Executives discuss future of health care at roundtable

WASHINGTON — From electronic health records to population health management to the threat of Ebola, the future of health care was the topic of an executive roundtable discussion at the 2014 Hospital of Tomorrow Forum, presented by U.S. News & World Report.

Moderated by Brad Kimler, executive vice president of Fidelity Investments, the roundtable included Carl S. Armato, president and CEO of Novant Health, Gary S. Kaplan, MD, chairman and CEO of Virginia Mason Health System, and Elizabeth G. Nabel, MD, president of Brigham and Women’s Hospital. In the discussion, titled “Navigating a New Era in Healthcare,” the discussants highlighted what has worked for their systems, what has not, and what they are doing to ensure a healthy and viable future.

Brad Kilmer: We’re at the Hospital of Tomorrow conference, but everyone has a day job, and that’s the hospital of today. I thought I’d break the questions up about some of the more sticky situations you face during the day, and then go beyond.
So, when we talk about the Affordable Care Act (ACA), we often talk about health care reform, but let’s talk about the fundamentals. What do you see with the flow of uninsured patient volume: better or worse? Give us the state of the state.

Carl S. Armato: We have seen probably a neutral to slightly positive impact. Of course, we operate in four states — North Carolina, South Carolina, Georgia and Virginia — that have not expanded Medicaid, but what I will tell you is that the ACA has sparked an energy of innovation throughout the health care system, of us transforming the model in itself. As far as new patients with insurance, we have not seen as much as we anticipated.

Gary S. Kaplan, MD: We’re quite the contrast. Washington state has certainly expanded Medicaid; we’ve had a relatively successful launch of our exchange. We enrolled over a million people using the exchange, and have expanded Medicaid significantly at Virginia Mason. We’ve seen our charity care actually cut in half in 2014, compared to 2013, and we have seen significant increases in the Medicaid population. That’s a good thing because we think some of those new patients are now on Medicaid, so in addition to getting reimbursed for these services, they’re now part of the health care delivery system, which is even more important. They’re able to get care management resources, as well as many of the things we know contribute to our health standing relative to other countries. So I see the beginnings of progress on this front.

Elizabeth G. Nabel, MD: In Massachusetts, we’ve had a very interesting experience. As many of you know, we have had a state form of the ACA since 2006, and so we expanded very quickly into state-run exchanges. We already had a pretty high level of commercially paid individuals in the state to begin with; plus, we had a very strong charity care system because we have so many academic medical centers in Massachusetts. So, about 4 years into our version of the ACA, we had a state exchange that was working very well, and we thought we had probably 97% to 98% of the citizens of Massachusetts who had an insurance policy, which is great. So we expanded access. We then encountered real challenges around utilization and cost, and that’s pushed us very dramatically into a payment reform situation right now. What’s interesting is when the federal ACA came into effect in January of 2014, we had to shut down our state exchanges because it wasn't compatible with the federal rate. We relied on the federal contractor to set up our state exchange, and that actually set us back.

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Kimler: One of the things that Medicare and Medicaid are focused on is the meaningful use of EHR. Do you have anecdotes on how to make them meaningful?

Kaplan: I think ‘meaningful’ is a key word here, and I think we’re running the risk of automating bad information and bad processes. What we’re focused on at Virginia Mason is redesigning our processes and then automating them, because otherwise, we’re just going to move garbage at the speed of light, and that’s not going to do anyone any good. So we’re really focused on detailed workflows, and how to use our EHR to facilitate and improve our processes.

Armato: At Novant Health, we’ve actually designed our EHR with the patient in mind, to ensure that the patient will interact with the system. Yes, it’s needed for our providers and physicians, but we really designed it so that our patients would utilize the information. I’m proud to say that in a short period of time, we already have over 400,000 patients who are already actively engaging with us through e-visits, video visits and web-based scheduling. We’re encouraging them to read their lab tests, access the information that’s out there, and really take ownership of their medical records.

