Bagley slides edited - ACP · Boosting Professional Satisfaction ... • We need to change the way...

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Changing Times, Changing Practice: Finding The Joy In Medicine

Alaska ACP and AKOMAApril 2, 2016

Bruce Bagley, MD

www.stepsforward.com 2STEPSForward.org

• Discuss the current changes in the practice environment and payment reform as a context for practice transformation

• Professional satisfaction and some of the causes for physician burnout and its consequences

• Introduce the AMA STEPS Forwardprogram to aid in practice transformation

Today’s conversation


• Now, more than ever…high quality, effective patient care is a team sport

• “Patient-centeredness” is more than a catch-phrase…it must be real, palpable and everyone’s responsibility

• Integration and collaboration must trump fragmentation and autonomy

• Care must be systematic and IT enabled for better reliability and better outcomes for patients

• The visit is no longer the “central commodity of healthcare”

Key assumptions

= Influences our thinking on an issue

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• Physician leaders

• Information technology enabled

• Clinical integration

• Prepaid global payment system

Healthcare delivery system trends

-Robert Pearl, MD –CEO, PMG

“80% of the strategies for managing population health and controlling total healthcare costs are related to primary care activities.”

www.stepsforward.com 5

Team-Based Care

It is time to change how we do our work…a strategic distribution of the work is essential


Hero model or real team care?

Hero model

• Physician in charge-“Captain of the ship”

• Physician authorization required for most orders

• Staff works to optimize physician workflow and throughput

Team care

• Physician provides clinical expertise and knowledge

• All make decisions appropriate for level of work

• Entire team participates in optimizing outcomes for patients

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Characteristics of a team

• A group of skilled individuals

• Driven by a common goal

• Agree on a game plan

• Play or work together often enough to get to know each others strengths and weaknesses

• Regularly discuss the play and interactions to improve on achievement of the goal

• Ideally has an experienced coach or captain to observe the play and make suggestions for improved performance on pursuit of the goal


Strategic distribution of work

• Categorize the work

-- Complex work

-- Standard work

-- Innovative work

• Identify the standard work, characterized by “rules-based decision making” and move it into standing orders and protocols

• IT systems can help to organize the work and allow all team members to contribute at the appropriate level

“Teaming‐ How Organizations Learn, Innovate and Compete in the Knowledge Economy,” Amy Edmondson, Jossey‐Bass 2012


Technology and Connectedness

It is time to embrace technology and make it work for our patients, our physicians and our staff

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www.stepsforward.com10STEPSForward.org

Technology and connectedness

• We must apply the great technology we already enjoy in our everyday lives to enhance the healing relationship

• Knowledge management, communication, patient engagement, education and information exchange

– Community-wide Health Information Exchange (HIE)

– Electronic health records

– Point of care registries

– Patient portals

– Email with patients and e-visits

– Video visits


Patient/family/caregiver engagement

• The “block-buster drug” of the 21st Century

• Access redefined-”How can we help you?”

• Patient self-management support

– Motivational interviewing

– Informed medical decision making

– Shared goal setting

– Outreach and between visit follow up

• Patient reported outcomes of care (beyond CAHPS)

www.patientfamilyengagement.org

www.stepsforward.com12

Patient portals enhance relationships

• Full digital engagement on a mobile platform

• Email with patients

– Triage and distribute like phone messages now

– Reduces phone traffic

– Less keyboarding by staff

• “Texting” for coaching and reminders

• Wearable devices

• Appointment and Rx requests

• Education and support groups

• Video visits for elderly

Tech companies will take charge of this space if we continue to ignore it!

