The study analyzed in the research by Falk, et al., should serve as a wake-up call for health care organizations and related stakeholders. It is quite possible that unless physicians have skin in the game, reducing costs and variation and improving outcomes will not be realized.
I attended a health care conference many years ago, when terms like “managed care” and “capitation” were used in lieu of value-based care, which has become the predominant health care delivery model in which providers, including hospitals and physicians, are paid based on outcomes.
Engaging physicians in this new model, however, and leading them along the path of value-based care, is not easy. Physicians are overworked, managing large volumes of patients and, like other professionals, they are often resistant to change and challenging to engage.
Feeling engaged is a significant driver of physicians’ job satisfaction and certainly the cornerstone of any successful population health program. Beyond the usual steps considered important for building engagement — such as aligning mission and goals, supplying necessary resources and providing opportunities for professional development and career advancement — Falk, et al., investigate the impact of different health care delivery models — accountable care organizations, bundled-payment and co-management systems versus employed physicians versus unaligned and independent physicians — on physician engagement and medical decision-making, with the goal of enabling organizations to adopt strategically effective alignment models.
Analyzing physician drivers of health care spending is complex. It is not readily apparent that culture and risk-sharing arrangements between physicians and health care organizations can play a critical role in cost savings or health outcomes. In fact, Falk finds physician employment alone had little effect on truly aligning physician behavior. The results should serve as a wake-up call for health care organizations and related stakeholders. It is quite possible that unless physicians have skin in the game, reducing costs and variation and improving outcomes will not be realized.
In addition, findings from this study demonstrate sharing data with physicians has a profound effect on their behavior, overshadowing the impact of shared savings on physician decision-making. The bell has been rung to look beyond alignment and business arrangements to achieve success in value-based care systems. Look to the data — cost-benefit analyses, clinical practice guidelines and best practices — to engage physicians in quality and cost accountabilities.
In value-based arrangements, it is essential that physicians receive ongoing feedback about their performance. I realized the importance of having real-time data in my prior job with a population health care management company. My role as medical director was to visit physicians contracted to an independent practice association, many who shared financial risk, and discuss their “report cards.” I visited them in their offices regularly. Physicians are generally more receptive to physician colleagues than nonmedical administrators.
The most meaningful elements in shaping practice behavior of primary-care physicians consisted of physicians knowing the status of their HEDIS measures and measures of inpatient, outpatient and emergency room use. Pharmaceutical prescribing also was a component of the dashboard; a generic dispensing rate of 90 percent or greater was expected. (The selection of devices was not as relevant to primary care physicians as specialists.) Primary-care clinical outcomes were benchmarked against regional standards.
While generally accommodating and agreeable, physicians occasionally disputed the results and questioned the veracity of the data analytics. A key point Falk discusses is the importance of data transparency. I also would emphasize data integrity. Data breaches result in loss of trust and might undo relationships that took years to build. But when data is solid, physicians literally cannot afford to be numbers-blind in the era of new payment methodologies.
It should be noted that Falk focuses on drug and device use — and for good reason. New drugs and technology rank among the most important advances in medicine in the past half-century, but they also are the costliest. The keynote speaker at the aforementioned health care conference was a well-known health care economist, who asked the audience what the most expensive piece of medical equipment was. Participants guessed MRIs, CT scanners and other plausible answers. The speaker shook his head, then reached inside his jacket, pulled out a pen and held it high in the air for the audience to see. Everyone chuckled, suddenly aware and silently knowing that orders, prescriptions, consultations, etc., written in a vacuum will never control costs or necessarily lead to improved outcomes.
Studies have shown, in fact, that physicians influence about 85 percent of patient outcomes with the decisions they make and the orders they write. Whether they work independently or in risk environments might have little bearing on their treatment choices. Physicians relish their autonomy and pride themselves as free thinkers, regardless of where they work. Their ability to leave their current jobs for new practice opportunities frequently is underestimated by health care recruiters and organizations, and so is the role that engagement plays — not only in their career decisions, but also their use of clinical resources.
Arthur Lazarus, MD, MBA, CPE, FAAPL, is a member of the Physician Leadership Journal editorial board. He is medical director for Cigna Group Insurance and an adjunct professor of psychiatry in the Lewis Katz School of Medicine at Temple University in Pennsylvania.