Professionalism and AccountabilityThe Vital Link To Quality of Care

Christine K. Cassel, MDBuilding the Bridge: Maintaining Quality in the Face of Change

University of Texas System Clinical Safety and Effectiveness ConferenceSeptember 21, 2012

Key Aims for US Health Care

Access

Affordability

Quality

Are

all

three

possible?

NOT without physician engagement and leadership.

Knights, Knaves and Pawns

Julian Le Grand, British economist, on different underlying frameworks for social policy:

The Question: How not to undermine socially positive motivations, while affecting behavior with external incentives?

LeGrand – citizens of post-war England.

We apply these concepts to 21st Century US physicians.

Source: Jain, SH and Cassel, CK. Societal Perceptions of Physicians: Knights, Knaves or Pawns? JAMA 2010; 304(9): 1009-1010

What motivates physicians?

Financial(extrinsic)

Professionalism(intrinsic)

Regulation(extrinsic)

Knights?

Knaves?

Pawns?

WILL P4P STRATEGY WORK?

The Roles and Expectations of a Physician: Complicated and Complex

CustomerCustomer

Contractor

ConsumerConsumer

SocietySociety

CitizenCitizen

PatientPatient

Pharma, EMRs, etc.

Pharma, EMRs, etc.

Insurance/Medicare

Insurance/Medicare

Hospital, clinic,

practice

Hospital, clinic,

practice

Evidence, communityEvidence,

community

Provider

Professional

Healer Comforter

Team Leader

Scientist/ Expert

Physician

Complexity science at work

Outcome is measurable?

How to measure physician quality/performance

For payment For “meaningful use” of HIT For public reporting

• “Physician Compare”• “Consumer Reports”

For improvement strategies For licensure For Maintenance of Certification

Can these be aligned?

Results to Date Medical malpractice system

• Does not compensate most victims of medical negligence• Does not lead to better care overall

Pay-for-Performance• No consistent results for physicians• Better on metrics linked to payment, not overall quality• Missing complexity, teams, systems

Public Reporting of Scores• Data too granular, limited meaning for patients• Peer comparisons more effective for improvement

IMPACT = Professionalism and Accountability

Specialty Certification/MOC Choosing Wisely

Allergy & Immunology Anesthesiology Colon/Rectal Surgery Dermatology Emergency Medicine Family Medicine Internal Medicine (250,000) Medical Genetics Neurological Surgery Nuclear Medicine Obstetrics & Gynecology Ophthalmology Orthopedic Surgery

Otolaryngology Pathology Pediatrics Physical Medicine

& Rehabilitation Plastic Surgery Preventive Medicine Psychiatry & Neurology Radiology Surgery Thoracic Surgery Urology

24 Member BoardsCertify more than 750,000 physicians

Maintenance of Certification

Based on principles of adult learning

Designed to ensure that physicians keep current and practice high quality medicine• Employs active learning with feedback• Performance assessment and improvement

Knowledge exam every 6-10 years

Performance/knowledge self-assessment more frequently (1-3 years)

Performance Assessment Tools:

1. Internet based data collection/analysis (PIMS)

2. Registry based reporting?

3. Practice based data collection

Examples of ABIM Condition Specific PIMS

Asthma Diabetes

Cancer Screening Hepatitis C

Care of the Vulnerable Elderly HIV

Chronic Kidney Disease Hypertension

Chronic Obstructive Pulmonary Disease

Osteoporosis

Colonoscopy Preventive Cardiology

Note: Includes those completed or enrolled in MOC. A greater proportion of those who have completed IM MOC (33%) rather than enrolled in IM MOC (20%) did so because it was required for employment.

59

%

51

%

45

%

36

% 42

%

19

% 23

%

10

%

49

%

20

%

22

%

18

%

4%

61

%

42

%

34

%

30

%

25

%

4%

43

%

55

% 60

%

45

%

60

%

0%

10%

20%

30%

40%

50%

60%

70%

IM certificate (Internists)

IM certificate (Subspecialists)

SS/AQ certificate (Subspecialists)

Professionalism: Why do they do it?

