The founder of an alternative to MOC "would love to disband it" if boards come up with a new plan to make MOC meaningful and cost-effective.
The debate around maintenance of certification (MOC) has been raging for more than two years, during which some physicians have effectively changed the conversation around what it means to stay current in their profession.
This week, I spoke with two of them: Paul Teirstein, MD, is chief of cardiology for Scripps Clinic in San Diego, and creator of an alternative certifying body, the National Board of Physicians and Surgeons (NBPAS).
Scott E. Shapiro, MD, FACC, FCPP, is a cardiologist at Abington (PA) Medical Specialists, president of thePennsylvania Medical Society, and member of the American Medical Association (AMA) House of Delegates.
They spoke about their respective thoughts on the state of MOC, ongoing advocacy efforts, and what this work means to practicing physicians. The transcript below has been lightly edited.
HLM: Dr. Teirstein, how do you feel about what you've achieved so far with the NBPAS?
Teirstein: We've had great success. We have over 4,000 diplomats and over 40 hospitals have accepted the National Board. It continues to grow. We get a handful of doctors that apply every day.
I would love to disband it if the American Board of Member Specialties (ABMS) member boards would come up with a plan that is meaningful and was the right price and not despised by doctors.
They've made changes in the right direction, but we have a long way to go until we have less onerous, less costly, meaningful ways of demonstrating that we're keeping up with changes in medicine.
The changes have been too slow. And they're being replaced with take-home tests, which give us doubts about whether they'll be any real learning going on. Finally, we've not heard a thing about reducing costs.
HLM: Dr. Shapiro, how have attitudes within the culture of medicine shifted regarding board certification in recent years?
Shapiro: I think the AMA is a very good litmus test of the current environment.
The AMA doesn't [traditionally] make decisions like we did in June to really condemn those boards that still have these high-stakes, punitive computer exams. And in debate, many really applauded those that focused on continuing education and not maintaining profits.
HLM:Dr. Teirstein, you must have put a lot of uncompensated time into NBPAS by now. How have you juggled it with the rest of your career?
Teirstein: I probably spend 20% of my time now, and it was a lot more in the beginning.
The time I spend [on NBPAS], which has been maybe a thousand times more than it would have been if I'd just done my MOC, I think is meaningful work because we've made positive changes. I think we've really helped physicians and therefore I'm happy to spend my time doing it.
HLM: What is your advice to individual physicians who want to effect change in their professional environments?
Shapiro: Continuing professional education is the cornerstone of our profession, and I think making sure that we're all participating in activities that are meaningful to our practice—and not merely jumping through hoops that don't help our patients or our profession—is important.
Teirstein: It's not that hard to do something [to address problems] and it feels good. And the Internet resources that we have available to make changes these days are pretty powerful.
When I started this, I was told by innumerable physicians that I shouldn't waste my time. I have emails that say the horse is out of the barn, it's a done deal. But it turns out that it wasn't a done deal and that we can undo things that aren't right.
Medical groups participating in the bundled payments program for cancer care are eager to innovate care, exchange ideas with other providers, and improve communication with patients and families.
"Excited" was the first word Eric Whitman, MD, medical director of Atlantic Health System's Carol G. Simon Cancer Centers in New Jersey, used to describe his reaction to Atlantic Health's acceptance into the Oncology Care Model program.
Atlantic Medical Group was among nearly 200 practices chosen by the Centers for Medicare & Medicaid Services to participate in the five-year bundled-payment demonstration that launched July 1.
"We actually heard in April that we'd been chosen, but [CMS] said there were a lot of things you had to do between being chosen and being accepted. And we had to decide we wanted to do it as well," he told me.
"In the end, our group felt that this was a very exciting new way to go forward in cancer care. We're essentially doing research into how to provide care and how to, most of all, communicate better with our cancer patients and their families. The government is funding us to investigate new ways of doing that," he says.
Comparing Notes
The benefits extend beyond the individual medical groups and their patients. "One of the fascinating things built into the back end of the grant is that you must share your ideas and experiences," Whitman notes.
