“Whatever you can do, or dream you can, begin it. Boldness has genius, power, and magic in it.”(1)
— Johann Wolfgang von Goethe
From coast to coast, great programs and organizations led by physicians working hand in hand with multidisciplinary teams are improving the quality of direct patient care services and the overall administration of health systems and physician practices. These improvement goals have become established in the overarching framework of the “Triple Aim”(2):
Better care for individuals.
Better health for populations.
Lower growth in expenditures.
For years, the Triple Aim has served as the lodestone for many of the improvement initiatives across the U.S. healthcare system in the public and private sector. Yet much remains unaccomplished in broadly achieving these aspirations. With this in mind, breaking through the impasses constraining the healthcare delivery system will require far-reaching changes in how healthcare is provided and how physicians lead.
First is the ongoing need for innovation in contemporary medicine, in both professional roles and system design. Transformed physician leadership will be critical to the successful conceptualization and implementation of new interventions, models, and systems that improve the quality of care.
Second, understanding historic difficulties in improving the efficiency and effectiveness of health services is framed within the language of complexity theory. No unique villain has led to our current system’s inadequacies. Rather, complex adaptive systems evolve. Without understanding how complex adaptive systems operate, leaders will fail to recognize and mitigate unintended outcomes in their attempts to address organizational problems.
The science of predictive modeling in advanced systems can improve reliability and thus improve care in complex systems such as integrated delivery systems, academic medical centers, multispecialty medical groups, or medical homes. More importantly, the ongoing fiduciary responsibilities embedded in a physician’s professional role can serve as an immutable principle that supersedes particular circumstances. The redemptive quality of professionalism has the capability to inculcate evolution rather than devolution in the complex adaptive systems in which healthcare is delivered.
The third theme is the evolving path to leadership for physicians in the rapidly changing healthcare system. Physician leaders may develop their skills by undergoing a paradigmatic shift in perspective, from playing an isolating heroic role that does not function well in complex adaptive systems to becoming a professional whose duties and actions are integrated in a health-centric manner in the community they serve.
This new professionalism emphasizes the ongoing relationship between the health of individual patients, the health of the physician, and the health of the community in which both reside. The importance of collaboration across the entire healthcare ecosystem and the broader community in which it resides is essential, and physicians who engage and lead efforts that positively impact the systems and underlying processes will do so with their clinical, technical, business, and strategic skills.
INNOVATION TODAY
The publication of To Err Is Human in 1999 heralded a growing dissatisfaction with the status quo in the healthcare industry by shattering the illusion that the U.S. healthcare industry was of high quality second to none. Subsequently, we have seen a renaissance of sorts in the industry with a reengineering of delivery system models and quality management processes coupled with discoveries and advancements of biomedical technology.
Remote health monitoring systems, point-of-service clinical decision support tools, artificial intelligence-designed diagnostic technologies, and new nanotechnologies that improve health technology instrumentation are driving solutions less dependent on high-cost, facility-based healthcare delivery.
Over the last 20 years, there has been increasing recognition that an unfettered fee-for-service payment system is a major culprit in the high-cost, inadequate quality nature of the delivery system. The Affordable Care Act (2009), MACRA (2015), and 21st Century Cures Act (2016) have strengthened the industry focus on value delivered across the spectrum of patient care services, bringing to the market new innovations in care delivery, biotechnology, and information science.
Innovation in patient care delivery models and comparative effectiveness research is being driven by the expectation that there will be a significant return on investment for those who bring more efficiency to the market.
For every challenge in healthcare today, there are opportunities to uncover breakthroughs that advance the quality of care delivered. But as Clayton Christensen pointed out, innovation is intrinsically disruptive.(3)
The complexity of the healthcare delivery system creates an environment in which innovative solutions to problems do not always easily fit into the system. The capital outlay for financing technology, third-party payers, and the highly regulated environment are not necessarily conducive to rapid transfer to evidence-based, point-of-care solutions.
Disruptive innovations arrive in the healthcare mainstream market clumsily, although the penetration of retail medical clinics, telemedicine, electronic health records, and pharmacogenomics do indicate adoption of innovations in the healthcare market is accelerating.
Incremental improvement has been more the rule in delivery system transformation because of the inherent conservatism of the third-party payer system. However, the Affordable Care Act created enough disruption in the insurance industry to accelerate the pace of change.
In 2006, the Institute of Medicine organized the Roundtable on Evidence-based Medicine (now known as the Roundtable on Value & Science-Driven Health Care), which conducted workshops focused on issues pertinent to improvement in the science of medical practice. In 2010, the roundtable released Redesigning the Clinical Effectiveness Research Paradigm: Innovation and Practice-Based Approaches: Workshop Summary, which summarized the workshop presentations.(4)
From the presentations, a number of themes emerged on how the science of medical practice should be redesigned to be more clinically effective.(4) Many of the themes articulated at the workshop (Figure 1) have subsequently been embedded in the health reform legislation.
