by Jeff Keeling
The following is the entire Q and A from the Journal’s wide-ranging August 12 meeting with Ballad Health’s seven physician leaders.
Business Journal: You’ve got a mixing of Ballad employee physicians and extenders, and you’ve got independent practitioners – there’s a requirement for an open system – how do you align that and make sure Ballad’s objectives are going to be met without violating the COPA.
Dr. Mark Wilkinson (VP, Medical Staff Services an Hospital Based Program): “Many facilities have had open medical staff pre-dating the merger. The rationale is with us needing to partner with all physicians in the community. We want them to be interfacing with the hospital on all levels, be it on staff or engaging us on the outpatient side either way. We covet those relationships closely. We want to make sure that we are working in alignment with our physicians and the needs of the community that they represent. That’s part of the rationale behind the open medical staff, obviously.
“With the team of leaders around the quality piece and Dr. Vashist and his role, our intent is to build on the existing procedures and protocols we have around quality assurance so that we can make sure we’re practicing good quality medicine in our facilities as well as impacting the utilization of scarce resources. We’ve got some models in place within our facilities that allow us to focus on the quality piece, help our physicians provide better quality health care to the patients there as well as also the outpatient piece that is represented by Dr. Rajoo, her expertise in high-value care models. It’ll be easy, I think, to align the open medical staff so that we’re focused on the quality for the patient.”
BJ: Have there been discussions about that with some of the independent practitioner groups already in terms of some of the objectives that Ballad is moving toward?
Wilkinson: “If we talk about the medical staff structure piece specifically, those committees that we are almost mandated to have at the joint commission and CMS, that focus on the quality initiatives within our hospitals, we always want our physicians be they employed or independent to participate in those meetings and to help us build the right processes to deliver that quality of care.”
Dr. Amit Vashist (Chief Clinical Officer): “As far as independent versus employed, we have the all-encompassing clinical council, which includes our independent physicians, employed physicians, outpatient, inpatient, diverse specialties, and within that we have several subcommittees. Health informatics, high-value care, patient experience, medical staff services subcommittee, and we are all, with a very explicit purpose, aligning the goals of independent employed physicians with those of our broader health care systems.”
BJ: I can imagine that sometimes is a process that starts with people with varying views.
Dr. Matthew Loos (Chief Academic Officer): “One of the beautiful things about physicians in general is that we are trained to be critical thinkers, and so whether you’re a Ballad physician or nurse practitioner or you are a private physician or nurse practitioner we’re all trained to focus upon what is best for our patients. And so what Ballad is really trying to do is not work through mandates and declarations, so really more of a collaborative. Really much more of partnering with not only our own physicians and providers but also with the community providers and physicians and showing them and helping to understand from them that the best practices we know in medicine are the things we all want to achieve together, and that a lot of what Ballad is trying to do is just provide the infrastructure to achieve those goals.”
Wilkinson: “Within a framework of state and federal regulation.”
Dr. Chris Metzger (System Chair, Clinical Research): “I agree with Matt, these are mutually aligned. If you’re trying to do this efficiently and consolidate services, get the areas of expertise not to compete but rather cooperate. These are mutually aligned goals. If you can do that cost-effectively you have more opportunities to provide health care. Quality, and doing it correctly and cost-efficiently naturally satisfy the COPA. Rather than trying to say ‘follow a, b and c of the COPA,’ the Ballad model should by its nature and design fit together with the COPA.”
BJ to Mark Wilkinson: I don’t want to spend too much time on this, but in terms of the Level I (trauma center) decision and EMS, and it sounds like you work with a lot of the EMS providers, how do you gain buy in from say the Kingsport-area EMS folks that are concerned about that change so that the flow of patients that are being transported can get to its ultimate level?
Wilkinson: “At least in my opinion in emergency medicine we have a handful of emergency physicians as well as a trauma surgeon that oversee the medical direction for the local EMS agencies. That relationship we’ve had with those agencies definitely helps us to get their involvement into Ballad Health initiatives and of course it’s always a team decision that we come to regarding the way we approach the pre-hospital arena. The medical directors play an important role but our EMS partners are willing to be at the table to have those discussions and are eager to partner with the health care system for the best interest of the patient.”
“Most recently we worked on some guidelines for patient destinations based upon the clinical specialties available at the facilities. That’s challenging because of some CMS regulations around reimbursement for patient transports. They’ll pay to the closest facility whether that facility’s appropriate or not for that patient’s care. We’re trying to do some work behind the scenes to influence that piece, it’s the ET3 (Emergency Triage, Treat and Transport) program through CMS now with the ultimate destination for patients.
“Dr. Rajoo and I have been spending a lot of time with EMS working on community paramedicine trying to bring the resource to the patient and leaving the patient at their home instead of accessing an acute care hospital. So there’s been a lot of work along those lines. Although it’s in its infancy in Tennessee there is probably some low hanging fruit in order to get the patient cared for appropriately closer to home.”
BJ: Is that somebody that might be an observation patient, but instead they can actually not have to come to the hospital at all?
