Cowboys and Pit Crews: Change is Here

by John H. (Hank) Duffy, founder, JHD Healthcare Partners

shutterstock_240686083.jpg pit crewA few years ago, New Yorker magazine published a commencement address from Atul Gawande, a surgeon, writer, and public health researcher, who spoke to students at Harvard Medical School. Dr. Gawande made the very insightful remark that today’s medicine doesn’t need “cowboys,” the lone rangers who do everything themselves. Rather, in today’s medical environment, you want the patient to be surrounded by a “pit crew” — several medical professionals collaborating on how best to care for one person. Never before has the industry experienced such a dramatic shift in ideology, and culture change it requires.

The public’s experience is that while we have amazing technology and highly trained clinicians, there is little consistency with doctors and technology coming together to provide an actual system of care, from start to finish. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.

The solution to rallying the front lines around this new methodology is aligning incentives — creating frameworks for success where the physicians are incented to team, to look at clinical quality, to manage clinical costs, and to be patient-focused.

With the healthcare landscape shifting from a pay-for-service model to one based on accountable care and qualitative patient outcomes, the way physicians are incentivized and compensated needs to change in step with what the market is dictating. Physician compensation is a major issue in this transition. At one extreme, physicians are suspicious about changes in their income. At the other extreme are legal regulatory issues related to compensation.

The reality is that no matter how you configure it, any successful physician compensation plan needs to be built around 5 pillars:

  1. It (still) needs to be volume- or productivity-related. Within this are two components that must be artfully balanced: panel-sized — how many patients the physician is responsible for; and how many encounters (wRVUs) — how busy is the physician?
  2. It needs to require demonstrated clinical quality. This can be broken down into two parts. First, are the patients being given the right protocols (pap smears, vaccines for children, and best-practice processes for illnesses)? Secondly, are they staying out of the hospital and living longer?
  3. It should include clinical cost management. There is a saying that the most expensive item in healthcare today is a pen: the pen that writes multiple MRI screens, multiple pharmaceutical scripts, multiple X-rays, and more. It’s the physician’s ability to quell his or her use of the pen (or mouse) that will be the greatest impact on clinical cost. More often than not, it’s because the physicians are practicing what we call “defensive medicine”: prescribe the Z-pak, do the CT scan just to be “safe” – rather than focus on rational clinical need.
  4. It must focus on the patient experience. Enhancing the patient experience starts with opening up the schedules to get the patients cared for on a timely and convenient basis. The patient experience is knowing your patient when they come in the door, knowing what’s going on with them. It’s the antithesis of having all the patients re-do their paperwork every time they come in the door, rather than greeting them and asking if anything has changed.
  5. It has to include citizenship. It’s more than showing up at work. Citizenship is teaming with your colleagues, being a part of the group, helping to find solutions and sharing in both successes and opportunities for improvement. Being a part of the health system not only of your patients, but also your provider organization, is important in this new healthcare landscape.

There are several things that have to happen to get us from being cowboys to being well-oiled pit crews, starting with a significantly different communication process. This is not about management trying to hustle down the cost of the physician cohort; it’s about moving from fee-for-service to fee-for-value. Here’s what your communication plan needs:

  1. Education on all sides. All sides need to understand the other. You have to have an involved physician cohort in the development of your organization’s methodology; you can’t take two or three accountants and have them go in a room and develop the methodology. It’s a process that is going to take time, and you can’t do it in 3 weeks. We just completed one successfully and it took 10 months.
  2. Explain the positives. Show physicians the upside to this alignment,….how it will be good for the patients. Explain what there is to be gained and how the entire organization is going to be aligned. Otherwise, assumptions will be made that they are the ones bearing the brunt of this change. Show them the upside, which lies in tangibly demonstrating clinical quality.
  3. Data. It’s easier to say than to deliver on, but you have to give physicians data on their panel size/demographics, clinical outcomes, to the extent you can get clinical costs, and more. Also, get them comparative data, which should be blinded initially to ensure the data is correct, and then once you have enough built up to be meaningful, make it transparent to all providers. It’s the way to get us all in the same boat, and the way for us to start to feel like we’re reliant on each other, and focus more on the patient.

The reality is that change is inevitable. CMS has said it wants 70 percent of its payments under a value-based stream of contracts by 2018. Whether this happens for your organization in late 2017 or late 2018 doesn’t matter; it’s inevitable. There are going to be winners and losers, and the winners are going to be the ones who learn how to do this sooner.

Teaming — like a good pit crew.

For more information on how JHD Healthcare Partners can help your organization through this transition, please contact us at For a copy of the “Cowboys and Pit Crew” commencement address, please visit


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