Key to the redesign efforts for physicians in practice and in healthcare services administration is the opportunity to close the gap between science and bedside care, leading to an improved quality of life for many patients.
COMPARATIVE EFFECTIVENESS RESEARCH
As the efforts of this roundtable and other groups fed into the national health and science policy development framework, ARRA put in place the language to launch a new long-term comparative effectiveness research program on a national scale. Its purpose is to validate the comparability of existing and new medications, interventions, and tools for use by physicians and patients. The Patient Centered Outcomes Research Institute (PCORI) was established to lead research from this new perspective. ARRA appropriated $1.1 billion for PCORI.
PCORI’s focus has been to compare outcomes to determine the effectiveness, including risk and benefits, of two or more approaches to healthcare. Comparative clinical effectiveness research examines strategies for prevention, screening diagnosis, treatment, or management of clinical conditions, methods to improve the delivery of care, interventions to reduce or eliminate disparities in heat, and health communication techniques.
The focus of the grants are conditions that affect large numbers of people across a range of populations; conditions that place a heavy burden on individuals, families, specific populations, and society; and rare diseases.
Particular attention focuses on racial and ethnic minorities, older adults, low-income people, residents of rural areas, women, children, individuals with disabilities, people with multiple chronic diseases, patients with low health literacy/numeracy or limited English proficiency, LGBT persons, and veterans and members of the armed forces.(5)
Since it began operations in 2012, PCORI has funded hundreds of studies that compare healthcare options to learn which works best, given patients’ circumstances and preferences.
Initially controversial, PCORI was refunded in 2020 with broad bipartisan support for an additional 10 years at $150 million annually. Its reauthorization changed the language of PCORI’s statute with explicit mentions about its responsibility for research to consider the economic burden of interventions on patients, including out-of-pocket costs.(6)
Despite the ongoing work of PCORI, clinically effective, cost-efficient innovation diffuses slowly in the current delivery system. Fuchs and Milstein argue that the reason for this slow adoption of innovation is multifactorial and fueled by “perceptions and behaviors of major participants in health care.”(7)
They note that hospital administrators have faced financial challenges because of the enormous capital acquisition costs for technology at a time in which the industry is transitioning to outpatient service delivery models. Likewise, they note that physicians are challenged by fears that changes brought on by innovation will have adverse impacts on their practices, compensation, and autonomy.
FOCUS ON PRACTITIONERS
The 2015 MACRA legislation created the Physician-focused Technical Advisory Committee (PTAC) in part to improve how the Medicare program pays physicians for the care they provide to Medicare beneficiaries. PTAC encourages the development of alternative payment models, referred to as physician-focused payment models, by making comments and recommendations to the Secretary of the Department of Health and Human Services on proposals submitted to PTAC by individuals and stakeholder entities.
PTAC allows input into Medicare payment policy directly from physicians and other stakeholders in the field.(8) The PTAC vision statement is:
PTAC was created to contribute to a national priority to improve the efficiency and effectiveness of the U.S. healthcare delivery system. We believe that proposed solutions from frontline stakeholders in our delivery system can substantially enhance quality, improve affordability, and influence policy development and system transformation.
PTAC provides a forum where those in the field may directly convey both their ideas and their concerns on how to deliver high-value care for Medicare beneficiaries and others seeking healthcare services in our nation. PTAC is committed to ensuring our stakeholders have access to independent, expert input and that their perspectives and innovations reach the Secretary of Health and Human Services.
PTAC will continue to submit comments and recommendations regarding physician-focused payment models submitted by stakeholders to the Secretary, as required by statute. In addition, we will expand our communications with the Centers for Medicare & Medicaid Services (CMS) and stakeholders to identify opportunities to further inform and prioritize the work CMS, including the Center for Medicare & Medicaid Innovation (CMMI), and other policymakers are undertaking to modernize healthcare.
Since its inception, PTAC has received more than 40 proposals and provided input directly to the secretary on 28 of them at the time of this writing. The breadth of innovation in the proposals coming directly from practicing providers indicates the capacity for design thinking the provider community is capable of when coupled with appropriate methods of support.
