Advances in patient care delivery are being made on a continuous basis these days at Cedars-Sinai Health System, an integrated delivery system that encompasses an 886-bed Cedars-Sinai Medical Center on the Westside of Los Angeles, as well as a medical staff of more than 2,000 physicians, a staff of over 10,000, and many ambulatory clinics in the Los Angeles area.
Among those helping to spearhead change is Scott Weingarten, M.D., senior vice president and chief clinical transformation officer for Cedars-Sinai Health System. Weingarten, who practiced medicine as an internal medicine physician for many years, worked for some years at Cedars-Sinai Medical Center as an administrator, co-founded Zynx Health, and then returned to Cedars-Sinai in January 2013, has been helping to lead numerous teams in clinical transformation efforts in the organization. He spoke to HCI Editor-in-Chief Mark Hagland in Los Angeles just before the opening of the annual AMDIS Physician-Computer Connection Symposium, being held June 24-26 in Ojai, California. Below are excerpts from that interview.
What are you and your colleagues up to at Cedars-Sinai Health System these days?
A whole bunch of different things. With the transition from fee-for-volume to fee-for-value, we’re really focusing on initiatives to demonstrate outstanding quality of care at more affordable cost, while improving the patient experience across the entire health system—inpatient and outpatient. So we’re enabling Cedars-Sinai Health System to succeed in the new world of value-based healthcare.So I’m focusing on initiatives related to clinical quality, efficiency, the patient experience, and patient engagement.
Can you provide a few examples?
We have a population health initiative. We have commercially insured patients; two Medicare Advantage contracts; three accountable care organizations; we have Vivity—it’s a commercial HMO. We’re a one-eighth owner; Anthem is a one-eighth owner; as is UCLA; as are five other organizations. We’re focused on a geographically distributed network delivering high-quality, affordable care to the community.
How many members are in that HMO?
It’s substantial and growing. It started January 1 of this year. But it’s had substantial growth.
Tell me a bit about the ACOs that Cedars-Sinai is involved in?
Two are private-insurer; and one is the Medicare Shared Savings Program. And the two contracts with private insurers are with Anthem and Aetna.
How many enrollees are in the three ACOs?
In total, all the patients under population health care delivery number about 70,000, encompassing all those programs.
How have these programs been changing care delivery, and especially how physicians work?
We have a lot of programs, including work to reduce avoidable readmissions; intensive care management to identify fragile patients; and we have physician and nurse practitioner house calls. We communicate with our patients very regularly. And we’ve seen a substantial reduction in avoidable readmissions. And every single population health admission is reviewed by multiple physicians. So every admission is seen as a possible opportunity to improve ambulatory and team-based care. And we find many opportunities. And in the last 18 months, we’ve seen a 30-percent reduction overall in both primary admissions in the population health group. And then we have a readmissions program across selected patients who go to skilled nursing facilities; and we’ve seen a 25-percent readmissions reduction among those patients.
And we benchmark ourselves on our admissions rate, and we look at Milliman benchmarks, and we’re among the best in the country along that dimension.
What are the key elements in leveraging tools to help the physicians better examine the care they’re giving?
We provide real-time feedback and decision support in the EHR. And we’ve hardwired over 200 “Choosing Wisely” recommendations into the electronic health record. And they fire in both the ambulatory and hospital setting, 200-300 times a day. And in August, it will have been two years that we’ve hardwired them into the EHR. I still think we’re the only hospital organization in the country to have done that in that scale so far.
What is it that turns the key for most practicing physicians as you make this shift?
It’s a combination of things. I think physicians want to do the right thing. They went to med school to help patients; they’re trained in the scientific method. And they need to know that what they’re doing is scientifically valid. If you can’t convince physicians that something is the right thing to do for patients, they’re not going to do it. And I respect that. I used to be a practicing physician; and if someone couldn’t convince me something was right for my patients, I wouldn’t do it, either. So they need to understand that all of this is good for their patients; and they need to understand all the changes taking place at the national and local level; and also to understand how change will help them better take care of their patients. And that’s why we’re seeing the development of narrow networks—where physicians are being excluded from caring for patients, sometimes for quality, more often for resource utilization issues. And that can be upsetting for patients and for the physicians. So we talk about all the developments going on nationally and try to make it relevant for them. So for them to continue to care for the community, they need to demonstrate high-quality care at efficient cost.
And we provide them with those resources to help them, because it’s very hard for physicians in small practices. And with MIPS [the new Merit-based Incentive Payment Program]—in 2019, physicians will either need to participate in alternative payment models, or in MIPS. Beginning 2019, they’ll get a 5-percent annual bonus for participating, whereas there could be up to a 9-percent downside under MIPS in Medicare reimbursement over time, and that could be very difficult for the physicians.
And a lot of physicians are trying to figure out what alternative payment models mean for them. So we try to explain to them what’ going on and what it means. On a very simple level, physicians want to take good care of their patients, and want to have the opportunity to continue to care for their patients. And when you explain what all this means, with very few exceptions, get that.
What will happen in the next few years, around these changes?
I believe more physicians will participate in alternative payment models, in organized contracts; you’ll see consolidation in healthcare. Physicians may need scale to demonstrate excellence in quality and clinical efficiency. So you’re seeing more physicians becoming employed. That trend is going to continue. And in some markets, solo practice, unaffiliated, will become very difficult.
What do healthcare and healthcare IT leaders need to do, around all this?
I just read a survey in a publication that said that most CMIOs want to take on more responsibility. [SSI?] And they were asked, would they want to be CMO, CIO? The number=one response was, clinical transformation officer: they want to be involved in clinical transofmration. So this is their opportunity to help their organization succeed in the transition from fee-for-volume to fee-for-value. In many organizations, CMIOs are still in tactical roles, with implementations and post-iplementations, getting this live and that live. And in opinion, CMIOs are some of the smartest people I’ve ever met. And that undervalues their capabilities; they should have a much more strategic role. So when executives at an organization revising their strategic plans for the future, the CMIO should be at the table, and in discussions broader than just how to leverage technology.
So CMIOs should become more strategic; they should understand their organization’s strategic plan, and should be at the table when people are having conversations about achieving their orgnaizations’ long-term goals. So the technology is the means to an end; the end is providing the best-possible care at an affordable cost. The technology is just an enabler.
What do you think you’ll hear, and what would you like to hear, at AMDIS, this week?
I’d love for the conversations to be strategic, in addition to tactical. So all of their organizations are undergoing fundamental transformations. Some will be very successful, but not all. Some will be severely challenged through the transition. And I’d love to hear all the AMDIS attendees talk about how they’re going to help their organizations succeed at a time when healthcare reimbursement is changing, patient care is changing, through a combination of strategy and executing on proven tactics.