More than 20 percent of care delivered in the United States is unnecessary, according to a 2017 survey of physicians. Sometimes, physicians over order tests, prescriptions, and procedures out of fear of malpractice, the survey found. Other times, they do so because patients expect them to take some sort of action. The volume-based system of care is designed to provide easy access and a profitable return for doing something even if it delivers little value to the patient.
For years, there has been much discussion around the need for change in health care to improve quality of care and reduce costs—two cornerstones of value. However, the survey results mentioned above point to a need for culture change that puts physicians in the driver’s seat for value and empowers and incentivizes best outcomes. It isn’t enough for physicians to buy into an organization’s commitment to value. They must also be empowered to design and lead the organization’s approach, moving from a participant mindset to one of ownership.
Case Study: Holston Medical Group
For Holston Medical Group (HMG), a regional medical group that serves 200,000 patients in the Appalachian region, a physician-owned, physician-led model has led to culture change and sustained improvement. HMG’s experience points to three ways physician-owned, physician-led models can drive increased value.
Freedom to innovate for greater value. HMG physicians are partners in a physician enterprise that allows them to collaborate with their peers in taking patient care to another level. Such collaboration reduces burnout and significantly improves quality of care and access to care while reducing costs. Some of the physician-led value innovations the group has introduced include:
- A pharmacogenomics testing partnership that enables physicians to test ways to apply precision medicine in clinical settings, carefully and artfully advancing the value promise of precision medicine.
- An extensivist clinic—staffed by physicians and nurses with intensive care and emergency care experience—that helps patients with complex care needs avoid a trip to the emergency department and a potential inpatient stay. Among patients who have been treated in the extensivist clinic, 80 percent return home and 20 percent are admitted to the hospital by the extensivist physician who cares for them in the hospital and transitions their care back out.
- Home-based technologies that capture vital healthcare data, such as cardiac and blood pressure data, from patients with complex healthcare needs. Use of such technology strengthens the relationships with the patient and their physician-led team, and improves the quality of the scientific and social insights needed for value creation.
- Ownership of both the quality and quantity of care focusing efforts to identify patients and help educate and manage these patients within the physician-patient relationship to a better outcome.
At HMG, physician-led innovation has reduced hospital admissions, with admission rates that are lower than state and regional averages under most value contracts. This innovation also has lowered the rate of emergency department (ED) visits, with an ED utilization rate that is 25 percent better than those of other providers in the market. Additionally, HMG has achieved high quality and patient satisfaction scores as well as having consistently reduced the cost of care, resulting in financial benefits for both physicians and patients.
Flexibility in making investments that address the patient’s whole health. Physicians themselves invest time, capital, and effort to build the infrastructure needed to promote and operationalize care including information exchange and analytics. One area where physician-owned practices excel is in the ability to respond quickly to changes in the market and to collaboration and investment in patient-centric care.
For example, medical groups often face difficulty obtaining data that can help measure patients’ social risk and act upon it in ways that improve health and outcomes. Several years ago, HMG took a significant step toward breaking down care information barriers by investing in a cloud-based community health information exchange (HIE) to build a real-time “common record” for a patient. No matter which participating community provider a patient sees, that provider has access in real time to the patient’s medical records along with the key alerts needed to fully utilize the data.
A culture that promotes value. HMG serves one of the most economically challenged areas in northeast Tennessee and southwest Virginia. Many patients are high-risk or rising-risk. Given the health challenges its patients face, meeting elevated standards for quality, cost, and outcomes under value programs requires buy in from each of HMG’s internal stakeholders—from physicians to front-office staff. Transitioning to a culture where patients feel empowered to make care decisions based on access to information and a trusted physician provider is critical to physician-led success.
Education has been critical to building a value culture at HMG, beginning with its medical team. Physicians needed to understand not only why it was important to make the shift toward value-based payment and processes, but also how HMG would make this transition. Leaders held lunch-and-learn sessions on value with HMG’s medical staff, bringing physicians up to speed on the value landscape and the factors accelerating the move toward value. Nurses as well as front-end and back-end staff were provided with education through monthly meetings that included a value component. Through these meetings, all staff became aware of not only the need for change, but the quality metrics that would determine HMG’s success under value-based models, such as vision screenings for patients with diabetes, documentation of body mass index, and medication adherence among asthma patients.
Since 2013, these efforts have enabled HMG to increase the number of patients enrolled in pay-for-value contracts from about 23,000 to nearly 44,000. Pay-for-value payments increased by 44 percent, with more than $13 million in value-based revenue annually.
By taking note of a few key lessons learned by the HMG team, practices can make significant steps toward value-based care. Practices can build the systems for common workflows, such as automatic prompts for front-desk staff. It is also important to streamline point of care for patients and physicians by providing access to comprehensive patient data through systems like the community HIE. Lastly, practices should focus on value contract performance. At HMG, the Value Initiatives Committee meets biweekly to review payer contracts and to determine the milestones achieved, the gaps in performance that needed to be closed to meet value program requirements, and the action steps needed to elevate performance. Most importantly, the committee reviews whether HMG is putting the patient first as it operationalizes its efforts.
A Physician-Led Approach to Value
Putting physicians in the driver’s seat for value gives physicians ownership over a practice’s approach and encourages high levels of collaboration. The insights gained when physicians design and lead their practice’s value initiatives better position practices to meet their community’s greatest healthcare needs, reducing costs of care while making a deep impact on patient health.
Scott Fowler, MD, JD, FACOG, is president and CEO, Holston Medical Group, Kingsport, Tenn.