transforming the provider enterprise – the path to ......transforming the provider enterprise –...

Authors: Steve Levin, Mark J. Werner, MD, and Michael Tsia

Transforming the Provider Enterprise – The Path to Sustainability and Results


Unique Considerations for Academic Health SystemsAddressing these issues is especially complex in academic health systems due to the significant level of teaching in the ambulatory setting and the part-time clinical role of many faculty, which often reduces efficiency and limits their willingness to invest significant effort in its restructuring. The federated structure of many academic health system ambulatory practices, in which departments often manage their outpatient operations, makes it difficult to implement and enforce uniform standards of care and provider performance across the enterprise. Faculty compensation approaches, which sometimes provide minimal reward for clinical success or focus primarily on individual RVU production, also impede development of team-based models to improve economic and patient satisfaction performance.

Challenges Facing Many Provider Enterprises

Continued growth in financial support as increases in physician compensation outpace revenue growth

High provider dissatisfaction and costly burnout in some disciplines

Ineffective utilization of advanced practice providers (APPs) and other care team members, which increases costs and frustrates team members who are unable to provide patient care services for which they are trained

Significant performance variability in key areas, including productivity, provider engagement and patient satisfaction

Inefficient use of facilities, which increases operating costs and results in sub-optimal capital deployment

Insufficient integration and coordination of care across disciplines, with implications for patient service and care

As health systems seek to address COVID-19’s economic and patient care challenges, success increasingly hinges on the ability to create high-performing provider enterprises. The current situation is no longer sustainable. Transformation of those enterprises is required to remain successful. The challenges highlighted below show that many provider enterprises are structurally and financially unsound, a situation which has become untenable in the current environment. The remainder of this paper describes how health systems can enhance patient-centered care while reducing their investment per physician and improving operating margin by 20-30 percent or more.

Introduction What Needs to Change A Potential Model Forward The Path to Sustainability and Results


What Needs to ChangeThe provider enterprise must be fundamentally redesigned to achieve required financial and operational improvements. Redesign should start by focusing the care model on the types of patients the enterprise expects to serve and adapting delivery to the needs of those patients. Incremental improvements to business models will not achieve the required degree of change. The entire enterprise needs to be reimagined to achieve a set of core principles and performance requirements which inform the design of key processes. These principles should include:

Primary care models should be tailored to care for the unique patient cohorts that a practice expects to serve, typically including groups such as healthy, rising risk, high risk, and medically complex and frail patients. The role of physicians, APPs and other care team members should be tailored to each cohort, as illustrated in the figure below; most practices do not currently customize their approaches to reflect the different patients served.

Integrated, interdisciplinary specialty teams should be organized to care for a shared group of patients based on specific conditions and diseases.

Physician time and effort should be focused on providing care that requires their unique expertise. For PCPs, this means the majority of physician time is invested on creating the plan of care for medically or diagnostically complex patients, rather than on sick visits for healthy or medically stable patients.

The roles and composition of teams supporting these physicians should be structured to fully utilize the unique skills of each clinician and to best care for each patient cohort served by the practice.

Care Team Staffing Tailored to Patient Cohorts

HEALTHY

RELATIVE CLINICIA

N IN

VOLVEM

ENT

RISING RISK HIGH RISK MEDICALLY COMPLEX & FRAIL

Non Provider Clinicians

Physicians

APPs



Care should be delivered through multiple modalities (virtual care, in-person physician office visit, off-campus imaging center, home or other remote monitoring, etc.) to meet the unique needs and preferences of each patient. As our telehealth adoption tracker shows, The COVID-19 crisis has accelerated the deployment and adoption of virtual care. It will also emphasize a broader long-term trend of care migrating to the most accessible and affordable setting, such as ASCs, home and congregational care facilities. Providers will need to reconfigure care models to adapt to these modality shifts.

Ambulatory care facilities should be located, sized and staffed to enable effective utilization, in light of changing care modalities, team compositions and economics.

Integrated data and information should be used to optimize both care and operational efficiency.

COVID-19 Accelerates Shift to Alternative Modes of Care

Clinic

In-Patient

Home

Virtual

ASC

A Potential Model ForwardThe approach to designing and implementing new care models based on these principles will vary for each specialty. The section below describes how these principles can be used to redesign primary care and orthopedic care (as an illustrative procedural discipline).

ILLUSTR

ATIVE RELATIVE VOLU

ME

PRE-COVID COVID POST-INITIAL-SURGE* LONG-TERM

Orthopedic Care

Primary Care


*Markets may experience multiple surges and post-surge periods

https://reports.chartis.com/telehealth_trends_and_implications/


Most primary care practices operate with a ratio of well under one APP per physician, with limited customization to patient

cohort and underutilization of APP capabilities. This care team typically manages the health for approximately 1,600–2,000 patients. The graphic below illustrates one potential example of a fundamentally different model in which each physician works with a team of two APPs and two RNs and shifts a meaningful portion of visits to virtual care, enabling the team to manage a panel

size of approximately 5,500–6,000 patients. This team composition and other attributes, such as more streamlined

business functions, enable the practice to serve significantly more patients at a much lower cost per patient.

