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FRONTIERS
of
H e a l th
S e rvic es
Ma na gement
Breaking Down Clinical
Silos: Enhancing Care
Coordination
Feature articles by
Michele M. Molden, FACHE; Charles L. Brown III;
and Bryan E. Griffith
William B. Leaver, FACHE
Coming in the Fall Issue of Frontiers
The Moral Compass for Healthcare Leaders
Feature articles by Ruth W. Brinkley, FACHE, and
John J. Donnellan Jr., FACHE
Commentaries by
Nicholas Wolter
M. Jane Mohler
Anna Marie Hajek
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FRONTIERS
o f H e a lt h S e r v i c e s M a n a g e m e n t
Frontiers of Health Services Management is committed to providing our readers with com­pelling, ­in-depth
features and commentaries that are of current importance to the practice of health s­ ervices management by
drawing on the expertise of the best practitioners and scholars.
Editorial
1 Margar et F. S chulte, FAC H E
Features
At the Heart of Integration: Aligning Physicians and Administrators to Create New Value
3 Mi c hele M. Molden, FACH E; C h a r les L. Br own I I I ; a n d
Bryan E. Gr iffit h
Volume to Value
17 Wi lliam B. Leaver, FAC HE
Collaboration Across Clinical Silos
36 M. Jane Mohler
Breaking Down Clinical Silos in Healthcare
45 A nna Mar ie Hajek
Philips Healthcare
This issue is made possible in part by the support of Philips Healthcare, an ACHE
Premier Corporate Partner. ACHE would like to thank Philips Healthcare for its
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ACHE and the editorial staff of ACHE publications reserve full editorial control over the content of ACHE publications.
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c o n t e n t s
Commentaries
Physician-Led Models of Accountability and Value: Observations on
Payment Policy and Culture
28 Ni c holas Wolt er
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Frontiers of Health Services Management
Maureen C. Glass, FACHE, CAE, Publisher, Foundation of the American College of Healthcare Executives, Chicago, IL
Margaret F. Schulte, DBA, FACHE, Editor, Health Administration Press, Chicago, IL
Joyce A. Dunne, Managing Editor, Health Administration Press, Chicago, IL
Cepheus Edmondson, Layout Editor, Health Administration Press, Chicago, IL
editorial board
Richard F. Afable, MD, Chief Executive Officer, Hoag Memorial Hospital Presbyterian, Newport Beach, CA
Brian Barnett, FACHE, Executive Director, Arkansas Specialty Orthopaedics, Little Rock, AR
Georgia Casciato, FACHE, President, Georgia Casciato Healthcare Consulting, IPM Healthcare, Downers Grove, IL
Patrick A. Charmel, FACHE, President/CEO, Griffin Health Services, Derby, CT
CAPT Peter E. Kopacz, FACHE, Executive Director, Naval Medical Center, Portsmouth, VA
Mimi P. Lowi-Young, FACHE, CEO, Alzheimer Society of Canada, Toronto
Brian S. Madison, FACHE, President, The HCS Group, Plymouth, MI
Sean McCallister, Operations Administrator, Providence Health and Services Alaska, Anchorage, AK
Robert A. Minkin, FACHE, Senior Vice President, The Camden Group, El Segundo, CA
Brian R. Poplin, DHA, FACHE, President/COO, Medical Staffing Network, Boca Raton, FL
Amy R. Richards, FACHE, Director, Business Planning Services, VHA Pennsylvania Inc., Pittsburgh, PA
Janice L. Samberg, FACHE, Patient Care Manager, Gentive/Odyssey Hospice, St. Louis, MO
Kimberly A. Smith, Partner and Co-director Eastern Region, Witt/Kieffer, Burlington, MA
Ebony M. Weston, FACHE, Director, Women’s & Preventive Health Services, University Health System, San Antonio, TX
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Editorial
Si l o s a re a part of everyday scenery here in the rural Midwest, where I live
Margaret F. Schulte, DBA, FACHE, is adjunct instructor in the master of science in
medical informatics program at Northwestern University in Chicago and instructor in
the health policy and administration program at The Pennsylvania State University in
University Park.
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E D I TOR I A L
amid stretches of farmland. The structures rise up from the fields and in the
little towns, standing tall and sturdy and impenetrable as they keep the wheat,
corn, and soybeans separated, protected, and dry. The crops are, of course, commodities, and each protective silo is dedicated to the crop it stores. Therein lies
the analogy to healthcare in the United States, where our systems are really an
amalgam of many silos of clinical care.
The image of the grain silo so common in the countryside, when applied
to healthcare delivery, conjures up a picture of each clinical department, each
specialty, and each service department standing alone, doing what they do expertly: diagnosing and treating the unique symptoms of patients entering the
silo in search of the specialty service performed there. As implied by the analogy, these silos of care do not support or encourage the involvement of other
specialties to address the patient’s comorbidities; the whole patient; or often,
for that matter, the patient’s voice and preferences. These silo walls were built
over many decades. They can be powerfully immune to change.
Despite the inherent rigidity of silos, the forces of transformation continue to gain strength, driven by patients, by economics, and by a society that
expects high quality and safety in care at a manageable cost. Systems of care
are gradually transitioning to structures in which “silos” are being replaced by
“teams,” and the provider-centric focus of the past is giving way to a patientcentric focus for the future. In this transformed model, teams will come together in horizontal and vertical organizational structures in which the patient
is at the axis point. In that future, the people, technology, and processes of care
will function as a team, with each member knowing her unique role and relying on the expertise of all team members. In this space, clear communication
flows to and between all team members. Just as with a winning sports team, all
care team participants function as a unit characterized by a diverse set of skills.
Feature authors Michele M. Molden, FACHE; Charles L. Brown III, MD;
and Bryan E. Griffith observe that the current US healthcare system “is incapa-
Ma r g a re t F. Sc hult e , FAC H E • 1
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ble of providing the type of integrated and coordinated care across a continuum
that drives incremental value for patients and healthcare organizations.” In the
second feature article, William B. Leaver, FACHE, speaks to this in the context
of managing chronic disease, a major driver of healthcare costs. He points out
that “Our silos of care—from physician to hospital to home care or long-term
care, all with different payment models and incentives—were preventing appropriate coordination of chronic disease.”
However, as Molden and her colleagues observe, “To truly transform the
US healthcare system, greater alignment must occur between hospitals and
physicians through clinical integration.” Leaver is in full agreement. He emphasizes that the key to coordinating care “is to begin with the patient and
the physician.” The patient expects to know that his doctor has a voice in the
health system at which he is being treated, that the physician is poised to be
the patient’s advocate in the huge enterprise that is the local health system. The
patient also expects that he, as a patient and consumer, will be heard and will
be viewed in the totality of his personhood, not as just a medical problem, when
he presents for medical services. The relationship between the hospital and
the physician is key in the transformational process, so the two parties must
together design and build a relationship within an organizational structure in
which physicians may influence the care environment’s transformation.
Each of the feature authors and the commentators are consistent in pointing out that the three key ingredients for a successful transformation of healthcare delivery are (1) delivering value for the patient through a patient-centered
model of healthcare delivery, (2) placing priority on the hospital–physician relationship, and (3) transitioning from the fee-for-service payment system to one
based on value, not volume.
The silos may not come down easily, but they will eventually succumb to
demands that we place on ourselves, and that our patients place on us, for better quality of service balanced with lower costs.
The editor of Frontiers would like to hear from you! If you have comments
or thoughts about this or any issue of Frontiers, please share them by
e-mailing Margaret Schulte at [email protected].
2 • f ro ntier s o f h ea lt h s e rvic e s m a na g e me nt 29 :4
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At the Heart of Integration: Aligning
Physicians and Administrators to
Create New Value
M ichele M. M olden , FACHE; C harles L.
B rown III; and B ryan E. G riffith
Sum m a r y • Because of its ability to create real incremental value for patients
Michele M. Molden, FACHE, is executive vice president and chief transformation officer at
Piedmont Healthcare in Atlanta; Charles L. Brown III, MD, FACC, FSCAI, is chief of cardiovascular services at Piedmont Healthcare and chief medical officer at Piedmont Heart in Atlanta;
and Bryan E. Griffith is area director for Piedmont Heart Surgery in Atlanta.
f e a t u r e
and providers, physician–hospital integration will continue to play a major role
in transforming the way healthcare is delivered. Integration is more than a transaction, and without developing the right culture, new integrated organizations
will struggle to transform their current model of care. Confronted with regulatory and specialty-specific environmental forces, cardiovascular physicians have
integrated with health systems at a higher rate than other specialties have. In
2007, Piedmont Healthcare launched Piedmont Heart as the first integrated
cardiovascular care delivery program affiliated with a community healthcare system in greater Atlanta. Piedmont Healthcare had successfully brought together
hospitals and cardiovascular physicians in an organizational structure that allowed for the right culture, resulting in true integration and patient-centered
care. Today, Piedmont Heart is one of the largest physician groups in the United
States focused on delivering high-quality outcomes, aligning multidisciplinary
cardiovascular initiatives, and allowing for smart, strategic growth.
It has taken Piedmont Heart nearly five years to create new, incremental
value from its center-of-excellence organizational structure, clinical pathways
development, and Patient First program. Piedmont Heart had the advantage of
starting earlier than many other physician–hospital integrated structures. As
US healthcare moves from an industry driven by volume to one focused on
value, it is organizations like Piedmont Heart that continue to drive smart integration forward and focus on innovation, despite potential disruption, that will
be successful.
Michele M. Molden, FACHE; Charles L. Brown III; and Bryan E. Griffith • 3
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T
oday’s US healthcare system is complicated by silos that segment payers,
hospitals, and physicians. It is incapable
of providing the type of integrated and
coordinated care across a continuum that
drives incremental value for patients and
healthcare organizations. To truly transform the US healthcare system, greater
alignment must occur between hospitals
and physicians through clinical integration. Change of any significance is almost
always disruptive to the system it affects,
as the components of that system are
forced to alter current proThe US healthcare system’s cesses. Physician–hospital
multi-silo culture will not integration is no exception,
go quietly into the night, and even with strong evidence confirming its benand breaking the bonds efit, transformative inteof this traditional and
gration can test the resolve
hierarchical design will not of all parties involved.
Piedmont Healthcare
be an easy task.
(PHC), a not-for-profit,
integrated care delivery health system
in Georgia, recognized the potential to
increase value through physician–hospital
integration, specifically in cardiovascular
(CV) services. In 2007, PHC created the
Piedmont Heart Institute, now known
as Piedmont Heart, an integrated entity
based on a foundation of total alignment
between physicians and hospitals. Initially
forced to overcome numerous challenges,
Piedmont Heart now serves as evidence
that progressive innovation may initially
be disruptive but ultimately delivers
greater value to a health system and the
patients it serves, and it is likely necessary to transform current models of care.
The importance of breaking down silos
in healthcare is broadly accepted, and the
development of Piedmont Heart addresses
only one type of silo. The US healthcare
system’s multi-silo culture will not go qui-
etly into the night, and breaking the bonds
of this traditional and hierarchical design
will not be an easy task.
PHC views the path to transforming
healthcare as two evolutionary curves.
The first curve, which we refer to as
Curve A, represents the rise and eventual decline of an industry that makes no
adjustments to address changing external
forces and stakeholder demands. Curve
A in healthcare is based on volume and
is provider-centric, silo structured, and
driven by fee-for-service payment. To
remain viable, healthcare organizations
must move to a new curve, a new way of
operating—Curve B. This is the healthcare industry’s new model of success,
based on value and integration that is patient- and population-centric and driven
by global or bundled payments for the
outcomes achieved.
The gap between curves is significant.
Healthcare organizations must learn to
optimize performance in the current
environment (Curve A) while preparing to
move to a new, innovative way of operating
(Curve B). A powerful vehicle for change
that spans curves A and B is physician–
hospital integration. Integration is necessary in both curves and may be a prerequisite to transform healthcare delivery from
Curve A to Curve B.
Physician–Hospital
Integration
The term integration suggests a true alignment of vision and goals between multiple
parties. Because organizational transformation requires an effectively integrated
structure and culture, successful integration is much more than just a transaction between hospitals and physicians.
MedAxiom (2013) describes the integration process as having three steps:
4 • f ro ntier s o f h ea lt h s e rvic e s m a na g e me nt 29 :4
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1. Transaction
2. Cultural integration
3. Creating value
Significant value from integration is
gained only after the vision and goals of
the integrated parties are aligned and
a favorable and directional culture is
established.
Background
PHC’s Path to Integration
Overview
In 2005, the Atlanta metropolitan CV
service market was highly fragmented and
competitive. At least three major health
systems, including PHC, competed for
CV market share. Multiple CV physician
groups provided care across Atlanta, but
few had significant geographic reach and
even fewer were true CV multispecialty
f e a t u r e
The integration of CV physicians into hospitals and health systems has occurred as a
result of national attention focused on the
increased prevalence and resulting cost
burden of CV disease in the United States.
To lower costs, the Centers for Medicare
& Medicaid Services significantly reduced
Medicare reimbursement for CV imaging services. This reduction triggered the
migration of CV physicians from the independent group practice model to hospitalbased arrangements. A recent MedAxiom
(2013) survey found a 253 percent increase
in the percentage of CV physicians who integrated with hospitals between the spring
of 2010 and the fall of 2012. At 53 percent
of all respondents surveyed, more CV physicians are now integrated with hospitals
than are not, with an additional 14 percent
reporting that they are in the process of
integrating.
practices. Physician leaders from three
prominent Atlanta-area CV groups began
discussing potential integration strategies between their groups and between
the groups and a health system partner.
These physicians recognized that the other
physician practices were not the enemy
and, by working together, the combined
group could create a more sustainable and
more highly differentiated clinical practice
that could achieve regional or national
regard—a goal that would be extremely
difficult to achieve as independent practices. Representatives of the three independent CV groups approached the then
chief executive of PHC and told him they
wanted to merge into a single group and
were looking for the right health system
partner. This visionary executive immediately let them know that PHC should be
their choice.
PHC had a long history of positive
physician relations through physicians’ inclusion on PHC’s governing boards and in
other positions of influence. The organization considered its current and future relationship with physicians to be paramount
and was prepared to offer employment to
the interested parties. The strategy was
a high-risk gamble because of the financial investment and the potential impact
it could have on organizational culture,
but it also could produce great reward for
patients and the health system.
After much consideration and due
diligence, in mid-2007 the PHC board of
directors approved the partnership, and
the new entity was formally established in
October 2007. As part of the agreement,
PHC acquired three CV practices, thereby
employing 62 cardiologists and 650 staff,
and committed ongoing capital to expand
CV services at its flagship tertiary hospital in Atlanta, Piedmont Atlanta Hospital
Michele M. Molden, FACHE; Charles L. Brown III; and Bryan E. Griffith • 5
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(PAH). The partnership represented an
opportunity to create a world-class heart
program for the region by instituting clinical excellence and a culture that promoted
innovation, research, and teaching.
