24 April 2015
Dear Interested Readers,
Inside This Week’s Letter
This week’s letter comes to you from Savannah, Georgia where I am attending GPIN’s semiannual meeting. I hope that if you are not familiar with GPIN, the Group Practice Improvement Network, you may understand a little more about what it is and the role it is playing as it brings physicians and other healthcare professionals from the premier medical group practices from around the country together to discuss the challenges that face healthcare today after reading what follows.
After a pretty compulsive review of what was said at GPIN, I slip into some musing about how much more difficult but important Lean is in medical group practice compared to hospital practice.
You may down load a PDF of “Elizabeth McCarthy’s Story” on the strategyhealthcare.com website. The audio version is proving to be a test of my skill. It is over an hour long. Perhaps you will soon be able to listen to it on your portable audio device as you take a long walk but it will not be this week.
GPIN Report
The GPIN meetings are always a highlight of my year because they consistently present a wonderful combination of new information from well-chosen speakers, reports from selected member organizations of their recent improvement and innovations in care delivery and practice evolution, and an open mike for town meeting like discussion of the “hot topics” that face us all. Over the years of attendance friendships are built and collaboration and sharing becomes an expectation. Between the two meetings each year the network continues its work through the Internet and ongoing exchanges in phone conferences. You can learn more about GPIN on their very attractive website.
https://www.gpin.org/
If you click on the tab labeled members, you will see a list of the most progressive medical groups from around the country. I think that it is important to emphasize the core purpose of collaboration and learning that is explained in the statement of the history, mission and vision of GPIN that I have copied below.
GPIN is a nonprofit organization created in 1993 by the founders of the Institute for Healthcare Improvement to provide a vehicle through which medical groups achieve and sustain performance excellence by sharing knowledge of best practices.
Our Mission
GPIN serves as a catalyst for large multi-specialty group practices to achieve performance excellence through shared learning.
Our Vision
GPIN member groups will be leaders in quality of care, patient experience and cost effectiveness.
As the offspring of IHI, it makes sense that the mission and vision of GPIN are essentially an alternative expression of the Triple Aim. The “hot topics” list for the open mike conversation, is a good place to start the review of the meeting because the list is derived from a vote of the attendees about the ranking of the important topics of the moment. In many of the forty plus meetings over the history of GPIN, physician compensation programs have frequently topped the list. Below you will see the current list and the number of votes each item received.
- Primary Care Redesign/Care Teams/Mental Health and Pharmacy Integration-116
- Analytics/Reporting to Support Population Health Management-92
- 82- Consumerism-Virtual/Mobile/Retail/Employer-based/Price and Access Sensitive Care.
- Transition to Managing Total Cost of Care (on Fee for Service Payments)-82
- Leadership Development/Governance/Cultural Integration-80
- Patient experience/ Engagement/Shared Decision Making-76
- Physician Compensation-43
That list is a window into what is important today in the view of the leading medical groups in country. It is a list that should interest you and if you do any review of the subject matter of these letters you will realize that these subjects are of great interest to me. Another window into what is important is the list of organized table discussions for lunch at GPIN. This time the list is alphabetical and not ranked.
- Access Improvement
- Behavioral Health Integration
- Clinical Variation Integration
- Clinical Variation Reduction
- Cultural Perspectives on Medical Group Mergers
- Diabetes Prevention
- How to sell a large group practice
- Medicare Advantage and MSSP
- Patient Experience Improvement
- Performance Dashboards
- Primary Care Redesign
- Process Improvement Successes and Pitfalls
- Transitions of Care/Preventable Admissions
The program at GPIN also includes several short (about 7 minutes) "G-Force" presentations. These presentations are much like the “report outs” in Lean that occur on a Friday morning after a group has worked Monday through Thursday on a Kaizan or Rapid Improvement Event (RIE). Again it is worthwhile to look at the topics. - Incorporating Centralized Refills into a Contact Center (Baylor, Scott &White)
- Paradise By the Dashboard Light (Crystal Run)- This was a presentation about the introduction and use of dashboards to effect improvement in quality metrics and population health. It is about adaptive change in a medical practice.