Wilkinson: That would at least eliminate an unnecessary emergency visit if those paramedics go to the home, assess the patient, maybe call the physician on duty that manages that patient and get advice regarding medication adjustments. Then the patient can stay home and not access expensive levels of care at the hospital. That’s something we’re invested in as a health care system. Even though right now our revenue’s generated through patient visits to the emergency room and to the hospital, we’re definitely wanting to impact population health positively by having people staying away from the hospital. The other piece is trying to make sure we get our patients to the right level of care at the right time and not overutilize our tertiary care facilities with the low acuity patients.”
BJ: I had heard concerns about bed availability at JCMC and perhaps the other tertiary hospitals for higher acuity patients who need to be there and there’s not a bed, and you’ve probably got space at (lower acuity hospitals) Franklin Woods or Laughlin or Sycamore Shoals. It sounds like I’m hearing you say there’s this sort of unintended consequence of a law that actually may prevent a patient initially getting to the acuity level facility that is best for them and that also may end up meaning that they end up at one of your higher-acuity facilities when they don’t need to be there. That’s a great explanation for that and I’d say it’s very frustrating.
Wilkinson: “It is. Part of my work to do now is to look at the true intent of the CMS regulations regarding the patient disposition and placement in the facility, and possibly work with our legislators on change to that language to make it more conducive to getting the right patient to the right location. There’s work to be done there for sure and that’s relevant to the Kingsport market as well as the Johnson City market, Bristol market, all of those locations would benefit from an alteration to the destination.”
BJ: The news release says you’re going to be working with the federal government, state Medicaid programs and payer partners. It sounds like that would be a perfect example, a real-life example where if it costs $600 more to transport somebody to the place they should be, and that costs $4,000 less and also leaves your high acuity beds open for someone that needs them. That sounds like a win for everyone.
“We’re talking more like $40, or $100 tops. It’s a mileage (reimbursement).”
BJ to Amit Vashist: What do you think are the biggest barriers to achieving even greater success in both quality improvements and cost of care reduction, and how do you and others think those barriers, whatever they may be, can be overcome as this integration continues to move forward?
Vashist: “I think when we talk about barriers we also should think about the opportunities. The biggest barrier, and I think I’ve spoken with every physician leader in this room, the biggest barrier is the barrier of culture. Physicians practicing differently. One of the things when we merged last year was the formation of the clinical council, and one of the biggest goals of the clinical council other than med-staff regulations is to reduce unwarranted clinical variation. Whatever the best evidence guides, we’re going to follow those pathways of care.
“Within the clinical council we have something called the high value care/evidence-based medicine subcommittee that is precisely looking at some of the patterns, some of the cultural patterns that prevent us from practicing best evidence-based medicine. A lot of things are also, in a physician’s world, kind of a fragmented mindset, ‘some things are not my responsibility.’ So the cultural change we are trying to bring in the physician enterprise, nursing enterprise, is that this is our enterprise. Zero harm is incumbent upon us.”
“So we are in this together. Nursing, infection prevention, even housekeeping – we are tied right from the top to the bottom. That’s why we have come up with a very bold slogan, that we’re going to be, not even aspire, we’re going to be a zero harm, top decile health care system if we follow the things that we are talking about.”
BJ: I think I heard you say, just kind of the culture of practitioners who want to be independent and want to be able to choose even the vendor they practice with or the type of device that they use, which is very understandable but that ultimately that can decrease the quality of outcomes. So they talk about vertical integration in terms of inpatient and outpatient, but it sounds like you’re talking in terms of silos even within the hospital, patient care people to people who are cleaning the rooms all the way up to surgeons, that the quicker those silos can get broken down the better you guys will have an opportunity to get to that zero harm model.
Vashist: “There are three key facets why we have variation, why we have all those challenges. There are people, processes and technology.
“We deal with the people and the processes partly through avenues like the clinical council and various other forms. Technology we realize is a big part of the change effort. Having two EMRs (electronic medical record systems) certainly was not conducive to long term growth as part of the zero harm or the best organization we can be. That’s why we’re going to have one EMR system starting next year.
“If we change the people, the culture, that’s a huge part, but you have to look at your processes – why does one hospital follow a different set of processes and maybe there is an opportunity to beg, borrow, steal and copy some best practices being used by our hospitals.”
BJ: And that also sometimes involves some humility if you’re not the one whose process is going to survive this to say, ‘we’re all in this together.’ That goes not just for health care but just in any organization where you’ve got different people who may have done things differently and there’s integration. That’s a hard thing to do.
Vashist: “When we initially started we talked about all these barriers, but once we led the way, a bunch of physician leaders, a movement was started. So now we are at a situation whereby we are not just relying on the champions for change. There are three types of people in an organization when you enact a change effort – you have the champions, you have the fence sitters and you have the resisters. I think in our journey we have got to a point whereby we have some of the fence sitters who are looking at some of us champions and saying, ‘what can I do?’
“For example, a soon to be launched program called ‘early recovery after surgery’ is led by surgeons, orthopods, anesthesiologists, people from various surgical sub-specialties. It was a clinical council effort driven by Dr. Patterson, and now people who are not even members of the clinical council – hard core surgeons in the trenches – are coming to us telling us, ‘this is what we have seen in the trenches, can we join you?’ So we are creating a bigger movement of change.”