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Population Health Management

Moving from the sole focus on the individual patient to include a system of care for all


Population health puzzle pieces

www.stepsforward.com

Population health management

• Focus on the single patient AND a sub-set of the practice panel (e.g. diabetics)

• Identify the high risk/high needs patients

• Risk stratified care management and care coordination

• Improve care and reduce cost by focusing on complex patients and high reliability systems to help them

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• Community health

– Population related measures

• AMI deaths per 100,000

• Asthma admissions per 100,000

• Average BMI in the community

• Prevalence of diabetes in the community

• Population Health Management

– Practice level “sub-population”

• Diabetic patients

• Asthma patients

• Heart disease patients

• High risk/high needs patients

– High risk/high needs patients

• Systematic assignment to risk groups

• Individualized care plans

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Population health definitions


www.stepsforward.comSTEPSForward.org

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Risk-stratified care management

Patient Needs And Complexity

Level 1 Level 2 Level 3 Level 4 Level 5 Level 6

1. Health and prevention2. Lifestyle coaching3. Shared goal setting

1. More help and support2. Care plan critical3. Registry required4. More clinical training5. Customize


EBM process to better patient care

Research• Many clinical studies pointing

to best treatments or management of condition

EBM guidelines

• Summary of best advice for patient management

Clinical performance measures

• Short list of performance measures- “outcomes”

Systems in practice

• Point of care registries


5 Critical functions of a Point Of Care registry

1. List of all patients with the condition

2. Patient status screen or “snap shot” of the EHR to identify gaps in care

3. Aggregate of all patients on list with results and targets

4. Support for outreach efforts

5. Quality reporting as byproduct of the process of care

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Value-Based Payment andAccountable Care

The US health system is moving from “volume to value” in payment strategy so why not get ready?


• How providers are paid makes a difference

• Blended payment modeled in Comprehensive Primary Care initiative from CMS

• CMS announces value based considerations will constitute 30% of payments by 2016 and 50% of payments by 2018

• To succeed ACOs must distribute resources internally in proportion to the value created for patients

• Primary care infrastructure needed for success

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The changing payment environment

STEPSForward.org

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Medicare advantage and ACOs

• Both require robust primary care infrastructure and capability with embedded behavioral health

• Risk stratified care management and care coordination essential

• Clinical, financial and information technology integration is key to success

• “Shared sense of responsibility for service, cost and quality” must drive the culture


Payment transition strategy

0

10

20

30

40

50

60

70

80

90

100

2014 2016 2018 Future ?

Revenue Stream

Pay for Performance

Capitation

Salary

Fee-for-Service


“The Road to Value-Based Care-Your Mileage May Vary” –Deloitte University Press 2015

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How will we get from volume to value?

• Adjusting the dials on four incentive types

– Salary, Fee-for-service, Capitation and Pay for performance

• Support for robust primary care infrastructure

• Interim strategies such as bundled payments or partial specialty capitation

• Global payments to organizations that are accountable for triple aim results

• Timeline for change


Medicare Access and CHIP Reauthorization Act (MACRA)

• Merit‐based Incentive Payment System (MIPS) uses point system +/‐ 4% or more bonus– Consolidates PQRS, Value‐based modifier, EHR incentives and Meaningful use programs into one program with same quality measures

• Pathway for physicians to participate in Alternative Payment Models (APM) 5% bonus– MSSP Accountable Care Organizations– Comprehensive Primary Care initiative type PCMH


“If we build it…they will come” –Field of dreams

“If we build it with them…they will already be there”

Christine BechtelNational Partnership for Women and Families

STEPSForward.org

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Three “take-away ideas”

1. The movement from volume to value is real and inexorable. It will proceed slower than desired by employers and governmental agencies and faster than desired by providers and health plans

2. Risk stratified care management and care coordination will soon be the “standard of care” without which providers and organizations will be considered lacking

3. Integration, collaboration and systematic team-based care are the keys to success in the future


Boosting Professional Satisfaction

The Rapidly Changing Payment and Practice Environment is Resulting in Additional Stress for Physicians and Practice Staff. Professional Satisfaction is Flagging but There are Specific Actions You Can Take.


