My portion of the session examined how different types of practices have different staffing needs and consequently different levels of staffing. More interestingly, I think, Andy then described how to create a high-performing care team and how value-based payment requires a different mix and number of staff than what a practice would need with fee-for-service payment.
Swanson and I sat down for the Executive Session podcast to discuss this topic at some length, including about his background in performance management in a health system and why he believes that when going through any kind of transition – be it payment models or building teams – it needs to be focused on patient centricity.
“That notion carries forward through value-based payments and getting care teams, as led by their physician or physician groups, to be most focused on the patient,” Swanson said, “which I think if that filters through the teams, then you get to be a high-delivery or high-performance delivery team.
Gans: Can you talk about how high-performing teams need to be both patient-centered and physician led?
Swanson: Any team, regardless of the industry that you're in, must be focused first on a goal in order for it to be high performing. In our business, the patient is the goal, right? … If that becomes the team's sole focus, putting the patient in the middle, and that becomes the goal, more broadly speaking, we’ll say the patient panel, if we're thinking about population health effectiveness, then I think everything flows downhill from there. So certainly, the team is taking direction and leadership from their physician leader and making sure that the physician is aligning the care plan, not just for the patient but across the entire team. So they can execute their skill set for that patient at the best of their ability and at the highest use of their degree or licensure.
[One] of the key differentiators, as practices move from fee-for-service to fee-for-value, is the whole notion of keeping entire populations healthy or out of the clinic — changing role definitions to better suit care coordination capabilities for the benefit of the entire population, not just for a sole patient during or immediately before or immediately following their visit. And I think that takes some buy-in from the top.
Gans: You described how value-based care requires practices to look at aspects such as care coordination. Then there’s telemedicine — providing care to the patient that may not require a face-to-face visit. Can you give some more insights into these extensions into value-based care?
Swanson: From a care coordination perspective, it's working the patient through the continuum of care, be it at my practice setting, an alternative practice setting or most importantly, most of the time, patients aren't in a care setting, right? How do we make sure that we're keeping in contact with the patient when they're not in a care setting? I think this becomes paramount. And I think those groups and practices who are doing patient communication the best are beginning to have the most success with driving down costs, keeping patients in the appropriate care setting, while maintaining optimal clinical outcomes.
You mentioned telehealth, but I think all sorts of access conversations come to bear, because if you're not talking about a traditional patient visit, then you have to be talking about where do you access the patient in a time that will be beneficial for both the patient and for the provider group and the care team, making sure that they can devote the appropriate type of interaction with a patient when the patient needs it when they're able to give it.
I think all of these things play into kind of a successful navigation of population health management. Then the trick becomes, who in the practice is responsible for these things? … That's where the conversation goes to next, when practices are looking at an existing staffing plan and saying, “I've got these nurses and these MAs and these types of administrative support, be it billing or leadership, and how and what do I do with these current staff members?” Because we're busy seeing patients every day — ao how do I take on the extra burden of this population health management?
Gans: The traditional staffing model where, for example, each doctor has an assigned nurse — it could be an MA, an LPN, or a registered nurse, depending on the case complexity and the desires of the doctor — and that nurse would provide virtually all patient services. Value-based care, because of a very diverse set of tasks needing to be performed, oftentimes, you need to look at a team approach to providing care to the doctors. How can a practice implement it?
Swanson: I think part of the excitement in this navigation to value is that I think it offers role expansion and new duties to care teams that may be a bit stuck in a rut. … If you look to a nurse or an MA who might need to change or have a different skill set and think this notion of interacting with our technology to do more proactive [outreach], either through secure messaging or telephonic research, or in the future, maybe its programming the bot, right?
I think that's where you look at a nurse and say, “instead of devoting your day, every day, to working hand in hand with the doctors, maybe for this quarter or this this year, you're taking on the responsibility of our patient panel and thinking about kind of care management differently” — certainly interacting with other providers, including the physicians, to talk about case-by-case and patient-by-patient situations.
Taking a nurse out of a role that is direct patient care (one-to-one perspective) and putting them into a one-to-many education setting, I think, can be really invigorating for that care team member. I think there are plenty of great providers who, stuck in a rut, perform one way, and given an opportunity, can really thrive in a different sort of setting. And I think people are open and willing and wanting to have kind of a new experience as it relates to that; that just builds the team.
