Nashville Post Vitals

winter 2016

The importance of satisfaction Precision push VUMC leading ambitious initiative

TECH’S TANTALIZING PROMISE

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growing, learning transparency and outreach are at the heart of lifepoint’s quality programs

Tennessee Health Care Hall of Fame

Innovation inside

Opening up to new ideas, models

11/9/16 4:00 PM

We are pleased to welcome Joe to our team.

Joseph C. Levi, CFPÂŽ Senior Vice President - Market Manager The Bank of Nashville - Synovus Securities, Inc.

We are proud to welcome Joe Levi as a Senior Vice President to our Synovus Securities and The Bank of Nashville team. Call Joe today and discover how his experience and service can provide comprehensive solutions that are designed to help you reach your goals.

615.271.2117 bankofnashville.com

Investment products and services provided by Synovus are offered through Synovus Securities, Inc. Synovus Trust Company, N.A. GLOBALT Investments, a separately identifiable division of STC and Creative Financial Group. The registered broker-dealer offering brokerage products for Synovus is Synovus Securities, Inc. member FINRA/SIPC. Synovus Securities, Inc. is a subsidiary of Synovus Financial Corp and an affiliate of Synovus Bank. Synovus Trust Company, N.A. is a subsidiary of Synovus Bank.

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Banking products are provided by Synovus Bank, Member FDIC. Divisions of Synovus Bank operate under multiple trade names across the Southeast.

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INTRO

XXXXX

CONTENTS

INTRO

24

A SATISFIED PATIENT

Health care providers address customer satisfaction

36

learning, growing

LifePoint positioned to help patients outside hospital walls

74

‘A PERSONALIZED MEDICINE HUB’

VUMC to use $71.5M grant for federal precision medicine initiative

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NASHVILLEPOST.COM

on the cover: photo by eric england

11/9/16 2:38 PM

PARTNER LETTER

T

he following pages reveal vibrant stories of people working to change healthcare to change the world.

These are the stories of entrepreneurs, business operators, clinicians and community leaders who come to Nashville – and to the challenge of healthcare innovation – from very different backgrounds and with sometimes sharply different perspectives. But, these pioneering spirits and practical-minded veterans are united in a drive to fundamentally reimagine what healthcare is … and could be.

Because of these leaders – and so many others who share their passion, creativity and tenacity – Nashville continues to shape how America’s healthcare will be funded, structured, measured, managed and, ultimately, how it will serve.

Jarrard Phillips Cate & Hancock, Inc. is proud to be part of this vibrant community. In our work with healthcare leaders across the U.S., we seek to embody and disseminate those same pioneering, collaborative spirits that have defined Nashville for years.

We’re excited to join with NashvillePost to showcase these innovative leaders and hope that the wisdom they share will serve as a catalyst for your own business endeavors. Together, we can continue to make our healthcare system not only stronger but smarter – both here in Nashville and across the nation.

David Jarrard

President & CEO Jarrard Phillips Cate & Hancock, Inc.

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11/9/16 9:42 AM

INTRO

CONTENTS

Healthcare Management’s Clare Moylan tackles facility turnarounds Read more on page 50

checkup

44 FAST START

Faros forges future with strong first year

44 FULLY CAPITALIZED

Contessa preps for 2017 with funding in place

46 DATA BANK

Hedgeye’s investment thesis and wage and employment trends

48 THREE QUESTIONS open

08 YOU SHOULD KNOW

Teeth aligner company is all smiles

10 THE JOURNEY Premise CEO stresses culture, alignment

21 HACKING HEALTH CARE

Volunteer programmers help Faith Family prep for future

26 QUALITY CARE …

LOW COST Rural state physician group benefits from ACO model

12 TECH @ WORK

28 ENDANGERED SPECIES

13 COMPANY & PEOPLE INDEX

31 RULE CHANGE

VU dean’s website pools research papers, articles

14 DATA BANK

Big-picture trends

16 WHERE THE ACTION IS Harpeth Capital pro talks investment themes

17 FATTY LIVER FIGHT

NuSirt’s Joe Cook oversees clinical trials for breakthrough drug

features

18 BLOCKCHAIN AND HEALTH CARE’S FUTURE

Rural hospitals risk closures, rely on entrepreneur relief

The fight against sepsis is ready for data science

32 SELF-DIRECTED SELF-CARE Ease of use, tailoring, motivating are keys to changing habits

34 MANAGING A POPULATION’S HEALTH

Leveraging social determinants of health can yield positive results

40 INDUSTRY TITANS

Disruptive technology could be industry savior

Tennessee Health Care Hall of Fame inducts second class

PR pro David Jarrard sees ‘new story’ being written

49 PENALITIES FOR NONCOMPLIANCE

Bass attorney sees challenges for health care officials’

52 ON TOP OF THINGS

Children’s gets highest-level high-tech addition

53 MAKING MEDICAL SPACE MATTER

Healthcare Realty completes major Midtown project

features

54 END TO MALPRACTICE?

60 ‘SIMPLE NUDGE…BIG DIFFERENCE’

