Clinical Leadership is Essential

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A Tale of Two Rural ACOs …” | Value-Based Medicine

Clinical Leadership is Essential by Dave Amin – I received a call from a small rural health center in the Southwest.  This center is the sole health care provider for a very large service area and most of the service they provide is ambulatory in nature. They are dedicated to their community and provide extremely high quality primary care and inpatient services. It is a proud community with loyal patients and committed healthcare workers.  At the time, I was the medical director for a Rural ACO in New England.

The Southwest-based center faced a challenge. The center participates in a Rural ACO which has struggled to gain the acceptance of the physician staff. There was a lack of understanding about what ACO participation meant to the organization and how it might benefit patients and the health system as well. The hospital CEO finally called a “time-out” of sorts and scheduled a day long retreat to bring the physicians together and hear their concerns. The hospital CEO wisely concluded that physician engagement and buy-in would be a key driver in their potential success. The goal of the retreat was to educate the physicians, hear their concerns and give them the opportunity to exercise some governance over the ACO process. The Southwest-based Rural ACO reached out to me because they had heard of some of the changes that were successfully incorporated at my Rural ACO. 

Clinical Leadership is Essential

I faced nearly identical challenges when I assumed the medical director role at my Rural ACO one year prior – a complete lack of physician engagement. Restructuring our ACO efforts around the clinical operators such as clinicians, nurses and care managers resulted in a turn-around of unprecedented proportions. Our ACO will save $8M+ in 2017 on a panel of 11,500 Medicare patients. This far exceeds our savings threshold of $1.2M. Our success was not by accident and had little to do with my presence. 

Our success had everything to do with getting our clinical staff involved in every aspect of the ACO experience. We formed 8 working groups composed of clinical staff, IT staff and practice managers to tackle our toughest challenges. The solutions needed to come from the front-line staff. We worked tirelessly to educate everyone on the “why” of what we were trying to accomplish. We let them push back and ask thoughtful educated questions – this resulted in even greater buy-in and even better process changes and fresh ideas. This success did not go unnoticed.

“I shot straight from the hip and we discussed some tough topics”

The Southwest Rural ACO director of population health reached out and asked me to fly out to their retreat and start the process of physician engagement with their primary care staff. I happily accepted. I spent one day with their 10 or so primary care physicians and some support staff. We discussed foundational topics such as: What is an ACO? What is a clinically integrated network? Where is the value in value-based medicine? Is this all going away? What does this mean to patients?

 What does this mean to me? I kept the format conversational and simply told the story of my Rural ACO and how we came to terms with the needed changes. I shot straight from the hip and we discussed some tough topics and had open and honest discussion – right in front of a very supportive CEO. I had a great day talking to wonderful people, and everyone thanked me for taking time to fly out there. However, … I wondered if I had made a difference.

Clinical Leadership is Essential

One month later I checked in with their director of population health to see how things were going. I was delighted to hear her say “the doctors are on fire!” They had trained all their medical assistants to do annual wellness visits, they were hard-wiring chronic care management processes, they were beginning to think through capturing accurate coding to assist with risk adjustment factors and perhaps more importantly – they were asking questions and starting to take control of the needed process changes. 

I marveled about how one simple conversation could make such a difference. Where is the magic? It is not magic at all. It was all about physician engagement from a physician to a physician and sending the right message. Early physician engagement is better than later, but it is never too late. Top down driven policy changes, work flow changes and well-intended but unexplained demands are DOA in the clinical space – they will never be fully executed. Bringing in the clinical operators early, educating them, giving them the time and resources and mentorship to be successful is critical. There can be no success without the clinical operators driving the value-based medicine bus. 

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