Mark Briesacher, MD: Hi, this is Dr. Mark Briesacher. I'm president of the Intermountain Medical Group. I'm here with Dr. Celia Garner. Celia is an internist at Avenues Specialty Clinic. I actually first heard of you, Celia, before we met because Dr. Anne Pendo, your partner, was just raving about this new internist at the clinic. Me being a pediatrician, of course, I would often times get asked by moms and dads, "Well, who should I see?" I was thrilled to ... Even before we met, I started referring patients to you.

Then, of course, I would hear back. Your patients just loved meeting you and being part of your practice. I'm really glad you could take some time today to come and talk about practicing internal medicine. Maybe talk a little bit about our recent work with Medicare Advantage and our upcoming work with Medicare Accountable Care Organization.

Let's dive into that a little bit.

Celia Garner, MD: Thanks, Mark. I'm happy to be here. I'll say the first time I met you was at a conference and I asked a naïve question, we'll say, at the beginning of my career. You were very gracious in your response and treated it very kindly.

Mark Briesacher, MD: Yeah.

Celia Garner, MD: You gave me a very good feeling from the very beginning. It was nice.

Mark Briesacher, MD: Okay. Thanks. Well it's a ... I kind of, all questions are good questions for sure, so yeah. Hey, so internal medicine is a really important especially for us in the medical group and with Intermountain Healthcare. 10,000 Americans turn 65 every day. Today, we have 10,000 more people on Medicare. They're either choosing to be on a Medicare Advantage Plan, or they're choosing to be on what some people might call regular Medicare, or Fee-for-Service Medicare, or Part B Medicare.

As an internist, that makes up a big part of your practice. I know your group has done a tremendous job this year in working as a team to manage the health, and create care plans for, and help your patients in transitions of care for those that are on your Medicare Advantage panel. I'm wondering what are your thoughts about ... What's special about your team and what makes all that possible?

Celia Garner, MD: Well, I think a few things. We work together well amongst the physicians. We also have a great care management team that we are very open to the suggestions they have. They're really sort of dealing with the behind the scenes getting in touch with people, getting people in to get seen when they need to be seen, following up on the various data that's presented to us so that we can help make sure that things are managed as they should.

I think, particularly, as the population ages and there's this expansion of how many people have chronic medical conditions, so much of the work that is happening, in terms of caring for these people, is not in the clinic visit. That, I think, has really been key in acknowledging that and realizing how much work has to be done before the visits, after the visits, and follow-up with people for various illnesses. I think that's made a huge difference. Our team, also, is very clear about, "Okay, this is my responsibility. I take care of this, and then I work with this person with this data."

I think having sort of our clear roles set and how they come together, the puzzle pieces, makes a big difference as well.

Mark Briesacher, MD: How do you guys stay connected as a team through the week or on a daily basis?

Celia Garner, MD: On a daily basis, I would say we are sort of more separate—physician, MA—and then the care management team will come to us as they need to have us involved. They have a very good system in place for ... They give us these bright fluorescent things when people need to meet with them. If somebody hasn't had their urine microalbumin tested they put a bright fluorescent reminder on the chart saying, "Urine microalbumin needed."

On a day-to-day basis, for the physicians and the clinicians, we're meeting with our MAs and going through the day through our schedules and really being clear about which patients are going to need which services. How we can make sure that those things happen.

Weekly, we have a huddle that is a more extensive huddle with the whole office staff. At least one physician, but usually there's more of like three or four of us. At least somebody from the PSR pod. At least most of the MAs usually end up coming, sometimes one or two will have to be away for various reasons, and then the clinic management staff. The clinic management staff—it's very important that they're there as well, because they also participate in making sure our phones are getting answered. The information that needs to be communicated to everybody is disseminated as it should be. We have a huddle board that follows the five safety, quality, access, experience, and stewardship. We use that to frame the various goals we're working towards as a clinic. We get the input from everybody as to what is working and not working. We started it ... Oh, boy. How long ago? Maybe it's been a year, maybe ... I don't know, somewhere in that range.

Mark Briesacher, MD:That sounds about right.