Ann Intern Med 2006; 144:29-36

Studies Linking Certification/MOC and Quality15% less mortality in myocardial infarction Acad Med, 2000, Vol. 75, pp. 1193-98

40% less mortality in colon resection Surgery, 2002, Vol. 132, pp. 663-70

Higher rates of preventive service

(Mammography, A1c monitoring, flu vaccination)

JAMA, 2005, Vol. 294, pp. 473-81

Higher rates of prescription of aspirin and beta blocker after MI

JGIM, 2006, Vol. 21, pp. 238-44

Decreased risk of disciplinary action Ann Intern Med, 2008, Vol. 148, pp. 869-76

Higher scores on IM MOC associated with better Medicare quality indicators for diabetes and mammography screening

Arch Intern Med, 20008, Vol. 168 (13), pp. 1396-1403

Higher rates on quality measures from RAND's Quality Assessment Tools

Arch Intern Med, 2010, Vol. 170, pp. 1442-49

Higher rates of chronic and preventive care Health Serv Res, 2010, Vol. 45, pp. 1912-33

IM MOC scores associated with better diabetes care Acad Med, 2012, Vol. 87(2), pp. 157-63

ABIM Research Partnerships

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95100

0

2.5

5.0

7.5

10.0

12.5

15.0

17.5

20.0

Percent

Standard = 48.51

Mean = 71.23 (SD = 11.90) Reliability of Composite = .91

Decision Consistency = .98

Total number of PointsN = 957

4% of physicians did not meet the standard

Diabetes PIM Composite Measure and Standard

Opportunities for Alignment:• Health Plans• CMS – Value Based Purchasing• JCAHO• MOL

Goals:• Reduce burden of redundant measurement• Enhance clinical relevance• Foster improvement

Michael Porter’s Value Framework – Ideas Whose Time Has Come

Fundamental question – What are we trying to do?• Clinicians and other stakeholders need shared

overarching goal• Otherwise, interactions devolve into gamesmanship

with goal of protecting each stakeholders’ interests

Our shared goal should be improvement of value as defined by the outcomes that matter to patients and costs over meaningful episodes of care

• Traditional concepts of quality put focus on clinicians’ reliability in performing processes

• Value framework puts focus on patients’outcomes, and motivates problem-solving, learning, and improvement through collaboration.From Thomas H. Lee, July 28, 2012The Value Framework as a Path Forward

Atul Gawande Tactics

Recognition that medicine is so complex that no human being can be in control of everything

• The risk that obvious things can be overlooked is real

Core values of checklist• Humility

• Discipline

• Teamwork• Linguistic -- We need to use the same

language• Standardization• Allocation of roles

We ask care redesign teams to determine the pause points where we can reduce waste, harm, and chaos

From Thomas H. Lee, July 28, 2012The Value Framework as a Path Forward

John Bohmer Operations

Teams that have responsibility for improvement of value – forever

Data on outcomes and costs collected as routine part of care

Incentives (financial and otherwise) for improvement

A leader who thinks constantly about improving performance

Formal and informal interactions among team members

From Thomas H. Lee, July 28, 2012The Value Framework as a Path Forward

Daniel Pink, Drive

Motivating people who solve complex problems:•Physicians

• Diagnostic accuracy• Complex factors – patients’ priorities?• Decisions in the context of uncertainty• Payment linked targets work best for routine

repetitive work• Salary and group targets work best for complex

work

Pink, Daniel H. Drive: The Surprising Truth About What Motivates Us. New York, NY: Riverhead Books, 2009.

P4P could…

Enhance Professionalism Damage Professionalism

Keys:

• Physician trust in measures and standards

• Organizational culture

The Choosing Wisely Campaign

Choosing Wisely is an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices.

Why stewardship? Why now?

Health care expenditures are increasing at unsustainable rates

• Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011

There is waste in the health care system—some say as much as 30%

Jack Wennberg, Dartmouth Center for the Evaluative Clinical Sciences.

One third of all physicians acquiesce to patient requests for tests and procedures—even when they know they are not necessary

Campbell EG, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007; 147(11):795-802

Physician decisions account for 80% of all health care expenditures

Crosson FJ. Change the microenvironment. Modern Healthcare and The Commonwealth Fund [Internet]. 2009; Apr 27

Donald M. Berwick, MD, MPP; Andrew D. Hackbarth, MPhil

JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362

Donald M. Berwick, MD, MPP; Andrew D. Hackbarth, MPhil

JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362

From: Eliminating Waste in US Health CareFrom: Eliminating Waste in US Health Care

Call to the Profession: Where are the Health Care Cost Savings?

Deficit pressures are making cost control inevitable. It will only be successful if physicians stop looking to others to find solutions and focus on approaches that improve the care for patients with chronic illnesses.

-Ezekiel J. Emanuel, MD, PhD

Medicine's Ethical Responsibility for Health Care Reform — The Top Five List

“A Top 5 list also has the advantage that if we restrict ourselves to the most egregious causes of waste, we can demonstrate to a skeptical public that we are genuinely protecting patients’ interests and not simply ‘rationing’ health care, regardless of the benefit, for cost-cutting purposes.”

