Assignment 3.2: The Lunchroom: Physician Engagement at a PCMH

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Home >Business & Finance homework help >Operations Management homework help >Assignment 3.2: The Lunchroom: Physician Engagement at a PCMH

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Case 21: The Lunchroom: Physician Engagement at a PCMH

OBJECTIVES

1. Propose interventions to improve engagement of healthcare providers in quality improvement initiatives. 2. Explain how staying current with healthcare system change can uncover opportunities for improved healthcare quality. 3. Describe how leadership can create a compelling vision for change in the processes that improve healthcare quality, efficiency, and access. 4. Analyze how healthcare staff well-being can impact organizational performance and patient care. 5. Distinguish between positive and negative responses to healthcare quality performance problems.

INTRODUCTION

The U.S. healthcare system lacks effective communication among providers and efficient coordination of patient care leading to higher costs and lower quality (Akinci & Patel, 2014). A new model of healthcare delivery, called the patient-centered medical home (PCMH), incentivizes certain innovations in health service delivery, such as coordinated care, improved access to primary care, and better management of patient chronic conditions (National Center for Quality Assurance [NCQA], 2018). The NCQA certifies PCMH model implementation in healthcare organizations, including the use of analytics to proactively identify patient care needs and the application of a physician-directed team that collectively cares for the patient (NCQA, 2018). The PCMH model of care can reduce clinician burnout and increase overall staff satisfaction (Reid, 2015).

Apollo Medical Clinic is a primary care practice with 40 providers at six locations throughout the Apollo Bay region. Although Apollo is professionally managed by healthcare administrators, the practice is jointly owned by 20 of the practicing physicians, including internal medicine doctor, Jonathan Sanders, MD. After seeing significant change in the U.S. healthcare system, Dr. Sanders perceives that he can no longer practice medicine in his ideal way, an emotional experience that follows a pattern similar to the Kübler-Ross Five Stages of Grief model of personal loss (Kübler-Ross & Kessler, 2005).

CASE SCENARIO

Denial: Reheated Fish Tacos

“None of this makes any sense,” Dr. Jonathan Sanders said to no one in particular. Sanders leaned against the counter next to the lunchroom microwave completely unaware that the smell of yesterday’s fish tacos had wafted into the Apollo Medical Clinic’s Northside Clinic location. Supposedly a refuge for all clinic staff, people rarely joined Sanders in the lunchroom. It was a large space with a round table with seating for eight. Sanders usually ate alone.

At 6 feet, 8 inches tall, people had always asked if Sanders played basketball, but he couldn’t remember how long it had been since someone had asked about his younger playing days. Or asked him anything personal, for that matter. When he began his career as a physician, Sanders spent plenty of time with his patients, educating them, taking the time to understand them, and helping improve their lives. Sanders thought he still provided his patients better care than they could get anywhere. He thought that he did not need to change the way he practiced medicine because the fundamentals had not changed— diagnosis and treatment of illness, coordination of care, and strong professional relationships with patients. These things he could control. The rest? Well, he felt like a hamster on a wheel, constantly behind, and never doing quite well enough.

“I’m sorry, Dr. Sanders. Were you talking to me? What doesn’t make sense?” asked Pam Bukowski, the director of PCMH for the large, multisite, primary care practice of which Sanders was a managing partner. Bukowski breathed through her mouth hoping that whatever Sanders was cooking didn’t cling to her clothes for the rest of the day.

“No, I wasn’t. I’m sorry,” Sanders said absentmindedly. Bukowski grabbed her bagged lunch from the refrigerator and turned to leave. “It’s just that,” Sanders continued, “the productivity-driven practice model does not work. The managers in this practice keep raising productivity targets, with the expectation that physicians will work faster and see more patients. It becomes a mentality for people like you, and you don’t question the wisdom of it. As a physician, my goal is not simply to meet productivity targets, but to take the time to get to know my patients.”

