Solomon

Changing Physician Practice: 

Changing Physician Practice Neil Solomon, MD, NAS Consulting (415) 836-6777 September 28, 2004

Imagine a Typical Office Practice: 

Imagine a Typical Office Practice

Fair Hills Primary Care: A Typical Profile: 

Fair Hills Primary Care: A Typical Profile Two primary care physicians together 10 years Office manager is wife of senior MD They have 3 MAs, 2 receptionists, 1 medical records/billing person Wait times usually run about 4 weeks for a routing appt, 8 wks for a physical Feels chaotic, runs late, fair quality scores Paper charts, looks same as when they started

Some of the Opportunities: 

Some of the Opportunities Set up chronic disease registries Implement Advanced Access scheduling Take advantage of batch reminders Redesign office for greater efficiency Utilize hospitalist program Computerize medical records Institute web-based communications

Why they don’t take hold…: 

Why they don’t take hold… We’ll do the work, someone else will reap the financial rewards Sounds good, but its too chaotic right now to implement anything new Health plans are administrators, we know how to care for patients I already get out late, this will make it worse My office staff could never handle this

A Framework for Implementing Change: 

A Framework for Implementing Change GOOD IDEAS DATA COLLECTIVE CONSCIOUSNESS REWARD SYSTEM Practice Improvement

Slide7: 

How you apply these concepts is more important than which ones you focus on or what specific component you select This is a rational model for change; also need to be mindful of emotional issues related to change Status quo needs to feel unacceptable to get offices to be open to change Think in terms of a 'deployment' strategy instead of a 'passive diffusion' method Important Issues Related to the Model

When does change occur?: 

When does change occur? Change will occur when: A andlt; BCD A = benefits of maintaining status quo B = pain of maintaining status quo C = vision of a different world D = small steps to achieve the vision

Pillar 1: Collective Consciousness: 

Pillar 1: Collective Consciousness Clear and shared vision Leadership from within the group Regular communication, including face-to-face meetings Internal compensation system that rewards what is important Resources from the organization to support the collective work and ideals

Developing Shared Vision: 

Developing Shared Vision 'Change is persuading massive numbers of people to stop what they have been doing and start doing something that they probably don’t want to do.' - David Nadler, Champions of Change

Collective Consciousness: 

Collective Consciousness Do I care what happens to others? What can we hold each other accountable for? Am I willing to rely on others for part of my success? Is the whole bigger than the sum of its parts? Who can I look to for direction and leadership? Do I get supported/rewarded for doing what we all agreed was important? For more see Leading Physicians Through Change by Jack Silversin

Fair Hills Gets Involved: 

Fair Hills Gets Involved Advanced Access discussed at IPA Board meeting; group agrees this is good idea Medical Director negotiates for participation in health plan sponsored Advanced Access program Call from IPA Medical Director to physician requesting he try it out IPA offers supporting analytic resources and provides a small $ incentive to office

Where Can You Get Started?: 

Where Can You Get Started? Promote/support group development Financially reward collective actions Look at physician organizations as an opportunity, not a threat Figure out which tasks best suited for medical groups, and which for the health plan

Pillar 2: Effective External Rewards: 

Pillar 2: Effective External Rewards Reward what is important and actionable Metrics must be credible Payouts must be large enough to get/keep attention Rewards for Process vs. Outcomes? Examples: CA Pay for Performance, Bridges to Excellence, DOQ-IT Program

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California P4P: 

California P4P Administered by impartial third party Measures designed/ratified by committee of medical groups, health plans and payors Clinical, satisfaction, and IT domains Results are based on pooled data Health plans use same metrics, design own reward systems Payouts are to the groups; they decide how to use/distribute the money At risk $ amounts to about $2 PMPM; approximately $50MM total in 2004

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Insert Diabetes Chart Anonymous

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Insert 2Timely Chart Anonymous

Anonymous MG Financial Picture: 

Anonymous MG Financial Picture

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Insert Clinical Measures Projected Payouts Hybrid (best projection for 2003) Data Distribution Payments based on Health Plan Results for Medical Group pie chart

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Insert Projected Payout for Satisfaction Measures pie chart (Satisfaction Projected Payouts)

