There’s no getting around it. Disruption in referrals under new Value-Based Health Care programs will upset both primary care and specialty practices under any change scenario. Physicians with historical relationships will undoubtedly resent an edict to redirect referrals, if they don’t understand or believe comparative data on cost and quality. On the other side of the equation, physicians who accept that aligning referrals with outcome data is part of being in an ACO will object if they see that referrals are driven, instead, by physician employment status.
Every participant in an ACO must eventually accept that achieving shared savings will require the enterprise to embrace a new approach to cost effective care—one that will be guided by the numbers. So, how to include both qualitative and quantitative analysis in that effort?
We suggested in Part 1 a process that was transparent and included both primary care and specialty physicians in review and collaboration over outcome data. But that’s no easy task. Physicians have been “talked to” with data for a long time. If the process is to be meaningful and effective, physicians need to buy in because they recognize the value of outcome data for themselves and their patients—not because they are coerced.
Here are three tactics that can provide this kind of value-added benefit—and still meet organizational goals:
Tactic 1: Physician Engagement Measures
Develop quality measures by which physicians will contribute insight, perspectives and beliefs about their patients’ outcomes and trends. The measure should provide structured data responses for physicians, so that the results can be calculated across a large physician base. Using Performance Measurement technology like a Registry, you can capture such data from physicians in response to good, poor or intransigent outcomes.
The purpose of creating a measure to collect data is twofold. First, you may be able to identify variables in practice style or patients that are affecting outcomes, which you can then test using Population Health initiatives. Second, asking physicians to contribute and be accountable, rather than passively review analytics, is the first step in an engagement process.
Using physician engagement as a Performance Measure is particularly apt because it directly measures how responsive a physician is to reviewing patient outcomes. It is an even more powerful approach to ensure that specialty referrals are directed to those who are highly engaged in the organization’s goal.
Tactic 2: Team-Based Competitive Population Health
Develop Population Health initiatives that foster coordinated processes to improve outcomes, using teams to introduce competition and create more focus. This can include initiatives that focus on patient population subsets using physician teams that include both primary and specialty components.
For example, a Population Health Registry can provide the means to track a small group of patients with poorly managed and trended intermediate outcomes in diabetes. The Registry will assign the patients to the teams based on prior status. Each team will then undertake a series of activities that share information and establish a coordinated care process. These could include:
- Review and incorporation of feedback for each patient in the group from both primary and specialist;
- Establishment of planned interventions for the subset, to test solutions that will get the patients on the path to improvement;
- Incorporation of regular feedback for all physicians managing the same patient through the Registry;
- Sharing of patient results and comparison with other teams.
With analytics, the comparative contribution of providers to outcomes improvement will be very evident. Identifying which teams of primaries and specialists “work well” together to achieve a common goal will be a useful factor to establish the direction of referrals.
Tactic 3: Appreciative Inquiry Process with Population Health
Appreciative Inquiry helps physicians focus on positive outcome improvements and what has made a difference. Population Health technology facilitates the identification of patients that have improved over time, and physicians can be asked to provide feedback on interventions as well as patient conditions, belief systems and other factors that led to the improvement. The data should be shared with all physicians through Population Health tools. This serves as the basis for testing those same interventions in practices or patient populations that have not experienced the same improvement.
Appreciative Inquiry taps practices’ pride in the care they provide. Referrals will be based on outcomes, but also on an understanding of those outcomes. This is best achieved by understanding both the good as well as the bad.
ACO success will depend on more complex factors than employment or cost and quality scores. Understanding the factors underlying data on performance will be important for ACOs attempting to achieve long-term savings. This can only be realized through better coordination of care, more commitment from providers and improvement in patient outcomes.
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