Reaching for the Possible: Group Practice and Quality

1. Reaching for the Possible:Group Practice and Quality AMGA Institute for Quality Leadership Annual Meeting San Francisco, CA October 1, 2009 James L. Reinertsen, M.D. jim@reinertsengroup.com 307.353.2294

2. It is no accident... Geisinger and ProvenCare �guarantee� Virginia Mason, Park Nicollet, ThedaCare and Lean Henry Ford and infection control, depression management Cleveland Clinic and CV services results Gunderson and Green Billiings and Positive Deviance Mayo and everything And it�s not just the old grey guys�new kids on the block as well�Allina winner of Acclaim Award Geisinger and ProvenCare �guarantee� Virginia Mason, Park Nicollet, ThedaCare and Lean Henry Ford and infection control, depression management Cleveland Clinic and CV services results Gunderson and Green Billiings and Positive Deviance Mayo and everything And it�s not just the old grey guys�new kids on the block as well�Allina winner of Acclaim Award

3. Why are group practices associated with high quality? Values Opportunity to select, nurture, and deselect members based on shared values Systems of �Public Practice� Common patient record �I�ll be down to take a look� Financial Buffers Opportunity to shelter physicians from the worst features of payment models High Aims Reaching for what�s possible

4. Possible, or Passable?

5. Possible, or Passable? Passable: Good enough. Adequate Aims are framed using required and expected as the touchstones Possible: Being within the limits of ability, capacity or realization....but... Being something that may or may not occur Framed using the unexpected, or even the theoretical ideal as a �reachstone�

8. A �Reachstone�

9. Risk of Failure

10. But medical groups are not the only organizations working on quality...

12. WellStar and the �Organized Medical Staff� 5 hospitals in Atlanta region 300+ doctors in medical group 1243 active and �courtesy� staff doctors $1B revenues Set aims in 2007: Reduce infections by 50% each year Reduce mortality rate 10% Improve evidence-based medicine reliability to 95% or greater

13. HAI Reduction ResultsVAPs, CLBSIs and PH CaUTIs

14. Safety and the Medical Staff at WellStar Safety behavior training initiated for all employees Mandatory training policy adopted by independent medical staff (MEC) for all physicians. Completion required by April 15, 2009 Email April 16 from Marcia Delk, CMO: �982 docs needed to be trained, 980 completed, 2 did not and were suspended yesterday.�

15. �Clinical Integration� Otherwise independent practices can bargain together if they... Adopt quality goals and practices Measure performance Hold to account for performance Report performance to payers and public

16. Provider Payment Reform for Outcomes, Margins, Evidence, Transparency Hassle-reduction, Excellence, Understandability and Sustainability

17. Prometheus: Basic Concepts Evidence-informed case rate is built based on resources needed to deliver care in a good CPG Negotiated base payment takes into account complexity of each patient�s condition (removes �incidence risk� and �severity risk�) Evidence-informed case rate (ECR) encompasses all providers treating a patient for that condition and is allocated among them in accordance with that portion of the CPG they negotiate to deliver Preventable complications are not paid for Quality scores (and payment) for your patients depend both on how you do (70%) and how the other doctors do (30%)... even if those other doctors are not in your own group

18. Which of these Group Practice Strengths could CHIOs, Clinical Integration, and New Payment Models Replicate? Values Opportunity to select, nurture, and deselect members based on shared values Systems of �Public Practice� Common patient record �I�ll be down to take a look� Financial Buffering Opportunity to shelter physicians from the worst features of payment models High Aims Reaching for what�s possible

19. A Health Care System�s Core Work

20. How this looks to many policymakers

21. How this looks to many clinicians

22. If we want the system to produce lower costs AND better quality, safety, and service, leaders must know how to improve processes�not just control the inputs

23. Corollary: If we squeeze down inputs, and leave the same creaky processes in place, we might reduce costs, but at some point we�ll reduce safety and quality as well.

24. For physicians, this means that it�s not enough to do a good job of working IN the system. We must also learn to work ON the system.

26. A Health Care System�s Core Work

27. So What�s Next in Quality? Value, �Kano 2,� the �Triple Aim,� and Overuse Diagnostic Quality

28. Noriaki Kano�s Three Levers for Improving Value

29. Triple Aim Improve� Health of the population Patient experience Overall cost of the health care system Simultaneously

30. The triple aim will not be achieved by making our current processes more reliable and efficient. We have to stop doing lucrative things that don�t help.

31. Inpatient reimbursement per decedent in last 6 months of life 2001-5 in PA

32. A Tough Question: �Could our group make it on Medicare alone?�

33. Cultural tensions between two views of quality Regulators, payors� Public reporting, P4P CMS Core Measures HealthGrades NCQA doctor Diabetes Recognition CMS/Premier �tick the boxes� Focus on process, reliability of EBM Measure what is available Doctors Professional reputation Diagnostic acumen Technical magic Bedside manner Good judgment Focus on outcomes, stories, legends, relationships Value what is unmeasurable

34. Which doctor�s �Quality of Diagnosis� is better? Doctor A Final diagnosis: Giant cell arteritis Length of process: 5 months Visits: 4 Specialist referrals: 3 Laboratory costs: $5,500 Imaging costs: $6,095 Doctor B Final diagnosis: giant cell arteritis Length of process: 10 days Visits: 2 Specialist referrals: 1 Laboratory costs: $455 Imaging costs: $245

35. Factors in Diagnostic Quality Time (to listen, question, think, touch�) Teamwork (ease of communication with colleagues, lack of turf concerns�) IT and decision supports for pattern recognition and memory Training and experience Individual ability and aptitude

36. Working From Group Practice Strengths Share and Live your Values: The patient is the only customer Responsibility to work both in and on the system

37. Technical Knowledge, Culture and Achieving the Possible Passable We�ve trained 20 Black Belts We�ve adopted 4 Red Rules We�re going Lean .... Possible

38. In a great organization, everyone can say, every day... I am treated with respect by every person I encounter, and.... I have the opportunity to do something meaningful, and.... When I do, somebody notices. Paul O�Neill

39. Adopt Real Systems of �Public Practice� Common patient record Not just reminders and alerts �Like practicing under a good chief resident� �I�ll be down to take a look� True cooperation and teamwork Working From Our Strengths (2)

40. Working From Our Strengths (3) Use Financial Buffering Every payment model has side effects. Design compensation systems inside your groups that promote high quality in the exam room.

41. Working from our Strengths:Adopt High Aims Benchmarks? Passable? Or the Theoretical Ideal? Possible?

42. What is Possible For... Health-care acquired infection? Suicide rate? Appointment access? Chronic disease outcomes? Cost per capita?

43. Reach