Aligning Physicians with Organizational Quality Goals: A Focus Group

1.  What tools are being used today to measure quality?

Two organizations were participating in CMS demonstration projects, although one participant was not convinced that “checking boxes to indicate you did all six things required for CHF” was really much of a proxy for measuring quality. Echoing that sentiment, another participant put it this way: “Quality is whatever CMS happens to be measuring at the time.”

On the other hand, the AHRQ Patient Safety Indicators, which make use of readily available hospital inpatient administrative data, are proving useful “to monitor what’s going on in real-time and have it on our radar.” One multi-hospital system looks at sentinel events at the corporate level and recently created a program to decrease central line infections. “Unfortunately you can’t find national data to benchmark against; no one wants to reveal that information.”

A teaching hospital in West Virginia is making headway with clinical analytics but is struggling to devise a balanced scorecard with physician-specific data that’s timely and reportable. Another teaching hospital evaluates everything back of Five Pillars of Excellence sued by the university: Service, People, Quality, Finance and Growth.

Certainly widespread adoption of electronic medical records (EMRs) will have an impact. “By moving to an EMR we can practice higher-quality medicine with little things like automatically sending reminders for mammograms. If your group can learn to mine data, you’re going to have it easy with quality metrics.

2.  What levers are being used in efforts to align physician behavior with quality? How do they differ for employed and affiliated physicians?

One teaching hospital has a 100% employed physician model, and all physicians are expected to meet the performance goals. For directors and managers, 25% of salaries are held back and tied into quality. Above and beyond the standards that everyone must meet, they choose for more measures to aim for.

For the physician-owned clinic, quality efforts are affected by legal restrictions and an intensely competitive market. “Compensation is primarily based on bringing business to the hospital, not on higher quality.”

Other executives concurred:

“Our employees are supposed to get bonuses based on patient satisfaction, but everything falls off when the bottom line falls off.”

“We have 400 employed physicians. None are evaluated on quality; it’s all based on productivity”

“We need a minimum number of physicians in each discipline to keep the hospital going, so it’s a no brainer. You’re trading quality for revenue every time.”

Others were more hopeful, believing that self-evaluation against benchmarks is a powerful lever. “A lot of physicians went to medical school because of their self-interest in performing.”

The just culture model is another lever that works. “Willful disobedience results in disciplinary action: ‘You knew you shouldn’t do that, you did it anyway, now you have to have proctor.’ It’s time consuming is necessary.”

3.  Does your organization publish scorecards?

Public reporting of quality measures has to be an evolution. The large, physician-owned clinic sends out individual data and help physicians interpret it. Then it looks at how physicians are doing as a group, as a clinic and finally as a system. “It’s a powerful tool, transparency, but you have to be culturally sensitive and give people chance to improve.”

Physician groups will resist having individual data published, but they’re OK with blind results. One common approach is to publish scorecards so physicians only see their name but can see everyone’s quality and patient satisfaction scores, although at least one executive believed the most effect approach would be “to post everyone’s score in the physician’s lounge on a big-screen TV.” At the children’s hospital, transparency varies by group. Everyone’s name is listed for pediatric trauma, but not for internists and competing cardiac groups.

Public reporting has its downside. According to one executive, mandatory online reporting in New York State has “profoundly distorted the care provided by cardiologists who don’t want a mark on their record and simply won’t take certain cases.” Similarly, after one teaching hospital went two years without a PICU infection, clinicians avoided reporting incidences and started arguing over the criteria to keep the record pristine.

4.  How are you engaging patients in quality efforts?

Patients and families are increasingly involved in quality efforts, beginning with wide use of the CMS grievance process, the Press Ganey survey and, increasingly, HCAHPS. The children’s hospital engages patients after any adverse outcome and whenever it opens or closes a unit. Several organizations have patient and family boards, whose members sit on various committees to provide their unique perspectives. More aggressive engagement includes running every complaint through a “culture or excellence process, beginning with a phone call to see what went wrong. At one teaching hospital, if a patient rates the experience below a 9 or 10, the nurse manager from the discharging unit calls to find out why.

6.  While healthcare reimbursement in the U.S. is still primarily fee for service, emerging models include bundled payments and accountable care organizations. How are you going to manage payment and financial incentives for non-employed physicians under these emerging models?

Laws need to catch up with these emerging models in order to move forward; it’s very difficult to structure them today. In several markets, physicians are clamoring for employment, leaving few independent practitioners standing. As one executive put it, “The way to get the cats to go where you want them to go is to move the milk. It will be painful, but regardless of how you feel about it, the financial levers are going to switch over the next 5 years. Every physician is going to somehow be engaged or employed. Other systems are slowly being choked because they are no longer financially viable.”

In New York City, another executive reported, “As a physician, you either relocate or become employed so the hospital can lose money on Medicaid and underinsured patients instead of losing it yourself.

Age matters, too. At one children’s hospital with mostly affiliated physicians, “the old-timers are trying to hang on as long as we can, but the younger physicians would’ve been happy being employed from Day 1.”

What does your organization do to make itself provider of choice for physicians?
In competitive markets, it’s increasingly difficult under current reimbursement constraints. “We try to give them the surgical schedule they want, but it’s harder and harder to generate revenue given reimbursement.” Even in sole provider communities, organization must work hard to keep the physicians in town. Effective strategies include reaching out proactively and offering lifestyle improvements. “It takes a lots of 1:1 effort. Our senior leadership goes out to the community practices before they come to us.” One organization opened an after-hours pediatrician call center with four nurses. “We charge them for it, but it’s worth it.”

7.  Ten years from now, how will patients in your community interact with your organization?

Not surprisingly, participants envisioned ever increasing transformation through technology, particularly online encounters and remote monitoring via the Internet. “We’ll see open access, where patients control scheduling, where they go for services and how they pay for them.” On one hand, patients will have closer relationships with their providers, particularly mid-level practitioners, yet care will be less physical. “With asthmatics, we can know whether or not they’re using their inhaler. Why be in the same place if you can get all the information you need online?”

In addition, nanotechnology will transform how we manage CHF, diabetes and other conditions. “We’ll see ‘smart bandages’ with biosensors built into them that measure heart rate rhythm and wirelessly transmit the information as appropriate.” Bright as the future may seem, “the capabilities will exist, but not everyone will get there,” particularly in less affluent markets. And will the large hospital corporations preside over this change? Not according to one executive from a multi-state system. “New organizations will enter the system to manage the whole continuum.”