All discussions of payment reform require an alert and attentive provider community. Physician burnout is clearly an impediment to this attention. It is estimated that 50% of physicians either have, or are at risk for burnout. The manifestations are protean and apparent to families of the providers and coworkers in the workplace. Not only do the effects impair patient management, but the willingness and enthusiasm to participate in health care reform to guide the engagement pathway from estrangement to emancipation. The Innovation Initiative and the Tenncare Episode of Care model, illustrate a successful program that is an ideal vehicle to accomplish this and show the way to more comprehensive models that will emancipate physicians.

 Pyramids & Cycle of Engagement, Robert Ripley MD, CEO, Ripley and Associates

Because there are so many contributing causes for burnout, it will be helpful to structure a "Pyramid of Engagement" to organize the causes in the context of possible solutions. The pyramid model has become popular in showing how the context of the entity of interest can be stratified. For a good description of an entity, it may be thought of as a level within the context of other levels. Putting multiple levels in a pyramid format clearly shows how the levels, or entities, are contextually related to each other. The first level and the apex of the pyramid of engagement is the physician which has characteristics as a group referred as intrinsic factors. The descriptors of the generic physician level imply causal factors that are intrinsic to physicians as well. For example, for burnout the intrinsic causal factors can be provider specific psychosocial aspects. The next level, just below the physician is termed the "collective", a useful term that implies many types of organizations that impact or include physicians. These include the environment the physician practices in (which may be peer groups), referral networks, ancillary providers, hospital affiliations, medical staff and insurance plan committees. An important part of the collective is the business model of the practice particularly as it relates to workflow and financial status. The third level of the pyramid, below the collective, are the extrinsic factors that impact and stress the providers either directly or indirectly. These include:

• Insurance programs that require invasive justifications for services.
• Quality metrics monitored by several plans.
• Evidence based medicine.
• Organizational pressures such as service volumes.
• Poorly designed health records forcing long periods of physician foraging to find information.
• Payment programs where accountable care and fee for service reimbursement are not aligned.
• Fragmentation originating from plans, which arise from lack of coordination, due to lack of common standards for quality and incentives.
• Ubiquitous lack of collaboration and coordination between preventative services, acute care, transitional care, and chronic care.

The usefulness of the pyramid is to group the many forces that impact, benefit, or harm physicians, in generic broad levels that allow relationships within and between levels to be visualized. Because there is now widespread recognition among many organizations of burnout, there is an awareness that something must be done to solve the problem. More than an ethos of physicians heal thyself, and with the effects of burnout reverberating throughout the health care system, there is an imperative for each organization to play a role in a family of solutions.

There is hope; however, for solutions for burnout. Before looking at the details, it is important to remind ourselves of the primary motives that give physicians meaning in the daily practice of medicine. Most of all, physicians think of themselves holistically, meaning they are adept at responding broadly to the scope of patient issues and needs. All physicians take pride in the beneficial outcomes of their patient's management. Connections with the patient and the provider collective that shares management of the patient is important to physician self-esteem. Here is an opportunity to engage physicians metaphysically, which is where meaning can be accounted for at the population level mediated by some form of collective. Once this accounting is done in a variety of ways, physicians can be engaged by recognizing issues that are important to them.

So the questions are, can there be a model that emphasizes the role of the collective that captures the details of the Pyramid of Engagement, which takes advantage of the virtues in medical practice that may be suppressed or latent? Can there be actions on the part of controlling organizations such as insurance plans that can recognize and combat burnout? Can these actions be standardized across insurance plans? Can population based information from insurance plans create a metalevel of information that promotes coordination and collaboration? Can a controlling organization be identified that is physician centered with the authority to address these questions and be the key component of the model? Most importantly, can these efforts combat fragmentation of the entire health care system that impacts physicians' practice on a daily basis?

Addressing burnout requires physician engagement, and the result of this engagement must be emancipation from the pressures causing it. The Pyramid of Engagement model is a stratification of many factors, some of which are stressors, which as noted includes the context of the collective and extrinsic factors of physician centered features. From the context of burnout the solutions can be stratified as well. This stratification, for the purposes of the model, starts with factors as they exist, and poses the possibility of changing, or transforming these factors. Therefore the model bridging from burnout to engagement, holding the possibility emancipation, provides for an orderly process defining the factors of burnout matched to the solutions. As the graphic illustrates, engagement can be a transformation of an inverted pyramid where the weight of the collectives and extrinsic factors bare on the physician, to a righted pyramid where the essential role of the physician is expressed as the virtues of medical practice placing the physician, as the driver, at the apex of the pyramid. Thus the model defines the transformation.

What is a good way to transform high dimensional features of the 3 levels of the pyramid to a physician centered metaphysical solution for burnout? A brief survey of possible solutions from the 3 levels of the pyramid is in order, to find the best solution that may be hiding in plain sight. Transforming the extrinsic factors of technology, fragmentation, misaligned agendas of public and private plans, is a long term process. Transforming the physician centered intrinsic factors requires changing the features of practice, more than changing physicians themselves. The features of practice that can most quickly transform is the collective. Culling a collective from a large government plan with its variety of providers may hold the most promise. In this case the TennCare program can be the solution hiding in plain sight. Building on its experience with episode of care technology and its essential ingredients of physician engagement via the Technical Advisory Group (TAG), the next generation of engagement can be the logical agent of transformation. The enhanced TAG can be named the Transformation Technical Advisory Group (2TAG). With the scale of TennCare as the largest plan in the State of Tennessee, with its diverse group of providers, all issues of scale, population (extrinsic factors), local (collective) and single provider, can be presented to a roundtable of providers and managed care personnel. Organized under the proven leadership of the TennCare program and supported by its data and models, the details of what transformed health care would look like can be determined.

It is clear that the problem of physician burnout is bigger than physicians themselves. Transformation that impacts the context of physician practice effects all of health care. This is a topic for extended discussion, but a good place to start is with physicians whose engagement in a positive manner is essential for transformation.