Best’s News Service: Move From Fee-for-Service to Population Health Management for ACOs to Succeed

Originally published on Best’s News Service by Jeff Jeffrey, Washington Bureau Manager

WASHINGTON – Physician satisfaction is a crucial part of the model for accountable care organizations, according to Dr. Debbie Zimmerman, the chief medical officer for Lumeris. She also spoke to Best’s News Service about improving clinical outcomes and physician incentives.

Q: What’s going on right now in the ACO, the accountable care organization market, and where do you think it needs to go from here?

A: What we are seeing in the market today is very interesting. We’re seeing that providers are really looking to move from volume-based practice, fee-for-service practice, to really value-based practice, really looking to get some of the expertise in population health management that maybe traditionally sat with the payer. We’re seeing providers moving, becoming more like payers, and we’re seeing payers really moving out into the provider space, and really realizing that they need to engage providers and change provider behavior if they want to achieve the goals of population health management, which we define as the Triple Aim +1™.

The Triple Aim is Don Berwick’s Triple Aim through the Institute of Healthcare Improvement. The goals of population management are to reduce per-capita cost while improving population management, improving clinical outcomes, and improving the patient experience. At Lumeris, through our experience with our own health plan, we’ve come to believe that the way to achieve that is really by engaging physicians and changing their behavior, so we’ve added a fourth thing, which is around physician satisfaction, because we really believe that we need to move them from fee-for-service to population health management if we’re going to achieve those goals.

Q: How do you go about bringing about a new system for them to adhere to?

A: It’s interesting because we really take our lessons from our own health plan, and our own health plan was started with a group of very entrepreneurial physicians who said, “We really want to do this. We really want to move to population health management.” To move to population health management, I should say, it takes changes in behavior on the physician’s side, but it also takes changes in behavior on the payer’s side. We describe a collaborative payer, so we believe that the payer needs to act differently to align with physicians, collaborate, really importantly, to put the right incentives in place. You’re saying, “What’s the motivation for them to change? Why should physicians change?” A lot of the motivation needs to be around how they are incentivized. Today, we incentivize them for volume, and guess what we get? We get volume, but we really need to align them around the Triple Aim +1™. When we do that, number one, it changes their behavior, it changes their perspective, and it really allows them to practice medicine.

Q: I understand that you have a primary care model, or the Nine C’s, as you call it. What is that, and what is the goal of this plan?

A: I’m going to take a step back and just talk about our 22 core competencies. We think of an accountable delivery system, or an accountable care organization, needs…As I said, the whole system needs to behave differently, and we’ve defined 22 core competencies for the system. The Nine C’s tie to those 22 core competencies, and they are about how a practicing physician needs to behave differently.

Those Nine C’s, I’ll tell you how they were developed, and then that might help. We look to our own experience, because we have been able to achieve Triple Aim +1™ in our own health plan by engaging physicians and changing their behavior.

We’ve been able to reduce cost by as much as 30%, been able to improve quality, and been able to be world-class in patient satisfaction, member satisfaction in that plan, and our physicians also are very engaged and happy, and rewarded, both in their enjoyment and economically.

We really look there as our model, so we went to the physicians and we interviewed physicians. We interviewed primary care physicians, hospitalists. We did a very exhaustive literature search to see what was out there in the literature around this and we came up with the Nine C’s. The first four C’s look familiar to many people because they really are the same as Barbara Starfield’s Four C’s. We realized that things were missing, so we added the additional five, and we think that they are very comprehensive.

The idea is…I always use first contact as an example. Maybe it’s the simplest one, but think about contact. Think about access to care. When you’re in the fee-for-service world as a physician, you wait until a patient shows up, and then you evaluate them. We have that playbook that says, “This is what I do every month, every week, every day in my role.” It takes work to achieve the Nine C’s, but the good news about it is any one role has a limited number of responsibilities. Together, it really is a team approach, and we talk about physician satisfaction. We see the physician is the leader of the team, but clearly, it takes a team to manage a population.

Q: You talked about changing the approach of some of these interested parties, the payer, the medical professionals, and the patients themselves as well. How do you actually get that mindset changed, or actually get them all at the table, working for the same goal?

A: I think it starts with a discussion around the value-based contract. We are really seeing that across the country, that payers are beginning to say, “I need to change the way I reimburse providers.” It’s interesting. We feel very strongly that it’s important that the payer and medical group change the way they are reimbursed, those metrics, but it’s also key that down to the individual physician that that’s changed as well. We talk a lot about internal physician compensation to change the behavior of that physician. The discussion often happens around moving to value-based contracting. We, at Lumeris, help facilitate that on both sides — the provider and the payer side — by having a framework. Everything from, “Here are the critical success factors for a collaborative payer. An aligned incentive contract that’s truly win-win, meaning we both have some skin in the game here,” is really key, but you have to make sure that the type of incentives in the contract are right that they’re balanced around the Triple Aim +1™.

You don’t want them all about improving efficiency. You have to have cost and patient experience as well, so what’s in the contract is important. It has to be measurable, it has to be credible, and then this transparency of data. You cannot manage a population and perform in a value-based contract if you don’t provide the information. Transparency of data, and then providing tools that take that data and change it into true information. That can change the way the care is delivered, and we talk about, really, two workflows. Then the other is the population workflow, often someone other than a physician, “Who’s going to help me improve the compliance with certain quality metrics, or identify the patient who has been seen and bring them in?” That’s the population workflow.

Providing information, and then we have a structure that we put in place to really encourage that conversation, so regular meetings where data is shared, regular meetings where information is discussed about performance. It happens, and we put that infrastructure in place. On the medical group side, there’s an organizational shift that needs to happen with the medical group, with the medical group leadership. Culture in leadership is really key, and having those early leaders, really important.

At the medical group level, there are also some changes that need to happen, internal physician compensation, this mentoring approach. Care management, the closer to delivery of care, is more effective, so we believe that providers should have care management. Then, there’s the physician. The physician behavior changes are really around the Nine C’s.

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