Engaging Frontline Physicians in Value Improvement: A Qualitative Evaluation of Physician-Directed Reinvestment

Figures & data

Table 1 Cost Savings Reinvestment Program – Year 1 Example Project Descriptions and Balancing Measures

Project Type & Name	Primary Service	Description	Attributable Savings Methodology	Balancing Measure
Clinical Improvement
Improving Appropriate Inpatient Level of Care^Citation53	Hospital Medicine	Clinician education and electronic health reminders to achieve appropriate level of inpatient care (wards/intermediate/ICU)	Validated post-implementation Δ in daily accommodation cost between IICU and MS bed x validated Δ (pre to post-implementation periods) average length of stay x validated post-implementation # cases	Hospitalist service length of stay, mortality, 30 day readmission
Reducing Inpatient Neuro Direct Costs through Cost-Conscious Checklist	Neurology	Implementation of cost-conscious checklist reviewed for each patient during morning rounds	Validated Δ (pre to post-implementation periods) in unit cost (hospital stay inclusive of all services) x validated post-implementation # cases	Neurology service length of stay, mortality, 30 day readmission
Repatriation of Chlamydia/Gonorrhea Testing	Pathology	Outsourced laboratory test brought in house	Validated Δ (pre to post-implementation periods) in unit cost (test cost) x validated post-implementation # cases that received new test	Not applicable given clinical equipoise
Rapid Molecular Influenza A/B & RSV Testing	Pathology	Emergency room switch from polymerase chain reaction to rapid immunoassay respiratory panel	Validated Δ (pre to post-implementation periods) in unit cost (test cost, laboratory, imaging, emergency room observation time) x validated post-implementation # cases that received new test	Not applicable given clinical equipoise
Substituting gemcitabine for Mitomycin C for intravesical chemotherapy	Urology	Administration of medically equivalent lower cost bladder cancer therapy	Validated Δ (pre to post-implementation periods) in unit cost (medication cost) x validated post-implementation # cases that received gemcitabine regimen	Urology service length of stay, mortality, 30 day readmission
Product Utilization
Reducing Cost of Cardiac Rhythm Management Products	Medicine - Division of Cardiovascular Medicine	Negotiated lower prices for products related to Cardiac Rhythm Management	Validated Δ (pre to post-implementation periods) in unit cost (target product) x validated post-implementation # cases that received target product	Not applicable given clinical equipoise
Reducing Cost of Orthopaedic Spine Products	Orthopaedic Surgery	Negotiated lower prices for products related to Orthopedic Spine	Validated Δ (pre to post-implementation periods) in unit cost (target product) x validated post-implementation # cases that received target product	Not applicable given clinical equipoise

Notes: Δ Represents the change between the pre and post-implementation periods; pre-implementation (baseline) period varied depending on the project anywhere from 4–12 months without any transition or “ramp up” time.

Table 2 Fidelity to Intended Design in a Physician-Directed Reinvestment Program at an Academic Medical Center

Program Requirement	Summary of Findings	Example Quotation
Unchanged or improved quality despite downward pressure on cost	Projects that risk a reduction to quality of care were reliably rejected by oversight committee during selection Physician leads reliably select and report on appropriate balancing measures Incidental benefits reported	“ … so the equation is cost and quality. I can say unequivocally, the discussions I have been part of on the committee or witnessed, quality’s first … So cost savings is the goal, but only when quality is maintained or improved, only. The discussion stops if there’s ever any question …” (Chair 1). “You might wonder if in the service of reducing length of stay as it relates to cost, we are yielding more readmissions. But I, along with colleagues, have gone through them [readmissions] one by one to look at, ‘Are they related to us doing too little and getting people out of the hospital too quickly?’ There’s no clear pattern related to that” (Participating Physician 4). “ … we learned that they [nurses] were pushing the drug the wrong way, where it was more of a spill risk … I worked with the nursing educators to find a new system where it became safer …” (Participating Physician 7). “That one [alternate test], literally, will save eight hours of patient’s time” (Administrator 1).
Utilization of reinvestment funds towards non-compensation areas	Primary direction of funds towards research, followed by capital investment and education	“ … I’m going to see if [hospital] would be willing to put on solar panels which will generate revenue in perpetuity. And then allow that money to go into a fund which I can then use on QI [quality improvement] and education” (Participating Physician).

