Improving Physician Organization and Health System Performance
Clinical Innovators | Stephen Shortell, PhD, MBA, MPH, is the Blue Cross of California Distinguished Professor of Health Policy and Management and dean emeritus of UC Berkeley's School of Public Health, where he also directs the School's Center for Healthcare Organizational and Innovation Research (CHOIR). He is an expert on organized healthcare delivery systems in the United States. Dr. Shortell has done extensive research on the organizational correlates and institutional incentives for improving quality of care and health outcomes, particularly when related to the management of patients with chronic illness. He has authored or co-authored nearly 300 articles in peer-reviewed journals and ten books including Remaking Health Care in America. Dr. Shortell received his undergraduate degree from the University of Notre Dame, his master's degree in public health from UCLA, and his PhD in the behavioral sciences from the University of Chicago. He has been the recipient of several prestigious awards, most recently the 2015 TRUST Award for Healthcare Leadership granted by the Health Research and Educational Trust of the American Hospital Association.
You were the Principal Investigator on the National Surveys of Physician Organizations aimed at providing data on the management of chronic illness as it related to physician organizations. What did we learn from these studies?
There has been steady improvement in physician practices' use of evidence-based care management processes for patients with chronic illnessspecifically, asthma, congestive heart failure, depression, and diabetes. For example, between 2007 and 2013 small and medium-sized practices (1 to 19 physicians) increased their use of recommended processes from 21% to 29%, while larger practices (20 or more physicians) increased their use from 32.6% to 46.7%. These processes include use of disease registries, nurse care managers for seriously ill patients, patient reminder systems and quality of care feedback reports to physicians.
However, as these data suggest, there are only a small number of practices who are approaching complete use of these processes, and the overall average is less than 50% (even among larger practices that typically have more resources to devote to such efforts). Our studies and those of others have generally shown that larger practice size, greater use of electronic health records, and external incentives such as pay-for-performance programs and public reporting are associated with great use of these care management processes.
You mentioned that larger practices use more evidence-based care management processes. Does this translate to improved outcomes?
Practice size is usually positively associated with process measures of quality of care but not necessarily with outcome measures. For example, a recent study led by my colleague Dr. Lawrence Casalino at New York Cornell Medical Center found that smaller physician practices had lower ambulatory care sensitive admission rates (hospital admissions that should not have occurred if patients were receiving good primary care) than somewhat larger practices. We plan to explore in greater detail the relationships among practice characteristics, use of care management processes and outcomes of care in future research.
You have proposed entities that might be called population health organizations (PHOs) for financially sustainable, integrated care. Could you tell us a bit about what these organizations would look like and how they differ from Accountable Care Organizations (ACOs)?
Another term that some use for these organizations is Accountable Communities for Health (ACH). They differ from ACOs in moving beyond a given population of patients attributed to a specific ACO under a risk-bearing insurance contract to being held accountable for the health of an entire population of people living in a given communityregardless from whom they receive their medical care. They are essentially cross-sector (healthcare, public health, education, housing, transportation, etc.) organizations that come together to form an "integrator" body that accepts responsibility for and allocates resources for the health of a broad sector of individuals in a given community. They emphasize the role played by the underlying social determinants of health, and they may initially focus, for example, on lowering the incidence of new diabetics over a period of time or reducing the percent of children and adults who are obese. Potential funding sources come not only from existing payers and providers (via community benefit requirements) but potentially from local foundations and social investors to create "Wellness Funds." There is considerable interest in the concept across the country and, particularly, in some of the New England states, Ohio, Minnesota, and California, among others.
You have studied the management of cardiovascular risk in California's top-performing physician organizations. What strategies should be implemented to accelerate improvements in this area?
We have been engaged in a 7-year initiative to reduce deaths from heart attacks and strokes by developing and sharing patient centered evidence-based best practices among medical groups, clinics, and health plans. We do this throughout the state in a series of monthly meetings we call the "University of Best Practices." Some promising strategies to accelerate improvement include placing pharmacists on the care team; giving greater attention to home blood pressure monitoring; consistent use of a medication bundle that includes aspirin, an ACE-inhibitor and statin; and patient self-management programs emphasizing active engagement in their care. We have observed small but steady improvement in process and outcomes of care through these and related efforts.
Is it difficult to engage physicians in organizational change?
It is often difficult to engage anyone in significant change that will require them to do some things differently than they have done before. Physicians are no exception. It may help to re-frame the issue not in terms of "change" but in terms of "improvement." No one necessarily wants to change but most of us want to improve. Physicians want to improve. They want to be the best they can be. They want to be the best for their patients. What makes this so challenging is that it is no longer just about what one can do individually but, rather, as a member of a team delivering increasingly complex care in increasingly complex organizations. That is the challenge.
How "accountable" are ACOs? What needs to improve?
They are becoming increasingly "accountable," but, in my view, too slowly. Payments need to move more rapidly away from fee-for-service towards bundled, capitated payments. Global budgets with quality metrics and threshold should be built in. The success to date of the Massachusetts Blue Cross/Blue Shield Alternative Quality Contract is one example, but there are others. At the same time it is important to recognize that not all physician practices are in a position to assume the downside risk for losses so that a "glide path" is needed as part of the transition. Some smaller physician practices, those serving vulnerable populations, and those in rural areas are particularly in need of technical assistance and attention. What we are observing is the co-evolution of payment reform and delivery system reform, and it is important to manage the pace of change. Greater standardization of quality measures, as well as greater transparency of both cost and quality data will help.
Interview conducted by Katlyn Nemani, MD, who is a physician at New York University.
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