Drs. Angood and Cacchione; and Ms. Jaskie Moderators: Dr. Chazal and - - PowerPoint PPT Presentation

St Strat rategic gic Pl Plan anning ning Boo

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the e Val alue ue Tra ransf nsformat

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ion

• Drs. Angood and Cacchione; and Ms. Jaskie

Moderators: Dr. Chazal and Mr. Jacobovitz

Disclosures

Pet eter er Angood, good, MD MD

Nothing to disclose

Joseph seph G. Cac acch chione ione, , MD MD, FACC CC

Consultant Fees/Honoraria: Aim Speciality Health; United Healthcare Scientific Advisory Board

Richar chard d A. Chaz azal, al, MD MD, FACC CC

Nothing to disclose

Disclosures

Shalom alom Jac acobo

• bovitz

vitz

Officer, Director, Trustee or Other Fiduciary Role: Clene Nano Medicine

Suz uzett ette e Jas askie ie, MBA

Consultant Fees/Honoraria: Boston Scientific Corporation

Disclosures

Howar ard d T. Wal alpole pole Jr., , MD MD, MB MBA, FACC CC

Salary: Zoll Medical (Spouse)

Agenda

1 2 3 4 5 6

Strategy and the healthcare environment What does an effective strategy process look like Physician compensation is a strategic issue Break Programs must address these strategic issues Discussion – Q&A

Strategy and the Healthcare Environment - Trends

Peter Angood, M.D. February 18, 2016

8

8

9

A Brave New World!

1

Changing Definition of “Hospital

• spital”

 More

re Integr gration ation Opportuni tuniti ties es

 M&A Ac

Activit ivity

 Ph

Physici ician an Integr grati ation

• n

 Communi

unity Coord rdin inati ation

• n

 More

re Ri Risk Man anag agem ement ent

 Incre

reased ased Ac Account countabi abili lity

• R. Umbdenstock-Healthcare Executive Mar/Apr 2014 (pp.78-79)

1 1

53 Global Health Care CEO’s

Chal alle leng nges es for F r Future re:

Man

anag agin ing g Ch Chan ange

Fundin

ding g Car are

Defin

fine/M e/Measure easure Qual alit ity

Man

anag agin ing g Regula lation tion Lead adership ship Char aract acterist ristics: ics:

Inno

novativ ative

Insi

sigh ghtfu ful l on Pat atie ients

Insi

sight ghtful ful on Pro Provid ider ers

Coll

llab abora rativ tive

Dat

ata a Anal alytics tics

Humil

ilit ity

• R. Herzlinger & GENIE

1 2

FS FSMB MB Up Updat dated ed St Stat ats

 Nearly

y 900,00 ,000 li license sed d physicians s in in the US (280 physi sicians/1 ans/100,00 ,000 popul

• pulati

ation)

• n)

 Avg

vg. . age = 51yr yrs and ~79% are certif tified ed by by an Ameri rican Board rd

 2/3 of physicians are Male but…Female physicians increased by 8% in past 2 years  comp

mpare ared d wit ith only ly 2% of male le physicians

 34%

% of fe female e physi sician ians s are < 39 years

 comp

mpare ared d wit ith only ly 18% of male le physi sician ians. s.

 Activ

tivel ely li license sed d physician popul

• pulati

ation grew faster er in in older lder popu pulati ation

• n

 11%

% in increa rease se those se > 60 years vs. 1% in incre reas ase those se < 49 years s

 26%

% of physicians are now

• w over
• ver age 60 years,

,

 a d

demon monst strabl rable actu tuari rial al need for for an in increa rease sed d suppl pply y of physicians s

JMR 2013;99 ;99(2):11-24 24. .

1 3

Su Surge rge Wit ith Physici ysician an Em Emplo loyment yment

 ~75% in

incre rease ase in in numbe ber r of active e physici cians ns employed ed by hospi pita tals s sin ince e 2000

 ~75% of hospital

pital le leader ers s pla lan to in incre rease ase physici cian n emplo loyme yment nt with ithin n next 12 to 36 month ths. s.