Proposals to PTAC evaluated and reported to the secretary include:
The “Medical Neighborhood” Advanced Alternative Payment Model
Patient-Centered Oncology Payment Model (CPOP)
Eye Care Emergency Department Avoidance (EyEDA)
Patient-Centered Asthma Care Payment
ACCESS Telemedicine: An Alternative Healthcare Delivery Model for Rural Cerebral Emergencies
CAPABLE Provider Focused Payment Model
CMS Support of Wound Care in Private Outpatient Therapy Clinics: Measuring the Effectiveness of Physical or Occupational Therapy Intervention as the Primary Means of Managing Wounds in Medicare Recipients
Bundled Payment for All-Inclusive Outpatient Wound Care Services in Non-Hospital Based Setting
Making Accountable Sustainable Oncology Networks (MASON)
Acute Unscheduled Care Model (AUCM): Enhancing Appropriate Admissions
Comprehensive Care Physician Payment Model
An Innovative Model for Primary Care Office Payment
Alternative Payment Model for Improved Quality and Cost in Providing Home Hemodialysis to Geriatric Patients Residing in Skilled Nursing Facilities
Intensive Care Management in Skilled Nursing Facility Alternative Payment Model (ICM SNF APM)
Home Hospitalization: An Alternative Payment Model for Delivering Acute Care in the Home
Patient and Caregiver Support for Serious Illness
Advanced Care Model (ACM) Service Delivery and Advanced Alternative Payment Model
Incident ESRD Clinical Episode Payment Model
Multi-provider, bundled episode-of-care payment model for treatment of chronic hepatitis C virus (HCV) using care coordination by employed physicians in hospital outpatient clinics
Medicare 3-Year Value-Based Payment Plan (Medicare 3VPBP)
Annual Wellness Visit Billing at Rural Health Clinics
Advanced Primary Care: A Foundational Alternative Payment Model (APC/APM)
LUGPA APM for Initial Therapy of Newly Diagnosed Patients with Organ-Confined Prostate Cancer
Oncology Bundled Payment Program Using CAN-Guided Care
“HaH Plus” (Hospital at Home Plus) Provider-Focused Payment Model
Project Sonar
The COPD and Asthma Monitoring Project
The ACS-Brandeis Advanced APM
The CMS Innovation Center
The Center for Medicare & Medicaid Innovation, also known as the CMS Innovation Center, was established by the Patient Protection and Affordable Care Act to test innovative payment and delivery system models that show promise for maintaining or improving the quality of care in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), while slowing the rate of growth in program costs.
The Innovation Center is chartered to test, evaluate, and diffuse new programs with the promise of improving care coordination, payment and reimbursement models, population health management models, and overall communication and quality involved in patient care. The center is statutorily required to prioritize 20 models specified in the law, including medical homes, all-payer payment reform, and arrangements that transition from fee-for-service reimbursement to global fees and salary-based payment.
If a CMMI pilot model is considered successful, the Secretary of Health and Human Services may expand its duration and scope. As pilot programs are funded, those that prove successful will have the opportunity to be further explored and tested on a broader basis regionally and nationally. Projects will disperse across three areas identified by the Innovation Center in 2011(9):
Patient Care Models
Seamless Coordination Models
Community and Population Health Models
In the past 10 years, CMMI has launched 54 payment and service delivery models designed to transform the American healthcare system from one that pays for volume to one that pays for value. Currently, 40% of Medicare fee-for-service payments, 30% of commercial payments, and 25% of Medicaid payments are being made through some form of value-based arrangement.(10)
The success of CMMI is controversial. Gross savings that are calculated with the use of the model benchmarks are on average 235% higher than gross savings calculated in independent evaluation with the use of a retrospective control group.(11)
In 2021, Accountable Care Organizations have grown to 477 Medicare ACOs and hundreds more affiliated with private payers. Medicare ACOs alone serve 10.7 million beneficiaries and have saved Medicare $8.5 billion in gross savings and $2.5 billion in net savings.(12)
THE ONGOING PHYSICIAN LEADERSHIP JOURNEY
The healthcare delivery system is complex, changing rapidly, and far from physician-centric or physician-friendly in its current iteration. To improve the healthcare delivery system, it must be understood as a complex adaptive system in which physician leadership is obligatory for its success. This leadership draws on the traditional sacred power in the healer role, the ethical bond to the patient underlying the physician’s place in the community at large.
The path to leadership is a developmental one and should be built on a model of professional behavior for physicians where one lives one’s life with truth and dignity. Professional integrity for physicians must be based on a role in the community that provides health and balance. From shaman to hero to contemporary leader, powerful healers must address the health of the society in which they live.
Intrinsic Motivation. One does not happen to become a physician. An individual must have the desire or ability to take on the role. It is a competitive process that requires perseverance, delayed gratification, analytic intelligence, self-abnegation, but also self-confidence. At its best, it is a servant leader role.