Table 3 Facilitators and Barriers to Cost Savings Reinvestment Program Dissemination Using the Consolidated Framework for Implementation Research (CFIR)

Facilitator	CFIR Domain	Example Quotation
Opens doors to administrative resources	Inner setting	“I think the magic of this program is that it’s built a bridge between the administrative structure of the hospital and the physicians who want to do quality improvement. I think that was the missing piece before … It’s that projects come forward, they get prioritized with the people that do the accounting … prioritized with IT [information technology]. That that’s what’s been the magic … ” (Chair 1).
Overcomes institutional resistance	Inner setting	“ … the amount of bureaucratic and institutional resistance to these sorts of changes [project goal] makes it very important that there’s something like CSRP to do those sorts of things” (Participating Physician 1).
Cost saving as a need on a national scale	Outer setting	“I think it’s appealing to try and save cost all around … I wish we had universal healthcare, and cost was a non-issue … So the kind of ideologic part of me is interested in that” (Chair 4).
Incentive alignment with patients and health system	Intervention	“ … the most appealing [aspect of CSRP] is of course it aligns incentives. It’s something that anybody could wrap their head around … ‘I get to share in a financial benefit with the hospital.’ … Every physician would say that that makes sense” (Participating Physician 10).
Motivates intrinsically  Autonomy  Purpose  Relation to others	Intervention	“I think what really gets people interested … is probably autonomy. The feeling like they can actually make a difference in the work-place and they have control over the environment, and that they can actually [say], ‘This is a better place because of what I did’” (Non-participating Physician 3). “Put the blame wherever you will, but the truth of the matter is that the initiative around medical decisions now is … We [physicians] have lost that. It’s now in the hands of non-physicians and that needs to be recaptured and delivered squarely into the hands of healthcare professionals … ” (Non-Participating Physician 3). “Yeah. It’s fun to kind of work in teams. Obviously to work with [colleagues] and to get the data and see how we’re doing and, ‘Okay, we met our goal.’ That’s always kind of fun” (Participating Physician 5).
Motivates extrinsically  Funds  Recognition	Intervention	“I think that it’s [reinvested funds] existence regardless of what the actual calculus ends up being … just it’s existence … becomes a big powerful incentive and it already helps to drive project ideas forward” (Participating Physician 5). “There was a thank you banquet … where … the CSRP leads [were invited] to come and get a little trophy and all the relevant leadership was there. And that was nice and I certainly appreciated that … ” (Participating Physician 7).
Financial impact easily understood by diverse stakeholders	Intervention	“ … people pay attention to dollar signs … It’s a common language. You can tell me that the pediatric ID [infectious disease] group reduced the turnover rate for sepsis initiation rapid response from X minutes to Y minutes, but that’s not a currency I ever think about in my life [as a non-ID specialist].But once you put a dollar sign … There’s no translation required. It’s instant to everyone what that means” (Participating Physician 7).
Justifies time spent given competing priorities	Individuals involved	“I think societally, everybody wants to do what is right. I think curtailing costs without compromising quality [of] care is, should be the way it is. I think physicians have too much on their plate to be able to be motivated and incentivized to do something like this [improvement project], that it needs to be clear what the return is going to be” (Participating Physician 3).
Trust in the organization	Individuals involved	“My own perspective is the hospital’s been really supportive of my career … I think in some institutions there’s kind of a disconnect between the administration and the physicians and they do not get along … That does not happen at Stanford, at least not that I have experienced” (Participating Physician 6).
Barrier	Domain	Example Quotation
Ongoing access to data	Inner setting	“And actually that’s probably my biggest problem with the actual process now is getting the data, the first iterations around … is one thing. But then the problem is … getting the follow up data … ” (Participating Physician 12).
Challenging intra-departmental communication	Inner setting	“We do not have a lot of good ways of ensuring communication [within the department] … If you say …. ‘we can make the rounds of division or department meetings to announce it’, but then who shows up? There’s only a handful of people who show up or who are actually focused” (Administrator 4).
