The CEO of Presbyterian Healthcare Services is putting into practice what he's learned from having held multiple senior executive positions in his 17 years at the integrated health system.
He wanted the job badly. But it was far from a given that he would get it.
Despite his 17 years at the organization in diverse senior leadership positions of increasingly higher levels of responsibility, the board at the 108-year-old health system conducted a national search using a major executive search firm.
Even after he was named interim president and CEO following James Hinton's departure to Baylor Scott & White Health, Maxwell says he was "on pins and needles" while waiting for the search to conclude.
On another level, he didn't mind the wait. "It was important to me to know that, if I was offered [the position], the offer came in the context of being the best candidate," he says.
Now that "interim" has been removed from his title, Maxwell plans to build on Presbyterian's record as one of the more advanced integrated delivery systems in the country—especially its health plan operations. He recently spoke with HealthLeaders about how his team will execute that plan. Following is a lightly edited transcript of that conversation.
HealthLeaders: What are your top priorities?
Maxwell: We have the right business model, the right strategy, and we're starting from a position of strength. That said, we've landed on three areas of focus.
First, we continue to develop our people and give them the tools and skill sets they need to thrive in this changing environment.
Second is around our product, and that means improving experience for patients and members and their health outcomes. We'll continue to work on improving those results and eliminating variation.
Lastly, we'll focus on growth. In New Mexico, we have just over two million in population, so growth within the state is somewhat limited. But growth as an organization is important.
We're a little over a $3 billion system [revenue], but in today's world, that's not enough to take advantage of our back office infrastructure and scale. Some growth will come from the opening of a new Santa Fe medical center in 2018, but more of it will come from expansion of our health plan to providers outside the state.
HealthLeaders: How will that work given the states' varying regulations that govern health plan behavior?
Maxwell: One of our key advantages is our experience and expertise in an integrated system that handles both the financing and delivery of healthcare. We have been doing it for 30 years. Right now, we're partnering with 11 systems in North Carolina to create a health plan that will bid on its Medicaid population.
We have not yet finalized a definitive agreement but we're close. We have also talked with other provider systems throughout the country on projects like this and continue to develop these types of relationships.
We don't want to be consultants, but our core competency is running the insurance component, and we know how to link an insurance company with a provider system to deliver care in very different ways.
HealthLeaders: Presbyterian built its reputation on value-based care. What would hospitals and health systems that aren't as integrated find surprising about competing on value?
Maxwell: When you have an integrated system where 65% to 70% of revenue is fixed on a per-member, per-month basis, you're less worried about the number of units you're pushing through and the revenue associated with each of those units and more concerned with where you're going to deliver the care and what is going to drive the highest level of quality at the most efficient cost.
That causes you to make different decisions in treating patients.
HealthLeaders: Can you share an example?
Maxwell: One is our ED. A few years ago, we implemented a patient navigation project. Patients enter and are triaged, and if the patient's condition is not at the level of acuity for an ED visit, we navigate that patient to a primary care setting and take care of the patient in the clinic rather than the hospital.
You're moving your revenue stream from an expensive ED to a less expensive physician office and also attaching that patient to a physician. In most cases with these patients, the ED is where they think they enter healthcare.
We're trying to change that behavior, but it's not going to happen on its own. With an integrated system, the incentive piece is right. If your revenues are fixed, you're more motivated to move it out to a different venue.
If instead you're more aligned with the idea that delivering more units equals more revenue, why would you move the volume? Our strategy and experience comes from being an integrated system. We think that's the right model, but truly what is different is you have to be able to take the risks and manage the patients in a completely different fashion.
HealthLeaders: What about growth in services outside the state?
Maxwell: At this point I don't see that as huge opportunity. We're believers in managing care and we can do that through our health plan partnerships. We don't have the capital resources to go outside of New Mexico [in services].
HealthLeaders: What advantages will you bring to this role, given that you've served in so many other senior leadership roles at Presbyterian?
Maxwell: I've been the CFO of the health plan as well as for the hospital and physician practice and then CFO for the entire system. I know how those components work separately, but more importantly, how they work together.
Also, I've had the opportunity to be chief operating officer for the physician practice for two years, which was a nice learning experience in getting into delivery of care options. The new roles for me will be the community involvement that's required of a CEO and becoming the public face of Presbyterian.
The success of a groundbreaking business partnership with Duke University Health System has led to another in Kentucky, and a founding employee who recently assumed the role of CDO expects more deals to come.