MissionPoint CEO new partners and payment methods

62 A NEW MODEL

Saint Thomas focuses on clinically integrated care via dyad

64 PRIMARY CHOICE

New clinic a key factor in Nashville General’s turnaround efforts

66 CREATING CONCENTRIC CIRCLES

HCA COO talks ERs, urgent care centers

68 THE M&A DANCE Before inking deal, AmSurg and Envision handled an on-and-off suitor

70 TEN FOR THE FUTURE

Cleveland Clinic’s annual medical innovations list

72 FOCUSED FORUM

Virsys12 event showcases issues, industry players

76 ‘A NORMALIZER OF CARE’

Satchel Health takes off via telemedicine pivot

Legislative push seeks to quash lawsuits regarding medical mistakes

56 SENIOR-LEVEL INNOVATION

Brookdale incubates new ideas via entrepreneur program

58 FACING THE TRUTH

Some sobering news about the cost of addiction to your business

CLOSE

77 trust issues

Survey shows big gaps between key stakeholders

78 MANDATORY BUNDLES PUSHBACK

New models won’t compromise patient care

80 THE BIG QUESTION

Can we make a major switch? eric England

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NASHVILLEPOST.COM

11/9/16 2:37 PM

30TH AVENUE S. & VANDERBILT PLACE

WEST END’S FIRST CLASS-A OFFICE DEVELOPMENT IN 15 YEARS!

615.250.1800

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VANDERBILT PLACE 195,000 SQUARE FEET PRE-LEASING NOW

www.EakinPartners.com

11/9/16 9:42 AM

INTRO

EDITOR’S LETTER

editorial

TECHNICALLY HEALTHY

A big thank you goes out to our advisory board members, whose insights and candor helped us define and refine many of the ideas for this issue: Buddy Bacon CapStar Bank Molly Cate Jarrard Phillips Cate & Hancock Emily Evans Hedgeye Potomac Research Brian Fengler Evidencecare Mel Hall SpecialtyCare

Geert De Lombaerde, Editor gdelombaerde@nashvillepost.com

Emily Kubis Bernard Health

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winter 2016

production

Production COORDINATOR Matt Bach Graphic Designers Katy Barrett-Alley, Amy Gomoljak, Abbie Leali, Liz Loewenstein, Melanie Mays

publishing

PUBLISHER Jamie McPherson bUSINESS DEVELOPMENT CONSULTANT Jennifer Trsinar ACCOUNT EXECUTIVES Maggie Bond, Rachel Dean, Michael Jezewski, Carla Mathis, Marisa McWilliams, Hilary Parsons, Mike Smith, Stevan Steinhart, Keith Wright Sales Operations Manager Chelon Hill Hasty Account Managers Gary Minnis, Sarah Richmond, Annie Smith

marketing

EVENTS DIRECTOR Lynsie Shackelford PROMOTIONS MANAGER Wendy Walker Silverman sponsorship specialist Heather Cantrell

circulation

Subscription Manager Gary Minnis Circulation manager Casey Sanders

SouthComm Chief Executive Officer Chris Ferrell Chief Financial Officer Bob Mahoney Chief Operating Officer Blair Johnson Executive Vice President Mark Bartel Vice President of Production Operations Curt Pordes Vice President of Content/ Communication Patrick Rains Director of Human Resources Becky Turner Creative Director Heather Pierce

Nashville Post is published quarterly by SouthComm.

Advertising deadline for the next issue is Thursday, February 9, 2017. For advertising and subscription information, call 615-244-7989.

Copyright ©2016 SouthComm, LLC.

Jerry Youngblutt Boyden & Youngblutt

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art

Art Director Christie Passarello STAFF Photographers Eric England, Daniel Meigs

210 12th Ave. S., Suite 100 Nashville, TN 37203 www.nashvillepost.com

Dennis Weaver Advisory Board

6 vitals

Nashville’s health care sector has always been vibrant. But it has never been as heavily influenced or thoroughly reshaped by technology and new business models as it is now.

The emerging terms, concepts and applications — blockchain, dyad, precision medicine and more — can be simultaneously exciting and daunting for industry professionals to grapple with, much less for the lay person to understand. With health care and technology now overlapping in ever more intricate ways, the Post team is pleased to present a varied look at the issues impacting those who practice medicine, run hospitals, conduct research and create tech platforms.

There’s Green Hills-based NuSirt, which is on the cutting edge of developing a treatment for fatty liver disease. There are the local experts who were among those gathered recently at the Distributed:Health conference to ponder the possibilities of blockchain in health care.

And there’s the team of Vanderbilt University Medical Center academicians and researchers working to build a massive data center for the federal Precision Medicine Initiative Cohort Program. This is impressive and disruptive work.

This issue wraps up our Post magazine series for 2016 but rest assured we’re already chewing on ideas to make our next year’s batch even better. We’ll again focus on Middle Tennessee’s health care, development and technology sectors but first up will be Leaders, featuring our annual In Charge list of more than 400 women and men leading the way in their sectors.

