Dr. Briesacher: Hi, this is Mark Briesacher. I'm the Chief Physician Executive at Intermountain Healthcare. And I am here today with Karen Springer, who is the Chair of the Intermountain Medical Group board, and my friend. And Karen, thanks for being here.
Karen Springer: Thanks so much for inviting me.
Karen, I honestly, it's actually challenging for me to remember when we first met. There was just so many places where our paths were crossing, as I think back over the many, many years now, it's actually hard to pinpoint, "Oh, this is when I first met you."
Karen Springer: This is where we met. Either that was unmemorable or ... no I think we met when I first joined the board years ago. I think...
Dr. Briesacher: That would make sense.
Karen Springer: The first time that I met you.
Dr. Briesacher: And how many years has that been?
Karen Springer: Around 10 years I think.
Dr. Briesacher: 10 years. Well time is flying.
It is flying, very quickly.
Yes. Well we're here because there's some really big things happening within the Intermountain Medical Group. I think one of the things that's really on our minds, I know it's on our minds, the board's mind. It's certainly on my mind as well as our leadership team's mind is, physician and advanced practice clinician or APC compensation. I guess I think I'd be interested in starting with a pretty straight forward question is that, and that is, you recently attended your specialty meeting in family medicine that they held to get input from people, from family medicine docs, family medicine APC's on the compensation models for the future. I'm wondering if you can just share with everyone how that went and maybe some of the questions that came out of it.
Yeah, no we just recently had that last week or the week before and our associate medical director did a really nice job in explaining the reasoning behind some of the compensation changes as well as kind of what's going on in healthcare in general. I think the overall feeling from the group though was a feeling of angst of change which of course is always sometimes well most of the time angst provoking, right? But something where I think I've heard you say in the past, don't mess with physicians or APC's compensation and their schedule and I can never remember the third one what you said.
Dr. Briesacher: There was a couple more now. I include medical assistants and...
Karen Springer: Medical assistants.
Dr. Briesacher: And mental health integration are all on the list of things.
So I mean to have it feel like we've had that hit in relatively short period of time I think has made a lot of providers nervous and you know, just the thought of, are we losing autonomy which I know is really important for us as a corporation to have physicians in APC's really engaged in their practices and really take ownership over the care that they are providing and so that concern of loss of autonomy and of course just the general concern of oh, this is the way to pay us less, I think.
Dr. Briesacher: I've heard that one.
Yes. I think came up and really just trying to understand the just the complexity of I don't think anyone really understood or didn't understand I should say, some of the reasons behind it in terms of the team base care and things. It's just a matter of does it make sense to put this in salary and this much in production and is it gonna be too hard to actually hit those measures to actually get us up to medium pay or you know, those types of things. I think that was pretty much the big, those were the big concerns.
Dr. Briesacher: Well I guess I've been hearing some of the same. It's not surprising. We've been through this before. I think the medical group has changed compensation models in significant ways at least well, in two different times in a significant way...
Karen Springer: Right, yeah. Right.
Dr. Briesacher: Many other times in my...
Karen Springer: Smaller ways, right.
It's and I think these are, they're really normal feelings that I think they're really normal feelings that people are having and I would have these questions as well. Specifically to some of the worries like is this just part of a way to take away choice and take away and reduce compensation of that? That's really, that's not true. As I think about the future, this is ... things are different than they were five, 10 years ago. We now have 40% of the patients that we care for, we are completely fully and responsible for their safety and for their quality, for their experience of care. We are prepaid for that care and so it is a true value base proposition and I'm really interested and frankly need help from you and everyone who are seeing patients every week around figuring out well how does our compensation model need to evolve?
I also think it's important that and I wouldn't want to have anyone have a misunderstanding about this but one of the lessons we know from past changes is that while holistically they make sense at group levels and specialty levels, even at a practice level, when it gets down to it, there's always people when you change the model, there's always people who do a little bit better. There's a lot of people who do about the same and there's some people who do a little bit worse. I know this because I was in that latter group the last time we made a significant change in compensation. Because my practice spot, at that point in time had become much more ... it would become smaller and I had complex patients with lots of problems and the model, the fee for service model that we had with work [inaudible 00:06:41] we use doesn't really reward that type of practice.