BJ: Do you think that is the kind of thing that can gain traction as there are a few real wins that take place?
Vashist: “Absolutely. We had a big win in terms of clostridium difficile, C-diff infection, 30 percent reduction 90 days, we are down 42 percent more than a year later. That propelled us toward embracing more initiatives.”
Wilkinson: “Just as peer pressure impacts the teenager, peer pressure impacts physicians, too.”
Metzger: “I couldn’t agree more. Some of those things lend themselves to standardization, decreased variability, but how do you do that across campus. It’s good to get the best practice from some other hospitals. Are you involving Holston Valley and Bristol equally and looking at each of those as much as you can?
Vashist: “Yes. We are very sensitive to the geographic distribution, to the specialty distribution, but most importantly Dr. Metzger, and I say that in the clinical council, if you want to serve, one or both of these criteria – if you want to serve in an initiative you have to be either a doer and/or a contributor. It doesn’t matter – we have people from Russell County leading initiatives, we’ve got Dr. Beth Jackson from Holston Valley, Joseph Nounou from Bristol Regional Medical Center, Dr. Patterson from Greeneville.”
Metzger: “I think as you talk about barriers, that’s one way to decrease barriers is to make sure people feel they have a seat at the table. I agree the doers, the contributors, 100 percent. I would just make sure people feel involved and say, ‘yeah, we want to take this to our place.’”
Vashist: “We are very, very sensitive to that.”
Wilkinson: “We covet the input of all physicians from all across the system, so those meetings are not closed meetings. If you want to be involved in high value care then we want you to be involved.”
BJ: The clinical council in the release is referred to as “a leading model of physician partnership for quality improvement, and of course we’ve talked about that. Is that its sole objective, or does the clinical council incorporate efforts to engage the independent provider community to keep the playing field level, mitigate potential effects of Ballad’s market power – sections 5.04 and 5.05 of the (COPA) Terms of Certification specifically deal with that, which is competing services and physicians services. Is the clinical council involved in trying to be a part of making sure that Ballad is complying with that particular, pretty important portion of it, particularly to the people that were skeptical about that state action immunity?
Vashist: “I think the way the clinical council was structured, and that pre-dates me, is that it has representation from both independent as well as employed physicians. We have representation from practices as well as facilities. I don’t have numbers off the top of my head but if I were to speculate I would say that at least 30 to 35 percent or maybe even more are independent physicians, and they represent a sizeable portion of our subcommittees and are lending themselves to helping us out. We have been very sensitive to that.”
Dr. Clay Runnels (Chief Physician Executive): “Specifically answer your question I would say the clinical council is not charged with that duty, but the clinical council is absolutely compliant with that duty.
“The way the clinical council is formed is it’s primarily formed from recommendations from the medical executive committees, not from corporate Ballad or any sort of administrative entity. Members of that come specifically from the medical staffs themselves. The MEC (Medical Executive Committee) is a representation of their medical staff, an elected body from that. Many of the people that vote and are elected to the medical executive committees are independent medical staff. So although the clinical council is primarily charged with improving quality and reducing variability in the system, it is absolutely compliant with those regulations from the standpoint of, these are not handpicked or appointed by any sort of administrative person in Ballad. They are sent from the independent medical staff at those facilities and that’s how we end up with whatever mix we get of independent and employed, they’re elected by those medical staffs, so it’s not an administratively driven decision as to who participates.”
BJ: Can and have organic conversations arisen within that council about things other than quality, more like these kinds of issues that could bubble up with concerns on the part of the independent community?
Runnels: “Anything is fair game in any of those subcommittees. Our primary goal as physicians is to protect our patients. At any given time there are many conversations about how decisions will affect the patient as our primary responsibility, and frequently how it will affect those specialties, private or employed, with the policy changes that are recommended. Frequently discussed, whether it be the way the care is provided or how it impacts the person that’s being cared for.”
Wilkinson: “Really it is a cross section of the entire community which Ballad Health serves. All those physicians come from different corners of this region.”
Runnels: “Some of which may be employed, some of which may have been in groups that may have been critical of the merger. We have people from groups that have been critical of the merger that are part of the clinical council.”
BJ: And I would imagine that the public would actually want that.
Dr. Shari Rajoo (Chief Medical Officer, Population Health): “I was just going to add to what’s already been said, that the spirit of collaboration that’s been engendered in the clinical council has also spurred a lot of other participation. We have external physicians participating in our accountable care communities that’s headed up by Todd Norris and Paula Masters. We also have a population health clinical steering committee that is again both within Ballad and outside of Ballad – so we have the health department represented there pretty significantly as well as others, so I think that’s important. And we also have the pediatric division will be setting up a clinical pediatric advisory council.”
BJ to Matthew Loos: What’s the biggest potential positive you see from a physician dedicated to academic coordination for: the system; for the higher ed players in the market and for patients and the region as a whole?
Matthew Loos: I think in a word it’s collaboration. Where we live today is a situation where we have to be very thoughtful and responsible about the resources that we can dedicate to our system in this region. We all live in these communities, we all are a part of these communities and we understand that there is a symbiosis between the people that we are developing, the people that we are employing and the people that we are taking care of.
