Modern health care systems require more teamwork than ever to deliver the best treatments and solutions while keeping costs down. Physicians will have to get more involved in the overall picture, and focus on team building and team leadership. That’s the overall message delivered by Robert W. Pryor, MD, president and CEO of Scott & White Healthcare, who spoke on “Aligning Physician Hospital Incentives for Improved Outcomes and Reduced Costs” at the American Health Care and Exhibition, in Anaheim, California.
Scott & White was founded in 1897 in Temple, Texas, as a multi-specialty physician practice, and has grown to own and/or operate 12 hospitals, 60 clinics, and a health plan. Scott & White includes an academic medical center, suburban and rural community hospitals, critical access, and a children’s hospital. It employs more than 1,000 physicians, as well as 300 advanced practice professionals (which is the fastest-growing phase of primary care). Its health plan includes 210,000 members, and 35% of the organization’s business comes from that health plan.
For many physicians, the hospital is just one setting in their patient care experience. Many in private practice identify with their own practice but not the overall practice of medicine in the community. Physicians are reluctant to lead and be led outside of the medical model, Pryor suggests.
“‘One patient at a time’ is still how we think,” he says. “Peer review is difficult. We often see ourselves as representatives of our committee or our practice, not as part of the team overall.”
Economics Is Key
Pryor attributes much of Scott & White’s success to its being a physician-led organization. Its compensation packages are approved only by physicians, and an incompetent practitioner can be fired easily, whereas it might take years to terminate that same practitioner in an organization with a large voluntary staff. One looming challenge, though, is to persuade physicians to lead in-depth discussions of the economics of medical practice.
“You have to have accountability to a budget,” he insists. “We pair our chief medical officer with a chief operating officer: a physician and a lay administrator. All chairs report to the regional CMO, who reports to the overall CMO; each is paired to a COO; they have the same accountability.
“Hospitals, clinics, and health plans need to be pulled closer together. We have an increasing physician shortage. Physician time is the most costly per-hour time that we purchase in health care delivery. Can we deliver a team-based model that lowers costs while improving quality? Can we improve quality and access, while lowering per-unit cost?”
Scott & White’s physicians are compensated on an XYZ plan (base, supplemental, and incentives), in which the base salary (“X”) correlates to the number of procedures the physician decides to do in a year, and the supplemental pay (“Y”) can be negative if a physician is rated in the lowest 10% in patient satisfaction and quality of treatment. Physicians also can earn more by reducing readmissions, or by producing significantly more relative value units than agreed (“Z”). They also might earn extra money by relying more on advanced practice professionals.
Pryor says, however, that Scott & White’s physicians might return to a straight salary model, which they tend to prefer, rather than a productivity model.
“Physicians don’t always have to be incentivized by dollars,” he says. “I think they’ll do the right thing regardless. Outcome, access, and lowering costs will be our foci. You’re going to start being paid for quality.”
However, attracting people to the practice of medicine, one way or another, is critical. In particular, Pryor cautions, physicians are being driven out of family care because they don’t have time, in their 15- to 20-minute segments, to deal with comorbid conditions, especially mental health problems.
“A patient might have his hand on the door, and then say, ‘By the way, Doc, here’s what’s going on with me,’ but within the time segment allotted, we don’t have time for that,” he explains. “So we’ve embedded mid-level mental health providers in our primary care clinics. Now we can say, ‘Okay, I understand this is a big problem, so right now I’m going to take you to see my colleague down the hall—then we’ll get together next week and address this situation as a team.’”
Clinics, the Future
Scott & White’s future growth lies in its clinics, not its hospitals, Pryor says. The use of the former will go up; the clinic of the future might include a few hospital beds for administration of antibiotics, transfusions, and so forth, with the patient sent home at night to keep costs down.
To budget a clinic, Pryor says, it’s necessary to know a range of revenue that can be expected in the next year. It’s also important to keep a lid on costs without reducing or withholding services.
“We write generic prescriptions when we can, and individual medications rather than combi meds if the patient can comply,” he says, “We’re a low-cost island in the state of Texas. We’ve saved Medicare a lot in the past 10 years. We’re about half, in our Medicare costs, to the national average.
“We save money not just for Medicare, but also for Blue Cross, Cigna, and other carriers. When physicians practice in a cost-effective manner, they tend to spread that around.”
As another example of cost savings, Pryor discusses a Scott & White clinic in the remote town of Mason, Texas, where a practitioner might see something unusual on a patient’s EKG. She could call the main cardiology department and say, “We might have a problem”; the specialist there could call up all of the patient’s records as well as that EKG, and thus might be able to save the trouble of running a redundant test.
Teams are the future of health care, Pryor says, and it’s important to teach young physicians that they are part of the team: not the team, as past generations of physicians have often considered themselves. Extending that team into the home will be a major part of the process.
The community health care worker will be the fastest-growing occupation in the industry in the next few years, Pryor predicts.
“These workers don’t make decisions—but they have protocols,” he explains. “Heart failure patients who leave the hospital are visited by these workers for seven days after release. They do the ‘Cheetos sweep,’ look for salt, make sure the patients are taking their meds.
“In the old days, I visited patients at home, and I found out things I never knew from sitting across a desk from them. Medicine practiced in the home, with extenders, is where medicine is going. It’s how we’ll bend the cost curve.”
Joseph Dobrian is a contributing writer for Health CXO.