Professionalism and Accountability The Vital Link To Quality of Care

1. Professionalism and AccountabilityThe Vital Link To Quality of Care Christine K. Cassel, MD Building the Bridge: Maintaining Quality in the Face of Change University of Texas System Clinical Safety and Effectiveness Conference September 21, 2012

2. Key Aims for US Health Care Affordability Are all three possible? Access Quality NOT without physician engagement and leadership.

3. Knights, Knaves and Pawns Julian Le Grand, British economist, on different underlying frameworks for social policy: • The Question: How not to undermine socially positive motivations, while affecting behavior with external incentives? • LeGrand – citizens of post-war England. • We apply these concepts to 21st Century US physicians. Source: Jain, SH and Cassel, CK. Societal Perceptions of Physicians: Knights, Knaves or Pawns? JAMA 2010; 304(9): 1009-1010

4. What motivates physicians? Professionalism (intrinsic) Knights? Knaves? Pawns? Regulation (extrinsic) Financial (extrinsic) WILL P4P STRATEGY WORK?

5. The Roles and Expectations of a Physician: Complicated and Complex Society Patient Consumer Professional Citizen Healer Comforter Provider Physician Scientist/ Expert Customer Pharma, EMRs, etc. Team Leader Contractor Evidence, community Hospital, clinic, practice Insurance/ Medicare

6. Complexity science at work Outcome is measurable?

7. How to measure physician quality/performance • For payment • For “meaningful use” of HIT • For public reporting • “Physician Compare” • “Consumer Reports” • For improvement strategies • For licensure • For Maintenance of Certification Can these be aligned?

8. Results to Date • Medical malpractice system • Does not compensate most victims of medical negligence • Does not lead to better care overall • Pay-for-Performance • No consistent results for physicians • Better on metrics linked to payment, not overall quality • Missing complexity, teams, systems • Public Reporting of Scores • Data too granular, limited meaning for patients • Peer comparisons more effective for improvement IMPACT = Professionalism and Accountability Specialty Certification/MOC Choosing Wisely

9. Allergy & Immunology Anesthesiology Colon/Rectal Surgery Dermatology Emergency Medicine Family Medicine Internal Medicine (250,000) Medical Genetics Neurological Surgery Nuclear Medicine Obstetrics & Gynecology Ophthalmology Orthopedic Surgery Otolaryngology Pathology Pediatrics Physical Medicine & Rehabilitation Plastic Surgery Preventive Medicine Psychiatry & Neurology Radiology Surgery Thoracic Surgery Urology 24 Member Boards Certify more than 750,000 physicians

10. Maintenance of Certification • Based on principles of adult learning • Designed to ensure that physicians keep current and practice high quality medicine • Employs active learning with feedback • Performance assessment and improvement • Knowledge exam every 6-10 years • Performance/knowledge self-assessment more frequently (1-3 years)

11. Performance Assessment Tools: • Internet based data collection/analysis (PIMS) • Registry based reporting? • Practice based data collection

13. Professionalism: Why do they do it? Ann Intern Med 2006; 144:29-36 Note: Includes those completed or enrolled in MOC. A greater proportion of those who have completed IM MOC (33%) rather than enrolled in IM MOC (20%) did so because it was required for employment.

14. Studies Linking Certification/MOC and Quality

15. ABIM Research Partnerships

16. 20.0 17.5 15.0 P 12.5 e r c 10.0 e n 7.5 t 5.0 2.5 0 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 Diabetes PIM Composite Measure and Standard Mean = 71.23 (SD = 11.90) Reliability of Composite = .91Decision Consistency = .98 Standard = 48.51 4% of physicians did not meet the standard Total number of Points N = 957

17. Opportunities for Alignment: • Health Plans • CMS – Value Based Purchasing • JCAHO • MOL • Goals: • Reduce burden of redundant measurement • Enhance clinical relevance • Foster improvement

18. Michael Porter’s Value Framework – Ideas Whose Time Has Come • Fundamental question – What are we trying to do? • Clinicians and other stakeholders need shared overarching goal • Otherwise, interactions devolve into gamesmanship with goal of protecting each stakeholders’ interests • Our shared goal should be improvement of value as defined by the outcomes that matter to patients and costs over meaningful episodes of care • Traditional concepts of quality put focus on clinicians’reliability in performing processes • Value framework puts focus on patients’outcomes, and motivates problem-solving, learning, and improvement through collaboration. From Thomas H. Lee, July 28, 2012 The Value Framework as a Path Forward

19. Recognition that medicine is so complex that no human being can be in control of everything The risk that obvious things can be overlooked is real Core values of checklist Humility Discipline Teamwork Linguistic -- We need to use the same language Standardization Allocation of roles Atul Gawande Tactics We ask care redesign teams to determine the pause points where we can reduce waste, harm, and chaos From Thomas H. Lee, July 28, 2012 The Value Framework as a Path Forward

20. John Bohmer Operations • Teams that have responsibility for improvement of value – forever • Data on outcomes and costs collected as routine part of care • Incentives (financial and otherwise) for improvement • A leader who thinks constantly about improving performance • Formal and informal interactions among team members From Thomas H. Lee, July 28, 2012 The Value Framework as a Path Forward

21. Daniel Pink, Drive Motivating people who solve complex problems: • Physicians • Diagnostic accuracy • Complex factors – patients’ priorities? • Decisions in the context of uncertainty • Payment linked targets work best for routine repetitive work • Salary and group targets work best for complex work Pink, Daniel H. Drive: The Surprising Truth About What Motivates Us. New York, NY: Riverhead Books, 2009.