"We can all learn from each other. And if someone in, say, Kansas does something differently that seems to resonate with our patients or with us, we'll hear about it through the grant mechanism and can try it as well."
For the 12 participating practices affiliated with the US Oncology Network, the collaboration has already begun, through a comprehensive program with innovative tools and resources designed to help groups optimize the OCM experience and transition to value-based care.
"The move to value-based care will completely change the landscape of cancer care in the future, impacting all aspects of care delivery and reimbursement," said J. Russell Hoverman, MD, medical director of managed care at the USON and an oncologist with Texas Oncology, in an announcement.
The USON has spent the past six months developing a support program to help members learn about care and support team structure, developing and deploying patient care paths, technology and reporting needs, financial models for incentive alignment, and revenue cycle management.
Upping Their Game
All practices that participate in OCM are required to enhance their services to provide patient-centric oncology care. Some of these features, such as 24/7 access, many practices offer already.
The new work will vary depending on a practice's current strength and opportunities.
"The biggest thing for us, I believe, is going to be not just having electronic health records installed, which we're in the process of doing," Atlantic's Whitman says, "but having them configured in such a way to make sure we're communicating all of the desired data points to patients."
"On the back end, we're collecting the data we need to figure out if what we're changing has made any difference."
Fellow participant Henry Ford Medical Groupis also eager to take its existing best practices to the next level.
In particular, Henry Ford announced last week a partnership with precision medicine software company, Syapse, to offer targeted cancer treatments to Henry Ford patients in Detroit and beyond.
"I think it's fair to say that this program is so new that it's going to evolve fairly quickly," Whitman says.
"There aren't a lot of hard and fast rules… There are big structures. But how you get to that structure and exactly how you implement it is going to honestly be the exciting part for everyone."
"The Orlando massacre is prima facie evidence that there's a gun problem not only in this state, but in this country," says one Florida pediatrician.
The first patient funeral Louis St. Petery, MD, attended as a new pediatrician in the late 1970s was for a child who had been accidentally shot by a sibling who found a loaded handgun in their parents' bedside table.
"That should have never happened. That gun should have been properly stored," he told me from his Tallahassee office last week.
Although pediatric visits have evolved over the last three decades to include a wealth of life-saving anticipatory guidance on risks such as swimming pools, household chemicals, and improper car seat use, there's a political taboo around physicians asking patients about gun ownership.
At the center of the controversy, is Florida's 2011 Firearm Owners' Privacy Act, known as the "gun gag law," which has not been enforced since U.S. District Judge Marcia G. Cooke issued a permanent injunction on June 29, 2012.
Last week, the state's 11th Circuit Court of Appeals held an en banc hearing on the issue again.
There's no telling when or how the court will rule, St. Petery says, but he is certain that he'll counsel parents about gun storage and safety regardless of the outcome.
He says he asks parents about guns not in an attempt to jeopardize their second amendment right to bear arms, but simply to keep children safe.
St. Petery, served as executive vice president for the Florida chapter of the American Academy of Pediatrics for 36 years, until stepping down last June.
"I disagree with the NRA [National Rifle Association]. We're not out to get rid of guns, but we are out to save kids," he says.
"The Orlando massacre is prima facie evidence that there's a gun problem not only in this state, but in this country," he says.
A Nonexistent Debate
The AMA has, since 1989, held a policy that encourages members to inquire into the presence of firearms in households and to promote the use of safety locks on guns in an effort to reduce injuries to children.
It continues to argue against the gun gag law.
"For doctors to do all they can to prevent the public health crisis of gun violence from continuing in Florida, the state should drop its defense of a law that stifles relevant medical discussions that are proven to save lives," AMA President Andrew W. Gurman, MD, said in a media statement on June 21.
An irony of this ongoing debate is that, in practical terms, there isn't one, according to St. Petery.
Throughout his decades of practice in the avid hunting community of North Florida, the total number of parents who ever became upset about being asked gun ownership is almost zero.