Piedmont Heart
Piedmont Heart is a physician-managed
and physician-governed entity. The decision to adopt this physician-driven structure, and its corresponding demand for
physician accountability, marked the beginning of the innovative decision making
that propelled PHC and Piedmont Heart
through the transaction and cultural stages
Piedmont Heart
Piedmont Heart’s vision is to be “a destination program for comprehensive CV care as
the premier quality provider of heart and
vascular services across greater Atlanta and
throughout the Southeast.” Piedmont
Heart strives to serve as a care model that
is based on a solid foundation of total
alignment between hospitals and physicians. Today, while many CV centers across
the country are experiencing declining
volumes, Piedmont Heart is growing at a
higher rate than the market in almost every
category. Since its establishment in 2007,
Piedmont Heart has become one of the
largest integrated CV programs in the
United States, with more than 90 physicians and 99 physician extenders, providing
a robust continuum of care for patients and
their families via PHC’s five acute care
hospitals and 25 statewide offices. Piedmont Heart physician specialties include
general, invasive, and interventional
cardiology; structural and valvular medicine; electrophysiology; cardiac surgery;
vascular surgery; thoracic surgery; and
sleep medicine.
of integration defined by MedAxiom and
allowed the organization to create value
early in its evolution.
As an independent entity within PHC,
Piedmont Heart is responsible for comprehensive CV service line management,
including strategic planning, CV physician
recruitment, education, research, clinic operations, finance and accounting, human
resources, the revenue cycle, quality
performance, philanthropy, and education.
PHC hospitals and Piedmont Heart share
responsibility for hospital-based CV service line operations. As Piedmont Heart’s
CV-related role within PHC expanded,
it came to optimize capital investment,
prevent the unnecessary duplication of
services, and avoid unproductive internal
competition.
Embracing Disruptive Innovation
The integration journey from Piedmont
Heart’s inception to today was far from
smooth. One of the first priorities for Piedmont Heart, and fundamental to its ability
to move at a rapid pace, was to create a
new Piedmont Heart culture, unique from
the cultures of its founding physician
groups and, in many ways, from the rest
of PHC. The act of creating that culture
was intentional and powerful, and the
new culture was characterized by speed in
execution.
While the rest of PHC found the upstart Piedmont Heart to be brash, reckless,
and disrespectful of the traditions and
rules of the old culture, Piedmont Heart
saw the established organization as overly
hierarchical, bureaucratic, risk averse, and
slow to make decisions. Such conflict is
expected in organizations that undergo
disruptive innovation of this nature. After
much dialogue, board interaction, conflict management, and some downright
6 • f ro ntier s o f h ea lt h s e r vic e s ma na g e m e nt 29 :4
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5/17/13 3:34 PM
nity to create a sustainable care integration
model that, once further defined, would
serve as a model of clinical integration for
other physician specialties.
Developing a positive new culture and
integrating a physician-driven entity with
hospitals can easily disrupt “the way we’ve
always done it.” Care must be taken to
ensure a newly created culture is not a
counterculture that disrupts the old and
new businesses to the extent that neither
is successful. Once conflict is resolved
internally, the value produced through
innovative integration models will transform the current, unsustainable healthcare
model and help shift providers to Curve B,
where patients and other stakeholders
experience greater value.
Innovations
That Create Value
Three areas in which Piedmont Heart is
already creating incremental value are its
center-of-excellence organizational structure, clinical pathways development, and
Patient First program.
Adopting the
Center-of-Excellence Model
Piedmont Heart’s first major innovation
was a patient-centric center-of-excellence
(COE) design. Rather than organize by
functional departments, like a traditional
hospital organizational structure, Piedmont Heart physicians organized themselves along a continuum of patient care
by disease state or condition. Piedmont
Heart’s six COEs, shown as vertical bars in
Exhibit 1, are Arrhythmia, Advanced Heart
Failure, Coronary Therapeutics, General
and Preventive Cardiology, Structural and
Valvular Heart Disease, and Vascular.
Because of the matrix relationships inherent in Exhibit 1, Piedmont Heart has input
f e a t u r e
uncomfortable years, the partnership
between the hospitals and physicians, and
often between physician and physician,
grew.
Piedmont Heart assumed responsibility for strategic and some operational CV
decision making from PHC hospitals,
including care processes, service rationalization, capital allocation, and physician recruitment. While decision-making
responsibility shifted, income statement
accountability between the hospitals and
Piedmont Heart did not always correspond, resulting in a disconnect between
revenue generation and the expenses
necessary to drive that revenue.
This is a critical issue to resolve in
the integration process. If the expenses
required to operate the physician group
are kept separate from the revenues they
drive in the hospitals, there is a tendency
to characterize these expenses as “losses.”
Instead, the expense to employ the physicians and manage the enterprise should
be viewed as an investment and, when aggregated with the corresponding revenue,
can result in greater benefit for the whole
than was possible before integration. Unless the expenses and the revenues are
calculated together, the organization may
not recognize the true value of the integrated enterprise. This lack of recognition
leads physicians to feel that their contributions are not valued and others to incorrectly view the integrated organization as a
financial burden.
PHC’s acceptance of Piedmont Heart’s
role has increased as the system itself has
focused more on integration and “systemness.” Many stakeholders, who did not see
it before, now view the development of
Piedmont Heart as a best practice for system service line development. For PHC,
forming Piedmont Heart was an opportu-
Michele M. Molden, FACHE; Charles L. Brown III; and Bryan E. Griffith • 7
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into most areas of PHC’s CV operations
and administration. Every COE meets
monthly to further cultural and operational integration in addition to collaborating on clinical and research priorities
and tactical clinical issues. Each is led by
a COE chief, who is accountable to a chief
over all COEs. When physicians join Piedmont Heart, they select a “major” COE on
which to focus based on individual interests, subspecialty training, and patient
population served. Under certain circumstances, physicians may also participate
in a “minor” COE. In a move toward even
more comprehensive integration, physician extenders have recently been asked to
form similar COEs.
COEs create a focused factory within
a factory that results in real subspecialty
depth of expertise and care standardization. For example, a physician who
chooses to specialize in general cardiology is no longer allowed to perform even
occasional interventions; similarly, an
interventionist may no longer perform the
occasional electrophysiology procedure.
Furthermore, Piedmont Heart requires
physicians to obtain subspecialty board
certification to work in a major or minor
COE.
Reducing variation in the type of care
provided typically increases the quality of
care and results in repeatability and reliability. At Piedmont Heart, moving away
from “cardiac multispecialists” is necessary because the current state of complexity in medicine dictates that no one person
can be an expert in many areas, and a shift
toward specialization is operationally possible because of the organization’s scope
and scale.
The COE structure brought physicians
of similar specialties together and asked
them to work as a team to identify and
implement best practices. It took them
away from the comfort of their legacy
Exhibit 1 Piedmont Heart COE and Organizational Matrix Model
Organizational structures and accountabilities
Policies and procedures
Risk, control, compliance
Business
strategy
Governance
Philanthropy, research,
innovation, marketing, education
PRIME
Finance, budgeting,
accounting
KPIs/metrics
Reporting definition
Performance scorecards/dashboards
Decision support
Information technology
Facilities/equipment
Finance
Performance
monitoring
Business
intelligence
Infrastructure
Tactical
Analytics applications and tool portfolio
Information access and delivery methods
Operations
Vascular
Structural and Valvular Heart Disease
Quality
General and Preventive Cardiology
Coronary Therapeutics
Advanced Heart Failure
Arrhythmia
Quality assurance
Peer review
Care evaluation
PHI department operations
Department clinical policies, HR, staffing,
model of care, patient flow, clinical quality
Strategic
Corporate strategy and alignment to goals
Organizational readiness
Executive commitment and sponsorship
Centers of Excellence
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5/17/13 3:34 PM
physician group practice, and by focusing
on the COE, they moved from a physicianpreferred decision-making paradigm to
physician team–driven decision making.
The COE structure was originally designed
to get similar-specialty physicians talking
and actively engaged. Once those relationships were formed, Piedmont Heart had to
decide
• what the groups should be talking
about,
• how their efforts should be aligned
with both Piedmont Heart and PHC
organizational goals,
• how to support the groups, and
• how to measure performance.
Defining and Developing
Clinical Pathways
Piedmont Heart defines clinical pathways
as comprehensive care management tools
used across the inpatient and outpatient
continuum of care. More than order sets,
clinical pathways are meant to improve
quality, reduce variation, and ensure
appropriate care is provided efficiently.
Essentially, a clinical pathway is a process
flow diagram created from evidence-based
guidelines and organizational standards
or best practices for how to treat specific
disease states.
PHC previously viewed clinical pathway development as order set development, and it measured compliance to
clinical pathways by compliance to order
set utilization. With the hiring of a director of clinical transformation in July 2011,
Piedmont Heart began to take a broader
view of what pathways were, how they
were developed, and the value they could
provide. Piedmont Heart’s work to develop
pathways started with identifying variations in care processes within the COEs
and then moved on to COE subcategories.
Each COE treats multiple diseases, which
have numerous possible approaches to
treatment, and potentially as many opinions on how that treatment should proceed as physicians in the COE. To help
organize and prioritize pathway opportunities, Piedmont Heart developed a “trunk
and branch” structure, which works as
follows: The trunk relates to a general disease state oriented to a COE, such as heart
failure. From that trunk, branches of the
disease subcategories multiply until finally
f e a t u r e
Piedmont Heart’s administration now
provides each COE with specific goals
related to quality, education, definition of
models and processes of care, and strategic growth. These goals include creating
and implementing clinical pathways and
furthering cultural integration and clinical
education.
Piedmont Heart COEs have created
new value for patients and the organization. For example, physicians within the
Electrophysiology COE had once practiced
eight different ways to dress a wound
after an implant procedure. Variation was
present not only between legacy physician groups but also within those groups.
Through the COE approach of review of
evidence-based literature, group discussion, and discernment, there is now one
best practice approach.
Other organizations interested in
adopting a similar structure should be
realistic about the time needed to establish this type of structure and the necessary commitment of the physicians to
achieve success. It is also important to
select the right COE chief and identify the
right focus areas early on so that COEs
do not spend time developing lower-value
solutions.
Michele M. Molden, FACHE; Charles L. Brown III; and Bryan E. Griffith • 9
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terminating in a detailed pathway, such
as a left ventricular assist device versus
cardiac resynchronization therapy device
pathway. Because each pathway takes time
and resources to develop, building an entire tree—trunk and branches—may take
two or more years.
While processes were initially identified as variable on the subjective basis of
perception, the approach quickly evolved
to one that used objective data to identify
the processes that actually suffered the
most variation. Process variation is now
measured by comparing
Piedmont Heart expects physician-to-physician
average resource utilizato see significant cost
tion for a defined patient
reductions next year
population. Through this
because of pathway
analysis, Piedmont Heart
implementation that
identified specific care proreduces variation in care. cesses with significant variation that would benefit
from implementing a standard pathway.
Once consensus was reached on a
general plan for developing Piedmont
Heart pathways, the organization spent
approximately four months collecting,
analyzing, and interpreting data on patient
care variation; recruiting Piedmont Heart
leaders and COE chiefs as champions; and
scripting pathway development meetings
and messaging to all stakeholders. COE
chiefs presented the concept of pathways
to their respective COEs, the process
by which to develop them, and specific
pathway opportunities for that COE. Then,
with multidisciplinary support from every
clinical and nonclinical group that was
part of the selected care continuum, the
COEs began the difficult work of crafting detailed pathways. Each Piedmont
Heart pathway development effort follows
a structured and consistent approach of
planning, analysis, design, development,
education, implementation, and monitoring quality and outcomes. Pathways are
iterative, and both their content and the
method for developing them are continually adjusted and improved.
The first pathways Piedmont Heart
addressed were those with clear clinical
variation and engaged COE members who
were energized about and open to standardizing care to drive increased value.
Quickly evident through this work was the
need for physician and care team member
education about what pathway development is and is not—particularly that it is
not order set development. Order sets are
helpful to implement a pathway through
technology but simply serve as a way to
direct care through various stages of the
pathway. As true wins have been achieved,
the pathway development program has
experienced increased buy-in within
Piedmont Heart and within other PHC
entities.
Piedmont Heart expects to have developed at least seven CV pathways by
July 2013. Examples of pathways already
developed include same-day discharge
(percutaneous coronary intervention),
therapeutic hypothermia management for
cardiac arrest patients, lipid management,
and management of atrial fibrillation in
cardiac surgery patients (Exhibit 2). Pathway work to date has focused on development; implementation is planned for the
next fiscal year.
Depending on the process affected,
pathways improve quality, cost, and revenue measures. Piedmont Heart expects
to see significant cost reductions next year
because of pathway implementation that
reduces variation in care. Pathways are
also expected to improve a variety of different quality measures that will be tracked
separately. Once the pathways are imple-
10 • f ro ntier s o f he a lt h s e rvic e s m a na g e me nt 29 :4
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5/17/13 3:34 PM
 
 
 
 
 
 
 
 Cardioversion
 
 
 
 
 
 
 
 
 
o 
1. 
2. 
3. 
4. 
5. 
6. 
7. 
OR
Exhibit 2 Piedmont Heart Management of Atrial Fibrillation in Cardiac Surgery Patients—Clinical Pathway
f e a t u r e
Michele M. Molden, FACHE; Charles L. Brown III; and Bryan E. Griffith • 11
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mented, compliance and success will be
gauged by specific quality and efficiency
measures, customized to each pathway.
After PHC finishes implementing a system-wide electronic health record, pathway
compliance will be centrally monitored so
that variations from established pathways
can be real-time teaching opportunities.
Piedmont Heart pathway development
has been difficult and required significant
resources. Efforts to standardize care
processes can meet major roadblocks if
an organization has not achieved a high
level of physician engageWe attribute Piedmont
ment and collaboration,
Heart’s pathway success which are hallmarks of an
to the physician–hospital integrated culture capable
of creating value. We atintegration model
tribute Piedmont Heart’s
combined with strong
pathway success to the
physician collaboration and physician–hospital integrathe management support tion model combined with
strong physician collaborato execute initiatives.
tion and the management
support to execute initiatives. To sustain
current accomplishments and allow for
expansion, the Piedmont Heart pathway
development team will soon add dedicated financial, case management, and
information services resources. Pathway
development is a noteworthy milestone
in Piedmont Heart’s evolution because it
underscores the commitment of the physicians who came from different legacy
physician groups to work together toward
agreement on the single best way to care
for a patient.
