1. FEBRUARY 2016 AMGA.ORG x GROUP PRACTICE JOURNAL 59
Now that the Centers for Medicare and Med-
icaid Services (CMS) has made its intentions crystal
clear—50% of payments based on value by 2018—
medical groups are accelerating their efforts at changing
their care model. In this flurry of activity, it is easy to
jump to the well-accepted tangible ingredients required
for success: a new electronic health record (EHR),
advanced reporting tools, patient-centered medical
home (PCMH) recognition, new payer relationships,
cost-accounting software, and the like.
Experience shows that you won’t de-
velop much traction if your physicians
are not on board first.
While all of these are indeed crucial elements,
experience shows that you won’t develop much traction
if your physicians are not on board first. Managing
risk to achieve success in the “Pay for Value World” is
largely a physician-led endeavor, and winning the hearts
and minds of the docs and supporting their success has
to be the initial priority.
1. Meet Basic Needs
Maslow’s hierarchy of needs1
teaches us that
we won’t be able to get our docs’ attention if they
are under severe stress in their everyday work
environment. Meeting their basic practice needs is the
basis of trust and forms the foundation from which
to move forward into new behaviors. This process
has become all the more challenging as we have
asked our providers to adapt to an electronic medical
record, which many find inefficient. Applying Lean (or
other) technologies to improve office flow, providing
more intense EHR training, using scribes to offload
physician clerical work, and incorporating advanced
practice clinicians are but a few of the ways we can
reduce provider stress.
2. Communicate the Burning Platform—
Emphasize the “Why”
While those in leadership are apt to be reading the
latest legislative and payment news, it is good to keep
in mind that many front line docs are barely able to
keep up with their clinical reading. They may not be
aware of the pace of change in your market and the
new behaviors that will be required. This education
should not be hard or controversial as most providers
naturally can see the need for less expensive, higher
quality care and are interested in providing it. They
mostly want the environment, tools, and appropriate
rewards for success. Although most have figured out
how to manage the fee-for-service treadmill, few are
truly enamored by it. The opportunity to improve care
with a dedicated support team has real appeal. The
Making the Move to Value?
First, Focus on Your Physicians
BY HOWARD B. GRAMAN, M.D., FACP

2. 60 GROUP PRACTICE JOURNAL x AMGA.ORG FEBRUARY 2016
fact that most agree there is roughly 30% waste in
our system and that we provide no better care at from
two to three times the cost of other developed nations
is enough to get most folks’ attention. Being specific
about recognized areas of waste in your own environ-
ment helps drive the point home.
3. Align Compensation to Reward Improved
Clinical Outcomes
Most medical group compensation plans are still
heavily or entirely weighted toward production. This is
understandable given the history of contract payment
methodologies. However, there is little doubt now that
nongovernment payers will follow CMS’s lead.
Physicians are quite sensitive to any discordance
between requested behavior and financial rewards. If,
for example, primary care docs are asked to enlarge
their panel, provide more virtual care, and delegate
care management to team members, they will bristle
at a traditional comp plan, which remains in pure “eat
what you treat” mode. New comp plans provide the
flexibility to expand value measures as the care model
and payment methods change. If you have not already
done so, it is time to create at least a 10% portion of
compensation related to value measures (quality met-
rics, patient experience, growth, citizenship, or group
financial performance) and allow for expansion of this
portion as payment changes progress.
4. Commit to Reduction in Variation
Despite the fact that medicine has well-recognized
experts in every field who help define guidelines for
care, many practicing docs resist the idea of following
them. They believe they are well trained and can make
individual judgments for each of their patients. While
there is certainly room for individualization for excep-
tions, the vast majority of patients would do well with,
for example, a standard stepwise approach to treatment
for hypertension or diabetes—often at a lower cost.
Guidelines for care, order sets in the EHR, advanced
radiology ordering algorithms built into the record,
and the Choosing Wisely®
recommendations2
are but
a few of the options we have to reduce variation. This
will need to become a group philosophy if you are to
flourish in a risk environment. A willingness to rigor-
ously define standards and address outliers will become
attributes of successful medical groups.
5. Coordinate Care
It is stunning to see how little communication there
can often be between primary and specialty care when
it comes to even the most common conditions that are
managed by providers within the same medical group.
