The ABCs of ACOs Creating a Culture of Collaboration with Physicians

1. The ABCs of ACOsCreating a Culture of Collaboration with Physicians Kathleen L. Lewton and Steven V. Seekins Principals, Lewton,Seekins&Trester Clark Jensen Senior Director—Marketing, Intermountain Healthcare Society for Healthcare Strategy & Market Development Sept. 14, 2011, Phoenix AZ

2. FROM: “ACO’s The Final Frontier”TO: “Well, maybe not?” • Proposal submitted when ACO’s were THE ultimate solution . . . . . . • ACO Watch website • Second ANNUAL National Accountable Care Organization Summit • Newly-minted experts and consultants by the dozen(s) • Blogs, op-eds, articles . . . . . . .

3. And then the winds shifted . . . . • CMS shared the details • And the big guns (Mayo, Cleveland Clinic, Geisinger among others) said “maybe not for us” • February survey: 70% of hospital execs cynical about medical homes and ACOs • New models will hurt our margins • And half of MDs don’t know what an ACO even is • BUT even if ACOs don’t turn out to be the ultimate magic acronym . . . .

4. Whatever the acronyms, hospitals & physicians must work as partners • Full physician ENGAGEMENT is the critical success factor in creating, planning and executing key initiatives relating to: • Quality (never events, readmits, hospital-acquired infections) • Think just about HAND WASHING • Cost control • The “total patient experience” • Patient acquisition (translation: admissions)

5. Time-Out #1: Take Your Own Pulse Self-Assessment of Your Organization’s Current State of Mind and Practice

6. Rate using a 5 high – 1 low scale: • Your hospital/system’s current physician satisfaction level (your personal opinion) • How well your CEO interacts with physicians • Overall effectiveness of your physician communications program • Quality of data you have about your physicians (current, detailed, quant and qualitative, etc.) • Your personal relationships with physician leaders • Depth of physician involvement in planning and decision-making • Board/management commitment to physician relationships as a top priority • Your level of worry about physician engagement

7. Status Report 9/14/2011

8. From the hospital POV, we are the center of the healthcare universe • From the patient’s point of view, things may be not quite the way we see it • Recent major research effort in “test market” type city in “mid-US” found the consumer “my healthcare” word cloud had a different picture

9. The patient POV on “healthcare” DOCTOR I asked my doctor and he . . I’d go where my doctor says my doctor thinks . . . . At my doctor’s office . . . . . . With some Rx and outpatient facility references thrown in for good measure

10. A quick reality check: • Doctors “have” the patients (almost all the time) • Most care (not in-bed care, just care in general) happens in the doctor’s office (or wherever the doctor SENDS the patient) • Doctors have the credentials and the license to treat • The phrase “Doctor’s orders” isn’t a cliché

11. And most significantly . . . . • The doctor-patient bond, albeit battered and tossed around in past few decades, remains the core of trust in the entire healthcare endeavor • Strengthen that bond and all benefit • Erode that bond, and our entire ‘industry’ suffers – especially the patients

12. When hospital leaders think about ACOs, they focus on “hard goods . . . • Here’s the typical list (from SHSMD Futurescan) of what a hospital leader would think about: • How MANY doctors do we need • Impact on patient volume • Governance and management capabilities • Capacity to manage total costs across episodes of care • Level of incentive alignment between hospital and physicians • Ability to be transparent and report publicly

13. Instead of focusing on the CORE issue: • Can these doctors and this team of board and hospital leadership work together as respectful partners? • Buzz words like “level of incentive alignment” reduce a relationship to a price tag • Six “Keys to Lasting PARTNERSHIPS”: • Align physicians with hospital strategy (control) • Sufficient capital ($$) • Practice acquisition (control and $$) • Physician compensation ($$) • Clinical integration via a contracting entity (control) • MANAGE physicians (control)

14. And what do hospitals think they have to DO to become an ACO? • Establish a legal entity including joint negotiation with physicians for contracts • Establish physician membership criteria to ensure physician’s full commitment • Common set of performance measures . . . • Create management system to track . . . • Establish an incentive system to promote collaboration and peer pressure to improve performance . . distribute shared savings • . . . . Drive clinical performance using physician-led committees

15. Alternatively . . . . • Continue (or begin) to work with our physician partners to create an organization that . . . .. . . .

