Sound Advice: Transitioning to Value-Based Hospital Medicine

July 13, 2020 - Hospitalists play an essential but often under-recognized role in driving value-based care and alternative payment models. With 50 percent of Medicare A/B spending taking place in the acute episode, it is critical to understand and address the quality of care provided in inpatient settings.

In a session during Xtelligent Healthcare Media’s Value-Based Care and Telehealth20 Virtual Summit, Sound Physicians Chief Clinical Officer John Birkmeyer, MD, discussed the importance of leveraging hospitalists as part of a value-based care strategy. He also detailed challenges, benefits, and best practices when implementing value-based care strategies as well as how organizations can successfully change their existing clinical care models.

Obstacles to implementing a value-based care strategy

In making the leap to value-based care, organizations are bound to hit a few snags along the way. For Birkmeyer and his team, it was essential to evaluate and get ahead of any potential complications.

“As we embarked on this journey, we saw at least three overarching challenges,” Birkmeyer said. “Number one was scalability. Sound Physician practices are currently in over 300 hospitals nationwide, each with their own unique circumstances and their own set of resources. Sound was looking for care models and technology that would lead to success in each one of those settings.”

It was also essential to ensure that this new strategy would add value to the organization's practices.

“Despite our commitment to developing new skills in value-based care, it was imperative that we did not distract or otherwise compete with our ability to drive traditional clinical performance to our hospital partners—that it continues to have very strong interest in maintaining excellence in patient experience, patient throughput in length of stay and case mix index,” Birkmeyer noted.

Additionally, entities looking to transition to value-based care should examine whether the initiative can financially support underlying investments in new resources.

“While our primary interest in embarking down the value-based care pathway was alignment with our clinical mission and vision,” Birkmeyer continued, “it was also incumbent that our investments in people, processes, and technology would be at least recouped by new ancillary revenue associated with value-based payment models.”

Designing a clinical strategy to generate reproducible outcomes

In developing a successful clinical care model, the most significant determinant of success is physician ownership of the total cost of care.

“We expect that physicians manage overuse and cost of care with the same professionalism and diligence that they manage other aspects of quality. Towards that end, we are consistent in patient-centered messaging and placing our own clinical strategies in the context of published clinical evidence,” Birkmeyer said.

“We provide regular and persistent onboarding and clinical education materials helping physicians better understand techniques for ensuring that care is aligned with patient preferences and other strategies for avoiding overuse,” he added.

Organizations should also pay close attention to high-risk patients when developing new care models.

“We place a special focus on managing patients that are in risk programs,” Birkmeyer emphasized. “In our own empirical experience, our results in managing total cost of care have been far superior when our physicians are able to flag and identify those for whom we are bearing risk. We also identify patients at clinical equipoise between going home and going to facility-based, post-acute care. And we ensure that both our care navigators and our physicians are disproportionately focusing on those patients.”

Results and lessons learned from new clinical care strategies

Birkmeyer and his team saw specific aspects of care change due to their newly designed clinical care models, most significantly around the proportion of patients discharged from the hospital to skilled nursing facilities (SNFs).

“Over a four-year period, we saw a 15 percent relative drop in the overall use of SNFs. We also achieved significant reductions in the proportion of patients discharged to a long-term acute care facility, or LTACH. That fell by 39 percent,” Birkmeyer said.

In addition to seeing improvements in certain elements of care, the organization learned that getting clinicians on board with new processes is no easy task.

“Changing physician behavior has been hard and slow. If I were to catalog some of the chronic challenges, at least within Sound Physicians, it has been the perception that transitional care and what happens after the patient leaves the hospital is often not my job from the perspective of hospitalists,” said Birkmeyer.

“There's a reluctance in many quarters to engage in activities that are not directly reimbursable, including advance care planning, transitional care, and spending time with patients and their families discussing the relative merits of different skilled nursing facilities.”

As time has gone on, however, physicians’ attitudes are beginning to change.

“Over the last two or three years, while there remain pockets of this type of resistance, we found that buy-in has been slowly improving, probably as value-based payment models become a more accepted part of the landscape,” continued Birkmeyer, “but also, more importantly, given changing paradigms in how physicians are taught and the increasing awareness of the value for patients and their families of going home.”

Going forward, organizations seeking to transition to value-based care models successfully will need to be willing to put in the time and effort necessary to achieve their goals.

“In the future, more holistic models, whereby all parties benefit from the success in reducing excessive spending and over-utilization, would be more effective than the current model. We've proven at least to ourselves that value-based care can, in fact, be financially viable at scale, even across very heterogeneous hospital settings. However, success requires focused investment, continuous learning, and, most of all, significant patience,” Birkmeyer concluded.

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About the Sponsor

Founded in 2001, Sound Physicians is a national physician practice organization with a proven track record of improving quality, satisfaction, and financial performance for its partners nationwide. We deliver results under risk-based payment models by engaging our physicians in a holistic, value-based clinical model that spans hospital medicine, emergency medicine, critical care, anesthesia, advisory services, population health, and telemedicine.