One of the greatest joys in my nursing career has been the collaborative relationship with physicians.
Through these experiences I’ve found one of the foundational pillars of accountable care is the leadership and buy-in of physicians both strategically and at the point of care.
Yet, it’s clear that significant barriers persist to this level of physician engagement. In part one of this three-part series, we discussed strategies for managing the data required to support quality management programs. From the physician perspective, it’s not always clear that the time and effort required for these programs results in better patient outcomes. A recent study reveals only 27 percent of physicians and staff believe current measures are representative of the quality of care.1
For physicians, there is another layer of complexity that is often not addressed head-on. A primary care physician colleague, Wendy Oberdick, MD, summed it up perfectly in two questions: “What’s going to happen to my day, and what’s going to happen to my pay?” As part of an initiative to engage physicians, Clinically Integrated Networks (CINs) and Accountable Care Organizations (ACOs), must address these questions directly. Physicians must understand how participation in the network will affect the workflow and activities of their day, the value their participation will provide to their patients, and the impact on their compensation.
By collaborating with physicians, CINs/ACOs can employ strategies that will overcome the barriers to physician engagement – while addressing their concerns – and achieve goals for improved quality of care and decreased cost. To fully understand the barriers and solutions, let’s start with a brief review of the regulatory aspects of this equation because compliance with the Federal Trade Commission (FTC) and Department of Justice (DOJ) regulations forms the basis of any program.
Understanding Regulatory Compliance
The FTC and DOJ Antitrust Enforcement Policy from 1996 states: “Clinical Integration is an active and ongoing program to evaluate and modify practice patterns by a network’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality.” To that end, the FTC does not pursue action against clinical integration arrangements if they meet a three-part test:
1. The program is likely to achieve “real” integration of providers through
authentic initiatives, involving all physicians in the network;
2. The initiatives of the program are designed to achieve likely improvements in healthcare cost, quality and efficiency; and
3. Joint contracting with health plans is “reasonably necessary” to achieve these efficiencies.
For a physician to participate in joint negotiations with third-party payers – and hopefully receive rewards from those contracts – they must provide/allow data to be collected on the measures applicable to them from the quality program. What makes this so challenging is the differences between providers and regulatory bodies around the definition of “authentic initiatives.” Luckily, there are proven ways to overcome them.
Common Barriers to Physician Engagement
CIN/ACO executives will likely relate to these four common roadblocks:
1. Physicians are not included in the planning of the clinical and quality programs;
2. Access to valuable and actionable data is not easy or streamlined;
3. Performance expectations and goals are not clearly communicated or well understood; and
4. Physicians aren’t convinced of the ultimate value CIN/ACO activities contribute to their office operations or their patients’ clinical outcomes.
Three Ways to Overcome the Barriers
1. Inclusion. The key to a well-rounded program that reflects good communication and strong buy-in across the continuum – and that meets FTC and DOJ requirements for data integration – is inclusion. Include physician representatives from each of the specialty categories, such as primary care, medical specialists, and proceduralists, and from different backgrounds, such as independent, employed, academic, and hospital-based.
To achieve consensus and buy-in, provider representatives should be asked: What measurement of care is important to them (specialty-specific, outcome measures, cost of care); how should measures be presented (aggregated by network specialty/group/individual); and who is the champion from their practice for leadership, communication and workflows.
2. Easy access. Once the quality program is developed, easy access to data and results can make or break it as to whether network participants will actively monitor progress. First, they must have confidence the data is the most-up-to-date. Next, actively remove barriers and address the common complaints physicians have that prevent them from logging into their portal to check performance.
Common strategies include easy access to data with a single sign-on, data that is easy to read, and holding data in a place that providers already need to access. The data must also be valuable and applicable to the point of care to achieve overall goals and improve the engagement rate.
3. Clarity about the Program and its Goals. Do providers and their practices understand the program and the network’s goals? What’s more, do they understand how to collect and monitor the required data? This is often not straightforward, given approximately a quarter of physicians still do not document in a certified EHR.2 In my experience, it is not unusual for a CIN/ACO to have 10-80+ different EHRs and practice management systems in use across the network. For these reasons, clear communication of goals and performance are critical to success.
It is also important to understand practice workflows and respect the time spent caring for patients. A strong, trusted relationship with the practice executive will support communication of contract terms, quality program changes, opportunities for improvement and, most importantly, reasons to celebrate success.
The Real Value Lies in “My Day and My Pay”
Ultimately, for CINs/ACOs to successfully engage physicians, they must address Oberdick’s two questions: “What’s going to happen to my day, and what’s going to happen to my pay?”
First, every effort should be made to streamline the workflow and documentation, so the office is not bogged down with duplicate steps and “too many clicks,” and, any cost impacts or compensation for additional effort must be clearly outlined. Next, physicians need clear insight from data analytics about their clinical, financial, and contract term performance to move the needle toward success – and reward.
Lastly, understanding in the first years of network operations, financial success is not easily achieved, so it is important to set reasonable expectations about building infrastructure and competencies that will lead to future success for years to come.
The third and final article in this series will explore how CINs/ACOs can perform to contract terms, predict performance and how their performance will positively affect their reward.
Ronda Hefton, RN, BSN, MBA, is an integrated care consultant and guest contributor for CitiusTech.
1 “Physician practices spend $15.4B worth of time each year reporting quality measures, study finds,” The Advisory Board. March 9, 2016.
2 Need a reference. https://dashboard.healthit.gov/quickstats/pages/physician-ehr-adoption-trends.php