16. The devil is in the details . . . . • But while many hospital leaders are worrying about the CMS regulations, they need to first be worrying about how they can create the FOUNDATION – a true partnership with physicians – when their views of the world are so divergent

17. . . .but the mindset matters • Emphasis now on power and control • Leading hospital management consultant advises using a “council” model – employed MDs serve on councils, with “Board appointed fiduciary – the hospital CEO – with ultimate bottom-line accountability and veto power” • Meanwhile the president of the AMA says “Oh yes, there will be ACOs and they will be PHYSICIAN-led”

18. A quick scan of the current landscape shows lots of land mines • Hospital trade publication: • “One of the key goals of the ACO is to better coordinate care to reduce costs, which means reducing utilization rate of the most costly services, which drive up costs BUT are also key revenue generators for hospitals. . . . Volume will drop and hospitals will have to reach to a broader population base to make up for that lost volume.”MINDSET MATTERS. The big goal is no longer how can hospitals make more money, it’s the health status of a population

19. Current landscape • Study of hospital physician relations programs done by SHSMD finds: • Programs “also referred to as physician SALES programs” • Goal: get physicians to send patients to our hospital • Use sales plans and metrics • Only 13% of these programs report to CEO • List of responsibilities never mentions building or enhancing sense of partnership and collaborationMindset: SELL TO rather than work with

20. Current landscape: • Research done by SHSMD and major agency: “Recurring theme is improving physician relationships . . . Specifically, changes needed in the (drum roll) physician relations function” • 80% of CEO, consultant respondents say physician relationships is a major challenge – half mention “alignment” • Key disconnect: some see physicians as an internal audience, others still say “external” some say both (if they are employed)

21. An A-Ha! moment: Large urban system, discussion of “our” doctors focuses exclusively on employed docs.Q: What % of your revenues come from NON-employed physicians?A: Gee, not really sure.Reality: 70%

22. Current landscape: • Same study . . . . Intriguing insights “Our ability to integrate more physicians into our employed group and build that group, without alienating any of the independent groups in the process . . .” “We have to find a way to align the physician groups SO we reduce the amount of leakage that goes to competitors.”Mindset: Doctors exist to feed our need for patients.

23. And more . . . . • Communications is seen as a panacea . . . “We have to communicate TO medical staff what the changes are and GET THEM to understand” “Get them to understand OUR strategy and OUR goals” • . . .as is the fabled “alignment” “If they are employed, WE have to run the group as best we can. If not employed, it’s economic alignment . . . there are models where we are both at risk.”

24. Some glimmers of insight . . . “We have to view physicians as partners including being concerned about their financial welfare” (CEO) “We need get physicians to help us design programs that we deliver. For instance, we could have cardiac care physicians help design the cardiac care that the hospital delivers.” (CEO with good intentions) Mindset: When asked, respondents had difficulty identifying the skills and expertise needed to do all of this

25. And now back to real life . . . • Amidst all the talk of ACOs and alignment: • Major System X fires its radiology group, replaces with a contracted group – and announces it as a fait accompli to the medical staff . . . who are STILL furious 18 months later • CEO-no-confidence votes still occur • “Independent” physicians – who still do admit patients and generate revenue – more and more concerned about their role as 2nd class citizens

26. More real life . . . . • National Healthcare Leadership Survey: • Hospitals that report having (average scores): • Administration succession planning 4.67 (of 5) • Nursing leadership succession planning 4.33 • Medical leadership succession planning 3.54 • Administration 360-degree feedback 3.80 • Nursing leadership 360-degree 3.47 • Medical leadership 360-degree 2.31

27. One more dose of real life . . . . • Study after study finds that physicians say: • They have less time and no control • Unable to keep up with changes in practice • “I default to what I learned and feel comfortable with it even if it may not be the most current because I can’t do what I’m not sure I feel good at” • They are frustrated at best, furious at worst • Concerned about money (NOT what they planned) but even more concerned about . . . . • Not beingrespected (a core need)

28. Beware the conventional wisdom • Ownership is inevitable • Accenture – 13% or less will be independent by 2013. • REALLY? How many systems are even at 50% and it’s almost 2012? • And think about the stats – one Mayo with employed sure brings up the average • But acting out of that mindset has profound implications • Some other system wants yourignored independents

29. More conventional wisdom • Owned = aligned = partner = collaboration = shifts in practice patterns. NOT necessarily. • Most of all, owned = respected. • Key to success in ACO is $$ • AMN study of biggest obstacle to ACOs: • Physician alignment 42% • Capital 38% • IT 31% • Evidence-basedprotocols 25%