The joint venture between Duke University Health System and LifePoint Health started life as a bit of an odd duck. It combined the operational skills of a for-profit hospital company with the clinical skill and reputation of a top-shelf academic medical center.
Some imitators followed their lead, with mixed results. But Duke-LifePoint has thrived, with 10 hospitals under management, and some are far from the eastern South, where Duke's brand is most well-known.
Indeed, the creation the two organizations pioneered in 2011 may represent the acute care business model of the future, one that leverages the quality regimes of well-respected nonprofit health systems like Duke, combined with the operating expertise of a for-profit hospital operator like LifePoint.
The model will proliferate if Jeff Seraphine, LifePoint's chief development officer, has his way.
Seraphine was named to the post in February after serving 18 years at the company, which he joined as a founding employee. HealthLeaders spoke with him recently to discuss the new partnerships that have become possible, how the strategy differentiates the company, and how value-based principles and reimbursement are affecting acute healthcare. Following is a lightly edited transcript.
HealthLeaders: What are you most looking forward to in your new role?
Seraphine: I've been with LifePoint since 1999, starting as CEO of one of our first 20 hospitals. For the last six years I've served as a division and group leader, primarily with newly acquired hospitals, evaluating acquisition targets, and also with the Duke-LifePoint partnership.
We paused [acquisitions] last year as we absorbed a heavy acquisition load from 2015 and early 2016, so I'm excited to focus on building a robust pipeline so we can position ourselves as buyer of choice based on our ability to be a good partner and successfully drive quality.
HealthLeaders: How does the Duke partnership, and others since modeled on it, differentiate LifePoint?
Seraphine: What has made that partnership successful is that we came together on improving quality and established foundational trust before we bought a hospital together.
That aim has carried forward to 14 hospitals with almost $2 billion in annual revenue. There was a need for consolidation in North Carolina and the region.
Through the partnership, we were able to put together a unique value proposition that featured the best operational background like ours, with a strong focus on regional referral centers and community hospitals and team them up with a world-class academic medical center.
That resonated well in the market, but also outside the market.
HealthLeaders: So it led to additional partnerships with nonprofits. How did that begin?
Seraphine: Duke-LifePoint eventually extended beyond the original region into Michigan and Pennsylvania. Broadly, regional providers were taking a role in building out stronger networks.
Most of those occur with [organizations] already in the market, but occasionally that's not the best choice, especially for regional or rural referral centers that want to continue to be able to be tertiary hospitals and find that goal at risk in some of the regional network strategies.
Duke-LifePoint, or others like it, can be a unique value proposition for those types of hospitals. We also have a partnership with Norton Healthcare in Louisville.
Norton is highly regarded in the area, so it is a strong partner in that region. Since that partnership we've purchased two hospitals.
In addition to that, because we have become comfortable in our ability to operate in a partnership model, we have been willing to work with local hospitals to directly JV their local hospital and we do that in a way that allows them to maintain some ownership and participate in some governance.
HealthLeaders: Many experts see hospitals as a slow- or no-growth area in healthcare as more care moves outside its walls. How does the trend affect the company's strategy going forward?
Seraphine: One thing we're confident in is that well-capitalized, well-operated systems that have scale will be able to navigate through these difficult times when utilization is slow and we're getting a lot of risk in contracts.
Over time, being able to be a provider of choice for a sizable population and operate at scale that allows us to do things more efficiently than our peers will be a successful strategy.
As we forecast the future, we'll be successful if we're buying in a disciplined manner, and we're not paying for something inconsistent with where the market's going. We're essential in almost all our markets and we'll continue to grow out different service lines on an outpatient basis.
For smaller standalone hospitals, value-based payer relationships take significant resources and those are hard to come by in a soft-volume environment. Often they know the challenges, but it's difficult to invest in everything they need. We can help scale those solutions and build them out.
HealthLeaders: How does the drive to repeal and replace the PPACA affect your strategy?
Seraphine: Our assumptions are that there's not going to be an immediate change that's going to be overly disruptive. It's in everyone's best interest to find a slow transition, but it's also obvious there's not any near-term relief.
So that means there will continue to be a healthy pipeline of hospitals and health systems looking for different models. They will not be able to wait. We'll continue to be disciplined. We don't have to do anything in a certain time frame.
The HR department at Health First creates value by coaching senior leaders on identifying candidates with high potential and by raising retention rates.
Paula Just sees her health system's HR department's role as less of a traditional personnel operation and more of an in-house consulting agency, one that helps executives make the right hires by pinpointing their needs and taking mundane hiring practices off their worry list.
