Engaging Physicians: Insights and Actions for Results Steven M. Berkowitz, MD SMB Health Consulting, Austin, TX

2012 Clients- Two Lessons Learned

Engaging Physicians: Insights and Actions for Results Clinical Integration – Embracing data transparency – Implementing best practices – Excel at Pay for Performance Financial Integration – Enterprise-wide cost reduction Hospital Physician Partnership – An aligned, long term collaborative relationship

What’s New with Health Care Reform? Same Old Wine in a Brand New Bottle ?

What’s New with Health Care Reform?

You can always count on Americans to do the right thing… …after they’ve exhausted all the other possibilities !!” Winston Churchill

People do not change until the pain of staying the same… … exceeds the pain of changing. Anonymous

Medicine is a Team effort…. …..Why do we insist on playing Solo ! The Health Care Team

Medicine is a Team effort…. …..Why do we insist on playing Silo !

So, What’s This Going to Look Like? Form Follows Function InputsResults Efficiencies Hospitals Physicians

InputsResults Decreased payment: VALUE vs volume Some risk Increased demand: Greater volume Aging, chronic Transparency of VALUE: Clinical Outcomes Patient Satisfaction Cost Effectiveness Efficiencies: Clinical/ Operational Financial Infrastructure/ Governance Hospitals Physicians So, What’s This Going to Look Like? Form Follows Function

Winning the Game What is the best model for your organization? Any hand’s a winner…. Any hand’s a loser !!

What Does the Model Look Like? Form Follows Function ALL MARKETS ARE UNIQUE !! What are the needs of the community that you serve? Quality, accessible, cost-effective care What are the needs of the physicians? Quality medical care Practice/ economic stability What are the needs of the hospitals? Quality, accessible, cost-effective care Partnership relationship with the medical staff

Hospital Physician Partnership Financial Integration Clinical Integration Fundamental Requirements to be a Winner Integrating the Components of Health Care Delivery

Hospital Physician Partnership Financial Integration Clinical Integration X- ABC Hospital X X X Fundamental Requirements to be a Winner Integrating the Components of Health Care Delivery

Financial Integration Clinical Integration Fundamental Requirements to be a Winner Integrating the Components of Health Care Delivery Hospital Physician Partnership

Clinical Integration The Continuum Common Quality Goals Common IT Platform Best Practice Implementation Population Management Clinical Integration

– Embracing data transparency – Implementing best practices – Excel at Pay for Performance Financial Integration – Hospital-wide cost reduction Hospital Physician Partnership – An aligned, long term collaborative relationship Clinical Integration Engaging Physicians: Insights and Actions for Results

1. Embracing Data Transparency 2.Implementing Evidence-based Practices 3.Excel at Pay for Performance Clinical Integration Three Imperatives for Effective Clinical Integration

Value-Based Purchasing The increasingly informed consumer will make health care decisions on the basis of VALUE VALUE = Outcomes + Satisfaction Cost The CONSUMER ultimately determines which of the above elements constitute VALUE

The Role of Transparency Fundamental Types of Data Transparency Price Transparency Quality Transparency

Quality Transparency The Role of Transparency Fundamental Types of Data Transparency Price Transparency

Read all about it !! April 2005 Data Transparency

This is Your Life !! Data Transparency in Action

“What we concluded was that even when hospitals know their performance is not good, that's not sufficient motivation for them to do something. Making it public made a big difference in motivating them to improve.” Judith Hibbard, Health Affairs 2003 Data Transparency That which is measured, tends to improve. That which is measured publicly, tends to improve faster. Data Transparency

If the other guy’s getting better, then you’d better be getting better faster than that other guy’s getting better… …Or you’re getting worse. Tom Peters

Exposure to and Use of Quality Information Percent Who Saw and Acted Upon the Information Kaiser Family Foundation, October 2008 Choice of Hospitals

Data Transparency and Accountability Transparency is the best thing that’s happened to quality since antibiotics.. by decreasing variance and improving results. Data Transparency As transparency matures, it will rewrite the book on: Who is your competitor?