“Within academics the thing that’s really exciting to me is that we are for the first time going to with a coordinated and thoughtful effort look at where we have strengths and where we have opportunities to improve and then actually be able to work with our academic partners to try to fill some of those gaps. But then also to be able to invest in some of those opportunities from a Ballad perspective to help fill those gaps.
“And so we’re not just talking about minting new doctors, we’re talking about everything from EMS workers to radiation technologists to physicians assistants, to etc.”
BJ: So it’s all the way from the Tennessee Center for Applied Technology and LPN training up to fellowships?
Loos: Exactly. And also partnering with our business partners in the communities to see what they need to help grow, because a lot of what we need to do within health care relies upon attracting people from the outside. If I’m trying to attract a physician and her spouse happens to be an engineer, it behooves me to make sure that I have an engineering position available to her spouse. That’s what I mean by symbiosis – this is a much broader effort related to really trying to be transformative to this region.”
BJ: I would imagine that getting as many, particularly residents and fellows as the area needs may sometimes be a challenge whether it’s because of money or because people may be thinking about other places that they want to go. I would imagine having that integration and not two systems competing for residencies and a little extra revenue to juice that is probably going to help.
Loos: “It’s also so much about what this region offers as far as quality of life. Making sure we emphasize that and that we are as attractive as possible across the entire breadth of our region, both Southwest Virginia and Northeast Tennessee and really emphasizing the key aspects that make this area so incredible that we all know but that those from the outside may not have been privy to yet.”
Rajoo: “On the word transformative, because I think that’s really pivotal for us. I think when folks think about the Certificate of Public Advantage and the Cooperative Agreement, they think about just this being some construct for Ballad to benefit. But Ballad was at the table for the development of those and this is really a road map for health improvement of the region. That’s been spoken about here already, but I think that’s really the key point in my mind, that this is really a way for us to improve the health of the region and really enhance our community. So this is really about the community. This isn’t to me about Ballad, it’s about what we can do to elevate the quality of life for all the people that we live and work with.”
BJ to Chris Metzger: How do you intend to broaden the cardiovascular model of clinical research that’s been so successful at (Cardiovascular Associates) and (Holston Valley Medical Center) to other disciplines and other facilities? For instance, what are sort of the clinical “brass rings” in your view with respect to the COPA’s objectives, whether it’s engaging with vendors/partners, whether it be Type II diabetes, COPD, obesity?
Metzger: “We’ve been blessed (CVA) to have tremendous success in research here. We’ve been number one or two enrollers for 29 trials, published in the New England Journal, but the point is, we can share that systemwide.
“This is a beautiful area of the country for research. Not just the hills out there but the people. What I mean by that is, this is completely different from Boston or New York, where if I talk about a research trial they want their lawyer to approve it, they want three Google experiences. Folks here are trusting of their physician community and their leaders.
“People here a, have a lot of disease, b, have a lot of needs to be helped, and c, are a trusting people. So the model we created in cardiovascular is absolutely not limited to cardiovascular. It’s systemwide. We started with one person, one coordinator, and beat Massachusetts General, Cleveland Clinic every time. That same enthusiasm and same people we have will apply systemwide. And the beauty is, we put together this kind of model, there are all kinds of opportunities.
“One of the things that happens with success, success begets success. First time I tried to get a trial, they said, ‘I’m sorry, you’re from Kingsport? No thanks.’ And then after you’re number one or two enrollers three or four times, now they want you. Now they pay you more money, they come to you.
You take that and say, this is not just Chris, this is not Cardiovascular, it’s not Holston Valley. This is Ballad, which is even stronger. So all the networking with industry that knows we do a good job and that we’re a user-friendly place for them – we’re much more friendly than an academic institution. Cleveland Clinic, they hate enrolling there because it takes six months to get through their IRB (Institutional Review Board), they’re expensive, they’re rude, they don’t perform very well, as opposed to a place that’s friendly, that says ‘come on in, we’re gonna treat you well, we’re gonna perform well, our patients are gonna come back for follow up and we’re going to do well. So we’re going to take that model and go to a different system.
“The academic part of this is very exciting. One of the nice things is you can really network with the other institutions. We know the other institutions very well, they know us. For Massachusetts General, every year they send their advanced fellows down here to do a week of carotid training. In return I go up and do grand rounds and that sort of stuff there.
“Now we take this to population health and they are dying to work with us and see this whole thing roll out. They’ve got an opioid epidemic that they’ve got a model they want to take forward. So now, do I know much about opioids? No, but can we take all the different specialties and say, ‘who else do we need – psychiatry, social workers, primary care providers, ER – how do we do this?’ Take something that solves a problem for this region that can be everything about it. Academic – you can get publications out of it. Cost savings for the health care system – heck yes. Something that helps our region and satisfies COPA for population health – are you kidding me, it’s great. And then you combine that with other facilities. The bottom line is the network. We’ve got a name here, a very good name. That gives us a basis, if someone else says, ‘we want to do a research trial,’ you give them all the tips and tricks we learned when we failed the first five or 10 trials. Number two, you tell the industry sponsor, this is us. This is that same group that did all this, it’s just a different wing of it.
“You take the networking from the academic institutions who know us well. The industry partners who know us well. The tips and tricks from learning how to do good research. And then elevate everybody so that the whole system is elevated, because this is a beautiful part of the world to do research.”
