S M A R T E R D ATA WINTER 2018
Execs discuss progress, next areas of opportunity
JOINING UP
Post-acute services are increasingly integrated
T E L E H E A LT H TRENDING
Adoption rises as costs fall, policies put in place
DRIVING change
CRUCIAL CONNECTIONS
How retailers, not D.C., could jolt the system
B rentwood c are c on v ener na v i H ealth is booming and hiring — and just getting started
Vitals_Cover.indd 1
11/15/18 12:47 PM
ON PACE WITH THE PULSE OF HEALTH
The Finn Partners Health Practice is proud to represent best-in-class clients spanning patient groups, payers, product innovators, policymakers and provider organizations.
DVLSEIGENTHALER.COM FINN PARTNERS. THE HOLMES REPORT 2018 HEALTHCARE AGENCY OF THE YEAR.
NP_12-18_68.indd 68 DVLS-29112-01-Vitals full-page print ad-FINAL.indd 1
11/15/18 12:24 PM 11/8/18 1:21 PM
NP_12-18_68.indd 1
11/15/18 11:38 AM
OPEN
CONTENTS
DEPARTMENTS
08 NATURAL FIT
Oscar Health enjoys strong first 12 months in Nashville
08 EFFECTIVE TREATMENT
18
CaredFor now works with 50+ treatment programs nationwide
10 DATA BANK
A look at some key reference points and trends
12 THREE QUESTIONS
MAXIMIZING DATA
Marquee Dental Partners’ Fred Ward
15 SYSTEMATIC LEARNING
Local execs discuss what’s working and how Nashville’s practicality could use a little pixie dust
Applied Health Analytics lets companies focus on employee, patient education priorities
16 THE JOURNEY
56
CRUCIAL CONNECTIONS
Brentwood care convener naviHealth is booming, hiring — and just getting started
Xsolis CEO Joan Butters sees value that data offers
features
HCA leaders reflect on the hospital giant’s evolution, guiding principles
48 TRACKING, DRIVING EVOLUTION
Health Care Council’s fellows program celebrates growth, looks to future
49 COMMUNITY CENTERED CARE
Saint Thomas beefs up clinics as a retail-oriented response
51 FOUR TRENDS OF NOTE
Advisory Board pros outline big changes underway
52 PREDICTIVE POWER
Home health giant Amedisys finds analytics answers at locally based Medalogix
58 AMBITION, ENGAGEMENT, OUTCOMES
Local firms big and small get to grips with AI
Meharry institute aims to deliver real-time insights to help medically underserved
28 TELEHEALTH GOES MAINSTREAM
Low-cost technology, high demand suggest tipping point nears despite remaining barriers
FDA steps up oversight of cybersecurity in medical devices
32 HELMET TO HELMET
BGA football program uses new technology to monitor player head contact
34 UP FOR DEBATE
TOC.indd 2
44 50 YEARS OF GROWTH
26 DATA SCIENCE TACKLES DISPARITIES
spring 2018 | NASHVILLEPOST.COM
Patient satisfaction emerges as increasingly important metric
54 CARE TRANSITIONS
31 HIGHER STANDARDS
|
25 PRESCRIPTIVE PROMISE
2 leaders
42 SURVEY SAYS…
Will retail alliances, not Washington, save the health care system?
Hospitals are devoting more attention to little things that help patients avoid readmission
Rehab hospital’s bad options fuel growth, improvement
59 SKILLED NURSING’S CHANGED FUTURE
Adoption of quality standards will be key to survival
60 MICRO CITY LIVING
Donelson-based senior care facility offers a main street vibe
62 TURNING THE TIDE
Public, private sectors look to reverse alarming opioid trends
63 LOOKING AT OPTIONS
Acadia exec talks about research, tech, future treatment methods
64 SHARED KNOWLEDGE
A Q&A with Community Solutions Fellow Collins Santhanasamy
ERIC ENGLAND
11/15/18 11:30 AM
The first and only financial advisor
In 2018, CapWealth Advisors founder Tim Pagliara was named No. 1 Financial Advisor
RANKED 1 in Tennessee
in Tennessee by Barron’s at the same
by Forbes and Barron’s.
how CapWealth Advisors can grow,
time as being named No. 1 wealth advisor in Tennessee by Forbes. A distinction no other financial advisor in the state has ever achieved. To learn more about this special feat and preserve and protect your wealth, visit BestFinancialAdvisorTN.com.
Timothy J. Pagliara Founder, Chairman & CEO
NP_12-18_68.indd 3 CAPW001098-008_M1ab_NashvillePost_First_9x10.875.indd 1
11/15/18 11:39 AM 8/17/18 9:18 AM
OPEN
EDITOR’S LETTER
editorial
GROWTH, UPHEAVAL
We are thankful for the following advisory board members who provided us valuable insights and advice as we set out to prepare ideas for this magazine: Beth Breeden, Lipscomb Ed Caldwell, CarePayment Harrison Frist, naviHealth Nate Jackson, Aladdin Temp-Rite Kim Lewis, TriStar Health System Johnel Reid, Centerstone Amber Sims, Saint Thomas Paula Torch, Waller
4 vitals
|
Nashville has boomed in many ways over the past decade. The entertainment industry has beefed up the Music City brand with dozens of new venues and attractions. Real estate developers have reshaped skylines and neighborhoods. Tech companies have sprouted and mushroomed into big-time players. And the important automotive sector has drawn more investment and jobs. But let’s be real for a second: Health care is still the top dog. No sector has added more jobs since 2008 — nearly 36,000, according to Chmura Economics, a quarter of the region’s total during that time — and no other sector is expected to grow as quickly in the coming decade. The industry’s annual economic impact in Middle Tennessee is now $47 billion, up from about $30 billion in 2008. Bear in mind that that growth has occurred during a time of reform and upheaval that still hasn’t settled. Big reimbursement changes have been and are still pulling post-acute players closer to the mainstream. Emerging technologies are continually tugging at the sleeves of everyone involved with patient care and those who pay for it. And competitors from outside the industry are stepping into the ring — or at least moving close to the action — thinking they can “fix” things. We’ve focused primarily on those big questions on the pages that follow. As with our other quarterly magazines, we’ve zoomed out from the daily news to take stock of the bigger trends. But if you’re reading this and don’t subscribe to our daily news website, you’re missing out on the hires, deals and decisions that are turning those trends into real change. We hope you’ll join us at nashvillepost.com as we chronicle those journeys. Here’s to a successful end to 2018 and a strong start to the new year. Geert De Lombaerde, Editor gdelombaerde@nashvillepost.com
Editor Geert De Lombaerde Managing Editor William Williams Contributing Writers Lena Anthony, Philip Betbeze, David Boclair, Stephen Elliott, Kara Hartnett, Victoria Leaung
art
Art Director Christie Passarello STAFF Photographers Eric England, Daniel Meigs
production
Production COORDINATOR Matt Bach Graphic Designers Abbie Leali, Mary Louise Meadors
publishing
publisher Amy Mularski advertising director Daniel Williams bUSINESS DEVELOPMENT directors Heather Cantrell Mullins, Jennifer Trsinar ACCOUNT EXECUTIVES Maggie Bond, Robin Dillon, Michael Jezewski, Carla Mathis, Mike Smith, Stevan Steinhart, Keith Wright Sales Operations Manager Chelon Hill Hasty Account Managers Rachel Hellewell, Gary Minnis
marketing
EVENTS DIRECTOR Lynsie Shackelford PROMOTIONS MANAGER Olivia Moye
circulation
Subscription Manager Gary Minnis Circulation manager Casey Sanders
business
president Frank Daniels III chief financial officer Todd Patton creative director Heather Pierce IT director John Schaeffer special projects coordinator Susan Torregrossa
FW Publishing, LLC Owners Bill Freeman and Jimmy Webb
210 12th Ave. S., Suite 100 Nashville, TN 37203 www.nashvillepost.com Nashville Post is published quarterly by FW Publishing, LLC. Advertising deadline for the next issue is Wednesday, Feb. 13, 2019. For advertising information, call Daniel Williams at 615-744-3397. For subscription information, call 615-844-9307. Copyright © 2018 FW Publishing, LLC.
winter 2018 | NASHVILLEPOST.COM
Editor's Letter.indd 4
11/15/18 12:41 PM
s pon s or e d profil e
compa n y profil e Bridge Connector is a technology company changing the way healthcare communicates. Offering true integration as a service, Bridge Connector’s approach gets interfaces live in days, not months, with no implementation or maintenance fees. Website: Bridgeconnector.com Phone: 844.727.4343
A Home-Health Innovator Automates Patient Alerts with Bridge Connector Graham Healthcare, a leading innovator in designing better healthcare solutions for over 20 years, is always looking for ways to improve the experience for patients at their facilities. Partnering with Bridge Connector to develop a strategic outlook on the future of efficiency through technology in healthcare, Graham has achieved a process that vastly improves care coordination, cutting down on readmission, manual time and, ultimately, costs. Graham accomplishes this by offering a family of health resources that cover every aspect of the postacute health continuum, and integration to achieve interoperability between these and thirdparty facilities. “As a nationally recognized leader of home health and hospice and a pioneer healthcare customer of Salesforce, Graham Healthcare Group needed an integration partner that could support bringing together multiple care and operational platforms. Bridge Connector has allowed us to take data from several data sources including Patient Ping and Connect America into our Salesforce org allowing us to eliminate manual data entry, streamline business processes, and improve care coordination.” says Justin DeWitte, CEO at Graham Healthcare Group.
NP_12-18_68.indd 5
A New Model for Healthcare Integration Healthcare integration has historically been a vacuum of resources, sucking time and money away from organizations trying to achieve the dream of interoperability. Bridge Connector changes that narrative with a full-service healthcare integration model. By forming strategic partnerships across the industry, they’re able to create interfaces with the support of vendors, instead of fighting uphill to get the information or access needed. This unique model gets Bridge Connector customers live in days, not months, with no implementation fees, no platforms to buy, and no interfaces The Results With the mission to change the way healthcare communicates, Bridge Connector’s integration model greatly decreases time to value, so healthcare organizations can focus on what they do best: taking care of their patients. “Working with the team at Bridge Connector has allowed us to accelerate our integration rollouts,” says Dewitte. “We also have appreciated the additional layer of integration support for this critical interface.”
Twitter: twitter.com/bridgeconnectus LinkedIn: linkedin.com/company/ bridgeconnector/ Instagram: instagram.com/bridgeconnector/ Locations: Nashville Knoxville Palm Beach Gardens
s pe c i a lt ie s Post-Acute and long-term care Specialty hospital and behavioral healthcare Ambulatory facilities Hospitals and health systems
11/15/18 11:42 AM
The Tennessee Chapter of HIMSS has totally embraced the mission of the National HIMSS organization of “Better health through information and technology�. Our Chapter is uniquely positioned to take on a leadership position due to our diverse members across the state, representing over 1,000 health and health services companies, with 700 of those based in Nashville. TN HIMSS has a rich history of providing events featuring speakers/moderators and panelists on leading health and healthcare trends, including advanced analytics, innovation, interoperability, cybersecurity and unique partner opportunities. Our Board of Directors is comprised of a seasoned, diverse set of executives from all areas of the industry and our Ambassador organization consists of future leaders within the industry. On behalf of our 2,100 members, welcome to the Tennessee Chapter of HIMSS and it is certainly our pleasure to partner with the Nashville Post and Vitals. Sincerely,
Eric Thrailkill President
TN HIMSS
NP_12-18_68.indd 6 1101-3854 HIMSS TN LETTER FOR VITALS-final.indd 1
11/15/18 11:42 AM 11/8/18 9:09 AM
CONNECT. ENGAGE. INSPIRE. Professional Development ––––– Workforce Development ––––– Advocacy
Innovators and Incumbents: Better together
Join today at tnhimss.org
Thank You to Our Annual Sponsors
Ad design/production courtesy of Broderick Advertising, Inc. / www.broderickadvertising.com
NP_12-18_68.indd 7
1101-3854 HIMSS TN FP ad for Nashville Post VITALS-final.indd 1
11/15/18 11:43 AM
11/8/18 9:45 AM
OPEN
TOUCHING BASE
EFFECTIVE TREATMENT CaredFor now works with 50-plus programs around the country by William Williams
CaredFor is riding high after only two years of operations. Brothers Parker Polidor and Colin Polidor founded the company in April 2016 to help addiction treatment programs provide better long-term recovery support. This time in 2017, CaredFor had approximately 20 clients in various markets, including in Nashville. In 2018, the growth has been stellar. CaredFor now works with 50-plus treatment programs nationwide (many focused on opioid addiction) and has signed enterprise agreements with Pinnacle and Foundations, both Nashville based. The company also is part of Gov. Bill Haslam’s TN Together initiative. Parker Polidor says the company will be home to eight full-time employees by year’s end. “Every day, we hear stories from our customers about how CaredFor has impacted their patients and alumni,” he says. “The core component that makes CaredFor so powerful is our focus — providing users with a safe, private community to share struggles, find inspiration and celebrate … milestones along the way. We’ve heard stories of how the app has helped to get people back into treatment and prevented others from relapsing.” Specifically, the company licenses its platform to treatment programs for delivering personalized content, discussions
8 vitals
|
NATURAL FIT Parker Polidor
and calls-to-action in a branded app. By letting alumni provide reviews, testimonials and referrals, the platform doubles as a sales tool. Providers can track engagement with an analytics dashboard, seeing in real time how often users are logging in as well as the content they are accessing, while helping them identify who might be at risk of relapse. Despite the progress, CaredFor and similar companies face challenges in collecting data to measure progress and outcomes. “It has been difficult to bring together data from different sources that would help us to demonstrate a clear impact of how patients are doing posttreatment,” Polidor says. “The more data we have access to, the more we can quantify the value we add and improve the product.” Polidor says one of the most effective treatments for those addicted to opioids is medically assisted treatment (MAT), which combines medications like suboxone, methadone and/or naltrexone with counseling and other behavioral therapies. “One of the challenges of MAT programs is keeping patients engaged in treatment over the long term,” he says. “CaredFor helps MAT programs to keep engaged with their patients, which leads to improved outcomes and reduce attrition.” With 2019 looming, Polidor is encouraged. “Our team is launching a new product aimed at smaller treatment programs,” he says. “We are starting to work with payers about how to better engage family members who have a loved one in treatment to see how this improves outcomes.”
NYC-based Oscar Health enjoys strong first 12 months in Nashville by William Williams
Oscar Health’s growth surge this year is impressive. During the past 12 months, sixyear-old Oscar grew its membership by 250 percent, with more than 250,000 enrollments at 2018’s start. The New York-based health insurance company — which partners locally with Saint Thomas Health and TriStar Health and offers plans on the Affordable Care Act Health Insurance Exchange — has expanded to offer coverage in eight markets, including Nashville, and is eyeing an additional six cities in 2019. Dr. Dennis Weaver, Oscar Health’s chief clinical officer, says Nashville was a “natural fit” as a health care technology hub. “We knew that there would be a community of highly engaged members, and we were excited [about] working with some of the [nation’s] leading health care systems who call Nashville home,” Weaver says. Within a mere 12 months, Oscar has attracted nearly 22,000 members in Nashville, Weaver says, adding the company is prepped to expand into Memphis in 2019. Of note, Oscar also offers insurance plans for small businesses in Nashville. Weaver says boutique businesses and individuals share many of the same health insurance options needs. “Both groups need a partner to help them navigate the complex health care system, and Oscar has been designed from the beginning to deliver a more personalized member experience that uses intuitive technology to make health care simple.”
Interconnectivity is a key Oscar asset, Weaver says. Conventional health insurance companies primarily manage customer data, including medical information and claims, but don’t emphasize making that information easily accessible to providers or patients. Oscar, in contrast, connects patients directly with their providers and with their own data. Because providers have easy access to their patients’ full medical history, patients need not worry about managing and sharing that information with all clinicians they see. In short, the system renders unnecessary much of the need for electronic health record integration.
Dennis Weaver
With recently secured $375 million in funding from Google parent compant Alphabet, Oscar is planning to enter the Medicare Advantage market by 2020. Relatedly, it seeks to double its roster of engineers, designers and data scientists. Alphabet has long supported Oscar, originally investing via its venture arms Google Ventures and CapitalG. “This additional investment is an incredible vote of confidence in Oscar’s future,” Weaver says, noting the company has grown to 900 employees across four offices. Oscar projects by next year to serve clients in 14 cities in New York, New Jersey, California, Texas, Ohio, Florida, Arizona, Michigan and Tennessee. “So far, the reception in Nashville has been positive,” Weaver says, “and we are looking forward to bringing Oscar to Memphis in 2019.”
winter 2018 | NASHVILLEPOST.COM
Touching Base.indd 8
11/15/18 11:32 AM
NP_12-18_68.indd 9
11/15/18 11:43 AM
OPEN
DATA BANK
data bank
DIGITAL OBSTACLES
Health care technology continues to be a white hot destination for investors’ dollars and innovators’ attention. But there’s no guarantee new whiz-bang apps and IT services can crack one of the ultimate codes: Creating meaningful changes in consumer behavior. Here are some data points illustrating these trends.
The Industry Pulse report also asked industry stakeholders their thoughts on impediments limiting the adoption of mobile and digital health tools. At least 30 percent of respondents cited these six factors as contributors.
1. Security and privacy concerns 2. Limited functionality
INSTALLING INCENTIVES As part of its eighth annual Industry Pulse report, locally-based Change Healthcare researchers asked respondents how to best turn passive patients into active health care consumers. Here are the top five responses.
25.4%
3. Duplicative, redundant and confusing app environment 4. System interoperability 5. Health care illiteracy 6. Poor user interface design Source: Change Healthcare
Offer incentives for health behaviors
PRIVACY AND R&D The rollout earlier this year of the European Union’s General Data Protection Regulation is affecting businesses worldwide in a number of ways. A research report found that health care organizations differ greatly from other sectors in one specific area when asked where GDPR is having a big impact.
23.7% Establish provider-patient partnering programs
Function
Health care
Non-health care
58%
60%
IT
14.1%
Marketing 47%
49%
Sales 38% 41%
Promote health care literacy
HR 30% 30% R&D 41% 22% Source: GlobalData
12.4%
There are positive trends for health care R&D, too. A majority of U.S. adults surveyed this spring said they’re open to sharing their medical data — scrubbed of identifiable information — for research into disease treatments and cures.
Leverage health-risk assessments
i would share with… agree disagree
8.5% Implement gamification Source: Change Healthcare
10 vitals
|
Data Bank.indd 10
Organ/tissue/bone marrow donor programs
59%
17%
Academic/nonprofit researchers
57%
21%
Corporate researchers
52%
24%
Insurance companies
37%
37% Source: Gen Pop/Ipsos
winter 2018 | NASHVILLEPOST.COM
11/15/18 11:34 AM
DATA BANK
OPEN
Poised and prepared, Bass, Berry & Sims’ multi-disciplinary healthcare practice provides strategic counsel as clients strive to advance their objectives in the ever-evolving competitive
STILL POURING IN
landscape. Our attorneys are trained and tested,
The limiting factors pointed out in Change Healthcare’s study aren’t stopping investors from piling mountains of money into digital health projects, though: According to one research firm, global venture capital funding for digital health companies in the first nine months of this year topped $8 billion, up from $5.5 billion in the same period of 2017. Here are the focus areas attracting the most dollars.
having helped more than 200 healthcare clients
Source: Mercom Capital Group
Wellness
Clinical decision support
$728M
Mobile wireless Mobile apps
We are relentless in our pursuit of excellence.
We deliver outstanding performance marked by power and precision in areas including: MERGERS & ACQUISITIONS
$1.1B
Telemedicine
close transactions exceeding $90 billion.
Go Confidently.
$457M
Wearables
navigate complex regulatory challenges and
CONTRACTING, REGULATORY & OPERATIONAL COMPLIANCE & INVESTIGATIONS
Data analytics
INTELLECTUAL PROPERTY & TECHNOLOGY
0
$5OOM
$1B
$1.5B
$2B
HELP WANTED One area of opportunity for health IT dollars: A service or system that helps people navigate the care system. Almost two-thirds of respondents to Ipsos’ wide-ranging study this year said they disagree with the statement, “The health care system in the U.S. is easy to understand and navigate.” Asked if they’d be interested in a navigator service — human or automated — to work with and communicate with providers and insurers, here’s how those polled responded. Source: Gen Pop/Ipsos
Extremely interested
Interested
Neutral
Not interested RANKED 4TH LARGEST HEALTH LAW FIRM IN THE NATION BY MODERN HEALTHCARE , 2018
Not at all interested
Data Bank.indd 11 11 NP_12-18_68.indd
11/15/18 11:44 11:36 AM
OPEN
THREE QUESTIONS
THREE QUESTIONS Fred Ward
Marquee Dental Partners
Fred Ward took over as CEO of fast-growing Marquee Dental Partners from founder Jim Usdan earlier this year, about 12 months after coming aboard as COO. Ward has spent most of the past decade in the dental practice management business and before that was an operations VP at Carlson Hospitality Worldwide and restaurant giant Yum! Brands. He spoke recently with Post Editor Geert De Lombaerde about his background and plans for Marquee. You brought a deep retail background to your health care career. How did running groups of restaurants translate to working with dental practices? There are several parallels, but three come to mind. First, leading restaurant teams and leading dental office teams are similar. I have always focused on the people on my team to make sure they have what they need to do their best work. Both businesses are servicerelated so, other than financial growth, my measures of success are customer metrics. In the case of dental offices, we focus on patient growth and patient reviews.
12 vitals
|
winter 2018 | NASHVILLEPOST.COM
Three Questions.indd 12
11/15/18 11:37 AM
THREE QUESTIONS
Second, both businesses involve imperfect people working within imperfect environments, with imperfect equipment/tools and with imperfect customers. And what do we expect? Perfection! We expected perfection for 900 customers per day in the restaurant business. Hot food delivered within 60 seconds at the proper weight and delivered with a smile in a clean environment. Dentists are perfectionists, too. They expect it from themselves every time and from those of us around them providing support. Another restaurant experience that parallels nicely to dentistry developed during my time working with franchise owners. Any success I had leading, guiding and providing direction was the direct result of my ability to influence those owners. The same is true with dentists. I had and have no “authority” over either group. I do not have an authoritarian style anyway, but I am “management” and dentists are clinical. I can only influence.
oPen
my goals that Marquee Dental become a regional clinical powerhouse. We can accomplish that right where we are, so there is no requirement to expand to a larger geographic area. Of course, things change, so I am open to growing in new markets as things evolve. What has changed and is changing about the dental business that has dentists opening their doors to companies such as Marquee to talk about selling? Many things are changing at a rapid rate in the operation of a dental office. Doctors most often state three reasons for wanting to sell their practice. First, office and people management combined with staying up to speed on dentistry and staying sharp in the delivery of patient care make the job of running an office a challenging “day job” for anyone. Secondly, real frustration from receiving lower reimbursements for the same procedures that you did five years ago for more money is also a change
‘Any success I hAd wAs the
IN CHARGE
d I r e c t r e s u lt o f m y A b I l I t y
NOW ACCEPTING
to Influence’ You’ve chosen to keep Marquee’s growth focused on a relatively small geographic area. Is that simply an easy way to control some of your costs or are there other operational advantages to that approach? The decision to stay regionally focused is driven by a few key factors, and cost is not one of those factors. Within our geography of Tennessee, Alabama and Kentucky, there are five excellent dental schools, several cities with populations of about 500,000 people and at least three cities with more than one million people. There is a lot to do here within these three states, plenty of underserved people and a very high number of gifted dentists. It is one of
and a common reason dentists want to sell. What it takes to deliver high quality dental care costs more today, and yet doctors are receiving less for work that formerly paid more. Simply because of Marquee’s scale, we tend to get higher reimbursements and certainly get better pricing from our supply and lab partners. Finally, like in the medical field, migration has begun within dentistry toward a value-based system that ties payments for care delivery to patient outcomes and the quality of care provided. Many single-practice owners today want to hand over the migration responsibilities for their practice to a team like ours so they can focus on being a dentist.