Have a recommendation for inclusion? Send it our way at incharge@nashvillepost.com.

Thank you for your support this year. Here’s to a great holiday season and strong start to 2017.

Editor Geert De Lombaerde Managing Editor William Williams Contributing Writers Linda Bryant, Peter Chawaga, Stephen Elliott Cari Wade Gervin, Caroline Leland, Bill Lewis Copy editors Nancy Floyd, Lauren Langston Stewart

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designing for care Natural light. Intuitive wayfinding with visible destinations.

Comfortable settings for patients and families. Human interaction for assistance. Wellness. Future usability.

Innovative approaches. Safety. We design for the care of patients, families and staff.

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11/9/16 9:43 AM

OPEN

YOU SHOULD KNOW

YOU SHOULD KNOW

ALEX FENKELL SMILEDIRECTCLUB

Even by the high standards of Nashville’s health care scene, the rise of SmileDirectClub is something else. Since formally launching in May, the marketer of teeth aligners for people with minor spacing or crowding issues has hired 150 people, signed a lease for an entire floor of downtown’s Bank of America Plaza and received an investment from a blue-chip industry name that values it at $275 million.

Alex Fenkell and his co-founders — who include former Diabetes Care Club leader Doug Hudson, now the company’s CEO — founded SmileDirectClub to take advantage of the rise of 3D printing and telehealth. SmileDirectClub’s model takes a treatment that often requires numerous office visits and has a price tag of up to $8,000 down to a simpler process that costs $1,500 and is marketed at $99 per month. Patients make impressions of their teeth at home using a $95 toolkit and submit their results to licensed dental professionals. The company’s lab then makes an aligner for a treatment that on average lasts just five months.

The company’s rapid growth — its site now attracts about 500,000 unique visitors per month — has attracted the attention of Align Technology, the $1 billion maker of Invisalign products and dental scanners. In July, Align and SmileDirectClub signed a wide-ranging deal that has made the Californiabased company SmileDirectClub’s exclusive thirdparty supplier of aligners. Align also has committed to a loan of up to $15 million and invested nearly $47 million to take a 17 percent stake in SmileDirectClub.

There’s much more to come. In October, Fenkell helped open his team’s first retail store, in New York City’s West Village. Others might follow to help raise consumer awareness and expand delivery methods.

“It’s been a really fun two years to this point,” Fenkell says. “But we have a long way to go.”

Daniel Meigs

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SPRING 2016

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TRUSTED ADVISORS, EXCEPTIONAL ALLIES. Strategic Communications and Engagement for Healthcare

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jarrardinc.com | 888-844-6274

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11/9/16 12:27 PM

OPEN

THE JOURNEY

THE JOURNEY

Stu Clark Premise Health

Stu Clark is CEO of Brentwood-based Premise, an onsite health and patient engagement company created by the 2014 merger of CHS Health Services and Take Care Employer Solutions. The deal came with an integration and repositioning effort that Clark says is now truly bearing fruit for the company, which runs more than 550 health centers across the country for a client list that includes more than 200 of the nation’s largest employers. Here, he talks about the process that laid the foundation for its latest growth spurt.

daniel meigs

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11/9/16 2:22 PM

THE JOURNEY

Over the past 25 years, I have come to appreciate the importance of culture. But even with that appreciation, I underestimated its role in a company of this size. Ninety percent of our team members are dispersed across 45 states, Guam and Puerto Rico.

It is paramount that they associate themselves with our brand, our values and that they feel engaged. The Premise Health culture has created an environment where trust can exist and grow — so that innovation quickens and decision-making and execution occur.

Absent a strong culture, trust struggles to exist.

We have made the creation of our culture, the engagement of our workforce and the alignment of senior management our top priorities since the formation of Premise. When the merger occurred in 2014, we were given an opportunity by our lead investor — Water Street Healthcare Partners — to hit the reset button with our identity, both internally and externally. We rebranded the company with a new name and a new mission. But we also needed to reset the company’s culture and priorities.

We figured we had one chance to get it right and it had to count. My first priority was for my team to understand that change was necessary and that alignment was an absolute requirement. The team quickly began walking the talk.

To set the proper cultural and alignment standards for the company, we knew it was all about how we treat each other, hold one another accountable and how we find ways to succeed when circumstances interfere with the best-laid plans.

Our team knew that the rest of the company models their behavior, and if that behavior is inconsistent with our values, we have a problem. Integrity and accountability are not situational attributes — they must exist even when others aren’t watching.

When the Affordable Care Act was passed in 2010, it brought health care access to 30 million people across the United States. But it also made it harder for people to actually get an appointment in a system already stressed by a lack of primary care physicians and a rise in chronic diseases. Those trends spelled trouble for employers. If their employees couldn’t access care, they would continue to get sicker, affecting both their ability to excel at work and the cost of their health care. For many large employers, the best solution was to partner with an organization like ours to bring health care services to (or near) the workplace.