(MGMA Survey)

 Share

re of physician cian searches hes for for positi ition

• ns

s with ith hospita tals s hit it ~75% in in 2014 14

(Merri ritt tt Haw awki kins)

 Trend

d is is accel eler erat ating g => 3 in in 10 10 physici sicians ans are now

• w hospi

pita tal emplo ployee ees s

 2001

1 to 2011 11, , # phys ysic icians ians & dentist sts s empl ployed d by by US hospi pitals ls grew w by by >40% 0%

 60%

% FP & Peds; 50% Surgeons; eons; 25% % Surg Spec are emplo ployed ed – not

• t indep

epende dent (AHA & AMA)

1 4

Me Medscape: scape: Em Emplo loyed ed Do Doct ctor

• rs

s Repo eport

(~4600 00 Physicians cians in in 2014 14)

1 5

Em Emplo ployed ed or

• r Cons

Considering idering It It

1 6

 The old

ldest st and la large gest st educati ationa

• nal organi

nizati zation n sole lely y dedic icat ated to physici ician an le leader dersh ship

 250K

K educat ated d & current ntly y wit ith 11,00 000 physici cian an membe mbers s represe senti nting ng 45 countries

 75 expert

t faculty y across dozens ns of di discipline nes

 Approxima

mately 10 100 0 physici cian an le leader dersh ship ip course ses and several al certifi ificat cate program ams

 4 Master’s degree programs with more than 1,200 graduates (PhD in development)  More than

n 21,00 000 0 physici ician ans s have completed the popula lar Physici cian an in in Manag agement serie ies

 More than

n 2,200 00 physici ician ans s wit ith board certifi ificat cation

• n (Certified Physici

cian an Executive)

 >220

0 in in-hou house se le leader dersh ship ip course ses taugh ght each h year at hospitals als and healt alth h systems

 More than

n 3,200 00 onli line ne courses s deliv livered annu nual ally

 4 major li

live educat ationa nal l conference nces s per year

American erican Association

• ciation for

r Phys ysician ician Le Leader dership ship By y the e Num umber ers: s:

1 7

So What Are We Hearing Out There??

1 8

1 9

DiS DiSC Pre refer eren ence ce In Inst stru rument ment

Total

• tal respon

pondents: dents: 2,6 ,663 63 phys ysicians icians Forced rced cho hoic ice in inst strument ument – 28 sets ts of 4 w words ds:

• “most like me”
• “least like me”

St Stat atis istical ically ly val valid idat ated ed; ; some e sim imil ilar arit ity to My Myers Bri riggs

2

Conscientious nscientious Do Domi minat nator

• rs

Steadiness

• Performs

consistently

• Ponders all angles
• f any problem
• Likes stability

Dominance

• Quick to act
• Likes challenges
• Forceful

Influence

• Considers

people first

• Is talkative
• Likes to meet

new people

Conscientiousness

• Gathers data

before acting

• Is precise
• Likes to be perfect

14% 14% 29% 29% 50% 50% 7% 7%

2 1

BMC Health Serv Res. 2014; 14: 616. How physicians identify with predetermined personalities and links to perceived performance and wellness outcomes: a cross-sectional study

JB Lemaire, JE Wallace

2 2

2 3

MD MDs vs. . No Non-MDs MDs as as Le Leader aders

2 4

Transformational Leaders: Measurement of Personality Attributes and Work Group Performance High scores on transformational leadership were associated with a distinct personality pattern characterized by higher levels of pragmatism, nurturance, and feminine attributes and lower levels of criticalness and aggression. This enabling pattern formed the core of transformational leadership.

SM Ross, LR Offermann Personality and Social Psychology Bulletin 10/1997; 23(10):1078-1086.

2 5

2 6

Physic ysicians ians as as Ho Hosp spital ital Lea eader ers

How

• w are hospitals

als and healt alth h systems dif ifferent when n run by p physicians ns?

 Better underst

stan anding ng on nature of challenges ges & common mon know

• wledge

ge base

 Improved underst

stan anding ng of patie ient nt care operationa tional is issues

 Unw

nwilling ling to c compromi

• mise

se quality/ ity/sa safety/ y/labor for profit it

 Fin

inan ance ce as a mean ans s not

• t an end

 Ali

ligni gning ng dif iffering ng values lues (RNs, s, PHAs, , DOC OCs, etc.) .) & im improved in interact actions

• ns

 Great

ater value on physici ician an le leader dersh ship, , compens nsat ate appropriat ately