• We have seen the rates of professional satisfaction fall over the last few years

• The cause is multi-factorial

• The solution is available but not easy

• We need to change the way we do our work

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Professional satisfaction

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Burnout rates by specialty

General internalmedicine

Family medicine

50% Line


• EHR

• Increasing administrative tasks

• RVU driven front-line care

– Emergency medicine

– Primary care specialties

• Increasing regulatory burdens

• Working in an archaic model

• Uncertainty about future

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Causes of physician burnout


“Factors Affecting Physician ProfessionalSatisfaction and

Their Implications for Patient Care,Health Systems, and Health Policy”

AMA Sponsored research paper by Rand Health- 2013

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• Quality of Care– Ability to provide quality patient care- facilitators improve

satisfaction…barriers reduce satisfaction

• Electronic Health Records– Data input, “signal to noise ratio” and intrusion into physician/patient

interaction reduce satisfaction– Ease of access to data and patient records improve satisfaction

• Work Environment– Autonomy and work control– Practice leadership– Collegiality, fairness and respect– Work quantity and pace– Work content, allied health professionals and support staff– Payment, income and practice finances– Regulatory and professional liability concerns– Health reform

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Themes from professional satisfaction research


• Consequences:

– Patient satisfaction and quality

– Medical errors and malpractice risk

– Physician and staff turnover

– Physician alcohol/drug abuse and addiction

– Risk of physician suicide

• Origin:– Physical energy

– Emotional energy

– Spiritual energy

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Physician burnout

Like a bank account with the balance running low

Source: “Physician Burnout” Dike Drummond, MD‐ Family Practice Management, September/October 2015 www.aafp.org/fpm


• Symptoms– Exhaustion

– Depersonalization

– Lack of efficacy

• Five Main Causes– The practice of clinical medicine

– Your specific job

– Having a life

– The conditioning of your medical education

– Leadership skills of your immediate supervisor

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Physician burnout

Source: “Physician Burnout” Dike Drummond, MD‐ Family Practice Management, September/October 2015 www.aafp.org/fpm

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• The world we live in has changed dramatically in the last 10 to 15 years– Information overload– Connectedness…can’t get away– Pace of life is up two notches– Change is everywhere in everything we do

• The practice of medicine– More consolidation => less autonomy– More measurement and accountability– Higher patient expectations for service

• Changes in healthcare financing– Volume to value– Cost pressures – Proactive payment strategies from both employers and government

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Contributing factors to stress


• Unrealistic expectations or difficulty reaching goals– Income

– Family time

– Exercise, recreation and relaxation

– Healthy eating

– Professional development

• “Emotional bank account” balance is low– Relationships (spouse, family, friends, colleagues)

– Not enough time for reflection and spirituality

– Often giving more than receiving (physically, emotionally and spiritually)

• Everyone thinks: “You are a doctor…you must be OK” and therefore less in need of nurturing and support

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On a more personal level


• Externalities– Insurance hassles and payment rules

– EHR functionalities not optimal

– Medical liability

• Internal operations in the practice– The hero model still predominates

– Team approach is underutilized

– Too much reliance on memory and not enough use of systems to enhance reliability and consistency of care

– Sub-optimal use of health information technology and connectedness

– A “culture of improvement” and team-based positive approach to problem solving is weak or non-existent

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Getting at the root cause of practice blues

20%

80%

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www.stepsforward.com43

The Doctor 1891 Fildes

Undivided attention


I used to be a doctor. Now, I am a typist.”“

Elizabeth Kohnen, MD, MPH, Internist, Anchorage, AK

STEPSForward.org


The Doctor 2016

Continuous partial attention

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Where to begin


• Workflow Redesign – Improve quality

– Relationship with team and patients

– Planning and project management

• Communication– Patient/family/caregiver engagement

– Among team members

– Physicians Administration

Qualities of successful practices

STEPSForward.org


Taking Action

AMA strategies to revitalize your practice and improve patient care

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Getting Started with One or Two Modules

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I get to look at my patients and talk with them again. We’re reconnecting….

Our patient satisfaction numbers are up, our quality metrics have improved, our nurses are contributing more, and I am going home an hour earlier to be with my family.

”

“

Amy Haupert, MDFamily Medicine, Allina Health Cambridge Clinic

STEPSForward.org


Thank you!

[email protected]

STEPSForward.org

Bagley slides edited - ACP · Boosting Professional Satisfaction ... • We need to change the way...

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