Analysis of the first NEJM Catalyst Insights Council survey on the Leadership theme. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.
The journey from fee-for-service to value-based payments is going to require buy-in from everyone on the health care continuum. But who will be the most important stakeholders?
Physicians, according to 81% of participants in the first NEJM Catalyst Leadership Insights Council survey, are the most important stakeholders. Surprisingly, patients, who are supposed to be the epicenter of this evolving marketplace, are named the most important stakeholders by only 58% of Council respondents.
This survey was designed to assess the drivers of change in health care delivery, how well they are being addressed by leaders, and the skills and resources needed in this evolving health care landscape.
We are at an inflection point in the health care economy. Approximately 10,000 Americans a day are turning 65, causing a sizable swing from commercial insurance to government benefits providing coverage to citizens.
Reflecting this shift, the NEJM Catalyst survey ranks payment shifts as the biggest driver of change in the health care marketplace. Just over two-thirds (64%) of Council members say it is the most important driver. Council members from the Midwest score it even higher, at 75%.
Physician Fatigue with Fee-for-Service
Yet the predominant reimbursement schema today is still fee-for-service, and providers are frustrated because this system doesn’t give them the results or the incentives they want. Many physicians are facing low, even single-digit, profit margins. They have no wiggle room in these margins and risk going under. While some physicians are retiring as a result, others are joining hospitals or physician groups to reduce their risk. Still others are waiting for value-based payment to catch up.
The industry is anxious for change, as physician burnout rates rise. Researchers at the Mayo Clinic and the American Medical Association found that 54% of physicians suffered from burnout in 2014, a 10% increase since 2011. An author of the study from the Mayo Clinic, Tait Shanafelt, MD, said, “Burnout manifests as emotional exhaustion, loss of meaning in work, and feelings of ineffectiveness. What we found is that more physicians in almost every specialty are feeling this way and that’s not good for them, their families, the medical profession, or patients.”
Some good news is that health care’s migration toward a more team-based approach will ease the stress. Almost half of NEJM Catalyst survey respondents (47%) say care delivery model transformation ranks as the second most important driver of change.
VERBATIM COMMENTS FROM SURVEY RESPONDENTS
What important actions has your organization’s leadership team overlooked in responding to the evolving health care marketplace?
“The loss of joy in the practice of medicine and, the acceptance of the definition of quality health care by insurers.”
“Recruiting and developing analytical talent.”
“Measurement tools to monitor patient outcomes. De-emphasize volume and keep track of patient outcomes. Recognition of non-physician aids to improving patient outcomes.”
“Not enough attention to supporting mature physicians.”
“Building communication skills and infrastructure in traditional school of medicine departments.”
“Not developing necessary physician leadership skills and incorporating physician leaders in key planning and strategy.”
“Involvement of the practicing physicians from multiple specialties in responding to challenges. Too much top down.”
“Leveraging advanced BPM and technology (& integration) skills within the existing workforce, and purposely seeking out these skills in hiring.”
“The need for population health management tools to be in place.”
“Everything. Sad, but true; we are 100% reactive.”
The shift to multidisciplinary care teams, which can include nurse practitioners, social workers, behavioral health specialists, and others, is necessary, but it’s not without its own stressors, especially for physicians who were not trained to deliver care in this way. Time and resources must be spent to address the disruption that care delivery models introduce, and to teach everyone how to work together in the best interest of the patient.
Nearly half of respondents (49%) call the extent to which drivers of change are being addressed in their organization “appropriate.” As we move farther down the road to value in the next few years, that number should increase, and the 38% who say the response is “not enough” should shrink. A shift away from cleaver-like cost-cutting that revolves around layoffs and attrition, and toward quality approaches that rationally drive out waste (e.g., Lean and Six Sigma), will also increase comfort with change, in our view.
Not surprisingly to us, executives (61%) are far more satisfied than clinical leaders (48%) and clinicians (44%) with their organizations’ response to the evolving marketplace, according to the survey. More respondents in the Northeast (55%) feel their organization’s response is appropriate, compared with the South (43%).
The Right Ways to Prepare for Change
The primary ways that leaders are addressing change are realigning incentives and performance requirements for providers (tabbed by 45% of respondents) and focusing on organizational culture (44%). For instance, instead of scheduling more CAT scans, providers are studying the appropriateness of those exams and the effect on patient experience.
Although 59% of respondents say the top resource needed to successfully navigate change is data and analytics to inform decision-making, only 25% cite data and analytics as the most important driver of change.
While this might seem like a head-scratcher, it makes sense to us. Rich data is not yet available to most medical centers in this country in a way that is helpful with day-to-day management. And no matter how much data you have, if you’re not equipped to respond through a connected culture — that is, teams — you won’t be able to react appropriately. As bundled payments and capitation take hold and data begins to flow more freely, data will surely have a positive impact on, and be instrumental in, care delivery.
Yes, it would be great if health care organizations had moved beyond the need to build culture, communication, and teams, but we’re not yet.
And that is why the physician is the most important stakeholder at this critical time in health care. To get to the patient-centered model, you first need to fix the systemic problems that impact physicians.
METHODOLOGY AND RESPONDENTS
In June 2016, an online survey was sent to the NEJM Catalyst Insights Council, which includes U.S. health care executives, clinician leaders, and clinicians at organizations directly involved in health care delivery. A total of 495 completed surveys are included in the analysis. The margin of error for a base of 495 is +/- 4.4% at the 95% confidence interval.
The majority of respondents were clinicians (48%), with executives (25%) and clinician leaders (27%) nearly evenly split. Most respondents described their organizations as hospitals (37%) or health systems (16%). These hospitals were predominantly midsized (34% had 200–499 beds) or larger (47% had 500 or more beds).
Only 9% of respondents indicated that their major affiliation was with a physician organization. More than a third of those physician organizations tended to be big — 39% had 100 or more physicians.
Nearly three-quarters of the organizations (72%) were nonprofit, with the remainder of respondents coming from for-profit organizations. Every region of the country was well represented.
Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.
This Insights Report originally appeared in NEJM Catalyst on August 11, 2016.