Many health care leaders believe independent physician practices can’t perform well in the current environment because they’re not in a tight system with enough influence over provider behavior.
I know they can, because I led the development of two networks with these types of practices that outperformed many systems in our state on publically reported quality measures. In fact, they were among the top performers in Massachusetts.
To achieve results like these, physicians in your network must do things differently. That means you have to create an environment that actively engages them in improvement efforts, even when your organization’s name is not on their paycheck. Building that environment requires four essential ingredients: Culture, Trust, Decision-Making, and Local Infrastructure. Until the right environment exists, even the most basic request for change will be shot down.
Culture: Fostering a culture of quality involves, above all, respecting physicians’ professional values of self-direction, excellence, and putting patients first — often the drivers of physician behavior and engagement. This respect must be genuine and pervasive. Changing the culture is critical.
I learned this the hard way when I started building New England Quality Care Alliance (NEQCA), a network of community and academic physicians in eastern Massachusetts that is affiliated with Tufts Medical Center and today has nearly 1,800 physician members organized into regional groups of practices called local care organizations. The network was formed in 2006 to respond to market demands for higher value, and to strengthen our referral base to Tufts in a highly competitive environment that already had mature networks.
I asked our physicians to make the use of a very basic tool of population health management — a patient registry — mandatory, not optional, in their practices. I knew the practices needed to perform well in their managed care contracts, and they could do that only by incorporating systems like this into their workflows. It took many months and many meetings to convince the physicians that this was a good idea. The right culture did not exist across the network.
Much more change was needed to make NEQCA successful. The challenge was how to persuade a group that wouldn’t even consider the patient registry to accept other changes, identify needed improvements, and, with guidance, figure out how to make them. Our goal was to build an organization in which the physicians recognized that there was always room for improvement.
Using a combination of tactics to influence behavior — leadership, incentives, and tools — we held meetings to introduce the registry idea and presented data showing there was variation across our groups and an opportunity to reduce gaps in patient care and improve the network’s financial performance. To gain physicians’ attention, we made registry use a requirement to receive part of their bonus. Lastly, we provided a registry tool that was pretty easy for both physicians and practice staff to use, along with adequate training and support.
As of 2014, NEQCA was the highest performing physician network in eastern Massachusetts and the second-highest performer overall, based on quality measures reported by Massachusetts Health Quality Partners. It took almost that long to change the culture.
I saw this kind of transformation in the pediatric network I had the privilege to lead as well. Affiliated Pediatric Practices includes 90 physicians and nurse practitioners working in 17 community practices in Massachusetts. Founded in 1995 and currently affiliated with Partners Community Physician Organization, this network continues to perform at the top of the market in quality and patient experience.
Fundamental to respecting physician professional values is supporting self-direction; physicians need to figure out solutions on their own. To encourage this, we established NEQCA innovation grants at the local care organization level to fund fresh ideas. Many ideas were spread and many network-wide initiatives were started this way. Not all the ideas worked, of course, but they all came from physicians, and the network supported and funded the process. Among many examples, the network launched a pediatrics program that embedded pediatric social workers in practices to better care for children with behavioral health needs. For adult providers, burdened by payer prior-authorization processes for medication, the network established a pharmacy tech program to handle these prior authorizations.
At the same time, we gave individual practices significant autonomy. We set very high standards but did not require conformity. This allows the network to challenge the local practices and regional organizations to achieve quality and efficiency goals using local solutions. If encouraged, physicians will be motivated to change by the intrinsic desire to do better as professionals.
Trust: Establishing trust is critical for setting expectations in change management. In any kind of organization, you have to develop personal relationships with people to gain their trust. If you’re going to make this work in a network of independent physicians, a lot of relationship building has to happen. To do this, I spent time with physicians in their organizations. I probably knew 300–400 doctors on a first-name basis, and they knew me. If something went wrong, they would call me or others in the organization. They felt that they could be heard, and that what they said mattered.
Fostering trust in health care also involves making sure physicians know that patients always come first in your system. Some of our most important conversations with physicians were about this subject. At one of our annual quality conferences, for example, a physician described a patient who was considered due for a colorectal cancer screening by insurance claims but who had already had the test. The doctor wanted to know what to do. Very emphatically, I stated that the patient’s needs always come first, even if it costs the network performance dollars. I said the first day the network had to compromise patient care was the last day they would see me as its leader. I mentioned that we had an appeal process for this very reason, and that any physician who acted in the best interest of his or her patient would be individually protected.
Decision-Making: To support physicians’ values, you must engage them in everything that is done across the network, starting with creating a shared vision and the principles and policies that follow. The majority of our board members were community physicians, and while they mostly focused on high-level strategy, they helped set the principles upon which the organization did business, down to the committee level. There were many times when really tough financial decisions had to be made.
Our NEQCA funds flow committee, for instance, managed the distributions from pay-for-performance contracts, including surpluses. There were millions of dollars at stake, so establishing guiding principles was critical. One such decision involved how to distribute dollars related to health status adjustment methodology. For the first couple of years that we were in the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract, which rewards higher value care, the methodology we used turned out to be statistically unfair to pediatricians. We had to fix that — because our principle said allocations should be based on valid statistical analysis. Most of the network members were adult providers, so this would take money away from them. The policy was changed to make it more statistically fair. It was an example of good governance and decision-making.
Local Infrastructure: To be a successful physician network, you must expect structure and processes at all levels, especially within affiliated practices and local care organizations, because most of the necessary work happens locally. We required each practice and local care organization to have its own structure (such as regular practice meetings), establish a quality improvement team, and appoint a medical director to serve as a liaison with the network. It sounds basic, but if the local infrastructure is not there, you’re toast.
I believe that by engaging independent physician practices using the four ingredients of culture, trust, decision-making, and local infrastructure, you can accomplish the same — and perhaps even higher — quality performance goals than a single institution while at the same time respecting physicians’ sense of self-direction, excellence, and desire to put their patients first.