Population Health – the how

I continue to hear strategy pundits say they either don’t know what population health means or that population health doesn’t exist.

If they are confused by the definition or existence of population health, they’ve been asking the wrong people. Clinicians who have actually delivered Population Health at the bedside or in the exam room, rather than individuals who’ve merely read about it, are the better sources for understanding value-based healthcare.

Here’s my proof:

  1. If we define population health simply as lower total cost plus higher quality, and
  2. If we accept the AHIP / NCQA / Consumer Reports data showing which health systems consistently deliver the highest quality outcomes, and
  3. If we accept years of proprietary Aon-Hewitt data or other observations that Kaiser Permanente (KP) produces a 12-25% lower total cost of care than local competitors when benefit-to-benefit comparison is accomplished, then
  4. We can say not only is KP an excellent example of Population Health, it’s been doing it successfully for 75 years, ever since Dr. Sidney Garfield and Mr. Henry Kaiser began prepaid healthcare (Dr. Garfield received 10-cents per week for each employee to prevent and treat illness and injury, improving the lives of those hardworking men and women).

So the assertion by Nate Kaufman and others that population health is vaporware is not supported by the evidence.

How Kaiser Permanente (KP) does what it does is the real insight, the real question.  The how is clearly not easily transferable; otherwise KP’s local competitors would compete more effectively for top honors.

I also hear assertions that how KP does what it does is due to care protocols, or a single enterprise-wide EMR, or that Permanente physicians are employed. In fact there are many delivery systems in the US that have one or more of those attributes, and some that have all three of those attributes, yet their performance is variable.

Instead, I assert that how Kaiser Permanente does what it does is due to physician practice patterns that differ substantially from fee-for-service (FFS) and that those practice patterns are the result of (1) physician leadership, (2) physician culture and (3) systemic workflows that reduce the duration of time between onset of illness and definitive resolution of its cause.

Improving practice patterns is hard for any health system, and real physician leadership is a requisite.  That’s not easily understood by persons who have not led physicians.

Population Health – the (im)precision of language

hospitalNo phrase has less meaning in our industry right now than “Population Health” – this coming from the guy leading his firm’s practice in … wait for it … Population Health.

Everyone has a different picture in their head when those two words leave their mouth, yet that is the industry-standard term nowadays to convey “what comes after fee-for-service (FFS)”.  Here are merely the Top Ten most common meanings in the industry when those words are spoken:

10. Telephoning patients for the purpose of convincing them to consume preventive services

9. Disease Registries embedded in an EMR

8. Convince patients to modify their personal choices (usually via financial-pain or -pleasure)

7. Financial Bonuses to physicians for achieving a numerical score on quality metrics or for following a more complex coding and documentation process

6. Binding together physician practices for the purpose of negotiating higher professional fees (CIN)

5. A software bridge allowing a modicum of data-transfer between different EMRs

4. Buying or building more bricks and mortar to capture more patient care (revenue)

3. Convince patients to undergo biometric testing (patient engagement anyone?)

2. Enforcing the use of Evidence-Based-Protocols for common disease states

1. Providers assuming financial risk or gain for the cost of care provided

Those snapshots represent a small number of available tactics at best, and entirely miss the true meaning of Pop Health at most.  Here’s my definition of Population Health – “the manner in which healthcare design necessarily changes, once it is no longer paid for by piece.”

If the healthcare in question uses FFS as the mechanism for payment, by definition it AIN’T Population Health. The purpose of Population Health is to create higher quality care at lower or similar cost (better care experience, less harm, and more reliably favorable outcomes). In my experience, those better outcomes rarely occur and are never sustained over time, if paid for by FFS, particularly in the absence of group physician practice.

In order for care redesign to be funded and implemented by hospitals and physicians, those providers must be paid for what doesn’t happen: the ER visit avoided because the doc stayed late in the office to diagnose and treat the patient’s UTI; the cardiac cath avoided in the 22 year old with a pulled pectoralis muscle because a history and exam pays the same as cath; an admission avoided because the ambulatory physician did a great job of organizing the patient’s care, such that decompensation never occurred.  Spending time with patients, thinking about them and with them, and coordinating their care all take time, and as we all know, time is money. FFS can only account for what does happen (the ER visit, the admission, the cardiac cath); it’s non sequitur in the context of Population Health.

So the next time you hear the phrase Population Health, ask two questions: (1) “What the hell do you mean by that?”, and (2) “Before we go on, do we agree FFS payment of any type is NOT involved?”