Piedmont Heart’s journey to create
clinical pathways continues today. The
level of detail each pathway requires and
the multitude of possible branches connected to a trunk provide ongoing opportunity to add patient value. Most current
pathways have been specifically developed
for PAH, the largest and most complex of
the hospitals within PHC. In the future,
Piedmont Heart pathway champions will
work with all PHC hospitals to review applicable pathways, adjust them if necessary
to accommodate fundamental and acceptable process variations, and support their
implementation and maintenance. Piedmont Heart’s work on CV pathways is now
considered best practice within PHC, and
other clinical service lines are actively considering how to develop similar programs.
Putting Patients First
Most CV physicians divide their time
among making clinic visits, performing
office- and hospital-based procedures,
reviewing diagnostic study results, and
rounding on inpatients. That fragmented
approach preserves the individual physician’s “ownership” of the patient, but it
often results in inefficient time usage and
does not encourage physicians to “play to
their strengths” and work as an integrated
team.
Piedmont Heart recognized that the
quality of CV services at PAH, which
made up at least 40 percent of hospital
volume, could be improved, in part by
minimizing the chances that physicians’
attention would be diluted by juggling
multiple responsibilities. Additional
focus was needed to improve patient
outcomes, patient satisfaction, physician
extender and other CV clinical team
satisfaction, and the management of care
throughout an acute episode. Toward this
end, Piedmont Heart’s leaders sought
to determine whether many physicians
should continue doing many different
activities, often during the same day, or if
a few physicians should specialize in their
area of greatest skill and focus their day
on a single type of patient care activity.
12 • f ro ntier s o f h e a lt h s e r vic e s ma na g e m e nt 29 :4
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2012. For such a drastic change in the way
hospital CV care is delivered, from conception to implementation, the decision and
development cycle time was very short.
Patient First was successful because, as an
integrated organization, Piedmont Heart
was designed to allow quick and nimble
decision making wherein all major stakeholders are at the table with common
goals—uncharacteristic of a large institution that is vertically oriented.
Developing Patient First was a complex, patient-centric physician scheduling
exercise. A sample schedule appears in
Exhibit 3. Each week the schedule rotates.
If they are not included in the Patient First
weekly schedule, physicians are assigned
to the clinic, operating or procedure
rooms, diagnostic study reading schedule,
or time off. This scheduling process helps
Piedmont Heart utilize and balance its
resources to avoid the potential conflict of
multiple physicians trying to perform the
same activity on the same day when physical capacity does not allow it and patient
volume does not demand it.
Taking into consideration a matrix of
resources, necessary tasks, and projected
volume, Piedmont Heart’s Patient First
program creates weekly physician schedules for Medical Cardiology, Interventional
Cardiology, Electrophysiology, Cardiac
Critical Care, and CV Imaging services.
Each week, for the entire week, CV physicians are assigned to one of these services
on the basis of his or her Piedmont Heart
COE affiliation. Patient First physician
scheduling is managed by a team of physicians and administrators who create the
schedule based on physician preference
and patient need. The scheduling team
posts each schedule at least six months in
advance and serves as the point of contact
to manage scheduling request changes
f e a t u r e
After careful evaluation, Piedmont
Heart’s leaders recognized the need
to redesign the way care was provided
in the hospital to put the patient first.
The approach was to rationalize how
physicians spend their time caring for
patients through a coordinated medical
care delivery team model. The resulting
program, called Patient First, requires
detailed coordination between Piedmont
Heart and PAH, the physicians’ buy-in
to the idea of trusting their partners to
manage Piedmont Heart patients as a
team, and establishment of clear roles and
responsibilities for the entire medical care
team. A physician may not always care for
“her” patient, but she retains the patient’s
overall care management. Each member
of the clinical team had to understand his
or her role in the care of a patient, with
the CV physician serving as the “captain of
the ship.” Patient First sought to improve
CV patient care by decreasing inpatient
average length of stay, decreasing inpatient readmission rates, decreasing admission time for CV patients from the
emergency department, increasing patient
satisfaction, and decreasing the rate of
no-response-on-admit order status. All
of these measures contribute to delivering a seamless continuum of high-quality
patient care.
The Patient First program—probably
the most dramatic change implemented
through Piedmont Heart—provides
dedicated CV coverage around the clock
for PAH, similar to the way a CV hospitalist program would operate. Patient
First physicians follow a master schedule
that assigns them to specific CV service
responsibilities in weekly rotations. First
conceived in late 2010, Patient First ran
multiple pilots starting in April 2011
before formally going live in January
Michele M. Molden, FACHE; Charles L. Brown III; and Bryan E. Griffith • 13
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5/17/13 3:34 PM
and adjust physician schedules when patient volume increases or decreases.
By changing the fundamental approach to a week’s worth of work, Piedmont Heart allows a physician to focus
attention on one or two activities rather
than trying to manage multiple uncoordinated tasks related to a patient’s care.
The physicians on the hospital units
are available to answer questions from
patients and families, support the nursing staff, and schedule and coordinate
tests and discharges, thereby facilitating
an efficient process of care
A willingness to explore and reducing unnecessary waiting or holding
disruptive innovation
generally experienced by
that may not fit within
patients during inpatient
today’s model of care will stays.
become a key characteristic
Transformative care
models
often expand
of successful healthcare
the role of nonphysician
organizations in the next
providers to reduce costs
five years.
and increase efficiency
and access. Given the
need for better coordination across the
continuum of care, potentially significant
physician shortages in the coming years,
demographic trends including the aging
of the population, and potentially many
more Americans gaining access to health
coverage through health reform, physician
extenders must be used to the full extent of
their license. In Piedmont Heart’s Patient
First program, physician extenders play a
key role in enhancing coordination between multidisciplinary clinicians and support personnel. They contribute to more
efficient and more standardized processes,
patient education, and family communication. Physician extenders are critical to the
success of Patient First and are scheduled
to overlap with a physician to ensure continuity of care for the patient and effective
handoffs between physician rotations.
The Patient First program ensures
patient- and family-centered care and
improves ease of access. Physicians find
value in the program because it improves
teamwork and communication. It creates
shared accountability for CV patients yet
preserves the personal patient–physician
relationship. PAH has been very pleased
with Patient First results and the service it
provides to its patients and its clinicians,
in part because having a CV physician
available when needed aids timely decision making and education. Because of
its success, Piedmont Heart will continue
to optimize and expand the Patient First
program. Opportunities to optimize the
current operation include the following:
Exhibit 3 Sample Patient First Rotation*
Week 1
M
MD 1 (75%)
Tu
W
Week 2
Th
Hospital rotation
MD 2 (75%)
Hospital rotation
MD 3 (50%)
Hospital rotation
MD 4 (50%)
F
Clinic
MD 5 (50%)
Clinic Reading
Tu
Clinic
Clinic
W
Week 3
Th
Clinic Clinic
F
M
Clinic Reading
Clinic Reading Reading
Clinic
Clinic
MD 7 (25%)
Clinic
Clinic
Clinic
Clinic Reading
MD 8 (25%) Reading
Clinic
Clinic Reading
Clinic
F
M
Tu
W
Th
F
Hospital rotation
Clinic
Clinic
Clinic
Clinic
Hospital rotation
Clinic Reading
Clinic
Clinic Reading
Clinic Reading Clinic
Clinic
Week 4
Th
Clinic Clinic Reading
Clinic
Clinic
Hospital rotation
Clinic
W
Hospital rotation
Hospital rotation
Reading
Hospital rotation
Tu
Clinic
Hospital rotation
Clinic Reading
MD 6 (50%)
*Actual
M
Clinic Clinic Reading
Hospital rotation
Clinic Reading
Hospital rotation
Clinic Reading
Hospital rotation
Reading
Hospital rotation
Clinic Reading Reading
Clinic
Clinic
Clinic
Clinic
Clinic Reading
Reading
Clinic
Clinic Reading
Clinic
Clinic
Clinic Reading
Clinic Reading
Clinic
Clinic
Hospital rotation
Hospital rotation
Clinic
Clinic Reading
Clinic
rotations are determined by physician preference and patient need.
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• Expanding the program to weekends
• Improving the handoffs between
weekly care teams from one week to
the next
• Reducing the variations in care
processes within and between the
weekly teams
• Incorporating Piedmont Heart’s
cardiac, vascular, and thoracic surgeons
in a modified Patient First weekly
schedule
Potential for
Further Integration
To date, integration at Piedmont Heart
has focused on hospital-to-CV-physician,
physician-to-physician within the same
CV specialty, and physician-to-physician
across CV specialties. Because of the comorbidities of many CV patients and the
need for a team approach to care driven
by the extensive specialization in medicine today, Piedmont Heart physicians
will need to better and more formally
collaborate and coordinate with non-CV
physicians outside Piedmont Heart. Clini-
Lessons Learned
and Conclusion
A willingness to explore disruptive innovation that may not fit within today’s model
of care will become a key characteristic
of successful healthcare organizations in
the next five years. Innovative solutions to
healthcare’s biggest and toughest challenges are not always workable or broadly
accepted in today’s infrastructure, and
even when successfully implemented they
can be highly disruptive. At PHC, the real
disruptive innovation of Piedmont Heart
was putting physicians in charge of managing the clinical enterprise within the
walls of the hospital. The direct involvement of physicians in all aspects of patient care, along with their administrative
counterparts, improves quality and drives
increased value. As physicians become
“owners” of the process and outcomes,
they make better clinical and administrative decisions than nonclinical administrators could possibly conceive or imple-
f e a t u r e
Beyond PAH, the Patient First program
can be expanded in a modified form to
the other PHC hospitals for acute care
and, eventually, to Piedmont Heart clinics
across the health system to improve care
along the continuum. Creating a program
like Patient First requires an evolved and
highly integrated physician–hospital relationship. A Patient First–type structure in
a traditional practice model would significantly challenge that organization, so it is
important not to attempt change of this
nature until the culture of the integration
effort has some tensile strength. Effective
communication and change management
are also required to support an initiative of
this magnitude.
cal pathway development is a multidisciplinary exercise that, as it expands, not
only will require physicians from other
specialties to assist in creating pathways
but also, through standard processes and
increased communication, will better align
the various specialties. Piedmont Heart
will soon be partnering with other PHC
specialties in joint program development,
such as Erectile Dysfunction with Urology,
Lung Cancer Screening with Piedmont
Heart’s Thoracic Surgery practice, and
Women’s Heart Health Clinic with Obstetrics/Gynecology. Finally, as PHC focuses
more on population health, Piedmont
Heart will help to develop better vehicles
to transition patients along the continuum
of care and manage their health outside
an acute care setting.
Michele M. Molden, FACHE; Charles L. Brown III; and Bryan E. Griffith • 15
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5/17/13 3:34 PM
ment. By continuing to push innovative
initiatives, such as patient-centric clinical
integration, forward, even when it causes
disruption, value will be created that was
never possible in the old model of care.
In retrospect, the innovative disruption
of Piedmont Heart might have been better mitigated if we had known how much
disruption would be introduced. Piedmont
Heart could have practiced better conflict
management, more quickly broached
difficult communication, and established
a better set of expected outcomes at the
start so that expectations
The direct involvement of regarding authority and
physicians in all aspects accountability would have
been better managed.
of patient care, along
Overall, the experience
with their administrative of Piedmont Heart has
counterparts, improves
enlightened PHC to the
quality and drives increased power and potential of
alignment with physicians.
value.
It has produced a far better
clinical product than was delivered prior to
integration, as evidenced by better quality
and service outcomes. Healthgrades has
ranked Piedmont Atlanta Hospital as Best
in Atlanta for overall cardiac care, cardiac
surgery, and coronary intervention for
two consecutive years. Piedmont Heart is
proud to have more cardiologists ranked
Top in the Nation by U.S. News & World
Report than any other hospital in Atlanta.
Physician participation in improving
clinical processes and structuring care
delivery has truly transformed both the traditional physician practice and the hospital
operation. In the near future, PHC will be
taking what it has learned in CV and applying it to other clinical service lines.
Time is the integration regulator. Relationships cannot be built and innovations
conceived and implemented overnight.
They take time. It has taken Piedmont
Heart nearly five years to create new, incremental value from its COE structure, clinical pathways, and Patient First program.
While Piedmont Heart had the advantage
of starting earlier than many other physician–hospital integrated structures, the
organizations that keep pushing integration forward in a thoughtful way and continue to seek innovation, despite potential
disruption, will be successful.
Reference
MedAxiom. 2013. “2013 Hospital Integration
Survey.” Published January 10. www
.medaxiom.com/main/surveys/.
16 • f ro ntier s o f h e a lt h s e rvic e s m a na g e me nt 29 :4
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Volume to Value
W illiam B. L eaver , FACHE
Sum m a r y • Traditional fee-for-service medicine has put physicians on an
William B. Leaver, FACHE, is president and chief executive officer of UnityPoint Health,
formerly Iowa Health System, in Des Moines.
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Frontiers_29_4Summer.indd 17
f e a t u r e
unsustainable treadmill of volume that escalates healthcare costs regardless of
the quality of care they provide. This article shares the experience of UnityPoint
Health (formerly Iowa Health System) in designing and implementing patientcentered, physician-led, coordinated care as a building block for transforming
the delivery system. Keys to the effort’s success include aligning physicians,
hospitals, and home care delivery in terms of organizational goals and having
the ability to gather, analyze, and share data to manage population health.
On April 16, 2013, Iowa Health System became UnityPoint Health, dedicated to transforming the delivery of care through a coordinated system that
offers regional, organized systems of care in most of our markets in Iowa
and Illinois. These capabilities allowed the system to enter into value-based
accountable care organization contracts that cover more than 220,000 lives.
The transition ultimately will lead to population health–driven approaches in
which compensation will be based on the management of specific populations
or chronic diseases over a specified period. As increased value from care coordination becomes clear, the external environment will demand this better
system, and patients will expect it.
Wil l ia m B . L e ave r , FAC H E • 17
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Moving from
Volume to Value
Traditional approaches to contain costs
by reducing unit prices only encourage providers to increase units. Changing the environment from an episodic,
fragmented, hospital-centric care delivery
system to one that is patient centered and
led by physicians shifts the focus of care
provision from volume to quality outcomes. An environment characterized by
coordinated care achieves better outcomes
and lowers the costs of care. Coordinated
care not only increases
An environment
value but also provides
characterized by
strategic channels for
coordinated care achieves reimbursement.
Early in 2008,
better outcomes and
UnityPoint Health (forlowers the costs of care. merly Iowa Health System)
Coordinated care not only publicly recognized that
increases value but also healthcare in the United
States, as it was currently
provides strategic channels being delivered, would
for reimbursement.
not be sustainable. A
delivery system that was
fragmented, episode focused, and paid on
volume could not address both an increase
in Medicare beneficiaries and doubledigit health cost inflation without putting
programs, patients, and the federal budget
in jeopardy.
