Leaders at Coastal Medical made the somewhat unique decision to distribute the organization’s first shared savings as an accountable care organization (ACO) among all employees, in recognition of every staff person’s contribution to improvements in quality and in cost control. Al Kurose, MD, FACP, is President and CEO of Coastal Medical, an ACO, a member of Rhode Island's largest physician-owned primary care practice, and a member of IHI's Leadership Alliance. In this blog post, Dr. Kurose distills some of what his organization has learned on its ACO journey, including why they gave every employee a share of the profits. Dr. Kurose is faculty for IHI’s Population Management Executive Development Program.
It’s been a challenging and exciting time for Coastal Medical since we started our ACO work in 2012. So much of what we do has changed so quickly. We have a new business model. We’re changing care delivery. We’re designing and implementing new clinical initiatives and services for patients. We’re exploring the use of new software for analytics and looking at how we use data. There’s all this day-to-day work — the practical aspects of becoming an ACO — and we want to get as many of those things right as we can. However, as a leader in a nascent ACO, I would argue that some of the most important aspects of this work are in a different realm. I’m hopeful that sharing some of the lessons from our organization’s experience might be helpful to others.
Create a Shared Vision
One of the biggest lessons we have learned is about the need to create a vision of the care we want to provide, and the importance of making sure that vision is shared by everyone in the organization. We have to communicate and nurture that shared vision in a way that wins the hearts and minds of the providers and staff. We have to think about the values of the organization and make sure our current work aligns with those values and with our mission. How does each person’s new role fit into the larger picture of what we’re trying to accomplish?
A tremendous amount of communication needs to happen, and it has to be repeated and consistent, and it has to occur on parallel tracks. In many ways, we have the same message and same vision to share with our physician owners, our employed physicians, our advanced practitioners, our clinical pharmacists, our nurse care managers, our management teams, and our frontline staff. But there are also nuanced differences in how we communicate most effectively with each of these important groups, so we can get the best understanding and the most buy-in from every person involved in the work.
One goal is to effectively communicate to everyone what it means to be an ACO, so that on any given day, at any one of our sites, you could ask any physician or receptionist, “What’s this ACO thing?” and they would all basically give you the same answer.
Share the Work, Share the Wealth
We say that we’re all in it together when there’s work to do. This should also be true when we have moments of success. We should include everyone when we celebrate improvements in care, and we should share financial success whenever we can.
Coastal Medical has had shared savings contracts for about three years. More measurement, more reporting, and the implementation of all these new clinical initiatives has meant lots of new work for everybody in the organization, particularly out on the front lines.
Because of all this hard work, we’re seeing improvements in quality and in cost control. In the first performance year of our Medicare Shared Savings Program Accountable Care Organization (MSSP ACO), Coastal was able to save $7.2 million and outperform our cost benchmark by 5.4 percent. At the same time, we improved performance for the vast majority of our quality measures in 2013 versus the year before. We got a payment from CMS, and we also earned modest shared savings revenues from three other contracts.
We decided, as a management team and with our physician board of directors, to reinvest a portion of those payments back into the organization to cover the incremental costs of new services and to support our continued efforts to transform care. After that reinvestment, we had a portion left to make a shared savings distribution. This was a moment to send a message to every employee in the company. Rather than doing what might have been conventional — give all the profits in this first shared savings distribution round to the physician-owners — we distributed the savings among all employees in the company. As a leadership team, we decided that there was no better time to make it clear that all of us contributed to this success.
Chief Operating Officer, Meryl Moss, and Chief Medical Officer, Dr. Ed McGookin, have been deeply involved in this work. The three of us visited every site to speak with as many employees as possible. For three days, we drove around Rhode Island and met with 25 different groups of Coastal employees. Our message was this: “We understand that everybody who works in this organization has the opportunity to touch the lives of patients. We know what a difference it can make to patients how you answer the phone, how a receptionist greets people at the window, and how a medical assistant interacts with a person and establishes relationships with patients over time. We understand what you contribute to the care of our patients, we value it, and we want to say thank you for your role in this moment of shared success.” Being able to do this really brought home to us what a privilege it is to be involved in leadership. The feedback we received from employees at every level of the organization about these visits was overwhelmingly positive. Just being there, listening, and showing appreciation clearly had an impact that went beyond the distribution of checks.
Focus on the Benefits to Patients
It’s also important to convey that there is a higher purpose to our efforts. When we thought about making this shared savings distribution, as much as we knew it was significant to give every employee a bonus, we thought the message we presented with that bonus was more important. People choose to work in health care because they want to help people. Of course, everybody likes to get a bonus, but it’s critical that we tap into people’s primary motivation for doing their work, and it’s not money. To bring gratification and satisfaction to the people who work in a health care organization, we should acknowledge each individual’s contribution to the patients’ care experience, talk about how transforming care delivery is good for patients, and emphasize how this work facilitates an unprecedented level of service.
Everyone is doing more work and some of it can seem like a grind. The cynical view might be that we’re just jumping through hoops so we can get a payment, but we have the data to show that year after year, we are improving care for our patients as a result of this ACO work. These improvements include increasing the percentage of patients with high blood pressure who have their blood pressure under control, and increasing the percentage of patients with diabetes whose blood sugar is under good control.
This work is not so easy, and some of it’s still new to us. Sometimes it goes in fits and starts. We have to make adjustments, but it’s working. It’s working because we’re starting to make health care more affordable. It’s working because the quality and experience of care are better for our patients.
Lighten the Load When You Can
Meryl Moss, Coastal’s COO, has emphasized repeatedly that if you’re going to give your teams a lot of new work, you also need to take some work away whenever you can. One way we’ve done this is through a pilot project to centralize the prescription refill process. I worked in an office as a primary care physician for 20 years. Prescription refills are often taxing to both physicians and office staff because everyone is busy with so many other tasks. For this pilot project at Coastal, pharmacy techs are working under the supervision of a clinical pharmacist to refill prescriptions and complete prior authorizations using a very detailed protocol. Obviously, there are exceptions to this protocol, but for most routine prescription refills and prior authorizations, the work is now performed centrally for the offices in the pilot. This has given the office staff more time to work with patients. This new service has been very well received, and we are now scaling up to include every Coastal office.
Over time, our organization has developed a collaborative, inclusive process of workflow redesign. We’ve involved medical assistants and office managers, providers, management, and others, and we’ve asked, “What can we do to help? What can we do to lighten the load?” We understand that they’ve sometimes been overwhelmed by the number of new tasks that we’ve given them, so we try to make processes more efficient whenever possible.
Talk is cheap, and executives can say things to make themselves feel good, but the success Coastal Medical has had so far makes it clear to us that accountable care and care transformation are not passing fads. We believe this is where the industry is going and where our profession is going.
The journey into accountable care entails more than a little bit of risk taking. There are lots of investments we had to make to deliver new services before we knew whether or not we could really reduce the total cost of care. There are still many costs and components of health care delivery that we can’t control in a primary-care-driven ACO model. We can, however, have significant influence. This new business model should be powerful enough to make our new care delivery model sustainable, and we need that sustainability to support our goal of effectively managing population health.
It’s important to keep asking why our organization exists. We exist to serve patients. Everything we do has to meet that standard.
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