And fellow physicians? Little to no argument from them either. "Virtually every pediatrician in the state of Florida shares my opinion," he says.
"The only pediatricians who seem reluctant are the younger ones newer in practice who aren't sure about this whole issue. They want to ask but they're afraid," St. Petery says.
"All of the seasoned pediatricians have said, 'The heck with it. Even if the law holds, I'm going to do the right thing by the kid.'"
And should a gun question cause offense?
"If they want charge me, if they want to complain to the board of medicine: Go ahead; do it," St. Petery says. "I think that's the attitude of the vast majority of folks that I have spoken to about this issue."
The role of the hospitalist is alluring to physicians and hospitals and its growth is well established. But cultural and recruiting challenges remain.
The hospital-only specialty, which originated in primary care in the 1990s, has caught on throughout numerous sub-specialties.
Among OB-GYN, gastroenterology, and general surgery services, the growth of the hospitalist is driven in part by physicians' desires for greater work-life balance, particularly when it comes to call coverage.
As a result of the growing interest, the physician recruiting database Profiles, which interviews graduating physicians (residents and fellows) about their career goals and specialty choices, has started asking several sub-specialties about their interest in a hospitalist positions.
The question has been standard for internists, pediatricians, and family medicine for many years.
The results show that at least half of nearly all newly graduating specialists are open to the idea of hospital work, and percentages rose almost across the board over the past year.
"Outpatient-only practices have historically also been attractive to physicians, and this is the first evidence we've seen of widespread interest in hospitalist, surgicalist, and laborist roles for other subspecialties," Shane Hollander, head of sales and operations for Profiles Database, told me by e-mail.
The hospitalist role is a "relatively novel career option for new physicians in gastroenterology, neurology, psychiatry, OB-GYN, and general surgery, as such jobs (100% hospitalist/inpatient roles) weren't available to their predecessors, who may have been interested in hospitalist work, if given the option," he said.
Hospital Needs and Expectations
Hospitals themselves are also embracing the trend, as patients increasingly expect prompt, high-quality care.
In OB-GYN, for example, it's become almost impossible to get community-based physicians to commit to delivering babies at the spur of the moment, says Brian Price, MD, MBA, FACOG, national medical director for OB-GYN services at TeamHealth.
"I have discussions almost daily with chief executive officers or chief medical officers at hospitals who say their community providers are getting to the ends of their careers and no one coming out of medical school or residency wants to be available all the time or feel this pressure," he told me.
"And hospitals are feeling pressure to have someone immediately available to care for patients in labor and delivery."
A (Practically) Perfect Solution
But while hiring hospitalists is relatively easy—and the physicians they're covering often make more money staying in the office—adjusting to any paradigm shift takes time, Price notes.
A sense of lost control can be unsettling for physicians, even if they understand the hospitalist model from a practical standpoint.
"From a theoretical point of view, almost everybody can agree to it," he says. "But when it comes down to, 'Gee, how is this going to affect my practice? How is this going to affect my income, that's where the challenge arises. Whenever there's a cultural change, there's going to be resistance."
There are other potential pitfalls, according to Hollander.
"As the physician workforce becomes increasingly specialized, and healthcare becomes even more segmented than it already is, there will be an impact on patient care, probably both positive and negative," he wrote.
"Additionally, the impact of the sub-specialty hospitalist trend on physician recruiting may make the proverbial 'needle' in the haystack even smaller, and more difficult to locate, than it has been before, as the candidate pool become more divided, as will the practice roles, if the sub-specialty hospitalist trend continues to grow in popularity as it has recently."
Indiana University Health system has cut the metrics used to measure quality of care in its facilities from 199 to just 10. They are seeing successive monthly declines in preventable harm.
How many quality measures is too many? At what point does a healthcare organization's quest for performance improvement yield diminishing returns?
While many healthcare organizations have begun to refine the way they approach quality, the specifics depend on what matters to populations of patients and those providing their care, according to Jonathan E. Gottlieb, MD, chief medical executive for Indiana University Health system.