Nabel: Our health system consists of two academic medical centers, a variety of community-based hospitals, a rehab hospital, a psychiatric hospital, and then a large physician practice group. We’re now converging into one large EHR platform; it’s probably the single largest investment we have made in the last 20 years, but we’re committed because we think this is what we need to do to really integrate care. But what it has cost us — it’s almost the reverse of what you’re doing, Gary — you’re redesigning your processes and then you’re automating; we’re using the automation as an opportunity to standardize our processes. It’s been really enlightening — it’s been a great way to bring our practitioners together to develop a standardized care model. So that’s a huge investment for us, but we think the ROI at the end of the day is going to be tremendous, primarily in terms of patient care, but also on the financial side.

Armato: Yes, we’re seeing some early financial returns. We took 80 different systems, we’ve got 380 ambulatory sites consolidated down to one system, and we’re seeing 5% operating cash flow improvements. Just seeing the kinds of returns we’re seeing is impressive.

Kimler: One of the things the ACA tried to encourage is a greater focus on that chronically ill population, the 5% that drives 50% of the costs. What are you doing in your systems around population health management?

Nabel: We’ve made a big investment in population health management — we really think that’s an optimal way we can start to integrate our health system. We have a very large team that focuses on population health management across our health system; we have care coordinators who care for our highest risk patients. We have an internal way of managing risk through our commercial and our government risk-based payment system. Beyond our EHR, I’d say our population health management is probably our second largest investment. We know we’re not going to see an ROI in the near future, but it’s the best thing for patient care.

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Armato: We have 1,200 physicians in our Novant Health medical group, and a number of independent physicians throughout our markets. We’ve actually created, probably, 12 of these pods that have 150 to 200 physicians in the pods, along with all of these new resources of care coordination — social workers, pharmacists — who are now focused on taking care of 50 to 200,000 lives. What they’re doing is risk stratifying that patient population, and then proactively making sure patients find the right care, at the right time, at the right price.

We’re seeing new price points that we’re introducing into these pods, which offer 24/7 primary care, and we’re opening up access points with these e-visits and video visits, and truly, I am starting to see market share shifts to our system, because of the convenience.

Kaplan: When I think of population health, I think of who we care for, the populations of patients, some of whom are young, healthy adults, some of whom are frail elderly, and some of whom are patients with chronic conditions. I think many of our cross-country, patient-centered medical homes have taken a broad-brush approach, and have applied it to every patient. I think that is a very expensive, wasteful approach.

Kimler: Lastly, a very topical question: What, specifically, have you been doing in your organizations regarding the outbreak of Ebola and its diagnosis in the U.S.?

Kaplan: I think it’s about being very fact-based, both within our organizations and with our community, the public and our patients. We want to be factual about transmission, what we know to be true and what we know isn’t true. We also are prepared, and have raised our index of suspicion, and we’re undergoing practice drills in each of our venues. If a patient presents to the clinic or the hospital with any suspicious or unexplained symptoms, they’re immediately isolated, and the diagnostic workup begins with our standard precautions. We also collaborate with our public health department, and, of course, the CDC.

Nabel: Our emergency preparedness teams also got together and put into place an emergency plan, which was quickly disseminated so that all of our hospitals have the plan in place. We also have investigators who are in the process of designing Ebola vaccines that will quickly go into clinical trials, in collaboration with our pharmaceutical partners. Also, Atul Gawande, MD, PhD, (of Brigham and Women’s Hospital) has developed a checklist that the CDC is using for hospitals and physicians to prepare themselves.

Armato: We’ve been working with the CDC, and when physicians are going through histories and physicals, they’re talking about travel, and being on the alert for any suspicious travel. If I had to sum up our system, I’d say we are on high alert but low probability. – by Jennifer Byrne

For more information:

Kimler B. Navigating a New Era in Healthcare. Presented at: U.S. News & World Report’s Hospital of Tomorrow Forum; Oct. 6-8, 2014; Washington, D.C.