The Journey.indd 11

Being focused on one or a just few employers within a community offers us many advantages over the local providers. Because it’s convenient to visit our health centers, employees tend to go sooner, and for those who are reluctant to visit our provider, we reach out to them. We also have the ability to spend more time with patients, which allows us to address family history and lifestyle issues and then drive positive behavior change. For our health care professionals to accomplish all of this, they must feel engaged and must believe in our mission.

The word “alignment” has become popular recently, maybe even overused. I’m certainly no expert on the concept, but I have watched from the front row the importance of alignment to a company’s success. Well-intentioned, talented executives within the same company can get misaligned in a nanosecond, and it’s the CEO’s obligation to be on the lookout for this. There is natural and healthy tension between many departments within an organization, but this healthy tension can devolve into misalignment quickly. Misalignment is a death sentence if it is not addressed early and aggressively. Efficiency, morale, commitment and innovation all begin to disappear if misalignment takes hold.

We have utilized several strategies to establish and maintain alignment at Premise. My first step was to get some expert support, and we did that immediately after the merger in 2014. I hired The Table Group to start up a process whereby the executive team goes off-site and, in an uninterrupted fashion, talks about the tough issues, addresses interpersonal challenges and commits to a way through these obstacles. Strategy and communication tactics are established in these off-sites and we leave the session aligned and ready to lead the company.

This alignment can last two weeks or two hours but it does not establish itself with any permanence, and that is why maintaining alignment is one of the most important jobs of a CEO. We have daily, weekly and monthly tactics to ensure alignment at Premise.

Great culture and alignment do not happen quickly.

With us, it took more than a year to start seeing a difference in how team members viewed our culture, which we measured through Gallup engagement surveys and also internal surveys. But the cultural groundwork we laid at the beginning is paying off now. We have a united leadership team in place with the confidence to speak up when they see an op-

OPEN

‘I have watched from the front row the importance of alignment to a company’s success’ portunity or need to pivot. And our team members are willing to commit to projects and see them through because they understand our vision — and they trust us. We have achieved a solid level of alignment, though there is always room for improvement.

The trust that we’ve built within our teams is helping us move faster and work more efficiently. For example, we’ve decreased the amount of time it takes to implement a new health center. We are seeing great clinical and financial outcomes within our patient base. We’re also bringing new ideas and innovations to market more quickly. We just opened our largest and most innovative health center ever. It offers employees incredible resources to change their lifestyles, from plant-based cooking classes to personal trainers.

Its programs are integrated into the community, so there is an impact to the patient beyond the worksite.

There is no way we could have done this two years ago without a cultural and alignment reset.

With integration behind us, we’re looking forward to seizing the opportunities that spurred us to come together in the first place. Our model is proven to help people get healthier — and we believe it has an important role to play in the new value-based reimbursement world. We see a future where we partner not only with employers, but also with health plans and other providers.

That’s a big goal, one that requires us to create new markets.

As we step up to this new challenge, we know that trust is more important than ever. We must — and will — remain focused on our culture and alignment in order to achieve the vision that we’ve set forth.

We’ve said it from the beginning: This is our opportunity to change an industry. And we will do that with our culture and with alignment throughout the organization.

11/9/16 2:22 PM

OPEN

Tech @ work

tech @ work

Editor’s Cut: Healthcare in the Age of Analytics INDUSTRY Health IT DEVELOPER Informs FOR Getting up to speed on big data AVAILABLE pubsonline.informs.org

Studying the health care sector’s use of technology, Eric Johnson sees a split. The dean of the Owen Graduate School of Management at Vanderbilt University sees many entrenched players lagging in their use of IT and investing billions to catch up — much as manufacturers did with enterprise resource planning software two decades ago. At the same time, younger and nimbler companies are altogether bypassing established systems with new business models using data in smarter, more efficient ways.

“It’s interesting, confusing and amazing all at once,” Johnson says. “There are so many types of data out there and they’re so unstructured that they’re driving many interesting developments.”

To help bring some clarity to the evolving situation, Johnson recently helped launch “INFORMS Editor’s Cut: Healthcare in the Age of Analytics,” a curated website that pools research papers and articles as well as podcasts and videos examining how the use of data is changing the provision of and the policies behind health care.

Johnson, who has been Owen’s dean since 2013, says the content he is curating has three main audiences: Companies on the ramp toward effective use of analytics, researchers looking for a jumpstart or a deep dive and “students of any variety” aiming to efficiently soak up some knowledge.

“The goal is to go with the flow of the area,” he says.

“Some topics move faster than others and we’re not going to publish five more papers that look like others we’ve chosen.”

Johnson has been involved with Maryland-based INFORMS for about 25 years and is now its vice president of publications. His Editor’s Cut series is one of the organization’s first of its kind, helped in part by a local conference this year that was attended by 600 people. Johnson, who has long studied the use of IT in management, expects he’ll curate the site for “at least a few years,” adding jokingly that he expects the topic will be relevant for quite a while yet.