NOMINATIONS FOR 2019 Submit your nomination at I N C H A R G E@N A S H V I L L E PO ST.CO M NOMINATIONS END DECEMBER 5, 2018
daniel meigs
Three Questions.indd13 13 NP_12-18_68.indd
11/15/18 11:46 11:37 AM
OPEN
INDEX
A-E
Collective Health 34, 40
June Patterson 48
Collins Santhanasamy 64
Kathy Winn 28
Acadia Healthcare 49, 63
Concert Genetics 18, 23
Kent Riddle 58
Aetna 34, 51
Damian Mingle 25
Kevin O’Hara 18
Affordable Care Act 8, 36, 42
David Briley 27
Lena Walker-Winfree 26
Amber Sims 49
David Charles 28
LifePoint Health 28, 44
Amedisys 52
David Critchlow 29
Lisa Bielamowicz 34, 41
Prem Shah 60
David Reagan 62
Lisa Reich 42
Rachael Johnson 54
Day Health Strategies 34
M-N
Raiven Healthcare 25
American Hospital Association 28 American Hospital Supply 44 Amy Andrade 26 Applied Health Analytics 15 Ascension Saint Thomas 49 Association of American Medical Colleges 29 Axial Healthcare 18, 20 Baker Donelson Beerman Caldwell & Berkowitz 31 Battle Ground Academy 32
DVL Seigenthaler 18
Ernst & Young 34, 41
F-L Finn Partners 18
Parker Polidor 8 Paul Kusserow 52 PhyMed Healthcare Group 48
Rajaie Batniji 34, 40 Ray Guzman 48
Marquee Dental Partners 12
Elizabeth Ann Stringer 18, 20 Elliott Wood 52
Oscar Health 8
Marty Bonick 48 Mary Free Bed Rehabilitation Hospital 58 Medalogix 52 Meharry Dental School 26 Meharry Medical College 26
Riddell 32 Robert Chamberlain 15 Rosemarie Day 34 Sam Hazen 44 Spectrum Health System 58 Studer Group 42, 54, 58 SwitchPoint Ventures 25, 48
Bill Carpenter 44
Focus on Therapeutic Outcomes 43
Meharry Medical Group 26
BlueCross BlueShield of Tennessee 62
Food and Drug Administration 31
Metro Nashville Police Department 62
Brad Younggren 29
Fred Eaves 32
Michael Genovese 63
Brian Carlson 42
Fred Ward 12
Michael Heinley 18
Tennessee Department of Health 62
BridgeConnector 18
Gillian Hooker 18, 23
Middle Tennessee State University 26
TN Together 8
Bristol Senior Living 60
Gist Healthcare 34
Milton Johnson 44
Tommy Frist 45
Gregg Slager 34, 40
Nancy-Ann DeParle 44
Unity Point Health 15
HCA Healthcare 44, 49
Nashville General Hospital 26
Humana 51
U.S. Department of Health and Human Services 29
Nashville Health Care Council 44, 48
Cardinal Health 56 CaredFor 8 Centers for Medicare and Medicaid Services 29, 42, 54, 56, 59
InSite Training Tool 33
Syus 18 TennCare 64 Tennessee Bureau of Investigation 62
Vanderbilt Neuroscience Institute 28
Change Healthcare 10, 25
Jack Bovender 44, 46
Nashville International Center for Empowerment 64
Vanderbilt University 26, 28, 42, 48
Chris Gerard 52
Jay LaBine 56
Natalie Tate 62
Vanderbilt University Medical Center 28, 42
Clay Richards 56
Jim Sohr 16
naviHealth 56
Waller Lansden Dortch & Davus 59
Colin Polidor 8
Joan Butters 16
Nick Giannasi 25
Xsolis 16
Coliseum Capital Management 52
Joshua Douglas 18, 22
Nikki Rasmussen 43
Zumrut Ekinci-Zlabinger 64
14 vitals
Index.indd 14
Dennis Weaver 8
O-Z
|
winter 2018 | NASHVILLEPOST.COM
11/15/18 11:38 AM
TECH @ WORK
TECH @WORK Systematic learning Applied Health Analytics lets companies drill down on employee, patient education priorities
OPEN
Local health technology company Applied Health Analytics is promising its clients a better way to educate employees and patients via a new portal inside its bIQ suite of services. Rolled out this fall, the Learning Management System gives Applied Health Analytics’ hospital and other clients the chance to customize regulatory and workplace safety compliance courses as well as pull together educational content through one primary portal. Customers of Applied Health Analytics’ other services such as claims analytics and clinical coaching can pick up this new software for fees that depend on the size of the group that will use it. The Applied Health Analytics team beta-tested its system with Unity Point Health in Peoria, Illinois. The application, which is similar to some of the services marketed by downtown-based HealthStream, lets employers follow up on the courses taken with quizzes, which Applied Health Analytics CEO Robert Chamberlain says helps drive behavior change. “It’s very easy for an employer or a health system to identify educational needs, provide those needs online, append the ability to determine someone understands the content they’re intended to be educated on, and then add that to the patient or the employee file showing that they indeed participated in the LMS capability,” Chamberlain says. The system supports topics such as workforce compliance requirements, cybersecurity and specific care instructions. The latter is designed to better connect employees with patients. “You can utilize it to deliver care pathways,” Chamberlain says. “The Learning Management System becomes the method through which the health systems can communicate and monitor compliance with care […] You’re taking complex information, communicating it in an environment that the patient, member or the employee prefers, and in a way that can be adjusted to a level people are comfortable with.” That flexibility — content can be presented in various formats such as text, video or audio — makes it easier to personalize patient information and guidance for things such as making sure they are restricting certain foods and adhering to medication schedules. > Victoria Leaung
NASHVILLEPOST.COM
Tech at Work.indd 15
|
winter 2018 | vitals
15
11/15/18 11:39 AM
OPEN
THE JOURNEY
THE JOURNEY Joan Butters Xsolis
Sometimes, success comes quickly. Other times, it’s the result of a long grind that gets its due reward. For Xsolis CEO Joan Butters and her team, 2018 has been a case of the latter. The six-year-old company has added dozens of clients, beefed up its executive talent and secured funding for more growth in the year ahead. Here, Butters takes a step back to the seeds of that growth and peeks ahead to more opportunities. Early on, I saw the value that data and technology could bring to health care. After years leading data mining operations at AIM Healthcare, I realized there’s not another industry in which data is so crucial yet often used so inefficiently. Given the regulations that rein in large health care organizations, I knew I would have to start small if I wanted to make a true impact. In 2012, after leaving AIM, Jim Sohr (former president and CEO of AIM) and I founded Xsolis with a simple premise: We knew hospitals were struggling to keep up with government audits and, with our track record of proven success at AIM, we knew we were the ones to help. We worked on a prototype for the better part of a year before shopping it to potential clients, garnering a largely positive response. Then, a curveball: The government decided to pause its major audit program and the need for our solution disappeared overnight. Every entrepreneur experiences this crucial moment of uncertainty: D id I choose the right market, the right solution, the right approach? Although our solution at the time was moot, our business development efforts had uncovered glaring problems within the market. We’d witnessed firsthand how handcuffed hospitals are with financial decisions related to care and reimbursement. The stories of frustration and anxiety convinced us there was an untapped market.
16 vitals
|
winter 2018 | NASHVILLEPOST.COM
The Journey.indd 16
11/15/18 11:40 AM
THE JOURNEY
We’d been successful harnessing data for clinical data exchange and governmental initiatives, yet we felt this data wasn’t being utilized to its full potential. We posed a question to ourselves: “Why can’t we craft algorithms to sift through clinical data and determine what’s important in each patient’s record to help inform clinical and operational decisions?” The current system goes like this: After a patient shows up at the hospital, they’re assessed by a utilization review nurse, who’s responsible for determining if they should be admitted as an inpatient or remain outpatient. This process is complex and time-consuming, subjective and onerous. If these cases aren’t reviewed accurately and quickly, the patient’s insurance claim can be denied, leaving the hospital or patient footing the bill.
An early a-ha moment came courtesy of a client in Virginia. As we were presenting, the director stopped us, rolled back our PowerPoint a few slides and identified a way she’d take what we were doing a step further for an even greater impact. It was a pivotal point for us and reinforced our conviction that we were on the cusp of something big. That client, like each of our early adopters, helped us solidify the messaging, positioning and market awareness that propelled us forward. By 2015, we had about 10 clients. By the end of last year, we were active at 30 sites. From there, we hit an inflection point. We’re now at more than 100 and are on track to double that by the end of 2019. The market has accepted that artificial intelligence is the future and a collective realization has dawned that organizations not leveraging AI will be left behind.
open
SMARTER SPORTS
‘The sTories of frusTraTion and anxieTy convinced us There w a s a n u n T a p p e d m a r k e T .’ The tools for utilization review teams have barely changed over the years — faxes and priority lists on paper are still common! We realized technology, specifically artificial intelligence and predictive analytics, could solve key problems — the complexity, the subjectivity, the timeliness. We switched our focus to real-time predictive analytics and built a platform that automates a great deal of the administrative work that distracts caregivers from lending full attention to their patients. In 2013, a year into our venture, we were frenetically building our technology and figuring out our model. In early 2014, we landed our first client — even as we were working on our messaging, positioning and modeling. Our model required a breadth of data that we didn’t have, yet we couldn’t get more data without more clients. Many prospects told us, “This is a great concept and we’ve imagined something like this for a while. Come back when you can guarantee results.”
This year, we beta-tested and rolled out a technology platform that directly connects a national insurer and a regional hospital system. The hospital and insurer share a common framework of analytics, enabling them to coordinate their decisions on care and payment to mutual benefit. It’s a thrilling prospect and a natural evolution of how we serve the market. More broadly, we’re also looking beyond utilization review into areas where we can provide value through data. Our system has stored millions of patient encounters and made 18 million predictions, a veritable treasure trove for other applications and avenues. Yet, we’re being strategic and deliberate about those applications, asking ourselves key questions: How can we most effectively apply the data we have? What are we trying to solve for? Rather than being distracted by the next shiny thing or overstretching our capabilities, we’ll remain focused on being patientcentric and user-centered.
Join us on Post Sports as we cover and analyze the Nashville sports scene.
NASHVILLEPOST.COM
ERIC ENGLAND
The Journey.indd 1717 NP_12-18_68.indd
11/15/18 11:47 11:40 AM
FEATURES
FEATURES DATA
Making more of health care data Four local execs discuss what’s working, where they’re looking to do better still and how Nashville’s practicality could use a little pixie dust
he Post team in late October welcomed about 200 people to City Winery for a breakfast and panel discussion on how care providers, technology companies and patients are making better use of health care data. The gathering — which was sponsored by DVL Seigenthaler, a Finn Partners company, and organized in partnership with the Tennessee chapter of HIMSS — featured the following speakers: • Joshua Douglas, CTO of Bridge Connector
T
18 VITALS
|
WINTER 2018 | NASHVILLEPOST.COM
Vitals Panel.indd 18
• Gillian Hooker, VP of clinical development of Concert Genetics • Kevin O’Hara, CEO of Syus • Elizabeth Ann Stringer, chief science and clinical officer of Axial Healthcare Their conversation was moderated by Michael Heinley, a partner and deputy of the New York Health Group at Finn Partners. Here are lightly edited excerpts from the morning. Heinley: Let’s jump in. When it comes to using health care data more effectively, let’s talk a little bit about what’s working well these days. Even just a few years ago, some of this technology and the amounts of data that we have and the way that we manage it was not even imaginable. Josh, how is Bridge Connector making health care integration easier for health systems? Douglas: Historically, data has been siloed; we hear that a lot. EMRs held all the data. And really, the new models of integration and integration platforms as a service have brought us forward and unlocked those silos so we can access data within those systems. Really going through the clinical workflows and using different pieces of software — not just the EMR — for different things has really helped unlock that data out of the silos.
Heinley: It’s sort of the dream of interoperability becoming a reality. Douglas: It’s getting close. It’s getting closer every day, but we’ll see. Heinley: Kevin, what about from your perspective? How is that working in the hospitals, the health systems? Are there any that are doing a particularly good job and connecting the dots? O’Hara: First, taking a quick step back: The economic stimulus package that pushed adoption of EHRs got everybody pretty much caught up. And then over the last few years, you’ve had people migrating systems. And people are used to moving. When you move, you get things organized. So when people go through these migrations, there’s a lot of opportunity to clean data up and to get on new systems. There’s also been — particularly in our area — a lot of hospitals might have had a kind of a best-of-breed operating room documentation solution and that’s now generally been absorbed, without any surprise, by Epic or Cerner. So that move over the last four or five years — to everybody being on an EHR, a lot of people being on a consolidated single system and then really getting down that Cerner and Epic and
ERIC ENGLAND
11/15/18 11:41 AM
DATA
‘People spend an inordinate amount of time just getting data organized and clean and it doesn’t leave them a lot of t i m e t o d o s o m e t h i n g w i t h i t .’ Meditech — has greatly simplified what data sets look like. I think that’s been helpful. In terms of who’s doing well, I would say it’s kind of the usual suspects, the Intermountains, Cleveland Clinics. And some of them are systems that have been on these larger integrated systems for some period of time, and so you can almost see the future of what happens when you get very organized data, clean data, and you can get out of that realm. People spend an inordinate amount of time just getting data organized and clean and it doesn’t leave them a lot of time to do something with it. I think the folks that are doing well have already passed through that over the past few years and are now applying the resources to doing something with the data as opposed to just trying to figure out how to make it say something. Heinley: Are you also tapping into the EMR, EHR systems in terms of the data that you’re funneling in and out? O’Hara: Yeah. We get data about essentially the who, what, where and when of a surgical case. That can help you answer the basic questions that you need to answer about how many operating rooms you need to run and how to allocate time and how to standardize. But what ultimately you need to start to do is tap into other systems — supply and implant tracking systems, systems that deal with HR data. So that’s really kind of the next step and companies like Bridge Connector and others that are helping to bring that data together and get it out of those silos, that’s really what’s important now. Stringer: [There’s also] a sort of behind-thescenes grassroots efforts. Think about data science: It’s a new field that’s sort of responding to the aggregation of large data sets. And you have some really scrappy people who are just hacking away and trying to make things work. I think that ecosystem is really, really important for then get-
Kevin O’Hara, Syus
ting those ideas up and adopted to a more enterprise level. You’ve got so many people sharing information down at this grassroots effort and I think that’s really, really important. Heinley: That’s a really interesting point. Does anyone have a perspective on maybe coming in as a square peg and trying to fit into a round hole? Because there are legacy systems and these are new technologies and platforms. Is that a challenge that you ever have to face? Hooker: This is very much a challenge we’re facing in the genetic testing space. Right now, most genetic tests are ordered in the EHR using a miscellaneous code and maybe a free test field. But more often than not, there’s a piece of paper that exists in parallel to the EHR. So, there’s no tracking of whether a test was ordered, let alone what test was ordered. And when tests come back, they come back as PDFs. They get uploaded somewhere in the EHR — often not in the same place every time. You could walk into some of the most sophisticated systems in the country and say, “How many of your patients have been tested for X, Y, or Z?” and they can’t answer that question. Even systems that have sequenced everybody in their whole system couldn’t say who was having a clinical test. So the tracking is really poor and there are poor standards. And that’s one of the things we’re trying to do: Build standards for tracking that through the whole process.
O’Hara: Just to jump on that: There is a strange dichotomy between really interesting things that are going on at a high level with AI and machine learning and these really lowlevel issues like things being entered into a miscellaneous category. We deal with this constantly. We’re introducing benchmarking now and just the names that people use to describe surgical procedures… Even within the most sophisticated health systems and facilities, this is typically a mess. They’re just free text entries. Your typical community hospital may do 800 to 1,000 different types of procedures a year, with a knee replacement being one and an open heart procedure being another. And there should be 800 to 1,000 names. We have customers that have 18,000 different names and trying to determine what the average length of a total knee replacement is is sort of like getting out of bed and having to go find your clothes somewhere else. You can’t do the thing that you really want to do because you’re first hamstrung by trying to figure out which of those 18,000 codes describe a knee replacement. Heinley: Josh, what’s your take on the challenges that you have to face in this space? Douglas: I think there are two ways to solve it. One is with standardization, right? So you have code sets trying to solve those problems but they only go so far. We’re finding new things and constantly having new procedures and new tests — especially genetics that these code sets don’t typically cover — or there’s not enough expertise at the health care facility to apply the correct code. So one way standardization is coming down is through government regulation. But the other way is through data and modeling and natural language processing and actually using technology to comb over the data and really learn what the intent is. And I think that’s probably the better way of doing it. I don’t know that the governmental regulation is going to solve all of our problems. It’s brought us so far and it’s good in some ways, but I think we’re really looking at technology to solve those problems. Heinley: What about HIPAA and patient confidentiality? There are a lot of constraints around that, not the least of which is just data security. Elizabeth Ann, how much of an issue is that in your situation?
NASHVILLEPOST.COM
Vitals Panel.indd 19
FEATURES
|
WINTER 2018 | VITALS
19
11/15/18 11:42 AM
FEATURES
DATA
‘A lot of relationship building and gaining the trust of the provider starts at the level o f t h e d a t a .’
E l i z a b e t h A n n S t r i n g e r , A x i a l He a lt h c a r e
Stringer: This is a huge issue with the opioid epidemic and we always want to start with the patient, right? We’re all here in health care because we feel strongly about trying to help patients get better. So we also want to protect their information. But one of the problems with sharing information across systems is you do have some of these extra security and privacy rules. One of those, particularly in the opioid epidemic, that many people might not know about is that not all providers are allowed to know about diagnoses of the patients they’re caring for. At Axial, we gather claims data so we understand about the diagnoses from multiple providers of an individual patient and we would want to share that with all the providers that are touching that patient. But we’re not allowed in some states and in some markets to share information saying that this patient has opioid use disorder. So a doctor might be trying to make a decision about the best course of care — is an opioid appropriate or not? — and they aren’t allowed to know that that patient is in fact diagnosed with opioid abuse disorder.
20 VITALS
|
WINTER 2018 | NASHVILLEPOST.COM
Vitals Panel.indd 20
These are some of the challenges that we’re up against in solving the opioid epidemic. But [it’s similar] in health care more generally, right? What is appropriate for a provider to know? Don’t we want to give the provider that holistic view of the patient so that they can make the best decisions for that patient? Douglas: The HIPAA law is 300-and-someodd pages. And what you’re getting at, I think, is also patient consent, right? Having to deal with patient consent across integration of data — whether it’s from HIEs or whether it’s coming out of EHRs — consent’s a hard problem to deal with. And each state has different laws — is it opt-in, is it opt-out — and it’s a really complicated problem to solve and everybody’s worried about it. Nobody wants the Office of Civil Rights knocking on your door. Hooker: In genetic testing, there are a whole host of emerging problems that aren’t even addressed by HIPAA. Right now, your genetic information isn’t considered personal health
information. It isn’t considered protected even though — think about it — it’s inherently identifiable information. You can look at stories like the Golden State Killer who was tracked down using ancestry databases. There are a lot of concerns that arise when it comes to the fact that your genetic information may not just identify you, but it could identify your family members. So how are we going to handle permissions in that context? And then it expands even more broadly to who owns that data. A lot of genetic information is being used for research and a lot of folks are buying genetic information from the consumer market — the companies like 23andMe — or from research institutions to use it for great purposes, for the development of new technologies, for the development of new drugs. But I think there are a lot of questions to be resolved around permissions and whether folks should be made aware when their data is being sold, whether they should have a say or not.
Behavior changes Heinley: Elizabeth Ann, you mentioned providers earlier and I’m really curious about how they are reacting as a prescriber, a physician, somebody who has taken the Hippocratic Oath, when you’re putting in front of them data that could be to the contrary.
ERIC ENGLAND
11/15/18 11:42 AM
s pon s or e d profil e
compa n y profil e The Nashville Technology Council exists to be a catalyst for the growth and influence of Middle Tennessee’s technology industry. NTC’s vision is to establish Nashville as the nation’s creative tech destination by connecting, uniting, developing, and promoting the region’s tech community.