That's why I think listening really intently here over these next couple of months as people in family medicine and in medical specialties and in surgical specialties in the coming three to six months is they as they all wrestle with this question of what's the right compensation model for the future? I do know that we will get good ideas. We will learn things we have not thought of to date and what will come out is the best model going forward.
Yeah and I agree with what you've said. I mean this is very complex subject to try to incentivize the correct things. Make sure you're not incentivizing incorrect things but yet, try to keep things as much balance for the work that all of us have been providing up to this point and you bring up an interesting question just in terms of how are you going to look at the winners or those who are doing a little bit better versus those who might do a little bit worse in this new model? What are plans that you have or how do you plan to get some of that feedback?
Well first of all I think it would be important for everyone to know that this is just so typical of our professional relationship right, where I ask you questions and you ask me questions right back in your role as chair and in my role as a chief physician executive.
Karen Springer: Yes. It's a good thing you can handle it for me.
Well I think really the key thing when we go through a change like this and this is actually a lesson learned also from the past. Is that we need to be thoughtful about the transition. Our physicians and advanced practice clinicians, they all do such a great job everyday taking care of the people and families in their practices. Being open to accepting referrals for surgical questions and for medical subspecialty questions and maintaining that access to care for all of us and they have appropriately so built practices and built styles of practice around our business model to date. Well, around our old business model which was really a fee for service model.
They deserve the time to understand within a new compensation model how does my practice have to evolve? How does my pattern of seeing patients need to evolve? How does my team need to evolve so that I'm successful for my patients, right? Because there's just no doubt in my mind about how committed the medical group physicians and APC's are to...
Karen Springer: Yeah we definitely don't wanna show that we undervalue...
Dr. Briesacher: Right, exactly.
Karen Springer: What they do because they are so essential. We are so essential to the success of Intermountain and taking care of our population and our patients, right?
Deep down on the inside we are so aligned around why we're here, why we do the things we do everyday, helping people live the healthiest lives possible and thinking about how I and the team around me can contribute to that so they deserve time. In years past, we've just switched and we said, hey on January first 2019, here's your new comp model and we try to predict what's gonna happen but it's hard, right? Because you really don't know.
We will give time for people to understand hey, this is how it would work in the old model. This is how it's gonna work in the new model and give them the flexibility, the protection of a transition to begin to make the changes that are necessary.
Now I feel that in a lot of specialties especially on the ambulatory side, we have put all these tools in place with respect to funding mental health integration, funding care management that's in the clinic and what I suspect will happen is a lot of these physicians and APC's will begin to figure out well how can I figure out how to use them more effectively?
Yeah and I think that's important because as you were talking, I was thinking, okay so let's say I'm one of those providers who is doing a lot better in our current model versus in my shadow finances, whatever, report that I'm gonna be getting for this initial transition. Who or how are we gonna help that particular provider on an individual level to actually see how they can transform their team or transform their flow to help them be successful? 'Cause that's what we want, right? We want ... none of this is to make us be unsuccessful whether we talk about an individual provider level, a patient level, a corporate level, right? So but it seems that one of the important things is during this transition and ...
Karen Springer: But it seems like one of the important things is during this transition and it would be important to have those types, or those experts, or someone to come in say, "Hey," or someone I could reach out to. What kinds of things are in place for that? Or what have you guys thought about so far?
So I think the most important thing that we've done that's new in this place is the change to pivot towards specialty, specific leadership. So rather than ask a medical director who's tracking across 30, 40, even 50 different specialties, to understand how each of those specialties should be working, we now have in place for most specialties, and I think for most physicians in APC's in the medical group, a service line, specialty specific leadership structure. And these leaders, so let's just stick with the family medicine example, you know your family medicine leaders, they will have line of sight around which practices, which locations, which individual family medicine providers are really making the shift in a way that works great for them professionally, and it's working great for our patients and families. And they can connect you, if you are uncertain about how do I proceed with someone who has tried something new, and been successful, and quickly spread that across every family medicine practice across the medical group.