Physicians who refer back and forth frequently do
not take the time to sit down and decide how best to
manage the care so as to improve quality and patient
experience, reduce duplication, and improve provider
satisfaction. One way to solve this problem is to very
intentionally set up written Care Coordination Agree-
ments (CCAs) between primary and specialty care
whereby representatives from primary care and a given
specialty sit down and discuss how they will manage
care for the three to five most common diagnoses for
which they are jointly responsible. Through this pro-
cess, the initial agreed upon approach to care can be
established, the referral thresholds can be set, and the
diagnostic workup needed to make the consult most
efficient can be laid out. Also, follow-up assignment can
be agreed upon so everyone is working to the top of
his or her license. Sometimes, this may require further
primary care provider (PCP) training to reduce referrals
that should be managed at the PCP level (e.g., advanced
education about exam of the shoulder or knee). The
added bonus of developing these CCAs is the engage-
ment of the physicians and camaraderie that comes
from planning care together.
6. Promote Team-Based Care
Most physicians in practice today were educated to
do everything for their patient and be the sole decision-
maker about all aspects of care. This has become an
increasing burden over the years and has become a
major contributor to burnout. It is only in the past few
years that medical schools have begun to put education
about a team-based approach to care in their curricula.
Consequently, many docs are reluctant to delegate deci-
sion-making to others on their team. Selecting capable
people to surround and support the physician as well
as formal team care training are essential if physicians
are to be expected to relinquish control and delegate
responsibility. Most providers who are aided in having
this burden lifted are very grateful as it allows them to
use their expertise on the more complex problems for
which they have trained.
7. Develop Your Leaders
Recognition as a respected clinician is a necessary
but insufficient skill set for physician leadership. Far
too many physicians struggle with the transition from
clinician to leader, and we often underestimate the
amount of support needed to make this transition suc-
cessful. Such tasks as setting a meeting agenda, carrying
out performance reviews, having crucial conversations,
articulating a vision, and developing emotional intel-
ligence are teachable and learnable skills.

3. 62 GROUP PRACTICE JOURNAL x AMGA.ORG FEBRUARY 2016
Investing in leadership development is an essential
and cost-effective way to support success. In larger
systems or groups, some of the required skills can be
attained through internally structured “leadership
academies.” In smaller group settings, encouraging or
requiring attendance at any of a number of nationally
recognized leadership training courses is a great way
to achieve the same results. Assigned mentorship with
senior physician leaders within the group and, in some
instances, hiring an executive coach are excellent ways
to maximize the value of an already capable leader or
salvage a struggling clinician leader who needs profes-
sional support to reach full potential.
So, as you prepare your medical group’s pathway
to value-based care, consider these seven aspects of
physician support and development to ensure you have
the core strengths and skills to be successful.
References
1. A.H. Maslow. 1943. Theory of Human Motivation. Originally
Published in Psychological Review, 50: 370-396.
2. In 2012 the ABIM Foundation launched Choosing Wisely®
with
a goal of advancing a national dialogue on avoiding wasteful
or unnecessary medical tests, treatments and procedures. For
more information, see www.choosingwisely.org.
Howard B. Graman, M.D., FACP, is a general internist
with progressive leadership roles in large integrated deliv-
ery systems. Most recently, he was CEO of PeaceHealth
Medical Group, a 900-provider multispecialty group
with operations in Oregon, Washington, and Alaska. He
currently is vice president at AMGA Consulting Services.
Contact Dr. Graman at hgraman@amga.org.
Industry Insights continued from page 4
and all 7 conditions (light red). Overall, 59% of patients have
evidence of four or more comorbid conditions (orange and red).
Patients with HF are often high utilizers of ambulatory
services, requiring visits with specialists and primary care physi-
cians to manage and treat their numerous conditions.These
patients stand to benefit most from care coordination, which
can make treatments more efficient and less burdensome for
patients.
References
1. D. Mozaffarian, E.J. Benjamin, A.S. Go, et al. 2015. Heart
Disease and Stroke Statistics-2016 Update: A Report from the
American Heart Association. Circulation, December 16, 2015.
Accessed January 26, 2016 at http://circ.ahajournals.org/con-
tent/early/2015/12/16/CIR.0000000000000350.full.pdf+html.