Ramsey Abdallah, assistant vice president of operations for New York-based Northwell Health, leads strategic initiatives for over 29 hospitals and more than 800 ambulatory sites, focusing on ACO quality, performance improvement, and data analytics. At the NAACOS spring meeting, he spoke about what he’s learned about engaging specialists in value-based care. 

Abdallah explained that most of Northwell’s value-based care arrangements are through the MSSP ACO, where it has about 100,000 lives. It also has multiple Medicare Advantage and commercial contracts, and works with the state through Medicaid.

In this work, one of the core problems that Northwell noticed is that a vast majority of value-based care is designed around primary care. “Attribution is very PCP-centric, and quality measures are very PCP-centric. Incentive structures are also PCP-centric,” Abdallah said. “That made sense because the starting point for a lot of value-based care began with PCPs, but the landscape is starting to change, and we're trying to figure out how to engage specialists and bring them into this work. We have to rethink how we participate in this, especially because the way systems are currently structured, specialists drive the majority of the costs in utilization, and they also deal with many complex patients.”

Sometimes when you try to engage with specialists, you hear, “This isn't my job. I'm not going to deal with it. Go send them to the PCP.”  They also see a lot of disruption to workflows, Abdallah said, “because we're trying to take things that were successful in PCP offices and bring it into a cardiology office or urology office, and they weren't designed to fit into those locations. We also have misaligned incentives, and there's a lot of fragmentation with data. A lot of the reports and structures that we had were not designed to engage specialists.”

Specialty engagement is really a change management problem, Abdallah stressed. “One thing that we learned very early on at Northwell is that you can't go into a cardiologist's office and say, ‘You should do this because it's mandatory.’ I learned the hard way you get kicked out of the offices when you try to do that. What you have to do is design programs that fit those specific locations.”

He said you also have to identify the culture of the specific location and drive home the importance from a clinical perspective. Specialists will ask: How do I operationalize this in my office? You want me to screen patients for depression? I'm not structured to do that, and my office doesn't even know what that stuff is. 

Here is an example of how the health system approached change. Northwell had a very ambitious goal to screen for depression all patients who came into its ambulatory practices.

“When we looked at our historical performance, we realized there was a lot of opportunity to improve,” Abdullah said. “We dug deeper into the data and what we found is that Northwell is mostly a specialist-driven organization. Only about 27% of the patients saw a primary care doctor at Northwell, so just mathematically, if every patient who saw a primary care doctor, got screened and everything was perfect, we would sit at 27%, which is not a very good number to be successful. So engaging specialists wasn't really something that was a nice thing to do; it was something that we had to figure out how to do in order for us to be successful as an organization.”

Specialists would say they understand the clinical imperative, but they don't know how to do it. If they screen a patient, what happens to them? “The first thing that came up was the concern around liability,” Abdallah said. “But also, for many of the specialists, it wasn't about just screening patients. They want to make sure that if they did something, there was a human that picked it up, addressed the concerns of a patient, and that they were notified in return. They want to make sure that they left the patient in good hands and they got the information in back.”

In order for to get many of the specialists to buy in, Northwell created a Behavioral Health Access Center. If a patient screened positive, the specialist would send a referral to the Access Center. Within three days  someone would reach out to the patient and triage the patient based on the patient’s conditions and make a recommendation. “We guaranteed our specialist 100% response rate and closing loop within three business days. In the two and a half years of doing this, we missed one patient in three business days, and that's because he didn't check his email,” he said. 

Abdallah said Northwell also realized it had to layer incentives throughout this program. “We started building incentives through our service lines, where we worked closely with our chairs to amend some of the bonus structures that our physicians had, and we made performance a portion of that bonus,” he said. 

They also realized they had to tweak the incentive structure to bring in the operations colleagues, to have them be incentivized as well, because at Northwell the physicians don't run the practices; it's done through the operations team. “By having both groups have skin in the game, we got them to work together to participate in this work,” he said. 

Not surprisingly, the most difficult group to engage in this conversation was orthopedic surgeons. Abdallah said he learned that the best approach is to get one person to buy in and they become your advocate. “They don't listen to a guy who wears a suit, but they will listen to their peer,” he said. “When you want to engage specialists, you should figure out how to get peers to engage with them, because they really understand their pain points, both from a clinical perspective and from an operations perspective.”

He said they realized they had to make sure that the process was built around the support staff and did not put the burden on the physician. “That's why 99% of screenings done at Northwell are done through the medical assistants,” Abdallah said. He noted that 98% of Northwell’s screenings are negative, so there are very few instances where physicians have to intervene. They do have to put in the referral, because of some New York state guidelines around what nurses and medical assistants can do. “But we built out a process that allowed screening to take place and that didn't put all the burden on the physicians. What we are now finding is we are getting to that point in in our process where we're beginning to get to more of the delayed adopters. These are the last vestiges of clinicians who are the more difficult ones to adopt the change.”

• Build the infrastructure. It made perfect sense that they were hesitant to screen patients if they didn't feel that there was someone to pick up the referral and the information we would get back to them, Abdallah said. 

• Layer incentives based on the different structures. "We tried doing just physician incentives, but then we realized we had to bring in the operations incentives and  invest in peer-to-peer influence," he said. "You have champions. You have people who are very eager to participate in value-based care. Find who they are, jump on their back and have them take you to the finish line.”

• Be transparent with data. “We were very purposeful not to present it as a punitive item," he said. "I mean, 1% gains were celebrated. Even though people don't like participation trophies, 1% gains were massive for us, because what it showed is a slight shift. That built momentum over time. Once we created the culture that you use data to improve and not to punish, more people were willing to participate.”

What is next for Northwell? Abdallah said it needs to start addressing cardio-metabolic disease areas. “There is lots of fragmentation happening across the organization. We really need to systemize some of this work. We also want to build more specialty-specific performance metrics that are meaningful and matter to those groups. We are continuing to design shared accountability across the continuum. When we say specialty engagement, it's not just the specialist, it's everyone around the specialist — medical assistants, the nurses, the people who run our operations."