MURPHY: Operationally, we struggle with going from a health system where the focus is on larger blocks of information and dollars to the practice level where the copay is the margin. That's a very different focus than in an acute care hospital. The challenge is transitioning to this operational focus. As a big system with 45-plus hospitals and approximately 500 practice locations, we had to get our arms around this. As we acquire new practices, we have to be sensitive to the fact that these new practice leaders bring a new perspective compared with acute care.
HEALTHLEADERS: How do you to make the transition such that your physicians are able to practice at the top of their license?
MURPHY: It's part of a shift to team-based care. One of the key innovations we've implemented is the addition of health coaches in primary care practices. Health coaches look at patients who are coming into the practice in advance and review and prepare for the preventive care they should receive when they arrive. In addition, we work extensively with our Lean resources to address process redesign within the practice to optimize patient flow. This redesign is critical as well for the implementation of our EMR systems.
WALLACE: The retail side of the business is critical. Each health system has to look at how they're going to have this retail distribution in the marketplace. You've got the Minute Clinics, the Walgreens, those kinds of things. You've got your urgent care clinics, and in some markets a freestanding ED. You've got to make sure that you've got the services that patients need. The extender piece is going to change even though there are state regulations that sometimes prohibit some of that. You're going to have this huge jump in demand. The states are under tremendous financial pressure.
HARBECK: There is a lot of experimentation going on. For example, when a diabetic patient has an appointment, someone might meet with him or her beforehand to do all the prework. All the care posts for that appointment could be handled by a nurse practitioner or other extender. I keep coming back to the medical home as the basis for the care-quality measurement at the physician practice. Getting care quality under control for your employed and even affiliated physicians is absolutely key to the success of a health delivery network, whether it's an ACO or not.
HEALTHLEADERS: What remediation efforts have you studied to deal with the influx of patients that will come in 2014?
WALLACE: We have used more extenders than we have in the past, but I don't think we've got any magic bullet.
MOORE: When the payment model will pay either a midlevel or a physician, you have a problem. If they won't pay for a telemedicine consult, then you've got a problem. Besides that, the margin between the average salary of a primary care physician and the average salary of a midlevel practitioner right now is at the smallest level of difference than it's ever been. Primary care docs can't afford midlevels in the current cost structure.
WALLACE: It's the same dilemma that a primary care physician has when a Walgreens or an urgent care clinic opens. That's part of his or her patient base. You can't strip that out of there, so this gets back to that practicing to the level of your license and who they should be seeing.
WALLACE: We created an intensive care manifesto where we want certain things to occur in our intensive care units. As we've required some multidisciplinary rounds, it's amazing the kind of care difference and the savings that you get. But physicians are not used to working as a team.
HEALTHLEADERS: Let's talk about alternatives to full acquisition. Are those strategies still applicable under reform?
MOORE: We've seen a lot of movement toward that dyad leadership model. We're starting to bring our medical directors into an operational role and matching them with an operational leader. Some parts of our organization have created interdisciplinary leadership teams where physicians and the operations team are actually running the facility, making capital decisions, running the ORs. We have a number of physician service agreements where they're now fully running our inpatient and outpatient ORs with great cost reductions and improved quality scores. The amount of joint venturing that we're doing anymore has dwindled.
MURPHY: Many of these ideas are still applicable. The challenge is reacting in the current fee-for-service model of care and yet trying to build these new relationships as we transition to a value-based care system. The opportunity is to convince physicians that they need to align and work with your system in new ways. From an inpatient standpoint, clinical comanagement and gain-sharing are all good tools to achieve an initial integration strategy but not as applicable as a broad alignment strategy in which you're focusing on the continuum of care, which includes ambulatory, home care, and long-term care.