Bill G

I’d like to offer a slightly different perspective. We hadn’t talked about this, but many residencies are embedded in larger health systems or larger medical groups. And certainly when I worked at Providence, we participated in the CMMI, Comprehensive Primary Care Initiative, and then went on to have a Comprehensive Primary Care Plus practice. I think there were 17 residency practices nationally that participated in the Comprehensive Primary Care Plus. But in Providence, it was organized in the medical group. There were three residency practices that were some of the 30 position practices. It was very effective to have the residencies participate in the quality and efficiency network. And to actually have some guidance externally, too, about what your external benchmarks were.

Obviously, some of them were processed, but they really did have some pretty good outcome measures. And to sort of work creatively under a broader franchise. Having the individual practices able to work towards some agreed-upon improvement benchmarks was very helpful.

Warren

I think starting with where the outcomes should be is really helpful from an educational point of view. And it’s a challenge. You got to know where you want to go. And then people can choose different approaches to get there. But if you have common outcomes and shared ideas, then you can get there.

Bill G

The other thing that was brilliant on the part of Providence—given our current discussion—is that from the beginning there was paid time for the MAs in the participating offices to get together. A lot of the restructuring was really around the MAs. In fact, some of the great successes in terms of implementing preventive services outcomes were really all run by the MAs. It was quickly just figured out that you needed to delegate an awful lot of the outreach and responsibility for the delivery of evidence-based preventive services to the MAs. And then they would screen out those patients that seemed to be recalcitrant or reticent to participate and would funnel them up to an MD encounter. But 80 to 90% of that work and success was really restructuring and empowering the medical assistants.