 Antici

icipat pate chan ange ge wit ithin n healt alth h care in industry and sele lect ctively y emb mbrace ace new techn hnologi

• gies/

s/met metho hods ds, , e.g., ., new trends, s, governm nmenta ntal regulat ation

• n

 Better coordin

inati ation n wit ith referral al sources s (privat ate offic ices/ s/clini nics) cs)

 Less dupli

licati ation n of s sim imila ilar services ces wit ithin n region, n, more coll llabo aborat ation n among

• ng lo

local hospital tals

 Great

ater in insigh ght in into cli linical cal/pat patient care activity y on lo local and regi giona

• nal lev

level

(Kearn rns et al - Physician an Exe xecut utive Journal, , Jan/F /Feb 200 009)

2 7

Physic ysicians ians as as Ho Hosp spital ital Lea eader ers

Rank

Organization State Name of CEO/Presdient Physician?

1 Johns Hopkins Hospital MD Paul B. Rothman Yes 2 Massachusetts General Hospital MA Peter Slavin Yes 3 Mayo Clinic MN John H. Noseworthy Yes 4 Cleveland Clinic OH Delos M. Cosgrove Yes 5 UCLA Medical Center CA David T. Feinberg Yes 6 Northwestern Memorial Hospital IL Dean M. Harrison No 7 New York-Presbyterian University Hospital of Columbia and Cornell NY Steven J. Corwin Yes 8 UCSF Medical Center CA Mark R. Laret No 9 Brigham and Women's Hospital MA Elizabeth G. Nabel Yes 10 UPMC-University of Pittsburgh Medical Center PA Jeffrey A. Romoff No 11 Hospital of the University of Pennsylvania PA Ralph W. Muller No 12 Duke University Medical Center NC Victor J. Dzau Yes 13 Cedars-Sinai Medical Center CA Thomas M. Priselac No 14 NYU Langone Medical Center NY Robert I. Grossman Yes 15 Barnes-Jewish Hospital/Washington University MI Richard Liekweg No 16 IU Health Academic Center IN Dan Evans No 17 Thomas Jefferson University Hospital PA Stephen K. Klasko Yes 18 University Hospitals Case Medical Center OH Thomas F. Zenty III No

U.S. News Best Hospitals 2013-14: the Honor Roll

2 8

Physici ysicians ans as as Ho Hosp spital ital Lea eader ers

 Among

ng the nearly y 6,50 500 0 hosp spita tals s in in the Unit ited ed St States, s, only y 235 5 are run by physi ysicia cians ns

(2009 9 - Acad ademic emic Medicine) ne)

 Ove

verall ll hospit spital l quali lity ty scores

• res 25%

% hig ighe her r when en doct ctor

• rs

s ran the hospit spital, l, compared pared wit ith h ot

• the

her r hospit spitals ls. .

 For can

ancer cer car are, , doct ctor

• r-run

un hospitals spitals posted ed scores

• res 33%

% high igher scores es

Physi sici cian an-Lead Leader ers and Hosp spital al Performan mance: ce: Is There e an Asso soci ciat ation? n? (Goodal all July 2011 - Soci cial al Science nce and Medicine) ne)

2 9

ACOs Os – MS MSSP SP (CMS: 1/30/

0/14) 4)

 367 gro

roups ups of pro rovid vider ers formed ed ACOs Os

 5.3 million

llion Medic icare are patien ents s serviced viced (1 in 8)

 115,00

000 0 US doctor

• rs involv
• lved

ed in so some e way

(LEAVITT PARTNERS)

 First

st class ass of ACOs Os saved ed $380 0 millio llion n

 Of 114

14 ACOs Os in the pro rogram, ram, 54 ACOs Os saved ed mone ney y and 29 saved ed enough

• ugh to rece

ceiv ive e bonus. us.

 21 of 29 suc

ucce cess ssful ful ACOs Os with h rece ceived ed bonuses uses we were re physici sician an-led led.

3

(Dreyfus Model)

3 1

Where is Cards…Where are YOU

What Does an Effective Process Look Like?

Joseph Cacchione, M.D. FACC Chairman, Strategic Operations HVI February 18, 2016

1) Does your Organization have a plan?

• A. Yes
• B. No

2) Are you part of the planning process?

• A. Yes
• B. No

3) Are you seen as an owner or customer?