Celia Garner, MD: It has improved dramatically in its efficiency. I think, also, now it's just it's a really good time because there are so few times on a regular basis that everybody is together. Just the nature of how the clinics function, everybody has their own separate work that needs to be done and people get busy. This is a moment, as short as it may be, sometimes it's 10 minutes extending sometimes to 20. It's there. We're all there. If somebody's not there, they easily can get the information from somebody else as to what happened and what was discussed.

Mark Briesacher, MD: This sounds like ... I mean, this is continuous improvement that you're talking about. The project that we've rolled out across the medical group and across Intermountain Healthcare. The idea of teams gathering and being very intentional about how are we doing on our safety metrics? How are we doing on quality metrics? You mentioned the diabetic nephropathy screening, so what percentage of our Medicare Advantage patients have gotten that test?

It's very hard. That particular measure, when you compare yourself to ... If we look at our medical group and compare ourselves to other medical groups, that's a tough one. You have to be in that 93-96% screening rate to be at a four star, top quartile, top decile performing group. I think it's great that you guys do that. How did you feel about it when you first started?

Celia Garner, MD: Well, I think everybody ... Let me speak from the physician perspective. At first, you feel sort of like, "Why are they looking over my shoulder like this? Why do I need to be judged?" But, in the end ... Actually our previous partner, who just retired, she said to me ... I remember very early on when I had started. She said, "These things they help me be a better doctor."

I said, "What do you mean? Explain that to me."

She said, "Well, in the day-to-day I get involved in seeing patients in clinic and I'm sort of bogged down in that, and I don't have a way to look and say, 'Okay, how am I doing over all? Can I improve?' I look and I see, well, this diabetic, who I had previously had under really good control, all of a sudden, their blood sugars have been running really high. It just doesn't occur to me because it happens slowly over time. Then I can take a step back and say, 'Alright, what am I missing here that needs to change""

I think a lot of it ... Of course, with a grain of salt, some of it you feel the data may not be quite as accurate as it should be and that kind of thing. It does give you a picture that you just don't see when you're sort of focused on day-to-day care of individuals coming into the clinic. This helps you take a step back and say, "Hey, wait a second. Why is this happening? Am I not being aggressive enough and starting insulin? Am I ... Has this person had something happen in their life that has changed their eating habits?" Whatever the case may be. I actually think it's quite helpful.

Mark Briesacher, MD: What do you think it means to the staff? Your medical assistants, the front desk. What does a weekly huddle mean to them?

Celia Garner, MD: Well, I think, first of all, prior to doing that, I don't think they had any idea of what we were doing in terms of any metrics we were following. Of course, they knew we saw a lot of patients who are diabetic but they didn't know specifically what we were following. Why it was so important to get an accurate blood pressure reading. I think they understand that much better now in a way that helps connect them to their work more so than they would have been in the past. Also, helps them to say, "Okay, well, why do they want to do this? Oh, I see. It's so that we get ... Why is it important that a diabetic patient has their shoes off when you come into the room? Here we go, we have to do a foot exam to make sure their feet are in good shape."

Mark Briesacher, MD: Yeah, I think that's so important because people who go into healthcare ... One way that I like to think about this is we're generally people who want to help others. We actually hire healthcare as a career to help others. This actually applies to not just those that are directly involved in taking care of patients, whether that's in the hospital or the clinics, but all the other people on the teams—environmental services, our clinic managers, communications people. They've chosen these jobs because we are helping people every day. It really sounds like the huddle helps you connect everyone on the team to this is what it means to this person, or this is what it means to this group of people that we're caring for. That's pretty meaningful.

Celia Garner, MD: Yes, I 100% agree with that. I think you don't quite realize how valuable all those people are to making a patient's care be as close to perfect as you can make until somebody's out sick or something like that. The person answering the phones, huge, hugely important. I think it's often hard in the day-to-day life to feel the importance of that role. It helps to emphasize that.

Mark Briesacher, MD: I have found that this is also such a great time to say thank you, or to recognize someone who worked so hard to help a particular patient in the clinic. We just added that on to the end of the huddle, is the caregiver moment. One person gets elected each time to say, "Oh, so-and-so did this thing." It's amazing what some people, really, will do and go out of their way to do to make patients feel comfortable. Get done what needs to get done.

