I am a CMO in a medium-size community hospital with one third of our medical staff employed. Our employment model is a remnant of the past; productivity based on a pure net revenue model. It has worked extraordinarily well in the old paradigm.
We are entering into global risk contracts, and we all know these will multiply rapidly. As the article indicates, I think the only logical way to help our physicians align with the hospital is to be sure the incentives are also aligned with our vision of a future state of better coordination, improved chronic care, and accomplishment of the "triple aim"of improved population health, lower per capita cost, and excellent patient experience. To do so, the "system" can enter into these contracts, while creating common incentives across the entire medical staff, hospital, and other providers such as home health. There is no reason that we have to "pass on" the incentives of the contract to individual providers in our system. In fact to do so while contracts change so rapidly is likely to confuse individual providers, and lead to failure to accomplish change because the direction is not clear.
so what are the appropriate incentives? The primary care incentives are pretty clear: advanced medical home models have plenty of examples to choose from, including process and outcome measures for chronic illness care, care coordination, improved outpatient access, diminished emergency room and inpatient utilization, and so forth. A dilemma we are struggling with is how to incentivize our medical and surgical subspecialists. In the old models we distributed shared savings or "pay for performance" dollars to subspecialists based on the volume of visits as a proxy for "work". To sustain this model of distributing financial gain will undo all the benefits being built on the primary care side. The Dartmouth Atlas documents that one of the most important drivers of cost is frequency of visits to specialists. So what are the appropriate incentives for the specialists? Do we need to design specialty specific process and outcome measures for each one?
Are there any models out there to learn from?
Mark Novotny, MD, FACP, FHM, FACHE
Cooley Dickinson Hospital, Northampton, MA