Gans: You now may have the opportunity to find talented, motivated staff members who are in-house, and teach them new skills, let them take new responsibilities and through that, perhaps have promotion within the practice. Of course, as you start moving more away from maybe one-on-one nursing-to-doctor, you start needing to add new staff or retraining staff members. There are advantages to each model. Give us some of your thoughts on training versus recruiting —what should a practice executive be thinking about when they start looking at changing the care model?
Swanson: I think anybody who's making the journey — dipping toes or feet into the water of value-based care —what you’ll learn quickly is that your staff has different and ever-changing skill sets. I think you always will have an opportunity to upskill existing staff; I think the trick is defining what skills are reasonably achievable.
I keep going back to the patient panel management — a good nurse is working across patients today, and their providers and physicians to understand care plans not just on an individual basis, but across a diagnosis status. I think those clinicians, to have that ability to look across a patient panel today, are apt to learn some of the nuance of what a panel management plan looks like … because they already have a bent towards understanding the way multiple patients intersect with a similar care plan over time. That lends itself to an easy upskilling opportunity.
Where we're all struggling, I think, is the appropriate usage of aggregate data. Somebody who sees patients every day clinically may or may not be very apt to data aggregation and then the manipulation and analysis of data on a large scale. So that may be a place where the skill jump is just too far, that you may need recruit or hire in a different skill set.
That's where I think that the effective practice leader is going to analyze the current staff and then articulate where we can upskill and where we need to recruit for.
Gans: You and I have had discussions regarding MGMA’s data that supports the trend of added cost in staffing and added cost in adding new services as well as new technologies in the organization. If you were to look at MGMA’s data for practices that are Patient-Centered Medical Homes (PCMH), what have you seen in the shift in how practices staff?
Swanson: Some of the recent data points to shifts in the positive, meaning lower costs for groups who have identified as PCMH in things such as business operations support. ... The data says you gain about a quarter to a third of an FTE — what's great is you're shifting costs out of an administrative bucket because you need to shift that cost into a more clinically-facing group. So, in that cohort of recognized PCMHs or self-identified PCMHs, the clinical support goes up by about the same amount.
I think there's another aspect of this, which is getting people through all of the steps in a care plan not necessarily tied to a physician visit. That does require some more administrative and potentially some clinical time as well. So that's where some of these additional costs do come in.
Gans: What advice can you provide for a physician or an administrator who's leading a practice, who's about participate in an ACO or accept a capitation payment contract or otherwise transition its payment mechanisms?
Swanson: It circles back to the beginning of the conversation about building a highly effective and high-performing care team. … Let's make sure that all the physicians are on the same page and they understand what this means for them. … You would be surprised to hear about the number of groups who enter into this and some people don't understand its impact. They don't understand why it matters to them. And so I think starting at the top and getting alignment is the first step.
And then I think from there, what are the outcomes that we're looking to achieve in this new way of addressing it? You can start to articulate the goals of this contract or joining the ACO are to drive down costs and to increase quality of care. What does that mean across our panel? If I'm a specialist, if I'm a specialty group, it looks like one thing. If I'm a primary care group or a multispecialty group, it looks like something different. So talk about the actual goals, clinical goals, of how we're going to work to achieve those things.
Gans: Any other major takeaways?
Swanson: Good providers, physicians or other clinicians got into this game to take care of people, and I don't think that moving to a value-based payment model changes that at all. In fact, many physicians I have spoken with, when examining kind of the move to value, are somewhat reinvigorated because now I can look up from Patient Andy and see Patient Dave and the rest of my panel, and think about how do I provide the most optimal care for all of that panel, not just for a particular patient in front of me. I think it can be an exciting clinical conversation, to really lift up the capabilities of the entire team so that the physician, as the leader of that care team, can really recharge their entire clinical staff, and administrative staff as well, in supporting those patients through whatever part of the healthcare journey that they happen to be on.
When viewed in that lens, then value-based payments or capitation or whatever payment model is coming to bear, isn't necessarily the boogeyman, right? It's a new way of looking at a very age-old problem, which is providing the best care for an entire group. And I think that's the exciting part. I think that's what medical practices are taking some well-needed, recharging steps to get their practices in tip-top shape to make sure that their patients are in the same shape.
Additional Resource
Across the healthcare industry, the push is to deliver value rather than volume with value-based payment programs being the financing mechanism to drive change. Roadmaps to Value-based Profitability: A Practice Transformation Guide is the perfect starting point to gather information about how to prepare for, and maximize, your participation in value-based payment models.
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