Herding academic cats: Engaging doctors is key to teaching hospital reforms

It's a tough challenge to engage academic physicians in managing the health of an enrolled patient population.

Doctors traditionally have been trained to deal with the patient in front of them. Changing their focus to population health requires a different mindset. That's even more true for academic medical center doctors, who are steeped in teaching hospital traditions, or who may see clinical operations merely as a backup funding source for their research and education missions.

But some academic medical center leaders are finding innovative ways of working with their doctors to make their organizations more competitive in today's cost-conscious healthcare market. They are also getting their faculty physicians to collaborate with community-based doctors in new payment and delivery models such as accountable care organizations.

Joe Landsman, CEO of the 600-bed University of Tennessee Medical Center in Knoxville, said involving physicians in all major strategies and change processes is key. That collaboration has enabled his center to implement its clinical standardization and quality-improvement efforts. “It really starts with development of physician leaders,” said Landsman, whose operation includes 615 doctors, of whom only 158 are medical center employees.

A critical component has been his center's Physician Leadership Academy. It began as a 10-month educational program developed in partnership with the University of Tennessee business school that physicians attended for a half day each month. It has since evolved into a three-year program. “It gives them a wider base of knowledge than the world they live in, on the state of the industry and why transformation is necessary,” Landsman said.

He said his center has spurred physicians to take the lead in its standardization and improvement efforts, and touts the center's 94th percentile ranking last year in the Press Ganey survey of physician engagement. Press Ganey describes physician engagement as doctors' appraisal of their work environment, emotional experiences and workplace attachment.

The nation's academic medical centers are stressed as payment rates are under pressure, funding for medical research has decreased and funding for graduate medical education is being threatened. Some experts say shifting academic medical centers' focus to population-health management has to be a big part of the answer. And academic center leaders say involving doctors is key to this shift.

“Academic medicine is well positioned to be a part of the solution to the next generation of healthcare delivery,” said Mark Laret, CEO of UCSF Medical Center in San Francisco. “But it also has to overcome some of its longstanding traditions about how it has carried out that work. Those traditions are sometimes costly, oftentimes inefficient, and oftentimes are physician and learner-centered, not patient-centered.”

The cultural change required to get physicians to buy into standardization shouldn't be underestimated, said Dr. Andrew Ziskind, managing director of Huron Healthcare consultants. “What typically makes academic physicians renowned is what they do differently,” he said. Standardization reduces those differences.

Dr. David Nash, founding dean of the Jefferson School of Population Health in Philadelphia, calls population-health management “the road to redemption” for academic medical centers. “Progressive, leading academic medical centers are reading the writing on the wall and are building or modifying their education program to focus on these issues,” he said.

The hard part, however, is that population health is a team sport involving collaboration among different types of providers and staff, and that may conflict with physicians' traditional preference for autonomy. Population health or any systemwide improvements won't work without physician engagement, Nash said. “Anything that threatens the status quo is resisted.”

He recommends refocusing academic centers' three missions of education, patient care and research around population-health concepts. This can mean implementing team-based education in the medical school, setting up an accountable care structure or pursuing outcomes-based population-health research projects.

“You can't just pivot these places—you have to realign each aspect of the mission,” Nash said. “It's like turning a battleship around inside the Panama Canal.”

Laret said there are some obvious practices that academic centers need to reform. “Maybe we could rethink how we do rounds on day of discharge, so we could actually prioritize the discharge of patients ahead of the teaching rounds,” he said. “Not to eliminate the teaching, but to just rethink some of our historical approaches.”

Another obvious change is reducing unnecessary diagnostic tests. “One of the traditions of teaching was, 'Let's just order tests because the results are interesting,' ” said Dr. Elliott Fisher, director of the Dartmouth Institute for Health Policy and Clinical Practice. “Avoiding unnecessary tests is now considered high-quality healthcare.”

Landsman of the University of Tennessee Medical Center said standardization is not readily embraced by many physicians but is essential. In 2013, his center launched its clinical pathway process with the goal of having 80% of admitted patients assigned to an evidence-based standardized treatment plan for their defined condition. Last year, 68% of admitted patients were put on a specific pathway.

His organization has made sure to measure its progress. Results include a reduction in central line-associated blood stream infections (CLABSI) in adult critical-care units from 72 in 2008 to one in 2014. Another pathway success is the steep drop in critical-care catheter-associated urinary-tract infections, which fell from 121 in 2011 to 30 in 2014.

To engage doctors, Dartmouth's Fisher recommends appealing to their competitive nature by using quality measures that show what percentage of their patients have their diabetes or high blood pressure in check. “That's tremendously motivating,” he said. “Doctors are incredibly competitive.”

Like the University of Tennessee, the University of Arizona Health Network in Tucson is partnering with community-based doctors, and recently announced a merger with 25-hospital Banner Health.

Nash called the merger a harbinger of a future in which more health systems own their own medical school. He sees this as a positive development. “As delivery systems merge with medical schools, that will align their missions toward population health,” he said.

Beth Calhoun, an associate vice president at the University of Arizona's Health Science Center, said academic medical center researchers can help non-academic providers systematically analyze big data to better manage enrolled populations. “A university's health policy folks and healthcare economists can look at change in the healthcare-payment structure and find models,” she said.

For instance, academic center experts can help providers develop predictive models to identify patients who are high utilizers, then determine whether they use a lot of services because they're actually sicker or because their providers are not offering the right diagnoses or treatments. Through her center, the newly merged Banner-University of Arizona system will support the state's health-improvement plan, integrate primary-care physicians and behavioral-health professionals, and look at local renal care practice patterns and clinical outcomes to determine what factors influence a slower transition to dialysis.

Still another academic medical center partnering with community-based providers to work on population health is Nebraska Medicine, the new name for the University of Nebraska Medical Center's clinical operations. It joined forces five years ago with the two-hospital Nebraska Methodist Health System to form its Accountable Care Alliance, now known as the Nebraska Health Network. Nebraska Medicine has about 500 employed physicians and nearly 200 community doctors.

Dr. Harris Frankel, Nebraska Medicine's senior vice president and chief medical officer, said there was “trepidation and angst” when the alliance was first announced. But the partner organizations have been able to increase physician involvement as the clinicians have seen results in achieving better outcomes at lower costs.

Academic medical centers have to decide whether to create their own primary-care network or partner with established primary-care practices. “Some organizations may make the choice to build from within,” Frankel said. “Others, like ours, as we begin to dip our toe in the water of population health, we recognize the need to partner with community physicians to assist us in that endeavor.”

One example of how the Nebraska ACO partners worked to increase efficiency was to standardize orthopedic procedures.

“We're still competitors, but we are working together to create a critical mass of primary-care physicians between our institutions to manage the population in an effective manner,” Frankel said.

Other engagement challenges include building a health information technology infrastructure, negotiating how to pay for it, and developing a governance structure. Frankel said 80% of those challenges are political and 20% are technical, but academic and community doctors have shown “a willingness to achieve a common good.”

Frankel predicted that academic medicine, using its research and education missions, will drive major changes in clinical care and propel the move to population-health management forward. “Academic health science centers are going to play a vital role in population health,” he said.