THE EPICENTER FOR NASHVILLE’S TECH COMMUNITY
150 PERSON E V E N T S PAC E
2 EXECUTIVE CO N F E R E N C E RO O M S
LEARNING CENTER
R AT E S S TA RT AT $ 3 3 / H O U R IDEAL LOCATION FOR Off-site Team Retreats Board Meetings Launch Events Usergroup Meetups Professional Development Student Tech Enrichment
Tech Hill Commons: The Gathering-Place for Nashville’s Creative Tech Community Since its inception, the vision for Tech Hill Commons has been to provide the greater Nashville technology community with a space to come together, share their ideas, and spur-on each other to bigger and better achievements. After our first year of being open, we are well on our way to realizing that vision! Located in the Nolensville Corridor and near the rapidly developing Wedgewood-Houston neighborhood, Tech Hill Commons includes more than 9,500 square feet of space that houses the NTC’s new HQ and makes available:
• •
TECHHILLCOMMONS.COM
•
TECHHILLCOMMONS@ TECHNOLOGYCOUNCIL.COM
• • •
Event Center: 150 people Comcast Boardroom: 20 people ENA Conference Room powered by Cisco: 12 people Dell Learning Center: 48 people PwC Learning Lab: 22 people Coffee station presented by Kraft CPAs
Tech Hill Commons and the NTC has produced a combined 458 events with 18,421 attendees in the past year. Tech Hill Commons has formed a reputation in the
NP_12-18_68.indd 21
greater Nashville community as where creative tech meets. Hosting board meetings, training sessions, product launches, community hack-a-thons, and tech meetups alike, Tech Hill Commons has emerged as a leader in advancing Nashville’s place in the technology landscape. Few other aspects so perfectly encapsulate the NTC’s mission to connect, unite, develop, and promote than our work to support local tech user groups. In our first year, we hosted over 70 tech user group meetings representing over 5,800 distinct members. The NTC recognizes how important Nashville’s tech user group community is and is dedicated to supporting them by providing space at Tech Hill Commons for them to meet and grow. Whether you’re looking to challenge your team in an offsite retreat, teleconference with a client, develop the next generation of tech leaders, formulate your company’s next industry revolutionizing strategy, or launch your new innovation, Tech Hill Commons is available to exceed your organization’s needs. Learn more at TechHillCommons.com
500 Interstate Blvd. S, Suite 200, Nashville, TN 37210 Website: https://technologycouncil.com Twitter: @NashTechCouncil @TechHillCommons Facebook: https://www.facebook.com/ NashvilleTechCouncil LinkedIn: https://www.linkedin.com/ company/nashville-technologycouncil https://www.linkedin.com/ groups/51917 Number of Employees: 9 Number of Company Members: 450+ Founded: 1999 Contact: Phone: 615.873.1284 Email: info@technologycouncil.com
s pe c i a lt ie s 10th Annual NTC Awards:
January 24, 2019, the 10th Annual NTC Awards will be held at the Wildhorse Saloon. The evening is dedicated to celebrating Middle Tennessee’s rich community of developers and technology entrepreneurs, enthusiasts and institutions with awards in 14 categories. Tickets and tables are available at NTCAwards.com ApprentiTN
The NTC has launched ApprentiTN, the first technologyfocused apprenticeship program in Tennessee and will graduate its first cohort in early 2019. Learn more: ApprentiTN.com
11/15/18 11:49 AM
FEATURES
DATA
‘ Yo u c a n c o l l e c t a l l t h e d ata yo u w a n t. You could even present the data. I t d o e s n ’ t m a k e i t a c t i o n a b l e .’ Joshua Douglas, Bridge Connector
Stringer: This is a question we get asked a lot. How are providers actually taking the information that you’re using? Are those friendly conversations? When we think about what’s best for the patient, it’s really about getting to the provider. How do we change that provider behavior? At Axial, we have a model where we’re doing outreach to providers, educating them about their patient population. In these outreach efforts — phone calls, onsite visits — it’s really important to think about relationship building and gaining the trust of the provider, and a lot of that starts at the level of the data. When providers start to understand you have some patients that are really high-risk that probably need a different care path than they’re currently on, providers can get really defensive. I mean, I don’t want somebody to come in and tell me how to do my job, right? And so, I think the data can be one of those keys for helping us establish trust early on. The data is true. We can’t deny that. And beyond the data, one thing that’s really helpful to us in the opioid space is the fact that providers feel like they’re under a lot of scrutiny right now. They are really looking for those trusted partners to help them do a better job of delivering care. It has to be individual patient-based analysis first and then we roll that up to the provider level. Heinley: It’s the axiom that the data is only as good as how you can really use it and apply it in your situation. O’Hara: Yeah. Going back to what Elizabeth was saying a minute ago, I think what you’re describing is that, in the health care and medical fields, there’s a lot of faith that providers, doctors and surgeons are scientists. Right? They’re trained scientists and if you put the data in front of them, they’re going to use the data and respond to it. But one of my favorite areas of what we do is really also looking at them as human beings and
22 VITALS
|
understanding that there is a lot in the way you frame the data and present the data [that determines] how it’s going to be received and how it’s going to be used. As Elizabeth Ann was describing developing these relationships, I think there are a couple of interesting things: One is how do you do that in scale and also how do you use different communication methods. In our area of operating rooms, there is this concept that you have a wall of fame or a wall of shame. Something that hospitals focus on is surgical cases starting on time. What percentage start on time? So there’s this idea that, in the surgeon lounge, you’re going to post either a wall of fame or a wall of shame. And our approach is to do neither of those things. You figure out how to provide them the information. You treat them like grownups. You talk about your partnership with them and how you’re trying to help them do their job better and you try to find some third thing. It’s framing it about the patient having to not eat overnight, not drink, showing up in the morning, their family’s there and not wanting to wait around. And then you translate it into something like that as opposed to kind of being about the hospital or the surgeon. There’s a lot you can do with raw data. But if you have the best data in the world and you come at it completely wrong in terms of presenting it, you’re going to fall flat. There’s a whole realm around that that I think’s really interesting.
Douglas: One of the things that is important for me is to understand from a customer perspective — and that customer could be a clinician, it could be a registration person, it could be a surgeon — what they want to do. What do you want your new ideal workflow to be? Or how can we make this data actionable in your current workflow? I think that’s what we were getting at. You can collect all the data you want. You could even present the data. It doesn’t make it actionable. Tying into current workflows and delivering communications how doctors are used to getting communications is key in making that data actionable. Don’t try to change what people do day to day — whether it’s a clinician or whether it’s a registration person. Find out what they do, how they work and then present the data as they work through their normal workflow. When you try to completely change how somebody works, especially in the health care space, their initial reaction is to say, “Whoa, I can’t do that.” Or like you said, Elizabeth Ann: “Don’t tell me how to run my business. Don’t tell me how to treat my patients.” Just help them treat their patients at those action points. O’Hara: I think the challenge to that is that, to get improvement in the areas where our customers want to see improvement, it does require behavior change. Now, some of that may be just educating people, right? But how do you provide the framework for change to be easier? We look at a couple different models, and there’s nothing new in these areas but there are models for change management at organizational level. There’s a really good model by a guy out of Stanford named BJ Fogg. He talks about individual behavior change and it’s basically, “How difficult is the change and how bad do I want to make it?” Then you have this sort of curve that you want to be on the right side of by making it relatively easy and making the desire to do it pretty high. And if you’re on the right side of the curve, you’re going to get change. And if you’re on the wrong side of the curve, you’re not. But what causes that to happen is ultimately a trigger. What we looked at is how does the data provide a trigger. How do you put something in front of someone that triggers them to make a change that they probably already want to make and is pretty easy? But the challenge is that we do need to push people out of what they’re doing today or you’re going to get the same result that you got yesterday. But we do need to make it easy.
WINTER 2018 | NASHVILLEPOST.COM
Vitals Panel.indd 22
11/15/18 11:42 AM
DATA
‘We’ve looked to take a lot of lessons f r o m t h e c o n s u m e r s p a c e .’ Gillian Hooker, Concert Genetics
Hooker: That’s where we’ve looked to take a lot of lessons from the consumer space. There’s been a lot of innovation in [creating] interfaces that are intuitive and that folks can use. We’ve built a genetic testing formulary that looks like a marketplace. I would say it’s like organizing a grocery store where we’ve taken all the genetic tests that do similar things and put them together so that people can find them and they can really compare side by side the benefits and the limitations of this particular test over another. What are the cost implications? What are the insurance implications? Stringer: One of the things I’d like to add is that to make data and analysis actionable, we’ve got to bring together multidisciplinary teams. Thinking about a marketplace, how do consumers consume information? We need experts in a lot of different domains and bringing them all
ERIC ENGLAND
Vitals Panel.indd 23
together to solve a problem can be really, really tricky. So, in addition to the challenge that data provides, bringing stakeholders together in the design process is really key to making it actionable.
Talk versus reality Heinley: Let’s talk about hype. When you are dealing with different stakeholders, with decision makers, with folks in this room who are representing their organizations, how do you convince them that this or that is a new platform that they need to develop? I understand that health systems switching over technol-
FEATURES
ogy platforms is a long-term premise. So how do you separate that and how do you approach facilitating a decision-making process with these new platforms as the technology is rapidly advancing? Douglas: When I hear somebody say “big data,” that is an indicator that it may be hype what they’re talking about. Most data is not that big. When people say “big data,” they usually mean something like a distributed database or they’ll use big data and AI in the same sentence and they’re not the same thing. It’s hard to separate the hype from reality. I think there are some really good companies and some really good data scientists out there that are using things like unsupervised machine learning — which is kind of the next level of “Let’s let the computers and algorithms figure out their own algorithms and dig through the data to deliver some kind of analytics.” But how does that help a customer? How does that help a doctor make the decision? Well, generally, they can’t tell you, and that’s the key. The question is, “Can you do human analytics first and deliver something valuable to the doctor to make some kind of decision on a patient?” That’s way more valuable than coming
NASHVILLEPOST.COM
|
WINTER 2018 | VITALS
23
11/15/18 11:43 AM
FEATURES
DATA
in and saying, “Well, we can deliver a big data and AI platform.” That doesn’t actually mean anything, right? Hooker: We have a long history of hype in genetics. They even have their own name for it called genohype — instead of genotype. Remember when the human genome was sequenced and the announcement was made in 2003, there were folks saying, “Oh, in a couple years, we’re all going to have our genomes sequenced? We’re all going to be walking around with our genome on a watch, on a phone?” And here we are, 15 years later, and still maybe one or two million genomes have been sequenced worldwide, the majority of them for research or clinical purposes. It’s taken a long time to get even to where we are in 15 years, and in many ways we aren’t where we thought we would be. In other areas, we’re ahead of where we thought we would be — in cancer and molecular microbiology and things like that. So, it’s a mixed bag. Now, bringing in the AI piece, I think it’s sort of adding onto of a lot of the hype that was already there. Through it all, though, I think that there’s a core group of folks able to work through it and continue to innovate in very pragmatic ways. Stringer: As a scientist, I say prove it to me. And that’s something that I tell people all the time. Here’s a story that I thought was really interesting and sort of proved my point: I’d get asked all the time by investors and other leaders, “What are you doing to bring in new data sources and shouldn’t you be putting together legal information about somebody who has a DUI or something like that?” And it’s like, “Well, our models are pretty good right now. I don’t know how much more accurate you want them to get.” But in the latest Stanford Medical Center magazine, there was a profile of a scientist working with a physician on a predictive model for patients that need to be engaged in palliative care conversations and end-of-life conversations. It’s a really great piece. And you think about Stanford and their access to the EHR and in pulling in data from there. What they ended up pulling in — the data they pulled in to train their model — was just this sort of claims-based data. That’s the data I deal with so I found that very interesting, that I’m sort of challenged all the time about needing to integrate with EHRs and pull in the data from EHRs. And here’s, you know, Stanford — where so much innovation is happening
24 VITALS
|
— and they’re just using the claims part of this EHR. It’s something for us all to really consider. What are those validation outcomes? How much better we can get with these hype words? Heinley: The proof is in the pudding. Stringer: Yes. Heinley: So let’s bring this back home, to Nashville. I’d like to get your take on the future of the city’s fast-growing, data-driven medical sector. Douglas: I think it’s really exciting to see Nashville. I was born here and moved around a lot and ended up back here. I love this city. It’s exciting to see it shift from — and I mean no disrespect here — the old guard of health care such as HCA, CHS and so on and really get into the smaller, entrepreneurial, tech-focused companies delivering solutions for niche industries within health care. That’s what I get really excited about and when I come to events like these and meet people and hear about what they either are doing or want to do. Hooker: We talk a lot about knowing Nashville is both physically and sometimes is metaphorically situated between Silicon Valley and Washington D.C. and how that gives rise, in my perception and experience, to a very pragmatic innovation. It says, “Yeah, maybe we won’t all be wearing our genomes on a watch six months from now. In Silicon Valley, they might. But how do we really innovate at the real-world challenges of health care? How do we use real-world data to drive decisions and how do we deliver systems that can really reach a lot of different people who are in a lot of different places when it comes to health?”
O’Hara: Using the word pragmatic is how I think about it. We can hold ourselves out as the real world. You know, we’ve got the HCAs and the LifePoints and large companies that manage a lot of hospitals. We know what the reality is on the ground. That can be limiting in a way, too, right? But we’re going to be more about iterative innovations, pragmatic innovations. And that’s sort of what we think about ourselves. But that makes us, I think, inherently less of kind of a moonshot town. We’re not hype-y. We compete against some companies that are in Silicon Valley, that have raised tens of millions of dollars and they’re former Google engineers and former Uber engineers and their take is that health care is really broken. “The people who are doing it today are messed and they don’t understand how to fix it and we’ve got magic pixie dust and we’re good enough to come sprinkle it on you guys in Nashville and fix the messed up stuff that you’ve been doing for a long time.” And there’s some value in that, right? I mean, there’s this notion that, if you ask people what they want, they wanted a faster horse. So there’s that inherent tension that I think we in Nashville have a lot to offer in the regard of understanding how this stuff lives on the ground. But thinking about how to get out of that trap a little bit to take bigger moonshots is also important. Heinley: I saw a lot of heads nodding around the room as you were talking. Elizabeth Ann, anything to add to that? Stringer: I think another important part about moving the technology forward is the money that it takes to do that. When I think about Silicon Valley and the way they’re able to advance and innovate, so much of that is predicated on the money that’s there and the investor community. We have some great investors here in Nashville but we’re nowhere near the size of the capital that we would need here to do the things that they do in Silicon Valley. That does limit us a little bit more. And so there is more of that pragmatic approach. Data inherently is kind of sterile so how do you bring humanity to that? And there’s a connection here in Nashville with having such a large provider community, a hospital community that helps us really understand the health care ecosystem better and allows us to move forward. But it’s not going to look the same as Silicon Valley.
WINTER 2018 | NASHVILLEPOST.COM
Vitals Panel.indd 24
11/15/18 11:43 AM
DATA
Predictive and prescriptive promise Local firms big and small get to grips with AI by Kara Hartnett
ith the promise of improving outcomes and cutting costs, artificial intelligence is getting plenty of attention from numerous health care companies. Nashville players are no different and a number of groundbreaking AI projects are underway here. One of those is a prescriptive analytics solution that offers bedside treatment recommendations for clinicians in the behavioral health field. The program, developed by Raiven Healthcare in partnership with local consulting firm SwitchPoint Ventures, works as a collaborative database of clinician annotation and deidentified historical patient data. And while predictive analytics solutions have been making headway for a while, Raiven and SwitchPoint are taking it a step past the predictive stage and using artificial intelligence to create a prescriptive model. “A lot of groups haven’t made it there yet,” says Damian Mingle, chief data scientist for SwitchPoint and adviser to the partnership. In practical terms, Raiven’s platform reduces trial-and-error care practices by pooling the experience and data of physicians and applying the resulting data to individual patients and assisting doctors in their decisions and then incorporating new best practices far more rapidly than existing evidence-based medicine approaches. “Every case becomes a part of a collective, and how that collective works is on many
W
Damian Mingle
things — the underlying patients and the providers of care that have annotated their experience,” Mingle says. “When you think about the layers of contributions from both sides all going into the next patient that rolls through the door, it’s an incredibly powerful thing.” The prescriptive platform does not take the place of a physician’s diagnosis but provides another well-informed item for physicians to consider in their decision-making process. The upside: fewer follow-ups visits and tests and faster and cheaper diagnoses. “There is an optimality that a machine can get through technology that is harder to get at with just human intuition,” Mingle says. “What we try to do is help the human intuition by suggesting what the optimality could be.” The program’s care plan recommendations come with explanations of how the system arrived at the suggestions, something Mingle says helps keep doctors updated with best practices. More knowledge, better care. Nashville-based health IT giant Change Healthcare also has its hands in the AI industry, but in a different way. In August, the company announced its Dual Enrollment Advocate program, which blends artificial intelligence and behavioral science to personalize communication and outreach to Medicare Advantage members eligible for both Medicare and Medicaid.
Nick Giannasi, Change’s chief AI officer, says that about one-third of the nearly 60 million Medicare beneficiaries live below the poverty line and are, in theory, also eligible for Medicaid. However, only 10 million are currently dual-enrolled, which means roughly another 10 million people could reap the benefits. “If you can get them dual-enrolled, you can get them better coverage and care. It’s a meaningful opportunity both from the financial and moral population health perspective,” Giannasi says. In the past, outreach to members was done in a generic way. Giannasi says providers now have access to a substantial amount of information about their patients’ medical history and socioeconomic status. That information can be ap-
‘There is an optimality that a machine can get through technology that is harder to get at with j u s t h u m a n i n t u i t i o n .’ damian mingle, switchpoint
plied to understand and identify which patients are eligible for enrollment. And instead of simply sending out phone calls, the AI system pinpoints the best means by which to contact possible plan members, including by identifying languages, different content forms and pinpointing times of day. In essence, the administrative burden moves away from providers while patient engagement grows, including financially. “You are lowering bad debt and bringing revenue back to the provider that has just been sitting out there,” Giannasi says. “You are increasing revenue for providers with a lower-cost solution than what was previously standard, while cutting the time it takes significantly.” In the end, AI’s one huge need in order to be successful is data — and lots of it. Change Healthcare has a decided advantage on that front: It has a hand in two trillion transactions a year that its machines can learn from and use to identify trends. “We have a transactional network that covers two-thirds the population,” Giannasi says.
NASHVILLEPOST.COM
AI Applications.indd 25
FEATURES
|
WINTER 2018 | VITALS
25
11/15/18 11:43 AM
FEATURES
FEATURES DATA
Tackling disparities with data science
Meharry institute aims to deliver real-time insights to improve care for medically underserved by Lena Anthony
f the formation of data science institutes is the measurement, 2018 could go down as the year big data truly took hold in Middle Tennessee. Three higher education institutions have announced such ventures this year: Middle Tennessee State University launched its interdisciplinary center in June and, following a similar approach, Vanderbilt University opened one in August. By that time, Meharry Medical College officials were nearing an important big data milestone of their own: the one-year anniversary of mining a massive database for insights into health issues, challenges and trends impacting the health of a very specific population, Nashville’s medically underserved. The college celebrated the one-year mark with the unveiling of its new Data Science Institute led by Amy Andrade, who also serves as the school’s senior advisor on innovation and technology. The institute oversees a health care data ecosystem of 4 million anonymous and de-identified records from the 202,000 unique patients served by Meharry Medical Group, the Meharry Dental School and Nashville General Hospital over the past 10 years. Its database also pulls in social determinant and social media data sets as well as publicly available health and environmental data at the neighborhood level — things like air quality metrics, crime, violence and poverty statistics and access to affordable housing and grocery stores.
I
26 VITALS
Meharry.indd 26
|
WINTER 2018 | NASHVILLEPOST.COM
Amy Andrade
“When you begin to enrich the data with social determinants, you get a second and third dimension of that patient,” Andrade says. “And it really gets to the root of identifying risk factors and understanding what’s driving chronic disease.” Andrade says Meharry’s tool is easy enough to use that expertise in informatics isn’t needed. That’s thanks to a development partnership with Florida-based Clearsense. The company started working on the development of Meharry’s data ecosystem in October 2016 and took more than three months to aggregate structured and unstructured data from Meharry’s electronic health records systems and other sources using technology first developed by the National Security Agency. That was the easy part. The challenge was developing the 64-step algorithm that indexes the data (throwing out duplicate or erroneous records) and building the roadmap to a discovery tool. The database uses the open-source, big-
data-friendly Apache Hadoop software, which allows terabytes of data to be mined quickly. “It can run in real time and generate reports while you sleep,” says Lena Walker-Winfree, project manager for the Data Science Institute, who estimates the tool can help shave two to three years of preliminary work off of a research study. Dashboard users can now query the database using a variety of criteria, like ZIP code, cholesterol level or provider name, to access the information they need to identify at-risk patients and improve care for poor and minority populations. Additionally, Meharry research scientists such as Shawn Goodwin are using the tool to efficiently assemble research cohorts and hone their questions. One example: Goodwin recently investigated a link between cholesterol levels and the drugs methamphetamine and cocaine. Using the discover tool, Goodwin assembled a cohort of patients who were addicted to these drugs and then looked to see which ones were diagnosed
daniel meigs
11/15/18 11:44 AM
DATA
Top 10 Largest Healthcare Law Firms - Modern Healthcare 2018
with high cholesterol levels. Compared to the whole population, which has a 7 percent high cholesterol diagnosis rate, the rate among addicted patients was 48 percent. This correlation, while still unproven, could lead to better care for addiction. Goodwin notes that it took him two to three hours to find this possible link. Another group of users are Meharry’s medical students, who can take a survey of data science class this year and earn a certificate in data science during the next academic year. “This is the new evidence-based medicine that we will see within the next five to 10 years,” Andrade says. “We are giving our students an edge — no specialized training in informatics needed.”
The next phases
By the end of the year, Andrade and her team want to have in place a predictive analytics feature allowing users to view models or health forecasts for high blood pressure, cardiovascular disease, obesity and diabetes — four chronic diseases that disparately affect poor and minority populations. By the end of the first quarter,
wallerlaw.com Meharry.indd 27 27 NP_12-18_68.indd
Andrade expects the institute to release findings on the enrichment data — all of those nonpatient record sources — to help draw a clearer picture how environmental and social determinants of health influence these chronic diseases. Meharry also has plans to use the tool beyond the school’s campus. For a fee, researchers can access Meharry’s data by inserting their own algorithm into the tool and then removing it once they get their results. Using Meharry’s data can help researchers overcome the problem of racial and ethnic disparities in studies. “Most standard protocols are done with a majority Caucasian patient set, because that’s just the way it is,” Andrade says. “But we have to think about the fact that, by 2045, we will be a majority-brown population.” Andrade says outside parties haven’t shown much interest in Meharry’s platform yet, but she expects that to change soon. One major factor: The Meharry-led Indigent Care Stakeholder Work Team formed late last year is expected to release its report to Mayor David Briley before the end of this year.
Top 10 Largest Healthcare Law Firms - Modern Healthcare 2018 Top 10 Largest Healthcare Law Firms - Modern Healthcare 2018
FEATURES
“We know that so-called frequent fliers of indigent care aren’t just visiting Nashville General, but all of the area emergency departments, and at a significant expense,” Andrade says. “The vision is to have all of the major health systems based in Nashville involved in tackling the cost of indigent care.” One step in realizing that vision is a partnership between the area’s major health systems enabling the seamless exchange of patient consent forms that would improve the continuity of care. Such an exchange would help cut down on duplicate tests and provide clinicians, at whatever emergency department, with more complete patient care histories. Meharry could then also ingest more data and better calculate the total cost of indigent care in the Nashville region. “The network is necessary to enhance the patient experience as well as to provide continuum of care for the indigent across Nashville,” Andrade says. “We are capable of interoperability with other health systems in Nashville. At a time when everyone’s talking about interoperability, we can actually do it. I’m tired of the talk. Let’s do.”
wallerlaw.com wallerlaw.com
11/15/18 12:28 11:44 PM AM
FEATURES
FEATURES TECH
Telehealth’s march toward mainstream Low-cost technology, high demand suggests tipping point for telehealth is near, but many barriers remain by Lena Anthony
“
Time is brain” is one of the fundamental rules of stroke treatment. But in community hospitals where neurologists are lacking, it can be a hard rule to follow. Transferring patients as quickly as possible used to be the standard protocol when a patient presented with stroke symptoms. Today, telehealth is helping change that protocol, allowing patients to stay close to home and still be seen by a stroke specialist, who can diagnose and initiate treatment remotely. The latest annual numbers from the American Hospital Association show that 65 percent of hospitals use telehealth or telemedicine — defined as connecting with patients and consulting clinicians at a distance through the use of video and other technology — in at least one unit. That’s up from 55 percent in 2014. Telestroke and teleneurology have been most hospitals’ first foray into telehealth. That was the case at Brentwood-based LifePoint Health, which began its telehealth program in 2012, and Vanderbilt University Medical Center, which launched its service four years ago. But as the cost of technology decreases and its capabilities increase, a growing number of hospitals are using the technology to enhance other service lines, including behavioral health, ICU, genetics, pulmonology, cardiology, nephrology and primary care. “Name a service line and one of our hospitals has asked about how they can align it with telehealth technology,” says Kathy Winn, vice
28 VITALS
|
Telehealth.indd 28
WINTER 2018 | NASHVILLEPOST.COM
David Charles
president of strategic market and telehealth at LifePoint. “Given the non-urban markets we’re in, we see telehealth as an incredibly aggressive growth opportunity.” In 2015, LifePoint had 33 telehealth programs in 29 of its then-60 hospitals. This year, there are 78 telehealth programs in 47 hospitals, with another 23 programs in the pipeline. Some systems have their own hub-and-spoke telehealth network (with a LifePoint anchor hospital serving as the hub), but in most markets, the LifePoint facility is the spoke, relying on hub expertise from academic medical centers, tertiary health care facilities and regional or national partners. At Vanderbilt, meanwhile, no fewer than 41 service lines currently use telehealth, including endocrinology (diabetes), hepatology (Hepatitis), psychiatry and addiction counseling. Last year, VUMC handled 5,800 patient visits via telehealth. This year, it’s on pace to perform 7,000, a 20 percent increase, says David Charles, chief medical officer of the Vanderbilt Neuroscience Institute and director of telemedicine for VUMC.
