join David Taylor, Corporate Vice President, Cox Health, for the HealthLeaders Media webcast, "Determining Compensation for Physicians in Leadership Positions." Available on demand.