What matters most to physicians when it comes to population health and value-based care?
How can physicians and clinicians help accelerate the transformation to value-based care?
What challenges do physicians face that slow the transition to value-based care?
Navvis’ Chief Growth Officer and Executive Vice President of Physician Strategy Dr. Miles Snowden takes us on a deep dive into physicians’ perspectives of value-based care in this episode of the Navvis Take 5 podcast.
Listen in on this discussion between Dr. Snowden and Chuck Eberl, Navvis’ chief strategy officer, to find out what truly matters to physicians to drive performance in risk-based contracts. The transcript is below, lightly edited for length and clarity. You can also access the audio for all Navvis Take 5 episodes here.
Let’s start off with a broad question. What matters to physicians relative to population health and value-based care? Let’s go big.
Dr. Snowden: I’ll answer from the perspective of my own experience as a physician in training and as a physician in practice, and relate how that really impacts my current thinking about how to advance performance of the healthcare system, particularly physicians for all constituents. I really think it’s important for everyone involved in this value-based care transformation to understand where physicians come from professionally who are involved in this transition. So let me just for a few minutes sensitize you to the perspective of practicing physicians.
I’ll start by just making a statement: Most physicians are mission driven, and physicians generally don’t lose the magnetic north that brings them into healthcare in the first place — that is delivering patient care and valuing and enjoying the professional collaboration with other high performing physicians. The magnetic north of care delivery and the mission for physicians is cemented by really intimate relationships between training physicians and the individuals who they tend to come up against in their training. That is often indigent people in the community, veterans, and others who are facing extraordinary misfortune from a clinical or social standpoint.
If you think about having your formative professional years being spent working with some of the most unfortunate individuals in our societies, you begin to understand how it can be that a physician has cemented in themselves this concept of mission-driven. I can just remember so well many patients who I would work with who had spent a career in the military, had fought in world wars, or who had other extraordinary experiences in their life, and I had the opportunity to take care of them.
You just can’t help but be affected by that. In essence, physicians in their training experience see the democratization of suffering and illness and death and health as well. They have a distinct sense of community and of service — and intimate knowledge of the value and the complexities of illness, death, and recovery. It’s really important for everyone who’s involved in moving the physician community into a different reimbursement model that they first respect this basic fact.
Physicians don’t do population health. They do patient health. They see patients one at a time in sequential order, and more often than not in a very intimate setting and relationship. Healthcare requires forming a relationship that’s based on trust and the sharing of intimate information. Population health and value-based care are not going to change the dynamic of one physician being in one examining room or one operating room with one patient in an intimate relationship necessary for healthcare.
We should recognize that, and we should develop the systems and the processes that allow for the sequential one-on-one delivery of healthcare while also expanding our view of healthcare to be population-based. When I engage with physicians or other clinicians, I first acknowledge the intimacy and the propriety of their patient relationships, the democratization that they’ve experienced in their training, and the successes and the failures that every physician experiences and every physician is influenced by. With that respect as an initial starting point, I’m much more likely to move that physician to a different consideration in regard to value-based care. I would start with the recognition that physicians are not tools in a toolbox for value-based care. They are a very special component of healthcare delivery.
When speaking with others in the industry as to why the healthcare industry has been so slow to move into value-based care, the response is often that the system is not aligned to deliver value from that perspective and from the perspective of practicing physicians. What is driving this misalignment?
Let me again take the physician’s view here. I’d like to explain the economic position of the physician within the healthcare system. Physicians don’t get paid in relationship to expertise, in relationship to performance, or in a relationship to experience. The worst physician is generally paid about the same as the best physician in any community or any care delivery system or environment.
As a result, there really is no opportunity for physicians to increase their compensation as they become more experienced or as they become more expert over time. Physicians generally hit their maximum compensation when their schedules become full. That generally happens in three to five years after training. Think about that. Really a remarkably different experience economically for a physician as a result.
In part because physicians generally have a small business for their practice, they don’t really have a means of wealth accumulation. They may have a high income, but they don’t accumulate equity or wealth in the business of medicine, generally speaking. What is interesting to me is, can value-based care be a solution to some of these headwinds for the practice of medicine? This inability to be paid relative to your expertise, your performance, or your effort, or your ability to gain equity in a system of care that’s performing at a greater level than another. It may not be on its own sufficient, but it is an important component. Certainly value-based care transitions provide new physician leadership opportunities and that’s exciting to doctors. They want to lead, they want to have new roles.
Value-based care done right also provides differential compensation for differential performance. I’m excited about the concept that value-based care may indeed mitigate some of these challenges in the practice of medicine.
Value-based care can to a degree provide a basis for some physicians to build wealth through the development of proprietary insights, interventions, workflows, and tools and technology focused on advancing value-based care performance. There are a lot of physicians who are highly motivated to be innovative and create new tools. There should be a reward for that. The value-based care construct does provide an environment where such an award can accrue, whereas in the fee-for-service world, that’s generally not so much the case in that journey I just described.
I would say two things are in short supply for the physician. Those are capital and scale. To make a transition for a physician or a small group practice from fee-for-service to value-based care, you have this reality where you don’t pull forward the new economics of doing things differently for a year or two after you’ve invested in doing new things. That can create some significant headwinds on a cashflow basis. Having someone invest some capital up front is really helpful to physicians.
Secondly, scale. It can be pretty challenging to invest enough in data and technology and new people doing new things to your patient population to have it be prudent on the scale of a single physician or a small group practice. Scale and capital are in short supply, and external parties, for example, my own company, can provide those sort of investments to allow physicians to make this transition.