“Our vision is that every Vanderbilt provider, including physicians, surgeons, nurse practitioners, counselors, dietitians and pharmacists, will use telehealth as one of many ways to help care for their patients,” he says. That goal is still a long way off, but by next summer, Charles says an initiative should be in place to get Vanderbilt’s providers “telehealth ready.” One component is the rollout of its new EMR system, which integrates telehealth seamlessly into the platform. Patients and employers are often drawn to telehealth by the promise of convenience but there is huge clinical value in its ability to increase access to physicians and specialists, especially in underserved communities. One in four Tennesseans live in a “provider-shortage area,” Charles says. “Every time you have to transfer a patient, it’s a terrific hardship on both the patient and their families who have to take time off work, arrange transportation and find a place for lodging,” he says. “Being able to care for someone closest to their home and family, putting the patient in the center, is really at the heart of telemedicine.”
daniel meigs
11/15/18 11:45 AM
TECH
For some specialties where demand is high and supply is low — such as primary care and behavioral health — the community doesn’t even have to be rural or non-urban to be considered underserved. Only four counties in Tennessee — Sumner, Williamson, Wilson and Green — are not designated by the U.S. Department of Health and Human Services as a whole or partial health professionals shortage area for primary care. That reality is behind the growth of texting-based primary care provider 98point6. Since its formal launch in the state of Washington in 2017, the Seattle-based company has expanded to 35 states, including Tennessee. Its service is focused not only on diagnosing and treating acute conditions such as urinary tract infections, conjunctivitis or upper respiratory infections, but its board-certified physicians can also order lab tests and help patients manage chronic conditions. Patients access the service through an employer or via a personal plan. For individuals, the first year costs $20 and subsequent years are $120 — for an unlimited number of telehealth visits. It may sound like a loss leader, but Brad Younggren, chief medical officer of the startup, says the model is scalable and sustainable. The key is artificial intelligence and machine learning, leveraged throughout the visit, that create efficiencies not just for the patient but also for the physician. During the information-collecting process, patients communicate with a chatbot. Repeat users don’t have to input the same information on subsequent visits. Physicians, meanwhile, don’t spend time gathering the patient’s history. More and more, Younggren says, AI will take over non-core functions, allowing 98point6’s team of 15 board-certified physicians — all of whom are company employees — to focus solely on diagnosing and prescribing treatment. Younggren says the app helps address the shortage of primary care physicians — the Association of American Medical Colleges projects a shortage of between 14,800 and 49,300 by 2030, caused in part by physician burnout, retiring PCPs and increasing demand of healthcare services by aging boomers — but adds that 98point6 is not “out to replace existing relationships.” When additional care or follow-up is needed, a 98point6 operations team member connects the patient to a provider in their community. It can also find the lowest-cost location for lab work. LifePoint’s Wynn and VUMC’s Charles are each overseeing pilots of direct-to-patient primary care telehealth offerings for their organizations.
Kathy Winn
“A standalone service may be able to treat acute episodes, but they’re not treating the whole patient. What if there’s something more serious going on?” Winn says. “That’s really why we’re entering this space. We feel like we have an obligation that aligns with our mission, and direct-to-consumer telehealth is one more access point to having a relationship with LifePoint.” Charles says Vanderbilt’s approach is more about creating a patient-centered experience. “The old paradigm was, ‘Here we are on 21st Avenue. If you want care from us, you’ll have to come here. We want to be able to meet the patient where they want to be. Telehealth is just one part of that strategy.”
Barriers remain For all the promise of telehealth, obstacles still stand in the way of maximizing its potential. One of them is access to broadband internet. According to the Federal Communication Commission, nearly 40 percent of Americans in rural areas lack access to high-speed connections, compared to 2 percent of people living in urban areas. Even when a community hospital has access to broadband internet, its patients may not, preventing telehealth services like remote patient monitoring from being an option. State licensure requirements are another challenge. VUMC, for example, provides school-based telehealth services to public school students in Allen County, Ken-
tucky, an area that lacks access to pediatricians. But that means Vanderbilt providers working that service must also be licensed in Kentucky. “I could have a patient who lives in Kentucky but comes here for care,” Charles says. “If I needed to connect with them in their home, I can call them, but I can’t use telehealth. We really have to come up with a way to keep pace with the progress of technology.” That, too, is progressing on a national level, through the Interstate Medical Licensure Compact, which offers an expedited pathway to licensure for qualified physicians who want to practice in multiple states. So far, 24 states,
’We feel like we have an obligation that aligns with o u r m i s s i o n , a n d d i r e c t-t o c o n s u m e r t e l e h e a lt h i s o n e m o r e a c c e s s p o i n t .’ K at h y W i n n , L i f e P o i n t
including Tennessee, and the District of Columbia have joined the commission. By March 31 of this year — a year after the compact was founded — the expedited licensure process had been used by 906 physicians who were able to secure 1,301 medical licenses. Perhaps the biggest barriers to even more widespread use of telehealth are inconsistent reimbursement policies and a lack of payment parity. “There are regulations at both the federal and state levels that are archaic and treat faceto-face treatment as better than care delivered via telehealth,” says David Critchlow, senior vice president of government relations for LifePoint. “But if the outcome is the same, the payment should be the same.” One of Critchlow’s jobs is to keep up with the ever-changing reimbursement landscape for telehealth. He notes that 32 states have passed some kind of parity legislation — LifePoint has a presence in 19 of them — but they vary widely. And the federal government, in particular the Centers for Medicare and Medicaid Services, is modernizing its stance on telehealth, which is likely to push high changes throughout the system.
NASHVILLEPOST.COM
Telehealth.indd 29
FEATURES
|
WINTER 2018 | VITALS
29
11/15/18 11:45 AM
FEATURES
SMART. RELEVANT. ENGAGED.
FEATURES TECH
Just last month, CMS officials proposed expanding telehealth access to Medicare Advantage enrollees, giving these plans more flexibility in offering telehealth services to all patients — not just ones in rural communities — and removing the burdensome requirement that participants must receive telehealth service in a health care facility, as opposed to their homes. Earlier this year, an expansion of Medicare telestroke reimbursements to urban and suburban hospitals was signed into law. Previously, Medicare only reimbursed for telestroke at rural hospitals. Those are small steps in the right direction and Critchlow says they could signal bipartisan support for federal legislation that would eliminate state variations and streamline payment parity across all payers. “We’re making great strides,” he says. “On the federal level, there’s a lot of concern for rural health. I think they see telehealth as one of the ways to continue to keep quality services in a rural community. I’m confident we have the support to get it done.”
School Study
For a new subscriber special, go to N A S H V I L L E P O S T. C O M / SUBSCRIPTIONS
Telehealth.indd 30 30 NP_12-18_68.indd
Sevier County in East Tennessee is home to one of the most robust and longest-running school-based telehealth programs in the country. A partnership between Sevier County Schools and Knoxville-based Cherokee Health Systems, the program was started in 2008. Implemented across all 28 of the district’s public schools, the program has logged 14,600 visits for nearly 7,000 students and staff. Most of those visits involve acute illnesses affecting the ears, nose, throat, chest, lungs and skin, but asthma and diabetes can also be treated in the school setting. A school nurse works with AMD Global Telemedicine equipment such as high-definition cameras, stethoscopes and fiber-optic otoscopes, while one of two dedicated Cherokee Health family nurse practitioners is participating via video. School systems as far away as Singapore have come to study the Sevier program that simultaneously increases access to care, offers convenience for students and families and minimizes disruptions to the school day caused by doctor’s visits and the spread of illness, says Julia Pearce, regional vice president of Cherokee Health.
“Students don’t have to rely on parents for transportation to a doctor’s appointment, and parents don’t have to ask for time off to take their students to a doctor’s appointment, which in certain parts of rural Sevier County, could take half a day,” she says. “We’ve taken away so many of the barriers to care, while adding value to the schools.” More schools are understanding the benefits of telehealth, according to the latest Tennessee Department of Education health services survey. In the last school year, 219 schools reported that they had telehealth programs, up from 87 in 2014, says Lori Paisley, executive director of coordinated school health for the state. Paisley expects that number to grow further, as traditional barriers to implementation — funding, slow internet speeds and outdated reimbursement structures — are slowly eroding. Telehealth technology is cheaper and more reliable and 96 percent of Tennessee public schools have broadband internet access, according to the 2017 Broadband Internet Deployment, Availability and Adoption in Tennessee report. Last year, state lawmakers added school-based telehealth to the list of services that insurers, including Medicaid, are required to cover. Barriers to further growth remain, though. Reimbursement for telehealth can only happen when a school nurse is on site, but that’s not currently an option at many schools. In the Metropolitan Nashville Public Schools, only about half of schools have a nurse. > LEnA AnThony
11/15/18 11:59 11:45 AM
TECH
Jean W. Frydman
Higher standards
FDA steps up oversight of cybersecurity in medical devices by Jean W. Frydman
he Food and Drug Administration recently published a new draft guidance to address the “Content of Premarket Submissions for Management of Cybersecurity in Medical Devices.” While this is a draft guidance, it reflects what the agency is thinking regarding these submissions. The guidance was issued in October in part as a response to a report issued by the Office of Inspector General regarding the FDA’s review of medical devices that pose cybersecurity risks. Cybersecurity risks exist when networked medical devices cleared through the premarket notification (510(k)) process or approved through the premarket approval application (PMA) process by the FDA can be susceptible to cybersecurity threats. The OIG observed that the FDA often requires supplemental cybersecurity information from manufacturers where it determines the information provided in a submission is not adequate for hazard analysis related to its use of software or network connectivity. However, the OIG concluded that the agency has not been consistent in the information required for these types of submissions. The FDA’s draft guidance was issued to ensure medical devices — an increasing potential target for hackers — are better protected from unau-
T
thorized digital access. According to the draft guidance, “Cybersecurity incidents have rendered medical devices and hospital networks inoperable, disrupting the delivery of patient care across healthcare facilities in the U.S. and globally. Such cyberattacks and exploits can delay diagnoses and/or treatment and may lead to patient harm.” The new guidance covers the following activities: • premarket notification (510(k)) submissions, including traditional, special and abbreviated • de novo requests’ premarket approval applications • product development protocols that contain software (including firmware) or programmable logic • software that is a medical device. While manufacturers are required under Quality System Regulations to establish and maintain procedures for validating devices’ design, including software validation and risk analysis, the FDA is recommending that validation include design controls to ensure medical device cybersecurity and maintain medical device safety and effectiveness. Including these design controls may make it easier for the FDA to “find your device meets its applicable statutory standard for premarket review.” The recommendations in the newly released draft guidance describe using a more risk-based approach to the design and development of appropriate cybersecurity
protections. The FDA wants manufacturers to design programs to follow their devices throughout the device lifecycle, monitor new and potential threats and issue cybersecurity updates to thwart new attempts at unauthorized digital access of the devices. Because devices that connect to the internet or wirelessly to other devices pose a new and larger threat to cybersecurity, the FDA is requiring a Cybersecurity Bill of Materials be included in the manufacturer’s filing to identify key components and accessories that could render the device vulnerable to hacking. The FDA is creating a new Tier I level of standard for these devices to ensure greater security than Tier 2 devices (those that are not wirelessly or internet connected). Design controls for these devices should now include appropriate authorization such as IDs, passwords, time-limited sessions with auto logout and layered authorization — i.e. for patients, health care professionals and technicians. Authentication and authorization of critical safety commands will be considered in new submissions. In addition, proper labeling to warn patients and providers of the cybersecurity risks involved in these devices is essential. In parallel with the issuance of the new draft guidance, the FDA entered into a memorandum of agreement with the U.S. Department of Homeland Security, which outlines roles and responsibilities for sharing information related to vulnerabilities and threats to health care and public health that involve the cybersecurity of medical devices. The goal is to share such information to enhance mutual awareness, heighten coordination, catalyze standards development and enhance technical capabilities between the two agencies. This draft guidance by the FDA is the latest effort to address the growing concern regarding the potential for medical devices to be vulnerable to cybersecurity risks. As this is draft guidance, and given the constantly changing cybersecurity landscape, the guidelines regarding medical devices are sure to continue to evolve. So medical device manufacturers will need to ensure they are staying apprised of further developments.
Jean W. Frydman is of counsel in the Baltimore office of Baker Donelson Bearman Caldwell & Berkowitz and focuses her practice in food and drug law. bakerdonelson.com
NASHVILLEPOST.COM
Cybersecurity.indd 31
FEATURES
|
WINTER 2018 | VITALS
31
11/15/18 11:46 AM
FEATURES
FEATURES TECH
HELMET TO HELMET
BGA football program uses new technology to monitor player head contact by DAviD boclAiR
attle Ground Academy decided to tackle the issue of head injuries in football head on this fall. Administrators and coaches at the Franklin-based private school were no longer interested in the guessing game that — for many — involves the number and severity of hits to the head players absorb during practices and contests. So as part of BGA’s annual helmet-reconditioning program with equipment manufacturer Riddell, the school opted to have InSite technology added to its protective gear for the recently completed 2018 season. Offered as the only product that “analyzes and collects data from the field of play,” InSite tracks helmet contact in five different zones (top, front, back, left, right) and delivers real-time information to coaches and trainers while compiling a vast database that ultimately will provide useful information regarding each individual player and the team as a whole.
B
“We’re big fans of data and measurement here,” BGA Athletics Director Fred Eaves says. “We felt this was an opportunity to partner with Riddell to give us more information on what we’re doing. And hopefully the information could guide us to best practices to keep our [young people] safe. “… This is a hot-button topic — player safety and concussions — and we wanted to figure out what we could do to help in that manner and put our kids in the best position possible out on the practice field and in games.” BGA’s football team played 10 regular-season games followed by three more in the playoffs, the last of those a loss in the Division II-AA semifinals. That covered more than three full months during which players practiced and played. Most could not begin to guess the number of hits to the head any one player took during that time. However, BGA coaches and training staff have the exact number. For every player. They also were alerted each time a player absorbed dangerous or possibly consequential contact, which has provided the opportunity for immediate assessment and — if needed — treatment. The InSite system includes sensors installed to specific areas of the helmet. The sensors are small enough that they have no effect on the feel or performance of the helmet. There also is a hand-held device comparable to a cell phone, which a trainer or coach keeps on her or his person. Anytime there is contact in a dangerous area or
Battle Ground academy
Football Helmet.indd3232 NP_12-18_68.indd
11/15/18 12:02 11:50 PM AM
TECH
FEATURES
Proudly serving
NASHVILLE’S HEALTHCARE INDUSTRY
to a significant degree, a trainer or coach gets an immediate notification of the player involved and the particulars of the impact. “You almost think of it as another set of eyes at practice,” Eaves says. “There’s not as much chance of someone taking a hit and no one noticing that because it’s going to register on this meter. And then you can take time and evaluate that player on the field.” In the short term, the technology has convinced coaches to adjust practice schedules and the frequency of some drills for a particular position group — or even for the entire roster. Collected data can be analyzed based on magnitude, location and impact load for any player or group of players for a specified time period. In the long term, the data will provide a baseline of specific contact trends by which players can be measured and “advanced headimpact exposure metrics” that include the number of total impacts, the most common area of contact and the number of alerts that he or she has generated. That
Football Helmet.indd3333 NP_12-18_68.indd
allows for comparison to other high school programs and players of similar size and skill level throughout the country. The ultimate goal, of course, is to minimize the number of blows any player either absorbs to or delivers with the head. This is particularly noteworthy at football programs such as BGA’s, for which most players are involved on both offense and defense. “When you’re dealing with a small high school and a limited number of players, these kids only have a limited number of hits in them,” Eaves says. “So you want to make sure you’re protecting them and taking care of them.” The genesis of the technology was Riddell’s sideline response system, which was introduced in 2004. InSite smart helmets were developed in 2013 and, according to company literature, have become the “leading impact monitoring system in football.” This year Riddell introduced the InSite Training Tool, which is the result of data collected from more than 5 million impacts dating back
to the introduction of the sideline response system. It includes information from the NFL, in which more than 60 percent of players use Riddell helmets, as well as from 90 percent of the players in the college Football Bowl Subdivision. InSite technology is available to anyone who purchases Riddell equipment and, according to information from the manufacturer, high schools located in the Northeast have been more receptive to the technology than those in the South. But the use of InSite continues to spread. This year, BGA was the only Williamson County school that used the technology. The only other place in Middle Tennessee where it showed up was The Webb School in Bell Buckle, which plays 7-on-7. The information BGA has gotten from the use of InSite to this point pales in comparison to what is to come. Sometime early in 2019, school officials will receive from Riddell a massive amount of data that they can analyze and use however they see fit. Each football season will add to that database and will create a clearer picture of what BGA football players encounter, in terms of head trauma, during the course of a football season. At this point, those associated with the program don’t fully appreciate what they might see once they analyze all the information. But they’re looking forward to it. “I think with everything going on, the more data that’s out there the better,” Eaves says. “That’s what Riddell is trying to do, to get on the front end of that and be able to get that to people. “We, obviously, had some discussion at the administrative level and had some discussions with our coaches and the decision that this would be good for our kids,” he adds. “They will be part of our helmet, in general, moving forward.”
for
60 years
Scott Mertie
Lucy Carter Coding Compliance Reimbursement Practice Management
krafthealthcare.com 615-242-7351
11/15/18 12:11 11:50 PM AM
FEATURES
FEATURES CONSUMER
Debate: Retail alliances, not Washington, will save the health care system
On the following pages are edited excerpts of their conversation. The full debate and others under the Intelligence Squared umbrella can be viewed at intelligencesquaredus.org.
consumers? Well, in the last year, we’ve seen a sudden surge of consumer-oriented companies trying to figure out how to get into health care in a big way, like Amazon partnering with a bank and with Warren Buffett, with plans to figure out their own health care system for their combined million-plus employees; like CVS, the pharmacy, buying Aetna, the insurance company. They say they know consumers, they know data and they know how to deliver value. Are they onto something? Well, we think this has the makings of a debate. So, let’s have it. Yes or no to this statement: Retail alliances — not Washington — will save the U.S. health care system. In round one, we have opening statements from each debater in turn. Speaking first for the resolution, please welcome Gregg Slager.
Donvan: Traditionally, we who go to doctors, who buy medicine and who check in and out of hospitals have been known as “patients.” But somewhere along the line, we patients started to be called “consumers,” a term that suggests things like choice and competition and value for money. And if we are consumers of health care, then who would know best how to provide to these
Slager: Thank you, John. When we talk about saving health care, what we’re effectively talking about is achieving the triple aim: reducing unsustainable cost, increasing access to care and improving clinical outcomes. My partner and I believe that retail alliances — which are the convergence of health care with retail, technology and consumer product companies — and not government are capable of changing the system.
At Mayo conference, experts take on potential and pitfalls of newer market entrants
he Mayo Clinic’s annual Transform Conference in September featured a debate, moderated by ABC correspondent John Donvan, on whether a full-on retail approach can fix much of what’s not working in the U.S. health care system. The debaters were: • Rajaie Batniji, co-founder and chief health officer at Collective Health • Gregg Slager, a senior partner at Ernst & Young and a co-founder of the firm’s global health practice • Lisa Bielamowicz, co-founder and president of Gist Healthcare • Rosemarie Day, CEO of Day Health Strategies
T
34 VITALS
|
WINTER 2018 | NASHVILLEPOST.COM
Debate Retail.indd 34
11/15/18 11:52 AM
CONSUMER
We all have a lot of pain in the system. We’ve all experienced that. I won’t take you through it all. But we have the fragmentation of care. We have silos. We have difficulty getting access to care and getting appointments. And then the bills come in, too, and they keep coming in and you can’t figure them out. But that’s because we have costs that are out of control. […] And the sad thing is that outcomes rank last against comparable countries in similar developed nations. One of the things that John mentioned is the rise of consumerism and we think that this is a really important facet here. We have been trained by our online experience, what we want out of consumer interaction and we want that experience in health care, too. […] The government isn’t very good with consumers. When’s the last time you went to your DMV to try to get a license? We need new delivery models. The old ones aren’t working. Retailers have scale. They have the ability to make these changes. They can also activate through multiple channels the engagement that they have with their customers. […] The other thing is innovation. Tech and consumer product companies are creating amazing devices, wearables, implantables, digestables, things that can measure many of the vital signs that can give early indications of care conditions or diseases. Same thing with apps. So, I’m not saying that government doesn’t have a role here. Government has a very, very important role, but it’s to support retail. It’s to support innovation. They need to get behind promising initiatives. They need to also align incentives and then, most importantly, they need to put the infrastructure in place to gather evidence to implement appropriate regulation, because what we need in our transforming business right now is we need regulation at the speed of innovation, not innovation at the speed of regulation. Donvan: Thank you, Gregg Slager. Here to speak first against the resolution, please welcome to center stage Dr. Lisa Bielamowicz. Bielamowicz: I want to start with a little self-help moment. I’m a doctor, and I take my kids to the CVS Minute Clinic. It happened two weeks ago. You know how it is: I have an elementary school student. She comes home Friday evening, sore throat, fever to 102. You guys tell me; what does she have? Strep throat. Absolutely.
