Two years ago, I wrote a piece in HBR called “Turning Doctors into Leaders,” which began with the sentence “The problem with health care is people like me” — that is, physicians who had been trained in an era when excellence in medicine was defined by what you did as an individual. In the short period since, the concept that medicine is actually a team sport has become increasingly accepted. Because of medical progress, there is too much to know, too much to do, and too many people involved to give patients excellent care, unless we get better at working in teams. A lot better.
Sounds good — but it’s a lot easier to write or talk about than to do. In fact, organization and collaboration are unnatural acts in much of medicine, where payment is still fee-for-service and the culture of individualism still dominates. Progress is being made — more in some regions and at some delivery systems than others. In this post, I will assess that progress by giving grades in various key functional areas akin to those that sportswriters are currently giving baseball teams as they get ready to break spring training. Like those sportswriters, I will try to blend optimism and realism.
Ability to put a team on the field — C. The payment system actually is changing, and ambitious pilots like Medicare’s Accountable Care Organization contracts are underway. In these new contracts, providers share heavily in savings and losses. And, as a provider, I can tell you that we really hate to lose (i.e., bear financial losses for care we have given).
Thus, the organizations that signed such contracts, like my own, are working feverishly to manage the risk and manage populations. It is no longer theoretical — it’s real. Like an expansion team in major league baseball, we know that we probably won’t be highly successful in the first year or two, but we’re making progress. Meanwhile, the organizations that have not plunged into these contracts are watching jealously and nervously from the sidelines, with management teams wondering if they are failing their colleagues by being too conservative.
Who’s on first? — B. It’s pretty clear that the critical first steps will be to concentrate on taking care of those 5% of patients who account for 50% of costs. These complex, very sick patients frequently need many physicians and many medications, and the risks of chaos are high. That means the opportunity to create value by using teams to reduce chaos is high, too.
So an initial step for most organizations is to create management programs for these high-risk patients. The simplest approach is hiring high-risk patient case managers — usually nurses who follow 150 to 200 of these patients very carefully, calling them to make sure they are OK and not confused about their care. The more advanced organizations are embedding these case managers in physician practices, so they are not functioning like call center personnel at an insurance company, but as a member of the provider team. And the most advanced organizations are working to change the structure of primary care practices, changing them into “Patient Centered Medical Homes,” in which teams of physicians and non-physicians really function like true teams — starting the day with “huddles” to discuss high-risk patients, for example.
Building the scoreboard — C. Here is a tough area — building the ability to measure what we need to measure, and getting the data to flow in a timely manner. It may come as a surprise, but in healthcare we often don’t know what it really costs to treat a patient, and we often don’t know in detail how patients are doing when they are not in the hospital or right in front of one of their clinicians. We need this information in order to provide the best, most cost-effective care. We need the scorecard that tells us if we are improving, and that means building a collection of key data into the work of the team. This task is enormous. But I’m glad to say that it is underway in many organizations, including my own.
Bottom line: even in organizations that have made early commitments to team care, we feel nervous and uncertain, and have much to learn about how to work together. We wish we had a true spring training in which we could gain experience by playing games that didn’t matter. But the truth is that we wouldn’t put our heart and our resources into the new game if we weren’t playing for real. Opening Day has actually already come for many of us, and that is a good thing.
Thomas H. Lee is the network president of Partners HealthCare System, in Boston, and a professor of medicine at Harvard Medical School. This post first appeared at Harvard Business Review.
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