About a year and a half ago, Gottlieb overhauled the way IU Health measures its quality of care in its facilities, cutting the metrics used to measure it from 199 to just 10.
This past January, the team similarly whittled its priorities for population health, focusing now on just four "utilization" population health metrics and another eight related to quality of care.
Gottlieb spoke with me recently about how a tighter focus on quality has reduced preventable harms. The following transcript has been lightly edited.
HLM: How did you go about honing down these metrics?
Gottlieb: We began by asking our physician leaders, nursing leaders, and quality leaders to reflect on which measures were most meaningful to their family and friends receiving care, which would be enduring even as payment mechanisms came and went.
HLM: What kinds of tools have you given clinicians to help them improve?
Gottlieb: The best resources we have are our experts in infection prevention, which include both nurses and physicians. Their expertise, combined with sophisticated information systems, help us figure out how to reduce infections.
Without the help of the infection preventionists, it's very hard for a physician to determine that an outbreak might be related to a particular operating room, for example, or a piece of equipment.
HLM: What are your results?
Gottlieb: They are improving. Our targets are to reduce our preventable harm by 20% year over year. For the last four months, we've seen four months of successive decline.
HLM: Do you think you'll need to evolve your approach over time?
Gottlieb: Yes, in the next phase we're going to have to combine these general enduring metrics with a little more specificity. A patient who needs a knee replacement, for example, probably isn't looking at CAUTI [catheter associated urinary tract infection] rates.
And that will be something we'll need to balance because we don't want to balloon up to hundreds or thousands of metrics again.
We have formal safety and quality meetings quarterly. I think our focus has helped our leaders and clinicians look at the right things and not get distracted every time a CMS rule changes or a metric is added that we need to report.
We still report those, but we're not asking every frontline clinician to all of a sudden change their focus.
HLM: How will MACRA implementation affect your strategy for population health?
Gottlieb: The good news is that our enduring metrics are for the most part pretty aligned, so it's not as though we're reinventing something. I think we're mostly editing and focusing on the core metrics.
With MACRA, we are looking to participate in an ACO model.
For parts of our organization that doesn't apply, we'll participate with MIPS and look for maximum overlap and coordination between the metrics that we think are near and dear to the hearts of our patients and those that satisfy regulatory requirements.
The co-founder of a large primary care practice and long-term leader at the American College of Physicians says medical homes and new payment models improved his practice satisfaction "tremendously."
"At the heart, we're a private practice," Yul Ejnes, MD, MACP, an internal medicine physician and chair-emeritus of the American College of Physicians' board of regents, says of Costal Medical, the practice he co-founded with one partner more than 20 years ago.
Today, Coastal claims to be the largest primary care group practice in Rhode Island, with 19 locations and more than 100 clinicians. The group is a successful Medicare Shared Savings Program ACO, with all of its offices recognized by the National Committee for Quality Assurance as level-3 patient-centered medical homes.
Throughout this growth, Ejnes has remained a shareholder of the independent group.
"There are ways of staying in practice, seeing patients, and living in new realities," he says. "But [physicians] have to wake up and start paying attention and doing what they have to do."
Some of these tasks include learning about the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) and understanding new payment and practice models in general. I spoke with Ejnes recently; the transcript below has been lightly edited.
HLM: How has becoming an ACO changed your group's dynamic?
Ejnes: Becoming an ACO was an evolutionary step from becoming a medical home, which required us to start thinking in terms of population health, being proactive, and welcoming reports on how we're doing.
We're doing things we didn't do five years ago: having weekly care conferences, identifying and talking about our high-risk patients, working with our clinical pharmacist to manage drug costs.
This is stuff that wasn't part of what many of us trained to do or signed up to do, but it gives us some control over what happens with our patients as opposed to leaving it all up to the insurance companies.
HLM: For hospitals that own physician groups, what insights can you share about how they can engage physicians?
Ejnes: That's a good question. We formed our group because we didn't want to live under the jurisdiction of a hospital system.