The practice’s costs per patient under the practice’s management could drop from what is typically around $425 per year to $275,

even after including the increased costs for a larger team working with each physician.

Increased Number of Lives 5,500+ panel per physician

Expanded Care Team Deployment APPs see 66% of patients

Expanded Care Modalities 40% of encounters are virtual

Improved Financial Performance Costs per patient under the

practice’s management reduced by 35%

Team Mix Tailored to Patient Cohort

1Physician

2RNs

2APPs

3 MA/LPNs

2.5 Other Care

Team Members

Illustrative Primary Care Model Transformation

FUTURE STATE PROVIDER CARE TEAM

...CAN ENABLE...

Primary Care

a reduction of about

percent,35



For procedural disciplines such as orthopedics, clinic visits consume a notable portion of the physician’s time in traditional practices. Many health systems and proceduralists recognize that

meaningfully reducing outpatient clinic time to increase time in the procedural suite can be economically attractive and allow more patients to be served. However, few have realized

that goal. Now is an opportune time to make meaningful progress toward that objective, particularly given patient and physician concerns about unnecessary office visits. At one major academic health center, a physician leader estimated that there was an average of 10 office visits per surgical procedure, with the orthopedic surgeon handling most of those visits. The health system was able to successfully transition to a model where the surgeon provides roughly four office visits per procedure, with the remaining visits managed by

other care team members such as APPs or non-operative physicians, which dramatically raises physician productivity and revenues. In the end, surgeons should strive to have new

patient case conversion rates closer to 60–70 percent, which reflects both the team care model described and assertive use of clinical pathways embedded in robust referral management

utilizing non-surgical physician colleagues.

30–70 percent of all visits for wellness, stable chronic illness or minor illness are conducted virtually

25 percent of (or half of in-person) visits are conducted by non-physician clinicians within CMS regulations

Greater use of community partnerships to improve and maintain health status and address social determinants

Primary care teams prioritize and address social and behavioral needs before pursuing clinical interventions

Physicians spend the majority of their time serving medically or diagnostically complex patients, both in-person and virtually

Technology enabled on-demand care is available 24/7 and in-person care is available for extended hours 6+ days per week

Home/facility-based care for medically complex patients shifts to extensivists, home health and virtual modalities

There is intensified focus on self-management, effective tools and interventions used to engage consumers in their care

Provider education and decision support are used to reinforce specialty referral criteria

This significantly increased productivity is enabled by a number of changes in how primary care is delivered, including:

The optimal application of these principles will need to be developed for each provider situation based on the patients they serve and other unique attributes of their situation.

Orthopedic Care



REFOCUSED PHYSICIAN EFFORTUp to 40% increase in surgery capacity

EXPANDED CARE TEAM DEPLOYMENTAPPs see 60-70% of office visits

ENHANCED REFERRAL MANAGEMENT RNs direct 45% of cases

IMPROVED FINANCIAL PERFORMANCECosts reduced by 15-20%

Team Mix Tailored by Patient Type

Screening

1Physician

.5RNs

.5APPs

1-1.5 MA/LPNs

2 PTs, Trainers

Orthotists, Others

Illustrative Orthopedic Specialty Care Transformation

FUTURE STATE PROVIDER CARE TEAM

...CAN ENABLE...

Similar to the example offered, a new orthopedic care model would be to have non-operative APPs manage more office visits, transitioning two of every three visits currently managed by surgeons to APPs. This approach could free physician time, enabling an increase in surgical time of up to 40 percent. RNs would be used to better screen referred patients and direct cases to the most appropriate provider, again reducing unnecessary office visits for physicians. The model would also better integrate and leverage other members of the care team (physical therapists, athletic trainers, etc.) to improve medical management when appropriate, improving outcomes and patient satisfaction.

The model would also better

integrate and leverage other

members of the care team

(physical therapists, athletic

trainers, etc.) to improve medical

management when appropriate,

improving outcomes and

patient satisfaction.



A robust referral management process is used to ensure patients are seen by the most appropriate provider

Encounters are distributed to the right provider through comprehensive clinical guidelines, which match patient needs with the unique skills of each clinician

The care team is optimally utilized, increasing surgeon’s operative capacity

Physicians develop the plan of care and perform procedures, shifting pre- and/or post-op visits to APPs

Highly protocolized clinical guidelines are established and used to direct care

Self-directed virtual patient education is mandatory for patients

Non-operative clinicians augment surgeons

Clearly established protocols for PCP co-management are communicated and implemented

Relationships (referral or direct access) with specialty and general urgent care are clearly defined

This significant increase in surgeon productivity is enabled by a number of care model changes, including:

The reduced provider expense, paired with some reduction in nonclinical support staff due to higher efficiency from IT-enabled business functions, leads to a 15–20 percent reduction in the cost of care delivery per patient. Put differently, with the same number of providers in the practice, increased physician time in the OR rather than the clinic will create considerable capacity for new patient growth, enabling significant improvements in the numbers of patients served and the practice’s financial performance.

