The basic principles of Aristotle’s philosophy of nature can be understood from his analysis of change. In his analysis, Aristotle discovered that every change implies duality. A subject undergoes change when the action of an external or intrinsic motion renders the subject to a different state.1 According to Aristotle, change presupposes the acquisition of something new and the disposition of something prior. Through the change process, motion acquires something new and loses what is previously had. Change implies a passive principle and an active principle. If you believe Aristotle’s philosophy of nature as understood by his analysis of change, then like me, you believe that change is natural.
If that’s the case, then why is it so hard for organizations and people to adapt to change? In my belief, it is not the change, it is the transition to change that is difficult. Change is defined, “to make or become different.” However, transition, as defined by Aristotle’s motion, is “the process of changing.” Transition takes you from here to there. It is the essential ingredient for change. Sometimes change is thrust upon you and your life is turned upside-down, or the life you once knew is gone. Why, you may be wondering, are we talking about change and transition to change in the Acumen blog?
The business of Nephrology is consistently changing. While specific regulations from different Acts (e.g., the Affordable Care Act (ACA)) and laws are still evolving, overall healthcare trends and reforms have clear implications. The pace of change in nephrology will depend on specific market dynamics, private payer initiatives, government action, and a strong degree of care coordination across practice, hospital, and dialysis settings. The risk of ignoring the inevitable transition to change is to be on the wrong side of success. William Bridges, a leader in the field of change management, says, “transition involves an ending, a neutral zone and a new beginning.”2 Let’s take the transition to new reimbursement models as an example.
Letting go of the past is to honor and grieve the ending, but accept the change.2 The nephrology space (and all of healthcare) is experiencing a transformation involving reimbursement payment models. The conventional fee-for-service (FFS) reimbursement model is in the process of being replaced by the concept of value-based care, a reimbursement methodology that challenges the “volume-based care” associated with FFS and encourages healthcare providers to deliver the best quality care at the most reasonable cost, improving the overall value of care. According to Laura P. Jacobs, MPH, HealthLeaders Media[, “Medicare and some other payers are shifting dollars from specialty services to primary care—but not adding any new money to the ‘pot.’ The only hope of ‘upside’ will come through new payment models.” We honor you and we will miss you, FFS!
The Neutral Zone
According to Bridges, this may be the most uncomfortable transition stage to change.2 This is the stage of confusion. It is the time of ambiguity as you transition from one end to a new beginning. Clarity is needed in order to live in a new normal. The Triple Aim of providing quality patient care, while minimizing healthcare cost and enhancing the patient experience is a healthcare dream. However, how do we achieve such a dream? The truth is, it is yet to be determined. When speaking to nephrologists, they are concerned.
“How do I do more with less? I am spending a lot of my time and energy on the administrative arm of patient care,” states Dr. Afolabi of Fort Worth Renal Group in Fort Worth, Texas.
The challenges of transitioning to value-based care reimbursement models are in abundance for practicing nephrologists.3 When you feel uncertain and confused, seek to understand because knowledge is a powerful vehicle in the change journey.
A New Beginning
In this stage of transition, utilize the clarity that arises in the neutral zone and accept the challenge of working in a changed environment.2 Value-based care programs are designed to achieve The Triple Aim. Quality and efficiency are the goals of every value-based payment model. To get out of the neutral zone, I googled the different types of value-based care models:
- Pay-for-Coordination. A primary care physician leads and coordinates care between multiple providers and specialists to manage a unified care plan for patients.
- Pay-for-Performance (P4P). Reimbursement is directly related to achieving certain quality and efficiency benchmark measures.
- Bundled Payment or Episode-of-Care Payment. Healthcare providers are reimbursed with a set amount of money to pay for a specific episode of care, which encourages quality and efficiency.
- Shared Savings Programs (Upside and Downside). Physicians form entity groups and provide population health management. Quality and efficiency are achieved through coordinated team care and any realized net savings are given back to the provider. Do you belong to an ACO?
Each of these models consist of multiple models specific to specialty, episode, and patient population. As I continued to read, two things became abundantly clear:
- The Quadruple Aim is the new Triple Aim. The physician continues to be the center of the care delivery system. The Triple Aim expanded to a Quadruple Aim by adding the goal of improving and enhancing the provider’s experience.
- We can’t make these transitions alone. Various partnerships are necessary when creating strategies for tackling new problems and meeting new challenges. We must share the knowledge as we navigate the new nephrology space.
Partnerships matter! To achieve optimal performance under any of the proposed reimbursement changes (whether you are a small practice or a large practice), physicians, hospitals, and Leading Dialysis Organizations (LDO) must put aside old frameworks that assume one entity “controls” the other. Instead, innovation and demonstrating a commitment to healthcare improvement and operations will be required to remain financially strong.4 Change is natural and it is time to transition.
Wanda Harris is VP/General Manager with Acumen Physician Solutions, with over 25 years’ experience in our national healthcare landscape. As a national executive and business leader, Wanda drives strategic vision, fosters long-term sustainability, and establishes fiscally and operationally sound organizations within the healthcare landscape. She has worked with healthcare organizations like Hospital Corporation of America (HCA) and DaVita Healthcare Partners and was recently with Southwest Kidney Institute, Global Nephrology Solutions, and Renal Care Organization where she established several platforms to respond to the adversity our nephrologists are facing.
- Magee, Joseph M., Ph.D. 2015. The Problem of Change; Thomas Aquinas In English: A Bibliography.
- Bridges, William, Dinwoodie, David, Marshall, Edward, McCallian, Russ, Sereno, Bertrand, Shields, Jim, Zhao, Sophia. 2013. Adapting to Organizational Change: Center for Creative Leadership. 31pp.
- Bellovich, K. Presented at the Renal Physicians Association Annual Meeting. 2019; Chicago.
- Lafayette, Richard, MD. 2018. “The Changing Landscape of Nephrology: Will you Lead or Follow?” Kidney News.