BJ: What are some ancillary benefits to the system if that broadens out and there is a lot of additional clinical trial work?
Runnels: “When you get more involved in research, the ability to attract physicians who are interested in research and high quality care, the bar gets raised. When you’re known as a place where I can come, and I’m really interested in diabetes or cardiovascular, or I’m really interested in this subset of oncology patients, those guys and ladies generally are going to go to places where they can do that. So if we can improve the research our ability to attract high-quality providers to the region is going to improve as well
“Outside of the halo effect of just having the name, maybe they’re not interested in research but they want to go work with the guys that do do research on that. To me that’s the primary benefit, is attracting high-quality caregivers.
“Of course there are ancillary benefits. To be fully transparent, some of those will pay. Research can pay. I don’t want to emphasize that, but obviously health and research paying for themselves instead of just being a cost center would be important for us.”
Dr. Mark Patterson (President, Ballad Health Medical Associates): “It really comes to cutting edge care for our patients in our region and allowing that opportunity to attract the leaders in those areas of chronic disease that we really so much need help in in this region. I think that’s a real asset. People worry about, ‘do we have the best care here, do I need to go to Vanderbilt, do I need to go to Wake Forest, wherever that might be?’ No. We’re going to apply that here in our organization and as Dr. Vashist says we are going to get in the top decile of these areas. But we need help from top-ranked researchers and physicians too to be on the cutting edge consistently, and it keeps all of us geared up and excited and brings us all up to the level that we want.”
Vashist: I think that’s very well said, and one of the things that enamors me about this integrated physician leadership is everything that Dr. Loos, Dr. Metzger or the medical group is going to be doing, or Dr. Rajoo with the population health domain, everything is our business because we are in this together. So that is why it makes real sense for this region to have this integrated physician leadership model.”
Metzger: “This is the best of both worlds to attract good people. People that don’t want to necessarily deal with the bureaucracy of academic medicine and want to make maybe a little bit more money and have a better lifestyle can come here and say, ‘we can do these things in a place where you can both be a clinician and a researcher without some of the bureaucracy to go along with academic medicine.’ It’s the beauty of both worlds. It’s okay to get paid here, and for a Ballad healthcare system, research is payment on top of what you normally do. If you have a contract with a research company and you do a research procedure, guess what? Let’s say it’s a carotid stent. They hospital gets the typical carotid stent bill, but on top of that they get the research reimbursement for that. By the way, you fill out things in triplicate and they deny the bleepin’ thing, you’re fighting forever. If you do a research, you sign it, you see the patient and you have a contract. That contract is inviolable. So there’s nothing wrong with offering patients things that are often free. If it’s an investigational stent, that stent for the patient and the insurance company is free. You’ve helped the insurers, you’ve helped the patient. So it’s a good thing to do. The other things are offering cutting edge technology to patients first, but on top of that it’s good for financials and attracting physicians to our area.”
Loos: “Within what Ballad has committed to do for both states is creation of a consortium, so all of our partners in research and in academics, we’re all going to have the opportunity to share in the successes in this region. It’s going to really help industry, our academic partners and Ballad.”
BJ to Dr. Mark Patterson: What is the key to expediting your varying constituencies’ shift to risk and value-based payment models – both the legacy system-owned practice groups who may be accustomed to an RVU or fee-for-service paradigm, and then Ballad itself, which wants to get there, it’s stated and I believe it, but is fighting the headwinds of declining inpatient populations and revenue? How do all of you help Ballad get to actually being willing to step out on that limb towards more value-based, more risk-based and more shared models when it’s so comforting to want to hold on to the typically higher-reimbursing approaches?
Rajoo: “Both medical groups have been on that trajectory already and have made significant inroads, so this isn’t new, but probably the whole, as you had alluded to earlier, has really not made that leap. So a lot of the structures that are in place, payment models for where we send patients, those are not value-based payment models. And also the regulation. So there’s a lot of those things that are not really primed yet. Insomuch as medical groups have one foot in fee for service and one foot in value, moreso it is the government and the payers.”
BJ: I realize it’s just as much the system as a whole and probably not so much clinicians, who probably more than anybody realize that that’s where we want to get to.
Runnels: “I would say the leadership at Ballad Health has been willing to go to more risk-based care for a long time. The government has been a leader in that, they started that trend with the value-based mentality, but in many cases it was the other payers that lagged behind in their mindset. They didn’t know how it would work.”
Rajoo: “I think they’re learning as we go along, but the one thing about the antitrust, I don’t know that any of that belongs in a value-based world, because value-based contracts really ask you to pick preferred providers who are like-minded in decreasing the cost of care. The other piece with academics, as we do lose revenue because of this value-based migration, there is a need to replace that revenue, so some of these other efforts are aligned with that. But also the COPA and Cooperative Agreement commitments require a significant investment from Ballad, so we have to come up with that.”
