I agree that this is a challenge. It also doesn’t seem that the isolation of primary care from hospital and specialty medicine will reverse.
We have had a number of social events with limited help. Many people say they are too busy to attend.
Service level agreements between PC and specialties have been some help.
We are transparent with financial performance of the group and that has helped drive internal referral rates and, indirectly, communication.
Combined Leadership Council with primary, specialty and hospital medicine has been a helpful forum to bring issues forward and then arrange the appropriate conversations.
I recently went to a Team-Based Care conference in Green Bay by Bellin Health. They were having poor performance to population health metrics, physician burnout/turnover, decreased patient access and satisfaction. They purposefully developed an ambulatory team based care model. Their primary care team typically consisted of a physician, medical assistant and possibly advanced practice provider. Now they typically have 2 MAs per provider with teams including physicians, advanced practice providers, RNs, pharmacy, social work and behavioral health. They distribute pharmacy, social work and behavioral health across several clinics. MAs do a component of scribing and provider directed order entry. Providers are responsible to review and sign orders, meds, etc.
Since making this change they have seen improved performance to pop health metrics, improved provider and patient satisfaction and improved productivity. Provider turnover has reduced. They are now expanding to ambulatory specialty care.
It has taken a few years for them to do this.
I was impressed by the number of physicians from their system who were present and endorsed this method.
They have also addressed the regulatory issues associated with this.
We are in the process of developing this for our region.
We have used physician compensation committees to help set Quality and Service metrics. It has been helpful for these groups to help determine what is measured and where the thresholds are set. Q&S is typically set at 10%.
Examples of metrics: Chart closure at 48 hours, meeting attendance, teaching, peer chart review, committee membership/attendance, quality improvement projects.
Typically there are three metrics in a division each worth 3.33%.
It has been very helpful to have the physicians involved in setting the Q&S metrics.
I agree with your assessment of the difficulties.
Here are a few things we have found helpful:
-Medical Group Compensation Committees: this has been very helpful in aligning compensation to fair market value and the needs of the organization while giving the physicians a voice in their compensation. They can’t set their own compensation but are able to influence based on system guidelines. These are not paid positions and we haven’t had difficulty getting physicians to attend. This group also arbitrates physician compensation disputes.
-Compensation based on fair market value: we use three surveys (MGMA, AMGA and ECG). We benchmark against a three year rolling average to lessen the swings in payment.
-Our markets are mainly fee for service currently.
-We have two basic methodologies for comp:
* Coverage model (salary) with 10% at risk for Quality and Service. Hospitalists for example.
* Production model with 10% at risk for Q&S. Primary care is 80% production, 10% panel size, 10% Q&S.
The compensation committees choose the Q&S metrics with attention to simplicity. Preferably easy to pull from Epic.
We have other markets that are highly fee for value and they pay 90% on panel size with 10% Q&S.
We have worked to make the process transparent and connected FMV benchmarks.
I think the biggest factor helping to improve the process has been the development of robust physician compensation committees.
Two years ago one of our comp committees voted not to give compensation increases due to the financial status of the region. Because of the successful communication from the comp committee this ended up being a “non-event”.
Hope that is helpful.
We have had dyad leadership at many levels across our organization. We have set tight expectations of working together with shared goals.
The Washington State Medical Association has a dyad leadership course that has been helpful particularly for our newer leaders to help sort out how they work in a dyad relationship. https://wsma.org/WSMA/Resources/Physician_Leadership/Dyad_Leadership_Course/WSMA/Resources/Physician_Leadership/Dyad_Leadership_Course/Dyad_Leadership_Course.aspx?hkey=52afb8c4-f251-4836-89ea-893f550119f6