So, of course the doctor’s office is closed. So what do we do at 8 p.m.? We go down to CVS. We put our name on the list. We mill around, looking at magazines and hairbrushes for the better part of an hour. We get seen by the nurse practitioner. We are out in an hourand-a-half, antibiotic in hand. She’s back in school on Monday. Seems like it was fantastic, right? Now, while I was sitting there, I was remembering that I was going to be coming to you and defending the negative — that retailers aren’t going to be the ones to transform health care. […] Was [this visit] going to the doctor? Is it going to replace my daughter’s pediatrician? Absolutely not. You know what it felt like? It felt like we were meeting with the nurse across a card table in a broom closet in the back of CVS. I’ll be the first one to admit that I am not up here to convince you that Washington and the government is going to be the main change agent. But I want to give you some thoughts about what retailers would have to do if they’re going to truly transform health care. Simply: Are they in it to really change the system? And then, second, are they going to tackle the really big problems and the big cost drivers? And more importantly, will patients like you trust retailers to help them make those big health care decisions? I’ve been really blessed in my time working in health care to get to work with a lot of providers, doctors, hospitals, health systems as well as several of the major retailers. And I’ve gotten an inside window into their strategy in health care. Take CVS. These guys have been at it for a long time. […] You talk to them and you say, “Well, why haven’t you been able to grow this as quickly?” You know who their biggest obstacle is? The store manager. That guy is bonused on revenue per square foot — how much dog food and sham-
poo you buy when you are in CVS. He doesn’t like a dozen people with the flu mingling around in the back of the store. Now take Wal-Mart. Why are they interested in health care? Yeah, there’s a lot of money there. They think they can make money on it. But they’re more concerned about you and how much your health care costs. They think we are spending so much money as individuals that it is hampering our shopping power. They think if they can lower health care costs, they could in fact increase their revenue by three to five percent. They want to get into health care so that you can buy more junk from Wal-Mart. That’s their value proposition. Any of us who have been in health care know that change doesn’t come quickly. It has frustrated venture capitalists. They come in, they want to turn profits around quickly. It doesn’t happen. Retailers are going to get frustrated. And if they’re going to really make a dent in health care, it can’t just be about primary care. That’s seven percent of total health care spend. […] It can’t even just be about pharmaceuticals. That’s about 10 percent of health care spending. You have to tackle the big stuff: Hospital care, specialty care, the 10 percent of patients who account for 80 percent of costs who have really big, significant problems going on. I would ask you, if they’re really going to transform health care, are they interested in figuring out which hospital you should go to? Are you interested in having them tell you which hospital you should go to? To vote yes, you have to believe they’re serious about that and that you would trust them to be your partner when it’s your turn to walk through the hospital door. Thank you very much. And I hope you will consider our defensive position. Donvan: Thank you, Lisa Bielamowicz. Now on to debate for the resolution, please welcome to center stage Dr. Rajaie Batniji. Batniji: Nobody knew health care could be so complicated, so explained President Trump last year. He continued, “Let it be a failure. We’ll blame it on the Democrats.” Ladies and gentlemen, Washington is broken. And a broken Washington cannot save our health care system. The results speak for themselves. Washington responds more to the interests of pharmaceutical companies, big health insurers and hospital systems than it does all of us who are accessing care. Hospital payments since 2000 are up 60 percent, pharmaceutical costs
NASHVILLEPOST.COM
Debate Retail.indd 35
FEATURES
|
WINTER 2018 | VITALS
35
11/15/18 11:52 AM
FEATURES
CONSUMER
up 69 percent. […] Now, this isn’t a red-state issue or a blue-state issue. It was a Democratic administration that took affordability out of the Affordable Care Act and gave a multiyear, multibillion-dollar concession to big insurers so that they would support the bill. It was a Republican administration who gave up Medicare’s ability to negotiate drug prices for seniors. The result: Insulin, which cost $20 a few years ago for a senior, now costs that senior and his payer $700. […] So, employers have effectively become the piggy bank that is financing the runaway growth in health care spending in this country, paying for that proton beam machine the hospital didn’t really need [or] paying for that fancy new wing. And this cost comes back into our Medicare costs and our Medicaid costs because now the federal government also has to keep these hospitals afloat. Employers are beginning to take action. I see this in what Amazon, Berkshire and JPMorgan are doing. And when Warren Buffett says that he and his fellow CEOs are attacking the hungry tapeworm that is eating at the American economy, they mean it. Every CEO in America has woken up and begun to pay attention to their health care costs, recognizing that we can move from a system of health care that is sponsored by employers to one that is driven by them. There’s another beacon of hope, too, that I see. And that is what we see in retail. Like employers have an incentive to drive towards radical transparency and direct first-dollar payment, so, too, do retailers. […] Look at the cost of Lasik eye surgery, down 30 percent over the last 10 years. Nothing else in health care decreases in costs. Look at the cost of in vitro fertilization. As technologies improve, the costs have come down. We always see the inverse in health care. Donvan: Thank you, Rajaie Batniji. And our final speaker will be arguing against the motion. Please welcome Rosemarie Day. Day: So, the United States has some of the most innovative, life-saving treatments in the world. But for the 28 million uninsured Americans, those treatments are completely out of reach. And for the 82 million Americans who have health insurance but can barely afford what they’ve got, they are deferring care […] which actually puts their lives at risk. So in this lack of access to health care, we lag way behind comparable countries. We lag behind in other measures. We actually spend twice
36 VITALS
|
as much in this country and we get half the results. The bottom line is that if you want to address cost, quality and access for all, then retail is not enough. Let’s start with cost. We spend 18 percent of our GDP on health care. Other countries spend 10 percent. If we want to reduce our health care spending, retail is not enough. And why isn’t retail enough? The first reason is that retail alliances are for profit. A retailer’s bottom line is really not society’s bottom line. They are not oriented towards doing the common good. They need paying customers. Their priority is their shareholders, not what’s good for society. So if you’re a lowincome Medicaid customer and you have a lot of different complex needs or you’re an Amazon driver in between gigs, retailers don’t really see you as a money-making opportunity. That’s not to say there aren’t a lot of for-profit companies doing great things, but again, their priorities are their shareholders. If we turn to employers, let’s look at what they’re doing. They insure less than half of our population. The scale of the employers who can actually drive change is very small. When you look at the alliances like Amazon, Berkshire Hathaway and JPMorgan, they only cover a tiny fraction. Providers are not going to make changes if they don’t feel like they’ve got the people coming in the door who are really going to be able to affect that change. I submit that employers don’t have that scale. In fact, it’s government that has that scale. Retail alliances are not enough. Washington actually has to be part of the solution and I would submit that Washington is us. I’m a big fan of innovation. I think that that is part of the equation, but it’s not going to address cost, quality and access for all. We don’t need scattershot solutions. We need a better functioning system. So, I urge you to vote no on the motion that retail alliances will save us.
Donvan: Thank you, Rosemarie Day. And that concludes round one of this debate. In round two, the debaters address one another directly. […] Gregg Slager, both of your opponents argued that retail companies’ ultimate loyalty is to shareholders; not to the health of their employees or the health of their customers. [That] kind of gives the lie to the whole notion that we should be trusting them to take on this job. What’s your response to that? Slager: First off, I think that if you’re lowering your health care costs for your employees so you can buy more goods, I think that that’s important, because what you’ve done is you gave them choice. […] Also, you can look at some of the exercises that some of these retailers have gone into. CVS took cigarettes out of their stores; $2 billion of sales gone overnight because they want to be viewed as a health provider. If you think about retailers and what’s going on in the market today, they’re becoming more mission-based. They’re trying to build trust. Bielamowicz: If you’re talking health and wellness, I mean, is CVS really interested in that? I’ll agree that they waved the flag on cigarettes, but I was out in one in California a couple of weeks ago. There was still liquor and Cheetos all over the place. They are still selling those high-profit items. And I agree: Giving patients — low-income or high-income — the choice of a $60 cash primary care visit versus going to the doctor is a very important choice. But by changing that calculus, are we going to tackle the really big cost drivers in health care? There is no doubt that these companies are going to affect change in parts of the system. […] They are definitely going to change the way that primary care is delivered. I hope, both as a consumer and a physician, that Amazon comes in and pulls the rug out from drug companies. […] A lot of [spending] is in other places. Amazon’s not going to touch that. When you look at other retailers, look at CVS. What are they in addition to being a retailer? Well, let’s look at their balance sheet. $177 billion of annual revenue, $120 billion of that comes from being a pharmacy benefits manager, one of those secretive middle men who makes tons of money off of you and me and the employers by negotiating and coming up with secret drug prices. Donvan: Let’s take Gregg Slager into some of that. And some of what I think your opponent
WINTER 2018 | NASHVILLEPOST.COM
Debate Retail.indd 36
11/15/18 11:52 AM
S PON S OR E D PROFIL E
COMPA N Y PROFIL E
Lipscomb University’s Health Care Informatics programs — developing health informatics pioneers in our nationally-ranked programs. Accelerated Career Growth
Tailored Experiences
Motivated individuals who understand the relationship between people, information technology and the health care system are in great demand. In fact, employment positions in health care informatics are predicted to grow by 20 percent between 2016-2026. The Lipscomb University Master’s in Health Care Informatics can be completed in 14 months, providing students and graduates accelerated career growth.
This program was crafted to help you meet the requirements of an in-demand career. It is important that you have broad, transferable knowledge of information technology, health science, and business analytics that are relevant within the context of organizational relationships, so those topics are a foundation of our curricular offerings. You will also dive deep to develop competencies in emerging technologies like blockchain as well as in the utilization of data, information, knowledge, technology, and automation in health care innovation, development and delivery.
Cutting Edge Innovation
Our Health Care Informatics programs offer an innovative curriculum that incorporates foundational and emerging topics in health care informatics, including blockchain technology, consumer health informatics, and predictive analytics, which provides a solid foundation for your future within this rapidly developing field.
Concentrations
• • • •
NP_12-18_68.indd 37
Data management and predictive analytics Digital and mobile health Healthcare administration and management Blockchain technology
Lipscomb University College of Pharmacy & Health Sciences offers innovative graduate studies in health care informatics that prepare you for entrepreneurial, technical and executive leadership positions in a range of industries. Our experiential and faith-based approach to learning will set you apart — not just locally, but globally. And you’ll gain industry insight from cutting edge faculty at a top-ranked national university. Lipscomb University College of Pharmacy & Health Sciences Master of Science in Health Care Informatics One University Park Drive Nashville, TN 37204 Website: www.lipscomb.edu/cphs/mhci Phone: 615-966-5777 LinkedIn: https://bit.ly/2qxxCc6 https://bit.ly/2PRhvVq
S PE C I A LT IE S Program Highlights • Ranked #11 nationally among HCI programs. • Job placement rate exceeds 99 percent. • HCI employment is projected to grow 20 percent from 2016 to 2026. • The program focus is information technology, health sciences, and business analytics. • Classes meet every other weekend and students complete one class at a time. • Offering blockchain technology curriculum, research, and internship opportunities. • Complete a master’s in as little as 14 months; certificate is completed in five months. Ready for your next steps?
11/15/18 12:11 PM
FEATURES
CONSUMER
is saying is that the benefits that you’re talking about that the retailers may provide are real to the extent that they go. But she’s saying that they touch such a small part of the problem. Rosemarie Day made the same point, that retailers can’t scale to the real size of the problem. Slager: I don’t agree with that. I mean, if you look at the top two pharmacy chains, they have 20,000 retail locations amongst them. So, we have 5,500 hospitals in this country. If you look at, you know, the large retailers like the WalMarts and others, you’re adding another 10,000 or 15,000 locations here, too. And a lot of them are in rural locations, too — that are underserved, that can’t get to a doctor. Forty percent of them don’t have primary care physicians. So, this is the only place that they’re going to get their care. So, it’s very important to them. And a lot of them have diabetes, they have heart disease, they have the big contributors […] that make up 50 percent of our health care dollars. So if retailers can engage with them and they can help manage behaviors and they can do more preventive-type activities […] I mean, if it’s reducing our costs of care, that’s big. Day: So, I think there’s actually evidence that the retailers in these clinics and such do not try to locate in areas that are underserved. […] We were looking at a study in Chicago that showed that there were actual complete almost blackout areas where the retailers wouldn’t go because they don’t see it as a money-making place to have a clinic. And so we’ve actually ended up seeing some pharmacy deserts to go along with the food deserts that we talk about in urban areas. Donvan: Rajaie, what are [retailers] good at in dealing with the consumer? What do they know about consumers? What about their relationship, past relationships with consumers, and also the use of data, that you are arguing gives them an advantage? Batniji: When you go to that retail clinic, they know who you are, they know about you, they’re very familiar with you. But that’s actually not the entirety of the story. It’s actually more about how their incentives are aligned and how they’re competing. They’re competing to be the most convenient solution. They’re competing to be the lowest-cost solution for you. And that is really important if you think about the fundamental care issues that face us. To me, the definition of retailer isn’t just
38 VITALS
|
a pharmacy store. It’s anybody who’s bringing a retail approach to health care. That could be a surgery center. That could be an employer who has worked with a local provider system to change the dynamics of the game. Donvan: Why is that better? Batniji: Because your incentives are fundamentally aligned. In today’s world, who gets rewarded is who strikes the best backroom deal. And in the future, who gets rewarded is who provides the best service at the best price and takes care of the member and delivers outcomes. Bielamowicz: I agree that Amazon, Berkshire Hathaway, JPMorgan has some Amazon juju. But why haven’t other employer alliances like the Health Transformation Alliance, which had IBM, HCA, over two dozen large companies, done anything apart from cutting a few drug company contracts? Donvan: Rosemarie, you made the point that a retailer’s bottom line is not society’s bottom line. They’re sort of saying actually those two things are not in conflict with each other necessarily […] and that a CVS or any other provider at this scale would have absolutely every motive to have happy customers, happy consumers getting the health care they want and need, and that in fact there isn’t that conflict. Day: I think the key is who can actually be a customer. It has to be somebody who has a way to pay for something — whether that’s coming out of their pocket or the employer that’s covering their insurance or they’re on the Medicaid program and that’s actually a government subsidy. And there are a lot of people who don’t have access to any of those things I just mentioned, and so they’re shut out.
Donvan: But they’ve been making the argument that in fact it’s people of lesser means who are able to take advantage of things like a minute clinic at a Wal-Mart or a CVS, that they’re not cut out, that they actually have more opportunity and choice than they would otherwise. Day: To some limited extent. But there are still people who simply can’t even access that. Slager: If they can’t access that, they probably can’t access other care facilities as well. So, I think there is a better chance that they can access care in a retail environment. […] The reason why they’re lower-cost is because they don’t have these ivory towers full of doctors that get baked into the prices. The $4 generics or $4 for the employers or $40 visits… Those are rock-bottom prices, too. There are many more areas of the continuum of care that they are being cut out of currently in the way that the old model works.
‘ T h e k e y i s w h o c a n a c t u a l ly b e a c u s t o m e r . It h a s t o b e s o m e b o dy w h o h as a way t o p a y f o r s o m e t h i n g .’ R o s e m a r i e D ay , h e a lt h s t r at e g i e s
Bielamowicz: What about the ivory ICU? I don’t see Wal-Mart having a $4 ICU or a $4 operating room. Day: The better point for me to make is actually that it’s not just about the sniffles and the kind of low-hanging fruit, if you will, that a minute clinic can deal with. It’s the more intensive needs that they’re shut out of. Batniji: I don’t think we’re arguing that you’re going to get a triple coronary bypass in a Target dressing room. Nor are we arguing that government should completely abdicate its role. And, Rosemarie, with all due respect, the argument that employers are only covering half of America and therefore can’t exert change on the system just doesn’t hold water. […] Employers are the biggest payer in the system and they’re the business-class passengers. They’re paying the
WINTER 2018 | NASHVILLEPOST.COM
Debate Retail.indd 38
11/15/18 11:52 AM
S PON S OR E D PROFIL E
A talent & solutions firm. COMPA N Y PROFIL E Vaco is a talent & solutions firm, providing expert consulting, permanent placement, and strategic staffing for companies around the world, in the areas of accounting, corporate finance, technology, operations, administration and more. At its core, Vaco’s mission is to connect people to their dream jobs and help leading companies find talent to grow their business.
In an evolving healthcare market, the right healthcare IT partner is critical
Hiring & consulting – the human way. vaco.com 615.324.8226
NP_12-18_68.indd 39
Nashville has long been known as a national healthcare industry hub and global leader in healthcare. Our city has commanded a reputation for developing innovative healthcare companies and fostering leading industry talent. Nashville’s recent meteoric rise in popularity has only fueled these attributes. There are multiple factors affecting the healthcare industry on a national scale. New technologies continue to alter the healthcare landscape and companies are having to find ways to adapt to these changes. Nashville’s entrepreneurial spirit and growing population make us more than equipped to handle this continuing evolution. Healthcare organizations face complex decisions daily and working with the right healthcare IT partner can be a critical component of success. Whether your organization needs strategic guidance, legacy systems support, data management assistance, or planning an EHR implementation, Pivot Point Consulting, A Vaco Company can help. We assess your organizational needs, develop strategic goals, prioritize resources, and identify best practices and solutions. Pivot Point Consulting, A Vaco Company is a KLAS-ranked health-
care IT firm specializing in advisory services, EHR and ERP implementation and optimization, training and activation, project management and PMO, legacy support, technology services, and managed services. Clients range from large multi- hospital networks to academic institutions, pediatric hospitals and local community clinics. Vaco provides expert consulting, permanent placement, executive search and strategic staffing for companies around the world, in the areas of accounting, finance, technology, healthcare, operations, administration and more. As a premier talent & solutions firm, Vaco connects people to their dream jobs and helps leading companies find talent to grow their business. Since its founding in 2002, Vaco has grown to now serve 40 markets across the globe, 800+ employees, 4,300 consultants and $500M in revenue. Vaco has been named to Inc. magazine’s list of the fastest-growing private companies for the past 12 years and was ranked #4 on Forbes’ 2018 list of America’s Best Professional Recruiting Firms. From founding until now, Vaco is dedicated to developing long-term relationships, life-long careers and creative client solutions.
Website: www.vaco.com Phone: 615.324.8226 Twitter: Global: @vacoglobal Nashville: @vaconashville Facebook: Global: @vacoglobal Nashville: @vaconashville LinkedIn: www.linkedin.com/ company/vaco Instagram: @vaconashville
S PE C I A LT IE S Tap into Vaco’s vast global network and deep local relationships to find talent with the right skill set and best culture fit for your business. ACCOUNTING AND FINANCE From CFO searches to temporary contract positions, Vaco does the legwork for you. TECHNOLOGY Get top tech talent that’s ready to hit the ground running. HEALTHCARE IT Vaco delivers top business solutions to solve all your Healthcare IT needs. HR/ MARKETING/ SALES Build long-term relationships, lifelong careers and creative business solutions in a flash. OPERATIONS AND ADMINISTRATION Vaco delivers the right talent at the right time to keep your business growing strong.
11/15/18 12:17 PM
FEATURES
CONSUMER
Day: And I would add that insurers [have] often been accused of having a lot of power, maybe sometimes too much in certain markets. And yet they struggle when they go up against some of the large provider systems that have been increasingly consolidating and assembling their market power and almost in a sense being able to set prices. Slager: When I think about innovation and tech companies and consumer product companies, what they’re bringing to the table here are these demand aggregation platforms. You’ve seen them disrupt other industries. They disrupt travel. They disrupt media. They disrupt retail. Sixty percent of purchases are made through a demand aggregation platform online from a retail perspective and we’re building those things to try to drive similar disruption. Aggregating employee demand will encourage provider and supplier platform involvement, too, and it’s a virtuous cycle. We’ve seen it happen many, many times. This is where technology can help. It’s a virtuous cycle.
‘Employers do have the ability to exert t h e i r p o w e r a n d f i n a l ly s t a r t a c t i n g l i k e t h e b i g g e s t p u r c h a s e r s i n t h e s y s t e m .’ R a j a i e B at n i j i , c o l l e c t i v e h e a lt h
highest prices to these provider systems. Employers do have the ability to exert their power and finally start acting like the biggest purchasers in the system and get prices under control and federal programs will benefit from that by having lower prices and a more responsible system where we contain runaway growth. Day: Well, that’s really interesting because why are they paying almost twice as much as Medicare for the exact same things? That actually suggests that government has got more of the power to influence prices […] than the employers have shown to date for as big as you say they are. Batniji: What it actually proves is that employers have worked not directly, but rather through intermediaries that keep them totally in the dark about pricing and that’s what these
40 VITALS
|
employer alliances are all about. It’s about getting employers to work directly with the provider systems and finally exert their control and that will drive down costs. Bielamowicz: But when you get right down to it, large employers are only a third of all employed Americans. My family owns a John Deere dealership outside of Houston, Texas. My mother, who manages the benefits, doesn’t have the time, bandwidth or knowledge to not go through an intermediary to help them find good health care for their couple of dozen employees. It’s a completely different game for the folks who work for small business.
Donvan: And now we move on to round three, where each of the debaters makes a closing statement. First, Gregg Slager. Slager: I just want you to imagine Irene. And everybody knows an Irene. Irene is 56 years old. She lives with her husband. She’s on a fixed income. She’s got diabetes and she’s struggling with high blood pressure. She goes to her retailer once or twice a week with her husband. She’s enticed to come there to buy products that she typically buys, that the retailer knows through its intimate relationship and engagement and through using data analytics. While she’s in, she goes to the pharmacy, she refills a script, she buys some insulin strips. She stops to get her blood pressure tested to compare to her home results. It’s high. So, she stops by the clinic to get some questions answered. And what they do is they put her on a telehealth monitor with a doctor who talks to her about what’s going on, any other kind of things in her life that may be causing these things and then gives her a new prescription. She pays $4 for a generic. The retailer then sends her texts on care adherence and nutrition suggestions and whatnot, too. What the retailer is doing here is trying to address the chronic disease issues. It’s trying to address the long-term disease issues, which are big cost considerations for our system. It’s
WINTER 2018 | NASHVILLEPOST.COM
Debate Retail.indd 40
11/15/18 11:54 AM
CONSUMER
‘Aggregating employee demand will encourage provider and s u p p l i e r p l at f o r m i n v o lv e m e n t. I t ’ s a v i r t u o u s c y c l e .’ G r e gg S l a g e r , E r n s t & Yo u n g
also keeping her out of the ER. […] They are serving a need and they are really making an impact on cost of care. The government can’t do it. The old model care, too, is “We’ll build it. You will come wherever we are. You’ll pay whatever we [ask].” That’s not what retail is all about. We want you to understand that retail can fix this problem much better than government. Donvan: Thank you, Gregg Slager. That’s an applause line. Making her closing against the motion, Lisa Bielamowicz. Bielamowicz: Well, we are a long way away from of a retailer providing comprehensive health services. Remember my visit to the retail clinic? The nurse practitioner across a card table in a broom closet? Retailers will continue to up the game for convenient care. They might completely change that part of the system. But will retailers actually transform the system? Are they going to tackle the big cost drivers in health care, which are very sick patients coming in for very intensive care needs? Changing primary care is fantastic. It needs to be done. […] But I would ask you, if you’re going to vote yes, you would have to feel comfortable going to Wal-Mart when you’re worried you might have cancer and having them potentially direct you to a lower-cost provider. Will you trust a retailer with your end-of-life health care decisions? If you’re going to truly transform the system, you can’t just provide a telemedicine visit. You can’t just provide a $4 low-cost generic drug and you can’t just be quick care. You have to be motivated to provide care to really sick patients. And if you’re not willing to answer yes to that question for yourself personally, then I think you have to vote no. Donvan: Thank you, Lisa Bielamowicz. Making his closing statement for the motion, Dr. Rajaie Batniji.
Batniji: I see the urgency of fixing our health care system in every patient that I treat. And I recognize, like many of those who work in health care, I’ve been part of the problem. I’ve ordered a $1,200 bag of saline to save a patient’s life knowing that it cost my hospital $1 or $2. I know that I’ve created financial distress for my patient as he’s been sent to collections and that bill has my name on it and I’m not proud of that. Today, we’re faced with a health care system that needs saving. I have not heard my opponents make a single argument about how government can save our health care system. We’ve made several arguments about how retail can save our system and how employers working directly can take this system from a world of obscure contracts and dark, smoke-filled rooms and clear out the smoke and turn on the lights and turn this into a transparent system where we know what we pay for and we pay for value. So, let’s turn on the lights and clear the smoke. Please join us in this motion and vote for the resolution. Donvan: Thank you, Rajaie Batniji. Here making her closing statement against the motion, Rosemarie Day. Day: So, I want to close with a story. Gregg had Irene. I’d like you to meet Eloise. She’s someone I actually met when we were implementing health reform in Massachusetts.