The Education. The education of a physician requires four years of college, four years of medical school, then 3–10 years of post-graduate training to develop the clinical skills necessary for the competent practice of medicine. Medical education henceforth must also integrate those skills necessary for physician leadership beyond diagnostic, evaluation, and treatment skills currently emphasized. Effective communication, strategy and tactics, management, team-building skills, systems theory, and process improvement skills are equally important.
The Experience. Medicine is a practice. It is a daily application of one’s skills within the context of one’s social identity and obligation to serve the needs of patients. It is a one-on-one experience. In each encounter with each patient, there is a unique duty. The broadening of a physician’s duty to larger social obligations inherent in leadership requires the application of wisdom learned from these individual encounters to guide one’s actions in the wider context.
Convergence. Convergence is a point in the journey where physicians are able to amalgamate their erudition acquired from both education and experience. At this stage, the benefits of experience from the clinical and technical perspective start to benefit physicians in the shaping of their careers as leaders, so long as they are cognizant of their obligation to the community as a whole.
A New Professionalism. Existential professionalism balances one’s personal needs with the necessary obligation to the patient and to the community as a whole. Maslow’s “self-actualization” as a developmental stage becomes possible only when one’s basic needs are first fulfilled.
Within the context of the professional role, a physician can be self-actualized in leadership, which focuses not simply on the one-to-one relationship with an individual patient, but within one’s role and responsibility to society as a whole. This transformation involves the existential realization of one’s social role outside the constraints of the doctor-patient individual obligations.
Leadership involves expanding these duties to the community. In a world in which healthcare is improved through systems of care, teams of professionals, and collaborative care over a continuum, it will be critical to physician identity.
LET’S GET READY
The role of the healer is a powerful role. It is also the role of a servant. In the complex environment of contemporary healthcare, physicians find themselves at a critical juncture in history that beacons a call for leadership across the profession.
Since the medical community responds to emergencies both locally and internationally without hesitation, the entire profession must respond to the urgency of the healthcare system reform with as much passion as that displayed on the front lines of the COVID epidemic.
The simultaneous obligation to individual patients and to the community as a whole is a reorientation from the traditional clinical role and requires new skills, but the same perseverance and ethical commitment to healing is pertinent. Healthy communities require healthy leaders.
We need to be ready. Retail clinics, telemedicine, remote patient monitoring, alternative payment models, team-based care, artificial intelligence, whole-genome sequencing based life plans, precision medicine, virtual-reality based therapy, advances in longevity science, advanced robotics, care anywhere anytime, pandemics, climate change, social justice, integrated community care models, radiological images with images as precise as tissue under the microscope, microbiome diagnostics and therapeutics, predictive modeling as prevention medicine are already here, just not distributed evenly. We must lead.
Excerpted from Reframing Contemporary Physician Leadership: We Started as Heroes by Grace E. Terrell, MD, MMM, CPE, FACP, FACPE (American Association for Physician Leadership, 2022).
REFERENCES
Goethe J. Goethe’s Faust. New York: Anchor Publishing; 1962.
Centers for Medicare & Medicaid Services. CMS-1345-P, Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations. Proposed Rule. I(A). Introduction and Overview of Value-Based Purchasing. March 31, 2011.
Christensen CM, Raynor ME. The Disruptive Innovation Model. In: The Innovator’s Solution: Creating and Sustaining Successful Growth. Boston, MA: Harvard Business School Publishing Corporation; 2003, pp. 32–35.
Institute of Medicine, Roundtable on Value & Science-Driven Health Care. Summary. In: Redesigning the Clinical Effectiveness Research Paradigm. Innovation and Practice-Based Approaches Workshop Summary. Washington, DC: National Academies Press; 2010, p. 11.
Patient-Centered Outcomes Research Institute. Pcori.org.
Castellucci M. 10 Years After Inception, Industry Backs The Federal Research Institute. Modern Healthcare. March 14, 2020. modernhealthcare.com.
Fuchs VR, Milstein A. The $640 Billion Question—Why Does Cost-effective Care Diffuse So Slowly? N Engl J Med. 2011;364(21):1985–7.
Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. aspe.hhs.gov
Centers for Medicare & Medicaid Services. Centers for Medicare & Medicaid Innovation’s Seamless and Coordinated Care Models. https://www.cms.gov/priorities/innovation/about .
Health Care Payment Learning & Action Network. APM Measurement: Progress of Alternative Payment Models: 2019 Methodology and Results Report. HCPLAN. 2019. http://hcp-lan.org/workproducts/apm-methodology-2019.pdf .
Smith B. CMS Innovation Center at 10 Years—Progress and Lessons Learned. N Engl J Med. 2021;384:759–64. doi: 10.1056/NEJMsb2031138.
National Association of ACOs. naacos.com.