Just came to Health First, a four-hospital integrated delivery system in Rockledge, on Florida's Space Coast, three years ago from SSM Health in St. Louis.
She believes the HR team shouldn't just put new hires in front of training videos and get them to fill out the right paperwork.
Instead, the department should fill a key role in executive satisfaction by helping leaders more easily select the right hires by better defining roles, improving interviewing skills, and providing more time for evaluation of candidates.
"When we hire the wrong person, it creates enormous waste," she says. "There are lots of resources dedicated to onboarding, training, and administrative work that goes with bringing a new hire into the organization, and if they're here with us a short time, we ultimately lose that huge investment."
Looking for Value Creation
In charge of talent acquisition for almost every position besides physicians, Just and her team manage the onboarding process for every hire from pharmacists to housekeeping staff.
But the HR department creates value not in onboarding, but by helping senior leaders focus on the important elements of the open roles on their teams.
To improve the candidate and hiring leader experience, Health First brought in Cielo Healthcare, a vendor that applies technology and research to talent acquisition, resources a system the size of Health First couldn't develop in-house, says Just.
"As an integrated delivery network with 8,000 employees, that's not a resource we would have on our own," she says.
The vendor's resources allow Just and her team, at a high level, to help executives develop experience-based interview questions.
Hiring managers are coached—they know the work best—to better ascertain the likelihood of a candidate's success in a role.
It sounds simple, and is what every job interview should be tailored to ascertain, but it's often not how job interviews play out, says Just. Executives need training on how to hire effectively too—they don't come into management with that skill, necessarily. And they don't need to spend time reviewing resumes and setting up job interviews, either.
These changes in process have paid off in new hire satisfaction, which has improved from a baseline of 93% to 96%, and at least as significantly in manager satisfaction, which has improved from 69% to 97%.
"Prior to the partnership, our leaders really shouldered much of the burden of reviewing resumes, setting up the interviews and conducting them, and then we managed the onboarding," she says.
Now, a recruiter screens all resumes and each recruiter tailors how he or she interacts with the hiring manager. The effect should be that the better part of managers' time should now be spent evaluating candidates.
Another key measure of the new approach is 90-day retention, says Just.
"When we began, 90-day retention was at 86% and we have improved to 95%," she says. "That alone provided about $3 million in savings for us."
Realistic Job Previews
After a candidate has been identified as a likely fit by both their potential future manager and their potential peers (peer interviewing is required in the hiring process) the HR team goes a step further and arranges "realistic job previews," says Just—another safeguard against making a bad hire.
"The job preview lasts an hour or two, and the candidate is expected to shadow someone doing that job," says Just.
This type of investment of time in the front end of hiring pays benefits in some unexpected areas, says Just, for instance, in lowering the need for contingent labor.
Just and the HR team strive to schedule most staff shifts to care for patients and customers using their own full-time and part-time staff, with minimal use of overtime or traveler workers, in the case of nurses, she says.
"We have a number of things we've done to try to make sure we're improving our ability to use our core staff," she says.
Nursing Matters
It's no mystery that a shortage of nurses exists, and that shortage is felt acutely at Health First, because of its location about an hour east of Orlando, two hours south of Jacksonville and two hours north of Miami, large cities where nursing opportunities abound.
Health First created a number of ways to open up the nursing pipeline, including paid nursing internship programs for nursing students subsequent to their last year of training. That program has allowed Health First to extend offers to well-known new practice nurses earlier.
Previously, they wouldn't make a job offer without a license, "but at the majority of schools where we hired nurses, the board pass rate was so high that there was minimal risk in making the hire, and even if they don't pass, there's now a contingency plan so they can stay on as a nurse tech," says Just.
It's also partnered with the Health First Foundation to create incentives for its nurses to improve their education.
"There is a huge body of literature that supports that quality of care is improved when organizations have a higher percentage of BSN nurses," says Just.
To help improve that percentage, more than 80 scholarships have been provided to Health First nurses.
INNOVATION, STRATEGIC PARTNERSHIPS, COMMUNITY HOSPITALS
Through clinical research, strategic partnerships, early adoption of innovations and highly-specialized clinical programs, one Silicon Valley hospital is changing its role. Check out this live HealthLeaders Media webcast,Redefining What it Means to be a Community Hospital: Innovation at El Camino Hospitalon March 17.
Clinical integration between SSM Health's St. Anthony Hospital and Physicians Group and OU Medicine will continue.
