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Doctors leaving medicine spells trouble for health care. And there’s real reason for concern. A few weeks ago, the Mayo Clinic released its most recent study on physician burnout, revealing the highest rate in the survey’s 10-year history. Sixty-three percent of responding physicians reported one or more characteristics of burnout, with many noting depersonalization, an inability to maintain a work-life balance, and career dissatisfaction. The Mayo story was significant enough to be picked up by The New York Times. This worrisome trend creates a real quandary for Value-Based Care and adoption of Alternative Payment Models (APMs), since their success or failure hinges on physician engagement to transform health care.
Paradoxically, the biggest migration of physicians—often to corporate medicine—occurred in 2021. Physicians who were disillusioned over volume goals left private practices and health systems, in favor of employment in environments that appeared more financially- and technology-supportive, and that were aligned with physician goals. Those goals, it turns out, often blend well with Value-Based Care’s emphasis on care coordination and population health—taking pressure off physicians and still providing better care to patients.
Clearly, physician burnout and engagement are in conflict. You cannot hope to engage physicians who are disenchanted and no longer believe in your vision. To enable engagement, we must address the environment in which physicians are currently working.
But here’s a hidden truth that escapes many APM-transitioning providers: The role of physicians in the future will also be shaped by technology and discoveries that will fundamentally redesign health care. We are already adopting those now. While we must address current problems in the clinical workforce, we must also help physicians to shape their evolving role. These two perspectives must work together to achieve maximum benefit for physicians, patients, and APM Success.
Let’s examine the factors at play, and how to craft strategies and models to retain physicians and address their concerns. Only then can they be advocates in the transformation process.
New Data and Technology are Revolutionizing Physician Roles
Technologies like Artificial Intelligence (AI) and Genomics are both rapidly redefining health care. The world of radiology and imaging is increasingly transformed by AI, with machine eyes capable of identifying patients with future disease or risks long before any symptoms emerge. This capability is now working its way through clinical flows to primary care and specialty physicians.
Laboratory markers in conjunction with genomic or imaging data will reveal patient prognosis and speed of disease advancement. So, too, will treatment programs, combined with patient health data and genomic information, identify best clinical pathways based on clusters of characteristics and risks. These technologies will empower clinical and administrative interventions in APM entities to achieve better outcomes with more efficient use of resources. Consumers and patients are eagerly pursuing DNA testing to identify relatives and disease risk. As they become aware of their risk factors, they will also insist on integrating their data with their medical records and want to pursue in-depth discussions with physicians.
The availability of patient EHR data has done little to advance physicians’ understanding of their performance metrics. Few organizations have disbursed the comparative analytics and cost information needed to give physicians the Value-Based Care information they need. This includes metrics that show each of their patients compared to benchmarks and to all patients in similar settings, as well as the physician’s position relative to cost variation and patient outcomes across all other physicians. The implementation of value-based technology, especially if it includes episodes of care, enables a surge of performance metrics to physicians, helping them focus on improvements such as clinical interventions for their patients.
The new data and technologies, coupled with the market’s focus on value and health equity, are already profoundly impacting physicians’ roles. Accountable care assumes the existence of a physician-patient partnership, in which both engage and decide together on the course of care. This assumes that the physician is not just a clinician directing or prescribing services, but has these additional roles:
- educator;
- motivator to help patients modify lifestyle risks or adhere to treatments;
- clinical expert on research related to patient’s conditions;
- guide or navigator of the patient’s health journey;
- coordinator and participant in the patient’s care team;
- interpreter and synthesizer of patient’s health care results from all data sources (labs, imaging, AI algorithms, genomic, patient-reported data);
- participant in shared decision-making.
The future will involve a multi-level, multi-disciplinary care team to help the lead physician handle these functions—patient navigators/case managers, nurses, patient coordinators, social services, and so on.