But the model does work for some physicians. Speaking abstractly, because I haven't lived it, I would think it works when the hospital system says, "We're not going to get into your business. We're going to let you do your job and we'll provide support services."
I would think it would have to be the kind of environment where leadership is focused on the interests of patients and the physicians supporting the patients.
HLM: What about today's practice environment makes you optimistic?
Ejnes: Over the years I was more involved in the ACP, we were working on a lot of these initiatives that are now reality. In my personal experience, medical homes and new payment models, if implemented well, actually do make a difference.
And for me, it's improved my practice satisfaction tremendously. It's gotten a lot of the administrative minutiae off my desk and allowed me to play more of a role of a manager for that rather than a grunt worker. It's freed up time to spend in ways that is more meaningful for patients.
I'm not going to say I'm spending twice as much time with patients or getting out of the office an hour earlier, but the time I do spend is focused on things only I can do.
And at the end of the day, even if it's still a long day, I'm usually smiling.
Some proposed measures of the Medicare Access and Children's Health Insurance Program Reauthorization Act are more advantageous to physician groups than they appear.
Physician groups are reacting with understandable apprehension to the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA).
But not all the preliminary information about the aggressive timeline and multiple unknowns of the program is necessarily bad news for physician groups, according to the American Medical Group Association (AMGA).
AMGA, in a May 24 webinar about the Centers' for Medicare & Medicaid Services' proposed rule, identified the following nuances that may fall in medical groups' favor:
1. Advantages to Track 1 ACOs
While it may come as an initial disappointment to groups participating in Track 1 ACOs to not qualify for advanced alternative payment model (APM) bonuses under MACRA, the groups will not necessarily be in a bad position, explains David Introcaso, PhD, AMGA's senior director of regulatory and public policy.
ACOs should actually have an advantage over other groups reporting under the Merit-Based Incentive System (MIPS).
"Presumably, if you're a Track 1 ACO, you should perform well on all the component scores, which would mean that you're more likely to get a positive MIPS adjustment," Introcaso says.
"And keep in mind that theoretically you have no downside risk, so being a successful ACO could mean a positive MIPS score as well as shared savings."
2.Bearing Risk Just Got Better
For the minority of groups expected to qualify as advanced APMs in year one, however, CMS's 5% bonus applies regardless of performance, offering a welcome cushion to groups bearing substantial risk.
"Say you're a Track 3 or Next Generation ACO and lose money and have to repay some of that money to CMS. But you meet the threshold [to qualify as an advanced APM]. The 5% you gain is offset by whatever amount of money you lost because you blew your benchmark," Introcaso says.
"In some ways, that's how CMS and Congress thought through this logically, because they thought some number of advanced APMs in their own model might lose money."
3.Top Scores Get Calculated
Groups and individuals participating in MIPS, on the other hand, are allowed to select their own quality measures to report. While six measures (including one outcomes and one cross-cutting measure) is the minimum, there is no limit.
So a group could choose 10 measures, for example; and CMS would only count the six highest scores.
Moreover, CMS is aware of a potential gaming of its top-score policy should participants select measures for which they do not meet the minimum reporting standard.
"And if that's the case, CMS throws out the measure, and you can still score a maximum number of 90 points on the five [remaining] measures," Introcaso say.
It remains to be seen whether this loophole gets closed in CMS's final rule.
Adrienne Boissy, MD, says "any experience program that is going to have teeth must be designed in such a way that we're listening to and harnessing the power of the very people who serve patients."
Most patient complaints, many malpractice suits, and aspects of clinician burnout have one common denominator: Ineffective communication.
In a new book, Communication the Cleveland the Cleveland Clinic Way, Chief Experience Officer Adrienne Boissy, MD, MA, and colleagues share their patient-experience turnaround story and how to use their foundational communication model known as REDE (pronounced "ready"), which stands for Relationship: Establishment, Development, and Engagement.
"We're all going to be talking about the great patient experience programs we're rolling out, which is great," she says. "Yet this journey has made me realize that any experience program that is going to have teeth must be designed in such a way that we're listening to and harnessing the power of the very people who serve patients."