As the director of PCMH, Pam Bukowski knew better. She led the organization’s PCMH certification last year. “Actually, our practices have mostly transitioned to a PCMH model, so productivity is less important than it used to be. Sure, the fee-for-service financing still dominates, but we are moving toward value-based purchasing. I mean, the number of patients we see is still important, but more and more we are paid on the quality of care we deliver.”

“Who are you?” Sanders asked. Bukowski introduced herself again explaining that she wants the PCMH initiative to improve quality of care measures through better coordination of

care, improved access to services, and population health management. “Nice to meet you,” Sanders said. “Actually, we’ve met before. A few times.” Bukowski explained that she had visited his clinic multiple times to explain the PCMH model and her role in

enabling better use of analytics and team-based care processes. She reminded Sanders about the in-service education session in which she explained how diabetes management can be improved by reporting and team-based care.

Sanders could not understand it. He did not remember meeting Bukowski before. He did not know the terms “population health management” or “team-based care.”

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Anger: Five-Alarm Chili

“But that’s my job!” Dr. Sanders yelled with his face reddening. “As I’ve told you before, I control how I practice medicine. And yet you continue to ask me to work with all of these people. I don’t even know what they are supposed to do.”

Vanita Modi, MD, FACP, the chief medical officer of Apollo Medical Clinic, sat with Sanders at the lunchroom table. Sanders was eating his Five- Alarm Chili, a recipe that won him second place at a chili cook-off 10 years ago. (A veggie chili won first place, but Sanders dismissed that competitor because he thought that chili should not be vegetarian.) Modi ate her red lentil curry.

Modi was voted by the other partners to provide clinical leadership to the organization as the chief medical officer. Her job was to meet with the other physicians individually and discuss their performance. “Dr. Sanders, my main focus is to protect physician autonomy, and nobody dislikes productivity targets more than me, but the practice of medicine has changed. Demands required by the PCMH model mean that we have to change how we organize care delivery. Team-based care means leveraging the expertise of many individuals in our practice—case managers, patient educators, medical assistants—to deliver care so that you can provide services that only a physician with your deep expertise can provide.”

“Don’t flatter me,” Sanders scoffed. “No wonder we’re under so much financial pressure. We hire all these people we don’t need.” “I hear what you are saying, Dr. Sanders,” Modi said calmly, “but you are taking on too much by yourself. You are stressed trying to keep up.” “Damn right, I’m stressed!” “And, Dr. Sanders, here’s the thing, you just aren’t keeping up,” Modi said and then let the silence linger between them. Modi continued, “One of the ways that our payers—Medicare included—evaluate our practice is through healthcare performance measures. We became

an NCQA-certified PCMH to help us improve our quality scores. We are making progress, but we still have a long way to go. To keep things simple, I have some of the Diabetic Care Measures to review with you (Table C21.1). As you can see, compared to the national averages as the benchmark, Apollo is underperforming. On each of these measures, your scores are below the Apollo average,” Modi explained.

“Quality indices are the bane of my existence,” Sanders barked. “These measures do not reflect whether I deliver good care or not. These are simply what managers are able to extract from the health record system, and these data often turn out to be wrong,” Sanders said.

“These measures are the nationally recognized standards for diabetic care. These process measures are related to health outcomes, such as mortality and morbidity,” Modi said.

“You say you want to protect physician autonomy, but now you are asking me to spend a good part of my day collecting and reporting data on my performance?” Sanders asked irrationally.

“No, Apollo has a full-time quality director. I am asking you to let us help you improve your performance. Think about it. We can always talk about how later. Now, tell me about your chili recipe,” Modi asked in a conciliatory tone.

Bargaining: Arugula Salad With Avocado Citrus Vinaigrette

“Maybe I can make the best of a bad situation,” Sanders said to Jacki Stevens, Apollo’s quality director. Sanders was ready to make a deal with anyone. He just wanted to feel like a competent physician again. “I will start coming in earlier to tick off all the little boxes and get your records completed promptly. I will stop eating in the lunchroom. I’ll eat at my desk to work on my notes from now on.” Sanders was eating a salad and thinking about getting back into shape.