Stage I “The other guy” Stage III The entire nation ? Stage IV ?? The whole world ?? Stage II All hospitals in region Strategic Planning Who is Your Competitor… and the Role of Transparency? Increasing Transparency

Playing the Game What is the best model for your organization? Any hand’s a winner…. Any hand’s a loser !! Define and Excel in your Core Business !!

Two Fundamental Types of Data Transparency Price Transparency Quality Transparency

Do your hospital and physicians… … embrace data transparency ? Engaging Physicians: Insights and Actions for Results

1. Embracing Data Transparency 2. Implementing Evidence-based Practices 3.Excel at Pay for Performance Clinical Integration Three Imperatives for Effective Clinical Integration

Implementing Evidence-Based Medicine What Can we Learn from the Airline Industry ?

What Can we Learn from the Airline Industry? Teamwork: Guidelines and Checklists

Our Greatest Challenge in Clinical Medicine Eliminate the “DEADLY” Delay !!

The Deadly Delay… From Clinical Trials to Clinical Practice…

Where Do We Find the Best Practices ? Examine Your Own Specialty Literature Implement the Guidelines Recommended by your OWN Specialty Society

Most medical guidelines are based upon ambiguity as a guiding principle of protocol development What Can we Learn from the Airline Industry ? Elimination of Ambiguity “the elimination of ambiguity is consistently cited as a key factor in protocol success and safety” Degani and Weiner 1993

Example: Oxytocin Treatment Guidelines ACOG 2006 Compendium “Any of the low or high dose regimens outlined in table 2 are appropriate” (0.5 – 6 mU/min every min) “Each hospital’s OB/Gyn department should develop guidelines for preparation and administration of oxytocin” “The uterine contractions and fetal heart rate should be monitored closely” Evidence-Based Medicine

Example: Postdates Guidelines ACOG 2006 Compendium “ Women with post-term gestations who have unfavorable cervices can either undergo labor induction or be managed expectantly” “Delivery should be effected if there is evidence of fetal compromise….” Evidence-Based Medicine

Use any settings of the plane’s instruments you feel like Every airline and pilot can do it differently Be really careful as you get close to the ground Steve Clark, MD How to Land a 747 in a Strong Cross Wind* * (Had It Been Written by ACOG)

Do Guidelines Help or Hurt? “Yeah, but Pilots do not have to worry about Malpractice Suits” Obstetrician, Texas

Guidelines for Guidelines There will be MORE guidelines in clinical medicine Guidelines were NEVER intended to apply to all patients and do NOT take the place of individual physician judgment Expect physicians to occasionally deviate from guidelines in the daily practice of prudent medical care When so… … DOCUMENT In the medical record that: The patient was seen and evaluated The options were thoughtfully considered The best clinical judgment was used Discussed with the patient

Do Guidelines Help or Hurt? We keep missing the point….. Simply put… Evidence-based Guidelines reduce adverse outcomes ! Adverse Outcomes Adverse Outcomes protocols Evidence-based Guidelines improve patient care ! Evidence-Based Medicine

Do your hospital and physicians… …implement best practices ? Engaging Physicians: Insights and Actions for Results

Three Imperatives for Effective Clinical Integration 1. Embracing Data Transparency 2. Implementing Evidence-based Practices 3.Excel at Pay for Performance Clinical Integration

HospitalsPhysicians Pay for Performance

What Pay for Performance is NOT: A increase in revenue A break-even with revenue What Pay for Performance IS: A way to partially recoup some of the REDUCTIONS we will see in revenue

Pay for Performance What Pay for Performance is NOT: A increase in revenue A break-even with revenue What Pay for Performance IS: A way to partially recoup some of the REDUCTIONS we will see in revenue 5 – 10 % of Total Medicare… Or more !!

Complicated CMS Payment Schedule

VBP Program 2013 and 2014

Physician Value Based Purchasing Include in the rule making process for 2013 Based on quality compared to cost HHS is required to develop risk adjusted measures Measures published by Jan 1, 2012 Applied for some physicians in 2015, all by % payment reduction in % in 2016 and beyond

Hospital Acquired Conditions Going from known complication….. k ….. to known complication. Pay for Performance

Surgical Consent Form…. Death Stroke Heart Attack Emergency Surgery Infection Bleeding Allergic Reaction Nerve Damage Renal Failure ….