At that time, the following characterized healthcare delivery:
• Fee-for-service medicine had driven
primary care physicians onto a
treadmill of volume, which, by
definition, does not place the individual
patient at the center of care.
• Patients were being shuttled between
silos of care (or sites of care) without
coordination between clinicians.
• A small portion of our patients—those
with chronic health conditions—
consumed half of our existing
resources.
As one of the nation’s largest nonprofit
healthcare systems, we chose not to adopt a
“wait and see” approach regarding healthcare reform. Rather, we actively forged solutions and created innovative approaches to
transforming care delivery and payment
reform. With the support of our board of
directors, we embarked on our integration initiative, knowing that this approach
would entail some risk and that we might
ultimately create a better delivery model
without a payment system to compensate it.
As we are all too aware, our current
health system is complex and difficult
for most to understand, even for those
who work within it. We believed that
transformation to a better delivery system
depended on changing the payment structure. Intrinsically, fee-for-service payment,
which is reimbursed regardless of the
quality of outcome achieved, will continue
to escalate costs. In the past, public and
private payers tried to control costs by
focusing on the unit price paid for the
services delivered. The natural economic
reaction of providers, when their unit
price is steady or decreasing, is to produce
more units of service to maintain their
revenue. For a primary care physician, this
shift triggers a treadmill effect: Each year,
primary care physicians must see more
patients each day to maintain revenue to
support their practice.
This economic cycle must be broken to
stabilize or curb the costs of healthcare. To
do so, the system has to move away from
volume and toward value as a basis for
payment.
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UnityPoint Health Map
Where to Begin?
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About UnityPoint Health
UnityPoint Health is the fifth largest
nondenominational health system in the
United States. Following are some statistics
for our system as of this writing:
• 15 senior affiliate hospitals
• 200 physician clinics in 88
communities
• 14 community network hospitals
• 7 home care locations
• 4 total accredited colleges of nursing
and of allied professions
• 3,124 licensed beds and 2,421 staffed
beds
• 127,812 admissions (in 2012)
• 15,310 births (in 2012)
• 3.1 million patient visits (average per
year)
• 24,176 employees
• $2.8 billion operating revenue
f e a t u r e
Our senior leaders began the discussion
by considering how to position UnityPoint
Health for a future environment that
would not reward volume or, at the very
least, would pay a lot less for that volume.
We focused first on how to ease the treadmill effect on our primary care physicians.
We determined what specific factors
were driving the high cost of care beyond
a fee-for-service payment model. Certainly,
waste and duplication of services were at
play, but also at issue was a lack of coordination of care for an individual patient between clinicians and between silos of care.
A national study released in January
2012 by the Agency for Healthcare Research and Quality indicated that a small
number of patients—those with chronic
disease—account for 50 percent or more
of total healthcare spending (Cohen and
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Yu 2012). Our silos of care—from physician to hospital to home care or long-term
care, all with different payment models
and incentives—were preventing appropriate coordination of chronic disease.
So the future began to crystalize: If we
could manage or coordinate care, produce a better outcome and lower cost (i.e.,
better value), and get paid to do that, we
might have the means to break free of the
unsustainable economic cycle we faced.
Historically, UnityPoint Health has
been a hospital-centric system, not unlike
others across the country. To effectively
coordinate care, we needed to begin with
the patient and physician. Although the
effective management of chronic disease
depends on the patient complying with his
treatment regimen, including diet, medication, and exercise, managing chronic
disease is a process complicated by multiple factors. Our fundamental thesis is,
if we increase the potential for interaction
between the patient and the physician (or
her staff)—the number of touches between them—we likely increase the probability of compliance and, hence, a better
outcome. Lower cost is likely to follow.
In 2008, we changed our vision statement to a simple yet forceful phrase, “Best
outcome for every patient every time,”
which served as a catalyst for declaring our
intention to move from a hospital-centric
system to a patient-centered, physiciandriven system in 2009. The vision also
was the building block on which we
transformed our delivery system in that it
conveyed the following:
• Our purpose for operating is clinically
based.
• Our intention is to uniformly provide
the highest level of care to our patients.
• Our patients and the work of our
clinicians are more important than our
finances and buildings.
Exhibit 1 UnityPoint Health Road Map
Physician Alignment
Create Value
Demonstrate Value
Value-Based Contracting
Source: UnityPoint Health. Used with permission.
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Bringing the Care Together
Beginning in 2010, we pursued the creation of a single physician enterprise across
all of our regions, thereby bringing together
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Frontiers_29_4Summer.indd 21
our disparate employed groups. The rationale was simple: First, our care coordination brand would not be successful without
a single physician brand. Second, we could
not become physician driven if multiple
voices were trying to influence our direction. Finally, we would not transform our
delivery model unless a singular physician
influencer, along with other clinicians, was
involved in that transformation.
The work involved in bringing our physicians together could consume a separate
article. Suffice it to say, 18 months of discussion, debate, and persuasion ultimately
helped us to determine a shared vision
for future care delivery and to recognize
that we would either succeed together or
not at all. The development of our shared
vision was helped by our decision to create the Physician Leadership Academy.
Collaborating with the American College
of Physician Executives, we developed a
curriculum to help physicians learn and
master leadership skills. It afforded us a
great opportunity for deep discussion with
our physicians about our future environment and a sense of what it would take to
be successful. In addition, it strengthened
our collective sense that we were in this
together. Our first leadership class graduated in July 2011, and we are about to commence our third. The importance of the
Academy in helping coalesce our physicians cannot be overstated.
We recognize this physician enterprise
as a senior affiliate, equivalent to our
hospital enterprises. Its CEO has a seat at
the system executive table and on our parent board. Each region is treated equally
regardless of size or revenue. Inviting this
level of involvement sent a powerful, critical message to our physicians.
We also have the advantage in most of
our regions of operating a single, strong
f e a t u r e
We then built a road map (Exhibit 1)
to achieve our strategic intent, in which
physician alignment was the key to our
ability to create value, that is, to coordinate
care. We launched our initiative with an
impressive array of capabilities already in
place: great hospitals, excellent physicians,
a single home care company covering most
of our regions, our own fiber-optic network
connecting all of our employed physician
clinics and hospitals, a call center staffed by
nurses around the clock, and a common IT
platform throughout our hospitals and clinics. Although our employed physician base
(most of whom were primary care physicians) numbered about 700, those physicians operated in nine groups, each with
its own billing system and management
infrastructure. In short, we had many of the
elements necessary for a different delivery
model, but they were not integrated, were
not focused on the same objectives, or did
not operate under the same incentives.
The road map helped crystalize the path
to a future delivery model and an understanding that care coordination could not
occur without physician alignment. It also
built on our assumption that patients will
first look to their physician for guidance,
counsel, and answers. So if we desired to
manage care across the continuum or between silos, we had to put the patient and
the physician at the center and build coordination capability around them. Because
we realized that opportunities to demonstrate value or value-based contracting
would appear at any time and not necessarily when we were completely ready, the
road map was not assumed to be linear.
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home care presence. Three years ago, we
brought our home care services under
a single operating entity with common
management and a common focus. This
shift helped drive home the concept of
care integration so that we now can offer a
regional organized system of care in most
of our markets. Home care is a vital element in our care delivery model. The key
is integrating all of our care coordinating
capabilities, including home care, into the
primary care office.
Recognizing that
We define value as the best
chronic disease patients
clinical outcome combined most likely present with
multiple comorbidities, we
with the best patient
experience at an affordable established the Advanced
Medical Team (AMT)
price. We want the patient program in six of our eight
to see the value that care regions to help physicians
manage these complex
coordination brings.
cases. Led by care navigators, the teams work with the referring
physicians, home care services, and community resources to deliver appropriate
care in less acute settings than the emergency department (ED). The AMT program focused initially on treating patients
suffering from chronic obstructive pulmonary disease, congestive heart failure, and
the aftermath of heart attack. Now that the
program is being advanced and refined, it
is focusing on all chronic disease conditions. From scheduling regular appointments with patients’ primary care physicians to helping patients comply with their
discharge instructions to arranging transportation for patients to keep doctor and
therapy appointments, the care navigators
help patients live healthier lives and avoid
hospitalization or trips to the ED.
Some regions have also launched coordination projects to reduce nonemergency
visits to EDs. The Consistent Care program
at UnityPoint Health–St. Luke’s Hospital in
Cedar Rapids, Iowa, for example, targeted
103 frequent ED users and worked with
them individually to help them obtain care
from primary care physicians and even set
up their initial appointments. In the first
year of the program, those patients’ visits
to the ED declined by 68 percent (from
1,377 visits during the first nine months of
2011 to 438 visits during the same period
in 2012). The coordination among the St.
Luke’s team, primary care physicians, and
community support organizations also is
delivering significant savings in healthcare
costs—$971,246 during the periods studied. Today, 233 patients are participating in
the program.
With these inroads, the care coordinating capabilities began to come together to
create value. We have begun to integrate
this capability into our physician offices
and patient-centered medical homes. One
example is the integration of our call center capabilities. We maintain a call center
in Sioux City, Iowa, known as My Nurse,
that is becoming the first line of triage for
our physician offices. When the system
is completed, a patient will be able to call
My Nurse at any time, including after
physicians’ office hours, when those calls
are routed to My Nurse. The nurse who
answers the call will be able to identify the
caller as a patient of a particular physician
and have access to the patient’s electronic
health record. The nurse can then triage the patient by phone and determine
whether the patient needs to be seen immediately, how to manage the problem at
home if appropriate, and so on. The nurse
also will have access to the physician’s
schedule and can book an appointment or
request a prescription refill.
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The call center operation is expected to
provide a great experience for our patients
and great benefit for the physician. The
doctor’s on-call volume will be reduced,
overall costs will be reduced, and outcomes will likely improve because we will
be keeping the patient from visiting the
ED and potentially being exposed to other
illnesses.
Integrating Data
Value Brings Volume
We define value as the best clinical outcome combined with the best patient
experience at an affordable price. We want
the patient to see the value that care coordination brings. In our case, care coordination capabilities allow better access to
and better navigation through the system,
whether the patient needs directions to a
specific location or a medical solution.
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Frontiers_29_4Summer.indd 23
As we built this coordination capability,
the primary question that emerged was
how to deploy it to all regions throughout
our system.
In a multi-region system spread over
two states, duplication and redundancy
are likely to occur. With a keen understanding of the significant resources
required to create population health
management and care coordination across
our system, we wanted to standardize the
approach as much as possible. We also
appreciate that each region is different in
terms of the structure of its medical community. Examples of variations include
the way in which primary care providers
work with specialists, the ratio of independent to employed providers, and the size
of specialty groups. Our approach needed
to accommodate those practice differences
to be successful.
As Exhibit 2 shows, we came to an
understanding with our regional CEOs as
to who is responsible for what activities
in this transformation. Clearly, each CEO
has responsibility for the continuum of
care in her region, meaning she must decide which services are owned and which
are outsourced and which community
partners to collaborate with. We do not anticipate that UnityPoint Health will “own”
all parts of the continuum of care in each
region, so it will be necessary to partner or
collaborate with a variety of other clinical providers, such as federally qualified
health centers, community mental health
centers, and long-term care facilities.
Physician alignment, on the other
hand, is a shared responsibility throughout UnityPoint Health. To help the regions
meet that responsibility and others, we
f e a t u r e
Driving our clinical transformation is our
emphasis on the power of data. We have
begun to gather claims data available
through our current value-based contracts, and we are investing in software
capability to merge the claims data with
patient clinical data. With these tools, we
are beginning to see a clearer picture of
how and where our chronic disease patients are receiving their care, and we are
tracking the effects of those fragmented
episodes of care on the patient’s outcome.
Those data help the physicians and other
clinicians continually improve how we
deliver care because they point to gaps
in that care and where we need to bridge
silos. Finally, we are beginning to learn
what keeps patients healthier and enjoying a better quality of life than they had
experienced before.
Preparing Our
Regional Networks
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developed standards for the AMTs, our
call center, and other components of our
care coordination capability. While our
physician enterprise will determine overall
clinical initiatives for the system and the
transformation of our clinical practice
environment (e.g., migration to medical
homes), the deployment in each region
will vary according to its community’s circumstances. For example, the number of
employed physicians will vary significantly
between regions.
Finally, analytics and contracting are
conducted at the system level. As an example, investments in software to perform
analytics are handled system-wide, rather
than on an affiliate-by-affiliate basis. The
analytics and contracting activities will
keep evolving, so we want to ensure that
we are migrating to best practices quickly
and keeping pace in our capability. As we
continue to roll out care coordination ability, we want to be able to analyze claims
data and be able to share those data with
our providers as soon as they are available.
The ACO Transition
With the passage of the Affordable Care
Act in March 2010 came the ability to
participate in an accountable care organization (ACO). We viewed the advent of
the ACO-related Medicare Shared Savings
Program as an opportunity, first and foremost, to obtain claims data throughout all
levels of operation at UnityPoint Health.
Results from claims data are the only clear
way for our clinicians to see the impact of
silos on patient care, including the gaps in
Exhibit 2 Population Health Management
Community
Facilities and services
Physician alignment
Provision of inpatient,
outpatient, and ambulatory
services required to deliver
comprehensive patient care
Platform of physician
engagement and
collaboration to improve
quality, enhance patient
experience, and lower costs
Regional integration
delivery system
System and regional
integration delivery
system
Care coordination
infrastructure
Analytic support and
contraction
Advanced Medical Team,
Palliative/Hospice Care,
Call Center, Patient Portal,
UnityPoint Health Physicians
& Clinics Primary Care Office
Analytic capabilities
required to support and
contracts that reward a
population-focused care
model
System and regional
integration delivery
system
System
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Frontiers_29_4Summer.indd 25
independent physicians. But because we
still will be paid on a fee-for-service basis,
I view ACOs as a transition strategy to
something very different.
This transition period does afford us
the opportunity to understand how we can
better manage care and put together the
pieces of the care continuum both to create better patient outcomes and to be able
to measure those outcomes. It also gives
us a structure by which to talk to employers and to create a methodology with them
that will benefit them and their employees.
Now, I predict that the challenge with
employers will be that they will want to
keep all the savings accrued from the coordinated care model. Our argument is that
the capability to create those savings is
achieved through the development of significant infrastructure at significant cost.
We have made tremendous investments in
care coordinating capability, and we need
to be compensated for those investments,
leading to a question of value-based contracting: “What are you really paying for?”
Payment will be made for care management under a global, annual budget. Over
time, risk will be shifted from the payer
to the provider, reinforcing the need for
organizations to share the savings from
coordinated care.
Care coordination demands a strategic
shift—not only of priorities but also of duties, team concepts, and channels through
which to provide care. And change demands education. To address that need, we
will soon be creating a curriculum in our
colleges of nursing and health sciences to
educate the inpatient nurse in providing
care in other settings. And the more we
educate, and the better job we do of it, the
more we will break down the resistance
to that change because people will see we
are investing in them for the future. They
f e a t u r e
care and the impact other providers have
on the patient’s outcome. Combined with
our clinical data, the claims data we gather
will give us, for the first time, a clear
picture of the patient’s progress, or lack
thereof, through the system of care and
how chronic disease is managed.