A little more than four months after announcing that Oklahoma's University Hospitals Authority and Trust would buy out current partner HCA and then unite with St. Louis-based SSM Healthcare, those plans have been canceled.
On Monday, the parent of OU Medicine and SSM Health announced that the two organizations will no longer pursue a financial and governance union, but will leave in place plans to clinically integrate.
In a joint statement, neither UHAT nor SSM Health provided a reason for the failure of negotiations that would have completed the deal, only acknowledging that the parties mutually concluded the transaction could not be finalized.
Unions with private Catholic healthcare organizations and large public health organizations have often been scuttled by failure to reach agreement on reproductive issues.
SSM Health is also in the midst of a chief executive transition, with current president and CEO Bill Thompson set to retire in April, and new president and CEO Laura Kaiser set to begin her tenure in May.
The $750 million buyout of current JOA partner HCA by UHAT will continue, however, with the purchase of HCA's interest expected to close by summer of this year. HCA is the current manager and joint owner of OU Medical System hospitals and facilities, which include the flagship 680-bed OU Medical Center in Oklahoma City.
SSM Health, which has 20 hospitals and a Wisconsin health plan, owns and operates 601-bed St. Anthony hospital in Oklahoma City, Bone and Joint Hospital at St. Anthony, as well as St. Anthony Shawnee Hospital in Shawnee, OK.
SSM Health had been expected to take over day-to-day operations at all of OU's medical systems, hospitals and clinic buildings.
All three organizations remain optimistic about the benefits of clinical collaboration to enhance care coordination, share best practices, and, ultimately, improve patient care, according to the joint release.
Part of CHI St. Luke's growth strategy involves combining inpatient and outpatient services into a smaller, more scalable and less capital-intensive facility model: the micro-hospital.
Health systems used to depend on high-dollar inpatient care for growth. Not anymore.
With health plans and Medicare seeking to move care to lower-acuity, and thus lower-cost, sites, and with advances in technology adding to the practicality of moving procedures out of the hospital, the outpatient environment is poised for growth, while inpatient may stagnate.
CHI St. Luke'sHealth, a six-hospital health system in Houston, is like many health systems that responded to HealthLeaders' recently released annual Industry survey. It is looking outside the traditional hospital environment by adding physician practices and other outpatient sites of care.
But part of its growth strategy involves combining inpatient and outpatient services into a smaller, more scalable and less capital-intensive facility model, the micro-hospital.
CHI St. Luke's opened its first four-bed micro-hospital, Springwoods Village Hospital, in January 2016. David Argueta, its president, calls the facility an "innovative solution to get clinically appropriate high-quality care in a low-cost environment."
Speed to Market
Argueta, who is president of CHI's Woodlands-area facilities, which includes the micro-hospital as well as the 242-bed The Woodlands Hospital and 30-bed Lakeside Hospital, says he views micro-hospitals in general as one of the ways the health system is able to grow access points in a thoughtful manner.
"It really brings value-added services together in a more cost-effective manner than a big hospital or individual clinics," he says.
What also made this micro-hospital a particularly attractive opportunity is that it allowed CHI St. Luke's to negotiate an exclusive deal within the master planned community of Springwoods, in suburban Houston, 10 miles away from The Woodlands Hospital.
"We had an opportunity that a lot of people don't, which is to grow with the community," says Argueta, who adds that the hospital is scalable. The micro-hospital features four inpatient beds, 10 ED bays, four operating suites, two endoscopy suites, imaging, labs, and pharmacy and dietary departments.
'Scaled Appropriately'
It has everything a hospital has, it's just scaled appropriately, says Kevin Harney, a principal and architect with Earl Swensson Associates, the Nashville-based architecture firm that designed Springwoods Village Hospital.
"Some owners see this concept as a way to establish their brand and identity within a community and have even planned these micro-hospitals for growth to become a larger tertiary hospital," he says.
Earl Swensson Associates sees the niche as a growth opportunity as well. Springwoods Village is its first such facility, but Harney says the niche will grow, and the firm has several other such facilities in various stages of design.
According to The Advisory Board, most micro-hospitals are between 15,000 and 50,000 square feet average eight to 10 inpatient beds and are usually within 18-20 miles of a major hospital. In that sense, Springwoods Village is smaller than most and closer to a main hospital than many.
"We chose four beds," says Argueta. "I've seen some with more, but unless you have a real need to hold patients over for observation, you really don't need more than that."
"Micro hospitals, sometimes called an 'emergency hospital,' become, in essence, a matter of creating accessible, convenient care," says Harney.