Howard Brody, MD, PhD

New England Journal of Medicine

The “Top 5 Lists”

Funded by an ABIM Foundation grant, the National Physicians Alliance conceived and piloted the concept through its Good Stewardship Working Group

Developed lists of top five activities in family medicine, internal medicine, and pediatrics where the quality of care could be improved

Published in Archives of Internal Medicine Subsequent research published

in Archives found a cost savings of more than $5 billion could be realized if the recommendations were put in to practice.

First Nine Specialty Societies Developed Lists of Five Things Patients and Physicians Should Question

• American Academy of Allergy Asthma & Immunology• American Academy of Family Physicians • American College of Cardiology • American College of Physicians• American College of Radiology• American Gastroenterological Association• American Society of Nephrology• American Society of Nuclear Cardiology• American Society of Clinical Oncology

New Societies Joining Choosing Wisely

• American Academy of Hospice and Palliative Medicine

• American Academy of Neurology• American Academy of

Ophthalmology• American Academy of Orthopaedic

Surgeons• American Academy of

Otolaryngology-Head and Neck Surgery

• American Academy of Pediatrics• American College of Obstetricians

and Gynecologists• American College of Rheumatology

• American College of Surgeons• American Geriatrics Society• American Society for Clinical

Pathology• American Society of

Echocardiography• American Urological Association• Society of Cardiovascular Computed

Tomography• Society of Hospital Medicine• Society of Nuclear Medicine and

Molecular Imaging• Society of Thoracic Surgeons• Society of Vascular Medicine

Consumer Reports

Consumer Reports is a partner in Choosing Wisely and will support the effort by creating patient-friendly materials based on the society recommendations and engaging a coalition of consumer communication partners to disseminate content and messages about appropriate use to the communities they serve.

Tools and resources can be found at: www.consumerhealthchoices.org.

Choosing Wisely Consumer Groups

AARP Alliance Health Consumer Reports Midwest Business Group on Health National Business Coalition on Health National Business Group on Health National Center for Farmworker Health National Partnership for Women and Families Pacific Business Group on Health Leapfrog Group SEIU The Wikipedia Community (through a dedicated Wikipedian-in-

Residence)

In the Media

Physician Response

From the Blogosphere…

From cardiologist John Mandrola: “That our thought leaders are now proclaiming–and social media is amplifying– the values of clinical judgment and targeted thoughtful diagnostic and therapeutic interventions represents a monumental sea change. Malcolm Gladwell writes about small yet obvious ideas that come to stick. I think Choosing Wisely has a chance. I hope it sticks like super glue.”

Internist Eric Larson noted: “The Choosing Wisely initiative is remarkable because doctors’ professional advocacy groups are making recommendations that are often counter to their own economic interests. By recognizing elimination of unnecessary care as a matter of professional ethics, medical professionals in a broad range of specialties may be signaling that we’re reaching a tipping point toward solving America’s health care cost crisis.”

Dr. James Salwitz: “At its base, the Choosing Wisely Campaign is simple. What is the data? What really helps? What hurts? How can we work together to educate everyone about the best care? However, the concept of making decisions in this way is revolutionary. Without government or insurance control, it gives information so that patients and physicians can together make quality personal decisions, while maintaining medical freedom. With this kind of initiative, we, the patients, the doctors, the people, can seize control of health care in this new Century.”

What’s Next?

Roll out of communication skills modules to help physicians talk with their patients about appropriate care (Drexel University)

Catalyze others to use the information• Office practices• Health systems• Residency and medical training programs• Additional specialty societies• Consumer Groups

Elements of Success/Potential for Impact

1. Right Message

2. Right Messengers

3. Right Time

Academic Health Centers: Value Framework and Missions

Learning and improvement are core to our cultures

To fulfill our responsibilities to our communities, we have obligation to do all we can to make health care coverage for all affordable.

• But cost reduction alone is insufficient strategic orientation

Substantial opportunities to organize and improve care for patients drawn to academic medical centers.

• Vulnerable populations

• High risk/complex patients

Themes are attractive to a generation of outstanding, idealistic students and trainees.

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From Thomas H. Lee, July 28, 2012The Value Framework as a Path Forward

The Moral Test

“This is the threshold we have now come to, but

not yet crossed: the threshold from the care we

have, to the care we need. We can do this– we

who give care. And nobody else can … The buck

has stopped; it has stopped with you.”

Don Berwick

“The Moral Test”

2011 IHI National Forum keynote

Key Aims for US Health Care

Access

Affordability

Quality

All

three

are

possible.

WITH physician engagement and leadership.