It's almost taken for granted, right? We do it ... This happens every day a million times across the medical group, this happens. For us to take a moment to say, "Hey, that was ... You really, this really made a difference for this mom who came in, or this patient who came in."

Celia Garner, MD: Yeah. I think you forget it. In your mind, that's what you're here to do. You just forget that it's not ... A lot of it can be above and beyond really what's expected. That's nice.

Mark Briesacher, MD: Yeah. I'm really excited about the work that's going on with continuous improvement. I think we would want ... Both of us having gone through this, we would want all of our colleagues to know if they haven't quite gotten started that, first of all, it's normal for it to feel clunky in the beginning. If you're saying, "I'm not sure this is worth this time." That's normal, too. If you just stick with it, everything gets better. Your team feels better. You feel better. Care's improved. Everyone's connected.

Celia Garner, MD: Well, and I think like anything that involves change there is a period of feeling uncomfortable, feeling like, really, I think the old way we did it was better. Then you get to the other side of it and sort of say, "Well, maybe this part of it is useful and can be very helpful. Let's figure out how to make it even more useful. Let's tweak this and tweak that." Change is not necessarily so easy a lot of the time.

Mark Briesacher, MD: I think you're right. Let me ask you a different question. We haven't really talked about this before. You serve on the compensation committee, which is the compensation committee of the medical group board. It's a physician led, physician member group, that spends, I don't know, over a four month period of time every year. Of course, I've asked the whole group to actually sign on for the entire year, going forward.

You all really think hard about the future and how ... What role physician compensation is going to play at Intermountain for the future. As you think about ... I'm wondering what your thoughts on your experience with increased time and management for a panel of patients like Medicare Advantage. As you think about the Accountable Care organization starting in January, which essentially means that we have to ... Everything we do for Medicare Advantage today, we actually have to do for all Medicare patients. We have to see them for a comprehensive visit. We need to create a care plan. We need capture and document all their chronic health conditions, so we get the appropriate risk adjusted payment. We have to make sure that we're meeting all the quality measures so that we can be a four, and frankly, a four and a half-

Celia Garner, MD: Five.

Mark Briesacher, MD: ... Or five star plan. We want to be the best.

Celia Garner, MD: Right.

Mark Briesacher, MD: We are going to be the best. Then, of course, the whole utilization aspect of this. Are we getting the right care at the right time by the right team? All that has to be really guided by a primary care team. Knowing that's the future, what are your thoughts on compensation? In terms of how should that evolve when it comes to the future.

Celia Garner, MD: I think for primary care because, as we talked about before, so much of that care is going to happen outside of just an RVU generating visit. I guess it would move toward something like having the panel payment part be a stronger part of it. Then it would also encourage us to include our APCs more in the actual physical seeing of the patients when need be. It wouldn't be any sort of competition about who's generating which RVUs. I think having ... Probably, of course, there has to always be some measure of productivity to some degree. Panel management, I think ... I was just thinking yesterday, probably, I probably deal with about 25 message logs on patients related to various things. There are times, also, when you find people are coming in for things that you're kind of like, "Well, you're an elderly patient. You're somewhat frail. You didn't necessarily need to come in to the clinic for this. We could have dealt with this via phone if we had the system in place to make things happen appropriately that way."

I think the RVU system for primary care, in particular, is just not going to be an adequate system moving forward because it's just prioritizing the wrong things.

Mark Briesacher, MD: Yeah. Well, I think that's very insightful. We're actually, as you know, we're going to start working with Sullivan Cotter, a consulting group that specializes in physician compensation. They're going to help us understand what the best practices are across the country. What other high performing groups have done to be prepared for this future. That work's going to happen over the next nine months. I think it's going to be pretty interesting to see what they have to say.

Celia Garner, MD: Agreed. Well, and it also, of course, in light of who knows where the health policy on the greater picture is going. This'll be-

Mark Briesacher, MD: We're one Tweet away, right?

Celia Garner, MD: Yeah.

Mark Briesacher, MD: From the whole thing changing.

Celia Garner, MD: It'll be kind of interesting to know ... Well, because you made big all this planning around the ACOs and then who knows. They may disappear in five years.

