Specialty practice demonstrates high-value care while relentlessly pursuing continuous improvement in patient-centered care and cost reduction
by Alan Kimura, MD, MPH, President and Managing Partner, Colorado Retina Associates
Featured in the March/April 2019 Colorado Medicine.
The physician and administrative leadership of Colorado Retina Associates (CRA) understands that the highest-value care is delivered by physician-led organizations that strive for excellence in clinical care with person-centricity and modern business practices.
CRA is the dominant retina practice in the Rocky Mountain West and western Great Plains, with 12 physicians working alongside 128 staff seeing 24,000 unique patients per year for an annual workload of 64,000 visits. From a population perspective, our practice is the final hope for persons with both very common sight-threatening conditions such as age-related macular degeneration and diabetic retinopathy, as well as very rare inherited or inflammatory diseases.
My own Master’s of Public Health training exposed me to a larger perspective on health care that medical training alone did not provide. Coinciding with my degree was the passage of the Affordable Care Act – and the growth of the larger dialogue on how to improve health care quality while reducing costs. While the ACA addresses cost and value to a point, true transformation of the fragmented health care ecosystem can more easily be accomplished starting with physicians and patients.
To meet quality and cost goals, CRA knew we had to evolve our entire leadership and operational processes. We explored peer practices across the country to see that they were solving the same clinical and business challenges that we faced, but they were doing it better.
In the 21st century physicians must know the business skills of finance, data and outcomes, and human relations, but
I would also argue that you ideally need the “big picture” and forward view obtained by having fluency in health care policy, to “skate to where the puck is going to be.”
I continued my training in leadership and management through the Johns Hopkins School of Public Health, the American Academy of Ophthalmology Leadership Development Program, the Medical Group Management Association, and also the American Association of Physician Leadership, and became involved in committees and workgroups at the Colorado Medical Society relevant to public policy and quality improvement.
Our practice signed on to the Transforming Clinical Practice Initiative (TCPi); we were the first practice in Colorado to have completed the TCPi certification and have since been named an “exemplar practice.” Our involvement with TCPi has further demonstrated the value of developing data and outcomes measures to redesign care with patient-centricity – all to improve quality of care and reduce waste and inefficiency.
We analyzed our basic practice metrics: From 2012 to 2017 we had experienced a 27 percent growth in clinic visits and a 37 percent growth in new patient visits but we had not addressed the need for more robust staffing, revenue cycle management, IT and clinical infrastructure to meet administrative burden. What gets measured gets managed; what gets measured, managed and rewarded
gets repeated. We needed a major overhaul with better oversight and performance metrics.
CRA committed to our culture of patient-centered care built on a foundation of continuous quality improvement. We constantly challenge ourselves to be a high-performer clinically, providing excellent care to patients and holding surgical rounds to shorten the post-fellowship learning curve. CRA was an early adopter of the AAO IRIS Registry (Intelligent Research in Sight), which aids in quality tracking, and our practice is in the second year of deploying Lean Six Sigma to drive continuous process improvement using metrics, benchmarks and internal feedback loops, resulting in care well above peer practices, while demonstrating improvement over baseline.
My experience with Lean Six Sigma has been overwhelmingly positive: Our subject matter experts guided us through a remarkable process of self-discovery unique to our organization. Innovation bubbles up from the front-line workers rather than command-and-control directives pushed from above. Lean is a fundamental reordering of how the work is done. The efficiencies created are more respectful of patient time, allowing more patient interaction to discover their values and preferences to guide care. Another clear benefit is a reduction in stress of staff and physicians, in turn positively feeding back upon patient care.
It has been an eye-opening, transformative experience.
In addition to data to support excellent clinical outcomes, CRA contributed $20.3 million in cost savings in 2017 to the health care system, with a projected $23.5 million in cost savings for 2018, by prescribing lower cost, off-label pharmaceuticals for first-line therapy. CRA physicians perform 64 percent of their major surgeries in ambulatory surgery centers whenever medically appropriate. CRA also saves payers by providing same-day access with their physicians on call 24/7 including nights, weekends and holidays, thereby avoiding emergency room visits. In early 2018, CRA transitioned to a cloud-based EHR that allows on-call doctors access to patients’ charts and images for higher quality triage.
The next projects we are working on are, as specialists, attempting to integrate with primary care in the larger medical neighborhood to improve communication and patient referrals from and back to primary care, and to begin to leverage our data and outcomes to generate a performance story that makes the business case for quality and cost-effective delivery of care to payers, changing the discussion from arguing for another few dollars on a given code to reworking how value-based care would look for both the provider and payer. For instance, with data demonstrating “exemplar practice” status, how can a practice get relief from the inefficiencies of prior authorization and the revenue cycle? Showing payers how we have implemented data-driven care redesign, beating benchmarking of peers to demonstrate high-value care with high quality, and that we are aligned with their interests will hopefully translate into better contract terms.
I believe that physicians in all practice settings do not have to choose between taking care of your business and doing the right thing for the health care system. You can do both by studying your own clinical and business operations to wring out the waste.