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Culture-driven innovation in primary care

Insight Article - December 15, 2020

Governance

Value-Based Operations

By Carman Ciervo, DO, FACOFP, primary care family medicine physician, Cooper Health Alliance, Camden, N.J., carman.ciervo@gmail.com; Anthony Wehbe, DO, MBA, FACOI, internal medicine, physician executive, Sena LLC, Philadelphia, Pa., DrWehbe@senallc.com.; and Joseph Lyons, CPA, MLA, CIA, CISA, owner, Lyons Advisors, joe@lyonsadvisors.net.

Primary care physicians continue to retire at an earlier age than in the past.1 This, coupled with fewer residents entering primary care disciplines,2 has created the perfect storm for patient access in the industry.

Despite rigorous technological efforts to enhance opportunities for patients to connect with healthcare providers virtually, most patients, particularly baby boomers, are still seeking face time with their physician, either in the office or via telemedicine. 

Addressing primary care gaps

There are efforts to grow primary care to include advanced practice providers (APPs) to close the access gaps in many areas of our country. In some instances, wait times to see a primary care physician can be a staggering six weeks. This negatively affects patients’ willingness to follow up for routine care, and it also creates gaps in care that often lead to unnecessary hospitalizations and duplication of services. Such decreased access diminishes patient satisfaction and drives up the cost of care.

Most health systems have been working for the past two decades to address the dearth in access to primary care. In 2011, the leadership of Kennedy Health System embarked on a strategic journey to address the rapidly evolving landscape of the southern New Jersey and southeastern Pennsylvania markets. Kennedy maintained a hospital-centric strategy with minimal attention to medical staff development and continued reliance on independent practitioners for referrals.

Like many health systems, Kennedy acquired physician practices in the mid-1990s, but had not acquired the organizational competence to manage these practices. The absence of leadership and related managerial skills resulted in poor physician engagement. Practice operations underperformed causing termination of Kennedy’s physician enterprise.

Instituting a new strategy

By 2011 it was clear that a new strategy was needed. A formal planning process was initiated, supported by the Center for Applied Research and involving Kennedy medical staff members and representation from the medical school affiliate, the University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine. This inclusive process with key stakeholders identified the health system’s strengths and weaknesses. It gave the medical staff officers and key members of the medical staff a professionally facilitated, open forum that revealed strengths and weaknesses. These internal discussions combined with a market assessment led to clarity about how Kennedy would not only remain sustainable, but also thrive in achieving market share growth.

Core to the strategy was improving access to primary care via a geographically distributed network of primary care practices throughout the community. The challenge was significant given the past failure and the five competing health systems that already had established employment-based strategies. Soon after the strategic planning was completed, a senior medical director for clinical integration was hired to begin to execute the plan to grow primary care access by creating and sustaining an employed medical group.

The importance of inclusiveness

The painfully learned lesson from past failure was the importance of creating a foundation of trust. The prospect of a medical group starting de novo in a market with intense competition from mature, health system-affiliated groups was formidable, but nonetheless the best option. It was critical that strategic differentiators drove medical group growth and more important, the culture.

At the core of the trust strategy, Kennedy leadership decided not to incorporate restrictive covenants into physician contracts. This was in opposition to the conventional wisdom that advised protecting market share against departing physicians by imposing strong restrictive covenants ranging from 10 to 25 miles and extending for two to three years after employment termination. To respond to the risk regarding the lack of restriction on departing physicians, leadership chose to seek strategic advantage through a culture of inclusiveness wherein physicians and advanced practice providers (APPs) were part of the decision-making process at every level.

A deliberate decision was made to be guided by the oft-used adage that “culture trumps strategy.” This proved that, right from the very first recruit, Kennedy leadership was ready with a meaningful, trusting gesture to the physicians considering employment. This led to an extremely low physician departure rate, virtually no primary care physician vacancies and stable access for patients. As a result, visit wait times were not lengthened by provider position vacancies.

Stability of primary care practices was supported by the trusting relationship between the physicians and Kennedy Health Alliance administration, including the form of the employment agreement. The traditional legal formatting and length was modified so the contract was contained within a comparatively short offer letter with a signature line at the end for the prospective recruit. While the agreement was legally binding for both parties, the letter format conveyed a sense of collegiality absent in conventional contract formats.

Some of the other initiatives used to build trust revolved around nurturing relationships throughout the organization; fostering an environment of engagement among physicians, APPs and frontline staff; incorporating much-needed services such as behavioral health services and nutrition counseling; creating an integrated care team that covered the continuum of care and supported/fostered new practice models from key frontline leaders. A fundamental strategy for nurturing and supporting the culture is structured communication, which included the implementation of a HIPAA-compliant texting platform that allowed for secure communication. In addition, newsletters were published routinely with town halls held periodically to communicate updates.  

Conclusion

Innovation will continue to be an important component in patient care and for providing options for primary care physicians and APPs. This will require a culture that responds to the individual needs and preferences of each patient, provides rewarding professional work for physicians and APPs, and achieves these two goals with sustainable practice models. Success will depend upon the ability to maintain an engaging culture and leadership’s desire to improve how and when it is delivered.

Notes:

  1. Zhang X. “Disruption in Primary Care and Patient Outcomes: Evidence from Physician Retirement.” Job Market Paper. Nov. 17, 2018.
  2. Knight V. “American Medical Students Less Likely To Choose To Become Primary Care Doctors.” Kaiser Health News. July 3, 2019. Available from: bit.ly/3m9sSUY.
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