Grace Terrell, M.D., CEO and president of High Point, N.C.-based Cornerstone Health Care, gave a keynote presentation on her organization’s bold jump into population health management at the iHT2 Health IT Summit in Atlanta on Dec. 3.
The keynote, “Using Analytics in Value-based Contracting," was delivered on the final day of the iHT2 Health IT Summit (the Institute for Health Technology Transformation is a sister organization to Healthcare Informatics under the joint umbrella of the Vendome Group, LLC) at the Omni Atlanta Hotel at CNN Center. At the core of Dr. Terrell’s presentation was the idea that any system’s population health journey will require a complete transformation from what traditional healthcare has been about.
At Cornerstone, one of the fastest-growing physician groups in the Southeast, now with 365 physicians and mid-level health professionals, one of the traditions is to start every committee meeting with a patient story. Thus, Terrell started her presentation with the story of a patient who up until 10 years ago, did not receive medical care, despite a multitude of issues including diabetes, hypertension, and heart failure, Terrell explained. What the patient, in his mid-80s, did have, however, were two daughters who were quite attentive and engaged in his care. A three-pronged team of Terrell and the daughters were able to convince the patient to finally see a physical therapist. As such, while he still has his medical issues, he has been able to achieve a quality of life that he wouldn’t have had if not for social interaction and intervention, Terrell said.
This type of patient story, Terrell continued, is the center of the type of change that’s needed in U.S. healthcare. All businesses, no matter the industry, have five strategic choices, she pointed out: remain in the status quo; sell assets; collaborate by keeping assets while thinking of others’ assets; innovate; or transform. The difference between innovation and transform, Terrell said, is that innovating means doing your core job but figuring out new ways of doing it. “Transforming,” she said, “is becoming something else.” As such, in healthcare, “transforming is the option for many of us that is most attractive,” Terrell said. “It was our organization’s idea to no longer be a multi-specialty practice, but instead become a population health management hub.”
Five years ago, Terrell said, the healthcare business model was simple: physician reimbursement was mostly in a fee-for-service world that included more visits, more procedures, and integration only for referral bases, not for unified care. The population health model is far different from that, Terrell attested. “You have to show your outcomes. Efficiency has to be at the population level. The types of investments necessary are about health IT, clinical integration, and commercialization. We need to get out of this hamster wheel approach. It’s about redesigning healthcare around the needs of our patient populations. That can lead to real joy,” she said.
Terrell added, “A few years ago, you didn’t want the sickest and oldest patients. You wanted young and healthy people who had colds. That was easy and the economics were better,” she said. “Now, for the first time, the patients who are the sickest present the greatest opportunity. Isn’t it nice that as a primary care physician, you need to pay more attention to the Medicare patients with multiple chronic problems?” she asked
As such, Cornerstone’s population health management strategy has included significant change involving getting paid differently, doing clinical integration through a patient-centered medical home (PCMH), information integration, and organizational realignment, Terrell said. “We started with what we knew, which were care models,” she said. The organization’s PCMH strategy started in 2007, as it turned all primary care practices into medical homes while adopting an analytics tool to identify gaps in patient care. “We had better results in six months of this approach than we would have if we hired an endocrinologist with a $300,000 salary,” Terrell said. “It requires thinking and identifying, and creating a care model around that,” she said.
What’s more, Terrell noted that despite being of the earliest electronic health record (EHR) adopters in 2005, the organization soon after realized that the EHR wasn’t enough. “We needed to aggregate the data and integrate disparate data platforms. We needed to share data,” she said. Now, Cornerstone has a team of clinical data scientists that analyzes the data coming in and gives it back to the people who need it. “We are starting to pull in demographic data sources so we can think about social determinants of health. The data is out there that could have a significant impact on healthcare if we think about things differently.” Terrell admitted that it’s harder for hospitals to make this population health pivot, as they have much higher fixed costs and assets than medical groups. “We didn’t know if these population health strategies would be welcomed to hospitals,” she said.
In 2011, which Terrell calls “a huge turning point for Cornerstone,” the organization brought in outside consultants, who through a gap analysis, realized it was time to invest in things that were never a stable of the physician group before. Included in that was $25 million in borrowed money when shareholders agreed that it was time to shift towards a pay-for-value model. “We all signed our names to that. The debt was personal,” Terrell said. Then in 2013, Terrell paved the way for the launching of Cornerstone Health Enablement Strategic Solutions (CHESS), a company dedicated to helping health systems and other medical groups make the transition to value-based medicine. The message was loud and clear: Cornerstone was committed to value-based care.
As Terrell showed in her presentation, the results of these endeavors have been more than promising. Clinics embedded with internists, pharmacists, nurse practitioners, and psychiatric professionals were launched, as was a telemedicine service. Caregivers would follow a team-based approach by following patients from the hospital to everywhere else along the continuum. A Medicare Shared Savings Program ACO (accountable care organization) was developed. Eventually, all the primary care practices were recognized as National Committee for Quality Assurance (NCQA) PCMH Level 3—the highest attainable level.
The ACO proved very beneficial as well; in 2014, it had the fourth-lowest cost basis and sixth-highest quality scores in the country. Now, it will be part of the Centers for Medicare & Medicaid Services (CMS) Next Gen ACO model starting in 2016, Terrell said. Interestingly, Terrell said that one hospital that was part of the ACO dropped out, deciding to stay in the fee-for-service world for the time being. That same hospital also attempted to “raid” all of Cornerstone’s specialists, offering to pay them entirely on volume, rather than value, she said. “That may work in the short run, but if you look at our results in the ACO model we were in, it won’t work in the long run,” Terrell said.
What’s more, the analytics and reporting that were done on quality were completely transparent for physicians to see, Terrell noted. “All doctors got scores and utilization reports, and they became really interested in them. The quality is higher now as a result of hard work, culture changes, and transparency inside the group,” she said.
Terrell concluded her presentation by giving, in her opinion, the three transformational waves that will re-shape the health marketplace. The first wave is patient-centered care, taking place until 2016; the next wave, from 2014-2020, is consumer engagement; the third and final wave is the science of prevention, which Terrell said will occur between 2018-2025. “When you start thinking of big data from sources other than healthcare, as well as [the world] of genomics, the industry is not the least bit ready for that right now,” she said. We are in the middle of the first wave and we have two more to go. There is way too much fear of change in the healthcare system because change doesn’t feel safe. The pressure will be on us.”