The transcript below has been lightly edited.
HLM: What is the significance of promoting "relationship-centered" versus "patient-centered" communication?
Boissy: We knew we could have just a list of communication skills, but we wanted to really nudge thinking by using a model based in relationships. What we were really asking them is, "do you understand that part of your role may be to build relationships with your patients?" And if so, "what would your language look like?"
Also, I think everybody in healthcare understands that patients come first; but at the same time, there's a feeling that if patients come first, there are a lot of people left out of that equation.
Relationships allow you to pull everybody in, and more overtly honor clinicians' perspective and contribution to the patients we serve.
Lastly, we wanted to emphasize that these relationships can be therapeutic for both people. To us that was very powerful.
HLM: Clinicians sometimes say that time pressures make communication difficult, but your book says the opposite is true. How is expressing empathy more efficient?
Boissy: The evidence suggests that you can actually save time by making a single empathic statement. The rationale behind that is that if someone is coming to me emotionally charged and I ignore those cues and continue on my own agenda, those dues will either continue to surface and escalate.
Or the patient will stop talking because you've demonstrated that you're not willing to "see" the emotional human in front of you.
It takes longer to do all that. If we address the cue the first time, then it's done.
HLM: The book includes a lot of sample dialogue, especially surrounding difficult conversations. How important was it to include suggested wording?
Boissy: I think you have to, because you can't just say to a clinician, "You need to communicate better."
However, we have heard from a lot of clinicians who don't want to be told what to say or to be scripted. They're exactly right. We know that adults don't learn by scripting their conversations, especially not highly intelligent adults.
You have to allow them to leverage their own experience and come up with their own words. Some of them have the words intrinsically and yet some of them don't, so they need help.
We do one exercise where we go around the room and take turns giving an empathic statement, perhaps for a given scenario. And that way the learner has an opportunity to hear a collection of empathic statements that would work in a situation.
It generates some dialogue about what people intend to say compared to how they come across. When we ask, "What are you hoping to communicate to this patient?" invariably the clinician will say, "that I care." And then we say, "Well, why don't you just try that?"
Isn't it funny that so often we don't just say that out loud?
HLM: The book's opening scene describes a patient asking for pain medication. How can communication skills be applied to addressing the national opioid epidemic?
Boissy: As we've thought about some of those conversations that are really difficult for clinicians, I feel as though we've bumped up against this misconception that if you're an effective communicator, that you're ineffective about creating boundaries.
You can care about people but still set guidelines or boundaries about their behavior, or about what you will or will not do. It's an area that still needs a lot of work.
Because what I hear clinicians say is, "Well, I'm just not going to give it to them," drawing a hard line without communicating other things such as, "I care about you," or "this has got to be difficult." They can follow those statements up with, "And I'm not going to prescribe narcotics today."
Sometimes I also hear clinicians on the other side, say, "I'm just going to give it to them because I'm under pressure with these scores to make patients happy." But compromising professional integrity is not part of being a clinician.
So we have to find the middle, where empathy is still at the forefront yet we're capable of saying, "I'm not going to do blank." It's possible; it's just difficult.
HLM: What's next for this work?
Boissy: The sky's the limit. Communication work is so interesting because it's pervasive. It touches safety, quality, malpractice, errors, and leadership.
So one thing we're thinking about is how to create roots within the organization so that relationships become foundational to how we lead and how we keep our patients and our own people safe.
My hope is that these communication skills remain central to how we train leadership and it's not just a little effort over in patient experience. I just see the potential growing and growing.
Healthcare executives share insights on how to keep doctors satisfied with their jobs amid shifting practice preferences and reimbursement realities.
Finding good physicians is hard. Keeping them is Herculean.
Most physicians routinely hear from suitors about potential practice opportunities, and about 30% report receiving three to five solicitations per week, according to a survey from the Medicus Firm, a physician recruiting agency.
