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As healthcare systems move toward new payment and delivery models, physicians are the key to success.
Physicians have been challenged to provide better care at a lower cost. Add to this the fact that many physicians are overworked and continually asked to meet more mandates to receive their reimbursements, and the picture for them begins to look grim.
But physicians want to make things better-for their hospitals, their patients, and themselves.
As health systems progress towards new care and payment models, the key to success is physician engagement, and it must be cultivated early and at the highest levels.
Cosgrove"If doctors aren't engaged, implementing critical programs and new initiatives becomes all the more difficult," says Toby Cosgrove, MD, chief executive officer of the Cleveland Clinic.
"When physicians are fully engaged, an environment of trust and a genuine sense of value can be established. For example, physicians will have a stronger ability to practice at the top of their specialty and foster higher collegiality and collaboration. Ultimately, that is good for patients as well."
A recent survey conducted by McKinsey & Company reveals a "fundamental disconnect" between what physicians believe their role is in healthcare reform and what they are doing to move the system forward.
More than 70% of the physicians polled said they would make changes to their clinical practice, make greater use of evidence-based medicine, increase reporting of quality and outcomes metrics, or improve cost-saving efforts over the next few years. Nearly 85% said they would be willing to make changes to the way they worked, or collaborate with other physicians to decrease waste and improve efficiencies. Yet fewer than 20% of these physicians said they had actually started any initiatives to meet their goals.
Physician attitudes are the key barriers to the transformation of the healthcare market-and the study notes physicians either don't believe they have much control over wasteful practices, or they believe they are not equipped to implement changes.
The study suggests that improving physician engagement requires communicating the value of the change being initiated, establishing role models and utilizing peer review for motivation, training physicians on the impact of their day-to-day clinical decisions, and compensation and corporate structures that support physician efforts.
Physicians are grappling with new treatments, new administrative structures, new payment and care models, increased patient expectations-and all of these things can cause anxiety, fear, and anger that get in the way of forward motion.
Andrew A. Ziskind, MD, managing director in Huron Consulting Group's healthcare practice, says that in moving toward new care models, healthcare systems and physicians must find a better way to work together. "Unless we fundamentally redesign the way care is delivered, we're not going to be able to improve healthcare delivery," Ziskind says.
The "old school" method was that a hospital leader created an environment for voluntary medical staff to provide care. In the new model, the leader must create an environment that creates more engagement and partnership opportunities, he adds.
"The practical reality is, it's probably just like other industries. There are times when there's a good culture or a tough culture, and sometimes it requires a new leader," Ziskind says. "We're seeing more and more demands for physician CEOs for hospital systems. It simply has to be a leader who is good at building bridges between the hospital side and the clinical side."
But fee-for-service volumes are a huge barricade to moving to new care models and increased physician engagement, Ziskind says.
"Incentives are still aligned with do more, make more," he says. "Those incentives are often at odds with where we want health systems to go."
While it may be easier for physicians to stress over what they feel they don't have control over, Cosgrove says it's important to encourage a different perspective.
"Instead of focusing on the problems or challenges in healthcare, physicians need to engage and be a part of the solution. To help physicians get there, we need to shift the conversation to something different-something positive, optimistic and important," Cosgrove says. "We need to articulate a vision of what lies ahead with the focus on the patient."
Transformation of a health system depends on the will to organize care delivery around the patients' needs, he says. By putting patients' needs first, the Cleveland Clinic enables physicians to rely on their instinct to do what is in the best interest of patients.
BoissyCleveland Clinic's Chief Experience Officer Adrienne Boissy, MD, points to an example in which a Cleveland Clinic physician sought to increase the use of the intravenous tissue plasminogen activator (IV tPA) in the treatment of acute ischemic stroke. Despite being FDA-approved as a treatment, adoption was low, so a team led by neurosurgeon Peter Rasmussen, MD, designed an ambulance equipped with a computed tomography (CT) scanner and worked with critical care professionals to administer the drug and consult with neurologists through telemedicine.
But clinical strategies aren't the only aspects of healthcare demanding greater physician involvement.
Economics and changing payment models allow health systems to truly redesign care delivery, says Ziskind. He says health systems can start to organize the way they work with physicians much differently.
Financial incentives are a part of motivating physicians to embrace change, but a supportive organizational structure and stronger physician leadership are also key.
"We really do need more physicians that have good leadership skills," he says. "Many of the skills physicians have developed are the ones they need to be good clinicians, and they are not the same as the ones they need to be good administrative leaders."
More health systems are working on formal training programs to enhance leadership skills in physicians, he says. Hospital systems also need to review compensation packages, pursue technology programs that support better alignment, and make sure patient care is top priority. "The best way to engage and empower people is to have them be part of the process," Ziskind says.
MullarkeyMark W. Mullarkey, senior vice president of Texas Children's Hospital, says increasing physician involvement led to improved patient access to care, provider productivity, meaningful use metric outcomes, and physician documentation in inpatient cases. It also reduced the inpatient length of stay. But the road was not an easy one, says Mullarkey.
He says the goals at Texas Children's were achieved through shared governance, with administrators and physicians partnering to lead groups; regular and varied methods of communication and updates to protocols; transparent and visually appealing uses of data to back up changes; and old-fashioned competition.
"We used the physicians' inherent competitive nature," Mullarkey says. "With transparency, we were showing how one group was doing compared to others. They always wanted to be the best."
Mullarkey says Texas Children's worked with Huron Healthcare on five key areas-labor, practice management, physician productivity, clinical documentation and clinical operations.
"In each case, our physicians were bringing forth all kinds of ideas," Mullarkey says. "They were talking about what can we do better on a construction contract, food services, trash services and more. They were really there alongside us trying to hit the goals we were hitting."
Mullarkey says physicians were named to leadership teams at the start of the hospital's transition, and says early involvement was key in demonstrating a health system's valuation of the physicians' input. "Involving physicians early on meant they were part of the solution," says Mullarkey. "They own it as equally as we do."
As a result of increasing physician engagement, and using their suggestions to improve the health system, Mullarkey says the system improved its case mix index (CMI) through better documentation. "It's reflecting that there is better documentation of the true care delivered to the patient," Mullarkey says, adding that as the systems CMI went up, so did severity of illness and therefore diagnosis-related codes and reimbursement levels. By making these improvements, the hospital was able to go from a prediction of negative revenue to funding new construction.
"We were having trouble with being on census alert. The hospital was so full that the emergency department couldn't see more patients. We had no beds to be able to admit patients," Mullarkey says. But after a few years of hard work, Texas Children's put changes into place-with the help of physician leaders-that resulted in a 20% length of stay reduction that has held for the last two years. The hospital has added daily clinical rounding on each floor, and now projects discharges on the day of admission-all initiatives that were fueled by physician engagement.