Tom Sullivan | July 2, 2020
COVID-19 is a crisis like no other. The pandemic has illuminated well-known but too infrequently discussed racial inequities, stressed the health care system in terms of capacity and revenue, literally upended aging care delivery models and struck the bottom line at organizations slow to move away from fee-for-service toward value-based care.
Against that backdrop, Health Evolution convened, virtually of course, four of the industry’s top experts to discuss how CEOs can help physician practice groups during the pandemic to strategically emerge stronger on the other side of COVID-19.
athenahealth Chairman and CEO Bob Segert hosted the Health Evolution Executive Briefing Impact of COVID-19 on Physician Practice Economics: Collaboration to Maintain the Health Ecosystem. Joining Segert were American Medical Association Immediate Past President Patrice Harris, MD, ChristianaCare CEO Janice Nevin, MD and Marshfield Clinic CEO Susan Turney, MD.
The experts discussed the current state of physician practices, what’s needed to help them navigate the pandemic and what has to happen next, including actionable steps:
What follows is a closer look at their discussion relative to each of the above.
Taking the lead to avoid making existing inequities even worse
In all industries, health care perhaps chief among those, CEOs are conversing about diversity and equity, looking at the makeup of their board of directors and leadership team as well as who’s involved in shaping critical decisions.
“I can make the argument about the importance of physicians being around the table, making decisions regarding delivery and payment reform the best way,” Harris said. “So it’s the commitment to having a diverse set of physicians around the table when decisions and plans are made regarding care delivery.”
That means making sure health systems don’t deliver what Harris dubbed “privilege solutions,” including but not limited to telehealth, that are only accessible to people advantaged with smartphones, broadband and the infrastructure required to use those tools, whether in rural or urban areas.
Turney added that about 50 million people live in geographical regions with health care shortages and 60 million living in rural America. What’s more, when talking about inequities and disparities, the terms mean different things to different people.
“We have to think about that as we look to set national policy, and how do you get a clear, a robust and very focused agenda when there are so many differences across our communities?” Turney posited. “How do you come together to help set that agenda because what is needed in communities across this country varies dramatically? And how can we make sure that we fix it in a way that it doesn’t disparage someone in that journey?”
Weighty questions, indeed. If anything, COVID-19 has demonstrated how very real existing disparities are — and the reality that those must be addressed immediately.
“We will not be successful in impacting health unless we’re thinking about mental health issues, substance use disorder, food, housing, education, poverty and racism,” Nevin said. “We’ve got an opportunity. Let’s not squander that.”
Among the borderline cliché quotes resurrected during this pandemic is most frequently attributed to Winston Churchill: Never let a good crisis go to waste. Leveraging this particular pandemic will also require that CEOs lead on a number of fronts.
Fortifying the workforce
Achieving a more equitable health care system demands a workforce — and not just clinicians, either, but every employee — that is, bluntly, up to the difficult task.
“COVID has increased the level of stress, especially to those who are working on the front lines so it’s critical for systems to figure out what to do,” Harris said.
Harris pointed, for instance, to providers instituting wellness rounds, conducting post-shift debriefs and making mental health professionals available by phone or telehealth, particularly for those clinicians in areas with increased deaths and hospitalizations. What’s more, it’s important to make that a routine part of work because it can be difficult for physicians to ask for help even when they need it.
When ChristianaCare established the Center for WorkLife Wellbeing in 2013, the system initially focused on physicians. “Now it’s accessible to anyone who works in the system, whether it’s someone who is cleaning the floors, delivering the food, caring for a patient at the bedside and physicians in private practice,” Nevin said. “Certainly, through COVID-19, we ramped up the work that the center did and made those services available 24/7 either in person or virtually.”
While Nevin said she is grateful that ChristianaCare had that resource in place as the industry learns to co-exist with COVID, with some parts of the country continuing to worsen, caring for caregivers is even more necessary moving forward.
“It’s been really hard. They have done amazing, heroic, inspiring acts,” Nevin said. “But it has come with a lot of anxiety and concern about safety.”
Focusing on physician practice economics
Many medical groups, and rural health entities in particular, were struggling prior to the pandemic and that continues increasing as people shelter-in-place and cancel elective care and surgeries. And it has also become true of larger systems.
“Like most other hospitals and health systems across the country we closed down a lot of our facilities and saw outpatient visits drop by about 75 percent,” Nevin said.