The second thing, or change that's happened is Chris Thornock, our Vice President for Operations, he has begun to assign operations leader to support those medical directors and service lines so that from an operations perspective, your clinic manager, or physicians directly can reach out to a clinic manager, or an assistant operations officer in Weber County and say, "Hey we're down here in Washington County, down in St. George, and we need some help with understanding how you all did this."
So I think those are the main changes. I would go back and reference some of the investments that we've made over the past five to eight years with respect to care management and the mental health integration. To be those are fundamental things that have to be in place that allow us to make this transition with as little, as low a risk as possible for any individual.
And that actually I think is one of the exciting parts about this, is the opportunity to truly work together more as a team, and you gave the example of the family medicine service line, and I've already seen this where my Associate Medical Director for Family Medicine has organized a group of family medicine physicians and APC's to what is best practice, to kind of come together as a collaborative and be able to really study family medicine, which I would say we really haven't even done before with Intermountain, as I would assume for other service lines as well. I think it's so important as we do this transition, as you mentioned, this is complex, health care's complex generally, and changing quickly, and we do need to be able to work together more in terms of being successful and taking care of our patients. And that requires a level of collaboration I think that has not been encouraged or incentivized so far.
Dr. Briesacher: Were you referring to Jill?
Karen Springer: Yes, I was referring to Jill, yes.
Dr. Briesacher: Yeah, she's ...
Karen Springer: She's been doing great.
Dr. Briesacher: That project that she has pulled together is amazing and it's exactly what we expected to see, and she's certainly has been out at the front.
Karen Springer: Yes, yes.
Moving quickly, 'cause it's that sharing, those sharing of ideas is what's gonna make the difference.
Karen Springer: And that's the one thing nice about this service line change, right, is that we can move a lot more quickly, because now it is family medicine and we have that ability, like you mentioned, a medical director who was over, I don't know 50 different specialties, right? It's hard to say, "I should practice best practice this way, and so should a surgeon," you know? Obviously doesn't make any sense to have that.
[00:16:30] And that brings up a good point, and that is it's not our expectation, and it's not even ... Our guiding principles state that we need more than one compensation model so that we recognize the different types of practices that are present across the Intermountain Medical Group. And so if anyone has heard that, "Oh we're all gonna be on the same type of comp model," that's not the case.
Karen Springer: Yeah, that was actually brought up, and there is that going around, yes, so thank you for clarifying that.
Hey, I got one question for you. So knowing that this process is ... Produces worries, produces uncertainty, you've heard your colleagues express this in different ways through their questions, through their comments. What is it that I could do, and our physician leaders in the medical group could do to help everyone as we enter in this phase?
I think that's easy if you know me well, Mark. My top three answers, communicate, communicate, communicate.
Dr. Briesacher: Yeah.
Karen Springer: Does that surprise you?
Dr. Briesacher: I had predicted that would be the answer, but I just wanted to put it on the record.
I think ... Yeah, put it on the record, yes. I think that this is something that as with any change that causes some uncertainty, lack of communication creates more interesting, but not necessarily truthful stories, is the best way to put it, I think. And so hearing motives, hearing the why. Hearing that you understand, and are really, truly looking for input and feedback. That it's not just a decision that's already been made. Like you said before, it's like you expect to have ideas that have come up from front line physician's and APC's that you've never thought of. Because that's where the work is happening, right? So hearing those types of things are so crucial in terms of helping us through this transition and helping some of the angst.
I was thinking about this because you hear things and then if you don't know the situation well, or you don't know the person well, then it's easy to create or believe things that really don't make any sense, right? And so I've appreciated that about you in terms of being ... Doing this podcasts, you know sending out emails, I think that, and having an encouraging the service line leaders, and the geographic medical directors to do the same thing. As much as possible, keeping people informed in a timely manner. Creating ways to really get information both ways, right? I think would be essential.
I completely agree. And I guess I would also encourage everyone to keep asking questions. Nothing helps more than to have to really sharpen your pencil around how are we gonna do this? Or acknowledge, gosh, we have not thought of that up until this point. And I know we have not thought of all the things that we need to be thinking about. It's why this discourse, this dialogue, these discussions are so critical to help all of us get to what are these best models going forward.