• A. Owner
• B. Customer

Question- 1

Important Concepts

• Mission – Who we are?
• Vision – Where are we going?
• Strategy – How are we going to do it?
• Tactics – What are we going to do?

Question - 2

1) Are you aware of these concepts for your

• rganization?
• A. Yes
• B. No
• C. Don’t care

Strategy

A W Worki king ng Definition nition: Strategy is the process of profitably matching internal resources with constantly changing external demands

Five Iron Laws of Strategy

• 1. History Drives Strategy
• 2. Focus
• 3. Innovation
• 4. Diversification
• 5. All Growth Will End

Strategy – Nuts & Bolts

• Industry Analysis
• What is our position?
• How do I appeal to my customers?
• How do we organize?

Industry Analysis

• Suppliers
• Buyers
• Rivals (competition)
• Complimentors
• Substitutes(competitors)

Question 3 -Competition

1) Are we different?

• A. Yes
• B. No

2) Is There Excess Capacity in your market, driving

competition?

• A. Yes
• B. No

3) Switching costs / inertia (are your customers loyal?)

• A. Yes
• B. No

Tacit Coordination

• Public data
• Concentration in Markets
• Capacity
• Exit Barriers

Elements of Strategic Investment Decision

• Financial Planning – IE ROI
• What are the uncertainties? (sensitivity

analysis)

• Contingency
• Technology Forces
• Market forces

Strategic Investment Decision Tree

• New Product – IE TAVR
• Capacity Expansion – New “OR”
• Shut Down – Close programs within the system
• Sequential Investment

Two Growth Paths

• Incremental, year-to-year sustaining innovations (exploiting

what we know)

– Bringing a better product or service to current customers

• Breakthrough, disruptive innovations (exploring the known

and unknown)

– Finding new customers with product or service offerings that are not interesting to current customers

Strategic Business Leadership, March 2007

“Scenario Planning”

• A disciplined method for Imagining
• Driving Forces
• Ranges
• Create Scenarios using the portfolio of driving forces

Paul Shoemaker, Scenario Planning: A Tool for Strategic Thinking, 1995

Creativity is an idea (tangible and /or intangible) that changes a social system

“Creativity is any act, idea or product that changes an

existing domain, or that transforms an existing domain into a new one. And, the definition of a creative person is: someone whose thoughts or actions change a domain, or establish a new domain.

• M. Csikszentmihalyi, Creativity, 1996

Combine Facts and Imagination

Facts Narratives

• Observe Reality

“Make Believe”

• New Facts

“Invent Realities”

• Logic & Deduction

“Create Illusion” Intuition

Strategy Summary

• Does your organization have a plan?
• Are you aware of that plan?
• Are you an owner, constituent, customer or

barrier?

• Does your strategy have an execution plan

and how are you measuring success?

BREAK Tic ick- Tock…

Compensation is a Strategic Issue

Suzette Jaskie, President MedAxiom Consulting February 18, 2016

1) I am employed by a health system?

• A. Yes
• B. No

2) My compensation plan is based 90% or more on physician productivity.

A. Yes B. No

3) My performance is reviewed annually

A. Yes B. No

Question- 1

ED ED Admit t Hospita spitalist ist Disc scharge rge Prim imary ry Care re PCP Refer er to EP AF Abla lation tion PCP Reta tain in patie tient med edica ical managem emen ent Card rdiol iologis

• gist

Reta tain in patient tient medica cal l managem gemen ent Card rdiol iologis

• gist

Consu sult lt, , no proce

• cedure

re – no foll llow

• w up

Card rdiol iologis

• gist

Refer er to EP No AF Abla lation tion

ANTI-VISION or Blind Operations

CORP-329802-AA July 2015

Is Fee

ee f for r Service the Culprit or Notion ion of Clin inic ical l Strateg egy? y?

Compensation is a strategic issue

Value ue inc ncentivized ntivized healthc lthcare are syst stem em creat ates es integrat egrated d health lth syst stem ems. s.

1) I am involved in either an ACO or a bundled payment initiative.

A. Yes B. No

2) My compensation plan has changed since the introduction

• f healthcare reform.