12 LEADERS

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SPRING 2016

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OPEN

INDEX

INDEX

A-D

Clare Moylan 29, 50-51

180 Health Partners 72

Colleen Conway-Welch 43

Accenture 25

Contessa Health 44

Affordable Care Act 7, 14, 34, 42, 46, 49, 61, 78

Council on Aging of Middle Tennessee 22

AIM Healthcare Services 16 Alan Morgan 29 Alex Fenkell 8 Alfred Francis 22 Align Technology 8 Amplion 25 AmSurg 68-69 Andrew Smith 56-57 Aspire Health 16, 60 Baptist Memorial Hospital 44 Barbara Cannon 17 Bass Berry & Sims 49 Bill Anderson 28-29 Bill Carpenter 38 Bill Frist 16 Bill Sanger 68 Blair + MUI Architects 52

Clariture Health 16

Cumberland Center for Healthcare Innovation 26 Danielle Sloane 49 Dan Roden 75 David E. Young 44 David Jarrard 48 Dawn Rudolph 24 Dayle Rodriguez 56 Deloitte 14, 19, 78 Distributed:Health Conference 6, 20 Doug Hudson 8

E-H

Centers for Medicare and Medicaid Services 24, 26, 36, 44, 65 Centerstone Research Institute 44

Mike Eidsaune 56

Sam Hazen 66

Henry Foster 43

Mike Stewart 54

Satchel Health 76

Herb Slatery 54

MissionPoint Health Partners 60-61

Sekar Kathiresan 76

Humana 18

I-N IBM 19, 44 Indiana University Research and Technology Corp. 44 InVivoLink 18

Elite Sports Medicine and Orthopaedic 53

Eric Johnson 12 Fahad Tahir 62 Faith Family Medical Center 21 Faros Healthcare 44 Frank Groner 44 Frank Perry 64 Freedom Healthcare 16 Gilda’s Club of Nashville 22

Monroe Carell Jr. Children’s Hospital at Vanderbilt 52 MPower Performance Institute 53 Nashville Capital Network 44 Nashville General Hospital at Meharry 64

Shelagh Mulvaney 33 SmileDirectClub 8 Stanley Cohen 43 Stephanie Fetzer 19 Steve Kress 72 St. Luke’s Community House 22

Nashville Healthcare Center 64

Stu Clark 6

James Hildreth 65

Nashville Healthcare Technology Forum 72

James Ward 63

Nashville Technology Council 21

T-Z

Jarrard Phillips Cate & Hancock 6, 48

National Institutes of Health 74, 76

Jason Dinger 60

National Rural Hospital Association 28-29

Jack Johnson 54

Jeff Balser 75 Jeff Garzik 19

John Bass 18

Envision 68-69

Center for Medical Interoperability 19

Hedgeye 6, 46

Ed Cantwell 19

Brent Staton 26

Casey Bennett 44

Saint Thomas Health 24-25, 36, 60, 62-63

East Tennessee State University 44

Emily Evans 6, 46

Carely 56

Midtown Medical Plaza I and II 53

Jim Stefansic 44

Brenda Aubin 25

Brookdale Senior Living 56-57

Healthcare Management Partners 29, 50-51

Joe Cook 17

Joseph Webb 64

Neighborhood Health 65 NuSirt Biopharma 17

O-S

TeamHealth 68-69 Tennessee Department of Health 54, 65 Tennessee Health Care Hall of Fame 42, 45 Tennessee Hospital Association 36 Tennessee Justice Center 72 Tennessee Medical Association 54

One Drop 32-33

Terrence McWilliams 62

Josh Denny 75-76

Owen Graduate School of Management 12

Joshua Southards 21

Passport Health 16

Travis Messina 44

Justin Lanning 72

Patients for Fair Compensation 54

Turner Construction 52

Karen Springer 62-63 Leif Murphy 69 LifePoint Health 36, 63, 69, 80 Maggie Elehwany 29

Paul Keckley 78 Paul Kleckner 62-63 Pharos Capital Group 16

Mark Miles 22

Precision Medicine Initiative Cohort 6, 74, 76

Martin Ventures 44

Premise Health 6-7

Mary Bufwack 65

Renova PCA 72

MDsave 16

ReviveHealth 77

Medhost 28-29

Riverview Regional Medical Center 38

Chandra Osborn 32

Glen Casada 54

Change Healthcare 16

Greg James 62-63

Chris Holden 68

Harpeth Capital 16

Meharry Medical College 43, 64-65

Chris Kay 18

Haven Behavioral Care 16

CHS 6, 14

HCA 14, 21, 42, 66

Tom Tobin 46

Ty Webb 27 U.S. Department of Health and Human Services 36 Vanderbilt University 6, 12, 32, 43, 52, 74-76 Vanderbilt University Medical Center 6, 32, 43, 52, 74, 76 Vanderbilt University School of Nursing 43 Virsys12 72 Vocera 24

Rob Watkins 72

Wayne Oliver 54

Michael Zemel 17

Rusty Holman 36

Yarnell Beatty 54

Midtown 53

Ryan Macy 76

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OPEN

DATA

DATA BANK

the evolution of health care spending

GENERATION GAP Safety and quality concerns are a factor in slower health IT adoption rates. For instance, 43 percent of respondants to a Deloitte survey said they were concerned that telemedicine services could be of lower quality than seeing a doctor in person. But younger people are far more interested than those born before 1981 and are willing to pay more for it.