Hospitals and health plans can also do this partnership with physician groups, and I have found that that’s an effective solution as well. Sometimes they bring some of the very same shortfalls as the physician groups, but they certainly more often do have capital and they can contribute scale to the effort. There is good opportunity in the new relationships between health plans and physician groups and physician groups and healthcare delivery systems as well. I’d say the secret sauce for value-based care is probably getting the incentives right that are at work for physicians, getting the incentives that are at work in the examining room or the operating room consistent with those of the entity that is paying for all that care.
We need to find a way to pay physicians differently for doing things differently, quite simply. We need to provide them sufficient scale and capital to bridge them to doing things differently. We need to bridge them while retaining the respect that’s deserved from the journey they’ve had to get to delivery of care, to get to the art of the practice of medicine.
We need to not work around the physician. There’s a tendency to say, oh, we’ll just work around them. Let’s not disturb their workflow. It’s okay to disturb the physician’s workflow if that physician has been involved in creating the new interventions, the new processes, the new workflow, and they are invested in it. They feel like they’ve been heard and the propriety and the intimacy of patient care has been respected in that process. We have approached that at Navvis by spending a lot of our effort in building out competencies on physician enterprise transformation, helping physician groups develop governance, new compensation models and new processes to allow them to be successful at a greater scale in a more complex business model.
Consistent with value-based care physician coaching, developing physician leaders through our practice optimization, putting our practice optimization managers into practices to teach the staff how to view a patient encounter as something more than the treatment of the presenting complaint, network development, being sure that working in concert with physicians, we build post-acute networks that are high performing and support the overall economics of the contract. These things are all foundational to respecting the physician’s journey while also embracing the physician as a leader in that change and contributing capital and scale to the effort.
As the market matures and continues to migrate to value-based care, what advice would you give to a physician or other clinicians who are really looking to take leadership at their organizations in value-based care? How do they take charge and frame up the opportunity for themselves and their organization?
I think it’s important that others who are observing or catalyzing change to value-based care recognize that there is nothing about medical education and training that is intended to develop operators or managers or executives amongst physicians. If you think about what we instill in physicians in training, what we expect from physicians, it is the polar opposite of what we seek in operators and general managers.
Of course, there are exceptions, but generally speaking, physicians are taught through their training to value education and training and certification. In other words, they’re not opportunistic, they await the credentials. Specialization is valued in healthcare, which means that generalism, which is so important in operating models and management, is generally not taught or understood. In healthcare, in medicine, repetition is valued doing the same thing over and over. That means they’re not innovators, necessarily. They value the ability to do the same procedure over and over again with extraordinary expertise. We do need that. But it doesn’t produce innovators necessarily.
Physicians are all taught to be evidence-based, which means they’re not taught necessarily to be intuitive. And intuitiveness is important, of course, in any executive leader. Physicians are taught to be protocol driven. Flexibility is the counterpoint to protocol driven. That flexibility that’s so important in management is less valued and less prominent in the medical education process.
Physicians are taught to be a risk abhorrent. First, do no harm, meaning they’re not risk takers unless they can ensure they will do not a bit of harm. They won’t take the next step medically speaking, and that’s not necessarily an effective approach for someone in a management role.
Lastly, physicians are taught to be directive and decisive, yet we also know that in a management role, collaborative natures are very valuable. Physicians are generally not taught to be collaborative or consensus building, but rather be directive and decisive. If you think about the process of physician training, you can see how hard it is for a physician to go from medical training, medical practice, and to a generalist management operating role.
If we understand that and then invest in the physician who seeks to fulfill those roles, then we can be more successful in that regard. They require education and more importantly, mentoring. Physicians who become operators and generalist managers in healthcare delivery almost always have a highly effective and highly valued mentor, usually another physician who has gone before them. I did, in every step in my career. I’ve had a really important physician mentor who I have a great respect for. We provide that ourselves through our own businesses and our own efforts. But it could also be found just in the day-to-day push and pull of one’s career in a larger system of care delivery.
To sum it all up, physicians will have to learn to be professional risk takers to be successful as generalist managers. They can’t wait for the training. They have to recognize that sometimes you’ve got to prudently step out and realize that a month of experience is probably worth a year of training. That holds true in most professions.
Most leaders are identified for new opportunities through very subjective measures, not objective measures. Once you get past the entry level role, the question is usually, can I trust this person to get the job done. Not does this person have the certification or degree associated with the job. That is certainly the case with me when I look for new leaders. Advanced medical degrees are popular amongst physicians today, MBAs, MHAs, and MMMs, for example. Those have value, particularly where the physician feels more prepared for administrative work. But I can tell you that experience impacts my own judgment of a physician’s readiness to take on a management role far more than credentials. That’s how I would view that aspect of physician leadership.
Lastly, physicians not only need to be professional risk takers but also opportunistic. If you’ve got a challenge going on, reach out and say, I’ll take it, and don’t wait for the credentials to do it. Just do it. More often than not, we find that really smart, energetic, hardworking physicians can indeed be highly successful if they take this sort of approach.
About Miles Snowden, MD, MPH
Dr. Miles Snowden is Navvis’ Chief Growth Officer and Executive Vice President of Physician Strategy. He brings decades of experience as both a physician and executive leader. Previously, he served as the Chief Medical Officer at TeamHealth, one of the largest physician group practices in the U.S. He was at UnitedHealth Group for 10 years, serving as the Chief Medical Officer at Optum Health. Prior to that role, he was the Chief Medical Officer at Delta Airlines. To hear more from Dr. Snowden about physician leadership in population health, tune in to his conversation on the B-Time Podcast with Beth Bierbower.