Trinity Health CEO Joseph R. Swedish this week was named the new CEO of WellPoint Inc., effective March 25. Though Swedish is well known and highly regarded in the hospital sector, a number of health insurance industry analysts reacted with surprise upon hearing the news. Many acknowledged they'd never heard of the executive from Livonia, MI, who will soon lead the nation's second-largest health insurance company.

Swedish spoke with HealthLeaders Media this week about the challenges of the new job. Below is an edited transcript of the conversation. 

HLM: Why did WellPoint pick a hospital executive instead of someone with a more extensive health insurance background?

JS: My sense is that the board, looking at the landscape of the entire industry, came to the conclusion that we are all—and by all I mean providers and payers—exposed to a transformational era that necessitates different kinds of strategic choices, different dialogs occurring in the industry.

The payers and providers are going to have to lead the way regarding the health reform agenda. This transformational era specifically relates to what I call this "New Age of Consumerism" that necessitates that we align what the consumers want with access and cost reduction and care that is safer and higher quality. We are going to have to give them the technologies that are necessary to gain that kind of access.

Another area that is critically important is that both providers and payers are now aligning networks. In many cases they are narrow networks that really focus on meeting the agendas of better performance at lower costs. Then you look at the structural changes in healthcare specific to the advancement of exchanges and the new relationships that will be created between provider and payer and that speaks to the dialog being tremendously different, what I call the new story versus old story.

The contractual relationships are going to point right at more risk-taking on the part of providers or more engagement by the payers in terms of supporting these new models. The expectation of what I can bring is a different dialog based on my knowledge in the provider sector. Hopefully I can promote the kind of transformation that is necessary to better align those two interests.

HLM: What message does your hiring send to the healthcare industry?

JS: Regardless of the sector, it is all about leadership and the willingness to promote innovative approaches to the transformations that are necessary. The message is pretty loud and clear that we've come upon a new era. And there are organizations that are willing to be bold, and leadership is going to have to transform itself to adapt to this new era, regardless of whether you are a provider or a payer. It truly is a new ball game.

HLM: What are the different challenges posed with running a health system versus running a health insurance company, or are those differences blurring in this new age of integrated care?

JS: The differences are predictable; the metrics, the language, the expectations especially in an investor-owned area that I have taken responsibility for. That in many respects is a significant challenge.

But at its core we have a lot of leaders in both sectors who are very adept at moving with the marketplace. Even at Trinity we hired many people who were 'not traditional' as we were aggressively pursuing the hiring of actual talent. That certainly is a different approach from what we were accustomed to but it does lead to understanding the metrics of our industry, which I think will look radically different in the coming years than traditionally.

On the payer side there are new talents being recruited that better align with the new demands for new technologies and analytics. At its core it is all about leadership... The strength of the leadership is paramount to addressing transformation change. In that regard I don't think we are any different.

HLM: Do you have a specific agenda in mind for your first few months at WellPoint?

JS: It's getting aligned with the team that is in place, getting my bearings regarding the strategic plans that have already been formulated, possibly amending those plans based on a thorough review of what had previously been created, engaging with the marketplace.

Obviously, I have a newfound responsibility to deal with the investment community and the analysts that support our organization. Also, broadly speaking, throughout the United States we have a very significant reach.

One-out-of-nine Americans is insured by WellPoint so we are a far-flung organization. I am going to get to know a lot of people in a lot of markets and try to figure out how best to reintegrate our activities as timely as possible so we can be more efficient and effective.

HLM: It's been suggested that WellPoint is having problems adapting to the tremendous changes in the healthcare market place. Can you provide the push that gets things moving?

JS: It would be presumptuous of me to weigh in on that because I don't know the organization well enough to pass judgment. All payers are looking for the strengths that are necessary to effectively compete and provide better services to their members.

WellPoint is not different. The degree to which they are either ahead or behind I will leave to others to decide. My objective is to assess strategy and recast it if necessary, strengthen it in ways that are necessary, and work with the team to move forward. I like our chances based on what I've seen.

I consider it a very strong organization with a strong foundation that is in a transitional era just like everybody else. The questions are, what are we going to do to reposition ourselves and most importantly can we effectively execute? Beyond that, everything else will fall into place just fine it we can do well on both of those accounts.

HLM: How do you expect to spend your remaining time at Trinity Health?

JS: The good news is there is an incredibly gifted and strong team at Trinity that will carry the responsibilities to new levels of performance. They are very accustomed to achieving. That is a great blessing for the organization that's been formed over many years and one that I am very proud of.

The second point is that I have a lot of hand-offs to administer to new leadership that will come on board and to help support the team in the migration to a new leadership structure. In that regard I have a significant contribution in the governance and management transitions.

I will do what I can regarding some of the recent accomplishments, specifically the consolidation with Catholic Health East. It is of significant importance to me because I have such a command of the process and the transition we envisioned taking place.

There are a lot of moving parts but I'll say it again—it is all about leadership and Trinity has a tremendous leadership team that will carry forward without any hiccups.

HLM: What do you regard as your greatest accomplishments at Trinity?