Health care spending is expected to continue to grow more quickly than the economy overall. But, driven by new technologies and business models, where and when that money is spent looks set to evolve in the coming years.

Interest in telemedicine services for

THE BIG SPENDING PICTURE

46%

Avg. since Q1 ’11

HCA LifePoint CHS

Q1 ’15

Q2

Q3

Q4

Q1 ’16

Q2

2.6% 6.8% 4.9% 3.6% 2.9% 3.1% 1.6% -0.1% 4.3% 1.8% 0.1% -1.1% 0.0% -1.9% -0.2% 2.5% -0.2% 0.1% -1.2% 1.3% -0.6%

Revenue/adjusted admission

Avg. since Q1 ’11

HCA LifePoint CHS

Q1 ’15

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WINTER 2016

Q3

Q4

Q1 ’16

Q2

2.6% 6.8% 4.9% 3.6% 2.9% 3.1% 1.6% -0.1% 4.3% 1.8% 0.1% -1.1% 0.0% -1.9% -0.2% 2.5% -0.2% 0.1% -1.2% 1.3% -0.6%

Source: Avondale Partners, company reports

14 VITALS

Q2

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Seniors

34% 27%

26%

Seniors

Adjusted admissions

Boomers

Millennials

The implementation of the Affordable Care Act gave hospitals a big lift but its impact is fading.

(More on that on page 46)

Gen X

31%

hospital trends

Boomers

42%

39%

Care while traveling

20%

Seniors

Source: Centers for Medicare & Medicaid Services

Disease monitoring

Boomers

45% 47%

Post-surgical care

Gen X

Prescription drugs......................................... 6.6%

2025

Gen X

2014

Millennials

Home health................................................... 6.5%

Millennials

Government’s share of health care spending

Seniors

Hospitals.......................................................... 6.1%

17.5% 20.1%

43%

Medicare........................................................... 7.6% Out-of-pocket................................................ 5.5%

2025

46% 46%

Overall............................................................... 6.0%

Boomers

2014

55% 48% 47% 46%

Gen X

Share of GDP

55% Spending growth 2020-2025

Millennials

Federal forecasters this fall said spending on health care is projected to grow an average of 5.8 percent per year between now and 2025. Here are a few details from their work.

Minor injury

Willing to pay for telemedicine session

Millennials

$100

Gen X Boomers Seniors

$61 $43 $67

Source: Deloitte

NASHVILLEPOST.COM

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DATA

OPEN

SLOW ADOPTION An online survey of more than 3,700 people early this year not surprisingly found that more consumers are going online for health care-related purposes, most often for refilling a prescription. But the numbers below still trail online adoption rates for other big sectors.

TOP TARGET MARKETS Six digital health subsectors are on pace to attract more than $500 million in seed, venture or private equity funding this year. Here are their numbers through three quarters.

Online technology usage percentage

Refill a prescription.....................................................58% Measure health/fitness goals..................................32% Pay medical bill.............................................................31% Monitor health issues................................................24% Use cost-tracking tool................................................18% Receive alerts/reminders..........................................17% Record or transmit data............................................15% Source: Deloitte

HAMSTRUNG ACOs Most accountable care organizations, especially commercial ones, are making progress on quality scores and disease monitoring, a recent study led by a Harvard professor shows. But they have a long way to go when it comes to using technology to really ramp up their effectiveness.

Subsector

Funds raised

Patient/consumer experience Wellness Personalized health Big data/analytics Medical device Workflow Source: SmartAsset

DIGITAL FUTURE Investor funding for digital health companies is booming. The almost $2.4 billion put to work in the third quarter of this year nearly equaled all the money invested in 2012. The amount invested in each company also has grown. (2016 figure annualized based on Q3 data)

2010

$7.3M

2011

$6.7M

$1.9B

2012

$5.1M

$2.4B

2013

$4.6M

Commercial.............................31%

2014

$12.4M

Noncommercial.....................15%

2015

$11.7M

Source: Peiris et al., as published in Health Affairs

2016

$16.5M

ACOs with a uniform EHR system

Average deal size

$2.5B $25.1M $918M $27.8M $634M $24.4M $564M $14.1M $478M $12.0M $419M $7.1M

Average funding round

$1.1B

Total funding

$2.9B $7.1B $6.1B $8.7B

Source: StartUp Health

COVERAGE GAP

GROWTH STRATEGY

Most Nashville-area counties have health insurance coverage rates between 87 and 89 percent, but there’s a 10-point gap between the top and bottom outliers.

