Making the Leap to Accountable Care in a Physician-Driven Organization at Carilion Clinic

Sept. 10, 2014
In his presentation at the Atlanta Health IT Summit on April 16, Stephen Morgan, M.D., CMIO at the Roanoke-based Carilion Clinic, spoke about the journey of his organization, Carilion Clinic, towards accountable care and population health

In his presentation at the Atlanta Health IT Summit on April 16, Stephen Morgan, M.D., senior vice president and CMIO at the Roanoke, Va.-based Carilion Clinic, spoke extensively and in detail about “Carilion Clinic’s Journey with Population Health Management and Health IT.”

Dr. Morgan shared with his audience at the Health IT Summit, sponsored by the Institute for Healthcare Technology Transformation (iHT2), and held at the Historic Academy of Medicine at Georgia Tech, in downtown Atlanta, regarding the experiences of the eight-hospital, 600-physician integrated health system around accountable care and clinical transformation. (Since December 2013, iHT2 has been in partnership with Healthcare Informatics and its parent company, Vendome Group LLC.)

Stephen Morgan, M.D.

After putting into context the broad shift towards accountable care in U.S. healthcare, Dr. Morgan explained the core drivers pushing the Carilion Clinic towards accountable care, and creating an accountable care organization (ACO) under the Affordable Care Act (ACA). Indeed, the Roanoke, Virginia-based Carilion organization joined the Medicare Shared Savings Program (MSSP) for accountable care organizations (ACOs) in January 2013, and that step in itself has helped to spur the development of more coordinated approaches to care delivery and the acceleration of the creation of IT foundations to support the ACO financing and delivery model.

What’s more, the avoidable readmissions reduction mandate embedded in the Affordable Care Act (ACA), as well as implied in sharing risk with the federal Centers for Medicare & Medicaid Services (CMS), has further spurred activity already underway at Carilion Clinic to improve the management of such chronic illnesses as congestive heart failure (CHF), coronary artery disease (CAD), diabetes, and chronic obstructive pulmonary disease (COPD).

Morgan explained that, shortly after the Carilion organization reorganized itself as a physician-governed clinic in 2006, the organization’s leaders came up with a strategy to move forward on population health management, a strategy that is still being refined based on early experiences so far.

“Among the key questions we faced,” he told his audience, “was, are you able to manage risk? We had gotten into the Medicare Advantage program fairly early on, but realized that we did not understand how to manage risk, and actually had had to back out of that program quickly.” Among the issues besides the ability to manage risk, that Carilion Clinic’s leaders have faced, are: what kind of strategy is being developed for the integration of clinicians? How has the organization engaged physician leaders? How will the organization handle the necessary culture shift involved in moving from a fee-for-service-based reimbursement system to a payment system based at least partly on risk? What are the fundamentals for effective health IT and data management? How will the organization effectively manage the pace of change?

In fact, Dr. Morgan said, “We’ve been undergoing a huge culture shift. In fact,” he said, “we’ve found that culture has been one of the biggest issues for us. We’re getting through it, but it’s hard. And having an effective HIT and data management strategy,” he said, is also incredibly important. Related to both and equally challenging, he says, is the fact that “We have one foot on the dock and one in the boat” when it comes to reimbursement. “We’ve still got most hospital payment under fee-for-service; so it’s really tough, in terms of what we tell our doctors” about how to best manage the utilization of resources in a mixed-payment environment.

Among the steps that the Carilion Clinic leaders have taken since 2006 that have moved things forward, Dr. Morgan cited the following

> They developed a multispecialty medical group

> They focused strongly on nurturing physician leadership within the organizatio

> They have created substantial quality, safety, and process improvement

> They have implemented an electronic health record (EHR) enterprise-wide

> They constructed the Riverside campus

> They opened a medical school in partnership with Virginia Tech University

> They have implemented medical homes at all primary care sites

> In partnership with Aetna, they have created a commercial HMO, Whole Health, and a Medicaid HMO, MajestaCare; and Carilion has become a Medicare Shared Savings Program (MSSP) accountable care organization (ACO)

> They’ve built a culture of collaboration

“All of our primary care sites, around 40, are on the patient-centered medical home model, as defined by Carilion Clinic,” Dr. Morgan noted. “Initially, we worked to get all of our primary care sites certified as level 3 PMCHs,” according to the certification standards of the National Committee for Quality Assurance (NCQA), he noted. “But,” he added, “we moved away from that approach, because we found it was more process-oriented, and it was driving our physicians—and our nurses—crazy. So we tried to move instead towards creating PCMH elements that were more ‘value-added.’ But all of our outpatient locations now have a patient-centered medical home, with care coordinators.”

How do the leaders at Carilion Clinic view population health? “We view population health,” Morgan said, “in terms of how we take care of large groups of people proactively, moving away from episodes of care. So the transformation work in that area really gets down to the processes involved,” optimizing those processes to create better care patterns. “We developed a system-wide Transformation Oversight Committee, at the executive level, with care integration, informatics, and finances/contracting subcommittees,” Morgan reported. “We created it as a think tank-type committed, with an initial focus on COPD [chronic obstructive pulmonary disorder], and led by our organization’s chief strategy officer. We decided to go after COPD,” he said, “because we had CHF [congestive heart failure] programs in place—not as robust as we wanted them to be—but some programs, whereas we had absolutely nothing around COPD. And in meetings we had held in the community, one of the biggest concerns that came out of those was a lack of smoking cessation programs in our community, which was tragic, really.”

So the Carilion folks created a disease-focused, ambulatory care-based program, with the principles of the Triple Aim in mind (the Triple Aim being the conceptual construct developed by the Cambridge, Mass.-based Institute for Healthcare Improvement around improved care quality and patient safety, lower costs, and enhanced patient engagement as a core set of goals for the U.S. healthcare system). “We looked at this with regard to three levels of risk among our patient population—low-risk patients, who are about 45-55 percent of our overall population; rising-risk patients, about 40-50 percent; and the highest-risk, sickest, 5-10 percent of our population,” Morgan said.

“Our initial approach,” Morgan reported, “was disease-focused ambulatory care management; the second area to focus on was high-utilization management; and then we looked at ambulatory quality, and pay for performance. We’ve built programs around COPD, as I mentioned, and now CHF is next.”

With regard to IT, he noted, “All this population health work relies strongly on the infrastructure behind it: data analytics and reporting, clinical protocols and pathways, payment reform. We’re relying heavily on IT and analytics” in order to support this work, he noted.

In terms of key drivers and critical success factors, Morgan noted that “physician leadership and engagement” are absolutely “critical” in the development of IT infrastructure for population health. Physicians must have a seat at the leadership table, in a variety of ways, including through physician leaders’ participation in the development of strategy, as well as physician leadership around cultural change.

In terms of IT evolution, Morgan stressed that “You need to develop your strategic roadmap: first things first! We got ahead of ourselves several times, and have had to pull things back,” he conceded.

Among the key factors involved in the mix for the leaders at Carilion going forward: EHR integration, which Morgan described as “critical”; the development of a robust telemedicine program; the creation of patient portals and the advancement of patient engagement; the creation of a robust data warehouse; and the forward evolution of the ability to analyze and display data to all stakeholders involved.

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