Establishing a Presenceand Raising All Boats
In theory, a micro hospital establishes a presence in a growing market, capturing market share for a larger hospital system. Patient stays in these facilities are short, usually 24 to 48 hours, and patients who need longer lengths of stay or more specialized care can be transferred to a larger hospital within the system.
"A lot of the patients we see are outpatient surgical-type patients who may come through the ER and we may need to hold them overnight for surgery in the morning," says Argueta. "If they need higher level care, we're 10 miles away from the Woodlands Hospital."
CHI St. Luke's is bringing another micro-hospital online over the course of this year. That facility was received as part of an acquisition, and two others are in various states of planning.
Executive leaders serve across the local campuses as does Argueta.
"Springwoods Village complements the services we offer at our larger hospitals," he says, adding that the service area is experiencing annual growth of around 14% in surgeries and imaging, and the Springwoods Village option has helped eliminate wait times in imaging, and has allowed more time for surgeries.
"It's raised all boats for our North Houston campus," says Argueta. "Twenty-five years ago we were three access points in north Houston. Now we're at over 40 access points: 37 clinics and three hospitals."
INNOVATION, STRATEGIC PARTNERSHIPS, COMMUNITY HOSPITALS
Through clinical research, strategic partnerships, early adoption of innovations and highly-specialized clinical programs, one Silicon Valley hospital is changing its role. Check out this live HealthLeaders Media webcast, Redefining What it Means to be a Community Hospital: Innovation at El Camino Hospitalon March 17.
While repealing the ACA only requires 50 votes in the Senate, replacement requires 60. With little cross-aisle cooperation expected, the administration will need to scale down its ambitions, healthcare leaders say.
Repeal and repair may be all the president and Congressional Republicans can hope for in dealing with the ACA in the immediate future.
That's the message from Rick Pollack, president of the American Hospital Association, and Marilyn Tavenner, the president of America's Health Insurance Plans, at a Nashville Health Care Council event Thursday.
In a moderated discussion, Pollack and Tavenner dished on the political realities facing the administration's attempt to repeal and replace the Affordable Care Act, the state of the individual health insurance marketplaces and the bleak reality of how tough it is to get things done in Washington.
Their consensus: With so much up in the air, uncertainty is the watchword.
Despite the president's executive order to take regulatory actions to dismantle parts of the ACA, which does not depend on Congress, there's no consensus evident yet. And there may not be before the House hopes to wrap up legislation by the next recess, which begins March 19, Pollack said.
Maintaining coverage for the more than 20 million people who have received it under the ACA seems to be the big stumbling block for immediate action. Plans that are still in committee haven't been scored by the Congressional Budget Office. It's a big stumbling block for their constituencies as well, said both Pollack and Tavenner.
"There's nothing more important from our perspective than maintaining coverage for the 22 million people who have received it," Pollack said.
For those people, Congress may have to "repair" the ACA by extending subsidies short term.
"Close to 70% of individuals on the exchanges rely on those subsidies," said Tavenner, who was administrator of CMS under President Obama from late 2011 to early 2015. "These people cannot afford premiums without help."
She said Congress must resolve this issue by April, when health plans set price for policies to be sold 18 months hence.
"So we have to know about this year and 2018/2019 at a minimum," she says, which means the earliest any replacement might debut would be 2020.
Another priority of the administration and the Republican-dominated Congress is reforming Medicaid, possibly by providing block grants to states, allowing them broad discretion on how best to spend the funding.
The Case Against Block Grants
Pollack said that if the idea is to provide some level of flexibility to states, the federal waiver process might be a more workable idea than block grants.
"What is the accountability to spend [block grants] on healthcare? He asked. "It's all very unclear. But fundamental is if we're going to use block grants and per-capita caps to cut a program that's already seriously underfunded, it's not a productive discussion."
Tavenner agreed that state flexibility would be an improvement for Medicaid, and "all of us would support getting bureaucracy out of the way, but the president has been clear that his intention is to keep people covered. That means those states that have expanded will have to have a process to keep those people so they're not kicked off the rolls. Block grants make that more difficult."
Both also said doing block grants would be difficult or impossible under reconciliation rules.
Slow Progress Ahead
Tavenner expressed regret that the ACA as a whole is being tarnished when many problems that are most evident are in the individual market, meaning the public exchanges.
She cited the stability of the Medicare Advantage program, which close to one third of Medicare beneficiaries have now chosen. And despite high costs, the employer-sponsored market, which covers 150 million people, is stable as well, and about 75% of Medicaid is now administered through managed care plans.