Runnels: “And the second thought is, to answer your question about declining inpatient volumes, that’s a reality in health care and if you haven’t accepted that you’re not in the right place. But we’ve accepted the fact as an organization that there’s declining inpatient utilization. So what do we have to do? We have to take care of the patients where they are. We’re a health system. We take care of patients, so our focus over the coming years is going to be heavily in how do we – and it’s a natural shift inpatient to outpatient – how do we keep patients healthier. So that means looking at our primary care processes and our primary care structure in order to treat patients where they are and to keep them healthy, which for physicians is a great thing. Because if I keep a patient healthy I’d much rather do that than take care of them when they’re critically ill.”
Patterson: “The movement is a metamorphosis, it isn’t just a flip switch by circumstance. This is a change that’s going to take some years to accomplish overall but we all realize that shift is coming and that the charge really is quality patient care. That’s going to make this shift more doable and it’s going to make this shift better for our patients in general.
“Good quality care doesn’t equal availability of hospital beds and getting into the hospital. Good quality care equals taking good care of patients and keeping them at home where they can be with their families and get better rather than staying in a hospital and just absorbing the risk of being in a hospital.
“Some of the things that we can do are going to be innovative. We’re going to try to work with outside entities and other innovators in health care to try to develop improved opportunities for patients to reach their physicians without actually having to come to the office, for instance. Telehealth type thing. These can be online opportunities – this doesn’t mean you sit in front of a computer with an iPad or something like that, but it might mean a phone call. It might mean reaching a call center where you say ‘I need to see a physician today,’ and you’re informed that your physician is full, or maybe your physician is out of town. That center would arrange an appointment for that day for another provider to take care of them, rather than that patient going to the emergency department where they may have a very expensive treatment, plus maybe unnecessary testing depending on what the complaints are. You have all of that expensive care in the emergency department happen.
“So that allows increased contact between the patients and their providers, or at least a provider they know within their region that they can reach out to. There are a lot of other opportunities like that that are out there that we need to look at. We don’t need to be close-minded to any of them.
“It’s very uncomfortable, I know, for patients to start thinking about, ‘well, I want to see my doctor.’ We want to make those opportunities available within our medical group, but we also need to understand now in the age of CVS developing clinics, urgent care centers that we have, and they’re part of our medical group, we want to expand that availability of those centers and the marketing aspect where they’re more visible. Sometimes people don’t even think about urgent care centers, they just go to the emergency department instead. They would want to make that opportunity more welcoming and for them to seek that out after hours. It’s difficult for primary care offices to set enough time for walk in type patients when they generally have a panel of patients that they’re seeing. So we want to make sure that those more unscheduled visits that need to happen, happen there rather than in the hospital.
“Another opportunity could be home visits, and that’s coming around again. I think that’s a great thing. If we can work out a model, and there’s some out there we need to look at, where we have nurse practitioners that can actively seek patients that have come out of the hospital recently that need help with their medications, that need a higher level of care than a home health nurse, that can go out and reach that patient and find out where the slippery slope might be with that patient where they can look at opportunities for correcting it a little bit whether it’s medication, confusion, they left the hospital, they’re getting over being sick and they get home and say, ‘I didn’t really understand how those meds were supposed to be taken care of.’ Our home health and call in nurses do a good job with that, but sometimes it requires someone with a higher level of expertise to come in and say, ‘this may need to be adjusted, we’re going to work on that,’ and have the authority to make some changes without going through a number of phone calls. That’s just a couple examples of innovation we’d like to get started and other things we want to be on front edge of.”
BJ: Are you also heading up the legacy groups from Wellmont and Mountain States?
Patterson: “Within our medical group we have eight distinct organizations that are going to be rolled in together. It’s going to take a year and a half or so to get that done. But we have multi-specialties. We have everything from primary care, neurosurgery and everything in between. Subspecialty medicine as well as hospitalists and our urgent care centers.
“So we’re providing the services, but we’re not exclusive, and we aren’t trying to capture all the patients in any way. This is an opportunity for us to utilize our organization to provide the services that sometimes a private practice circumstance may have a more difficult time getting started with. We can start these one-offs, sub-specialty practices and within a bigger organization be able to help that survive where a single entity coming in might have a difficult time in this day and age doing it.
“As well as the fact that quite frankly many of the residents coming out of different programs are much more comfortable with employed models than they are with going into private practice models and we want to accommodate that. People who are more interested in entrepreneurial medicine and doing their own thing, I think it’s great and we need all of these inputs.
“Like these guys have said before, a lot of what I’m doing and all of this group of physicians are doing is tearing down the silos. Medicine isn’t, ‘we’re practices over here, and we’re acute care over here and we’re research over here and academics over here.’ It’s a web. We know as physicians how this web works because we work our patients through this web commonly and we know that our patients require everybody within this complex organization to maintain their health. So one of the main things I see coming out of this is the ability for us to speak a common language and work well together and to tear down those barriers to provide excellence in care.”
BJ: Does that include potentially barriers between the same type of specialties who are each from the other legacy system, and are you charged with some of that integration?
Patterson: “I’m part of the solution to that, I hope. We do have some differences in legacy, but what we have is a lot of commonality. The commonality is the fact that each of these providers, each of these physicians in these same specialties from different legacy organizations want excellence in patient care. They want their patients to be taken care of well (and) they want to also be productive in their practice. They want their practice to be well supported. Our organization is a service organization to the front line. These physicians don’t work for me, I work for them. The physicians on the front line need to understand that my approach and the Ballad approach is to support them and then develop this model where we can integrate and provide excellence in care across the specialties. If I’m not supporting them in their job, if I’m not making patient access available to their practice, if I’m not tearing down barriers for that, then I’m not doing my job.