Farewell, KP

At the end of this month, following 20 years of service, I will leave Kaiser Permanente.  For each of those years, I’ve given all I had to the organizations – particularly during the last ten years.  It’s simply time I do something else.

I’m proud of what we have built together:

We’re #1 in Quality in the state every year, now nine years running, and one of only three Medicare Advantage plans east of the Mississippi that has earned the coveted 5 STARS.

We are a medical group with a wide range of specialties, broad capabilities in analytics and the science of improvement; led by physicians, professionally managed.

And a medical group that works hard to get better every day. 

My decision to leave has nothing to do with our business in the Georgia Region.  Our care model and quality results are the envy of the Georgia market. 

Rather, it’s time I use my experience and skills to make a difference “out there” – beyond KP and beyond the Georgia market.  I’ve accepted a role with Huron Consulting, headquartered in Chicago.  Huron has a well-earned reputation for providing sustainable operational, financial and work-flow solutions to healthcare providers, intently listening to and serving its clients.   Huron also is a cultural fit for me – a collaborative team of hard-working consultants that enjoy helping clients.  I hope to help the industry transform from “fee for service” to “fee for value” and create safer, more effective, and patient-centric care.  That’s been my mission since my days in training.  It’s why I made KP my home these 20 years. 

I’d like to think I’m leaving our Medical Group in better shape than I received it.  And, as proud as I am of this organization, the next EMD will make it even better.  Please show him or her the same support, the same enthusiasm, the same high commitment to excellence and continuous improvement that you’ve given me. 

In these final days, I’m thinking of my happiest moments here… the time spent at the bedside with you, my trusted colleagues, together figuring out our patient’s illness and what you and I were going to do about it… documenting incisive medical reasoning… using evidence-based medicine… putting the interests of the patient and family above all others. 

I wish you all well. Thank you for 20 great years.

A Glass Once Empty, Now Half Full

glass half full #2Twenty years ago I sat with my fee-for-service (FFS) colleagues in the auditorium of St. Joseph’s Hospital (SJH), witnessing an appeal from hospital administration to join the fight to eliminate unwarranted healthcare expense. Revenue was down, expenses up, and the CFO was worried.  Our reply was an incredulous version of “… but we (physicians) control only 20% of the total expense!”, referring to our professional fees. We preferred to blame plaintiff attorneys, pharmaceutical and device manufacturers, and the for-profit insurance companies as the cause of The Cost Problem, rather than take an appropriate portion of ownership. It was then I first heard or thought, “Ah, but 80% of the spend flows from our pens.”

blame game #2In the 20 years elapsed, we physicians traded-in our pens for keyboards and double-clicks, and SJH never did solve their price / cost equation, ultimately having to sell the hospital to Emory, which has so far been better at raising prices than lowering expense.

But what about that physician crowd in the SJH auditorium, now 20 years older? What’s their present-day point of view regarding physician responsibility for America’s Healthcare Cost Crisis?  Mayo Clinic researchers published a study this week in JAMA answering that question (Views of US Physicians About Controlling Health Care Costs, Tilburt JC, et al. JAMA 2013;310(4):380388). Thankfully, we physicians are more insightful and courageous about our role in healthcare costs than 20 years ago.

the buck stops here

Oh sure, we still like blaming the lawyers (60% of physicians), insurance companies (59%), pharma (56%), and even patients (52%), but finally we believe …

  1. We should adhere to clinical guidelines that discourage the use of marginally beneficial care (79% of docs)
  2. We need to take a more prominent role in limiting the use of unnecessary tests (89%)
  3. We have major responsibility for reducing healthcare costs (ok, only 36% of physicians agreed with that one, but that’s a glass no longer empty).

Not unexpectedly, physicians compensated through a salary (rather than FFS) and/or who practiced in a group or government setting had more enthusiasm for cost-consciousness.   Physicians who have the most to gain financially from wasteful practice will be the last to assume responsibility in controlling costs. Alas, we still have far to go before we sleep… 85% of respondents believe “the cost of a test or medication is only important if the patient has to pay for it out of pocket.” For more information, see my prior post, The Morality of Resource Stewardship.

