Demand is growing for better outcomes at lower cost — and for health care organizations to present evidence-based claims to superiority. New delivery models, such as accountable care organizations and bundled pricing, are being tested as well; these models promise to improve quality and lower cost. At the heart of the initiatives is the predictive care path.
Organizations can use predictive care paths to define high-level processes: Care paths identify key steps to take and corresponding decision points. If they are crafted correctly, predictive care paths can account for variability among complex, nonlinear patient care processes, while creating general pathways to map each discrete element of care for a particular diagnosis or disease state.
Despite the challenges that organizations face when trying to reach clinician consensus, physician involvement is essential to the successful development, integration and maintenance of predictive care paths.
Expect Resistance and Be Prepared to Manage It
Organizations developing predictive care paths likely will face resistance. Clinical practice is evolving constantly as research advances, and it varies, sometimes significantly, among physicians. Each patient is, obviously, unique, resulting in an endless number of scenarios that cannot possibly be anticipated.
Moreover, given their extensive education, training and experience, physicians are reluctant to accept care paths that streamline the complex processes they learned to navigate over time. Physicians who perceive predictive care paths as cookie-cutter medicine will argue that a one-size-fits-all regimen will not improve patient outcomes.
In addition, traditional payment structures, such as fee-for-service reimbursement, do not encourage physicians to cut costs and practice more efficiently. Indeed, such structures have created an incentive for doctors to provide more services than may be necessary.
Finally, patient demands and legal liability pressures drive the practice of defensive medicine. Physicians cover their bases, often doing more than necessary, both to put their patients at ease and protect against future malpractice claims. Since physicians have little incentive to seek more efficient ways of improving outcomes, organizations may be reluctant to engage them in challenging traditional approaches to care.
These are valid concerns. But the physician's role in care path development and implementation is critical. Steps can be taken to strengthen ties between your organization and employed and/or contracted physicians.
How to Engage Physicians in Developing Predictive Care Paths
Administrators at any organization can use the following key steps to engage physicians in the development of predictive care paths.
Identify physician leaders to build your "dream team." Identifying physician leaders is key to successfully developing and adopting predictive care paths. To determine which physicians to engage as part of your dream team for managing this organizational change, ask yourself the following questions:
- Who are your MVPs (most valuable physicians)? When determining which of your star cliniciansto engage in the development of care paths, consider their commitment to outcomes and quality of care. Be sure to involve those who are committed to research, development and writing. You want skilled physicians who maintain pace with technological developments, new procedures or innovative methods.
- Who are your strategic ball handlers? Which physicians knowclinical guidelines and understandhow useful care paths can be?Physicians who are knowledgeable about existing standards, current evidence and research in progress are aligned strategically with your goals. Consider physicians who show an interest in reform initiatives aimed at improving quality, accountability and overall outcomes. Their involvement will keep your team's eye on the prize.
- Who are your team captains? It's imperative that you include physicians who can contribute to a successful implementation of care paths. Ask yourself: Which physicians will be important to convince, because they are capable of influencing others? Whose disapproval or alienation could lead to unrest among your staff?
Communicate effectively. Physicians are more likely to accept care paths if they understand that they are meant to guide decision-making and measure cost and quality outcomes without undermining their professional judgment.
Executives who communicate effectively rely on certain unique, nonclinical competencies, such as the ability to motivate, engage and listen to their peers. They must be prepared to handle behavioral, cultural or political challenges. To optimize communication among your team:
- Use meeting size to your advantage. Certainly, there are situations when a large group meeting serves a valuable purpose. However, you might find yourself relying more heavily on one-on-one meetings. Doing so will involve each physician to ensure she or he is heard, without getting bogged down in large — and often unproductive — group discussions.
- Plan your dialogue. Provide context, anticipate issues and be deliberate in your positioning.
- Anticipate resistance and resolve it. You may need to determine where people stand prior to a controversial meeting.