A. Yes B. No

Question- 2

Medic ical al Managem gemen ent t Primar ary Care Medic ical al Managem gemen ent t Cardiology iology Procedure edure

PROGRAM VISION Based on Clinical Standards and a Systematic Approach

Diagnosis Based Treatment

Requires new skills: Clinical Standardization, Team based care, Care and transition management and I.T. integration And new strategies: Programmatic approach, Clinical integration, Dyadic leadership, Ambulatory V.2.0 and Value performance

Compensation Frameworks

Base se

Productivity Models Productivity + Incentive Models Base Salary + Incentive Models Productivity

I P

= Base pay = Other Incentive = Productivity Incentive

P P

I Base se

P

I

KEY KEY

RVU or Revenue Expense Allocation Sharing Compensation Pool % Productivity % Sharing %Incentive Allocation Base Salary Productivity Incentives Other Incentives Productivity Thresholds

Source: Suzette Jaskie, MedAxiom

Will histor

• rica

ical model els s suppo port t transiti sitioni ning ng to value ue based sed care? Transforming to value based care will require

• rganizations to

redesign their delivery models Traditional models

• nly value direct

clinical activity Models based on productivity have no connection to

• utcomes

Comp and Salary Alignment

Base se

Fee-for-Service Transitioning Value Productivity

I P

= Base pay = Other Incentive = Productivity Incentive

P P

I Base se

P

I

KEY KEY RVU Models RVU + Incentive Models Base + Incentives Models

Source: Suzette Jaskie, MedAxiom

DOMAI AINS Deliv iverable erable exampl ples es Compen pensati sation

• n

Physician participation Leadership participation Medical director Program development Hourly or job description based fee Quality based incentives Quality metric improvement Clinical process improvement Patient satisfaction Incentive pool Operation Bundle coordination EMR/CPOE functionality On-start times Incentive pool Financial Purchasing Budget variance Cost per unit Multiple Program Outreach development Program expansion Expense support and/or physician time

Potential Compensation Incentives

Other Metric Examples

• Clinical Outcomes
• Readmission rates
• Patient safety
• National quality

indicators

• Efficiency/Process
• Standardization
• Length of stay
• Cost per case
• Supply cost
• Documentation
• Patient satisfaction
• Surg/Card

coordination

• Program

development

• Outreach

development

• AUC
• Quality assurance

programs

Improvemen ement t Go Goal l

Incenti ntive e Weight hting ng

Operative Mortality for CABG (Estimated Odds Ratio) 15% Surgical Re-Exploration (Estimated Odds Ratio) 15% Prolonged Intubation 10% Surgical pts Pts given Pre-Operative Beta Blockade 5% Develop CABG bundle task force and base-line assessment and plan 15% Reduce OR supply cost 15% 5% 90% adherence to CABG order sets 10% 80% appropriate discharge by 9:00 am daily 10% Post surgical discharge follow up visit within 7 days 5% 90% of patients enrolled in clinical research protocol 10%

Improvement incentives are worth 20% of physician compensation

Quality Finance OPS Sts Rsrc

Summary:

• Health systems strategies are generally in pursuit of some aspect of the

Triple Aim

• Achieving the triple aim, or value based healthcare will require a whole-sale

change to care delivery

• Hospitals want & need active physician participation at every level
• Physicians want & need active participation at every level

– Long-term success depends on it – Creates the best environment for improving quality, cost & service

• Compensation frameworks must be reframed in order to align strategy and

incentives

Key Strategic Issues

Peter Angood, M.D. Joseph Cacchione, M.D. FACC Suzette Jaskie, President February 18, 2016

CV Delivery Model

1. Will the current delivery model result in high value care? 2. Do I offer my patients programs or services? 3. Have I organized CV delivery that results in the best possible patient experience? 4. How will MACRA and Value Based Modifier impact the

• rganization’s revenue stream?

Physician Strategy

• 1. Is the delivery model organized to maintain physicians in

diagnosis and treatment mode MOST of the time?

• 2. Do I have the right people on the bus?
• 3. What is my recruiting and succession strategy?
• 4. Will the way we evaluate quality and physician

performance be relevant in the future?

• 5. Is the physician compensation plan aligned with the
• rganization’s strategy?

Ambulatory Strategy

• 1. Can I afford my outreach strategy?
• 2. Do patients and referring physicians have adequate access

to my program?

• 3. What e-health strategies make sense for my program?
• 4. Does my ambulatory strategy support growth?
• 5. Is the program offering the right services in the right

locations?