County

Coverage Rate

Williamson 94.3% Wilson 89.7% Montgomery 89.1% Sumner 89.0% Maury 87.9% Rutherford 87.7% Robertson 87.7% Dickson 87.4% Cheatham 87.0% Davidson 84.3% Source: SmartAsset

Nashville-based Aspire Health, a palliative care venture chaired by former Senate Majority Leader Bill Frist, has in the past 18 months raised almost $50 million from Oak HC/FT and the VC arm of Alphabet, among others. One simple reason why: The market is underserved and fragmented.

Hospitals with palliative care programs

With 300+ beds 90% With <300 beds 56% In New England 88% In the Mid-Atlantic 77% In the West South Central 43% In the East South Central 42% Run for profit 23% Public 59% Nonprofit 77% Source: Dumanovsky et al., as published in the Journal of Palliative Medicine NASHVILLEPOST.COM

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OPEN

INSIGHT

putting money to work

Where the investors are flocking

Three areas stand out in a crowded and active industry

by Adam Landa

Adam Landa is managing director at Harpeth Capital. harpethcapital.com

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It’s an exciting time to be in Nashville. We live and work in a city where new health care companies are starting about as fast as new restaurants and hotels are opening.

The challenges of the hospital sector notwithstanding, the vast majority of local health care headlines reflect positive developments — a startup has successfully completed an angel round, another has brought on an institutional investor to accelerate growth, industry veterans have completed a successful sale of their company — and the cycle continues.

Which begs the question we get asked (and ask ourselves) every day: “Where in health care are you spending your time?” While there are several areas that merit mention, we will for the sake of brevity focus on three that are garnering their fair share of attention: behavioral health, revenue cycle management and population health management.

Benefiting in many cases from reimbursement tailwinds and an emphasis toward improved outcomes, companies across the spectrum of behavioral health — inclusive of addiction treatment — are aggressively being sought with recent valuations reflective of investors’ appetite. In just the last couple of months, local companies WoodRidge Behavioral Care (a Harpeth Capital client) and Haven Behavioral Care were acquired by private equity groups, with our firm currently advising on yet another local transaction that will be among the higher EBITDA multiples we’ve seen.

Pharos Capital Group has been very active with both its mental health platform Seaside Healthcare and its recently acquired Beacon Specialized Living Services (which specializes in intellectual and developmental disabilities), and we are aware of another local private equity group that is looking to close a platform acquisition by year’s end.

Meanwhile, addiction treatment provider Freedom Healthcare (a Harpeth Ventures co-investment alongside Atlanta-based Fulcrum Equity Partners) is another example of a local company that is seeing a strong growth trajectory. What the buyers and investors want is evi-

dence of a robust and stable platform that can be leveraged and scaled to accommodate the increasing need for services, with strong interest for both community and facility based; behavioral, disability or addiction services; and adolescent, adult or geriatric populations.

While interest in behavioral health has accelerated in recent years, revenue cycle management has been a consistently strong sector for much longer. As this has occurred, the breadth of revenue cycle management services has evolved to address the current realities faced by payors, providers and customers. In addition, we see revenue cycle management expanding to include, among other paths, companies focused on pricing transparency, bundled service offerings and patient engagement.

Change Healthcare, AIM Healthcare Services and Passport Health are perhaps Nashville’s best-known success stories in the traditional revenue cycle management space, but recent startups are enjoying strong growth addressing other facets of that landscape. Co-founded by former Sen. Bill Frist, MDsave (also a Harpeth Ventures co-investment alongside New York-based MTS Health Investors) is seeing tremendous opportunities created by the reality of today’s high-deductible oriented insurance coverage and health care consumers’ desires for transparent and bundled pricing options as well as providers seeking solutions for engaging with value-oriented health care consumers.

Another example is Martin Venture-backed Clariture Health, offering digital marketing solutions to health care providers for patient acquisition. Though accelerating and improving collections will always be at the core of revenue cycle management, we remain very excited about new business models.

Population health — and data analytics in general — is another area garnering growth capital, with the entity formerly known as Google Ventures’ investment in Aspire Health, a company focused on patients and families dealing with end-of-life illnesses, among the larger local venture capital raises in recent years. Whether it’s a multi-faceted approach to managing post-acute care (naviHealth) or reducing hospital readmissions for atrisk seniors living at home (myNEXUS; a Harpeth Capital client), payors are eager to identify solutions to improve both care and care coordination while reducing cost.

In addition to the above, there continues to be tremendous interest for telehealth and alternative-site platforms. Rollups in the dental, dermatology and rehab spaces are also active, and even once-hot sectors such as home health and hospice are again getting attention.

I suppose that’s what makes health care much like living in Nashville. You think you’ve seen everything and there can’t possibly be room for more. Don’t worry, though; there’s a good chance another restaurant or two will open next week.

NASHVILLEPOST.COM

11/9/16 2:27 PM

ENTREPRENEUR

profile

Joe Cook

Fighting fatty liver disease

NuSirt’s Joe Cook oversees clinical trials for possible breakthrough drug

by Bill Lewis

Joe Cook had retired from the pharmaceutical industry, but the promise of developing a treatment for a disease that silently threatens the health of millions of people lured him back into the sector’s fold.