Fear of reduced future resources	Inner setting	“ … So it’s hard to budget for it. I thought, “well I could use [reinvestment] money towards some things that, you know, I could just never get approved on the capital budget because I’m always pushed off.” But at the same time maybe I do not want to do that, because that’s an incentive [for administration] to not give [us] money in capital budget” (Participating Physician 2).
Fee-for-service inertia	Inner setting	“And as we move more and more towards a population health type of a care delivery system, we have to have our faculty engaged. Unfortunately a lot of the Stanford system, like many other systems, it’s a widget based system … “let’s make more widgets cause we are going to all do better if we make more widgets’” (Chair 2).
Fee-for-service inertia	Outer setting	“And unless we want to deal with that [high prices paid by academic centers], nothing you do is going to drop cost. [If] we pay [1x] instead of [3x] for the [treatment], our health costs would drop overnight right? Of course the stock price for every single one of those [companies would] honestly going through the floor, right? So no one wants to talk that. They want to say blame the physician. We just pay a lot more, even [though] we pay 3X what they pay in Europe for the same product” (Chair 5).
Disincentivizes improvement prior to CSRP enrollment	Intervention	“It also dis-incentivizes incremental change. So we actually started improving some of the areas [related to project] about eight months or ten months before our CSRP period started. So we wished we had not done that … You want to be as bad as you can and then suddenly flip a switch and do all of the things at once, which is less than ideal. So we certainly were not having any moral issues with trying to improve care before we made this start up [with] CSRP. It was just sort of like a retrospective bummer” (Participating Physician 4).
Limited program capacity	Intervention	“The only unappealing feature is that not all potential CSRP projects can be approved” (Administrator 1).
Savings measures in “soft” dollars	Intervention	“I think CSRP is challenging, like you said, for a number of complicated reasons it does not always translate into real dollars. I think that’s why, my guess is, that they [administration] are hesitant to pay it back. It’s like, ‘What were the real dollars connected to this?’” (Chair 5).
Lack of high yield project ideas	Individuals involved	“Some of them [proposed project savings] seem relatively small, and I think about the hundreds of millions we spend on supplies and we are looking at a few things [in CSRP], sometimes, that are in the hundreds of thousands. I cannot believe that, if we took an objective third party view, that some of these [larger savings opportunities] items would not rise to the top” (Administrator 3).
Lack of physician time	Individuals involved/Inner setting	“It [time] is not fully protected. I’m the [role within department]. I get one administration day. I can tell you half of those days I’m either seeing patients or operating … It’s a fact of life” (Non-Participating Physician 5).
Reduced trust in the organization due to prior experience	Individuals involved/Inner setting	“It’s more because we were promised something that never came to pass [historical event] … But because CSRP would have a much greater percentage of clinicians that know and want to be part of this effort [without that history]” (Participating Physician 11).
Lack of training around cost	Process	“ CSRP is not providing any education … You have to come to them … and be engaged already, and then they’ll tell you if it’s something that they’ll support for two years” (Participating Physician 4).
Selection based on perception that improvement should be a part of one’s job	Process	“On one side, you are incentivizing a physician and hospital administration partnership to move forward a program that will save money, while maintaining or increasing quality, right? … But then just on the other side of that line, there is this line, right? Just on the other side, is rewarding someone for finally doing the job that they should’ve done a long time ago” (Chair 1).

Figure 1 Initiatives to engage physicians in value improvement and the legality of direct financial compensation.

Ruiz ColónG, Yang J, Svec D, et al. Physicians Leading Physicians: A Physician Engagement Intervention Decreases Inappropriate Use of IICU Level of Care Accommodations. Am J Med Qual. 2021;36(6):387-394. doi:10.1097/01.JMQ.0000735480.43566.f9

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