30. Case in Point:Integrating Independent Physicians

31. St. Joseph’s Hospital Health Center, Syracuse • Strategic planning process driven by ad hoc coordinating council of ten physicians (employed and independent) and five administrators • Five ten-physician task forces handled specific subjects and sought physician input via department-by-department advisory meetings – 150 physicians participated • Admins and doctors jointly presented to Board

32. Time-Out #2:Let’s Talk Questions, comments, discussion and debate on what you’ve heard so far

33. Now . . . . On to the ABC’s Attitudes, Building Bridges, Creating a Culture of Collaboration

34. “A”Attitudes: What Makes Physicians Tick

35. Tick, Tick, TickNot Captain Hook’s alligator - how docs think & feel • Informed insights based on a few decades working side-by-side with physicians in a non-hospital setting) • Doctors by nature are perfectionists, like challenges, like being right, are analytical, like being leaders (in the sense of giving the orders), are competitive, like doing things in ways that are accepted by their peer community

36. Tick, tick, tick . . . . • Doctors are very very smart and bright individuals, highly educated . . . • AND they want to be loved and respected as people, too • High ego strength is essential for what theydo • Huge info seekers, users (from gossip to research findings) • Driven by facts and numbers – data, data, data • Truly committed to their patients!

37. Physicians Doers 1:1 interactions Reactive Immediate results Deciders Value autonomy Independent Patient advocate Identify with specialty Administrators Planners, designers 1:N interactions Proactive OK w/delayed results Delegators Value collaboration Participate Organization advocate Identify with organization Different tocks . . .

38. Doctors are not all alike . . . • Chose medicine for different reasons • Huge variation from older to youngest • “This is NOT what I envisioned” • Medical vs. surgical – different mindsets • Communications preferences vary wildly • Infighting does occur: • PCP vs. specialist(s) • Specialist vs. specialist (ortho/neuro, plastics/ENT/head and neck, etc.)

39. Nor do they think about communications as we do • Study of paired CEOs/physician leaders Best info source CEO Physicians CEO 76% 32% Chief of staff 66 48 Thought leader in my specialty 22 52

40. Best communications tactics? Tactic CEO Physicians Liaison 62 32 Advisory boards 36 48 Newsletter 28 28 Personal mtgs. 94 80 CEO letters 60 38

41. More ticks . . . . • They want to: • Care for patients with the fewest possible hassles • To improve quality • To make sure their patients are safe • To build the body of medical knowledge • To hear things firsthand and directly

42. A great summary from UBM Medica: • A cross-section of American physicians appears to resemble a cross-section of middle-to-upper-income Americans • Professionally satisfied but struggling to find time for work and personal life • In wide agreement that medicine, although challenging, is a noble profession from which they gain great personal and professional satisfaction

43. Understanding physician attitudesis the core first step . . . • So disregard everything we just told you and listen to your own physicians • Not a standardized generic survey from some survey company – YOUR benchmark is your own physician satisfaction • Use surveys – phone, online, whatever they will do • And personal interviews (focus groups almost impossible with this audience) • Get your own “up close and personal” view AND set your own benchmarks to monitor change

44. AND . . . understand your board and C-suite attitudes, too • Is it “US vs. THEM” or “I’ll grit my teeth” or “I genuinely want to work WITH these doctors, but how?” • It’s up to us as the scanners/spanners to manage attitude adjustment via a continuum of approaches: • Facts, data, dose of reality • Persuasion, offering ways to ease the pain • Bringing in outside help who can say what you can’t • OR . . . .

45. Time-Out #3:Let’s Talk What are you encountering and what have you done about it, or what do you want to do about it?

46. “B”Building Bridges: From Better Communications, to Trusted Partners

47. A great starting point . . . . . • UBM study“Marketers should focus on connecting to the emotional satisfaction that physicians get from being physicians while promise help crossing the hurdles that get in the way”

48. The goal is engagement • This is a fine point, because it goes way beyond communicating TO or even communicating WITH – to a desired state of physicians who genuinely care about the success of the organization, and an organization that genuinely values the physicians • Not just their clinical expertise – their personal and professional selves

49. That “value ME” proposition plays out in so many ways • “I still like to be called DR. Jones, at least at first” • Start conversations with points of agreement and commonality – not “here’s the problem we have to fix” • Praise a physician publicly, address problems face-to-face privately (NOT in email) • Understand cultural and personal life sensitivities

50. To “value ME” begins with knowing ME • Knowing about the doctor’s background, hobbies, family, goals and worries • John O’Brien, when at Cambridge Hospital • “I like our doctors. I like going around and talking with them about all kinds of things. I keep in touch with them because I want to – it’s not some strategy.” • Now some call it “physician rounding”