"So what we're really talking about is the individual market," she said. "Put the rest aside and deal with the actual problem. The immediate problem it's never been stable and there are about 20 million people in that market."
She and Pollack predicted that little will have changed in six months, despite the GOP's promises of repeal and replace.
"We'll still be having this discussion six months from now," Tavenner said. Meanwhile, she added, Republicans will probably repeal the individual mandate, and will probably move to allow insurance to be sold across state lines.
"Politically, there will be an effort to pass something they can claim to call repeal," says the AHA's Pollack. "To do replace, you need 60 [votes]. Will Democrats engage?"
Two leaders of early-mover clinically integrated networks discuss how they started, grew, and fine-tuned their organizations.
Creating a clinically integrated network is like beginning a long journey, the length and destination of which is uncertain.
Improving care and reducing costs are the goals, but getting multiple organizations and dozens or hundreds of caregivers to pull together in the same direction depends on openness to evidence-based care protocols and technological (data) capability.
What also helps: A generous dollop of experience in motivating clinicians, especially physicians, to buy into the vision that improved patient care and lower costs are inextricably linked.
Joe Vasile, MD, and Mark Shields, MD, have more experience building CINs than most. Shields, the former senior medical director for Chicago's Advocate Physician Partners, remembers defining the term in the late 2000s as the parent organization geared up efforts to build what has become a 5,000-physician network. Shields left Advocate in 2012 and is now an adviser for Navigant Healthcare.
Vasile, CEO of the Greater Rochester (NY) Independent Physicians Alliance (GRIPA), was instrumental in creating a CIN with 1,300 physicians—half owned by the physician members and half by Rochester Regional Health.
Both physicians say building a CIN that improves quality and cuts costs requires diligence to at least four success factors.
1. Specific (and Limited) Metrics
The physician leaders involved in helping Shields set up APP's structure came to agreement over measurements of quality, cost of care, overtime, and efficiency. Put simply, the organization's ability to move those metrics would not only prove to purchasers that the organization was having an impact, but would prove the same to the organization's physician members, some of whom were skeptical at first.
Those in the early stages of setting up a CIN should focus on a few metrics, such as readmissions, length of stay and a few others, that will drive near immediate quality and savings results.
"At the earliest stage at Advocate, we had about 25 metrics," Shields says. "After a decade, there are 140 going across all specialties."
He says the goal is not to drown physicians in measurement and rankings, but instead to get them to focus on changing processes that affect a few metrics negatively. Vasile credits "actionable user reports" that help physicians and other caregivers address individual problem areas.
"That's when we began not to talk about integrity of the data and instead about how we're actually going to move the scores," he says.
2. Teamwork and Culture
Shields calls clinician culture the critical component to success, defining it as the ability to work together across specialties in conjunction with the hospital to drive quality and patient safety.
"You're working with them to help paint the picture of a rapidly changing environment and the implications for physicians," he says. "That's a big communication issue because it's difficult for them to step back and think two to five years ahead."
Vasile remembers a lot of dinner meetings with physicians explaining the goals and objectives of the CIN. Measuring their buy-in was critical. The best way to do that at GRIPA, he says, is through its clinician portal, which monitors whether physicians are logging in to access the tools. At this point, compliance is close to 100%. Vasile also says an "outspoken" medical director visits their offices and seeks feedback on compliance or lack thereof.
At the primary care level, GRIPA makes quality scores transparent among physicians, and identifiable by name.
"When you have that engagement, physicians are eager to hold themselves accountable," says Vasile.
Shields remembers monitoring clinicians' use of registries and other elements in the portal as a key early indicator of participation.
Every quarter there was a report card on the specific metrics of the specialties and early interventions were arranged with "folks that were lagging," he says.
Another positive influence on culture can come from including as many physicians as possible in governance from the board to the committee level, says Shields.
"My timetable, which I thought was aggressive, happened much quicker than I expected because the physicians started to ask why we were waiting," he says.
3. Compliance with Data and Labor-saving Tools
Compliance with the use of data and technology tools helps clinicians keep a close eye not only on the high-risk patients who represent so much cost in healthcare, but also helps monitor the so-called rising risk population, where earlier intervention can prevent future costs.
Tools in GRIPA's health information exchange, Vasile says, make early interventions easier to identify and effect. "We pick up many who have pulmonary disease, diabetes, and hypertension," he says. Care management is centralized, but each physician has his or her own care manager.