22. Enhance Professionalism Damage Professionalism • Keys: • Physician trust in measures and standards • Organizational culture P4P could…

23. The Choosing Wisely Campaign Choosing Wisely is an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices.

24. Why stewardship? Why now? • Health care expenditures are increasing at unsustainable rates • Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011 • There is waste in the health care system—some say as much as 30% • Jack Wennberg, Dartmouth Center for the Evaluative Clinical Sciences. • One third of all physicians acquiesce to patient requests for tests and procedures—even when they know they are not necessary • Campbell EG, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007; 147(11):795-802 • Physician decisions account for 80% of all health care expenditures • Crosson FJ. Change the microenvironment. Modern Healthcare and The Commonwealth Fund [Internet]. 2009; Apr 27

25. From: Eliminating Waste in US Health Care Donald M. Berwick, MD, MPP; Andrew D. Hackbarth, MPhil JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362

26. Call to the Profession: Where are the Health Care Cost Savings? Deficit pressures are making cost control inevitable. It will only be successful if physicians stop looking to others to find solutions and focus on approaches that improve the care for patients with chronic illnesses. -Ezekiel J. Emanuel, MD, PhD

27. Medicine's Ethical Responsibility for Health Care Reform — The Top Five List “A Top 5 list also has the advantage that if we restrict ourselves to the most egregious causes of waste, we can demonstrate to a skeptical public that we are genuinely protecting patients’ interests and not simply ‘rationing’ health care, regardless of the benefit, for cost-cutting purposes.” Howard Brody, MD, PhD New England Journal of Medicine

28. The “Top 5 Lists” • Funded by an ABIM Foundation grant, the National Physicians Alliance conceived and piloted the concept through its Good Stewardship Working Group • Developed lists of top five activities in family medicine, internal medicine, and pediatrics where the quality of care could be improved • Published in Archives of Internal Medicine • Subsequent research published in Archives found a cost savings of more than $5 billion could be realized if the recommendations were put in to practice.

29. First Nine Specialty Societies Developed Lists of Five Things Patients and Physicians Should Question American Academy of Allergy Asthma & Immunology American Academy of Family Physicians American College of Cardiology American College of Physicians American College of Radiology American Gastroenterological Association American Society of Nephrology American Society of Nuclear Cardiology American Society of Clinical Oncology

30. New Societies Joining Choosing Wisely • American College of Surgeons • American Geriatrics Society • American Society for Clinical Pathology • American Society of Echocardiography • American Urological Association • Society of Cardiovascular Computed Tomography • Society of Hospital Medicine • Society of Nuclear Medicine and Molecular Imaging • Society of Thoracic Surgeons • Society of Vascular Medicine • American Academy of Hospice and Palliative Medicine • American Academy of Neurology • American Academy of Ophthalmology • American Academy of Orthopaedic Surgeons • American Academy of Otolaryngology-Head and Neck Surgery • American Academy of Pediatrics • American College of Obstetricians and Gynecologists • American College of Rheumatology

31. Consumer Reports • Consumer Reports is a partner in Choosing Wisely and will support the effort by creating patient-friendly materials based on the society recommendations and engaging a coalition of consumer communication partners to disseminate content and messages about appropriate use to the communities they serve. • Tools and resources can be found at: www.consumerhealthchoices.org.

32. Choosing Wisely Consumer Groups AARP Alliance Health Consumer Reports Midwest Business Group on Health National Business Coalition on Health National Business Group on Health National Center for Farmworker Health National Partnership for Women and Families Pacific Business Group on Health Leapfrog Group SEIU The Wikipedia Community (through a dedicated Wikipedian-in-Residence)

33. In the Media

34. Physician Response From the Blogosphere… From cardiologist John Mandrola: “That our thought leaders are now proclaiming–and social media is amplifying– the values of clinical judgment and targeted thoughtful diagnostic and therapeutic interventions represents a monumental sea change. Malcolm Gladwell writes about small yet obvious ideas that come to stick. I think Choosing Wisely has a chance. I hope it sticks like super glue.” Internist Eric Larson noted: “The Choosing Wisely initiative is remarkable because doctors’ professional advocacy groups are making recommendations that are often counter to their own economic interests. By recognizing elimination of unnecessary care as a matter of professional ethics, medical professionals in a broad range of specialties may be signaling that we’re reaching a tipping point toward solving America’s health care cost crisis.” Dr. James Salwitz: “At its base, the Choosing Wisely Campaign is simple. What is the data? What really helps? What hurts? How can we work together to educate everyone about the best care? However, the concept of making decisions in this way is revolutionary. Without government or insurance control, it gives information so that patients and physicians can together make quality personal decisions, while maintaining medical freedom. With this kind of initiative, we, the patients, the doctors, the people, can seize control of health care in this new Century.”

35. What’s Next? • Roll out of communication skills modules to help physicians talk with their patients about appropriate care (Drexel University) • Catalyze others to use the information • Office practices • Health systems • Residency and medical training programs • Additional specialty societies • Consumer Groups

36. Elements of Success/Potential for Impact • Right Message • Right Messengers • Right Time

37. Academic Health Centers: Value Framework and Missions • Learning and improvement are core to our cultures • To fulfill our responsibilities to our communities, we have obligation to do all we can to make health care coverage for all affordable. • But cost reduction alone is insufficient strategic orientation • Substantial opportunities to organize and improve care for patients drawn to academic medical centers. • Vulnerable populations • High risk/complex patients • Themes are attractive to a generation of outstanding, idealistic students and trainees. From Thomas H. Lee, July 28, 2012 The Value Framework as a Path Forward

38. The Moral Test “This is the threshold we have now come to, but not yet crossed: the threshold from the care we have, to the care we need. We can do this– we who give care. And nobody else can … The buck has stopped; it has stopped with you.” Don Berwick “The Moral Test” 2011 IHI National Forum keynote

39. Key Aims for US Health Care Affordability All three are possible. Access Quality WITH physician engagement and leadership.