“Dr. Sanders, you don’t have to do all that. You can get high performance scores without doing all the work yourself. With Pam Bukowski’s leadership, Apollo has developed what’s called “population health management protocols.” Using the diabetes care as an example, we can help you identify all of your diabetic patients using our electronic medical records. Then, we can reach out to them to make sure they have appointments to see you to get the care they need, such as HbA1c testing and eye exams. These appointments don’t have to be very long. They can be brief patient check-ins, but then followed up by the patient educators and clinic coordinators. We now have the technology and personnel infrastructure to improve these quality scores without you bearing all the responsibility,” Stevens explained.

“Maybe there’s hope. If only I understood these electronic systems and the quality measures better, I could be a better doctor,” Sanders sighed.

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“You are a good doctor. You care about you patients. It’s just that everything’s more complicated now. We can help you improve the performance measures,” Stevens consoled.

Depression: Peanut Butter and Jelly Sandwich

“None of this matters anyway,” said Sanders as he dismissed what the chief financial officer Henry Kaplan was saying. Sanders felt resigned to performance scoring, but the whole idea just left him feeling empty.

“It matters a great deal that Apollo remains financially stable,” Kaplan said surprised at Sanders’s cynical attitude. Kaplan didn’t usually come to the Northside clinic location, but he was trying to increase his visibility in this important time of organizational change. Even for an executive responsible for the finances of the organization, it was good to build relationships with physicians over lunch. Usually, there were many staff in the breakroom chatting away. In Northside’s lunchroom, however, just Kaplan and Sanders sat at the table. Kaplan ate a fast-food burger and fries that he had grabbed on his drive over to the clinic. Sanders ate just a single peanut butter and jelly sandwich. He’s heard that some physicians in the practice were having trouble transitioning from getting paid for the number of patient visits to a model that rewarded performance on certain quality scores. Sanders certainly was having a hard time.

Kaplan tried to connect with Sanders. Kaplan admitted his uncertainty about how to transform Apollo from a fee-for-service financial model based on volume to a pay-for-performance model based on value. Kaplan asked for Sanders to provide his perspective on achieving success under these new value- based purchasing insurance contracts.

Sanders just slumped in his chair and stared at his PB&J. “I can see you’re trying to do the right thing, Henry,” Sanders said, “I just don’t see how any of this applies to me. I can’t really impact the scores. Maybe if I were younger. Not any more, though.”

Kaplan tried to motivate Sanders by saying, “I think it is important for all of us to take control over our organization’s strategy. If payers are paying us for increasing our quality scores, then we need to respond effectively. There’s good evidence that the PCMH model and value-based purchasing initiatives can improve patient outcomes. Our financial models show their promise, as well.”

Sanders sighed. “Do your financial models include all of the extra support staff we’ve hired—director of quality, director of PTSD—er, PCMH—and the patient educators?”

“Yes, they do,” Kaplan replied. “The insurance companies are paying us bonuses if we meet the healthcare quality performance benchmarks. If we don’t meet the quality standards, then we could lose money. That’s why we need everyone working toward these goals.”

“I guess it’s always been about the money,” Sanders complained to his sandwich. “I’m sorry you feel that way,” Kaplan responded, not knowing what else to say.

Acceptance: Thin Crust Margherita Pizza

“I admit that I’ve not really been myself,” Sanders said. He had been thinking about his choice of career a lot lately. “I’ve talked to other physician partners, and they feel like me.”

“I get it,” Apollo’s CEO Gina Vega said to Sanders. “I’ve talked to others, too. Many of you feel overwhelmed. I don’t blame you for being frustrated. I know that quality measures probably seem like an unnecessary nuisance defined by some anonymous person somewhere. As a physician seeing patients, you don’t think in quality measure terms,” she said. “You are just doing whatever you think is the right thing and hoping that will translate into a better performance score.”

“That’s exactly right,” Sanders said. “I think I speak for all partners when I say that we just want to be engaged in the goal setting and care redesign efforts. We don’t feel you’ve done this adequately.”