Achieve consensus on shared objectives. Health care executives and their clinical leadership teams must achieve consensus on the rationale for change. These objectives should be actionable and should motivate your team to take the necessary steps. As a starting point, shared objectives should include the following fundamental points:
- We need to meet the growing demand for better care at lower cost. No matter how long physicians, providers and organizations choose to ignore the elephant in the room, patients, employers, payers and policymakers are placing an increasing amount of pressure on them to improve quality and cost outcomes.
- We need to be reimbursed adequately for the value we deliver. In response to demand for better quality at lower cost, industry trends are moving toward new reimbursement models that reward the quality — rather than quantity — of services rendered (e.g., bundled pricing). As these new models replace fee-for-service reimbursement, physicians will be compensated for better care, and even may be penalized for high volumes of questionable services.
- We need to generate growth and compete for market share and patients by strengthening our value proposition. As value-based health care reform efforts take effect, patient and payer demand for cost and quality transparency will grow. To compete under these changing circumstances, organizations — and therefore, clinicians — need to communicate effectively a defensible value proposition.
Asking physicians to take accountability for cost and quality outcomes will require a major change in perspective after years of fee-for-service reimbursement. Without financial pressure to deliver effective andefficient care, physicians likely will ignore this objective, and some organizations will struggle to get their contracted physicians to see the light.
With time, contracted physicians will have no choice but to buy in, especially as value-based payment mechanisms become mainstream and economic pressures drive them to seek salaried positions. In the interim, administrators of physician practices may be able to offer support.
Work with physicians to develop predictive care paths. Once organizations agree on common objectives for a more value-based care model, they can begin working with their physician leadership team to develop care paths. Collaboration will allow physician and nonphysician stakeholders to take ownership.
Developing effective care paths requires balancing structured simplicity with clinical complexity. If you overengineer the care paths, they become unwieldy. But giving too little specificity leaves so much discretion that the resulting care path offers no potential for consistency and no way to evaluate compliance.
Care paths must allow for variability without outlining every possible course of patient care. To account successfully for all possible scenarios, key decision points must be identified. Extrapolating these decision points from such a variable process relies on clinical expertise that only physicians can provide.
Specifically, nonclinicians and clinicians will need to collaborate to:
- determine which evidence, data and research are going to be used to inform care paths;
- identify key decision points where physician judgment is critical;
- develop a strategy for integrating care across multiple physicians and provider organizations;
- explicitly define role clarity and accountability for care coordination within an evidence-based care process; and
- agree on metrics and processes for monitoring, evaluating and improving on care paths.
Engage physicians in the implementation, monitoring, review and improvement of care paths. While development of care paths is an important and challenging aspect of this strategy to improve quality and lower costs, success hinges on whether they are actually used. Your leadership team will need to continually achieve buy-in across the organization and monitor integration in clinical practice.
Once care paths are developed and implemented, organizations need to make sure they work. Clinicians, administrators and other members of the leadership team need to evaluate clinical and financial outcomes. Organizations should develop a plan to ensure that care paths are being monitored, reviewed and improved regularly. Clinician and nonclinician leaders will need to speak frequently to review metrics, determine implications, take corrective action and improve predictive care paths. As part of this plan, organizations should:
- identify who will be responsible for reviewing care paths, and how often these assessments should occur;
- promote engagement in the pursuit of excellence in evidence-based medicine (e.g., involvement in medical research/development, knowledge of changes in medicine, forums for sharing best practices, etc.); and
- embed these responsibilities and competencies in the "job charters" of involved clinicians and nonclinicians — and evaluate their performance in these areas the same way you review other competencies.
Taking measures like these will ensure that organizational ownership extends past the development and implementation of care paths and well into their ongoing use and continued improvement.
Health care executives face an unprecedented leadership challenge in today's environment. They have to build recognition among executives and physicians that the current business model and approach to care will not suffice. They have to develop personal competencies to engage physicians in a structured, participative process to develop new care models that meet emerging demands, diagnosing and resolving individuals' resistance to change along the way. And they have to ensure that these new models are implemented effectively and improved continuously to meet the growing demand for better outcomes at lower costs.
Michael Abrams, M.A., is the managing partner; Dana Hage, M.P.H., is a business analyst; and Eric Abrams, M.B.A., is a consultant at Numerof & Associates Inc. (NAI) in St. Louis.