The second opportunity with ACOs is
the ability to assess the effectiveness of our
coordination capability. We understood at
the outset of our capability development
that innovation would take place when
we were treating real patients rather than
operating under a theory or hypothesis of
coordination. That understanding has led
to greater recognition of what works and
what does not.
With Trinity Regional Medical Center and Trimark Physician Group, in
Fort Dodge, Iowa, among the original 32
pioneer ACOs, our system was an early
adopter of the initiative. We also partner
in the Medicare Shared Savings Program
with Wellmark Blue Cross and Blue
Shield, Iowa’s largest private insurer, in
operating an ACO in four regions. Collectively, these ACOs cover more than
220,000 lives.
Yet we view ACOs as a transition strategy to a more population health–driven
system of care. The ultimate result will be
an organization that is paid on an annual
basis, by way of a global dollar amount,
for the management of certain chronic
diseases and other healthcare issues. All
of the care coordinating capability we are
creating now will be useful in that environment. The ACO is simply a way to
measure financially the value that is created through increased care coordination,
care management, and the integration of
clinicians around the care of the patient.
It provides us a legal way to share savings with our physicians, in particular our
Wil l ia m B . L e ave r , FAC H E • 25
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5/17/13 3:34 PM
will see the opportunities before them
to do what they have always dreamed of
doing: providing total care for the patients
and patient populations we serve. No one
should fear that better coordination of care
will eliminate his job; instead, he should
know that it will offer opportunities in our
new model.
The challenge we still have is that the
fee-for-service world has not kept pace
with our innovation. The physician practice business model has not yet changed
significantly; physicians are still being paid
on a fee-for-service basis
Care coordination demands for all the ancillary tests
a strategic shift—not only performed on equipment
that they own and for other
of priorities but also of
services. Nevertheless, we
duties, team concepts, and
are committed to dramatic
channels through which to change, and we believe the
groundwork we have laid
provide care.
for the transition will come
in a flood more rapid than most expect.
Once fee-for-service rates change, we will
see dramatic changes for many individual
providers, physician offices, and critical access hospitals. And once the change starts,
it will advance more rapidly than most
people expect.
Starting in 2011, payers dramatically
reduced reimbursements to providers for
procedures in nuclear medicine and catheterization. Those cardiologists who had
previously been fiercely independent now
wanted to be employed to salvage their income. In the future, if the government and
insurance companies reduce unit rates—
and we believe they will—a wholesale rush
of physicians will be searching for opportunities to align with hospitals and health
systems.
Organizations in turn should be ready to
accommodate these physicians. At UnityPoint Health, independent physicians can
join our ACO, providing them a position
from which to help govern and direct our
care coordinating capabilities while allowing them to remain independent. They will
still be rewarded for the value they contribute to their patients while helping to direct
change at the system level through operations and governance.
Conclusion
Our system has been on a four-year
journey to transform our delivery model.
While we have made great progress, we
still have a long way to go. Deploying the
capability we have, tightening the alignment with our physicians, and developing
analytics are all in progress.
The greater learning is yet to come,
and that is about ourselves, our role in a
new world, and the way in which value
will be recognized. Figuring out how to
collaborate between traditional silos of
care and reorient clinicians to a different
view of their responsibility to the patient
will all take time. Leaders must provide
focus for others on the overall objective,
prioritize where to start, and communicate the good work being done for our
patients.
The difficulty we face as a profession is
having one foot in a fee-for-service world
as we are about to step into a value-based
world. The payment environment will not
transform in a nice, rational, straight-line
fashion. As leaders, we need to navigate
our organization toward a better system of
care and not hang onto the old model. The
external environment will demand this
better system, and the early adopters will
convince patients they should expect it. Organizations that want to get every last bit
of fee-for-service revenue are not serving
their patients’ best interests and will have
to play catch-up well into the future.
26 • f ro ntier s o f he a lt h s e r vic e s ma na g e m e nt 29 :4
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Our physicians, nurses, and other clinicians are inspired by the promise of doing
something better for our patients and
families. The transformation is under way.
We can either lead or get out of the way.
Our organization has chosen to lead.
Reference
Cohen, S. B., and W. Yu. 2012. “The Concentration and Persistence in the Level of
Health Expenditures over Time: Estimates for the U.S. Population, 2008–
2009.” AHRQ Statistical Brief #354.
Rockville, MD: Agency for Healthcare
Research and Quality.
f e a t u r e
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Wil l ia m B . L e ave r , FAC H E • 27
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Physician-Led Models of Accountability
and Value: Observations on Payment
Policy and Culture
N icholas W olter
I n 1 9 1 0, C h a r les H. Mayo, MD, observed that the previous 50 years
C o m m e n t a r y
had been marked by advances in the science of medicine and that the next
50 years would be marked by advances in the organization and coordination
of healthcare delivery (paraphrased from the 1910 commencement address to
Rush Medical College). Today, more than a hundred years later, Dr. Mayo might
well be disappointed to see the level of fragmentation remaining in US healthcare. But there is hope. As Molden, Brown, and Griffith report regarding Piedmont Healthcare (PHC) and Leaver describes for UnityPoint Health, when integrated and coordinated care is a priority, value can be significantly improved.
Molden, Brown, and Griffith describe how a partnership between three
cardiovascular physician practices and PHC successfully evolved into the fully
integrated, physician-run entity Piedmont Heart. That example of single-silo
integration can be compared to Leaver’s summary of UnityPoint Health’s broad
effort to coordinate patient care across silos, including its experience as a pioneer accountable care organization (ACO) and its participation in the Medicare Shared Savings Program (MSSP) pilot. Both feature articles emphasize
the importance of physician leadership and attention to metrics or benchmark
targets, though neither identifies specific measures.
Nicholas Wolter, MD, is chief executive officer at Billings Clinic in Billings, Montana.
28 • f ro ntier s o f h e a lt h s e rvic e s m a na g e me nt 29 :4
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5/17/13 3:34 PM
Piedmont Heart
• How will quality and safety metrics
compare to benchmarks?
• How will cost per episode of
cardiovascular care compare to
benchmarks?
• Will population health results be
measured and reported with good
metrics for quality measures, annual
cost of care, and admission and
readmission rates?
• Will bundling pilots be launched with
Medicare, commercial payers, or both?
• Will Piedmont Heart and PHC
budgets be integrated in a way that
yields reliable cost measures and
comparisons?
• How well will the care of patients with
multiple diseases be coordinated with
other specialties and clinics?
• Will real-time decision support
analytics help sustain improvement
activities?
• Will clinical pathway diffusion greatly
improve standardization where
appropriate, and will the quality
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Frontiers_29_4Summer.indd 29
and cost measures show definitively
improved value?
UnityPoint Health
UnityPoint Health is developing a broad
approach to coordinating care. Its efforts
to develop physician leadership; focus on
complex, high-cost patient populations;
initiate the advanced medical team model;
implement the nurse call system; focus
on emergency room visits; use home care;
and develop a single information technology platform are extremely promising
initiatives. In addition, the system’s early
participation in an ACO and the related
MSSP helped it to pursue the goal of
merging data from insurance claims with
its clinical database. The additional data
enable clinicians to see how silos affect
patient care and clearly illustrate how a
patient progresses through the system of
care and how chronic disease is managed.
Many questions about UnityPoint
Health will be answered over the next five
years. They include the following:
• How will physician relationships evolve
across UnityPoint Health’s many sites?
• Will the system’s data analytics reduce
variation in quality and cost?
• Will the physician leadership program
improve the performance and
continuity of physician leadership?
• In the ACO, will increases in the total
annual cost per beneficiary eventually
moderate?
Annual Healthcare Spending
As PHC and UnityPoint Health focus on
markedly improving the value they deliver
to patients and payers, it is of interest to
note that over the past four years the annual increases in total US healthcare costs
have moderated. In 2012, the increase was
C o m m e n t a r y
A skeptic might see the development
of Piedmont Heart as the fulfillment of
cardiovascular physicians’ wish to preserve
income and PHC’s desire to drive volume. Be that as it may, Piedmont Heart’s
centers-of-excellence design, trunk-andbranch approach to clinical pathways, and
Patient First program demonstrate its
commitment to patient-centered care and
ability to address highly complex medical,
logistic, and cultural issues.
While the infrastructure being developed at Piedmont Heart is impressive, the
organization’s progress over the next five
years will be interesting to track. The following are among the key questions that
need to be answered:
N ic hol a s Wolt e r • 29
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4.3 percent, and in the three years prior to
that, from 2009 to 2011, the average was
3.9 percent. This is the smallest increase
in average annual costs seen over a fouryear period in the last 50 years (McLaughlin 2013).
Some have attributed the slowed
growth to the recession, a high number
of uninsured, or the trend toward much
higher deductibles for people who are
insured. On the other hand, it might relate
to the innovations being introduced at
UnityPoint Health, PHC, and other healthcare organizations across the country.
In addition, the Centers for Medicare &
Medicaid Services (CMS) believes that its
new payment models and emphasis on
cost, quality, and safety transparency may
be contributing to this moderation (Blum
2013).
Institute of Medicine
Recommendations for
Healthcare Delivery
In its 2000 report titled Crossing the Quality Chasm, the Institute of Medicine (IOM)
identified six critical tools that healthcare
organizations need to effectively address
quality, safety, and waste in US healthcare:
•
•
•
•
•
Evidence-based care processes
Effective use of information technology
Knowledge and skills management
Development of effective teams
Coordination of care across patient
conditions, services, and settings over
time
• Use of performance and outcome
measurement for continuous quality
improvement and accountability
In its September 2012 report Best Care
at Lower Cost: The Path to Continuously
Learning Health Care in America, IOM expanded that list to include the following:
• Digital infrastructure: Capture
clinical, process, and financial data for
improvement.
• Data utility: Use clinical data for
improved care, coordination, and
knowledge while protecting privacy.
• Clinical decision support: Accelerate
integration of best knowledge into
care decisions using new tools and
incentives.
• Patient-centered care: Involve patients
and families.
• Community links: Promote community
partnerships.
• Care continuity: Reward effective
communication and coordination
between teams.
• Optimized operations: Reduce waste,
streamline care delivery, and focus on
improvements.
• Financial incentives: Structure
payments to reward continuous
learning and care improvement at
lower cost.
• Performance transparency: Increase
availability of information about care
quality, cost, and outcomes.
• Broad leadership: Make continuous
learning and improvement a core
priority.
Both PHC and UnityPoint Health
incorporate some IOM recommendations
in their approaches to leadership development, team care, operations optimization,
care continuity, and patient-centered care.
Performance transparency and financial
incentives are not as fully discussed in the
feature articles but will be critical going
forward. Both organizations seem to
30 • f ro ntier s o f h e a lt h s e rvic e s m a na g e me nt 29 :4
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Design and
Sustainability of ACOs
Much has been made of the need for,
and indeed the inevitability of, replacing
the fee-for-service payment model with
bundled, shared savings and global payment models. Some experienced observers
have questioned how well new payment
models will work, and some have noted
the importance of improving the current
fee-for-service system. In his discussion
of UnityPoint Health strategies, Leaver
expresses the opinion that new ACO strategies are very likely transitional.
In an interesting Wall Street Journal
colloquium (Mathews 2012), Don Berwick,
Jeff Goldsmith, and Tom Scully discuss
their views on ACO payment models. Berwick notes that Medicare Advantage covers
perhaps 25 percent of Medicare beneficia-
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Frontiers_29_4Summer.indd 31
ries. In his opinion, other Medicare subscribers may benefit from well-managed
ACOs, which typically offer patients more
choices than Medicare Advantage does as
well as improved quality and lower costs.
Goldsmith sees a “gap between the
policy world and the real world.” He cites
the high infrastructure costs of ACO
formation along with a lack of strategy
for patient engagement, and he expresses
concern about hospitals’ and specialties’
decades-long interest in “making more by
doing more.”
Scully, too, notes that ACOs drive more
power to hospitals and that “doctors need
to drive the bus.” He expresses the view
that capitation is a much better option.
Both Scully and Goldsmith emphasize
the need for physicians to improve value
through strategies such as the patientcentered medical home (PCMH). And all
three call for stronger focus on managing
complex, high-cost patients. Both PHC
and UnityPoint Health have clearly adopted that strategy.
In a recent Wall Street Journal opinion
piece, Clayton Christensen, Jeffrey Flier,
and Vineeta Vijayaraghavan (2013) voiced
strong concern about the ability of physicians to adopt the necessary new behaviors, the cultural importance of patient
engagement, and the unlikely possibility
that ACOs will save money. As an alternative, they advocate more promising “disruptive innovation.”
The Billings Clinic’s experience in the
Physician Group Practice (PGP) Demonstration and our early experience in the
pilot of the MSSP raises similar concerns.
For example, a smaller population, even
one of 12,000 beneficiaries, creates a
threshold of 3.4 percent before savings
are realized. Billings Clinic has decided
C o m m e n t a r y
recognize the indispensability of granular
data to drive the timely decision making
required to create a culture of continuous
improvement. Many US healthcare organizations lack the decision support information they need and must make do with
largely retrospective and less-than-accurate
granular data about specific procedures
or admissions. By combining insurance
claims data with their own clinical data to
gain a clearer picture of how and where
patients receive care and how fragmented
care affects outcomes, UnityPoint Health
is taking an important step in the right
direction. Even when accurate and timely
data are available, however, many clinicians find electronic health record (EHR)
tools to be underdeveloped and frustrating, and the clinical EHR must also be
significantly upgraded to assist with the
safety and quality improvements needed
in patient care.
N ic hol a s Wolt e r • 31
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to move forward in the MSSP despite the
limited likelihood of sharing in savings,
because we believe that our participation
promotes a continuous learning culture
and creates greater value for patients. Attribution, although now much improved
from the PGP Demonstration, remains
problematic, and the data we have received
show that over an 18-month tracking
period, only 60 percent of our originally
attributed beneficiaries remain in our patient group. Management difficulties arise
with the attribution methodology when
that many patients exit and new ones
enter. Patient notification
Both culture and
requirements are probleadership are critical to lematic, as is CMS’s slow
the development of future turnaround of information.
Despite our many
models of healthcare
concerns, we believe that
delivery.
ACOs point in the right
direction, even if, as suggested by Leaver,
they may be transitional. As Goldsmith
and Christensen and his colleagues observe, the savings may be relatively modest, strongly influenced by documentation
and risk adjustment, and show more
potential in highly inefficient and costly
markets. PHC and UnityPoint Health may
find Medicare Advantage and commercial
ACO partnerships more promising. In
addition, bundling payments for improved
care, patient-centered medical home payment models, and payment models focusing on high-risk and high-cost populations
may have more sustainable success.