JS: The organization created a lot of remarkable achievements around its commitment to becoming high performing in both the financial and clinical arenas. Financially it is one of the strongest health systems in the United States. It is recognized by its bond rating, AA, and its year-over-year performance in terms of profitability and cost performance.

Clinically it is a remarkable organization in terms of the pursuit of excellence and promoting quality and safety. The statistics will bear out that it is a safer, higher quality organization than when I arrived eight years ago because of the focus on metrics, the focus on our IT transformation and having unified medical records throughout our organization.

Our integration measures to a large extent have been met. We are taking that to a higher ground as we speak. But obviously we are able to do so because of the foundation that was laid over many years that allowed us to be more unified in our clinical and financial performance.

Finally, the growth of the organization is a remarkable achievement such as our consolidation effort with CHE, our acquisition of other organizations, the entrance into the Chicago marketplace through Loyola University Medical Center and Mercy South in a market where we were not previously engaged. So, those are just a few.

Primary care providers and other clinicians have long recognized the importance of home-based healthcare services as a cost-effective and proactive means of monitoring vulnerable patients to keep them healthy and out of the hospital.

Unfortunately, home health nursing uses a strict and narrow set of eligibility guidelines that often disqualify many people who could otherwise benefit from those services.

With that in mind Minnesota has become a national leader in a movement to create and use certified "community paramedics" to monitor and provide non-emergent care for patients in their homes.

Barb Andrews, RN, a veteran EMT, was one of the first providers in her area to achieve certification as a community paramedic. She now serves as the manager of the Urgency Center & Community Paramedic Program at North Memorial Clinic in the Twin Cities suburb of Robbinsdale, MN.

"Our healthcare structure is broken and people are falling through the cracks every day. We need to figure out who we can use to catch these people as they are falling," Andrews tells HealthLeaders Media. "Because regulations and the expense of home health nurses make it difficult to get people the services they need community paramedics offer extensive background experience and abilities at a fraction of the cost of a nurse."

North Memorial's community paramedic program has been operational since Oct. 15, 2012, with nine certified EMT/CPs on staff and five more EMT/CPs trainees prepping for certification in May. The hospital operates the program for eight hours a day, seven days a week. Each EMT/CP continues to serve primarily in the traditional role on emergency calls in the ambulance. But for one shift a week they change uniforms and drive their own cars to visit patients as CPs.

Because the program has no funding and can't bill for the services, it is limited to patients of North Memorial Clinic primary care physicians. "If we tried to see everybody the amount of requests would be astronomical. There are a lot of people interested in it," Andrew says. "We do not put restrictions on insurance or age. We don't want to duplicate services, so if they are eligible for home health nurses then we wouldn't go."

So far, Andrews says the typical patients "seem to be a lot of elderly people who don't have good family or social support."

"They aren't eating very well and they get confused about their medications," she says. "We set up their medications a week at a time so that they know for sure what to take and when to take it. We have helped people get set up with Meals on Wheels to make sure they're getting food delivered. Technically, if they are not homebound, that is what makes them ineligible for home healthcare. But we can draw the blood anyhow so they don't have to scramble to get to the clinic."

The CPs will spend from 30 minutes to two hours in each home discussing a variety of care concerns. Andrews says one patient receives a call from CPs every morning reminding her to take her meds before breakfast. "It's tailored to each individual patient, which is what I think is so neat about it," she says. "We don't try to fit the patient into a template of care. You set up what works around the patient."

To become certified by the state of Minnesota, community paramedics must have at least two years of experience as an EMT, and provide a letter of recommendation from a medical director. They must also go through more than 300 hours of training in the classroom and in clinical settings, where they learn how to assess patients in their homes and guide them to available services within the community.

The time spent in patients' homes can prove invaluable to providers because they're able to better assess the health challenges their patients confront beyond clinic walls.

"When the patient comes into the doctor's office you get a picture, but you can present anything you want in a picture," Andrews says. "When you go to the home you can't stage that. You are going to see things the way they really are. We learn a lot more about community assessment and how to hook people up with the available services in the community and turn the focus away from emergent care and toward managing long term chronic care and identifying people's needs in their homes. Even beyond their medical needs: do they need help getting their driveway shoveled? Do they need a ride to the grocery store?" 

"With some patients, the doctors will send us out just to check on their living situation. There doesn't have to be a specific need. Every patient is just as different in the clinic as they are in their homes so there isn't a template to follow because everybody has different needs."

Because the program is only about five-months old, Andrews says it's still too early to determine its cost-effectiveness. "We are absorbing the cost of the program but hopefully gaining in that we are keeping people out of the hospital," she says.

"We are keeping our patients in a better state of overall health and well being. But that is why we haven't extended it beyond the North Memorial community, because it can get expensive very quickly. We are all for helping people, but we have to keep our own boat afloat as well."

Minnesota officials are now crafting a framework for a fee schedule that will allow providers to bill for community paramedic services. Rather than looking at the program as "a pure source of revenue generation," however, Andrews says it's more likely that the value will come from the money saved by providing proactive, non-emergent care in the least-expensive environment—the home.