"I'm surprised it's not more," says Brett Waress, MHA, FACMPE, regional director for Health First Medical Group, a four-hospital, 300+ physician system headquartered in Melbourne, FL.
"Particularly for certain specialties, the recruiting firms are aggressive. For example, our hospitalists, and I'd say hospitalists across the country, receive at least a call a day, let alone the email solicitations."
So how tempted are physicians to respond?
According to the Medicus survey of 2,413 clinicians representing 21 specialties across the United States, 27.5% of respondents say they're definitely not making a career change within the next year, while only 7.6% are set on a switch.
If you count the majority of physicians falling between both extremes, however, that leaves a total of 72.5% docs who may not be looking for a different job, but who could be curious about a new opportunity, says Bob Collins, a managing partner and co-founder of The Medicus Firm.
That slice of physicians who claim they're staying put is shrinking fast, from 43% in 2014 to 34% last year to 27% in April 2016, Medicus research shows.
"For health leaders, that's a big deal because it's not just [about] recruiting physicians," Collins says.
"Now there should be as much emphasis on retaining them because the physician population has become more mobile than ever before. They're more willing to make a change if you don't meet their needs."
Get Creative About Quality of Life
The top factors that could drive physicians to change jobs are not unexpected:
Schedule/call coverage/work hours—a top motivator for 30.2% of physicians in training and 15.8% of physicians in practice
Financial rewards— a top motivator for 22.2% physicians in training and 29% in practice
Geographic location— a top motivator for 22.8% in training and 12.8% in practice
Compensation matters, particularly among in-practice physicians at a life stage where they face greater financial responsibilities or are thinking about retirement. It's not just about money, however. Recruiting and retaining physicians also requires some creativity, says Collins.
"There's only so much money to go around," he says. "[Systems] can't just back up the armored truck and say 'here's more money.'"
Healthcare leaders also need to promote physicians' quality of life, for example, by hiring enough clinicians to keep call coverage to a minimum or offering flexible work arrangements, Collins says.
Waress agrees. "Employment agreements need to have the flexibility for people to make a personal choice to work less or work more."
That's still a challenge for administrators, says Waress, who is renegotiating several of his group's employment agreements. "If you've got someone who's fulltime who wants to work 0.7 [FTE], you've got to cover the other 0.3 somehow, which makes it hard to get the fit."
Keep an Eye on the Horizon
Different physicians are motivated by different compensation methodologies, which vary mostly around how they weigh base pay, work RVU/production, and quality/utilization.
"Even within the same specialty, some physicians and some groups are very comfortable with no guaranteed base or an 'eat what you heal' model," Waress says. "Others in academia may [prefer] a straight salary with a small qualitative bonus or citizenship bonus with maybe a threshold for productivity."
Administrators need to stay on top of methodology trends in their specialty and how those options are viewed by physicians.
Regardless of how motivated physicians may be by production or steady salaries now, Waress warns that those models may be short-lived.
"Looking out on the horizon, particularly with MACRA, we're going to have to realize that the quality or utilization (meaning outcomes) component of the contract is going to have to change to align with how systems and payers, including CMS, value quality," Waress says.
"It's tough to be out ahead of it, but people in my position have to be really conscious of what drives reimbursement on the hospital side."
Get Real During Recruitment
Until then, Collins has some advice for physicians wooed by new opportunities.
"The grass may be greener on the other side of the fence, but you still have to mow the yard. In other words, it still requires work," he says. "Physicians need to be clear about what is important to them and what they're willing to sacrifice."
Physicians fortunate enough to earn in the 75th percentile, work 40 hours a week, and live in their most-desired location are the exception more than the rule, Collins says.
For most physicians it's a matter of prioritizing and conducting due diligence to ensure that a position will satisfy their needs on a professional, financial, and personal level.
"When I'm recruiting, I always try to get physician-to-physician communication," Waress says. "I leave the room or encourage them to go to dinner without me so they can really speak clinically and about what it's like to work with the group."
Experts attending HealthLeaders Population Health Exchange recommend considering physicians' needs before prescribing their roles in population health initiatives.