Fee-for-Service Transition
Both PHC and UnityPoint Health address
the difficulty of living in the fee-for-service
and new payment worlds at the same
time. PHC views this as being in Curve
A while trying to prepare for and move to
a new Curve B. One astute observer, Paul
Ginsburg (2012) of the Center for Studying Health System Change, contends that
physicians’ pay, even in the new payment models, will be based on a flawed
fee-for-service system. Even with some
changes in recent years, glaring differences remain between the reimbursement
of primary care physicians and that of
some specialty and surgical physicians. He
argues strenuously that modernization of
the physician fee-for-service system should
remain a high priority.
Some, including myself, believe that
recommendations to reemphasize the
same fee-for-service physician payments in
all sites (i.e., elimination of hospital-based
physician reimbursement) at levels we
believe are below cost go in the wrong direction and will drive physicians to further
increase volume in their owned facilities
or to seek hospital or other employment in
organizations that will then have their own
cost-related volume strategies (MedPAC
2012). A much better approach would be
to enforce appropriate criteria for the receipt of these payments so that physicians
and their organizations are motivated
to demonstrate true integration, system
approaches to coordination of care across
silos and over time, and improved value.
The importance of reforming the current payment system extends to hospitals,
where some services have large margins
and others have large losses. Such disparity can lead to driving major strategic and
investment decisions that are not always
in the best interest of coordinated patient
care, particularly those for patients with
multiple complicated disorders. Ginsburg’s argument, in my view, is a good
one and applies to current physician and
hospital payment policies. The impact of
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revising those policies could be equal to
or even greater than the impact of current
bundled and ACO payment designs. Recent studies have shown that cost variation
in post-acute settings is significant (MedPAC 2013; Schmitz and Simon 2009), so,
as noted, bundling may become a more
sustainable payment model even though
it too is based on the current underlying
payment system, including fee-for-service
payment for physicians. This need applies
to physician, hospital diagnosis-related
group, and hospital outpatient payment
policies. The UnityPoint Health investment in home care will potentially be
strategic.
I would like to address the many references made by PHC and UnityPoint
Health to the importance of culture. Billings Clinic dealt with its own version of
this important but difficult issue following
its merger with Deaconess Medical Center in 1993 (Billings Clinic 2006). Both
culture and leadership are critical to the
development of future models of healthcare delivery, though they are not as easily
defined and measured as are, for example,
financial benchmarks.
James Reinertsen is a former CEO of
Park Nicollet in Minneapolis and a longtime faculty member of the Institute for
Healthcare Improvement. He has facilitated retreats for Billings Clinic leadership on several occasions and shared
with us the graphic in Exhibit 1. Generated out of his and others’ work at the
Institute for Healthcare Improvement, it
depicts the key elements of leadership for
transformation.
The building blocks of setting direction,
establishing the foundation, building will,
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Final Thoughts
As I reflect on the current criticism of
quality and waste in US healthcare, I
think it is also important to look at what
we are doing well. PHC and UnityPoint
Health should be congratulated for their
vision, tactics, and significant efforts to
develop more value for patients through
service line and system integration. Of
course, that does not diminish their need
to develop good metrics for evaluating and
reporting improvements over the coming
years.
I have personally admired the transformational efforts of organizations such as
Geisinger, Virginia Mason, Mayo Clinic,
Denver Health, Henry Ford, Scott and
White, and Kaiser Permanente, to name a
few. All have very different patient populations, payer mixes, and health plan relationships, yet at the core all are multispecialty physician group practices.
This leads me to two final observations.
First, physician collegiality and the relationships across diverse specialties are key
C o m m e n t a r y
Culture and Leadership
generating ideas, and executing change
must be addressed by all organizations as
they develop their culture and leadership
strategies.
In Reinertsen’s opinion, it takes two or
three generations of leadership teams to
sustain and deliver a large-scale organizational vision and its underlying methods
of continuous improvement. Reinertsen’s
lengthy timeline is probably more realistic than the five- or ten-year timelines
of the current health reform initiatives.
Accordingly, to achieve sustainable transformational change, PHC and UnityPoint
Health will need to continue investing in
leadership training and related initiatives
over the next 10 to 20 years.
N ic hol a s Wolt e r • 33
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Exhibit 1 Leadership for Transformation
1. Set Direction: Mission, Vision and Strategy
Make the future attractive
PUSH
PULL
Make the status quo uncomfortable
3. Build Will
• Plan for Transformation
• Set System-Level Aims for
Performance
• Provide Encouragement
• Define the Business Case
• Learn Subject Matter
• Make Connection Between
Quality Work and Strategy
4. Generate Ideas
5. Execute Change
• Read and Scan Widely, Learn from
other Industries & Disciplines
• Benchmark to Find Ideas
• Listen to Customers
• Invest in Research & Development
• Knowledge management
• Understand Organization as a
System
• Use Model for Improvement for
Design and Redesign
• Use Change Leadership Model
• Review and Guide Key Initiatives
• Spread Ideas
• Communicate results
• Sustain improved levels of
performance
2. Establish the Foundation
• Reframe Operating Values
• Build Improvement Capability
• Use Evidence-Based Operating
Systems
• Personal Preparation
• Choose and Align the Senior Team
• Build Relationships
• Develop Future Leaders
© 2002 Institute for Healthcare Improvement
Source: Institute for Healthcare Improvement. Reprinted with permission.
to delivering value to patients. Both PHC
and UnityPoint Health emphasize those
in their work, but they have significant
strides yet to make.
Second, if coordination of patient care,
especially for complex at-risk populations,
is a critical goal, integration and group
development of and by physicians (not just
hospital–physician alignment); putting
patients at the center of goals and strategies; and partnering with others, such as
CMS and insurers, play crucial roles under
any payment model. A number of our very
best healthcare organizations have focused
on those areas, even in the fee-for-service
and capitated worlds, over many years and
even decades.
In his article “The Checklist,” Atul
Gawande (2007) profiled the intensivist
and activist Peter Pronovost, who observed, “The fundamental problem with
the quality of American medicine is that
we’ve failed to view the delivery of health
care as a science.” We hope that PHC and
UnityPoint Health continue to build on
their early strategies and successes and,
along with many others, help us to apply
science to healthcare delivery in ways
that lead to improved value. Closing the
gap that Goldsmith notes between the
policy world and the real world would be
very helpful in this endeavor. Fortunately,
physician and hospital leaders can pursue
continuous improvement and improved
value even in imperfect payment systems.
And we can hope that the many changes
now unfolding in US healthcare delivery
win the approval of Charles Mayo, who
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more than a century ago recognized the
importance of teamwork and coordinated,
patient-focused healthcare.
References
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is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
Frontiers_29_4Summer.indd 35
C o m m e n t a r y
Billings Clinic. 2006. “History.” Accessed
April 18, 2013. www.billingsclinic.com/
body.cfm?id=969.
Blum, J. 2013. “Improving Quality, Lowering
Costs: The Role of Health Care Delivery
System.” Statement before the US Senate
Committee on Homeland Health,
Education, Labor and Pensions, November 10. www.hhs.gov/asl/testify/2011/11/
t20111110a.html.
Christensen, C., J. Flier, and V. Vijayaraghavan. 2013. “The Coming Failure of
Accountable Care.” The Wall Street
Journal, February 18.
Gawande, A. 2007. “The Checklist.” The
New Yorker, December 10.
Ginsburg, P. 2012. “Fee-for-Service Will
Remain a Feature of Major Payment
Reforms, Requiring More Changes in
Medicare Physician Payment.” Health
Affairs 31 (9): 1977–83.
Institute of Medicine (IOM). 2012. Best Care
at Lower Cost: The Path to Continuously
Learning Health Care in America. Washington, DC: National Academies Press.
———. 2000.Crossing the Quality Chasm: A
New Health System for the 21st Century.
Washington, DC: National Academies
Press.
Mathews, A. W. 2012. “Can AccountableCare Organizations Improve Health Care
While Reducing Costs?” The Wall Street
Journal, January 23.
McLaughlin, J. 2013. “National Health
Spending Accelerated 4.3% in 2012, Still
Slower Than Past 5 Decades.” Becker’s
Hospital Review, January 8.
Medicare Payment Advisory Commission
(MedPAC). 2013. “Post-acute Care
Providers: Shortcomings in Medicare’s
Fee-for-Service Highlight the Need for
Broad Reforms.” In Report to the Congress:
Medicare Payment Policy. Published in
March. www.medpac.gov/chapters/
Mar13_Ch07.pdf.
———. 2012. Report to the Congress: Medicare Payment Policy. Published in March.
www.medpac.gov/documents/Mar12_
EntireReport.pdf.
Schmitz, R., and S. Simon. 2009. Substitutability Across Institutional Post-acute Care
Settings: 1998–2006. Report prepared for
the US Department of Health and
Human Services Assistant Secretary for
Planning and Evaluation. Published in
September. http://aspe.hhs.gov/daltcp/
reports/2009/instPAC.pdf.
N ic hol a s Wolt e r • 35
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Collaboration Across Clinical Silos
M. J ane M ohler
We f a c e s i gnifica nt challenges to healthcare integration—supply-
C o m m e n t a r y
driven demand; expensive new technologies (yet unlinked to better outcomes);
physician-centric care; and a lack of leaders and clinicians with knowledge of
epidemiology, quality improvement, finance, innovative models of care, and
best practices. We likewise face tremendous opportunities in healthcare reform
as we endeavor to provide a coordinated continuum of high-value services to
defined populations for which we are clinically and fiscally accountable. To truly
transform the US healthcare system, we must integrate our clinical care across
the care continuum, managing individuals and populations across episodes of
care and aligning funding through pay for value, per-episode bundled payment,
or elements of capitation, such as accountable care organizations (ACOs) or
global payments (Ginsburg 2012). We must prepare for this new environment
through clinical alignment of inpatient and outpatient systems and providers,
thereby creating seamless care.
Most healthcare experts now agree that breaking down the clinical silos of
complex healthcare organizations—known as integration—is beneficial. While
some have led this effort, others have resisted. Evidence from highly integrated
systems and early adopters indicates that integration improves value and access
and increases patient loyalty. Sufficient evidence points to sound principles that
can inform the clinical integration process (Suter et al. 2009).
In this commentary I consider clinical integration practices that are useful in breaking down clinical silos, examine how those practices were employed
at UnityPoint Health and Piedmont Heart, and offer personal anecdotes about
building innovative care programs in a large, southwestern, academic, integrated health network.
M. Jane Mohler, PhD, is a chronic disease epidemiologist, health services researcher,
and tenured professor of medicine in the University of Arizona College of Medicine,
where she helps to develop innovative models of care within the newly integrated University of Arizona Health Network.
36 • f ro ntier s o f h e a lt h s e r vic e s ma na g e m e nt 29 :4
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Exhibit 1 Critical integration factors and specific
recommendations for breaking down clinical silos are summarized in Exhibit 1 and
discussed below as they relate to the two
feature articles.
Triple-Aimed Leadership
and Culture
Reinvention requires exemplary—even
courageous—leadership, significant cultural change, and active imagining of the
future. It calls for working collaboratively
across the silos that divide payers, health
plans, hospitals, clinics, and providers to
forge a common vision, a shared culture,
and mutual accountability for patient
outcomes. The underlying beliefs, values,
norms, and behaviors of the system can
either support or inhibit clinical integration (Gillies et al. 2006). The difference
between leading to integration and managing to change is a shared, triple-aimed
vision for (1) improving the health of the
population; (2) enhancing patients’ experience of care, including quality, access,
Critical Components of Integration
1.
Triple-aimed leadership and culture
2.
Bifocal vision
3.
Patient-centered focus
4.
Diverse providers/interprofessional teams
5.
Stratified, population-based care strategies
6.
Communication and coordination across transitions of care
7.
Streamlined purchasing and support processes
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C o m m e n t a r y
What principles can be widely applied?
A healthcare system (whether taken as a
whole, such as UnityPoint Health, or as
one part of a whole, such as Piedmont
Heart) is a collection of critical functions,
including governance, planning, finance,
service delivery, monitoring, and evaluation, that are influenced by the prevailing
values, beliefs, norms, and regulations
of multiple stakeholders. Integration of
those functions requires understanding
and analysis of complex interrelated and
interdependent relationships, as well as
alignment with regulatory mechanisms,
accountability networks, reporting and
management procedures, financial functions, technological requirements, and the
fiduciary systems that monitor reimbursement processes—a seemingly overwhelming undertaking. Clinical integration is the
extent to which patient care services are
coordinated across functions, activities,
and sites over time to maximize the value
of services delivered to patients or covered
populations (Shortell, Gillies, and Anderson 2000).
M. Ja ne Mohl e r • 37
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and reliability; and (3) controlling the per
capita cost of care.
Both UnityPoint Health and Piedmont
Heart had visions of developing, pursuing,
and implementing triple-aimed strategies
to achieve greater value. In 2008, UnityPoint Health changed its vision statement
to “Best outcome for every patient every
time.” The same vision was exhibited by
Piedmont Healthcare/Piedmont Heart
when aiming to move to “a new way of operating . . . [a] new model of success, based
on value and integration that is patientand population-centric
Most healthcare experts and driven by global or
now agree that breaking bundled payments for the
outcomes achieved.”
down the clinical silos
Individuals, medical
of complex healthcare
practices, departments,
organizations—known as service lines, and academic
integration—is beneficial. units often perceive that
triple-aimed strategies
conflict with their interests. Providers
need incentives to focus on efficiency and
quality, and organizations must be restructured to align governance, management,
and provision of care in support of achieving shared objectives. Leadership must
ensure that top leaders, board members,
managers, and a select group of influential
champion providers are engaged. Piedmont Heart facilitated cultural change by
doing just that. It recruited administrative
leaders and chiefs of centers of excellence
(COEs) as champions and held scripted
pathway-development meetings with messages targeted to specific stakeholders.
It’s not enough to find champions,
however. The champions selected must
have the training in population management, quality improvement, finance,
and best practices needed to achieve the
organization’s clinical integration goals.
UnityPoint Health’s Physician Leader-
ship Academy, initiated in collaboration
with the American College of Physician
Executives, helps physicians learn and
master leadership skills, which strengthen
a collective sense of purpose. As Leaver
observes, “The importance of the Academy
in helping coalesce our physicians cannot be overstated.” Efforts such as this, as
well as online offerings, such as the Open
School certification program of the Institute for Healthcare Improvement (2013),
can provide low-cost training to ensure
that leadership, management-level providers, and staff share a common vision
and have the skills to apply it. Participants
in the integration effort must also have
access to information and information
support, with shared data reporting within
and across clinical silos to ensure that responsibility for system outcomes is widely
embraced and that metrics are used to
drive value.
