In Texas, meanwhile, Texas Health Resources lies in the center of what Varga calls "the Wild Wild West," where there is very little in the way of comprehensive clinically integrated physician networks. "If you were to describe the healthcare [market] in north Texas, you can say that it's very expensive with average quality [of care] and an average patient experience. And the healthcare system in north Texas is very rich," said Varga. "We are a byproduct of the demographics. Our population is growing rapidly now that a significant number of individuals are migrating to areas in Texas, due mainly to a lack of income tax. All of the drivers that everyone saw through the years to force integration of care has never existed in north Texas," he said, noting that one-third of the independent primary care doctors have no economic pressure to accept other patients, outside of those commercially insured. "So when you talk about meeting patients' increased needs and expectations, there’s no true imperative to enhance the care delivery model."
In central Massachusetts, Iitsuka said UMass Memorial isn't faring much better. "We are making low acuity situations more complicated so it fits us. We don't make it easier for our patients, and we don't use technology correctly," he admitted. "We need to look at patients and their families as our customers, rather than our doctors. Things such as outpatient clinics, technology, more access points for patients are where we have to shift our thinking towards."
Iitsuka additionally noted the desire to get the frontline staff to make the strong tactical changes that are needed such as getting patients' prescriptions filled before they leave. "Why aren't we providing that service? It's harder to set up a system in which someone goes up to the room, takes the prescription, and gets it filled," he said. "Our nurses said that we need to provide that service to improve the patient experience. For us, the frontline staff needs to drive that change because a top-down down approach won't work."
Even in the tech-heavy bay area, John Muir Health isn't embracing technology as much as it should be, though Sauter said the organization has worked with physician leadership to implement solutions such as an online treatement and diagnosis solution. That information is transmitted to the doctors who turn around verification and prescriptions within an hour during normal working hours, Sauter said. Additionally, in a month or two, the organization will add the option for patients to see physicians virtually, via online and video. "Our adoption rate was modest initially as our focus was only on existing patients, but we are in the process of making [the service] available to non-members," Sauter said. "To stand up against Kaiser and Sutter, who are are membership-based organizations, we have to compete in areas where they they don't."
Interestingly though, Sauter mentioned telemedicine provider Teladoc as "a tremendous threat to John Muir Health in being able to deliver consistent, integrated care across the continuum. He said that as a result, developing partners to keep patients in the community and keep care in the system is a necessity. "We are working with CVS in the minute-clinic setting. They have a nurse practitioner care delivery model, and they can expand access and share that clinical information with us and not [negatively impact] our delivery system," Sauter said. As such, disconnecting primary care physician compensation from production is one of the bigger things that John Muir Health did to adapt, he continued. "We segmented our population and created care models that were tailored to the individual needs of those patients. This allowed for virtual and online visits, and it's not coming out of the physicians' pockets to participate in these models."
Iitsuka agreed that inviting new partners for areas in which you might not perform very well is crucial. For example, UMass Memorial was struggling in the area of ambulatory surgeries, so for that aspect, as part of the organization's growth, it became a minority partner with another facility, Iitsuka noted. "It's critical for us to get the right services in our community, and it doesn't have to be us that has to control the healthcare value chain. Right now, we take care of people when they're sick, not when they're healthy.
We cannot be the gym membership health system, so we have to partner with the right people to help us with those things," he said.
To further meet consumer demands in Texas, Varga touched on the need to meet patients and populations where they are. Without a large driver for consolidation and integration in the north Texas marketplace, THR is working at it from an accordion-type perspective. “We are participating in full-risk Medicare advantage and have done well with the Medicare Shared Savings Program as well. We are evaluating a possible move into the NexGen ACO in the upcoming year as well. “But the approach we are taking now, by a sub-population basis, is building a care delivery model by meeting the patients where they are, and doing predictive modeling to look at the emerging risk population."
All of the panelists agreed that one of the biggest keys in adapting to consumers' changing healthcare needs is successful change management. "There is a process, almost like a grieving process for change," said Sauter. "Whenever people are made aware of change at first, people naturally get defensive and react negatively, then they warm up and get excited about it. We need to make sure that our changes in the organization follow that pattern. Telling a physician that his two easiest patients will be now be seen by Teladoc, well, that will get negative reaction. You need to be thoughtful about communication," he said.
Varga added that THR tries to use the essential elements of a change management dialogue: clarity and transparency; humility (we don't have all the answers); belief in both your work and those you work with; and exemplifying sensitivity toward those you dialogue with. "Can I put myself in the shoes of the individual on the other side of dialogue? As unreliable as our delivery model has historically been, as non-designed based as it's been, those folks have lived with that variation and figured out a way to get to a common pathway to meet most of the things we ask them to do. It can be tough to take that," Varga said. "We ask ourselves up front, are we really changing or are we just expanding?"
Iitsuka further noted the challenge of being pulled in different directions as a healthcare system. "You have people who want to bend the cost curve down and be in a bundle for everything, and then you have someone who wants to buy a cheap MRI. They want a slice not the whole thing. We have to serve all of these people. So we have to run on unparalleled tracks, and on top of that we have to take on risk," he said, additionally commenting on regulatory challenges such as not being able to prescribe a patient a medication unless you have an existing patient relationship in Massachusetts. "So that defeats some of purpose of virtual visits in our state," he said.
Indeed, at THR, there is a constant struggle on how to engage people outside of the organization's four walls, Varga admitted. The health system has 5,600 affiliated physicians, but only 500 of them are employed. "We're all financially stable, but we are creating an average experience,” he said. “At the same time," Varga continued, "we have to create a non-acute care model that leads to better health and well-being, and we have to merge those two models. We have resources to put to this, but the biggest challenge is having a marketplace that wants to be engaged in a different type of access model as opposed to the one they've always had."