If you want to achieve physician alignment in carrying out your population health strategy, there has to be some give and take, according to executives gathered at the HealthLeaders Population Health Exchange, held last month in Austin, TX.
Another four clicks in the EHR here, an unpaid hour of charting after dinner there, the burdens on physicians add up, noted Alan Pitt, MD, professor of neuroradiology at the Barrow Neurological Institute, part of Dignity Healthcare in Phoenix.
So when health systems add on a set of best practices to lower utilization costs and support value-based care, physicians often think, "Are you kidding? You've got something else you want me to do?"
"You can't just keep adding weight to physicians," Pitt said. "It's not a trash compactor they're living in."
Fortunately, there are ways to motivate physicians to support your goals. Here are three standout themes from a roundtable discussion during the Exchange:
1. Give Physicians a Voice
One of the most fundamental benefits systems can give physicians is easily overlooked.
"It sounds trite, but it's really true: Shared voice," said Helen Lindsay Macfie, PharmD, FABC, chief transformation officer for MemorialCare Health System in Fountain Valley, California, a 1,600-bed not-for-profit health system that includes a medical foundation and more than 2,500 affiliated physicians.
"One of the things that's really helped is physician governance [is] putting together a structure where physicians are helping us plan this, as opposed to it being an announcement and a surprise," she said.
MemorialCare's physicians' society has existed for 20 years, but has proved especially valuable in the transition to population health. The board of the society spans the entire system, and champions all of its informatics, best practice, and shared physician strategies.
"Obviously we have a big IT department, but [the board members] really provide leadership, serve as superusers, and provide guidance [and] support for everything we roll out," she said.
"And all of our best practices, including protocols, guidelines, and how they interface with the EHR, are all clinically agreed-upon."
Two key population health initiatives sponsored by this physician board include strategic plans around conserving the utilization of precious resources and reducing overdiagnosis and overuse.
2. Give Resources
Next, there are a myriad of ways to help physicians from an organizational standpoint that create win-win opportunities for success, according to Julia Andrieni, MD, vice president of population health and primary care, as well as president and CEO of Houston Methodist's Physicians' Alliance for Quality.
When Andrieni moved from Massachusetts to Texas to align scores of independent physicians flung over a large geographic area, she focused her strategy around understanding what the physicians would need and want to remain independent and to provide high-quality care for their patients.
"I know they want to remain independent, but what is it that I could provide for them that would give them value for their patients and their practice?" Andrieni, a primary care physician, recounted asking herself.
"So I thought, we're going to be the quality consultants for PQRS, Bridges to Excellence, Meaningful Use, Patient Centered Medical Home—any program tied to finance, a CMS regulation, or a private payer."
In exchange for a membership fee, physicians affiliated with Houston Methodist have access to a team of quality program experts in the above-mentioned topics and more. The system also hosts four to six educational dinners per year, where physicians earn CME for a variety of primary care topics.
"And I focus on the value my team can bring to them," she emphasized, "because I'm really trying to form relationships around how I can help them be recognized for delivering high-quality patient care."
3. Give Time-Saving Tools
IT resources are valuable to physicians, but only if they don't create more work than they save. For example, a lot of hospitals don't have the strongest Wi-Fi or cell service throughout the facility, noted Pitt. "This means that if you roll out a new application and expect me to use it, it may fail on my device."
On the other hand, physicians may welcome technologies that allow them spend more time on the work they want to do.
For example, Pitt said he's not threatened by the idea that advanced pattern recognition technology may one day perform much of what he does as a radiologist.
"It probably won't happen in my generation, but I would love it," he said. "If you can get rid of 80% of my work for normal cases and allow me to focus on the 20% that need some sort of human interaction to come up with a reasonable diagnosis, that's probably a good thing."
While an 80% work reduction might not be available anytime soon, ultimately the work/support equation needs to balance out.
So don't focus merely on how to align physicians with your organizational goals. First, consider ways to align your resources with their wants and needs.