Clinical integration must be a strategic
priority of leadership, and workflows must
be assessed and redesigned at the macro
(governance and management across
facilities and sites) and micro (care delivery) levels. This process includes creating
horizontal committees, work groups, and
service line management structures to implement and advance clinical integration
efforts system-wide. When applicable, the
practice plan and health plan should be
extensively involved in system operations.
Evidence shows that health plans that
employ their own providers or are tightly
affiliated with provider groups score significantly higher on clinical performance
measures than do other types of provider
delivery systems (Gillies et al. 2006).
Bifocal Vision
Leadership and management need bifocal
vision. They must be forward-looking; be
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world to a value-based world. In Leaver’s
opinion, “Organizations that want to get
every last bit of fee-for-service revenue are
not serving their patients’ best interests
and will have to play catch-up well into the
future.” UnityPoint Health’s commitment
to aligning for future reimbursement policies will likely stand them in good stead;
however, not all systems have deep enough
pockets to take UnityPoint Health’s preemptive approach.
Patient-Centered Focus
Patient-centered primary care is one of
the six domains of quality of the Institute
of Medicine and includes respect for the
patient’s values, preferences, and needs;
education; access; emotional support; involvement of family and friends; continuity and secure transition; physical comfort;
and coordination of care. However, to date,
care processes are largely designed around
the needs of the “medical guild” and not
the patient (Berwick 2002).
Patient-centeredness begins with improving patient communication. Systemwide adoption of tools such as the Studer
Group’s Five Fundamentals of Patient
Communication (also known as AIDET:
Acknowledge–Introduce–Duration–
Explanation–Thank You) helps to build a
culture of service and accountability. Next,
care processes must be reconfigured to
make them more responsive, transparent,
and engaging, and they should include
self-care support, team-based care processes, and convenient hours and care settings. Banks provide weekend, after-hours,
online, in-home, and community-based
(ATM) services, and so should healthcare
providers. Accordingly, UnityPoint Health
implemented a call center known as My
Nurse, which serves as the first line of
triage for its physician offices. A patient
C o m m e n t a r y
quick to respond to changes in population dynamics, demand, reimbursement
trends, and best practices; and simultaneously focus on the present and maintaining fiscal viability. The triple-aimed
approach often runs counter to the immediate self-interest of systems and hospitals
responding to current market forces, and
systemic efficiencies that reduce admission rates and bed days may threaten
profit because fixed costs are spread across
fewer encounters (Berwick, Nolan, and
Whittington 2008). In response, new bundled payment methods that share savings
and accountability, a shift of beds to more
profitable uses, and new service lines or
market niches may need to be identified
and developed.
Community collaboration that results
in diversification and realigned hospitalspecific specialties, the rightsizing of
capacity, and contracts with unique populations is wise and should be considered
where the community climate allows
(Gillies et al. 2006). Piedmont Heart
embraced the philosophy that it had to
“optimize performance in the current
environment (Curve A) while preparing
to move to an innovative way of operating
(Curve B).” However, Molden, Brown, and
Griffith’s discussion did not address efforts
to carve out community services based
on population needs; Piedmont Heart’s
approach may bring some benefit in the
short-term fee-for-service environment but
be oversized for true demand.
ACOs have potential to achieve the triple aim, but they have high start-up costs
and annual expenses, and their outcomes
have been mixed (McClellan et al. 2010).
UnityPoint Health was an early adopter
that viewed the ACO as a “transition
strategy to something very different,” that
is, a way of moving from a fee-for-service
M. Ja ne Mohl e r • 39
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can call after hours and speak with a nurse
who can identify the caller’s physician
and access the caller’s electronic health
record. In addition, patients can use My
Nurse to request prescription refills and
schedule an appointment. Leaver does not
mention whether UnityPoint Health offers
extended clinical days or hours to improve
access for busy employees and parents.
Piedmont Heart’s Patient First program was designed to improve delivery of
seamless, high-quality care. Its approach
to scheduling enables a physician to focus
on one or two activities
Evidence from highly
each week rather than try
to manage a variety of unintegrated systems and
early adopters indicates coordinated tasks related
to a patient’s care. Conthat integration improves sidered the most dramatic
value and access and
element of Piedmont
increases patient loyalty. Heart’s integration, Patient
First provides dedicated,
around-the-clock cardiovascular care and
ensures better coordinated care. While
better-quality care is, by definition, better
for the patient, it is not necessarily patient
centered. Molden, Brown, and Griffith do
not discuss the ways in which patients are
better supported but rather concentrate
on how consolidating and reconfiguring
provider duties and hours has decreased
variation and improved handoffs.
Diverse Providers/
Interprofessional Teams
Poor interprofessional collaboration and
communication can undermine care
delivery and patient outcomes (Reeves et
al. 2008, 2010). The demand for primary
care services is projected to increase
because millions of individuals will gain
health insurance coverage by 2016 and
the sizable baby boom generation is aging.
“Economic forces, demographics, the gap
between supply and demand, and the
promised expansion of care necessitate
changes in primary care delivery,” Fairman and colleagues (2011) report in the
New England Journal of Medicine. Prudent
use of mid-level providers has proved to
be cost-effective and safe. A systematic
review of 26 studies published in Health
Affairs found that “health status, treatment
practices and prescribing behavior were
consistent between NPs [nurse practitioners] and physicians” (Cassidy 2012). Increasingly, NPs, physician assistants, and
clinical pharmacists are treating patients
in acute care settings and emergency
departments (EDs); caring for individuals with common, easily diagnosable and
treatable acute problems in minute clinics;
participating in interprofessional teams
that care for elderly people with advancing
chronic conditions in home-based primary
care programs (Weaver et al. 2000); and
working in integrated behavioral health
programs with social workers, behavioral
health professionals, and community
health representatives to care for high-risk,
high-cost, dual eligible patients (Funderburk et al. 2011; McGuire et al. 2009). The
use of teams, information technology (e.g.,
the targeted telemonitoring with looped
intervention programs offered in the Veterans Health Administration and Kaiser
Permanente systems), and shared data and
the addition of nonphysician providers
have the potential to offset the increased
demand for physician services while
improving access to care and averting a
shortage of primary care providers where
shared-risk and capitated reimbursement
models are available (Green, Savin, and Lu
2013).
In Piedmont Heart’s Patient First
program, 99 physician extenders (teamed
with 90 physicians) formed COEs that
40 • f ro ntier s o f he a lt h s e r vic e s ma na g e m e nt 29 :4
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moved physicians away from the comfort
of their legacy practice and physiciancentric care to team-driven decision
making, utilizing mid-level providers to
the full extent of their license to enhance
coordination and ensure continuity of
care and effective handoffs. At UnityPoint
Health, Advanced Medical Teams (AMTs),
led by care navigators, help physicians
manage patients with complex chronic
disease. The teams work closely with referring physicians, home care services, and
community resources to provide a range
of services that help patients avoid unnecessary trips to the ED and hospitalization.
Population management addresses the
health needs of a covered population (demand) by matching capacity and services
(supply) to those needs, using stratified
population and patient-panel management
techniques focused on evidence-based
reduction of variation in care delivery
(Lynn et al. 2007). High-value healthcare
organizations take similar approaches to
care management through prespecification of subgroups, choices, transitions, and
pathways (Bohmer 2011). Many hospitals
and providers do not plan care processes in
advance, and, lacking systematic care strategies, they treat each new patient as a singular event. The well-being of people in the
healthy strata can be maintained through
health promotion and preventive services.
Improving care for patients with chronic
conditions requires integrated health
and social services, vertical integration of
secondary and tertiary care, and methods
of reducing inappropriate ED and hospital
utilization. Evidence-based best practices
are accumulating and are now widely available for uptake and local modifications.
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Frontiers_29_4Summer.indd 41
Communication and
Coordination Across
Transitions of Care
System-wide clinical communication
strategies such as SBAR (Situation–
Background–Assessment–Recommendation), created by clinical staff at Kaiser
Permanente–Colorado, enable clear
transmission of clinical information,
develop teamwork, and foster a culture of
patient safety. Specific tools are available at
the Institute for Healthcare Improvement
website (www.ihi.org), including SBAR
tools for use in specific settings.
Reimbursement dynamics have traditionally led hospitals to focus on care
within their walls and to view negative
sequelae beyond their walls, such as readmissions, as outside their purview (McCarthy, Johnson, and Audet 2013). However,
federal financial penalties for readmis-
C o m m e n t a r y
Stratified, Population-Based
Care Strategies
Piedmont Heart reorganized its delivery system into six COEs by disease state
or condition. Because each COE provides
the entire continuum of care to its patients, a provider can specialize in one area
to bring subspecialty depth of expertise to
each case. To standardize care, best practices are developed across COEs, resulting
in a unified approach. To improve quality
and further reduce variation, clinical pathways were developed from evidence-based
guidelines, organizational standards, and
best practices.
UnityPoint Health uses its AMTs to
improve the management of patients with
the highest-cost, most complex chronic
diseases. As discussed earlier, care navigators work with referring physicians, home
services, and community resources to
manage patients in home and community
settings and reduce avoidable ED use and
hospitalization.
M. Ja ne Mohl e r • 41
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sions now make hospitals accountable,
and readmissions are considered avoidable
if they could have been prevented by “(1)
the provision of quality care in the initial
hospitalization; (2) adequate discharge
planning; (3) adequate post-discharge
follow-up; or (4) improved coordination
between inpatient and outpatient health
care teams” (van Walraven et al. 2011).
The deterrent value of such penalties may
seem weak compared to the potential loss
of inpatient revenue; however, it is increasingly important for hospitals to institute
care transition programs
Health systems must
that span the entire system, including medical
reinvent themselves,
and surgical subspecialreengineer clinical
ties, intensive care, the ED,
operations, and streamline and outpatient services,
processes . . . to ensure that through the use of proour patients receive the grams such as the Society
of Hospital Medicine’s
safe, high-value care they
Project BOOST (Better
deserve.
Outcomes by Optimizing
Safe Transitions) (Jweinat
2010) or Boston University Medical Center’s Project RED (Re-engineered Discharge) (Jack and Bickmore 2010/2011). It
is also important to involve stakeholders
from the broader community, including
home health, assisted living, rehabilitation, and long-term care providers that
use quality improvement programs such
as INTERACT (Interventions to Reduce
Acute Care Transfers), in working together
to improve outcomes (Ouslander et al.
2011). Finally, all systems should collaborate with statewide quality improvement
organizations (QIOs), which are funded by
the Centers for Medicare & Medicaid Services to help hospitals seeking improvement in high-prevalence, high-cost clinical
areas, such as healthcare-associated infec-
tions. UnityPoint Health has launched
coordinated projects to reduce visits by
frequent ED users, which have resulted in
cost savings of nearly $1 million.
Streamlined Purchasing and
Support Processes
Many healthcare systems have already
achieved substantial economies of scale
through bulk purchasing and the use
of buyers’ groups, although fewer have
streamlined support processes throughout
the organization, such as legal relationships; financial service support; space
and equipment; hiring and credentialing;
clinic licensure; coding and compliance;
and computer, e-mail, and information
support systems. The 700 physicians
at UnityPoint Health operated in nine
groups, each with its own management
infrastructure and billing system. The
groups were not integrated, did not focus
on the same objectives, and did not operate under the same incentives. That is
Tools on the Web
Boston University Medical Center’s Project
RED: www.bu.edu/fammed/projectred/
index.html
Institute for Healthcare Improvement’s
SBAR Communication Technique:
www.ihi.org/explore/
SBARCommunicationTechnique/
INTERACT (Interventions to Reduce Acute
Care Transfers):
http://interact2.net/index.aspx
Society of Hospital Medicine’s Project
BOOST: www.hospitalmedicine.org/
ResourceRoomRedesign/
RR_CareTransitions/CT_Home.cfm
42 • f ro ntier s o f he a lt h s e r vic e s ma na g e m e nt 29 :4
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Summary
We face significant challenges to healthcare integration as well as tremendous
opportunities to advance healthcare
reform as we endeavor to provide a coordinated continuum of high-value services
to defined populations for which we are
clinically and fiscally accountable. As we
move away from fee-for-service and poorly
coordinated care toward value-based and
bundled care, systems such as UnityPoint
Health and clinical entities such as Piedmont Heart are leading the way, breaking
down their clinical silos, improving value
and access, and gaining patient loyalty.
Evidence points us to sound principles
that can inform the clinical integration
process.
Health systems must reinvent themselves, reengineer clinical operations, and
streamline processes, all of which require
collaboration across traditional silos, both
inside our organizations and outside into
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Frontiers_29_4Summer.indd 43
our wider communities, to ensure that our
patients receive the safe, high-value care
they deserve.
References
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the IOM’s ‘Quality Chasm’ Report.”
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Health, and Cost.” Health Affairs 27 (3):
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C o m m e n t a r y
changing with UnityPoint Health’s integration process.
In our newly integrated University of
Arizona Health Network, an attempt to
develop and launch an innovative interprofessional, home-based clinical care service
line for complex dual eligibles enrolled in
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plan, the health science colleges, and the
“integrated” healthcare system (Mohler
et al. 2013). The program was ultimately
sited in the College of Medicine Practice
Plan, and a complicated legal arrangement
was made between the health plan, the
practice plan, and the College of Medicine,
with service line creation deemed premature for our newly integrated network.
M. Ja ne Mohl e r • 43
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Jencks, and R. T. Kambic. 2007. “Using
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to Health’ Model.” Milbank Quarterly 85
(2): 185–212.
McCarthy, D., M. B. Johnson, and A. M.
Audet. 2013. “Recasting Readmissions by
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McClellan, M., A. N. McKethan, J. L. Lewis,
J. Roski, and E. S. Fisher. 2010. “A
National Strategy to Put Accountable
Care into Practice.” Health Affairs 29 (5):
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McGuire, J., L. Gelberg, J. Blue-Howells,
and R. A. Rosenheck. 2009. “Access to
Primary Care for Homeless Veterans
with Serious Mental Illness or Substance
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Mohler, M. J., N. Wexler, R. Slaughter, J.
Stover, P. Harrison-Monroe, T. Ball,
B. Coull, and M. Fain. 2013. “Overcoming
Academic Medical Center Inertia: Building an Innovative Dual Eligible Service
Line.” Poster for presentation at the
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Plano, Texas, May.
Ouslander, J. G., G. Lamb, R. Tappen, L.
Herndon, S. Diaz, B. A. Roos, and A.
Bonner. 2011. “Interventions to Reduce
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59 (4): 745–53.
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Barr, D. Freeth, M. Hammick, and I.