She was a 50-year-old woman, a single parent who had worked hard as a cleaning woman her whole life. She had no health insurance and she was struggling to put her two sons through college. She was a very proud woman but she wasn’t proud of her fainting spells which would happen at work and sometimes keep her from working. […] She wasn’t part of any retailer’s picture and she wasn’t part of any employer alliance. But she was finally able to buy some affordable coverage once we launched the health connector and she was able to see a doctor and get diagnosed. It turned out she had epilepsy and it was treatable. When she came to tell her story at our board meeting, she held up the bag of pills which she was now able to buy through the retailer and that was what was keeping her healthy and productively employed. On every front, she was doing the right thing and we were supporting her in that. I see this as a huge success story and it’s an example of where government insurers and retail all came together to address those big things that are the ultimate measures of our system, cost, quality and access. Why wouldn’t we want to have 28 million more Eloises? I think we can do that if we have the will. We talk about Washington as kind of this thing “over there.” I want to say that’s us and we have to actually harness the collective will to demand that of our system because if we have that, we can address and drive change. We can do that in conjunction with retailers, but it needs to come from the polis. And that’s us. Donvan: All right. Well, thank you for all that. I want to announce our results. Remember, you voted once before the resolution and once again after the resolution. It’s the difference between the two votes that determines who our winner is. Here are the results: Before, in the preliminary vote, 30 percent agree with the resolution, 36 percent were against, 34 percent were undecided. That’s pretty much a three-way split. On the second vote, the team arguing for went up to 49 percent. They pulled up 19 percentage points, which is the number to beat. The team arguing against the motion, their first vote was 36 percent, their second vote 47 percent. They picked up 11 percentage points. But that was not enough to win. It means we’re declaring our winner is the team arguing for the resolution, “Retail alliances — not Washington — will save the U.S. health care system.” Our congratulations to them.
NASHVILLEPOST.COM
Debate Retail.indd 41
FEATURES
|
WINTER 2018 | VITALS
41
11/15/18 11:54 AM
FEATURES
FEATURES CONSUMER
Survey says… Patient satisfaction emerges as an increasingly important metric by Kara Hartnett
onsumerism has hit the health care industry with some force — and providers are being forced to listen. Patients are taking (or being pushed to take) control of their health care and spending like never before and pushing hospitals and doctors to reform old practices in the name of patient satisfaction and retention. To get a glimpse at these needs, an ever-growing number of health care providers distribute patient experience surveys to better understand the growing demands of their patients and, in turn, improve their care practices. Lisa Reich, a consumer experience coach for Studer Group, says the surveys have promoted an environment of communication between health care providers and patients. “People want to know, and be in control, of their health, and that is data proven by the patient experience surveys,” Reich says. “If health care providers want to retain their consumer base, they have to learn to communicate efficiently with their patients and treat them with the respect they deserve.” In the past, the health care industry provided little opportunity for consumers to switch providers. With a high retention rate, health care providers had no reason to incentivize or adapt to patient needs to earn customer loyalty. Ac-
C
42 VITALS
|
cording to Accenture Consulting, the era of digital health — featuring electronic health records, consumer portals, online appointment scheduling, health data sharing and price transparency pushes — has changed that, and consumer experience has risen to near the top of health care provider’s priority list. With patient retention in mind, the Affordable Care Act gave inpatient providers another reason to prioritize patient experience surveys. Starting in October 2012, the Centers for Medicare and Medicaid Services began withholding about 2 percent of total Medicare reimbursements from hospitals. Each year, only facilities with high patient experience scores and a measure of certain basic care standards will earn that money back while top performers will receive bonus money from the pool. These Medicare-mandated surveys — they’re called Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS, and
patients around the country take more than 3 million of them annually — have given rise to concern over tying hospital reimbursements to subjective patient experience metrics. To detractors, they could cause harm by diverting attention away from clinical outcomes and care quality. Other concerns include the handful of patients who have unrealistic expectations for their care and outcomes or who might call out factors not instrumental to their health, such as hospital food court options or other patients. Still, Brian Carlson, the senior director of patient experience at Vanderbilt University Medical Center, says patient satisfaction only plays an incremental role in the broader Medicare reimbursement picture. “There is also quality in there and outcome measures that are in the calculations as well,” Carlson says. “So the calculation for reimbursement is very complex. Patient satisfaction scores are required, though.”
WINTER 2018 | NASHVILLEPOST.COM
Patient Satisfaction.indd 42
11/15/18 11:55 AM
CONSUMER
Regardless of reimbursements, Studer Group’s Reich believes providers use the survey data to understand how to take care of their patient populations as well as possible. But there are wrinkles: A national study conducted by the University of California revealed that patients who reported being most satisfied with their doctors actually had higher health care and prescription costs, and were more likely to be hospitalized than patients who were not as satisfied. Worse, the most satisfied patients were significantly more likely to die in the next four years. Reich believes those findings are based on skewed data. “People that are closer to death are seeing more health care facilities,” Reich says. “That end of life is usually when you cross the paths of health care, and in my mind they would probably be the best ones to describe it.” The study also says health care providers may be less inclined to talk patients out of unnecessary treatments or to raise concerns about smoking, substance abuse, mental health or obesity as to not offend or upset them. Despite those potential flaws, Carlson believes the patient experience surveys play a fundamental role in creating a better and more efficient health care system. “All that experiential stuff has an influence on the patient’s outcomes. We do not want to cause undue stress when they need to be focusing on the condition they are being treated for,” Carlson says. “That is the way that we can bring attention and priority to it. No. 1, it’s always about the outcome, but the patient experience is just as important in that whole equation.” To Reich, provider-patient communication is the key to high customer satisfaction results. She says providers have been working to better connect with their patients by talking through treatment options in detail face to face and then providing written materials to take home. Bigger trends also are contributing: Patients are showing more initiative in understanding their care plans because, thanks to changing protocols, they are spending less time in inpatient facilities and more time taking care of themselves at home. “They have to know how to take care of themselves when they leave our care, and we have such a short window to teach them that,” Reich says. “My personal feeling is that the survey helps us find very critical ways that we can improve, and what will work for us and our patient population.” To improve those communications and boost their scores, clinicians are installing programs
to ensure they are doing their due diligence when providing insight to a patient’s care. That could mean demonstrating courtesy and respect and making sure no questions go unanswered. Similarly, Reich says nurses have developed systems to provide optimal care such as rounds — where on-duty nurses check rooms every hour — and a five-step patient communication system called AAIDET, which stands for answer, acknowledge, introduce, duration, explanation and thanking. On an administrative level, Carlson says, health care providers use the data to set goals. They will look at historical trends, pinpoint data sets that need improvements and create action plans based on the information provided. “Another value we find in this survey is the actual context the patients are giving in the form of comments,” Carlson says. “Those comments give us contextual definitions to what our patients are experiencing. That is much more beneficial in improvement efforts because not only can we show the number has declined, but here is why.” Most health care providers lean on third parties to handle surveys. These organizations generally work with other health care entities to include similar questions. Carlson says this helps Vanderbilt leaders see how they’re doing compared to their competitors. In the spirit of transparency, hospitals normally not required to report HCAHPS or patient experience data have been doing so to provide insight to potential consumers about the quality of care provided.
Promoting providers Many providers use another customer satisfaction rating system, Net Promoter Score, to gauge their consumers’ loyalty. A net promoter score asks patients for feedback on a 1-10 scale about how likely they would be to recommend the health
care facility to others. Accenture’s 2014 Global Consumer Pulse Research notes that consumers are much less likely to advocate for their health care providers than they are for other services. But the research also showed that 44 percent of consumers choose their health care provider based on personal recommendations. Using promoter scores allows providers fast data on patient loyalty and sheds some light on whether they could benefit from recommendations. Whereas many organizations have adopted the practice, others aren’t certain the depth of the data compares to traditional surveying means. Carlson is skeptical. “In health care, it’s a process to get care. The experience is the sum of all of those processes, the sum of all those experiences and interactions,” he says. “So to just ask one question and get one response back… Directionally, it tells us how we are doing, but if we aren’t doing well … where is it? There have to be more questions asked there. That’s why surveys in health care are so long right now. We need the data and feedback to pinpoint what we could be doing differently.” The Net Promoter Score system may also incorporate cultural biases: An article in Psychological Science showed that people in individualist countries choose the more extreme sides more frequently than those in collectivist countries. For instance, an U.S. citizen is more likely to rate a service as “amazing” or “terrible” than someone from Japan, who will stick to “fine” or “not satisfactory.” Also, consumers in the “neutral” and “dissatisfied” categories often don’t fill out surveys, increasing the potential for results that skew upward. Nikki Rasmussen, a clinical lead for provider relations at Knoxville-based Focus on Therapeutic Outcomes, says her company is trying to remedy those issues by adding a commentary line for patients to elaborate on their quick scores. FOTO’s system also calls for consumers to fill out surveys while still in the clinic, pushing up response rates. Whatever form providers use to survey the patient experience, they are paying attention to the data trends and evolving to create giltedged patient care. That said, patients also have to do their part. “What I would want [consumers] to know is that we do use the data from the surveys and that we appreciate the time and partnership,” Carlson says. “When they receive a survey, it is very important for them to fill it out.”
NASHVILLEPOST.COM
Patient Satisfaction.indd 43
FEATURES
|
WINTER 2018 | VITALS
43
11/15/18 11:55 AM
FEATURES
FEATURES MANAGE
Nancy-Ann DeParle, Jack Bovender and Milton Johnson
‘An awesome opportunity to learn from each other’ HCA leaders reflect on the hospital giant’s evolution, guiding principles
his fall, the Nashville Health Care Council convened a large crowd at War Memorial Auditorium for an event spotlighting the 50th anniversary of what is today HCA Healthcare. The evening’s highlight was a panel discussion featuring former CEO Jack Bovender, current CEO Milton Johnson and CEO-to-be Sam Hazen as well as LifePoint Health CEO Bill Carpenter. On the following pages are some of the HCA execs’ (lightly edited) thoughts from that talk — which was moderated by former White House policy staffer, private equity investor and HCA board member
T
44 VITALS
|
WINTER 2018 | NASHVILLEPOST.COM
HCA Growth.indd 44
Nancy-Ann DeParle — on some key moments from the company’s five decades and the philosophies behind running the company.
Moments that stand out Johnson: Two things come to mind. I go back to 1985 and I was 29 years old and had been at HCA, at that point, about four years. It was proposed to merge HCA into American Hospital Supply. The deal didn’t happen; Baxter wound up taking American Hospital Supply out. But if
that would’ve happened, how that would have affected Nashville and how that would’ve affected HCA, we never will know. That was a transaction that Tommy (Frist) was surely supportive of. But Baxter came in and just made a bid that was over the top and it broke our transaction up. But I remember that very clearly, thinking about that impact. If that transaction happened, would HCA have still remained in Nashville over the years? The second thing, again, is about the impact on Nashville. […] You have to recall that — I think it was around the 1994-1995 timeframe — Columbia/HCA was moving its corporate office to Louisville, Kentucky. It was leaving Nashville. With the HealthTrust merger that happened in 1995, part of that negotiation was — and Tommy remembers this well, I know — HCA had to stay in Nashville as part of that transaction. Although it never really felt like it moved to Louisville, technically, it was declared the corporate headquarters of HCA for a period of time. But then of course, it was able to stay here.
DONN JONES
11/15/18 11:56 AM
MANAGE
‘[Spinning out other companies] reflected the bench that we had, that we could send an executive off and watch them be s u c c e ss f u l . T h a t h a s c r e a t e d a c i r c l e t h a t h a s c o n t i n u e d f o r 5 0 y e a r s .’ DeParle: Sam, you’re smiling. What have you got? Hazen: I don’t even know that Tommy knows this story. In 1992, I was 32 years old when the transaction between Columbia and HCA occurred. In the discussion about the corporate office, I was the lead negotiator for I don’t know who — I had three or four people, all of whom could fire me. I was negotiating against Carl Pollard, the chairman of Galen [Health Care], Rick Scott was the CEO and then there was this gentleman I’d never met, Tommy Frist, who was pulling for Nashville. So I’m there negotiating with the governor of Kentucky and the secretary of commerce and trying to get this deal done. I remember telling my wife, “I don’t know which direction to go. Everybody involved in this event can fire me. I’m not sure we’re gonna make this so let’s start saving some money.” When I roll it forward to the early ‘90s, in any industry, there’s always a period of consolidation that occurs that I think sets a platform for an organization to really grow and prosper. When I look today at HCA and I look at that four-year cycle — I think it was 1992 through 1995 — where the company put together four or five different public companies all at once. It introduced us to new markets: San Jose, California; Denver, Colorado; San Antonio, Texas; Austin, Texas; deeper penetration in South Florida… Today, what is tremendously unique and powerful about HCA is this incredible portfolio of markets that we have. The legacy is it came from that period. And to be perfectly candid, we all got jobs because of that period. As difficult as it was, it’s a tremendous learning lesson. It’s a lesson for any management team to understand. Whether it’s about consolidating too much too quickly, not having the infrastructure in place that you need, not having the culture that you need… All of those things can break down a great acquisition strategy.
M i lt o n J o h n s o n
When I think about that period, that’s a very important period in who we are today as an organization and how we were able to benefit from that time period.
Growing the family tree DeParle: HCA has a history of supporting its team members who leave to start new companies or join other companies. I’m interested in why that is. Some employers wouldn’t like that. Bovender: I think this goes back to particularly Dr. Frist Sr. and Tommy and their attitude toward the people who were working for us or are working for us. If they want to go out and try something on their own, [there is a] “Go with God” kind of philosophy. Tommy is one of the great entrepreneurs in the history of the U.S. He doesn’t get recognized for it because he didn’t grow up in the Henry Ford/ Edison days. He’s a modern entrepreneur with significant achievement. He recognized that in the spirit of other people, many of them sitting in this room today. He always approached a person leaving with that kind of attitude: “I hope you make it. We’ll do what we can to support you.” Even when they were potential competitors in the future. Johnson: It’s the spirit of the company that you’re getting at. It was always supported. I can remember individuals who wanted to be a CEO of
their company and they knew, because of various circumstances, that maybe that wasn’t going to happen — at least not on their time frame at HCA. So they were supported to go out and start their own company and build their own company and get that experience and build jobs. Also, you’ve got to remember that we’ve created a lot of companies, whether it was the psych company that we spun off before or the ambulatory surgery business that we spun off. There were always businesses that we decided might be better businesses on their own than under the HCA umbrella. To see those companies flourish is something that gave HCA a lot of credibility in the investment community. It reflected the bench that we had, that we could send an executive off and watch them be successful leading their company. That has created a circle that has continued for 50 years. Their success really has promoted our success.
Great managers to great leaders DeParle: Let’s talk about leadership for a minute. I’m interested in what advice you have for people who aspire to leadership positions inside their companies. Hazen: We’re fundamentally in the people business and so we have to have individuals who can lead an organization through other people. I think it starts with a great purpose and then underneath that, it has to have a strong value system that really supports the purpose. We have an incredible pool of talent today and we’ve had an incredible pool of talent historically. There’s an awesome opportunity inside of HCA to learn from each other and build a leadership platform that allows the company to succeed. It’s about understanding the business, it’s about making decisions, it’s about doing the right thing, it’s about having a strong value system — and really honoring the fact that we are a very important, almost public service-type of utility service in many of the markets where we are. What people don’t understand about HCA today is that we’re much larger than a hospital company. We have roughly 2,000 facilities providing anywhere between 125,000 and 150,000 patient visits a day. That requires 250,000 employees, 40,000 physicians and numerous families and friends. The leadership structure has a huge responsibility to take care of those people in those
NASHVILLEPOST.COM
HCA Growth.indd 45
FEATURES
|
WINTER 2018 | VITALS
45
11/15/18 11:56 AM
FEATURES
MANAGE
‘ A l w a y s p u t p eo p l e a r o u nd y o u w h o w i l l t e l l y o u t h e t r u t h .’ Jack Bovender
And the last thing I’ll say is humility. When you win, you win as a team. In a big organization like HCA, no one person can be responsible for our success. It is a team effort. If you can put together accountability, purpose, inspiration, relationship-building and humility, then you can lead. DeParle: Jack, that strikes a chord with you?
Sam Hazen
kinds of situations. For us, having the right purpose in connecting the business that we’re in to decision-making systems allows us to generate good people and ultimately good leaders. Johnson: I have the opportunity to speak to a lot of the younger people in the company and that’s a question they always have: “How do you become a leader in this company?” I try to describe it as, “How do you move from possibly being a great manager to being a great leader?” and understanding first of all that it’s a different role.
46 VITALS
|
WINTER 2018 | NASHVILLEPOST.COM
HCA Growth.indd 46
To make that transition, first, you have to have a sense of accountability. As a leader, you’re going to have to make a lot of decisions and you’re going to make some mistakes. You have to stand up and take responsibility for the good decisions as well as the bad decisions to be an effective leader. No. 2, Sam’s absolutely right. You have to connect the people you’re leading to a sense of purpose. You have to inspire them to accomplish something that’s worth the effort you’re asking them to put into it. Then you have to invest in building relationships as a leader.
Bovender: Yes. When I speak to MBA students and others and they ask me what are the attributes of leadership, I always say the most important one is humility. This is a team sport that we are involved with. It’s not about the person at the top. It’s about the team. Many years ago, someone gave me a plaque that said: “The goal of the usual leader is to make people think more of the leader. The goal of the exceptional leader is to make people think more of themselves.” I think that’s the real key to creating an atmosphere where everyone is committed to the things that Milton talked about and nobody is reaching constantly to get the credit for accomplishments. And then I’ll say one other thing that I think is extremely important. A good leader surrounds him- or herself with people who will tell them the truth even when they don’t want to hear it. In other words, they will say to you, “If you do what you’re thinking about now, you’re going to screw up and screw up big time.” In my case, when I was chair and CEO, that person was Bruce Moore, who is sitting in the audience back here — and is still around and still doing the same thing, I’m sure. But I’m very serious about that. Some leaders, over time, tend to aggregate around them people that tell them, “You’re the greatest thing that ever happened to this company or this industry or whatever.” And that’s very, very dangerous. Always put people around you who will tell you the truth.
DONN JONES
11/15/18 11:56 AM
WE ARE THE REAL ESTATE DOCTORS. You only want the best for your health, and the health of your business. If you want the best real estate outcome consult with Foundry Commercial. Our practice is commercial real estate.
+
SERVICES CORPORATE ADVISORY
PROJECT MANAGEMENT
LANDLORD REPRESENTATION
INVESTMENT SALES
PROPERTY MANAGEMENT
DEVELOPMENT & INVESTMENTS
foundrycommercial.com
NP_12-18_68.indd 47
11/15/18 12:18 PM
FEATURES
FEATURES MANAGE
Members of the 2018 Fellows class marked their commencement at the Noah Liff Opera Center.
Tracking, driving evolution
Health Care Council’s Fellows program celebrates its growth, looks to future by Stephen Elliott
n January, when the seventh cohort of Nashville Health Care Council Fellows will convene for its four-month-long session, the health care executives from across the country that form the group also will connect with a larger group, the fellows program’s growing alumni network. The Health Care Council touts the relationships built by participants in the program, launched in 2013, even among participants from different years. Case in point: SwitchPoint Ventures CEO Ray Guzman (Class of 2017) and PhyMed Healthcare Group CEO Marty Bonick (Class of 2014), who met during Guzman’s time in the program and have developed a professional and personal relationship since.
I
48 VITALS
|
WINTER 2018 | NASHVILLEPOST.COM
Fellows Program.indd 48
“While we’re a traditional business, we’re doing things very non-traditionally using information that wouldn’t have been possible without the partnership [with Guzman],” Bonick said in a Health Care Council profile. “You can get a lot further, a lot faster.” Organized by former U.S. Senate Majority Leader Bill Frist and Vanderbilt University health care economics professor Larry Van Horn, the fellows program is designed to bring together senior health care executives from different, sometimes siloed, sectors of the industry in order to brainstorm — and sometimes put into practice — improvements to the country’s health care ecosystem. It has changed, and grown, some in its six years, but still remains committed to that original mission, says June Patterson, director of the program. “These conversations started about 2011 and 2012 as an idea, and to fast forward [to] seven years later, that passion working with those leaders to identify and understand and address all of the most pressing problems in health care has been an inspiring constant through the program’s evolution,” Patterson says. The changes have included a geographic expansion: One in five participants now comes from health care organizations based outside of Middle Tennessee. And they’ve changed as issues in health care have changed: Last year, Frist and Van Horn added a session on the opioid crisis, including presentations from addiction and behavioral health experts. Another new topic of
discussion this year was food pharmacies and dietetic prescribing. In addition to the new topics, the fellows program also added a functional change this year: a white paper that Patterson says “the rest of the industry can benefit from.” Next year, it will add a closing retreat, “something giving the fellows a final chance to reflect on their experience and talk about practical ways that they can apply their learning to improve the health care system.” During the course of the program’s four months, fellows participate in eight day-long sessions. The application process, conducted every fall, is thorough. Candidates must be C-suite members or senior executives at a health care organization of any size and endorsed by two other senior health care leaders. For now, it’s only open to participants based in the United States. As their network of alumni expands, the program’s organizers believe the opportunity for collaboration and innovation within the health care industry will grow, too. And it’s only fitting, they say, that it’s based in Nashville, home to innumerable industry leaders. “We’re just really proud that this program exists in Nashville, and we’ll continue to broaden our scope as it relates to the national conversation, and do all that we can to prepare the future leaders of health care to give them all the tools that they need to make the health care system the best that it can be for all of us,” Patterson says.
Nashville Health Care Council
11/15/18 11:58 AM
MANAGE
More communitycentered care Saint Thomas beefs up clinics as a retail-oriented response by Geert De Lombaerde
s retail philosophies make greater inroads into health care, incumbent players are having to become more nimble in how they connect with patients far less willing and able than in the past to take large blocks of time to visit sprawling hospital complexes. One of the ways leaders of regional health system Ascension Saint Thomas are reacting is by developing what executives call robust care centers. These facilities are focused on primary care, but also offer services that in the past were housed at hospitals but in recent years have been pushed into retail settings. With robust care centers, Ascension Saint Thomas is looking to bring under one roof various community health care services, including nutrition guidance and osteopathic treatments. Chief Strategy Officer Amber Sims says the health system’s push to build on its primary care presence with an expanded menu of services began in 2015. The traditional, overhead-heavy acute-care approach, she says, focuses first and
A
foremost on how to fill hospital beds and perform as many surgeries as possible. “We wanted to flip the model upside down and asked, ‘What does the community need?’” she says. “We dug down to the psychographic level. We looked at factors such as disease prevalence and internet use.” The robust care center approach still focuses on primary care but also rotates various specialists as well as imaging and physical therapy services if the data shows the surrounding area needs them. Plans are in the works, she says, to add behavioral health services, including telepsychiatry, at some locations. (Ascension Saint Thomas and Acadia Healthcare this fall received state approval to build a 76-bed mental health facility in MetroCenter.) The system has set up or built out locations in Midtown, Franklin, Bellevue, Hendersonville, Gallatin, Murfreesboro and at its River Park Hospital in McMinnville. Some are home to only a few primary care doctors, others more than 10. Sims says the sites have exceeded expectations “across the board” and that other centers are possible, including in some of the more rural regions Saint Thomas’ network covers. But Sims says that will require some more thinking and testing; today, her team’s approach is to focus on highertraffic sites where patients’ biggest objection to getting more complete care is inconvenience. Sims and her team — which includes Ascension researchers in St. Louis and analytics firm Sg2 — are far from alone in thinking differently about patient access points beyond hospitals. Industry leader HCA Healthcare, for instance, has in the past two years grown its network of physician clinics around the country by nearly 50 percent to roughly 1,200 and now runs about 130
Amber Sims
‘A s a n i n d u s t r y, w e h a v e to think more about how we serve consumers, n o t p a t i e n t s .’ amber sims, ascension saint thomas
urgent care clinics, up from 96 a year ago and 71 at the end of 2016. Similarly, HCA has been building freestanding emergency rooms and now operates about 80 of those facilities, up from 64 in mid-2017. What is different about Ascension Saint Thomas’ approach is the scope of services grouped in high-traffic areas. In essence, the robust care center model is an incumbent health system’s response to the rise of urgent care clinics that handle minor illnesses and injuries. While those facilities have clearly resonated with consumers as fill-in-the-gap options, their limited offerings mean patients needing follow-up care must still reconnect with the care spectrum at more conventional locations. The robust care center model makes those follow-ups more accessible. “We’re trying to think more like a nontraditional competitor,” Sims says. “In some ways, we’re behind. But when I look at different markets, I also feel like we’re ahead. We’re pushing against some pretty hard habits.”
