From Private Practice to an Integrated Health System ...apps.sportsmed.org/meetings/am2016/files/Schickend... · Private/Small Group Disadvantages •Limited resources, time and incentive

From Private Practice to an Integrated Health System: Playing to Your Strengths

Mark Schickendantz, MD

Director, Cleveland Clinic Center for Sports Health

Associate Professor of Surgery, Cleveland Clinic

Lerner College of Medicine

Head Team Physician, Cleveland IndiansBusiness of Sports l AOSSM l July 2016

Business of Sports l AOSSM l July 2016

Why Integrated Health Care Delivery

Systems (IDS)?

• Current US healthcare system is:

Fragmented

Complex

Expensive

Highly variable quality

The goal of an IDS is:

Delivery of high quality, cost effective care

Address the health care needs of the community


Volume vs. Value

• Current volume-based payment system (fee for

service) rewards more work

• Supports fragmentation; inhibits integration

• Value-based payment systems (pay for

performance) rewards quality work

• Supports integration; coordinated, patient

centered care


Health Care Delivery Models


• Approximately 850 IDS’s presently in the US

• Most are evolving along this continuum

What is an IDS?

• “A network of organizations that provides a

coordinated continuum of services to a defined

population and is willing to be held fiscally and

clinically accountable for the outcomes and

health status of the populations served”

• Patient centered

Improved patient experience

Increased communication, information sharing

Address community health care needs


American Journal of Managed Care 2013

Home

Wellness / Fitness

Center

Retail Pharmacy

Physician

Clinics

Diagnostic /

Imaging Center

Urgent Care

Family Health & Surgery Center

Community-Based Care

Acute Care

Recovery and Rehab Care

Hospital

Inpatient Rehab

Skilled Nursing

Facility

Outpatient Rehab

Home Care

Acuity

Integrated System



What are the keys to success?

• It’s not size or specific structure that matters.

Rather, it is..

• “An organizational commitment to, and a culture

of, continuous quality improvement that is most

closely linked to better performance as measured

by clinical quality, patient satisfaction,

organizational learning and financial

performance”


Shortell, 2005, Med Care Res Rev

In order to be successful, Integrated

Health Care Systems must:

• Attract the best qualified medical, scientific, and support staff

• Excel in specialized medical care supported by comprehensive research and education

• Develop, apply, evaluate and share new technology

• Excel in service

• Provide efficient access to affordable medical care

• Ensure that quality underlies every decision


The Cleveland Clinic Way

What are the barriers to success?

• 3 General Categories:

–Operational

–Governance

–Cultural

• All have the potential to de-rail the process



Multispecialty groups are difficult to form due to

income disparity of various specialties.

There is a lack of payment methodologies that

promote group function.

Competition exists between hospitals and physician

groups.

Hospitals have different business cultures than

physician groups.

A lack of consistent quality performance measures

exists for hospitals and physicians.

Different information systems exist.

Some physicians cannot see the value in integration.

Operational Barriers


Governance Barriers

• There are usually two forms of governance within

hospitals that have competing priorities and cultures – the

hospital board and the medical staff leadership.

• Hospital board members typically lack a health care

background or clinical expertise and are not prepared to

evaluate quality issues.

• Because of its loose structure and emphasis on

individual physician interests, medical staff governance is

not well suited to promoting collective responsibility for

quality and operational efficiency.

• Commonly, medical staff leaders cannot render decisions

on important policy and organizational matters in a timely

manner because they require support of all or most of the

physicians.


Cultural Barriers

• A high degree of competition in the local health care

market creates unfavorable conditions for hospital and

physician alignment.

• Physician practices do not typically engage in formal,

long-term strategic planning, and small practices do not

usually participate in continuous quality improvement.

• Hospital leaders work in meetings, but physicians value

time spent in direct patient care.




What About Quality

• IDS’s have demonstrated improved quality of care:

• Lower:

admission rates

Length of stay

Adverse outcomes

• Improved:

Chronic disease management

DM, HTN, CHF

• Higher:

use of EBM

use of preventative care


Newhouse; Int J Integ Care 2003

Rittenhouse; Med Care Res Rev 2010

Ramalho; J Manged Care Pharm 2010

What About Cost

• There is a positive correlation between integration and high

performance on quality measures

• However, no correlation between high performance on quality

measures and financial performance has been demonstrated

• Utilization of services has been lower in some systems

(appropriate?)

• Integration has not been shown to reduce the cost of services


Weeks, 2010; McCarty 2009


Medscape 2015 Physician Survey


Current Employment Trends


AAOS Department of Research and Scientific Affairs: Orthopaedic Practice in the U.S. 2014. American Academy of Orthopaedic

Surgeons. Rosemont IL.





Salary: Employed vs. Self Employed

27.5 %





Play to your Strengths to Avoid Dissatisfaction

Your Potential Strengths

• Clinical and surgical excellence

• Academic expertise/leadership

• Political/Organizational skills

• Clinical and basic science research

• Team/event physician participation

• Innovation

• Community service

• Business acumen


Private/Small Group Practice Advantages

• Business Ownership

• Autonomy

• Control

– Schedule

– Vacation

– Meeting

• Income potential

• Ancillary ownership

– PT

– Imaging

– ASC


Private/Small Group Disadvantages

• Limited resources, time and incentive for research

• Limited resources, time and incentive for education

• Financial responsibility

• Malpractice cost/exposure

• Time commitment to running the practice/business


Integrated Health System Advantages

• Availability of other medical specialists

• Support for academic activities

• Support for research activities

– Personnel

– Financial

– Time

– Resources

• Focus on practicing medicine, not running a business

• Malpractice coverage/legal protection

• Financial security


Final Thoughts

• Current economic and political climate supports the

development of IDS’s

• Integrated Delivery Systems are growing in size and number

• Physicians are trending toward employment models of

practice, even though self employed physicians in general take

home more salary

• An honest assessment of your strengths is required in order to

make a solid decision regarding the best situation for you as

an individual practitioner


Diagnos( c*and*Therapeu( c*Musculoskeletal*Ultrasound*of*the*Ankle*and*Foot*

Gregory*Harkey,*M.D.*

Cleveland*Clinic*Founda( on*

February*23,*2013*

Thank You!

From Private Practice to an Integrated Health System ...apps.sportsmed.org/meetings/am2016/files/Schickend... · Private/Small Group Disadvantages •Limited resources, time and incentive

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