Drive within Physicians

motivation - money

Seventy years of behavioral science research has failed to overcome folklore about what motivates most Americans.  Corporate language makes frequent use of the terms “bonus”, “incentive”, and “pay-for-performance (P4P)” in a context not supported by the scientific study of motivation.  Indeed, many healthcare pundits are writing enthusiastically of financial schemes intended to motivate individual physicians to achieve greater levels of clinical achievement once ACA is fully implemented, most recently in the Wall Street Journal (Monday, June 17, 2013: Squaring Off: R2).  But those writers don’t adequately understand (1) the human condition in general, (2) physician behavior in particular, or (3) the difference between what individuals can accomplish verses systems and teams.

daniel pink drive

I’ve written previously about this topic (“How do you get doctors to …?“, “What Role, Money?“, “Happy Doc = Happy Patient“).  But this week I’m rereading Daniel Pink’s sentinel 2011 book, so I wish to revisit the concept of physician motivation.  Here’s what Mr. Pink’s research says, as applied to clinicians:

autonomy - fishbowl

#1 Autonomy: good bosses state “the why” and “the what” of the desired work-product, and then create conditions for people to do their best work to achieve those outcomes.  It should be emphasized, unbridled physician autonomy has created many problems for patients through the centuries (physicians failing to use best practices often causes patient harm; for more information, read my three prior posts on Evidence Based Medicine [EBM]).  A physician’s job is to solve as many patient problems today as possible.  How those problems are solved is very much the business of the physician, necessarily guided by empathy, duty and The Scientific Method (PDSA cycles!).  Solving complex problems like obesity and heart failure requires an inquiring mind and the willingness to experiment toward better solutions.  Autonomy creates physician engagement – the fuel for creativity and discretionary effort.

mastery - asymptote

#2 Mastery: nothing compares to the feeling we get following a well-reasoned diagnosis, or well-performed surgery, leading to the prompt resolution of the patient’s problem.  To have the tools, time, and environment to constantly improve as a clinician, and to be our best each day, is a motivational drug unlike any other.  That’s sometimes called Flow.

#3 Purpose: the opportunity to do “meaningful work” is a universal motivator for all.  The relief of pain and suffering is meaningful work indeed.   Have you written Your Sentence?

fairness - scales

We find it comforting (or if you prefer, fair) in America to pay more to those individuals within a specific job class who achieve better individual performance (fine by me), but we mustn’t confuse our cultural concepts of compensation fairness with the science of professional motivation (drive).    Furthermore, we must not confuse system-wide financial incentives, often necessary to pay for the human and technical infrastructure required for continuous performance improvement, with individual incentives; two common examples of the former include paying large multispecialty medical groups for better population-based clinical outcomes, and no longer paying hospitals for avoidable complications.

critical conversations - sillouettes

Moreover, money has no role in the performance management of individuals, particularly highly trained professionals such as physicians and surgeons.  Individual underperformance against a set of clear job duties and expectations is typically due to (1) poor workflow or systems-design, (2) inadequate skill set or “fit”, or (3) weak bosses (including the tolerance of toxic workplace culture).  Addressing the root cause of an individual clinician’s underperformance has nothing to do with money (“No bonus for you!”).  Individual clinicians who produce reliably good results and promote a healthy workplace culture, get to remain in their position.  Money is absent in that equation.

A River Runs Through It

I’ve written 60 posts in 100 days.  To what end?

the what

The What has focused upon (1) root causes of the high and rising costs of healthcare in the US (providers paid via fee-for-service, irrational pricing from hospitals and device manufacturers, and the obesity epidemic), (2) the benefits of physician-led multi-specialty group practice (an infrastructure of continuous improvement, a culture of accountability and evidence-based practice), and (3) my deep connection and concern for our natural environment (parks, The Beltline, and trees above all).  But that’s not why I write.

the how

The How has made use of (1) studies and observations in the temporal medical and lay literature, (2) my 30-year experience as a clinician and 15 years as leader, and (3) and attempt to provoke you toward new thinking and behavior in the care you receive or give.  But that ain’t why either.

Loud opinion overshadowing quiet facts, partisan politics replacing civil debate or compromise, and poor logic distracting us from effective problem solving (see The Problem to be Solved) won’t lead to a better future for our patients or our profession.  So I’m doing the best I can to redirect our physician and lay community toward a different outcome – a future that emphasizes health over healthcare, healthcare value over volume, and an effective transition to The New World, disruptive and disquieting as it will inevitably be, necessarily so.  That’s Why I write.

why how what circles

The Military Ideal of Duty and Service applies to Medical Leadership

heartbreak ridge

At the age of 19, he and his mates in Company I, 23rd Infantry Regiment were ordered to make an assault straight up the rocky, heavily fortified mountainside near Chorwan, North Korea.  The men clambered up the slope taking out one enemy bunker at a time; those who made it to the crest alive sustained the inevitable North Korean counterattack that night, while exhausted and low on ammunition.

heartbreak soldier comforting another

And so it went for 30 days and nights in September-October 1951 – a day’s ascent often followed by the night’s retreat.  Vertical trench warfare.  What began in the morning with tanks, artillery, and air-cover often ended in hand-to-hand combat in the pitch of night.  Entire Companies of 100-200 men were wiped out.  I am told that my father was the last man standing in his unit after defending his position all night with a machine gun, a knife and a few grenades.  The Battle of Heartbreak Ridge, The Korean War.

He was promoted to Sergeant, First Class in the middle of the battle.  This morning I reread the letter of promotion from Major General Robert Young:

“One of your first duties is to the men under you; get to know them and their capabilities and limitations, see that they are taken care of, do everything you can to solve their problems. In addition, you must set an example to your men in appearance, discipline, courtesy and professional skill, whatever your primary duty may be … Why will you do these things?  Because you are a leader.”

Private Grey in color guard, ca 1950

I am in no way comparing the brutal life-and-death of battle to the air-conditioned environment of medical leadership. I’m saying the miliary ideal of duty and service to those in our unit fully applies to medical leadership.    Do we reliably treat our colleagues with courtesy?  Do we take care of one another?  Do we solve problems?  Those of us entrusted with the privilege to lead must continuously ask, “Am I doing enough for my colleagues?”

In anticipation of Memorial Day 2013, Schreiner reread Citizen Soldiers, by Stephen E. Ambrose, published 1997.

A Caste System Among Physicians

caste system

In historical Hindu society, a complex hierarchy of socioeconomic groups arose that can be oversimplified by the graphic to the left. Priests held the highest place in society, followed by the warriors using swords, then merchants trading goods, followed by laborers doing the most manual work.  Each group’s social and material wealth was preserved by limiting the financial and social opportunities of the group lower.

greek warrior

Did the era of fee-for-service healthcare (FFS) over the last several decades unintentionally create such a caste system among physicians? Perhaps our Priest Class is represented by cardiologists, radiologists, and orthopedic surgeons; our Warrior Class represented by gastroenterology, dermatology, and most surgeons; our Merchant Class represented by primary care and cognitive specialties; and our Laborer Class represented by associate practitioners.

Before you scoff, consider this. In most hospital systems in the US (whether for-profit or non-profit), members of the highest paid specialties control more of the resource allocation (investments in equipment, space, and personnel). Think of the surgeon who gets a robot (which might not improve outcomes in 80% of the patients who receive surgery using it), along with a dedicated operating room and team of specialized personnel, whereas a cognitive specialist or primary care physician doesn’t get a cross-functional process-improvement or patient-engagement program to reduce hospital readmissions or improve self-care of chronic disease.  There’s more immediate income for hospital, surgeon and device manufacturer in robotic surgery; there’s more long-term cost for America in suboptimally managed chronic disease.  American healthcare will be forced to reconcile that math within the next few years.

robotic surgery At the dawn of the Specialization Era (1950s), the highest paid specialties received an income 2-fold (200%) more than the median income for primary care physicians (source – Department of Commerce, published in Time 30July1951:70). Today, the highest paid specialties receive an income four-fold (400%) more than the median income of primary care (multiple sources). Moreover, those higher paid specialties have more discretionary income from clinical care to buy buildings, imaging equipment, faux-research programs, and other infrastructure designed to generate non-clinical income, which in many cases eclipses clinical income.

patient as ATM machine

I see a day in America’s future when …

(1) resource allocation within health systems is based upon “doing the most good” for a community of people, rather than generating the most income for hospitals, physicians or device manufacturers,

(2) the highest paid specialties earn no more than 3-times primary care, and

(3) governance of the delivery system is distributed among physicians, staff and patients, based upon criteria other than magnitude of revenue generation.

healthcare teamThat’s the way it’s been at Kaiser Permanente for 70 years.

For those of you in non-KP integrated delivery systems, it’s in your interest to dispatch the physician caste system prior to the widespread use of bundled payments from payors.  Well, unless you are a Priest.

What Role, Money?

arm wrestlingI had a heated discussion this afternoon with a MAG buddy of mine – a solo-practice orthopedic surgeon practicing in a rural area of Georgia.  He began with “I’m (fed up) with the bashing of fee-for-service (FFS).  There’s no (alternative) compensation methodology that creates similar levels of physician productivity.” And off we went.