- How to Sell A Large Group Practice (Dean Health Systems)
- A New MD Incentive Compensation Plan for the Transition from FFS to Value (Hartford HealthCare and Medical Group)
- Trust Me, I Am A Doctor (HSHS Medical Group)- A description of how a very large and diffuse system in Illinois maintains and aligns physician relationships with a large well-orchestrated annual strategic planning retreat.
- Intermountain Diabetes Prevention Program: Stepping Back to Step Forward (Intermountain Healthcare)
- Home Run Program: Longitudinal Home Care for Complex Patients (Reliant Medical Group)
- Primary Care Redesign: RN Care Coordination (University of Wisconsin Medical Foundation)
If you have survived reading my lists up to this point, we are almost finished but I feel compelled to review the outstanding presentations that round out the agenda and are the meat of the GPIN experience. Even more than the “hot topics” conversations, the lunch conversation options, and the G-Force presentations, the longer (one hour to ninety minute) presentations by a mixture of outside experts and internal presenters are the true “main course” for me. It is in these discussions that the big new ideas come forward or that you are provided a new perspective on an issue in practice that would be “soft” in most healthcare discussions but adds real understanding in how to build relationships. The first presentation of any GPIN meeting is usually an informative and entertaining presentation from someone whose work is affiliated with healthcare but is not a mainstream concept in the mind of most doctors who have a very traditional view of practice. This year was no exception. Kelly McGonigal, a PhD. psychologist and author from Stanford gave a riveting and entertaining presentation full of practical tips entitled “Supporting Behavior Change”. Her thesis was that most of the techniques that we use to engage patients in programs of improvement actually drive them away. Change requires a will to change or improve, tools to overcome the understandable barriers or reasons people fail to realize their good intensions, and support to encourage them as they attempt to make measurable and sustainable changes. We waste a lot of money and time trying to engage patients using inefficient tools like threats and rational arguments. Dr. McGonigal’s research is on “willpower” and she is the author of The Willpower Instinct: How Self-Control Works, Why it Matters and What You Can Do to Get More of It.
The second presentation was of great interest to me, -entitled “Aligning Leadership and Boards in Merging Physician Groups: Methods Used and Methods Learned.” The presentation was a review of the negotiation process employed to move Atrius Health from an affiliation of seven independent organizations to a full asset merger of four. The discussion was co lead led by Kathy Gardner who is the Chief Administrative Officer of Atrius Health and Jeff Weiss of Vantage Partners, the consultancy associated with the Harvard Negotiation Project founded by Roger Fisher.
Perhaps the three lectures on Thursday represented the most business-focused discussions. The first was a review by Michael Chernow, an economist who is the Leonard Schaeffer Professor and Chair of Health Care Policy at Harvard Medical School. I have heard Professor Chernow speak on many occasions and I am very familiar with his work. His analysis was a high point of the program for me. His thesis was that progress has been made since passage of the Affordable Care Act but the future will be more about successful redesign of delivery than just a function of finance. He expressed concern that bonus payments for quality do not necessarily lead to lower costs and higher quality healthcare.
He reviewed all of the current trends in finance and benefit design and gave warning about the potential for continuing cost problems and suggested some theoretical approaches to benefit design and waste elimination that may be a better choice than quality bonuses and pay for performance. His talk included evidence and learning from an in depth economic analysis of the AQC of Blue Cross Blue Shield of Massachusetts and the Pioneer ACO of CMMI. One very satisfying conclusion that he made was that high-risk patients in the care programs of the Pioneer ACOs liked the care that they received.
Many people in the room heard for the first time about the use of reference pricing in value based insurance design where high value services are priced low to stimulate use and low value service are priced at higher rates to discourage utilization. As with all finance mechanisms, complexity abounds. One clear direction though is that in the future patients will bear more risk and a higher percentage of the total cost and providers will bear more risk.
I am a healthcare economics junky and love a talk like this one. Professor Chernow’s opinions are always well documented and his views are the composite of careful observation, the review of huge amounts of data and reasonable projections from what he sees now to what is likely to happen. I think wise people should listen to what he is saying and follow his suggestion that they more intensely increase their efforts to improve the efficiency of their practices while vigorously eliminating waste and improving patient services and satisfaction. Professor Chernow’s suggestions translate for me into a prescription for Lean.