Shields agrees that embedding care managers in the practice facilitates conversation and action between patient or family member and the practice.
4. Selecting and Narrowing the Post-acute Network
Getting the post-acute network right is particularly important for the Medicare population, says Shields.
Selecting which entities you want to work with based on data can be difficult, but performance data, as well as data on length of stay and readmissions, is available from Medicare.
"Health systems are often surprised that [skilled nursing facilities] are interested in partnership, but they shouldn't be because they are a key source of referrals," says Shields. "You can be fairly selective on who will be your preferred partners."
GRIPA, for instance, is tightening compliance and hard-wiring proper care transitions as a way to continuously evaluate its preferred network. The CIN will soon narrow its list of 60 skilled nursing facilities to about 25.
"This drive to integrate physicians to drive quality and cost effectiveness is not going away," says Shields. "There may be some tweaking of insurance products, but whether commercial, Medicare, or Medicaid, they're all driven to increase quality and cost effectiveness, and this process will accelerate."
Genetic / Personalized Medicine The opportunities are vast for healthcare providers to incorporate genetic medicine into their offerings, but so too are the challenges. View this live HealthLeaders Media webcast, Getting Involved in Genetic Medicine with Cleveland Clinic, on February 27 and learn how Cleveland Clinic addresses the logistical, medical, and ethical complexities of this expanding field.
Laura Kaiser has served as COO at Intermountain Healthcare for five years. She will start at SSM Health in May.
St. Louis-based SSM Health has named Intermountain Healthcare Chief Operating Officer Laura Kaiser as its next president and CEO.
A Missouri native, Kaiser has served as second in command at Intermountain for five years. She will start in May at SSM Health.
She was named following a nationwide search to pick a successor to current President and CEO Bill Thompson, who announced his retirement in 2016. Thompson, who has served as president and CEO at the nonprofit since August 2011, will retire at the end of April after 37 years of service with the company.
In naming Kaiser as the next leader of the Catholic, not-for-profit health system with a 20-hospital health system and 60 outpatient care sites in four states, the SSM board noted her more than 30 years' experience in improving clinical quality while also improving operational performance and growth.
"Ms. Kaiser is a gifted and visionary leader with a proven track record of achieving extraordinary results," said David Cosby, chair of SSM Health's board of directors, in a media statement.
"We believe she is the right leader to help lead our organization into the future, while ensuring the strength of our mission and providing our patients and customers with the exceptional care and service they have come to expect from SSM Health."
Kaiser's Priorities
Facilitating complementary integration among the health system's varied businesses will be among Kaiser's top priorities. In addition to its hospitals and outpatient care sites, SSM operates a pharmacy benefit company, an insurance company, a technology company, and two accountable care organizations.
Intermountain is similar in size to SSM. It is considered one of the more integrated health systems in the country, with a health plan, dozens of outpatient and primary care sites, and clinics and 22 hospitals.
Kaiser will also guide SSM's transition to a value-based model of care.
"It is an honor and a privilege to join the wonderful SSM Health caregiver team and to lead this extraordinary faith-based healthcare system with an international reputation for quality," she said.
Prior to her time at Intermountain, Kaiser spent 15 years at Ascension Health, where she was ministry market leader of the Gulf Coast/Florida region.
Tom Price, President Trump's pick to lead the U.S. Department of Human Services, is the first physician to hold the office since the 1990s. He has vowed to take down Obamacare.
Healthcare industry groups hailed and hammered Rep. Tom Price, (R-GA) MD Friday after his appointment as secretary of the U.S. Department of Health and Human Services was approved 52-47 by the Senate.
Price is the first physician to lead HHS since President George H. W. Bush appointed Louis Sullivan, MD. Sullivan served from 1989 to 1993.
Opposition to the nominee centered on his opposition to and determination to weaken the Patient Protection and Affordable Care Act. Another focus of the confirmation hearings was the orthopedic surgeon's stock trades while he was a member of the House.
Reactions from industry associations and groups ran the gamut.
The Healthcare Leadership Council, a coalition of chief executives from across healthcare, including health services giant Baylor Scott & White Healthcare and Walgreens to the device and implant manufacturer Stryker, praised Price's confirmation.
"We view this as a vote for patients and for strengthening our nation's healthcare system," said HLC President Mary R. Grealy. "Dr. Price brings to HHS the healthcare insights of a practicing physician and the policy knowledge he demonstrated as House Budget Committee chairman. These are assets that will enable him to begin work immediately enhancing the quality and accessibility of care for all Americans."
