Leadership in the Emerging Health System: Brown & Toland’s Leaders Push Ahead Towards the Future

As the November/December cover story of Healthcare Innovation noted, “Everyone participating in the U.S. healthcare delivery and payment system understands that the COVID-19 pandemic has had a dramatically destabilizing impact on all sectors of the industry. With ICUs filling up across the country and infection rates from the virus exploding beginning early in the year, the leaders of the nation’s hospitals, medical groups, and health systems had to shift quickly to telehealth-based care delivery to the extent possible, while dealing with a shutdown of elective procedures mandated by the Centers for Medicare and Medicaid Services (CMS) that ran from mid-March to mid-May, and cratered the elective-procedure revenues on which patient care organizations depend for survival. But even as patient care organizations in some communities had begun to go back to semi-normal operations, others began to experience dramatic and incredibly difficult surges in COVID-related inpatient admissions.”

Even so, the cover story noted, “[B]eyond the immediate crisis that leaders of the U.S. healthcare delivery system are still facing around the pandemic, industry leaders are reflecting on longer-term issues, as the system shifts further towards value-based payment and away from fee-for-service payment—at a time of great financial and operational instability. The pandemic, those interviewed for this article agree, made it clear just how fragile the patient care organization financial outlook really is, for so very many.”

Among those interviewed for the cover story were Kelly Robison, CEO, and Shannon Decker, Ph.D., vice president of clinical performance at the 1,500-physician-plus Brown & Toland Physicians multidisciplinary medical group in San Francisco.

Brown & Toland’s leaders have been moving forward on multiple fronts to strengthen their ongoing shift into the new value-based healthcare. Among other developments, on Nov. 25, they announced that they had finalized an agreement with the San Francisco-based Altais Clinical Services, a division of the healthcare services company Altais—initially launched last year by Blue Shield of California—for a full business affiliation. As a press release published on Wednesday morning stated, “The two organizations have formally joined to expand the transformation of patient care for improved health outcomes at an affordable cost and accelerate the improvement of the physician and patient experience. That move, Kelly Robison, and Jeff Bailet, M.D., Altais’s president and CEO emphasized, would give Brown & Toland additional tools to support the organization’s population health management and care management work, especially in terms of leveraging the data analytics needed to make such work successful.

Earlier this autumn, Robison and Decker spoke with Healthcare Innovation Editor-in-Chief Mark Hagland for the cover story, regarding their organization’s forward advances. Below are excerpts from that interview.

Kelly Robison: I see a transformation of the medical model. Most medical groups are IPAs [independent practice associations]. And we’re seeing a transformation into more of a model in which physicians get more support from the organization through employment or practice support. In other words, there will be a shift toward greater integration. Second, you’re seeing more risk across broader populations, and more total-cost-of-care-based risk. Third, more technology-enabled solutions to help physicians manage their practices, and more practice-based support.

Shannon Decker, Ph.D.: COVID has provided the opportunity to get there even faster. People are looking for higher quality and more value. That’s the value-based model—and we’re pursuing that model.

How would you frame the physician culture change necessary for this overall transformation, and how the physician culture has been evolving forward?

Robison: I think that physicians by nature tend to be entrepreneurial, and I’ve been in healthcare for nearly three decades. Over the years, the management of healthcare has become so complex, and there’s been such a squeeze on reimbursement, and on top of that, there’s been so much consolidation that now, a physician’s range of choices is so different. So for those physicians who want to remain entrepreneurial, and who want to remain independent and not have their destiny controlled by a hospital-based system, they need some kind of help. And that’s where organizations like ours can help: we can support physicians in their practices, while allowing physicians to retain an entrepreneurial spirit.

Decker: I’ve noticed an evolution. It’s important to recognize that it’s a symbiotic relationship. And when we approach physicians, it’s not about telling them what to do; they already know what to do.

How are you, in the leadership of your organization, helping practicing physicians to prove their value in the emerging healthcare landscape—and how are leaders across the health system doing so?

Decker: We need to consider the place where people are coming from, and the messaging, and the best practices for moving people forward. When you think about change theory, that involves finding out where they’re at, and showing them the data—maybe only one piece of the data rather than all of it. And it becomes a place of service. I don’t want to sound Pollyanna-ish, but that truly is what gets people to move. As far as the data, you need to show them that it’s useful. And it needs to be accurate, reliable, and regular; you can’t expect to move people without data. You need to make it regular; you can’t give them data once a year and expect them to change. I had a physician who people told me about: they said, you’ll never get through to him. But it literally was just a matter of listening to him.

What do the next five years look like to you, as the healthcare system evolves forward into value, both at Brown & Toland, and across Northern California?

Robison: As for Brown & Toland, we’ll see growth, and a transformation of our models to more and more physicians being employed, and a pretty intensive deployment of technology tools to help support care.

Can you explain the legal relationship of the physicians to the organization?

We’re in a corporate practice of medicine state, so in a hospital setting, a physician organization will be a foundation, and for us, it’s a medical professional corporation, and so it’s technically a medical professional corporation that employs them, arranged and managed by us. And we’ll also see more consolidation. And we’ll see an increase in government-sponsored programs.

Which of the types of accountable care organizations are you involved in right now?

We were one of the original Pioneer ACOs, but we’re not participating in the MSSP [Medicare Shared Savings Program]. We are participating in Medicare Advantage and in Medicaid managed care.

And what is the breakdown of your payer mix?

We have 70,000 HMO risk-based lives, 75,000 in ACOs, and 175,000 in fee-for-service. And another 5,000 in Medicaid managed care. The ACOs are all commercial; we have contracts with 17 private payers.

What do you see as the biggest couple of challenges and opportunities in the next few years?

Decker: I think that one of the biggest challenges is physician fatigue, if we don’t support our physicians enough, and if we don’t get the data we’re looking for, and the technology to be able to keep pace. And in terms of the data, it’s not just about getting data on risk and quality, but also making sure we have the best data and technology on our side. The biggest opportunity is also technology. With COVID-19, we’ll have technology and be more innovative in the past.

Robison: The social determinants of quality will pose both an opportunity and a challenge. There are a lot of factors that come into play in terms of how to better deliver care and achieve holistic outcomes—how to integrate mental health back into care as well as nutrition, transportation, etc., that’s something that the entire healthcare industry has to prioritize.

What should healthcare IT leaders be doing right now, in order to support all of these efforts?

Robison: I think there are a lot of shiny pennies out there right now; HIT leaders really need to be focusing on implementing tools that genuinely make it easier to practice. There are a lot of fun things, and nice-to-have things, but with physicians being so busy, it’s got to be about streamlining their work lives; they can’t be one-offs.