The Path to Sustainability and ResultsThe care team transformation described above may feel difficult to implement due to the magnitude of change entailed; however, health systems can take manageable steps now to quickly realize meaningful returns while building the capacity for continued change. Specific actions to begin the journey include:

01 02 03 04 05IDENTIFY TEST SCALE AUTOMATE ENGAGE



Identify a few specialties where you can successfully design and implement a new model. Successful pilots help the health system incubate and adapt changes while also creating physician champions who become advocates for change. Future practices are more likely to adopt change if their colleagues are supportive. The pilots should include a mix of primary care and specialty care practices.

Rapidly test application of the models described above and their impact within your environment. Determine key measures of success (margin, physician engagement, patient satisfaction, new patient growth, etc.) and establish analysis to quickly assess and refine performance.

Scale-up infrastructure needed to implement new care models in additional specialties. Once the initial proofs-of-concepts are launched, evaluate the elasticity of APP and care team member resources throughout the organization and, if needed, plan to rapidly recruit. In addition, the technology platform needed may take time to develop and should be designed immediately.

Determine opportunities to automate business functions and enable patient self-service to streamline operations. Empowering patients to perform tasks such as self-scheduling not only improves patient satisfaction but also enables labor cost savings and enables care team members to focus all or most of their time on patient care rather than support for business functions.

Engage physician leadership by communicating the case for change, defining their role in designing new models and explaining the implications for compensation. This approach can position physicians as owner-operators accountable for performance and leading change. Physician compensation plans should also be redesigned and reoriented around the success metrics of the new care model.

01IDENTIFY

02TEST

03SCALE

04AUTOMATE

05ENGAGE

Care model transformation has been on the to-do list of many health systems for some time. The instability of the current environment provides an opportunity to make changes which might be resisted in more stable periods. Many health system leaders have commented on their organization’s willingness to make significant changes over the past several months—changes that would have met resistance in the past, which slowed their adoption. Now is the time to act given the changes required from the harsh economic realities caused by COVID-19. More importantly, patients, providers and healthcare workers all recognize that change can help improve outcomes, value and experience for everyone. This is the time to bring provider enterprise transformation off the to-do list and make it part of the new reality.



About the Authors

Steve LevinDirector, Academic Health System Segment [email protected]

Steve Levin is a Director with The Chartis Group. He has over 35 years of experience as a management consultant to the healthcare industry. He is a nationally recognized expert in a number of areas pertaining to academic health system organization, governance, funds flow and strategy. He also has significant expertise with clinical program development, mergers and affiliations, and academic strategy. He has worked closely with the leadership of numerous universities and their academic health systems to help define their strategic direction and to help the leadership team to implement that direction over several years.

Mark J. Werner, MDDirector, Clinical Consulting and Chartis Physician Leadership [email protected]

Mark J. Werner, MD, CPE, FAAPL is a Director with The Chartis Group leading Clinical Consulting, the Chartis Physician Leadership Institute and our work with the physician segment. In this role, Dr. Werner leads clinical consulting efforts across the firm focusing on: enterprise physician alignment and leadership, medical group performance, adoption and change management, performance innovation, population health, provider-payor relationships and the translation of strategy into clinical operations.

Michael [email protected]

Michael Tsia is a Principal with The Chartis Group. He serves as an advisor to executive leaders at leading academic health centers, children’s hospitals and community integrated delivery networks on numerous topics, including enterprise strategic and financial planning, provider workforce planning, payor-provider partnerships, and organizational economic alignment/funds flow. Mr. Tsia has been a leader in management consulting with The Chartis Group for over 10 years and regularly speaks on a variety of healthcare strategic planning topics. He also serves on the Board of Directors for Methodist Hospital of Southern California.

© 2020 The Chartis Group, LLC. All rights reserved. This content draws on the research and experience of Chartis consultants and other sources. It is for general information purposes only and should not be used as a substitute for consultation with professional advisors.

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About The Chartis Group

The Chartis Group® (Chartis) provides comprehensive advisory services and analytics to the healthcare industry. With an unparalleled depth of expertise in strategic planning, performance excellence, informatics and technology, and health analytics, Chartis helps leading academic medical centers, integrated delivery networks, children’s hospitals and healthcare service organizations achieve transformative results. Chartis has offices in Atlanta, Boston, Chicago, New York, Minneapolis and San Francisco. For more information, visit www.chartis.com.

transforming the provider enterprise – the path to ......transforming the provider enterprise –...

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