By Craig Tanio, MD

There is a saying that “culture eats strategy for lunch.” Never has this been truer than when looking at primary care or physician group delivery system innovation.  Health care industry leaders must invest more time creating and scaling the right culture as they innovate.

There has been a great deal of controversy on the ability of the Primary Care Medical Home (PCMH) to impact total medical costs. Critics have noted that PCMH is adding additional costs to the structure without systematically demonstrating improvement in total costs and quality.

A great deal of time has been spent debating the proper structures, processes and financial incentives that are necessary to create value in physician-led-risk or shared-savings models. However, I suspect the real issue is that culture is a major driver of performance, and it has not been systematically measured or managed.

At ChenMed, we have developed a primary-care-led model focused on the care of seniors with multiple and chronic health conditions.  Funded through full-risk arrangements with Medicare Advantage plans, we outlined an overview of the original Miami-based model in Health Affairs last year [1].

Over the last three years, we have scaled the model from five centers in Miami to 36 centers in eight markets in the Southeast and Midwest.  This has required us to adjust our model in ways that allow it to readily scale. We have been able to make the fundamental economics work while rapidly scaling the medical practice, and are actively working on innovations to improve value every day.

One of the foundations of our strategy is getting the physician culture right.  This is not easy to measure from a health services and policy research perspective.Yet, it matters a great deal from a practical and business perspective. McKinsey and Company has developed an influence model on how organizations create the right behavior and mindset shifts, which we have found useful [2].

• Foster understanding and conviction.  “I know what is expected of me – I agree with it, and it is meaningful.”  One of our first insights, as we began to scale the model, is that clinician mindsets are critical. Dimensions that are important include the ability to develop relationships – with patients and members of the team, as well as a passion for taking care of complex patients.The most important mindset, however, is the desire to be accountable for outcomes, and to change performance in areas under a physician’s direct locus of control.  For example, a physician may readily note multiple drivers of a preventable hospital admission, but he or she can only directly control three to four. These valuable mindsets are readily visible when ChenMed physicians are discussing cases at our three-times-a -week physician or interdisciplinary team conferences.

• Role-modeling.  “I see superiors, peers and subordinates behaving in the correct way.” It is critical for physicians to see ideal behaviors. We have found that reviewing physician actions on-call is an ideal forum to highlight examples where physicians have performed above and beyond the call of duty; and where there are opportunities for development. An example of an exemplary program is a “Weekend Worrier” program that physicians in Richmond developed. In this program, physicians can sign out their patients for whom they are most worried, and their fellow physician on-call will check in with those patients adhering to designated instructions and times.

• Developing talent and skills.  “I have the skills and competencies to behave in the correct way.” We have found it takes two to three years to fully train physicians from residency and fellowship programs to be skilled at taking care of panels of high-risk patients.  We have created an ongoing curriculum to train physicians.  We have developed a multi-modality approach including online videos, in-house classroom sessions, and train-the-trainer programs. There are both content (e.g., congestive heart failure management) and skill (e.g., how to work with case managers) modules.

• Reinforcing best practices with formal mechanisms.  “The structures, processes and systems reinforce the change in behavior I am being asked to make.“ We recently completed internal annual reviews of 90+ primary care physicians.  We have developed an internal process that looks closer to a professional firm Partner performance review than a traditional physician review. It incorporate a significant amount of qualitative assessment, 360-degree feedback and focus messages around professional development.  Quantitative metrics include risk-adjusted panel size, clinical quality, patient satisfaction, staff and physician engagement and risk-adjusted efficiency. Medical Directors take into account all of the data to come up with an overall performance review that is a synthesis of outcomes rather than a formula driven approach. When we reviewed physician outcomes, a clear pattern emerges – physicians usually require tw to four years and a steep learning curve to optimize outcomes of their patient panels. There is also a clear association with qualitative metrics and quantitative metrics.

We are at the early stages of delivery system innovation and look forward to collaborating with like-minded institutions to increase the pace of innovation. We hope these perspectives are useful to individuals who are on the risk journey.

Craig Tanio, MD, MBA is chief medical officer of ChenMed.