Mark Briesacher, MD: Yeah.

Celia Garner, MD: Who knows where we're headed.

Mark Briesacher, MD: I think you point out that this is probably some of the most dynamic and rapidly changing time that I've ever seen.

Celia Garner, MD: Yes, and I think that's where, in terms of how the clinic is functioning on a day-to-day basis, there needs to be systems in place and encouragement of embracing changes in how care is delivered. It can't keep plodding along as it's been plodding along.

Mark Briesacher, MD: Right.

Celia Garner, MD: It's just not going to survive.

Mark Briesacher, MD: I agree with that. I'm glad you brought this up, because you mentioned APCs a few moments ago. Of course, that's the acronym for Advanced Practice Clinician: nurse practitioners, and physician's assistants, and certified nurse mid-wives. I'm wondering, what has your group ... What's been the discussion at Avenues Specialty Clinic around how the team needs to evolve for the future.

Celia Garner, MD: Well, so we've actually ... Initially, when the discussion started around the possibility of hiring an NP or PA to help meet some of these goals of care for our patients there was resistance. We've just finally hired somebody on. I think we're all seeing how much of a role she can really play in helping make sure ... One person alone really can't do it anymore. Unless they're really willing to work kind of 24—just be available 12 hours a day every day of the—which nobody wants to be.

I think seeing how she can play a role in helping to manage the overall patient panel and getting—I think that working more as a team, is really where we need to head. Certainly when I started, it was much more kind of the individual physician and their MA doing their thing. There wasn't a lot of cross collaboration. I think that's just going to have to change. We're going to have ability to rely on each other to do certain work for each other's patients. Particularly, with the advanced pride that we have a PA. Our PA is going to have to play a role in managing some of the patients' care in a way. Which is uncomfortable, because we tend to be the kind of people who like the control and knowing exactly what's going on every moment with the patients.

I think at some point that actually impedes the patient care rather than making it as good as it can be.

Mark Briesacher, MD: Right, I completely agree. What you describe it is, in terms of your early experience, I can tell you is exactly what we experienced when we hired a nurse practitioner for our pediatric practice and had asked to her to really help all of our families whose children had asthma. What she was able to do is take pretty good performance in all the quality metrics and safety metrics around asthma care, and we became great at it. It was so helpful to us. I'm passionate about our patients in terms of the care being safe and high quality and a great experience. I'm also passionate about our caregivers, our physicians, APCs, nurses, and medical assistants, who I know are so committed to taking care of their patients. Even to the extent of 12 hour days become 14 hour days. I admire that commitment, but I also know it's not sustainable.

Celia Garner, MD: Right.

Mark Briesacher, MD: We are all families.

Celia Garner, MD: That's the issue.

Mark Briesacher, MD:We all have people who love us and we love them. We all have interests outside of work that are important to do. Whether that's reading, or fly fishing, or playing basketball, or skiing. I certainly felt that adding a partner who could help us care for people with, or kids with chronic conditions, actually made our liv- Not only improved care and the experience, but it made our lives better.

Celia Garner, MD: Yes. I can see that very clearly. Even just, we just had somebody start. Gosh, it not even, eh, it's been about a month. That's it. Even in that time period, you can see ... Not only for us, but for the patients. I see a diabetic who's been poorly controlled. I start a new medication and I'm saying to her, "Okay, I want you to follow-up with this person in the next couple weeks about where their blood sugars have been. How the new medication is going." In a phone call that might take 20 minutes.

Mark Briesacher, MD: That's right. I think you're on to it. Hey, well I think not a surprise to me that your clinic is continuing to think ahead, and dive in, and grow as a team. You guys were great before, and it just sounds like things are really continuing to improve from there. Thanks for sharing your thoughts, your ideas, your experiences.

Celia Garner, MD: Of course.

Mark Briesacher, MD: I'm looking forward to see how good it's going to be up at Avenues Specialty Clinic.

Celia Garner, MD: Hope it'll be great.

Mark Briesacher, MD: It's going to be great. Okay.

Celia Garner, MD: Thank you.

Mark Briesacher, MD: Thanks.

Celia Garner, MD: Yeah, of course. My pleasure.