"If we can keep people healthier and prevent them from utilizing extra sources that saves money and keeps the patient healthier—which is really the ultimate goal."

For every dollar spent investigating Medicare fraud and abuse in the last three years the federal government recovered $7.90. That return on investment is the highest three-year average in the 16-year history of the Health Care Fraud and Abuse Program, federal officials announced on Monday.

"Our historic effort to take on the criminals who steal from Medicare and Medicaid is paying off: We are gaining the upper hand in our fight against healthcare fraud," Health and Human Services Secretary Kathleen Sebelius said in prepared remarks.

"This fight against fraud strengthens the integrity of our healthcare programs and helps us fulfill our commitment to our seniors."

The HCFAC—a joint initiative of the Department of Justice and HHS—in its annual report said that the government recovered $4.2 billion in fiscal 2012 and $4.1 billion in fiscal 2011.

Over the last four years federal officials have recovered $14.9 billion—up from $6.7 billion in the prior four year period—from drug companies, hospitals, physicians, healthcare executives, vendors and assorted scam artists. Since 1997 HCFAC has returned more than $23 billion to the Medicare Trust Funds.

Sebelius and U.S. Attorney General Eric Holder in a joint media release credited enhanced screenings and enrollment requirements, expanded recovery efforts for overpayments, increased data sharing among government agencies and greater oversight of private insurance abuses for the improved rates of recovery.

Sebelius and Holder also credited:

• The ongoing expansion of the coordinated Medicare Fraud Strike Force teams, which now operate in nine regions, including Medicare fraud hotbeds in Miami, Detroit, Houston, and Brooklyn. Using more advanced data analysis the teams can now fly red flags on irregular or suspiciously high-billing patterns that could signal fraudulent activity.  In May 2012, for example, the strike force arrested 107 people, including doctors and nurses, in seven cities who were charged in schemes involving about $452 million in bogus billings to Medicare. Strike force teams in nine cities worked investigations against 278 defendants who allegedly attempted to bilk Medicare of more than $1.5 billion.
• A new automated provider screening system that screened all 1.5 million Medicare-enrolled providers and flagged nearly 150,000 of them as ineligible or fraudulent.

On the civil front, Holder and Sebelius said the federal government recovered more than $3 billion in fiscal year 2012 under the False Claims Act, including price rigging by drug makers, illegal marketing of medical devices and drugs for uses not approved by the Food and Drug Administration, Medicare fraud by hospitals and other providers, and Stark Law anti-kickback violations.

In addition, the federal government collected nearly $1.5 billion in fines and forfeitures, and obtained 14 convictions under the Federal Food, Drug and Cosmetic Act.

One in five flu patients exhales so much more of the airborne virus than other flu patients, that researchers are asking whether these "super emitters" pose a greater likelihood of transmitting  the virus to the people near them.

Werner Bischoff, MD, assistant professor of infectious diseases at Wake Forest Baptist Medical Center in Winston-Salem, NC, and lead author of a study published in the Jan. 31 online edition of The Journal of Infectious Disease, told HealthLeaders Media that more research is needed before he can determine the potential threat that super emitters may present to healthcare providers.  

"It's too early at this stage to offer any broad recommendations to healthcare providers or caregivers overall," Bischoff says. "The study looked at the release of the influenza virus. We did not look at the transmission patterns. We need to take a further step to find out how influenza is transmitted and what we can do to prevent it."

The study examined 94 patients at Wake Forest Baptist who were screened for influenza symptoms during the 2010-2011 flu season. Nasal swabs were taken, and air samples were obtained from within one foot, three feet and six feet of patients during routine care.

Of the 94 patients, 61 tested positive for the flu virus and 26 released influenza into the air. Five of the patients emitted up to 32 times more virus than the others. Those patients also reported a greater severity of illness.

Bischoff says researchers could not find a way to proactively identify the super emitters. "We collected a lot of data from these individuals and we looked into that, but it was a pilot study so we had a very limited amount of participants," he says.

"So, we tested pretty much everything that we collected from them: from vaccinations to other medical conditions they may have had to age-related factors. Nothing could be matched, but that doesn't mean there couldn't be a link between some of these factors and the super emitters' status by itself. Next would be to look at that in a larger study overcoming the limitation of the pilot study."

"If we can identify them we can implement some preventive measures, be it face masks or anything else we can come up with to protect any caregivers that come into close contact with them."

It is generally believed that the flu virus spreads mostly through large particles emitted within three to six feet of the infected person. As a result, existing infection-control efforts for bedside providers have required the use of fitted respirators during bronchoscopies, intubations, cardiopulmonary resuscitation, and other aerosol-generating procedures.

However, Bischoff says that most of the influenza virus in air samples collected for the study was found in small particles during routine care up to six feet from the patient's head. Those small particles float in the air for hours and can travel relatively long distances, and can more easily penetrate non-fitted protective masks.

"Everybody emitted the virus up to six feet from the patient's bed. It was pretty much at the end of the patient bed when you stood in front of it," Bischoff says.