“My job has to be there to decrease the access barriers and to decrease, frankly, some of the administrative headaches that come from practicing medicine these days, to the best of my ability. Some of those are government driven, payer-driven, things that we have to deal with, but we really want to decrease those if we can.”
Metzger: “We all thought value-based medicine was going to be here 10 years ago, five years ago and it’s not. There’s still always going to be a little bit of RVU that’s driven into everything no matter how value-based you are. How much work you do is going to generate revenue, but we just have to work more efficiently and cooperatively. And all the quality control things are going to make a big difference.
“Towards your question. There are very different models out there. There are some that are very RVU-driven still. Some organizations are more advanced in value-based medicine. The hope is that you can work toward the middle. There are some groups that are already, we don’t need to name them in there, but there are some groups that are already advanced in value-based medicine, and it’s coming. Whether you like it or not, quality control, cost-per-case, decreasing readmissions, all those things are going to be important to all of us as a healthcare system.”
BJ to Dr. Shari Rajoo: The COPA metrics, the population health goals that really the system can’t completely control, because I can sit on my back porch with my oxygen tank and a Big Mac and a cigarette and you can’t stop me. That’s got to keep you up at night, because you know you’re sitting and looking at what are going to be some expectations. Just like teachers’ year to year and improvement in the public school system. Not all of it’s in your control. That aside, how do you take those and start making some consumable pieces out of those that you can really start to make some impact on and see?
Dr. Shari Rajoo: “The COPA and Cooperative Agreement metrics are broken down into plans. We have the rural health plan, behavioral health plan, the children’s plan, the population health plan. I think in terms of breaking it down, that does help. With that said, there’s still a very, very gargantuan road ahead. But I think – many people made these comments earlier – the commitment of Ballad, the energy of the community, that cannot be overstated. That’s a huge element of this, and our engagement of the community through our providers in the clinical council, our providers in the population health clinical steering committee but also the accountable care communities. We have an accountable care community in Tennessee and one in Virginia, (and) over 200 organizations that are part of it. We can’t make this journey without partnering with our community. This is for them, so they have to be part of devising the solution if you will.
“Today I may not be able to change someone’s having a big Mac on their front porch while wearing oxygen, but hopefully through several generations of helping to build a strong foundation for children and families we will change these behaviors over time. So this is partnering with the schools, this is partnering with women who are pregnant who may be addicted or not, but making sure that family has the support to raise healthy children. Then those children, that’s our future, so then they have academic opportunities, they have other opportunities in this area and we’re growing the population, which you know right now our population growth is stagnant. This is multi-factorial, but we are really building a pretty robust relationship with our communities to help drive our success in these areas, I believe. And I think of any region, this region can do it.
“You talk about the Cooperative Agreement, the COPA, people forget, they think this is a Ballad thing, they forget it’s a community thing. But this is also something that I believe that the nation is watching, and we can really be a demonstration for other communities around this nation as to how to move a population to become healthier. And I believe our people want it.”
BJ: There was a time when there was a certain triple board certified physician running a health system here, and it was purported to be very physician-centric (Wellmont under Dr. Richard Salluzzo). Do you feel like the substantive clinical leadership that is being set in motion here, including you guys and what we’re talking about today, does it exceed and does it need to exceed any level of clinical leadership that you have experienced in either legacy system or other places that you’ve been for this effort to succeed as a whole?
Runnels: “Undoubtedly. The commitment that we have to the clinical enterprise here, the physician input, physician leadership, is unlike anything I’ve ever worked in. Just putting physicians in leadership roles is not the goal. So now we have clinical input, physicians in leadership.”
Business Journal: They can give all of you a title.
Runnels: “Right. It’s the mission that’s important. And the mission is to engage our entire medical staff, our entire medical group, to focus on population health and focus on zero harm in our hospitals, to focus on patient centeredness in the patient experience.
“Our job is not necessarily just to give input or to be a figurehead at the top of an organization. We are solely focused on how we involve, energize and drive forward the clinical enterprise, including all the physicians and their interactions with nurses and ancillary services to accomplish the mission of Ballad Health. That’s really what it’s about for us.”
BJ: If that were relatively easy, I think we would have already seen a lot of hospital systems with true substantive physician leadership. What is it that makes it hard for the non-clinical administration and the clinical leaders to actually make that work to its greatest end? Because it’s got to be hard, or this wouldn’t be different from what you’ve done before.
Metzger: “There are models that are physician-run. Cleveland Clinic for example. They still make money and do ok. I think it’s just different mindsets and learning to trust folks. There are two different mindsets. Businesspeople think business, doctors think doctors and we’re not good at thinking the other way around. Doctors can be great at taking care of patients and have no idea that they just lost a ton of money and in so doing they hurt the ability of the system to contribute and help the next person. Conversely, hospital systems can say ‘that’s ridiculous’ and forget that there’s a patient involved in this dollars and cents. That’s the beauty of taking the physician leadership that Clay talked about and say, ‘alright, if we’re going to be on this we have to then convince the hospital system that we are partners. We’re not in this to get more paycheck or a title on an org chart. The idea is, let’s work together. The goals are aligned, they really are. We want to provide quality health care as low cost as possible, sustain the ability to do that, but you just have to get through that little trust factor there, completely two different mindsets if you’re not careful.