The Definition of Physician Productivity.  I’ll send him the link to one of my previous posts (“The Real Definition of Physician Productivity Might Surprise You“), but we agreed that wRVUs can be a part of measuring “work-done”, particularly when comparing the unequal burden of caring for a patient-population with higher levels of diabetes or kidney disease, or lower levels of medical sophistication.  But fundamentally, he defines physician productivity as “things done to patients today”, rather than “patient problems solved today or avoided tomorrow.”

the one word that could save your life

The Role of Money in Determining Physician Work Ethic (or if you prefer, in Determining Discretionary Effort).  My friend firmly believes that money is the ONE, dominant motivation of physician work ethic – that salaried physicians will “work (only) when they want to.”  He went on to say that higher levels of pay will create higher levels of effort.  But I know my friend gives the same level of high effort in the OR when operating on a Medicaid patient as he does when operating on a commercially insured patient, producing an incongruity in his argument.

in money we trustIf not money, then what?  I spoke of group culture (interdependency among and accountability to one another, ensuring reliably high levels of effort by all), and inherent altruism among physicians, but he would have none of it.  For him, those concepts were somewhere between mythology and ideology.  He offered a (not-so) hypothetical case of a little girl with a newly broken elbow presenting to the orthopedic office at 5:01 pm, ostensibly ushered into the FFS office, but turned away by a salaried orthopod.  He was incredulous at my declaration that a given physician’s behavior in such a circumstance would be (ie, must be) dissociated from the presence or absence of compensation.  I never got to plug Daniel Pink’s work.

daniel pink drive

This conversation unnerved me.  Not because I am unlikely to ever change the mindset of my friend relative to the role of money in physician behavior.  And not because of some ridiculous belief we physicians should work for free; I believe physicians should be highly compensated for the high stakes, high intensity, narrow-tolerances of our privileged craft, just not through a FFS mechanism.


Rather, I believe my friend’s point of view is likely reflective of the majority of FFS colleagues.  Thus, our profession is threatened even more than I once believed.  W.W.O.D?

william osler, ca 1890s



Putting the Crosshairs on Scope

For years, pharmacists, chiropractors, advanced-practice-nurses, podiatrists, optometrists and so on have fought in the General Assembly of the State Legislature for the expansion of their “Scope of Practice”, referring to the legal lines that define the limits of practice for a given healthcare practitioner, under state licensure.

MAG icon, high-resolution, July 2011For those same years, my beloved state physician association has fought on that same battleground, staunchly opposing such expansion of permissible practice for non-doctors.  This year was no exception.  MAG staff estimates they spend 70% of their year on this sole topic, giving less time to address other pressing matters (health insurance exchanges, payment reform, industry upheaval).

crosshairsPerhaps there is a more efficient way for the professional advocacy groups to spend our time.  Perhaps we can emphasize our common ground and explore root causes of the conflict, then seek a negotiated agreement for the betterment of Georgians and each professional discipline.  Perhaps its time to put the crosshairs on Scope.

Let’s begin with examining root causes of the conflict:

  1. some of the conflict has to do with money: by expanding the limits of practice for non-physicians, the latter can earn more money, at the expense of physician income
  2. some of the conflict has to do with clinical disagreement; podiatrists feel their (no pun intended) sole focus on the feet should empower them to perform more operations on the feet, whereas orthopedic surgeons feel their expansive training and surgical experience is better suited to create an optimal surgical outcome for complex conditions of the feet
  3. some of the conflict has to do with varying assessments of unintended risk to patients; what if, in giving pharmacists the right to administer pediatric vaccinations, kids saw their pediatrician less, leading to missed interventions for scoliosis, developmental delays, sexual health or abuse?

Beyond self-interests, I believe each professional group has altruism in their heart, wishing to improve the health of the communities they serve.  If so, could we agree that any negotiated change in Scope of Practice fulfill two premises:

#1 the proposed change in scope must have sound clinical evidence to support it (see my many previous posts on evidence-based-medicine [EBM]); for example, the requested increase in scope of practice must not only be supported by proof of expanded abilities of the health profession in question, but must also be proved (from a modest clinical trial) to likely “do good and no harm”

#2 the proposed change in scope must be in the public’s best interest (e.g., making low-risk influenza vaccine more accessible to citizens by granting pharmacists the ability to administer them)

team careMAG must maintain its role as the leading voice of Georgia healthcare. The citizens and legislature of Georgia will judge us by our ability to effectively work with, not against, the other healthcare constituencies who deliver care in Georgia.  Let us physicians make the first move to reach agreement on a scope of practice issue that promotes quality, access, affordability and safety with at least one of our healthcare colleagues in pharmacy, nursing, or another field before the 2014 legislative session.