General Strategies for Physician Engagement
Most discussions of physician engagement focus on the significant issues of communication and inclusion. These are foundational strategies that can jump-start the process of engagement; but in the end, much more is needed. Structural strategies include:
- Share performance data with physicians including scorecards, cost variation, cost metrics like readmission rates, process statistics, clinical documentation improvement queries, and clinical resource consumption.
- Involve physicians in boards, committees, and task forces to be part of decision-making.
- Develop training programs for physicians in critical areas, like motivational interviewing and shared decision-making.
- Align compensation incentives with value-based goals, so that physicians are not conflicted with meeting production goals. This sounds easier than it is. The real task is to align communication and the entire reward system toward quality, health equity, and costs. You will need to translate ideals into specific goals that your APM hopes to reach in patient care, how they will be measured, and how physicians will be rewarded for their contribution to its success.
Even these initiatives will not be enough to fully engage clinicians in an APM. Here’s why: All of them embed a hierarchy in which the physician remains an actor in the enterprise, but who is directed in the play by someone else. Their role is essential, but insufficient.
3 Models of Deeper Engagement Strategies to Help Physicians Lead
Consider deeper engagement strategies that will launch better benefits for your APM, your physicians, and patients. Take advantage of the full capacity of your physicians to engage in care redesign and build on their expertise of collaborating that was fostered by their group training.
All these models assume that you have the value-based care technology needed to create condition-based and procedure-based episodes, and that you embrace the concept of clinical care teams composed of all the physicians and other clinicians involved in a patient’s care.
1. Deploy a “Physician Activation” program.
Create a series of initiatives that, while similar to the engagement strategies listed above, are more expansive, strategic and physician-led. There are many different variations on this theme, but one of the most interesting is described in a 2020 article in Clinical Orthopaedics and Related Research, which highlights several possibilities for physician-led rethinking of clinical care delivery, organizational strategy and structure, and how data should flow to physicians. The central concept is that we should enable health care to return to a model in which physicians take ownership of outcomes, safety, patient-centeredness, and value.
2. Empower physicians through Lean Management to generate care innovation.
Lean Management concepts are focused on eliminating waste in each step of the health care process. As a physician engagement strategy, Lean Management puts physicians in charge of patient-care delivery redesign to eliminate redundancies and complications that stand in the way of efficient and effective care. Out of this process, “breakthrough” innovations are achieved by some organizations. Like Physician Activation, it also rests on physicians’ ability to use data and technology to enhance collaboration, as well as political clearance to deal with the organizational culture.
3. Use multidisciplinary pathways as a tool to engage physicians in higher value care.
Most complex care involves patients with multiple issues and more than one physician. Although care pathways could clarify the process for both patients and physicians, their use is not universal. One third of physicians surveyed indicated that they do not use pathways approved by their organizations.
Guided by episode of care data for conditions and procedures, physicians engaged in care team delivery pathways that involve not just one physician specialty would be a huge advancement. It could enable the evaluation of multiple approaches to pain, outcomes improvement programs, cost amelioration, and so on.
Multidisciplinary pathways have been undertaken in cancer care and advanced systems, but APM entities could help participating physicians engage in this approach. It’s a model that could lead to connections between community-based and university-based systems to conduct research on treatment protocols, resource sharing for patient self-management programs, and community connections for financial and social services.
Physician engagement is often misunderstood. Asked following a recent presentation, how I would engage physicians in stop-loss discussions for their ACO, my response was, “Why would I want to do that?” Instead, engage your physicians in their very best skills. I love the term used in the referenced article in Clinical Orthopaedics and Latest Research: “Top streaming—maximize clinical staff to work primarily at the top of their license.” Physicians have the expertise to work us out of the muddle of value. if you don’t act to let them do it, you will lose them to those who will.
Founded in 2002, Roji Health Intelligence guides health care systems, providers and patients on the path to better health through Solutions that help providers improve their value and succeed in Risk.
Image: Arseny Togulev