Engaging Frontline Physicians in Value Improvement: A Qualitative Evaluation of Physician-Directed Reinvestment.

Purpose: 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.