And that's important to know that it's safe, and even encouraged to ask questions, right? I mean you know as we have transitioned our medical group board, the level of questions and discussions has significantly deepened and changed, and challenged. Yet, we are, as board members, encouraged to do that, right? In order so that way we could have the best ... We want to have that decision making process where those questions can be asked and should be asked so that way we can actually arrive at the best decision.
I think it'd be important to mention at this point that the ... When people ask me, "What's been the biggest change with our new board and committees?" So have over, we have like 45 physician and APC leaders across-
Karen Springer: 42.
Dr. Briesacher: 42. 42 exactly. 45 ish.
Karen Springer: Ish. Yes.
Dr. Briesacher: And they are ... They are this diverse group-
Karen Springer: Spread through all-
Dr. Briesacher: Yeah.
Karen Springer: Specialties.
Dr. Briesacher: Specialties-
Karen Springer: And geographic areas.
Dr. Briesacher: Counties, up and down ...
...the state of Utah. But the biggest change we've seen is the level of discussion has increased so much that we've actually doubled the length of our meetings and we've doubled the amount of time we give to every topic and we still are struggling with getting through each topic because of the engagement of the probing questions, of the governance with teeth that we are now experiencing. And it's all been for the good, right? Operations has gotten better. I think communications have incrementally gotten better. We got a long way to go. But they've incrementally gotten better. And we certainly are getting a lot more strategic input and having more strategic discussions with the new board structure.
Yeah, and I think you would agree too that there are things that after discussions, or at least the questions during our meeting has kind of changed the strategic direction of where originally the plan was.
Dr. Briesacher: In fact, this very project, this very conversation is a product of that discussion. Because we were on a timeline that was much quicker, and the board said, we don't think you should go that quick, and this is why, and management agreed 100% and we adjusted the plan, and here we are now.
Karen Springer: Yes, yeah definitely.
So one of the things that I think has been a struggle, as we know, there's a big talk about caregiver burnout, and in this conversation, maybe we could just focus on physician and APC burnout. So I'd like your thoughts on how this compensation model change will affect, hopefully positively, but how you see that this would change, improve physician burnout. I know that I've heard that compensation generally, but various models can be a significant contributor to physician and APC burnout. So what are your thoughts on that? 'Cause that's something we talk a lot about at the board, and our committee as well.
Right, I actually, when you asked that question, I was immediately thinking about Takie May, who leads the committee that thinks about this all the time. She's a hospitalist up at Logan Regional Hospital. And I was just thinking in my mind how important this is to her, and I'm so thankful for her leadership on this really important topic.
There actually is peer reviewed literature that has examined this question. And I was at the American Medical Group Association meeting this past spring, listening to Tait Shanafelt. You know Tait Shanafelt is a physician who was at the Mayo Clinic and studied physician burnout-
Dr. Briesacher: Clinic and studied physician burnout with Steve Swenson and he's now, Dr. Shanafelt, is now at Stanford, your Alma Mater.
Karen Springer: Yes.
Where he is leading the efforts there around physician well-being, physician and APC well-being, physician and APC well-being. But, he shared, from his research, is that compensation models that are based on productivity as compared to compensation models that are more based on value where there's more of a salary component and payments that are made for clinical quality, safety experience outcomes, that in comparison, the productivity based models are associated with higher rates of burnout with physicians. We, thankfully, are beginning to measure this. We're right in the middle of our all caregiver survey right now. This is something that we are going to be able to track over time. I think the long and short of it is that ... This is probably the part that resonates the most with me is, you want to avoid situations where this a dissonance internally around what's the absolute best thing to do here and what do our systems encourage or incentivize us to do?
I think there are many times where if we all had time and we had the autonomy to make decisions about time, that we would take that with our patients. That might be on the phone, that might be a video visit, it might be appropriate for them to come in. It might be appropriate for them to come in, but not see me, rather see a partner in my practice or a specialist that's in the group. To be able to do that unencumbered by any thoughts about, "Well, what's this going to mean to me?" I think over time has value. Now, I want to be really clear about this because knowing the physicians and APC's in the medical group, I know they are not thinking on a patient by patient basis about, "Well, what's the RVU for this?" I also know, though, at the end of the month when we get our reports, we do look at our RVU's and we think about how we're spending our time. That's when these questions can come up. My hope is that when I think about a compensation model for the future, that that's a model that also contributes to reducing the amount of burnout that people are having and promoting their well-being and resiliency.