The next presentation was a combined effort by Community Health Network of Indiana, Dartmouth Hitchcock and Intermountain Healthcare of Utah. All three groups have taken the roster review techniques of population health and extended the effort to improve the access and care for the sickest 5% who have the highest utilization of resources down to the next 10% or so of their patient populations. This second population is labeled “the rising risk” and they are the people who will be sickest next unless they are rescued from the course that they are traveling.
All three programs utilized concentrated techniques of the Medical Home and involved strategic integration of Behavioral Health and Social Services. All three programs showed improved clinical and financial outcomes. The three presentations underlined the reality that when we focus our management skills on a population the cost of care improves, resource utilization becomes more appropriate and patient satisfaction and outcomes improve.
The last presentation of Thursday should have been the equivalent of a Friday the Thirteenth movie for most of the audience. It was a review of all of the venture capital backed urgent care programs and the walk-in clinics of CVS, Walgreens, Walmart and others as well as all of the electronic touches now available for care and the new “lower cost concierge practices” that will attract more and more employers as options for their patients. I have touched lightly on many of these topics in previous discussions of consumer driven healthcare and cell phone innovations. Tom Charland who is CEO of Merchant Medicine, LLC, produced a Harvard Business Review worthy discussion of these business which have long passed the tipping point to persistent reality.
Most medical groups and health systems do not have viable plans to compete with or partner with these disruptive businesses and they will lose more than their margins as a result of their lack of awareness. These companies now have thousands of outlets and investors are funding more expansion as they pick up the pace of blanketing the country with easy to access options for inexpensive care.
We have long passed the curious introduction of the “doc in the box”. Ambulatory healthcare as we have known it may be fading into the background and soon be a memory over which few tears are shed by service and price oriented consumers who are tired of waiting for hours to see good old Dr. Marcus Welby. There do not need to be many defectors to care in these new models for even groups as great as the ones at GPIN to lose their small margins. Other less competitive practices will be blindsided by losses that will make them the equivalent of corporate road kill not unlike your local Block Buster Video Store which you once loved but now do not miss as you click on Netflix and On Demand. I think many groups should read Dr. McGonigal’s book about willpower and translate her principles for personal change into a corporate program of behavioral change.
As the program ended for Thursday and I began my walk under the live oaks, along the Savannah River and through the parks and neighborhoods of Savannah that look somewhat like a flat Beacon Hill, I was thinking about a conversation I had the evening before at the reception at the end of the first day. In conversation with a healthcare executive from further down the East Coast we speculated about the future. He sees a small percentage of today's groups as ready for what is coming. He sees on the other end of the spectrum a significant number of organizations that will cease to exist over the next five to ten years. In the broad middle we find most of our medical groups. Their continued existence is uncertain. Some will make it; some will not. The survivors will need willpower, focus, and leadership. They have a lot to do to come from behind.
I am writing on Friday night while I anticipate the grand finale of GPIN tomorrow. There will be a continuation of the “hot topics” exercise as well as presentations entitled “What Hospitality Can Teach Healthcare” and “Aligning Medical Group Culture Using Provider Performance Evaluations”. When the morning is over all of the attendees will return to their practices in every region of the country to begin to apply what they have learned. GPIN has transferred many improvements and innovations over the last 22 years. I fear that without GPIN we would be facing an even more uncertain future.
Retirement has its benefits. I get to hear all of the great presentations. I attend all of the social events where I see old friends and collaborators. I leave without the burden that most of the other attendees carry, which is to go to work on Monday and continue the difficult work of transforming their medical groups.
Lean in Medical Group Practice
Wednesday morning John Gallagher, Paul De Chant and I met to continue a discussion that we have been having for a few months. We have come to the conclusion that as difficult as it has been to establish Lean in the hospital, it is even harder in the ambulatory environment. In the hospital environment Lean can be applied to quickly demonstrate impressive improvements in emergency rooms, operating rooms and on the floors of the hospital. In the hospital Lean yields rapid improvement in the revenue cycles of hospital finance and the efficient management of inventory. The hospital has many processes that are crying to be considered as value streams and there are environments that have already established standard work that is quite similar from institution to institution. The well-defined environment, the fact that patients are present until problems are clarified and the usually brief nature of hospitalizations shorten the time to measurable success that is coupled with significant ROI that impresses and encourages management and the board. Paths to the hospital are relatively clear and the flow from the hospital clearly marks a milestone in the process of care.
