ACO Leader Keeps Focus on Interpersonal Relationships
Working on value-based care programs is partly about improving scores on quality measures for Trinity Health’s Naomi McMackin, M.D., but another key focus for her is reducing physician burnout and bringing collaboration and joy back to the practice of medicine.
McMackin is the regional chief medical officer of the clinically integrated network for Trinity Health Mid-Atlantic’s PA region. She works in Bucks County, Pennsylvania, and is the medical director for the BPCI-Advanced at St. Mary Medical Center and is the physician leader for the Colleague Health Plan Alternative Payment Model.
Speaking at the NAACOS Fall Conference last week, McMackin said she has seen many of her physician friends lose the joy of work. “When I get together with my med school friends, they're stressed out, and then the pandemic hit and we're all struggling. I love my work because my goal is to bring back the joy, to meet with our teams and remind them why we are here, to be that spark of energy because they're the ones doing the work.”
She said that when she first started learning about ACOs, her focus was on improving certain scores and improving outcomes. “That is really important,” McMackin said, “but what I recognized very quickly was that we have to do both. We have to focus on the performance, but it's that interpersonal connection — either between the patient and the provider, between the ACO and the provider — those relationships is what brings joy into work.”
She gave an example involving the diabetic eye exam measure, which is not a CMS measure but is in many of her group’s Medicare Advantage plans. Some primary care physicians she met with said they didn’t don't know why this was their measure because they don't do that type of exam. Why are they held accountable for this? They refer out, and never get a report back. Their data doesn't look good no matter what happens. “I listened, and first thought let's get a diabetic eye scanner. Let's just focus on that performance. Let's scan everybody. We're going to improve your numbers,” McMackin recalled. “But was that really the right thing to do? Is that the problem I'm trying to solve? Am I trying to get that number in that box to be higher? Do patients really need a diabetic eye scan or do patients with diabetes need an ophthalmologist to do a dilated exam, check the pressure in their eye and make sure they don't have glaucoma, refract them and make sure they don't have cataracts, so they're not at risk for falls because of decreased visual acuity. What are we actually trying to do?”
She and her team were able to get their ophthalmologist and primary care doctors around the same table and say this is the help that we need. “We provided them with education on coding to try to capture some of that work. We taught the ophthalmologist how to close the loop so they can run their own reports and maybe pull their own patients back in to get their eyes re-examined,” she said. “We've really tried very hard to dig into the process of education directly to patients and get those letters back in our EMR.” Two weeks ago, she got an e-mail from one of the physicians with an exclamation point saying ‘thank you, a patient of mine saw Dr. so and so in the eye clinic, and now I have the record. Now when I do that comprehensive visit, I can close that gap in care.’
“You want collaboration, not just outcomes,” McMackin said. “We want them to feel a part of something, not isolated, not feeling like they're carrying the weight of the world on their shoulders, but bringing those key stakeholders together to improve outcomes.”
Noting that they have been successful in their enhanced track ACO for five years, she said that when they talk about innovation, it's really about meaningful data. “What we do is continuously audit all of the charts, about 200 per week. We have a person, not artificial intelligence, going into people's charts — either remotely or in person to pull quality measures,” McMackin explained. “Then we teach them how to improve them, and this has really been the key to our success because we have taught our independent practitioners how to create their own practice transformation action plan, and then we help them and hold them accountable to it. This has been the main key for our non-claims-based measures across the organization.”
“With the ACO, we have created an interprofessional team that has extended the reach of the primary care practice. Every single person who has a hemoglobin A1c poorly controlled is referred to our ambulatory pharmacist and they work with those patients longitudinally to improve that outcome,” McMackin explained. “We also heavily invest in social influence of health assessment and partnerships to overcome them. We know that to really get in that 90th percentile for quality, we have to find those patients who lack access, and this is how we level the playing field and build equity with that goal of achieving justice for our patients. We have to partner with community-based organizations and faith-based leaders. We cannot do this on our own and as a health system, we can't afford to own it all. We have to partner and that has been crucial.”
She says that what she is most proud of is that her leadership team has become the people that the doctors call to escalate all sorts of things. ‘That's how I know we've gotten to that collaboration. They call me and say, ‘I can't get this person out of the house. She doesn't need to go to the ER but she lives in a basement apartment. She's home-bound and needs labs, what do we do? That's the kind of collaboration that I see the ACO pulling together. It really is what brings the most joy in my work. I love when the docs call me. I never know what they're going to ask, but it just feels good to know that there's somebody there to help and support them during this crazy time. A lot of it is really preventing burnout. We can be that catalyst. We don't have to add to the burden. We can be the solution to the burden. We can stop and listen. I have the desk job now. I get to be the one to take the problem and dig in and try to solve it while they're going to see patients. That's my responsibility.” She said perhaps other ACO leaders can think of it in that way, too. “How can you make it better for that physician or that provider who's in front of a patient just to make it a little less burdensome?”