Frederick A. Boop, MD, the association's president, said in a statement that "as a practicing physician, [Price] understands all aspects of the healthcare system, which is essential to run HHS effectively."
Other organizations bemoaned his confirmation, however.
Physicians for a National Health Program President Carol Paris, MD, called his appointment a "body blow to the health and welfare of all Americans," adding that Price's vision for reforming healthcare would result in millions of Americans losing their existing health insurance coverage, and millions more "having to make do with bare-bones policies that offer little to no meaningful protection." She also said he could be expected to "undermine" Medicare, Medicaid and safety net hospitals.
The Center for Medicare Advocacy, a Connecticut-based nonprofit that provides resources and legal help to Medicare beneficiaries and their advocates, warned that Price could be counted on to help House Speaker Paul Ryan (R-WI) privatize Medicare.
"It would be tragic if renewed efforts to privatize Medicare succeed in returning the health of older and disabled people to the profit-driven insurance industry," CMA said in a prepared statement.
Other organizations were simply congratulatory, accepting Price's confirmation and attempting to move forward.
Such was the tone of a statement from America's Health Insurance Plans, the industry association for commercial health insurance companies. AHIP's president, Marilyn Tavenner, was the administrator of the Centers for Medicare & Medicaid Services during the second Obama administration.
"AHIP congratulates Dr. Price on his confirmation. We look forward to working with him and his staff to develop and implement consumer-focused, private-sector solutions that will make health care more affordable and accessible for every American," she said.
America's Essential Hospitals, a 275-member association of nonprofit hospitals—many of them safety net hospitals, congratulated Price on his confirmation, despite the threat his efforts may pose to its members under an ACA repeal.
"Secretary Price has an extensive clinical, administrative, and academic background in healthcare and long experience as a legislator," reads the organization's statement.
"He was shaped in part by his earlier work caring for low-income and other vulnerable people at an essential hospital—institutions that fill a safety-net role, provide lifesaving services to all, and drive economic activity throughout communities."
Price was formerly director of orthopedics at Grady Memorial Hospital in Atlanta, that city's safety net facility.
AEH said it looked forward to working with him and the administration to "ensure essential hospitals can sustain their commitment to disadvantaged people and underserved communities."
Price took the oath of office Friday morning, administered by Vice President Mike Pence.
Essential facilities could lose $40.5 billion between 2018 and 2026 if the Affordable Care Act is repealed without a 'comparable' alternative, says America's Essential Hospitals.
Repealing and replacing the seven-year-old Affordable Care Act could create a ripple effect with devastating consequences for safety net hospitals.
These facilities will suffer financially to the tune of $40.5 billion from 2018–2026 if the law is repealed and Congress fails to quickly pass a "comparable" alternative, according to an analysis by America's Essential Hospitals.
If Congress repeals the ACA without enacting a comparable replacement, the analysis predicted, safety net hospitals would face:
Coverage losses amounting to $6.1 billion
Medicare cuts reaching $10.7 billion
Cuts to Medicaid Disproportionate Share Hospital programs totaling $23.7 billion.
The 275-member association of nonprofit hospitals asserts that even if Republicans submit legislation that is similar to their December 2015 attempt to repeal the law, member hospitals—many of which serve as the safety net hospital or health system in their city or region—would lose $16.8 billion over the same period.
Although the 2015 Obamacare repeal plan would have restored cuts to the DSH, the 2015 plan's proposed coverage losses would still have left these hospitals significantly worse off.
'Unsustainable Losses'
"These numbers really show what's at stake for the patients who depend on the doors being open at essential hospitals," said Bruce Siegel, MD, MPH, president and CEO of America's Essential Hospitals, in a media release.
"These are unsustainable losses that would jeopardize vital services and access to care in communities across the country."
Many of the association's members operate on zero margin already, and that they provide about 20% of the uncompensated care nationwide, Siegel said.
Anything less than a comprehensive replacement immediately upon a repeal of the ACA would put members in severe financial difficulty, he said.
The association's policy brief advises legislators and policymakers to adhere to the following:
Policymakers must pair any repeal of the ACA with a simultaneous, comprehensive replacement.
If policymakers repeal the ACA without an immediate replacement, they must also repeal the act's steep cuts to hospital payments.
In any scenario, coverage must be maintained during the transition to a replacement plan.
If Congress has neither replaced the ACA nor restored the hospital cuts by the October 1, 2017, start of fiscal year 2018, it must delay for two years the Medicaid DSH cuts scheduled to start in FY 2018, according to the brief.