Journal of Healthcare Leadership (Apr 2022)
Engaging Frontline Physicians in Value Improvement: A Qualitative Evaluation of Physician-Directed Reinvestment
Abstract
Stacie Vilendrer,1 Alexis Amano,1 Steven M Asch,1,2 Cati Brown-Johnson,1 Amy C Lu,3 Paul Maggio4 1Division of Primary Care and Population Health, Stanford School of Medicine, Stanford, CA, 94305, USA; 2VA Center for Innovation to Implementation, Menlo Park, CA, 94025, USA; 3Department of Anesthesia, Stanford School of Medicine, Stanford, CA, 94305, USA; 4Department of Surgery, Stanford School of Medicine, Stanford, CA, 94305, USACorrespondence: Stacie Vilendrer, Division of Primary Care and Population Health, Stanford University School of Medicine, 1265 Welch Road, Mail Code 5475, Stanford, CA, 94305, USA, Email [email protected]: Physicians can limit upward trending healthcare costs, yet legal and ethical barriers prevent the use of direct financial incentives to engage physicians in cost-reduction initiatives. Physician-directed reinvestment is an alternative value-sharing arrangement in which a health system reinvests a portion of savings attributed to physician-led cost reduction initiatives back into professional areas of the physicians’ choosing. Formal evaluations of such programs are lacking.Methods: To understand the impact of Stanford Health Care’s physician-directed reinvestment in its first year (2017– 2018) on physician engagement, adherence to program requirements around safety and fund use, and factors facilitating program dissemination, semi-structured qualitative interviews with physician participants, non-participants, and administrative stakeholders were conducted July-November 2019. Interview transcripts were qualitatively analyzed through an implementation science lens. To support contextual analysis of the qualitative data, a directional estimation of the program’s impact on cost from the perspective of the health system was calculated by subtracting annual maintenance cost (derived from interview self-reported time estimates and public salary data) from internal cost accounting of the total savings from first year cohort to obtain annual net benefit, which was then divided by the annual maintenance cost.Results: Physician participation was low compared with the overall physician population (n=14 of approximately 2300 faculty physicians), though 32 qualitative interviews suggested deep engagement across physician participants and adherence to target program requirements. Reinvestment funds activated intrinsic motivators such as autonomy, purpose and inter-professional relations, and extrinsic motivators, such as the direction of resources and external recognition. Ongoing challenges included limited physician awareness of healthcare costs and the need for increased clarity around which projects rise above one’s existing job responsibilities. Administrative data excluding physician time, which was not directly compensated, showed a direct cost savings of $8.9M. This implied an 11-fold return on investment excluding uncompensated physician time.Conclusion: A physician-directed reinvestment program appeared to facilitate latent frontline physician innovation towards value, though additional evaluation is needed to understand its long-term impact.Keywords: physician incentives, professional autonomy, cost savings, motivation, quality improvement, program evaluation, quality indicators, health care, organizational innovation, work engagement