The ambulatory environment is more diffuse and much more variable than the hospital world. Care can stretch over years. Different types of problems are often mixed together in the schedule and within the schedules of the staff in the same office. Who sees the patient is often the unpredictable result of a combination of a variety of issues that are constantly changing. The time with the patient is compressed and the time the patient is likely to be away until the next visit is expanded. There is no opportunity to “park” a patient for a while to allow time to diminish the ambiguity of the moment. Ambulatory systems are often spread over wide geographies and within the same organization they vary remarkably in terms of the support they receive from specialties, from their expenses or cost structure and by the resources available for investment.
Experiments to test the financial or operational efficiency of a redesigned flow may be harder to construct and evaluate in the medical group practice than in the hospital because of the smaller changes that can occur because of the nature of the environment. It may be harder to show an ROI when just a few offices in one or two specialties have been participants. Whereas the place to start in the hospital may be absolutely clear because of the dysfunctional emergency services or OR delays that are unacceptable, it is often difficult to know where and how to introduce Lean in the diffuse environment of the ambulatory practice.
Ambulatory practice is now trying to master multiple learning curves. Primary care clinicians and managers are simultaneously struggling with Medical Home certification, meaningful use, preparation for ICD-10, demands for improved customer service, basic and radical changes in payment methodology, declining revenue, increasing transparency and the demand to produce evidence of improved outcomes and better utilization of resources all while seeing staggering numbers of patients in a system financed by volume and utilization. Lean is the answer but the catch twenty-two is how do these physicians and practices find the time in the midst of all that is changing to learn how to take advantage of Lean's ability to help solve many of the problems that make each day a few steps closer to “burnout”.
Our thesis is that there is a plausible way to learn how to solve the problems that currently challenge ambulatory practice while combating the wolves at the door that threaten them. We believe that Lean success is fostered by leadership that understands the importance of a culture of respect for those that do the work and for those for whom the work is done supports. Lean leaders distribute responsibility for decisions to the point of service and practice coaching, mentoring and teaching to insure that no one must make a decision without the support they need.
Successful Lean organizations have long-term concepts of transformation even while they are addressing short-term problems that may represent problems that demand immediate attention. Successful Lean organizations understand that the tools of Lean are necessary but insufficient to create lasting transformation. A culture of quality and a commitment to the pursuit of excellence are also necessary but insufficient for success in the new economic systems that are evolving. Tools, culture and leadership must come together in ways that can be sustained before Lean can produce lasting success in the ambulatory environment.
As more and more practice is centered in the ACO model and more and more ACOs are being created by ambulatory practices, the ability to use Lean to look at enterprise wide processes that include the management of suppliers and contractors push the demands on Lean understanding past where many hospital centric delivery systems may see a need to go. Professor Chernow sees a future more dependent on improved processes of care and waste elimination and we agree. As difficult as Lean seems to be in the ambulatory environment it does succeed with sustained effort, good leadership and a consulting partner that can educate while introducing the solution to the long list of problems that are each day's challenges.
The Ice Is Out and I am Out of Town
For months I have been anticipating the melting of the last little iceberg on our lake and now it has happened when I am out of town. Those trout and bass have not tasted my flies for months and they are always hungry in the spring. I win if they lose their focus for just a split second. The fish will have to wait because this weekend I will be walking around Coconut Grove with my granddaughter and I hope that you will find someone special to take you around some block near you.
Dr. McGonigal talked about “want” power and won’t power as well as willpower. Her scheme is to achieve behavioral change you must want it. To get started willpower is necessary. To sustain the effort you must find ways to avoid or hurdle the barriers that will arise and to do that you need won’t power, as in, "I won’t quit". One big asset to "won’t power" is a companion to go walking with you.
We all want to be active. We just need a little will and some won’t.
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