NASHVILLEPOST.COM
Saint Thomas.indd 49
FEATURES
|
WINTER 2018 | VITALS
49
11/15/18 11:59 AM
THANK YOU
for a Great Morning at our Vitals Breakfast Panel! OCTOBER 25, 2018 | 7:30-8:30 AM | CITY WINERY
A SPECIAL THANKS TO OUR M O D E R ATO R A N D PA N E L I S T S Gillian Hooker, Elizabeth Ann Stringer, Michael Heinley, Joshua Douglas and Kevin O’Hara SPONSORED BY
NP_12-18_68.indd 50
IN PARTNERSHIP WITH
11/15/18 12:19 PM
MANAGE
trends raising eyebrows among health system CEOs
Jessie Goldman
Advisory Board Research pros outline big changes underway by Jessie Goldman and Yulan Egan
very year, Advisory Board Research convenes a series of meetings for hospital and health system CEOs. This year’s meetings covered providers’ role in addressing the opioid crisis, the impact of vertical integration on strategy and the growing importance of cost discipline. Here are some provider leaders’ “a-ha” moments from those talks as well as what suppliers and service firms should keep in mind moving forward. • While the payer mix shift has challenged margins for some years now, health system executives are recognizing that a more dramatic case mix shift is yet to come. In the past decade, providers have been focused on the fact that more Americans are aging out of commercial insurance and into Medicare, which reimburses at a relatively lower rate. But while the Medicare population has grown, it’s also gotten relatively younger and healthier. As the baby boomers have aged into Medicare, they’ve brought down the average age of the Medicare population. That’s about to change in a big way. The first baby boomers are now turning 75 and, as they age, they require higher levels of medical care over more profitable procedural care and surgeries. As providers confront this worsening case mix, expect more focus on improving collaboration across acute, post-acute, home-based and other outpatient sites and on shifting care delivery to the most cost-effective delivery setting.
E
Yulan Egan
• After years of Medicare-led transformation, players in the private sector now threaten to disrupt the delivery system and they’re giving even the most seasoned provider organizations pause. Over the last decade, providers have responded to a slew of new rules and regulations designed to control the health spending curve. While CMS continues to experiment with a variety of strategies for curtailing spending, private-sector players — particularly technology companies, retailers, and large employers — are setting their sights on the health care industry as well. Though this is not the first time we’ve seen the potential for outside disruption in health care, hospital CEOs agree that this moment feels unique. First, the mere threat of Amazon entering health care is catalyzing change across the industry. And second, consumers are also becoming more willing to engage with differentin-kind health care models. • Both private- and public-sector actors are turning their attention away from hospitals and health systems and toward independent physicians as preferred agents of change. The recent wave of M&A — whether CVS’ proposed acquisition of Aetna or the rumored merg-
er between Walmart and Humana — spotlights a growing interest in lower-cost delivery settings. And a growing number of entities have zeroed in on independent physicians as the key to controlling health spending and unlocking value. But while commercial insurers have long recognized the power of independent doctors in transforming care delivery, the more groundbreaking shift we’ve seen over the last year is that Medicare is taking a page from the private sector’s book and also is eyeing physician-led care management solutions. The recently proposed ACO rule is designed, in part, to help maintain physician independence and promote physician innovation. Suppliers and service firms that have focused exclusively on the hospital market should start thinking about how the rising prominence of independent physician groups may impact current and future business. • All hospitals — regardless of their financial status — recognize that long-term sustainability will require a heightened focus on cost control. Look for elevated spending decisions and more cost scrutiny in decisions. With health system revenue growth already on the decline, providers find themselves confronting an increasingly challenging financial landscape. While future success will require continued revenue growth, few health systems will successfully maintain margins without a comprehensive cost control strategy. In our recent survey of health system C-suite executives, they ranked “preparing the enterprise for sustainable cost control” as their top strategy priority for 2018 and beyond. No one has tapped out all potential savings. Even the most progressive CEOs left our most recent meeting with some ideas for how to bend their organizations’ cost curve. Looking forward, providers need to do more than simply slash a few budget line items. While most suppliers already face centralized purchasing committees, expect to see more organizations elevate signature authority. And anticipate a greater focus on investments that can improve staff productivity, automate administrative and clinical processes and ensure scalable growth — for example, micro-hospitals or home-base acute care models.
Jessie Goldman is a senior analyst and Yulan Egan is a practice manager at The Advisory Board Company. www.advisory.com
NASHVILLEPOST.COM
Advisory.indd 51
FEATURES
|
WINTER 2018 | VITALS
51
11/15/18 11:59 AM
FEATURES
FEATURES POST-ACUTE
Predictive power
Home health giant Amedisys finds some analytics answers at locally based Medalogix by Geert De Lombaerde
“
In the end, quality should win,” says Chris Gerard, COO of home health and hospice provider Amedisys. “If you’re first in quality, you should be able to keep taking market share.” In today’s health care arena, quality is increasingly built on the combination of smarter data and better use of that information. At publicly traded Amedisys — which is formally headquartered in Louisiana but has a large executive office in Cummins Station downtown — that meant building out a team to identify higher-risk patients in need of more attention. The insurance companies with which it partners are clamoring to avoid costly, unnecessary hospitalizations and a 2020 overhaul of the Centers for Medicare & Medicaid Services’ home health payment model have Gerard and his peers looking for tech tools that can help. Gerard and his boss, CEO Paul Kusserow, found some in San Francisco in January when they met Elliott Wood, CEO of local predictive modeling software company Medalogix. Wood sat in on Amedisys execs’ presentation at JPMorgan’s massive investor conference and afterward connected with Gerard, whom he knew from his work at Medalogix client Kindred Healthcare.
52 VITALS
|
Amedisys.indd 52
Chris Gerard
Wood pitched Kusserow on Medalogix’s datacrunching products, which flag high-risk patients early on, giving clinical teams the chance to more effectively intervene and coach patients on beneficial behavior changes. Wood was not in San Francisco to hunt for a new investor, and Gerard didn’t immediately think about pulling out Amedisys’ checkbook. But the men’s conversations about the Medicare Advantage market and the broader shift toward value-based contracting led gears to start turning about a closer collaboration. “It just made so much sense,” says Wood, who joined Medalogix in mid-2013 as senior vice president of product management and, after moving into the COO seat, took over as CEO in August of last year. He says Medalogix’s major-
ity owner, Coliseum Capital Management out of Connecticut, called a partnership with Amedisys a no-brainer; the companies announced in late August a deal wherein Amedisys acquired a minority stake in the Nashville company. For Medalogix, the potential to scale through Amedisys is impressive: The public company runs more than 320 Medicare-certified home health care centers in 34 states and the District of Columbia. Through the first nine months of this year, its home health division booked an operating profit of $130 million on sales of $871 million. Work started this fall to integrate Medalogix’s software into Amedisys’ systems, a time-consuming process — the legal and compliance folks would like a word — that Gerard says should be complete
WINTER 2018 | NASHVILLEPOST.COM
11/15/18 12:02 PM
POST-ACUTE
‘Five years ago, no one was with us. now, there are massive changes c o m i n g .’
Elliott Wood, MEdalogix
for one of Medalogix’s products in the coming weeks. Then the work on a second product will begin. Amedisys’ leaders have made quality a calling card in recent years, pushing their average patient care star rating to more than 4.4 (one a scale of 1 to 5) from 3.5 in the spring of 2016. (The national average is about 3.25.) Getting a firmer handle on patient data creates a virtuous cycle that helps push that number higher still. “People truly want to receive as much care as possible in their own
home rather than an institution,” Gerard says. “Collecting more data points in the home — and the deviations of those data points — gives us the information to move more quickly. It lets us get ahead and be more predictive.” On a recent conference call with analysts and investors, the Amedisys team also pointed out that the added insights and predictive insights they can get from Medalogix will help them better identify patients who might be near a transition to hospice and palliative care.
Elliott Wood
And Gerard reinforced the value Medalogix can bring in the coming years as Medicare’s payment parameters shift. “We can really use their ability to analyze the data and help us in developing the care protocols that achieve the right patient outcomes with the right number of visits
HEALTH & WELLNESS KEY TO REGION’S FUTURE SUCCESS This region is recognized for economic vitality and quality of life. The Nashville Region’s Vital Signs report is a collaborative process led by the Nashville Area Chamber of Commerce that allows Middle Tennessee to forecast emerging issues and challenges, while we still have time to develop regional solutions. Good health in Middle Tennessee starts in our homes, schools, workplaces, neighborhoods and communities. Poor health brings a significant personal cost, but also damages the economic competitiveness of our region. With a tight current labor market and an unprecedented number of workers expected to retire in the coming decade, health plays a vital role in determining Middle Tennessee’s future productivity. Employers play an important role in helping to address health issues through innovative programs for their employees and by building a culture of health and wellness in the workplace.
FEATURES
over the right amount of time,” he said. “This is a super win for us to be involved in this.” With Amedisys helping put wind in Medalogix’s sails, Wood has big goals for 2019. He is aiming for his team of 22, based in WeWork’s downtown One Nashville Place hub, to grow to between 30 and 35 by the end of 2019. The door is open for Amedisys to increase its involvement over time with Medalogix. Nothing is in the works at this point, however, and Wood says that suits him just fine. It lets him and his team focus on their strategic plan and hit their marks. “I’m excited about the opportunities in our industry right now,” he says. “Five years ago, no one was with us. Now, there are massive changes coming and data and analytics are a big part of that.”
Nearly one in 10 persons in the region lacks health insurance (9.7%)
Smoking rates Nashville region: 18.2% United States: 15.1%
More than $500 million is lost annually in productivity for the Nashville region due to absenteeism and presenteeism associated with diabetes, obesity and hypertension in the workforce.
Good health requires policies that actively support health:
To learn more about the health of this region and how you can get involved, visit nashvillechamber.com/vitalsigns or nashvillehealth.org. Health Amedisys.indd 53 53 NP_12-18_68.indd
Transit
Housing
Work
Nutrition 11/15/18 12:41 12:02 PM
FEATURES
FEATURES POST-ACUTE
CONNECT WITH YOUR CIVIC DESIGN CENTER IN NEW WAYS
civicdesigncenter.org
SEARCH “NCDC” GET THE APP AND BECOME ENGAGED TODAY! ATTEND • VOLUNTEER • JOIN Tricky Transitions_.indd NP_12-18_68.indd 54 54
TransiTions can be hazardous To The boTTom line Hospitals are devoting more attention to the many little things that help patients avoid readmission by PhiliP bETbEzE
are transitions have always been important for the patient. Until relatively recently, though, they haven’t been a source of financial angst for providers. But with the advent of readmission penalties from the Centers for Medicare and Medicaid Services and similar penalties private payers are implementing, that’s changing rapidly. It’s not that hospital leaders ignored the importance of patient transitions out of acute-care settings in the past. But now, they recognize
C
that their wallets could take a hit from less-than-optimal care transitions, which are among the most dangerous points in the care continuum for patients. Medication errors harm 1.5 million people a year, and 60 percent of errors occur at the time of transition — at a cost of $3.5 billion a year nationwide. In the 2017 fiscal year, a whopping 79 percent of hospitals faced penalties for readmissions totaling an estimated $528 million. In 2018, those numbers have risen to 80 percent and $564 million, respectively. The problems are especially acute among elderly patients: About one in five ends up back in hospitals before 30 days. Many things can go wrong when a patient moves from an acute-care setting to outpatient rehab, a skilled nursing facility or home. Taking care of a complex patient to avoid readmissions can itself be complex and frustrating for both patients and caregivers, but tactics to avoid those complications can be disarmingly simple if they’re applied consistently. Many, if not most issues can be avoided through a combination of rounding, education and follow-up phone calls, says Rachael Johnson, who led a session on care transitions at the What’s Right In Health Care conference hosted late this summer by consulting firm Studer Group. Johnson works with hospitals and nonacute care providers to help eliminate communication
11/15/18 12:22 12:03 PM
POST-ACUTE
FEATURES
Where
and instruction problems that may land patients back in the hospital unnecessarily. Hospitals often find the process of reducing readmissions difficult because the factors can seem beyond their control. Yet by ensuring certain activities are performed during and following an acutecare stay, hospitals can have a big impact on lowering readmissions. Regardless, they are compelled to instigate processes to help take the lead in eliminating readmissions because reimbursement penalties accrue mostly to them.
Tactics that work Some tactics can include developing preferred provider networks of post-acute facilities that agree to follow treatment protocols proven to lessen the likelihood of a readmission. More directly, hospitals can lessen the likelihood of a readmission through a thoughtful and prescriptive program of education and follow-up that can be implemented by the discharge nurse or care managers — and in most cases, managed by nurse leaders. At one 200-bed Texas hospital, Studer Group worked with the nursing staff to complete 32,000 rounds in a year-long engagement. That personal touch aimed at educating patients and their caregivers helped lower the average length of stay by 0.6 days and generated more than $28 million in annualized benefits, says Johnson. Trust between the team of caregivers in the acute setting and the patient or patient’s family is built through rounding, follow-up phone calls and constant monitoring, she says. Such a process can also build confidence that patients and caregivers can manage the care they receive in a rehab facility, a skilled nursing facility or at home. “That trust is built through communication,” says Johnson. “It’s not something done every now and then, but should be part of your daily operations as a leader.”
Rachael Johnson
Care management in the acute setting sets the stage for success after the acute stay, Johnson stresses. For instance: Did the patient care staff accurately complete bedside shift reports in a timely manner? Did they always record a patient’s pain score, whether a patient is receiving pain medication and post instructions via whiteboard in the patient’s room about when to repeat dosages? Did they always record the responsible registered nurse’s and med-tech’s name on that whiteboard? Was the patient rounded on within the past hour? Have caregivers had a conversation with the patient and family member about the plan of care and where the patient is on that continuum? Are bed alarms on? Have fall precautions been taken into account? “If you’re doing those in rounding, you’re making sure that patient is safe in your care,” says Johnson.
Priorities post-discharge After discharge, hospitals should have regular check-ins with patients or their caregivers to make sure they are progressing. Perhaps a member of the care team calls within one to three days postdischarge to make sure things are going well and to answer any questions. Better yet, the hospital should provide easy contact information for caregivers on staff for post-discharge questions that may prevent a readmission.
“Post-visit phone calls are a powerful tool,” says Johnson. One organization she worked with had a 14.8-percent readmission rate prior to implementing the centralized care transition call model that Studer recommends. Nine months later, the organization had saved $1.5 million and its readmission rate had dropped to a mere 2.5 percent. The importance of regular touch points with post-acute care providers is similarly important, Johnson says. Regular communication about specific patients between care teams at the hospital and the discharge facility, if not the home, is critically important and should begin at admission, says Johnson. After the patient is discharged, care navigators should call the facility and talk with a patient’s nurse, establishing regular touch points — especially for those at high risk of readmission. “Is the patient taking blood thinners? Has the patient had to go back to the ED? Are you managing the patient’s pain? Is the patient participating in therapy? What is the anticipated discharge date? Have you performed medication reconciliation? You’re doing a full handover and it’s complex,” she says. Once those baselines have been set and checked, staff at the acutecare facility should be calling the patient’s new facility at least once a week until the patient goes home, she says. Implementing a sturdy post-discharge regime that prevents unnecessary readmissions involves simple actions, but implementation can be difficult. It requires diligent management and back-checking to make sure simple tasks are being done frequently and consistently. “You can start small, with one patient population, but you need to start somewhere,” Johnson says, and then replicate the program until it takes hold organization-wide. “Teach, validate, reward and coach,” she says. “Then monitor.”
marketing professionals go to connect,
learn and network
#MeetMeAtAMA
C
M
Y
CM
MY
CY
CMY
K
Join us for an upcoming event Healthcare Marketing Event: Marketing in the Healthcare Industry November 29, 8am Marketing Professionals Holiday Networking Mixer December 11, 5pm Power Luncheon: Tractor Supply Co. Putting Customers First January 10, 11am
to learn more about our events visit:
nashvilleama.com Tricky Transitions_.indd NP_12-18_68.indd 55 55
11/15/18 12:23 12:03 PM
FEATURES
FEATURES POST-ACUTE
Crucial connections Brentwood care c o n v e n e r n a v i H e a lt h is booming and hiring — and just getting s ta r t e d by Lena Anthony
he shift from volume to value in health care reimbursements is well underway. Pure fee-for-service now accounts for just 37 percent of payments, according to the Change Healthcare-sponsored State of ValueBased Care in 2018 survey of payers. By 2021, just a quarter of reimbursements are expected to be volume-based. In their place are growing alternative payment models like Accountable Care Organizations and bundled payment arrangements — such as the new Bundled Payment Care Initiative Advanced from the Centers for Medicare and Medicaid Services — that hold hospitals and health systems accountable for the quality and cost of care after patients leave the hospital. BPCI Advanced kicked in on Oct. 1 and reimburses providers (whose participation is voluntary) for up to 32 clinical episodes based on a 90-day episode of care that includes post-acute services. If providers spend less than the target price, they are paid a bonus. If they spend more than the target — thanks to the patient being readmitted due to complications, for instance — they are assessed a penalty. This isn’t CMS’ first 90-day bundle. Predecessors include BPCI, which launched in 2013, and the Comprehensive Care for Joint Replacement Model, which came in 2016. But this lat-
T
56 VITALS
|
NaviHealth.indd 56
WINTER 2018 | NASHVILLEPOST.COM
Jay LaBine
est iteration really lives up to the “Advanced” in its name. The formula for payments is more complicated, yet CMS is releasing reconciliation reports — which help providers see how they are performing — less frequently. And while previous models featured either no penalty or one that phased in over time, participants in BPCI Advanced will be on the hook for downside risk from day one. CMS does, however, allow providers to share up to 50 percent of that risk with a convener. That’s where Brentwood-based naviHealth comes in. The seven-year-old company’s business was booming before BPCI Advanced was announced
early this year — it already manages an estimated 40,000 annual episodes under the original BCPI — and executives plan to expand to 20 new markets over the next 12 months. Some of that will be as a BPCI Advanced convener, some will be for the growing number of members it helps manage through insurance plans like Medicare Advantage. A recent ownership change should help naviHealth CEO Clay Richards and his team fulfill that promise — and illustrates the growth of the business in recent years. New York-based investment firm Clayton Dubilier & Rice this summer paid Cardinal Health $736 million for a 55 percent stake in the company. The implied
ERIC ENGLAND
11/15/18 12:04 PM
POST-ACUTE
valuation of about $1.3 billion is almost quadruple that of August 2015, when Cardinal bought 71 percent of naviHealth for $238 million, net of cash acquired. The company’s aggressive growth strategy calls for adding between 400 and 500 people over the next 18 months. The company currently employs a little more than 1,000, 425 of them based in the Nashville area. About 50 percent of these workers have clinical roles — coordinating and/or providing post-acute care. Whenever new bundled payment initiatives are announced, naviHealth works with health systems to evaluate their options: If it’s voluntary, should they take part? If there are multiple clinical episodes, as there are in BPCI Advanced, which ones should they participate in? “One thing that tilts the decision-making toward using a convener is the expertise,” Chief Medical Officer Jay LaBine says. “The analytics tools that naviHealth has at its disposal are critical. Evaluating clinical episodes is a critical decision point and it takes a lot of infrastructure of analytical data and expertise that most hospital systems do not have.”
’Evaluating clinical episodes takes a lot of infrastructure of a n a ly t i c a l d a t a a n d expertise that most hospital systems do n o t h a v e .’ J ay L a B i n e , n a v i h e a lt h
Once the bundle is selected — total joint replacement, for example — naviHealth partners 50/50 on the resources needed to manage the patient from hospital admission through post-acute recovery. As part of the partnership, the company also assumes 50 percent of the risk — both downside and upside. One of naviHealth’s tools is a proprietary decision support tool that can predict a pa-
tient’s care path by comparing that patient to a database of more than 2 million patient records collected since 1999. (While naviHealth was founded in 2011, it acquired locally based predictive modeling venture SeniorMetrix and workflow tools developer Curaspan, which were both founded in 1999.) The tool analyzes factors such as health status, basic mobility, daily activity and cognitive function and helps naviHealth direct each patient to the most appropriate post-acute care setting. Depending on factors, that could include a long-term care hospital, a skilled nursing facility or the patient’s home — with or without the involvement of a home health agency. Meanwhile, naviHealth also vets post-acute care providers and selects those that produce the best outcomes. The company embeds clinical coordinators and clinicians at care sites to help improve or maintain the quality of their care. In addition, these naviHealth employees are monitoring key performance indicators like length of stay to ensure continued appropriateness. That data then makes it back to the hospital and post-acute care provider, in the form of a best practice benchmark report. “This feedback loop allows for improvement processes and helps us identify quickly when something isn’t working,” LaBine says. The naviHealth team also produces patientfacing reports that keep patients and family members informed about what to expect from their post-acute care. LaBine — who joined naviHealth this year from Michiganbased Spectrum Health, a 12-hospital system and longtime naviHealth customer — says that’s a change from previously common practices that left patients without much guidance about what would (or was supposed to) happen once they left the hospital. It seems to be working: BPCI clients saved an average of 8 percent — that works out to about $2,000 per 90-day episode — and the number of people discharged from a hospital to their homes rose 7 percent. Meanwhile, health plan clients have recorded a drop of between 10 and 20 percent in readmissions and a 15-percent reduction in post-acute medical expenses. With more providers coming aboard and more data feeding naviHealth’s systems, look for those numbers to grow and costs to fall further. “We expect the impact to be even greater as the number of participants has increased across a shared mission — to deliver more coordinated, high-quality care so patients get home faster, safer and more satisfied,” LaBine says.