What did groups do with the information?: 

What did groups do with the information? Fixed flawed data systems Learned how to self-report Set up registries for each of the cohorts Educated MDs about P4P, and what they were expecting of them Designed bonus pools based on P4P Considered other internal investments

Landscape Elsewhere: 

Landscape Elsewhere Many health plans and purchasers developing new incentive programs Most programs pay directly to MDs Most programs focused on processes, not outcomes or clinical measures So far little uptake in some of these programs, but lots of attention and interest

Fair Hills Experience: 

Fair Hills Experience Performed poorly in two P4P clinical domains—asthma and CAD care Requested data and determined that patients were falling through the cracks Motivated them also to avidly implement Advanced Access, and to seek help from outside One of the MDs got involved in their IPA’s P4P committee to decide how to use the funds

Pillar 3: Reservoir of Good Ideas: 

Pillar 3: Reservoir of Good Ideas External sources of ideas and information Institute for Healthcare Improvement (ihi.org) Institute for Clinical Systems Improvement (icsi.org) Diabetes CQI Project (diabetescqi.org) NAS Consulting Services (nasconsulting.biz) Center for Health Care Strategies (chcs.org) Published research on effective behavior change strategies EMR vendor expertise and experience Health care consultants and thought leaders Internal expertise and experience

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Slide27: 

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Beyond Information: 

Beyond Information Collaborative models for change Shared experience and common brainstorming People learn from stories and 1-on-1 interactions Intellectual/emotional support systems Regular check-ins create milestones How do you make the time for this stuff in a busy practice? Inconvenience of collaborative learning sessions Opportunity cost of missed clinical time Sustaining change at least as hard as effecting change in the first place

Fair Hills Team Takes Life: 

Fair Hills Team Takes Life Send team to Advanced Access training workshop Learn about program, but more importantly begin to see how they need to function as a team Succeed in implementing AA, move onto other redesign activities One of the MDs takes on IPA role to spread the program to other offices

Pillar 4: Data Resources: 

Pillar 4: Data Resources Disease registries Locally maintained Remote/commercial products Feedback reports Resolution Health type communications Point-of-care reminders Data warehouses CAPG Clinical Data Repository Health plan data warehouses

Challenges of data collection: 

Challenges of data collection Data: what, where, when, how? Very hard to perform data entry at office Analytic resources are not easy or cheap Poor computer and web access in offices Skeptics will find and focus on the few errors Even if they believe the data will they use it?

CAPG Clinical Data Repository: 

CAPG Clinical Data Repository Single, shared data repository to support quality and business improvements Data aggregation - acquired, cleansed, normalized and matched Data quality and integrity checking Regularly scheduled benchmark reports Quality Utilization Ad hoc web-based reporting tool Run queries on subsets of own data Accessible to multiple users from an organization MD level feedback Patient intervention opportunities Support for point of care reminders Data extracts returned to users for internal analyses

Slide34: 

Health Plan Eligibility and paid claims data (facility, POS, mental health and vision claims) Health plan/PBM Pharmacy data Medical group Physician claims/encounter data Laboratory Claims and results data Hospital Claims data CAPG Clinical Data Repository Clinical Data Repository Inputs

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CAPG Clinical Data Repository Patient action lists Disease registries Web based ad hoc reports Comprehensive, high quality clinical data Data extracts Clinical Data Repository Outputs Benchmark reports

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Fair Hills Becomes Data-savvy: 

Fair Hills Becomes Data-savvy The IPA creates a diabetes registry and sends lists of patients missing tests to office Fair Hills takes data into free-standing database and adds some other key info Fair Hills also collects metrics on access on a monthly basis to track success of that project Office manager has become much more computer literate, and sometimes has her son ( a 'computer whiz') help out in the office Everyone looks forward to monthly snapshot report showing how the office is doing

Additional Factors Influencing Change : 

Additional Factors Influencing Change Status quo is unacceptable Something clearly in it for the physician office—financial, time, control, patient care Relatively open-minded and trusting relationship with health plans Environment that facilitates sharing experiences (successes, challenges, strategies used) Community orientation