Yeah, I've heard Steve Swenson talk a little bit about the whole compensation model versus caregiver burnout, and like you said, it does seem to be that turn, which contributes a lot to that. You know, hopefully not too hard of a question here, Mark, so one of the things when you talk about getting rid of some of the turn is a potential decrease in RVU's because you're not always having to see the patient and you might be doing more things on the phone. How are we going to address the potential decrease in revenue that comes from that? That could be unintended or unknown consequence of a compensation change.
This is a hard question not because it's a hard topic, but it's a little bit technical to explain so I'll give it my best shot.
Karen Springer: Excellent.
Look, again, it goes back to 40% of the patients that we care for are at full risk or were at full risk. This becomes what our finance and revenue cycle colleagues, when they say, "Flow of funds," this is what they're talking about. We need to figure out how to recognize how a family medicine physician like you, Karen, who is taking care of, how many Medicare patients do you have on your panel? Do you know? A couple? A hundred? Maybe five?
Karen Springer: Probably 10 percent.
Right, so for those patients that you are ... were at full risk for, what is the flow of funds? Not only on a fee for service basis, daily work RVU basis, but what about the flow of funds related to how your work is impacting the per member per month expense that we are experiencing based on how your patients are using the health care system? That's what we have to figure out? It also shows why this is such a hard question this time around. I don't know if it's harder than the questions before, but-
Karen Springer: It's different.
Dr. Briesacher: Like all new things, it's different.
Karen Springer: It's different, yes.
Dr. Briesacher: So, it feels harder.
Karen Springer: Right.
This is why we need all the good ideas out there to come up with a model that actually helps us be aware of these flow of fund questions. What's the fee for service business? What's the fee for value business? And, allows physicians and advanced practice clinicians to modify their practice, modify the way they care for people, and do that in a way where they are protected from living in both of these worlds. That's ... And, by protected, I don't want to be ... I don't say that to be patriarchal in any way, shape, or form, it's more I want them to be successful professionally, I want them to meet their professional and their personal goals, I want them to have the right balance of life and work, and I want them to keep coming up with ideas to help us be successful in this health care environment that we are experiencing today. Models that will promote that are definitely the ones that we want to be moving towards.
I'm so glad you said that because I think you recognize that, you know, one of the best ways that we can be successful is to help our caregivers, and in this case we're talking about providers and APC's or physicians and APC's, to feel that balance and be successful. I think you would also agree with this that what we put forth in the next year or two because of the complexity as things change, this is probably not the last compensation change that we will have, right? It's a matter of getting to good and then continuing to improve and change as we see how things work. I think that's an important message that maybe we sometimes feel, and maybe that's where some of the angst comes, " Oh, here's it going to be and this is now how it's going to be forever and all time." I think we recognize that health care is constantly changing, our percentage of those who we have at risk from that population standpoint is going to be increasing, right? As those thing in local health care challenges or different environments, that's all going to play in effect. This is why we look at compensation every year.
You know this, there's three models of compensation; yesterday's, today's, and tomorrow's.
Karen Springer: Yes.
I think it's always important to know what's not going to change. We know that compensation models will evolve, but what won't change is our mutual commitments to each other with respect to our mission, what will not change is the ideas around being fully transparent and communicating well and listening really hard when we ask these questions of each other, and what will not change is the board's commitment to and the medical group's leadership commitment to each physician and advance practice clinician with respect to how they're doing professionally. Are they meeting their goals? Do they have the right balance of work and life for them? Are they doing well? When they're doing well, everything else flows from there; care is safer, care is better, the experience is one that anyone would want to have, access becomes an easy thing to solve for because there's so much joy in work, and we will be fine from a stewardship perspective. I know we will. But, I certainly need everybody's ideas and their help as we work through this.
That's great. Thanks, Mark.
Dr. Briesacher: Thanks. This was fun, Karen.
Karen Springer: It was fun.