More data, more answers Embedded care management is just one part of the equation that equals value-based care success for providers and navigators such as naviHealth. Another key factor is a robust data and analytics system. But properly understanding the exact costs of managing patients in a 90-day bundle and knowing how variables like mobility, activity levels and cognitive function can impact patient outcomes is a complex puzzle, for sure. “A lot of it is financial data and a lot of it understanding the conditions that are part of these bundles,” says Jay LaBine, naviHealth’s CMO. “Total joint replacement is one thing, but conditions like sepsis and heart failure are a lot more complicated to understand. We have a really foundational number of employees who can take quite confusing data from CMS and health plans and put it into an interface that is surprisingly provider-friendly.” LaBine says that interface is a differentiator for naviHealth, which boasts a growing team of data scientists that numbered 13 this fall. At press time, Glassdoor listed 16 open “data science” positions at the Brentwood-based company. Of naviHealth’s 1,000 total employees, about 70 are in data science and that number will grow as its leaders expand the company’s analytics offerings. “More and more, we’re going to be examining the population we’re engaging with and understanding their population health analytics,” says LaBine, whose company bio notes his passion for population health. “If a person with a chronic condition like heart failure, COPD or asthma has a behavioral health condition, they’re at a higher risk for readmission. If they live alone, the risk is even higher. More and more, we’re going to factor in social factors that could lead to adverse events or deterioration of their medical condition.” > Lena Anthony
NASHVILLEPOST.COM
NaviHealth.indd 57
FEATURES
|
WINTER 2018 | VITALS
57
11/15/18 12:05 PM
FEATURES
FEATURES POST-ACUTE
Ambition, engagement, outcomes Rehab hospital’s bad options fuel growth, improvement by Philip Betbeze
he leaders of Mary Free Bed Rehabilitation Hospital in Grand Rapids, Michigan, in 2011 faced what could only be described as a lose-lose situation. Regional market leader Spectrum Health System wanted the rehabilitation hospital in its home city for itself and made an offer to buy the 127-year-old independent. Either choice came with significant risk. Reject the offer and Mary Free Bed faced the likelihood it would, as Spectrum built its own rehab operations, lose patient referrals from the dominant local player. Those referrals represented 60 percent of patients and 70 percent of its revenues. Accepting the offer meant a loss of its treasured independence and a likely loss of the 30 percent of the revenues it received from other referral sources. Yet here was an offer they couldn’t refuse. Or could they?
T
58 VITALS
|
Mary Free.indd 58
“We were stubborn when we faced this threat,” says CEO Kent Riddle. “We wanted to stay [neutral] like Switzerland so we refused the deal.” Riddle and his chief clinical operations officer, Ingrid Celek, shared Mary Free Bed’s story of growth and improvement in late August at the What’s Right In Health Care conference in Nashville sponsored by consulting firm Studer Group. Riddle’s tenure began during that time of transition as it struggled with less-than-optimal occupancy and an employee engagement and accountability problem. Riddle had gotten involved at the board level after his wife Susan suffered a traumatic brain injury in a 2002 crash with a drunk driver and spent a large part of her recovery at Mary Free Bed. By 2011, he was the hospital’s board chairman and semi-retired. When Mary Free Bed’s CEO at the time announced plans to retire, the 120-member Mary Free Bed Guild that owns the hospital — and where his wife was a member — asked Riddle to take over. An engineer by training, Riddle led a push to keep Mary Free Bed independent but instill a sense of ambition and much more accountability. In a health care landscape featuring shifting alliances and new business models, merely delivering quality care wasn’t going to cut it anymore. His team set out to both build employee engagement and accountability while boosting patient satisfaction and outcomes and building a statewide referral network. They set what Riddle calls a “crazy goal” of being the sixth-largest rehab hospital in Michigan and the 39th-largest in the country. “We decided to go big because we had a burning platform. We’ve added new staff, new elec-
tronic medical records, added rehab modalities, subacute and we’ve expanded around the state,” Riddle says. “We measure every incremental change in speech, swallowing, cognitive. We exceed the national average in those and our goal is to get people home and at the same time reduce acute-care hospitals’ length of stay. Engagement leads to outcomes.” The outcomes have been good. Since 2011, Mary Free Bed has: • Grown inpatient beds from 80 to 167 • Registered a 255-percent growth in patients served • Doubled its employee base • Grown average daily census from about 40 to 300 • Grown total beds from 80 to 395 • Grown daily outpatient visits from 300 to 450 • Grown from eight physicians to 35 And since 2015, when the main hospital moved into a new facility: • Patient satisfaction has increased from 45 percent to 99 percent • Therapy productivity has risen from 63 percent to 75 percent • Employee engagement has risen from the 59th percentile to the 90th • Nursing turnover has shrunk from 29 percent to 10 percent Riddle says the hospital’s best decision was strategic: “We’re not going to join one system, we’ll integrate with them all,” he says. “And if, four years from now, we’re invited back to speak here, our referral network map will be three to four states.”
WINTER 2018 | NASHVILLEPOST.COM
11/15/18 12:06 PM
POST-ACUTE
FEATURES
Skilled nursing’s changed future
Adoption of quality standards will be key to survival by Jeffery Parrish
killed nursing facilities have historically been at the bottom in the hierarchy for government reimbursement of health care providers. Reimbursement challenges, limited funding, harsh inspections and high employee turnover have left many SNFs with little motivation to embrace new governmentsanctioned standards and practices. Generally, government attempts to impact the operations of these facilities has been met with skepticism at best. However, the latest move to improve industry standards of care is one worth adhering to, particularly if facilities want to survive. For years, SNFs were — in harsh terms — “warehouses” for the elderly, and many industry leaders had business backgrounds rather than experience in the health care sector. However, this model is shifting. Reflecting the transition to a value-based care model, the federal government — which provides funding to SNFs through Centers for Medicare and Medicaid Services — has determined it will only provide reimbursement to SNFs that deliver high-quality care. This transition is due in part to the government’s realization that it would be economically calamitous to place the millions of baby boomers in the oncoming “silver tsunami” in these “warehouses” and without regard to quality of car or patient outcomes.
S
waller lansden dortch & davis
SNF Quality Push.indd 59
Jeffery Parrish
In November 2017, CMS introduced Quality Assurance and Performance Improvement standards to ensure that SNFs have a roadmap to systematically change and focus their operations as a health care provider rather than solely as a repository. To implement a successful QAPI program, SNFs review all areas of operations and prioritize patient care and quality of life. Adoption of the QAPI standards helps SNFs excel on state and federal surveys and earn higher quality ratings, which in turn, improves CMS reimbursement and can enhance their reputations and increase referrals. Naturally, some of these facilities have responded to these new standards with the typical cynicism reserved for government intervention, but now, they do so at their own peril. By raising the care standards for SNFs, the government is demanding a widespread shift that will eliminate the “warehouse” model and shepherd the expansion of the clinical care model. The shift in skilled nursing facilities can be evidenced in the type of care and how services are delivered. Now, many patients who arrive in nursing homes come directly from a hospital to receive care before being transferred to their own home — transforming the outdated notion of an SNF as a place for long-term care to a facility that provides short-term, post-acute care. And for those patients that do receive long-term care, a facility that is set up to merely house
them will no longer suffice. In recent years, therapy departments have emerged, helping patients navigate physical, speech and occupational therapy without the cost and discomfort of the hospital. It is expected that SNFs will continue to expand to accommodate the services — such as respiratory care — that patients need. It will not be a surprise if many of the SNFs we see today cease to exist five years from now. For many, their model is simply not designed to support adherence to QAPI standards. But for those who are invested in producing quality results, creating profitable partnerships and reducing hospital readmissions, it is a worthy guideline for practices that will be rewarded. Furthermore, as the number of SNFs in this country declines and the wave of baby boomers needing care hits, there will be a move toward facilities that can provide post-acute care in facilities intended for short-term stays. So, while many SNFs remain committed to the notion that QAPI is just another federal regulation, to CMS, “it represents an ongoing, organized method of doing business to achieve optimum results.” Or, in layman’s terms, the key to survival.
Jeffery Parrish is a partner at Waller Lansden Dortch & Davis, where he serves as a senior legal advisor to health care companies. wallerlaw.com
NASHVILLEPOST.COM
|
WINTER 2018 | VITALS
59
11/15/18 12:07 PM
FEATURES
FEATURES DESIGN
Micro city living
Donelson senior care facility offers residents a main street vibe by William Williams
enior care facilities — much like various offerings in the health care realm — continue to evolve, with many assuming a form and function that would have been unthinkable even, say, five years ago. The level of sophistication and the number of specialty offerings have elevated. And the improvements are not limited to high-end facilities carrying robust costs. In fact, many of the more mid-tier senior living operations have become increasingly diverse in their amenities, more advanced in their level of care and even a bit clever in their physical presentations. Consider, for example, Bristol Terrace Assisted Living and Memory Care in Donelson. Opened earlier this year, the facility is billed as a “minicity,” complete with main street-esque signs, an ice cream parlor, a movie theater and a gift shop. The facility also offers a full-time physical therapy gym, a private dining room, an indoor terrace and full food and beverage services. Owned and operated by Tampa-based Bristol Senior Living, the facility is expected to eventually boast 50 full-time employees, including full-time nurses and 24-hour staffing — and all for a cost lower than those of the more luxurythemed senior living facilities. For example, monthly rates start at $2,800, with the national
S
60 VITALS
|
WINTER 2018 | NASHVILLEPOST.COM
Assisted Living.indd 60
‘ O u r t ea m de s igned t h i s f acili t y t o m irror a h o m e - li k e a t m o s p h ere .’ median average, according to the Genworth Cost of Care Survey 2017, at about $3,750. All Medicaid programs are accepted. Dr. Prem Shah, Bristol Senior Living president, says the Donelson Bristol Terrace will meet the growing demand for affordable senior housing in the Metro Nashville area. “Our team designed this facility to mirror a home-like atmosphere and allow residents to maximize their independence,” he says. The Bristol Terrace model is interesting — and very micro. Of note, Bristol Senior Living focuses on facilities in Florida, with the company specializing in the repurposing and conversion of closed or distressed facilities. Bristol Terrace is the company’s first community in Tennessee
Dr. Prem Shah, Bristol Senior Living
and its vibe and offerings are, in part, a product of the work of Tampa-based Wolfe Architects. “This has been done in The Netherlands where they adapted a village-like atmosphere for the residents,” Shah says, declining to disclose the cost to upgrade what had been home to Donelson Care and Rehab. “Even the smallest details mirror a person’s younger days. They have a grocery store, hair salon and theater. Studies have shown stimulation is of large benefit to those aging, particularly with forms of memory loss. We had the opportunity and space, so we decided to make a mini-town at Bristol Terrace as well. Not only is the building designed for aging but everything from the food and staff is designed to help this population.”
ERIC ENGLAND
11/15/18 12:10 PM
DESIGN
FEATURES
When asked why Bristol chose Nashville (and, more specifically, Donelson) for its first Tennessee facility, Shah says the opportunity simply presented itself. “There was a vacant nursing home that was closed down so we had the opportunity,” he explains. “Secondly, there was — and still is — a large need and demand for affordable care in that area. As large as Nashville is, there were hardly any communities catering to memory loss or assisted living for middle-income families. We wanted to be an option for those people and we strive to be actively involved in smaller, local communities like Donelson.” As to a key element of success regarding the design, Shah says it is difficult to narrow the choice. “We would like to think that the entire conversion from a nursing home to an assisted living facility was a success,” he says. “Given the fact that we had to use an existing structure and space and did not have a new product to work with, it came out wonderful — in fact, better than we ever would have thought.” Shah says each detail was carefully pondered and planned. The color schemes, signage and flow was researched and then implemented, with elements of feng shui, no less. “We had to have vision and depth as well as make sure each space had functionality,” he says. “Specifically, we put a tremendous amount of time and effort designing our common area and mini-city. The common area did not exist whatsoever so that took a lot of planning. The mini-city was something I have also wanted to do, but never had the opportunity. It was a total collaboration between myself, our team, the architect and the contractor.” Bristol Terrace’s mini-city component has yielded surprising usage. “In fact, the families and visitors adore it just as much as the residents,” Shah says. “Obviously, it helps remind the residents of their younger days, but it also provides a place for congregating and socializing. Our goal is to maximize independence and encourage our residents to enjoy the amenities. Whether it is our indoor terrace or ice cream parlor, there also seems to be a buzz in the mini-city and that was the purpose of designing it.” Though not even 12 months into operations, Bristol Terrace has been successful enough to spur the company to consider additional facilities within the state. “We are always looking for other opportunities and ways to grow,” Shah says, “and Tennessee would be a wonderful place for that to happen.”
NASHVILLEPOST.COM
Assisted Living.indd 61
|
WINTER 2018 | VITALS
61
11/15/18 12:10 PM
FEATURES
OPIOIDS
David Reagan
Turning the tide
Public, private sectors look to reverse alarming opioid trends by Kara Hartnett
everal recent government and privatesector initiatives are helping combat the opioid epidemic in Tennessee and across the country but it is becoming apparent that the road to full recovery will be long and hard-fought. In the Centers for Disease Control most recent report for the 12-month period ending in March of this year the agency reported a 2.8-percent decline in overdose deaths in the United States compared to the 12 months that ended in September of last year. That represented an estimated 71,073 people. Unfortunately for Tennessee, this finding is not echoed on a local level: 1,776 people died in the Volunteer State due to overdose last year and 71.4 percent of those deaths were opioid-related — a 9-percent rise from 2016. Overdose is now the No. 1 cause of death in the state, surpassing vehicle accidents for the first time. Plenty of attention is focused on fixing that. Among the most notable trends in Tennessee has been a drop in providers’ prescribing
S
62 VITALS
Opioids.indd 62
|
practices. One in seven people prescribed opioids later present substance use disorder, but new research shows that changing prescribing practices can help prevent drug dependency. “Long-term use of opioids is really about the dose and duration of their initial therapy with opioids,” Tennessee Department of Health Chief Medical Officer David Reagan says. “There’s a strong affiliation with the first few days of use. The length of the first treatment course strongly correlates whether or not individuals will be abusing opioids a year later.” Leaning on that finding, providers have cut back on how much they recommend opioids for their patients. Prescriptions across the state have fallen 14 percent, morphine milligram equivalents (MME) dispenses are down 32 percent and patients receiving more than 120 MME per day have come down 38 percent. Another initiative that is helping transform the way opioids are prescribed is the prescription drug monitoring program mandated by the state. Key findings from 2017 suggest that, partly due to the program, doctor shopping has fallen by 76 percent while searches of the state’s controlled substances database have jumped 363 percent and the number of punishments for drug diversions — from a legitimate to an illegal channel — has quadrupled.
Last year, nearly 1.6 million long-acting opioids were distributed to patients in the state’s prescription drug database, down from nearly 3.2 million in 2010. “We are in a better place in relation to amount of opioids being distributed every year,” Reagan says. “From 2012 to 2018, we are 43 percent lower now in the amount of opioids dispensed.” Although the pharmaceutical market is now being well regulated, illicit opioid-related overdose deaths are still on the rise. That has pulled law enforcement much closer to the center of the opioid epidemic. “Not only are we seeing stronger opioids such as fentanyl and carphentanyl, we are seeing an influx of other illicit drug use such as meth and cocaine,” Reagan says. In October alone, Metro Nashville Police Department precinct-based undercover detectives charged 386 people for drug-related crimes. The most notable of them involved 37.9 grams of cocaine, four grams of marijuana, 28 grams of heroin, 150 hydrocodone pills, seven guns, three vehicles and $27,339 in cash. Fentanyl figures very prominently in this picture. An extremely powerful synthetic opioid similar to morphine — it is up to 100 times more potent — it is involved in a large portion of overdose deaths, which has led the the Department of Health to issue a public health and safety advisory. The Tennessee Bureau of Investigation says law enforcement officials in Tennessee have made several seizures of late of at least a kilogram of fentanyl analogues across the state, in forms such as heroin or counterfeit versions of hydrocodone, Percocet and other pain relief medicines. Natalie Tate, vice president of pharmacy at BlueCross BlueShield of Tennessee, says providers are paying more attention to the illicit market to understand opioid demand trends so they can reverse the effects in the black market of medicine hoarding, diversion and other factors they can control. BlueCross officials this summer pulled OxyContin from their covered drug list, replacing its with Xtampza and Morphabon because those medicines’ street value is lower and much less likely to be distributed illegally. Overall, Tate says overcoming the opioid epidemic will take a village. “The opioid epidemic didn’t happen overnight, and it’s going to take a marathon to get through it,” Tate says. “There is no one single solution. It has to be at the community level and we all have roles to play.”
WINTER 2018 | NASHVILLEPOST.COM
11/15/18 12:11 PM
OPIOIDS
Michael Genovese
‘Not everyone is using the latest options’ Acadia exec talks about research, tech, future treatment methods
fter working for two years as chief medical officer at an Arizona addiction treatment center owned by Acadia Healthcare, Michael Genovese moved to the corporate level nearly two years ago and has been Acadia’s chief medical officer since late 2017. In light of the increased attention addiction is getting heading into 2019, Genovese spoke to Post Editor Geert De Lombaerde about the evolution of addiction treatment and some of his aims at Acadia. Here are some excerpts from their conversation.
A
How has addiction treatment evolved in recent years? A lot of people will say, “Isn’t it great that the stigma around addiction is going away?” Yes, it is. But it’s going away slowly and it does still ex-
ist. And that’s despite the surgeon general saying a few years ago that addiction is not a moral failing but a chronic disease. There’s real science behind this: A lot of data shows that we’re vulnerable due to genetic factors or environmental factors. So we need a lot of scientific advances to treat these conditions. We need choices. We are underserved and not everyone is using the latest options available to them. One thing we as a company are doing is giving people treatment options. Have we accumulated enough knowledge to effectively know how to treat different addiction patients? The recent House bill addressing the opioid epidemic will help. If we can get more more funding for research on non-addictive pain medications, that would be great. If we get good at predicting, preventing and early detection, we’ll have a much better chance to help people. There is some good research being done out there and there can always be more. If we can smartly integrate that research with how we treat patients, that’ll be a positive. We need to have respectful discourse among our disciplines. For a long time, the discussion on addiction treatment was polarized between those in favor of an abstinence-based approach and those wanting a medicationbased approach.
How does technology figure in this picture? I like to say I’m an integrative psychiatrist — that means everything is on the table. If a patient presents with pain, anxiety and/or addiction, I’m going to be using all modalities to treat that. That could be acupuncture, physical therapy, transcranial magnetic stimulation — which is also good for pain — or studies that tell us about that patient’s genome. We can utilize that to optimize prescribing. Some people say there is not enough data yet for that. I’d say, “Well, I’m treating patients now. I can’t wait.” As doctors, we respect the data and we use the data but we can’t rely solely on the data because it’s always evolving. I would like to see health care providers and insurers work together more. There is a middle ground on collecting data. Insurers want more data; OK, let’s collect it. Where it gets tricky is in deciding which measures to use. Think about alcohol use disorders: What should we measure? Everyone’s ideas for success are different. But we’re at a point where people are coming to the table looking for middle ground. I’m encouraged by that. What are your longer-term goals for Acadia in that respect? I want all facilities to have their own particular characteristics for patients. I want doctors and nurses to have some autonomy and be culturally relevant. That said, there should be a standard for all to adhere to. I want our care to be better than the minimum, for us to be a role model. Among medical professionals, there’s an understanding that addiction is a disease that should be treated with respect. There is a role for me and other doctors to educate patients, members of care teams and the public. Look at the HIV crisis from the 1980s and early 1990s, how we improved that situation. A lot of that was due to public education. We now have medical students doing rotations in addiction treatment, residents and nursing students. That will help. In some of the studies we’re doing now, we’re using rating scales for how people are responding. We’re looking at longer timeframes and seeing if we can better measure things. It will be incumbent on us to adopt new technologies as they come out — things such as TMS, genomic information, ketamine injections for depression and mobile apps. We have the capability and the desire to look into those things and figure out how to make our treatments better.
NASHVILLEPOST.COM
Acadia.indd 63
FEATURES
|
WINTER 2018 | VITALS
63
11/15/18 12:11 PM
FEATURES
FEATURES GLOBAL
Shared knowledge
A Q&A with Community Solutions Fellow Collins Santhanasamy
he nonprofit Nashville International Center for Empowerment played host this fall to two fellows from a U.S. Department of State-funded initiative that places grassroots leaders from around the world in American organizations, both as a way for the fellows to learn skills to bring back to their home countries and to support the local groups. One of the local fellows, Zumrut Ekinci-Zlabinger, founded an organization that helps Syrian refugees assimilate in Austria and Turkey, to which she will return after the fellowship. The other, Collins Santhanasamy, will return to his native Malaysia to continue his work bringing traveling medical clinics to hard-to-reach rural communities. He previously started a similar project in Bangladesh, where he attended school. The Post’s Stephen Elliott spoke with Santhanasamy this fall about health care in the United States, Malaysia and Bangladesh as well as some of his aspirations.
T
What does your work at NICE include? Here, those who do get accepted into the health insurance plans like TennCare are able to access some medical care. But there are certain groups of refugees who are not qualified for health care plans and one of my goals at NICE was to be able to develop a health care program for these patients who are being left out or are slipping through the cracks. What sort of medical issues are common among refugees? Many of them come from third-world countries and when they come to the States, there is a drastic shift in their lifestyle. They come from an active lifestyle to a sedentary lifestyle. Back home, the kind of diseases we are used to are infectious diseases — malaria, dengue — but when we come over here to the States, it’s more obesity and diabetes and cardiovascular problems because of the lifestyle change.
64 VITALS
|
Collins Santhanasamy
So many of our refugee clients who are coming here are not used to these kind of diseases. Back home, we only see the doctor when we are really ill and we don’t really do regular checkups, we don’t really do exercise. So when they come to the States, the idea of health has to shift. What does your organization do and how might that change after your time here? We had been working with urban poor and with homeless communities, but we have been unable to reach out to rural communities. When I return to Malaysia, I hope to bring what we have done in Bangladesh and implement it in Malaysia with a little bit of modification for rural communities. The logistical part of bringing these volunteers into these particular areas is very difficult because most of the roads to access these villages are not paved roads. We need four-wheel drive; we need equipment. Another problem that we are facing is that we want to be sustainable. If we go in and if we just touch a village and we just go there and do it once and then we never come back to this village
again, it’s very pointless. We need to follow up with our patients. We need to collect the data. We need to see how we are actually having a positive impact in their lives. How will you go about building those programs? We want to start a program where we’re going to target five villages. We’re going to go to these villages every three months and we’re going to host medical camps in these villages every three months for a period of two to three years. After that, we will have an assessment to see how we have made an impact on the lives of this village. For us, ideally, the most sustainable way to deal with this problem would be for us to come into these rural communities and to start up clinics, but that’s not something that’s feasible right now because we don’t have the budget and we don’t have the manpower. We are unable to maintain these facilities and so we are trying to start up a very basic level, which we would consider like medical camps. The dollar goes a very, very long way in countries like Bangladesh and Malaysia and we are able to do a lot with a very, very small budget.
WINTER 2018 | NASHVILLEPOST.COM
Refugee Care.indd 64
11/15/18 12:12 PM
boom THANK YOU F O R A G R E AT EVENT! SEPTEMBER 19, 2018 5:30-8:30 PM | WEWORK EAST NASHVILLE
THANK YOU TO OUR SPONSORS SPONSORED BY
LIBATIONS PROVIDED BY
NP_12-18_68.indd 69
FOOD PROVIDED BY
11/15/18 12:24 PM
Why wait for a disease to become chronic before treating it?
Chronic disease is a struggle for millions of Americans and the single largest contributor to rising health care costs. At UnitedHealth Group, we take a comprehensive approach to help people manage their chronic disease or prevent it in the first place. We use data and analytics to help predict individuals who are at risk and then offer them incentives and support to make healthy lifestyle choices. And our technology allows them to stay connected with their care team. This is what health care can do when it’s caring and smart.
unitedhealthgroup.com
NP_12-18_68.indd 70
11/15/18 12:25 PM