In July 2012, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) announced the first round of 108 Health Care Innovation Awards (HCIA). Each award tests a health-care-delivery innovation focused on specific populations and settings. Health conditions, target populations, and workforce models varied. Settings included outpatient physician practices (both primary care and specialty care), hospitals, patient homes, emergency rooms, community health centers, community-based mental health centers, skilled nursing facilities, and rehabilitation hospitals.

The objective of this study was to identify the roles and responsibilities physicians assume as part of new health care delivery models and the strategies that facilitated adoption of interventions by physicians across a sample of 21 HCIA programs.

BACKGROUND AND OBJECTIVES

Physician Engagement Strategies in Care Coordination: Findings from the Health Care Innovation Award Programs

Megan Skillman, MPA; Caitlin Cross-Barnet, PhD; Rachel Singer, PhD; Sarah Ruiz, PhD; Christina Rotondo, BA; Roy Ahn, PhD; Lynne Snyder, PhD; Erin Colligan, PhD; Katherine Giuriceo, PhD; Adil Moiduddin, MPP; Melissa Atlas, BA ;Tianne Wu, MPH

Facilitators:

Reputation: Programs, program staff or program organizations that were

recognizable were able to engage physicians more easily.

Prior experience: Some programs had a previous pilot or iterations of their

program, which had established a relationship between the program and

their target physicians on which to build during the HCIA period.

Placement in hospital system: Programs working within a hospital system

often encountered wider resources and higher-level administrative support,

which allowed for physicians in the system to get on board with fewer

concerns over risk, liability, or competition.

Barriers:

Financial competition: External physicians were distrustful and concerned

that program staff would recruit their patients.

Liability: Physicians reluctant to change practice (e.g., to redirect patients

from the emergency room) for fear of being held liable.

FFS environment: Payment models did not encourage involvement;

attending meetings, presentations, or referring was usually not reimbursable.

Limited physician time: Physicians had little time to refer to programs

during short routine visits, and lacked the time for team meetings or other

engagement activities.

FACILITATORS AND BARRIERS TO PHYSICIAN ENGAGEMENT

Our study suggests that integrating physicians into care teams through appropriate education, orientation, and support can accelerate the adoption of innovations within institutions.

Buy-in from physicians and other providers may build high-level institutional support for emerging value-based payment models.

The question of whether physician engagement actually leads to improved patient outcomes for certain chronic diseases remains uncertain, deserving of more research attention.

POLICY IMPLICATIONS

We are grateful to John Kralewski and John Christensen for sharing their expertise about the current landscape of physician engagement. We are indebted to the HCIA Disease-Specific and High Risk NORC evaluation teams for their expertise, collaboration, and analysis across the programs discussed in this study.

Research reported in this poster was supported by the Center for Medicare & Medicaid Innovation under Contract No. HSSM-500-2011-00002I, Order No. HHSM-500-T00009 and Order No. HHSM-500-T00010. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

For more information, please contact:

Megan Skillman, MPA | Principal Research AnalystNORC at the University of Chicago4350 East West Highway, Bethesda, MD 20814Skillman-Megan@norc.org | office (301) 634-9518

ACKNOWLEDGEMENTSPHYSICIAN ROLES

Physicians took on varying roles and

levels of involvement across HCIA programs

Enlist physician leaders to create buy-in and engagement among their colleagues (n=14). For example, when physician engagement became a challenge in an integrated delivery program, the program’s physician leadership personally explained the program to outpatient specialists in order to establish connections and encouragea collegial environment. Other programs with multiple sites assigned physician champions for each site.

Delineate and explain staff roles to physicians (n=8). Programs successfully engaged physicians by developing guides and other materials to introduce the evidence-base for the program and explain staff roles and contact information.

Some programs consolidated communication by establishing a single point of contact. This individual built credibility with physicians by building relationships over time and served as a hub for innovation-specific knowledge. Physicians appreciated the ability to reach a designated individual who could address their concerns rather than having to coordinate conversations with multiple nurses or other staff members.

Clarify communication channels with physicians and define how such communication will take place (n=17). Most programs continually evolved in their processes to establish regular communication between physicians and care teams in order to adapt to physicians’ needs and preferences. Five programs found it useful to share information about physician preferences with other team members. These tailored communication strategies extended to sharing data through health IT platforms in order to facilitate interoperability, improve bidirectional communication, and mitigate logistical challenges.

IMPLEMENT TARGETED COMMUNICATION TO FACILITATE TEAM-BASED CARE

Demonstrate how the program would improve physician workflow and information sharing but not increase administrative burden. Recognizing the value of physicians’ time helped programs engage physicians. Physicians appreciated programs that saved them time by handling auxiliary services such as transportation to appointments and patient education.

Providers were interested in programs’ positive outcomes; however it is difficult to demonstrate such outcomes in a short time frame. In addition, reform strategies that sought to stabilize a high-risk population over time may not show overall improvements for more than two years.

Involve physicians at the beginning of interventions (n=5).

For example, one clinic-based program that expected to rely on physicians in the community (rather than on-site) arranged individual meetings to explain the program, including how an algorithm assigned risk levels to individual patients.

Conduct formal outreach to physicians external to the program’s institution. Leaders at one program held 15-20 presentations for outside physician practices to share information about the program, distribute brochures, and describe workforce roles.

Share information and data (n=5). To be effective, education had to target specific physician interests in formats that were easy to access, and it had to focus on metrics that physicians believed they had the ability to impact. When programs focused on a specific chronic condition, related biometrics data (e.g., improved A1c levels in diabetics) were most useful to physicians.

EDUCATE PHYSICIANS ON PROGRAM AIMS

METHODS

Site visits and telephone interviews with over 500 individuals, including 330 program staff and 76 physicians

Data Collection

A qualitative study within a larger mixed-methods evaluation of CMS Health Care Innovation Awards

Study Design

Coded transcripts using NVivo software to identify themes related to

Interactions among program physicians

Interactions between program and external physicians

Level of success with physician engagement (frontline staff, research team, advisor)

Improvements in physician workflow or caseload

Facilitators and/or barriers to physician engagement

Data Analysis

CREATE DIRECT INCENTIVES FOR PHYSICIANS TO PARTICIPATE