Will your hospital (and physicians)… …excel at pay for performance? Engaging Physicians: Insights and Actions for Results

1. Embrace Data Transparency 2.Implement Evidence-based practices 3.Excel at Pay for Performance Clinical Integration Three Imperatives for Effective Clinical Integration

Common Quality Goals Common IT Platform Best Practice Implementation Population Management Clinical Integration The Continuum

The Role of Information Systems Health Care Information Systems -- We are so far behind !!! 1 Zettabyte = 1,000,000,000,000,000,000,000 bytes = bytes = bytes

More Than Meaningful Use Health Care of the Future….. …. We can’t get there from here …. Without Information Systems !!

EMR and Evidence Based Order Sets are not just another IT initiative…. …. it is a Clinical Transformation to how we will be practicing better medicine in the future. More Than Meaningful Use

The Role of Information Systems Electronic Medical Record The EMR will do for health care What the assembly line did for manufacturing.

Financial Integration Clinical Integration Fundamental Requirements to be a Winner Integrating the Components of Health Care Delivery Hospital Physician Partnership

Financial Integration FFS Common IT Platform FFS + Incentives Bundled ProductsGlobal CapGlobal Cap + IncentivesFull Premium Financial Integration The Continuum Financial Integration

Clinical Integration – Embracing data transparency – Implementing best practices – Excel at Pay for Performance Financial Integration – Hospital-wide cost reduction Hospital Physician Partnership – An aligned, long term collaborative relationship Financial Integration Engaging Physicians: Insights and Actions for Results

Hospital-wide Cost Reduction!! There will be a focus on Cost Control like we have NEVER seen before in our careers.

Physician Hospital Other Rx Admin Total Health Care Costs ???? ? Post- Reform Health Care Costs Cost Reductions Cost Reduction The Role of Successful Partnerships

Physician Hospital Other Rx Admin Total Health Care Costs ???? ? Post- Reform Health Care Costs Cost Reductions Any decrease in health care expenditures is a pay cut for somebody in health care !! Cost Reduction The Role of Successful Partnerships

Total Cost of Care - Hospitals Goal: 20+ % Total Cost Reduction

Minimal Opportunity Total Cost of Care - Hospitals Goal: 20+ % Total Cost Reduction

Minimal Opportunity More Opportunity Total Cost of Care - Hospitals Goal: 20+ % Total Cost Reduction

Maximum opportunity ! Minimal Opportunity More Opportunity Total Cost of Care - Hospitals Goal: 20+ % Total Cost Reduction

Financial Integration Clinical Integration Fundamental Requirements to be a Winner Integrating the Components of Health Care Delivery Hospital Physician Partnership

Clinical Integration – Embracing data transparency – Implementing best practices – Excel at Pay for Performance Financial Integration – Hospital-wide cost reduction Hospital Physician Partnership – An aligned, long term collaborative relationship Partnerships Engaging Physicians: Insights and Actions for Results

Accountable Care Organizations Definition: An ACO is a health care provider organization that is accountable for meeting the health needs of a defined population, including the total cost of care and the quality and effectiveness of services.

Definition: An ACO is a health care provider organization that is accountable for meeting the health needs of a defined population, including the total cost of care and the quality and effectiveness of services. Lets get back to basics Accountable Care Organizations

A Final Thought… Somewhere in the Atlantic.…

So, What’s This Going to Look Like? Form Follows Function InputsResults Efficiencies Hospitals ??? Physicians

Fundamental Requirements to be a Winner Integrating the Components of Health Care Delivery Shared Infrastructure and Governance Financial Integration Clinical Integration

– Embracing data transparency – Implementing best practices – Excel at Pay for Performance Financial Integration – Hospital-wide cost reduction Infrastructure Integration – An aligned hospital-physician partnership Engaging Physicians: Insights and Actions for Results

Who Benefits? The Patient !!

To the world you may be just one person, But to one person you may just be the world. Unknown