Vega heard this from the physicians at Apollo before. She led Apollo for 5 years and was the COO for a local hospital system’s physician practice for 4 years before that. She knew physicians didn’t want a motivational speech; they wanted to be understood. They didn’t necessarily want more pay or longer vacations. More than anything, physicians want to help patients.

In the lunchroom this day, Vega brought a pizza of Sanders’s choice to share with him. Sanders preferred a thin crust margherita pizza. Vega pulled a second slice from the box and asked Sanders, “Based on what you know about today’s healthcare environment, what would be the ideal way for you to practice medicine?”

“I want the PCMH model to conform to how I want to practice, as opposed to the other way around,” Sanders said. “This notion of one-size-fits all PCMH practice does not work.”

“Makes sense to me,” Vega agreed. “Ever since I first met with you, I knew that you believed that a personal physician can improve patients’ lives. These are our shared values.”

Sanders smiled and grabbed his third slice of pizza, feeling good that he was convincing Vega of his way of thinking. Vega continued, “It’s just that the changes in the health system have outstripped any physician’s ability to coordinate care and improve quality by

themselves. There’s simply too much to do—patient segmentation, quality measurement tracking, medical practice redesign, all of it. That’s why we invested in the management tools and staff to become a certified patient-centered medical home.”

“These investments mean that I have to see more patients, right?” Sanders challenged. “Not necessarily. What we need is for you to practice at the top of your license. You should be helping patients with things that need your highly trained

expertise. If others can do a job, then you need to let them,” Vega said and then paused for effect. “Frankly, to reach our goals, Apollo will need you to change your approach some.”

“See, here we go,” Sanders warned. “You know what?” Vega asked. “Your patients need you to make some changes. The Diabetes Care Measures reveal that some of the basics of medical

care can be addressed. Do we want to be the type of organization that tries to figure out if our diabetic patients can control blood pressure or take their statins?”

“Sure we do,” Sanders agreed. “Well, in that light, our current care processes need to improve. I think the change will be difficult for you, but if we get your ideas, we can put those to

work for you. Imagine how care can be better—maybe even great—for patients,” Vega said. “So you want ideas on how team-based care could lessen my workload and improve my quality scores?” Sanders asked, maybe coming to terms with

practicing medicine in the new reality.

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DISCUSSION QUESTIONS

1. Describe in what ways health system changes have impacted how Apollo Medical Clinic operates. What actions have the leadership taken to respond to these performance challenges?

2. Describe how Dr. Sanders’s approach to medical practice is consistent with the waste in the medical system?

3. Discuss to what extent Apollo Medical Clinic leadership has held Dr. Sanders accountable for his behavior and performance. How would you recommend holding Dr. Sanders accountable?

4. Describe how physician engagement should be approached recognizing that some physicians suffer from burnout and a feeling of loss of a career ideal associated with Kübler-Ross’s Five Stages of Grief.

5. Describe what principles of physician engagement in healthcare quality management the CEO Gina Vega demonstrates.

PODCAST FOR CASE 21

Listen to how experts approach the topic (you can access the podcast by following this url to Springer Publishing Company Connect™: https://connect.springerpub.com/content/book/978-0-8261-4514-7/front-matter/fmatter2)

REFERENCES

Akinci, F., & Patel, P. M. (2014). Quality improvement in healthcare delivery utilizing the patient-centered medical home model. Hospital Topics, 92(4), 96–104. doi:10.1080/00185868.2014.968493

Kübler-Ross, E., & Kessler, D. (2005). On grief and grieving: Finding the meaning of grief through the five stages of loss. New York, NY: Simon and Schuster.

National Center for Quality Assurance. (2018). Patient-centered medical home (PCMH). Retrieved from https://www.ncqa.org/programs/health-care- providers-practices/patient-centered-medical-home-pcmh

Reid, R. (2015). AHRQ transforming primary care—Transforming primary care: Evaluating the spread of group health’s medical home. Retrieved from https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/tpc-profile-reid.pdf