Value-based Healthcare: "Physician Activation": Healthcare Transformation Requires Physician Engagement and Leadership.
The Problem The United States health system is wrestling with major challenges related to the growing burden of chronic disease, rising healthcare costs, and variations in patient outcomes such as episode of care costs, readmission rates, and alignment of decision-making between the patient and care team. Physicians are in a unique position to propose and implement multistakeholder solutions to address the problems that plague our health system, but this will require greater engagement on the part of the physician community in implementing high-value care practices. The lack of competition based on value delivered to patients continues to be a major threat to the long-term vitality of our health system. Despite promising results with some alternative payment models [3, 5], most health policy "innovations" intended to improve value have largely been focused on cost containment or process standardization. Examples of true alignment among all parties (patients, physicians, health system, and payers) in improving value delivered to patients are rare. Additionally, we are seeing a growing crisis in our profession: increasing loss of physician engagement in the health system. Although the issue broadly affects all physicians, orthopaedists appear to be particularly prone to this problem, with higher percentages of orthopaedists "dissatisfied or burned out" than their peers in other specialties [7]. Physicians, although still an essential driving force in the delivery of health care, may be focusing on metrics that are easily within their control, on predictable rewards such as generating collections, and on filling their operating rooms, rather than defining and implementing viable solutions to our current challenges. This deactivation may be a form of physician burnout, characterized as a chronic condition with loss of physical, mental, and/or emotional energy, and negative attitudes towards patients and colleagues. Burnout can also be viewed as self-mediated withdrawal from professional activities, such as collaborative team engagement, quality and safety improvement, and patient-centered care. Additionally, a burned-out (or "deactivated") physician may disengage from the innovation and high ownership of patient care that characterizes high-value health care. As has been previously discussed, patients and their level of activation in their care likely positively influence their outcome (although there is some conflicting evidence that the difference may be mitigated in some circumstances) [1, 2]. We propose a novel, analogous measure linked to the provision of high-value care: "physician activation." A New Measure: "Physician Activation" The most effective healthcare systems are those with the most-engaged physicians, for a variety of reasons. Technical excellence and cost-efficiency, although important, do not inherently create value alone. The physician and patient, aligned through shared decision-making, can ensure that value is generated throughout the care delivery experience (and not just satisfying the needs of the health system, insurer, or physician). Moreover, broad governmental initiatives, which have been used to enhance value, may generally be effective at policing behavior but are poor at impacting outcomes and run the risk of being perceived as paternalistic, further disengaging physicians. On the other hand, physician-led initiatives can have a profound impact on the efficiency, safety, and value of care delivery. Voluntary, physician-engaging bundled payment programs for hip and knee arthroplasty such as the Bundled Payments for Care Improvement model, enhanced recovery and outpatient arthroplasty programs, multimodal pain management techniques, lower-cost and safer venous thromboembolism protocols, and improved blood conservation strategies are just a few examples. Patient activation is generally assessed through a patient-reported outcome measure, the Patient Activation Measure-13, which groups patients into one of four categories ranging from low (disengaged) to high (pushing forward despite barriers) [4]. A proposed "physician activation" scale would also contain four levels of activation (Table 1). Through engagement with their health team, appropriate interventions, and their own efforts, patients can modify their activation levels, which could be upregulated via systematic changes built into the clinical practice algorithm [2]. Similarly, physicians in the highest activation states (Levels three and four) would be well-equipped to partner with their health systems in transforming delivery and payment models.Table 1.: Physician activation increases from overwhelmed and disengaged (Level 1) to highly self-efficacious and resilient (Level 4)The Ideal: The Activated Physician Many high-value health systems have used strategies to increase physician engagement, focusing on the professional education and development of their physicians, emphasizing activation through the organizational structure and clinical care pathways with high physician input (Table 2). Physician-aligned and physician-activating systems also recognize the financial value of the physician beyond collections and professional fees. This value can be quantified and incentivized through several mechanisms: service-line organizational structure, physician ownership stake in the enterprise, comanagement arrangements, programmatic support, or gainsharing arrangements. Critically, the success of such programs in the long run must come from valuing health outcomes and high-quality, cost-effective care, rather than volume for volume's sake. Successfully judging these outcomes requires effective data that are obtained, processed, and dispersed in a time-efficient, transparent, and risk-adjusted manner [9].Table 2.: Strategies for improving physician activationSeveral challenges are readily apparent for any system trying to embrace a culture of physician activation, the anticipation of which may help mitigate the negative impact of their challenges. First, in some health systems, the institutional hierarchy tends to favor nonphysicians as decision makers, essentially sidelining physicians. This phenomenon has resulted in people with nonclinical backgrounds serving in key health system leadership roles. Additionally, there are often communication barriers between the physician and nonphysician health system leaders—differences in professional training resulting in differing lexicons and differences in schedule availability, with physicians often available only at times that do not conflict with patient care. Physicians who attain leadership roles are also often put into the unenviable position of feeling that they must bridge a gap between two adversaries—the health system and their physician group. Because of the nature of funds flow, it is often the health system (where most healthcare dollars flow) that sits in the driver's seat for empowering these physician leaders. Thus, the physician leadership often feels beholden to the institution over their constituent physician group and may make decisions that they might not have if the power dynamics were more balanced. All of these factors conspire to limit the activation of physicians and contribute to a general "commoditization" of physician services. Clinical productivity goals easily overwhelm vision when it comes to transforming delivery systems and payment models to deliver greater value to patients. As previously stated, "what gets measured gets managed" [6]. If volume is incentivized, volume is what is delivered. Despite an increase in burnout and workplace disengagement in our modern health system, the trend can be reversed through many of the strategies outlined above. One excellent example of a system facing these challenges directly can be seen in the Mayo Clinic, in Rochester, MN. Longitudinal monitoring of their physicians' emotional wellbeing over several years revealed that burnout was increasing across physician groups, and this burnout was also tied to decreases in clinical productivity [8]. Mayo Clinic recognized the rising rates of burnout and disengagement and implemented a multifaceted strategy to help improve physician wellbeing. The key components of the intervention relied on recognizing that physician burnout is the responsibility of both the system and the physician, and Mayo Clinic harnessed both to make broad changes throughout the workplace, focusing on building community and improving workplace culture and alignment through a data-driven approach. Through these efforts, Mayo Clinic was able to reduce physician burnout by approximately one-third (from 49% to 32%), well below the national average [8]. Conclusion Of all the key players—patients, health systems, healthcare administrators, payers, politicians, and physicians—physicians' insights may be the most essential to introducing innovations that will improve value for patients. However, physician engagement in care innovation is waning, and efforts are needed to encourage physicians to come forward and lead rather than resist health system transformation. With more-widespread physician activation and more-substantial, high-level physician leadership and engagement, the steady march to a value-based healthcare system can be accelerated.
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