ChristianaCare’s strategy prior to COVID-19 was “everything that can be digital will be and everything that can be done in the home will be,” so the system had a foundation from which to launch virtual technologies across 170 practices and specialties.
Segert said athenahealth’s network of some 120,000 physicians typically conducted approximately 5,000 telehealth visits a day pre-COVID and that number spiked to 150,000 visits a day by mid-April; it has since dropped to 75,000, which is still considerably more than before the pandemic.
“I can’t tell you how many practices I have spoken with that said telehealth was the lifeline for them economically, as well as for their communities because they were able to extend care the best they could,” Segert said.
Changing care delivery models
While telemedicine visits are up and practices that have adopted the technology are leveraging it to protect as much revenue as possible, the opportunity is more substantial than simply replacing in-person care with virtual visits.
“The opportunity is to build on that and use the technology to change the care delivery model so we can do even more,” Nevin said.
Harris agreed and added that the industry needs to be thoughtful about telehealth moving forward and avoid a knee jerk reaction to try and continue everything that happened during the pandemic.
“Let’s develop metrics. Let’s make sure we are clear about the objectives, right? We will absolutely want to have a thoughtful conversation about what we should continue,” Harris said. “Maybe what shouldn’t continue, and we also have to keep in mind patient preferences.”
Truly changing care delivery models is a monstrous undertaking and one that will invariably also consume financial and personnel resources at a time when CEOs are facing nurse and physician shortages amid the potential for COVID-19 to drive people out of the health care profession altogether at the exact time when it needs the right people to build and serve communities.
Then there’s the seemingly insurmountable issue of health care costs.
Building a bridge to value-based care
“We need to lower the cost of care,” Turney said. “One way to do that is leverage resources that have been around for a long time but haven’t really been optimized.”
Turney explained that resources transportable across different health systems, such as a hospital at home program combined with telehealth and being used with health plans such as Medicare Advantage, but not Medicare Fee-For-Service, that will reimburse for those services can be more effective than thinking about each individually. “It isn’t an either/or,” Turney said, “It’s a both.”
Recognizing home as a site of service, Turney cited as an example, enables patients in certain circumstances to get the same or higher quality care within their home at as much as a 30 percent lower cost, with fewer readmissions, fewer ER visits, and shorter lengths of stay.
“We have to seriously look at these opportunities, and I think the pandemic has created a bridge to make sure that people take this work seriously,” Turney added.
Whether COVID-19 pushes more CEOs to embrace value-based care or ultimately revert back to relying heavily on fee-for-service and whether that future positively or negatively impacts the finances of physician groups is an open question at this point.
“We’re at an inflection point where there’s a huge opportunity to do some of the things that need to be done to support high value care so cost is reduced and care becomes affordable,” Nevin said. “Providers that have health plans have fared reasonably well because what they lost on the provider side they may have had opportunity to make up on the plan side. Practices that were capitated had a regular source of revenue that was not dependent on volume.”
Naturally, however, what the payers bring to the table and partnerships they are willing to enter will determine the future.
“For the private practice physicians in our community, the whole notion of going at risk has been scary. Risk is a four-letter word in health care,” Nevin said. “But I’m hopeful that, because of the experiences we’ve had, we’ll craft more partnerships so we can care differently for the people that we serve, all the people, and with a source of revenue that we can depend on.”
Harris added that the risk needs to be reasonable. AMA supports new payment models, she said, but wants to make sure these payment models make sense and “allow equitable opportunities to succeed while offering high value care.”
Ultimately, CEOs, policymakers and the health care industry need to be deliberate and thoughtful about next steps. Simply jumping into solutions, technological or policy-wise, without understanding and measuring for sustainability is a recipe for failure.
“We’re going to have to move fast. We might make mistakes along the way, but we’re going to have to regroup quickly so that we can really get to the desired outcome,” Turney said.
Harris called on leaders to come together with a commitment to hold conversations in which the focus is not on who wins and who loses. “It can be additive,” Harris said. “And we can be respectful.”
What’s needed next? Alignment of incentives among providers, payers, government and patients.
“When there’s a win-win-win-win across all four,” Segert said, “I do believe it can have a meaningful impact on accessibility, quality and sustainability of our health care system.”
Watch the Impact of COVID-19 on Physician Practice Economics: Collaboration to Maintain the Health Ecosystem webcast here: