The doctors are in


Above: Ballad Health’s newly named physician leadership team includes (front, l-r) Dr. Mark Patterson, Dr. Chris Metzger, Dr. Shari Rajoo, Dr. Clay Runnels, (back, l-r) Dr. Mark Wilkinson, Dr. Amit Vashist and Dr. Matthew Loos. Photo by Jeff Keeling

by Jeff Keeling

Editor’s Note: This print article reviews the big picture and background surrounding Ballad Health’s decision to name seven physicians to new, administrative leadership positions within the hospital system. Those physicians discussed in much more detail how their roles can impact Ballad and the region during their August 12 interview with The Business Journal. For a complete version of that interview, click here.

The seven physicians sitting around a conference table at Ballad Health corporate headquarters August 12 brimmed with enthusiasm. For more than an hour, they answered questions about their newly announced leadership roles at Ballad. Conversation ranged from research, graduate medical education and population health to quality of care, changing payment models and the involvement of independent providers not employed by Ballad when, increasingly, care is shifting away from hospitals.

“Just putting physicians in leadership roles is not the goal,” said Clay Runnels, Ballad’s first-ever chief physician executive. “It’s the mission that’s important, and the mission is to engage 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.”

With Runnels were Chief Clinical Officer Dr. Amit Vashist, Chief Academic Officer Dr. Matthew Loos, Chair of Clinical Research Dr. Chris Metzger, President of Ballad Health Medical Associates Dr. Mark Patterson, Vice President of Medical Staff Services and Hospital Based Programs Dr. Mark Wilkinson and Chief Medical Officer for Population Health Services Dr. Shari Rajoo. All remain practicing physicians as they enter roles they say can make Ballad a truly physician-led hospital system.

If that happens, their comments suggested, Ballad will be better positioned to meet the requirements of Tennessee’s Certificate of Public Advantage (COPA) and Virginia’s Cooperative Agreement. Those documents, created to shield from antitrust enforcement the inpatient hospital monopoly that resulted from Mountain States Health Alliance (MSHA) and Wellmont Health System’s merger, place significant clinical quality, access, population health and cost requirements on Ballad. Doctors, nurses and other direct care providers will have as much if not far more to do with Ballad’s successfully meeting those requirements as administrators will.

“There are models that are physician-run,” said Metzger, who is tasked with broadening into other disciplines what has been a very successful cardiovascular clinical trial/research program at Cardiovascular Associates, a group known for its physician-led and managed history. “Cleveland Clinic for example – they still make money and do okay.” Still, he added, “there are two different mindsets … 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,” Metzger added. “Conversely, hospital systems can say ‘that’s ridiculous’ and forget that there’s a patient involved in this dollars and cents.”

“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 … you get the nice mixture and partnership and build that trust and it works.”

The road to doctors in the C-suite
An email helps explain the doctors’ reason for enthusiasm and suggests the August 1 physician leadership announcement may have had as much to do with doctors actively encouraging Ballad’s administration as it did with the administration pulling doctors along.

In late March, Ballad CEO Alan Levine emailed the system’s employed physicians and extenders (nurse practitioners and physician assistants) with an update centered around two goals. The first is aligning the eight “legacy” practice groups from former rival systems Wellmont Health System and Mountain States Health Alliance. The second – what Levine referred to as the “ultimate goal” – is developing a “partnership” with Ballad’s physician leaders that transforms the system into one in which those doctors “work more substantively with administration to develop and implement operational decisions that optimize care delivery and financial outcomes.”

In plain English, Levine was saying he’d like to see doctors much more involved in Ballad’s top-level decision making, not just clinically but financially, than they had been in either legacy system. He was admitting, albeit in carefully worded language, that clinicians, not administrators, hold the keys to an ideal future state: one in which Ballad earns sufficient revenues while achieving excellent clinical outcomes. And at least in some measure, Levine was responding to physician lobbying efforts. He referenced being “intrigued by” what he called “a fairly bold proposal” that came from a visioning committee of doctors. The proposal, modeled after what Levine’s message called “many forward-thinking and leading institutions in the United States,” was, nevertheless, “one that does differ from various models within our system.”

Levine said he was “excited by the potential for such a transformation, and what it can mean for … achieving our goal of becoming a top decile performing health system.” Still, he warned that such a shift “comes with accountability” and that no one should think “the movement toward physician leadership” will be easy. He promised a period of input from a range of providers, and a move toward a “Charter for the physician enterprise.”

Fast forward four months. Ballad announces a physician leadership team headed by Runnels. Levine reiterates Ballad’s goal of being “a national leader in both clinical quality and value-based care,” and stresses the importance of collaboration with doctors. He says those “trusted clinical experts” will help Ballad navigate to “closer partnerships with the federal government, state Medicaid programs and our payer partners who all want closer value-based relationships.”

Window dressing or window into the future?
Labeling a hospital system as “physician-centric” is one thing. Achieving it is another, but Runnels said Ballad’s recent moves toward physician leadership are unlike anything he’s worked in before.

“I’m confident that the structure we’re in now is the right mix,” he said. “We want to provide value to our customers, who 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.”

The new physician leadership’s degree of legitimacy may stem partly from the COPA’s requirement that Ballad establish a “clinical council” that includes both employed and independent physicians. The council’s primary COPA responsibility was to develop a common standard of care, credentialing standards, quality performance standards and best practices requirements, as well as providing input to management regarding clinical integration. In a health care environment moving toward payment based on quality and outcomes, and with the COPA and Virginia’s Cooperative Agreement focused on access, cost, quality and population health improvements, the council’s influence expanded beyond its explicit mandate.

For instance, sections 5.04 and 5.05 of the COPA’s Terms of Certification deal with competing services and physician services, with requirements meant to mitigate the impact of Ballad’s market power including strong language about maintaining an open medical staff. While not specifically charged with making sure Ballad complies, the clinical council is, Runnels said, “absolutely compliant with that duty.” Members are elected by medical staffs, “not handpicked or appointed by any sort of administrative person at Ballad,” Runnels said. “They are sent by the independent medical staff at those facilities and that’s how we end up with whatever mix we get of independent and employed.”

Inside the council’s subcommittees, Runnels said, “anything is fair game.” And the clinical council includes “people from groups that have been critical of the merger.” Wilkinson, the VP overseeing medical staff services and hospital-based programs, agreed. “Really it is a cross-section of the entire community Ballad Health serves and which all those physicians come from in different corners of this region,” Wilkinson said.

Rich Panek, who leads State of Franklin Healthcare Associates, one of the region’s large independent medical groups, said he’s hopeful Ballad’s physician leadership decision will mark a step in the right direction for the hospital system. SoFHA, whose practitioners work with more than 120,000 patients, and a handful of other large independents have more experience than Ballad in value-based payment models at the outpatient level.

With care, and thus revenues, trending that direction, Ballad and the SoFHAs of the world will have to figure out how to create the best-case scenario for themselves and for patients – devising the kind of “pro-competitive” arrangements that allow both parties to generate sufficient margins without running afoul of legal restrictions.

“We know a number of physicians that were announced in the changes,” Panek said. “We personally know Clay Runnels and we think that’s a good decision that will probably help with the collaboration in the community. We’ve known him for a long time and we think he’s reasonable and he’s trustworthy.”

Collaboratively or not, Runnels said Ballad will certainly place a strong focus on outpatient care.

“We’ve accepted the fact as an organization that there’s declining inpatient utilization … Our focus over the coming years is going to be heavily in ‘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.”

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