Koppel. 2008. “Interprofessional Education: Effects on Professional Practice and
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Barr, D. Freeth, I. Koppel, and M. Hammick. 2010. “The Effectiveness of Interprofessional Education: Key Findings
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Anderson. 2000. Remaking Healthcare in
America: The Evolution of Organized
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Suter, E., N. D. Oelke, C. E. Adair, and G. D.
Armitage. 2009. “Ten Key Principles for
Successful Health Systems Integration.”
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P. C. Austin, and A. J. Forster. 2011.
“Proportion of Hospital Readmissions
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Weaver, F. M., S. L. Hughes, A. GiobbieHurder, A. Ulasevich, J. D. Kubal, J.
Fuller, and J. Rowe. 2000. “The Involvement of Physicians in VA Home Care:
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677–81.
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Breaking Down Clinical
Silos in Healthcare
A nna M arie H ajek
Each o f t h e feature articles in this issue of Frontiers of Health Services
Anna Marie Hajek is president and chief executive officer of Clarity Group Inc. in
Chicago.
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Frontiers_29_4Summer.indd 45
C o m m e n t a r y
Management begins by addressing the many factors that have developed and
are spurring significant changes to healthcare delivery in the United States.
To those of us involved in the healthcare industry, these factors are not new. In
some cases they were also at play in the early 1990s, when they contributed to
both the advent of and the backlash to managed care. What makes this time different is that, although unsustainable healthcare costs, decreasing reimbursements, and new payment structures mandated by the Affordable Care Act are
realities, the changes to the healthcare delivery system are coming from within
healthcare itself instead of from the health insurance industry.
Both articles emphasize that integration of resources and coordination
of care play crucial roles in reaching goals for enhancing community health
and reducing the overall cost of care. Both articles also encourage healthcare
providers to avail themselves of newer reimbursement models stemming from
the Medicare Shared Savings Program, bundled payments, and, ultimately,
global capitation. Although both articles discuss transformation, their perspectives differ: Leaver focuses on the structural realignment of a large multistate
healthcare system, while Molden, Brown, and Griffith focus on a service line
realignment within a healthcare system. Whether through disruptive innovation, as discussed by Molden, Brown, and Griffith, or through coordinated care,
as described by Leaver, each system achieved a new type of service delivery that
brought physicians and hospital resources together in a more coordinated way.
Each article describes an approach to confronting the clinical silos of care, and
each system appears to have made good strides in breaking down the clinical
silos in its geographic area.
Anna Ma r ie H a je k • 45
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Why Is Breaking
Down Silos So Difficult?
As the articles illustrate, restructuring,
whether of an entire healthcare system or
of a service line, is not easy and requires
commitment to a shared vision. That
vision first needs to be created and then
needs to be reinforced over and over until
it becomes accepted and sustainable. Many
times the initial conversations begin from
a need for self-preservation and, as both
feature articles note, subsequent progress
requires hard discussions
Patient satisfaction has as and real dedication to workmuch to do with how safe ing from common ground.
patients and their families Healthcare is composed of
a host of special interest
feel while in the healthcare groups whose members
organization . . . as it does have their own specialwith how well the patients ized, academic preparation,
social system, and approach
feel.
to the work they do. The
many differences can lead to widespread
mistrust, which can be dispelled only by
the passage of time and working together
to build relationships. Eventually, broader
understanding will help the groups to put
new approaches into perspective and check
their biases at the door when meetings are
held. And ultimately, they will recognize
that the issues at stake are more important
than their differences and that collaboration
will make their goals more attainable.
I believe these articles reflect the laserbeam perspective that today’s healthcare
leaders and boards of directors have about
how to organize, integrate, and align
their organizations to be successful with
fewer resources and how to genuinely
improve healthcare quality and patient
satisfaction. The changes described in
these articles have massive structural and
cultural ramifications, and their architects
should be applauded for their foresight
and their dedicated, consistent leadership
in achieving their goals. Another area of
focus, however, is equally important to the
discussion of breaking down the silos we
have in healthcare today, and it is far more
granular and pervasive in our healthcare
delivery system.
Where Is Patient Safety
in This Conversation?
As both articles show, the organization of
healthcare delivery is both specialized and
complex. As new structures are formed,
the delivery system expands to include
them, whether as owned or as contracted
resources. The only real constant in all the
restructuring is that patients, residents,
visitors, and staff all remain part of the
ever more complex organization. Combining and coordinating the many pieces into
a true system of care with standardization,
clinical integration, and shared data are
important activities, but the necessity of
addressing the impact that the new structures may have on patient safety across the
continuum of care is equally important.
I have a different perspective on the
new delivery structures that relates to
another aspect of breaking down the silos
of healthcare. One reality that will not
go away with more far-reaching, innovative structures is the potential for patient
harm regardless of how the system of
care is structured. In fact, as systems of
care expand, so do the potential sources
of harm. Ironically, the management of
patient safety—or more specifically, the
integrated management of risk, quality,
and safety in the healthcare setting—is as
fragmented as the healthcare delivery system itself. As we work to gain coordination
in the delivery system, we must include
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Understanding Risk–Quality–
Safety Silos
Overlaying the healthcare system’s fragmentation and clinical silos is the parallel fragmentation of risk–quality–safety
management. Each area has a different
genesis:
• Risk management—insurance and
claims management
• Quality management—regulations and
accreditation
• Safety—response to medical error
(pointed out by the 1999 Institute of
Medicine report To Err Is Human)
The three areas do share the following
characteristics, though:
• Each is largely a hospital-based
function, although movement to
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Frontiers_29_4Summer.indd 47
physician practices is beginning to
happen.
• Each is considered an administrative,
not necessarily a clinical, function.
• Each is typically managed from
a different part of healthcare
administration: legal, finance,
medicine, nursing.
• Each collects data largely for its own
purposes and, in some cases, for
external reporting to such bodies as
the Centers for Medicare & Medicaid
Services and The Joint Commission.
The current healthcare delivery system incorporates risk, quality, and safety
into its infrastructure as separate functions, which has led to many competing
agendas.
Breaking down risk, quality, and safety
silos parallels breaking down clinical silos
in that all of the areas have traditionally
been managed myopically, each focused
on its own responsibilities without regard
for the total system of care. When trying
to understand a situation, each area tends
to look at an incident, a process, or a case
from its own perspective rather than applying multiple perspectives to a whole
data set; this approach undermines the
ability to recognize the overall impact on
the quality of care that an action or event
may have.
The Cost of Medical Error
In a study sponsored by the Society of
Actuaries and conducted by Milliman
Inc., Shreve and colleagues (2010) report
that medical errors continue to be made
and are costly to the US economy. In their
measurement of a medical claim database for a large insured population, they
estimate that 6.3 million medical injuries
C o m m e n t a r y
the coordination of risk, quality, and safety
management in the mix.
We live in a litigious society, where
potential allegations of medical malpractice pose a real threat for healthcare
providers—hospitals and clinicians alike.
Compounding the situation is the fact
that patient safety and medical error are
well-known consumer issues today. The
looming threat of malpractice suits must
be managed, and the process is simple:
no harm, no claim. Patient satisfaction
has as much to do with how safe patients
and their families feel while in the healthcare organization (hospital, clinic, doctor office, etc.) as it does with how well
the patients feel. When those factors are
taken together, it begs the question of
why healthcare leaders may overlook the
benefits of integrating the management of
risk, quality, and safety.
Anna Ma r ie H a je k • 47
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occurred in the United States in 2008 and
that 1.5 million of those were associated
with a medical error. They also estimate
that those injuries associated with a medical error resulted in a cost of $19.5 billion—mostly for additional services and
prescriptions needed by the medically
injured individuals, but also among the
costs were $1.4 billion related to increased
mortality and $1.1 billion related to lost
productivity caused by days missed from
work. The study does not take into account
the costs of potential medical malpractice
lawsuits and settlements,
The combination of
which might have added
healthcare system
billions more to the total
transformation and risk– cost.
These data clearly ilquality–safety management
lustrate the importance of
may well enable healthcare addressing risk–quality–
organizations to provide safety management within
greater benefits to their the healthcare delivery
system. Hospitals have
patients and communities. committed resources and
energy to promoting their
culture of safety with some success, but
how they can continue to do so within the
new healthcare organizational structures
is untested. To leave risk–quality–safety
management out of strategic planning for
structural transformation is to ignore potentially disastrous threats to the success
of the restructured enterprise.
What Can Be Done?
Several approaches can be used to close
the gap between the new structures for
healthcare delivery and the issues of risk,
quality, and safety. For example, both
feature articles note that the first priority when planning to break down clinical
silos is to engage physicians in meaningful
ways that will promote feelings of equality with the healthcare system. As the
alignment frameworks come together, the
organization can build incentives into the
physician compensation structures that
encourage real participation in efforts to
manage risk, quality, and safety. This raises
clinicians’ awareness of the importance
of risk–quality–safety management to the
leadership of the organization and helps
clinicians to mitigate their own potential
exposure to medical malpractice.
Another avenue is to extend the hospital’s carefully nurtured culture of safety
to the outpatient areas. This requires the
creation of a reporting culture in which
clinicians and staff are encouraged to
report unsafe conditions, system breakdowns, near misses in patient safety, and
actual harm to a patient. Such reporting
needs to be done quickly so that issues can
be immediately identified and dealt with.
While reporting has become standard in
the hospital setting, it is not standard in
outpatient settings, from the laboratory to
physician offices to rehabilitation centers
to patients’ homes—wherever care is
rendered. The establishment of a reporting culture needs to be a priority in every
organization’s quest to enhance healthcare
quality and patient satisfaction and to
reduce costs.
Each article discusses the need for data
to drive change in clinical processes, and
the same is true in the advancement of patient safety. The concepts of being a learning organization and knowledge management are not new, but in September 2012
the Institute of Medicine’s Committee
on the Learning Health Care System in
America issued a report that brought those
concepts into clear focus. We must be able
to collect data to help in decision making, and in the case of risk–quality–safety
management, those data need to be near
real time for an organization to achieve its
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Frontiers_29_4Summer.indd 49
rable from state to state and usually apply
only to hospital systems and not to longterm care facilities, physician offices, or
other healthcare entities. In 2005, President George W. Bush signed into law the
Patient Safety and Quality Improvement
Act (PSQIA), and enabling legislation
was passed in late fall 2008. The PSQIA
establishes a way for healthcare providers,
very broadly defined in the act, to report
unsafe conditions or incidents of harm or
potential harm in a protected environment
that guards against discovery in the event
of a medical malpractice lawsuit. The act
affords federal preemption to state laws
to level the field nationally. The protection
is extended to healthcare providers who,
through working with a patient safety
organization (PSO), collect information
for the purposes of improving healthcare
quality and patient safety and report that
information to the PSO for analysis and
recommendations for improvement. The
goals are to build a national patient safety
database that could be used to alert providers to issues creating harm and thereby
prevent future harm and, through the
PSOs, to build a repository of best practices to enrich the safety of our healthcare
system.
While the Affordable Care Act did a
lot to spur the creation of new healthcare
structures, the PSQIA enabled providers
to begin to address patient safety on a national level. Together they create a wonderful and timely opportunity for providers
to build the risk–quality–safety network
around the new structures being formed.
The PSQIA creates a safe learning laboratory for the new healthcare configurations
and facilitates the emergence of issues
that might otherwise go unraised for fear
of retribution or the possibility of legal
discovery and medical malpractice. The
C o m m e n t a r y
goal of reducing the potential for patient
harm. As I stated earlier, as a system of
care grows more complex, more sources of
potential harm arise.
Both articles also discuss the importance of educating all the parties to create
a shared vision and to give clinicians and
staff the tools they need to work in a variety of healthcare settings. The same tactic
can be employed in risk–quality–safety
management. Using the collective wisdom
and insight of risk–quality–safety professionals to promote a system-wide culture
of safety can result in an educational
curriculum that is custom tailored to a
specific organization.
The power of web-based information
technology cannot be underestimated.
Organizations are spending considerable
money and resources on the implementation of electronic health records to bring
their system of care together and support clinical integration. The impact of
creating and joining a health information
exchange, which requires even more of an
investment, is also just now beginning to
be realized. Again, parallel to these systems must be a risk–quality–safety network so that issues can be reported quickly
and patients’ safety-related information
can be traced through the system of care
as easily as their clinical information is.
This risk–quality–safety network needs to
be separate from the electronic health record because it is designed to bring quality
issues to light, and to encourage reporting, information needs to be entered in a
protected space.
Recognizing the importance of this
protected space, many states have enacted
medical studies acts or similar qualityassurance measures to protect investigations such as medical peer reviews. The
problem is that the laws are not compa-
Anna Ma r ie H a je k • 49
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Affordable Care Act went so far as to state
that healthcare organizations that have
more than 50 beds and wish to be part
of networks in the newly created health
insurance marketplace must have a patient
safety evaluation system (PSES) in place
to address any potential safety issues. The
PSES is a key requirement of the PSQIA
for both healthcare providers and PSOs.
It appears, then, that the combination of
healthcare system transformation and
risk–quality–safety management may well
enable healthcare organizations to provide greater benefits to their patients and
communities.
Conclusion
Leaver and Molden, Brown, and Griffith
describe two successful organizational
restructuring plans that integrated facilities
and clinicians, required cultural change
and a whole new approach to achieving
excellence, and accessed reimbursement
systems to support their strategies. In
both cases, the leadership and boards of
directors took big risks but persevered and
made significant investments in infrastructure, resources, and education to ensure
success. They paid equal attention to
making their organizations patient-centric,
starting with improved access to their
healthcare resources, and they have made
good strides in achieving their goals.
As Molden, Brown, and Griffith state,
“The US healthcare system’s multi-silo
culture will not go quietly into the night,
and breaking the bonds of this traditional
and hierarchical design will not be an easy
task.” I encourage healthcare leaders to
not assume that the management of risk,
quality, and safety will automatically take
care of itself as they create and execute
their strategies for new healthcare delivery
systems—because it will not. I applaud the
emphasis each article places on breaking
down clinical silos and using education to
build consensus and establish common
ground. I hope that the same courage and
similar approach can be applied to breaking down the risk–quality–safety silos that
keep our healthcare systems, in whatever
form, from being true healthcare safety
zones for our patients, visitors, and staff.
References
Institute of Medicine. 2012. Best Care at
Lower Cost: The Path to Continuously
Learning Health Care in America. Report
of the Committee on the Learning Health
Care System in America. Washington,
DC: National Academies Press.
———. 1999. To Err Is Human: Building a
Safer Health System. Report of the Committee on Quality of Health Care in
America. Washington, DC: National
Academies Press.
Shreve, J., J. van Den Bos, T. Gray, M.
Halford, K. Rustagi, and E. Ziemkiewicz.
2010. The Economic Measurement of
Medical Errors. Schaumburg, IL: Society
of Actuaries.
50 • f ro ntier s o f h e a lt h s e rvic e s m a na g e me nt 29 :4
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