“Good systems have learned long ago, the businesspeople cannot run a hospital without physician input, period. Physicians cannot run the business aspect without the businesspeople, period. So you get the nice mixture and partnership and build that trust and it works.”
BJ: In a patient catchment area that’s growing at 15 percent a decade, a system can survive without it. But can this region possibly afford not to have this work?
Rajoo: “I might also challenge that we (anywhere) can survive without doing it. I think we would have needed to do it, whether it was the value-based conversation that changed the equation, and I think that does have a lot of input from CMS, which was the purveyor of that movement. I think ultimately we would have come to this and I think it’s just, to Dr. Metzger’s point, it’s a different mindset that everybody needs to look through. I think everyone’s really ready and primed for that relationship because at the end of it again are patients, being very patient-centered and people that we know and live with. I think that’s a difference between if long ago somebody else came in and bought either system. That’s the beauty of Ballad, because everybody who’s here lives and works here, and that makes a difference.”
BJ: You’re right, sheer demographics are going to dictate it for the entire nation at some point, but it’s probably hitting here faster, harder and with devastating consequences if something’s not done. Because you’ve got higher inpatient utilization than you have in other places and you know that’s going to end, and you’ve got low population growth and a lot of old, sick people. It’s a lot more real here than it is some places, probably.
Runnels: “What we’re talking about is finding the right mix, which I believe we have. I’m confident that the structure we’re in now is the right mix. But really what we’re trying to do is balance the value equation for our patients, because we want to provide value to our customers, which are the patients, and the payers and our local employers. Those are three key stakeholders for us. Balancing that value equation, which is quality over cost – if you get too focused on financing then the quality suffers and your value proposition is out of balance. Vice versa, if all you ever talk about is quality and just figure the finances are going to take care of themselves then you end up in trouble financially. What we’ve got to do and I think we have the right balance to do this is to really balance the value equation for our patients, to provide as Chris, Dr. Metzger said a minute ago, to provide the highest quality we possibly can at the lowest cost.”
BJ: These titles and this structure, was it envisioned in anything particularly specific prior to Ballad actually getting off the ground, or is this something that kind of organically had to be figured out and now you’ve gotten to that point?
Teresa Hicks (Ballad Director of Communications): “I would suppose that it’s more of the latter.”
Runnels: “I would say more organic.”
Hicks: “There was nothing pre-merger that was discussed about a structure like this or we probably would have done it before now.”
Metzger: “I think it’s actually a testimony to Ballad, because I think they would be more used to a different model, quite honestly. It was often Mountain States legacy, and that’s not a knock, it’s just an observation, but I think it’s a beautiful sign of a good thing that they’re recognizing that we ought to do this. Anybody can criticize Ballad or anybody else, but without Ballad, no hospital system here was going to survive independently. So you have a couple options. You can band together and do this correctly, or you can sell out to somebody anywhere, and they’re going to rule you from Atlanta or Charlotte, and you think they really care what the people in this room think? The answer is, ‘hell no.’ They’re going to rule you from afar and they’re going to say, ‘these little guys in Tennessee and Virginia, they’re going to do what we tell them to do.’
“Conversely we say, ‘we’re going to put together a merger.’ That is no easy thing to do. No easy thing to do. You’ve got all these different people working and you have to evolve over time. It’s not perfect at first. But nobody thinks, ‘hey, I’m going to have 21 hospitals and we’re going to all work together when we were fierce competitors, and we’re all different, big hospitals, little hospitals, independents, not independents.’
“So now that you’re there, how do we this better after two years? Within two years to come and say ‘let’s do this, let’s take these docs and let’s align and do this,’ I think is a testimony that says ‘we’re going to try to do this the right way.’ It is organic, it is evolutionary, but it’s a nice testimony to folks that took big risks to try to do the right darn thing for this region and say, ‘OK, we may not have everything perfect.’ Who does when there are 21 hospitals, you tell me? We’re going to get better, and this is what we’re going to go to. I think it’s a good thing.”
Patterson: “One of the things that’s very important to understand also is that the physician leaders here are all continuing to practice medicine. We are not 100 percent administrators. We practice at least weekly, generally, within the organization. I saw patients today and will tomorrow. We do this routinely and it gives us a real down to earth, real world view of what we’re doing up here and I think it’s very important we see that.
“Also, when people in my community talk about ‘Ballad did this, Ballad did that,’ I tell them it’s really important to understand that Ballad is an entity. It’s a name and an entity. The people who are taking care of you are the same people who took care of you last year and five years ago, and we’re still here with the same people. The nurses, the administrative people, the people in the cafeteria who are helping us take care of patients throughout the organization are the same people.
“We have a different organization and we’re working toward a more unified goal across the region. There’s no question in my mind, the prime concern of the organization is to improve the care of the people of this region. No question in my mind.”