“That’s a good reason to come to work,” says Cook, a pharmaceutical and biotech industry veteran who serves as executive chairman and president of NuSirt Biopharma.

NuSirt, which operates executive offices in Green Hills and research facilities in Knoxville, is conducting clinical trials of a medication to treat non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH).

Byproducts of America’s obesity epidemic, the two diseases collectively affect between 85 million and 120 million Americans, Cook estimates.

“It goes hand in hand with fatty belly,” says Cook, a founder, director and past chairman of the board of publicly traded Cambridge, Massachusetts-based Ironwood Pharmaceuticals.

NuSirt is conducting clinical trials of a medication that combines several ingredients, including Sildenafil — better known as Viagra — to combat the fatty deposits that cause scarring that can impair liver function or even result in cancer.

OPEN

Cook says there are few treatments for fatty liver disease. Even discovering its presence is challenging. Patients are faced with a potentially painful and risky largeneedle biopsy that may yield an unclear result.

The biopsy procedure “is as unpleasant as it sounds,” says Barbara Cannon, NuSirt chief operating officer. Not surprisingly, the disease is often undiagnosed.

NuSirt recently entered a strategic partnership with Derio, Spain-based One Way Liver S.L. (OWL Metabolomics), which has developed diagnostic methods that don’t involve a needle.

“No one wants to go to a doctor and have them core out part of your liver,” says Cook, who retired in 1993 as a group vice president of global operations at Eli Lilly after more than 28 years of service.

With the new methods, patients could be tested every time they have an annual physical, says Cannon.

If doctors could easily and accurately diagnose fatty liver diseases, NuSirt’s medication could be prescribed to treat them in the early stages — assuming the drug wins FDA approval.

The medication works by mimicking the effects of a calorie-restricted diet in which the body has less fat that can wind up in the liver.

“It’s as if you ate less,” says Cook, who served as chairman of publicly traded Amylin Pharmaceuticals Inc. from 1998 to 2009 and was CEO from 1998 to 2003.

During ongoing clinical trials, NuSirt’s medication will be tested and patients’ conditions will be evaluated.

The outcome of OWL’s diagnostic process will be compared with the results of biopsies. During the upcoming third phase of the trials, NuSirt will follow 1,000 patients for 18 months.

The process takes time, but it’s much faster than the pace of trials using unproven substances. By using proven drugs, NuSirt is able to avoid years of toxicology testing.

Developing an unknown molecular compound can cost as much as $1 billion. Though development of NuSirt’s drug won’t require that level of expenditure, the cost is nonetheless a “nine-digit number,” says Cook, who is also a principal and co-founder of Mountain Group Capital and a board member of Castle Biosciences, Clinical Products and publicly traded Corcept Therapeutics.

With that expense and the potential size of the market in mind, Cook says it’s possible that new partnerships or an acquisition could be in NuSirt’s future.

“Most [new drugs] don’t make it. It’s a very risky business,” he says.

And an interesting business at that.

After being introduced to research by Dr. Michael Zemel, a University of Tennessee faculty member who founded NuSirt in 2007, Cook decided to invest in the company in 2010. In May 2013, he joined as an employee.

NuSirt’s treatment holds the promise of improving the lives of millions of patients, Cook says. In financial terms, the market for drugs being developed by NuSirt and other pharmas could be as significant as $25 billion in a decade.

“It’s not unlike the diabetes market in size,” Cook says.

“I wouldn’t say the entire market is ours,” he adds, before noting that if the clinical trials are a success, “NuSirt will have a significant piece of it.”

ERIC ENGLAND

NASHVILLEPOST.COM

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Blockchain and health care’s future

operate here, accounting for 250,000 local jobs and $1.5 billion in state and local taxes, per the health care council. And as problems with the current health care system continue to emerge, there is cause for concern.

“There’s this perfect storm going on where in 2022, we’re going to reach $5 trillion in health care spending,” Bass said. “The numbers are simply getting too big. We all hope that technology — and hope specifically that blockchain technology — has a big role to play in flattening that prosperity and getting health care under control.”

by Peter ChAwAgA

An industry in poor health

Disruptive database technology could be industry savior Beyond the country music tropes and Bible Belt platitudes, Nashville should be best known for its place in the health care industry.

Headquartered in the city are 16 publicly traded health care companies with a combined $73 billion in global revenue, according to an impact study the Nashville Health Care Council conducted last year.

It was not surprising, then, that Distributed: Health picked iconic local structure Schermerhorn Symphony Center to host in September its first-ever conference on blockchain databases for the industry. Specifically, blockchains involve widely distributed databases that live on many individual devices instead of existing on central hubs. The innovative technology was on full display in a day of panel discussions and presentations, all exploring a step forward for health care in its hotbed.

“Nashville is blowing up,” John Bass, CEO of medical data company InVivoLink, said as he gave the event’s opening address to hundreds of attendees in the symphony hall. “We’re in a great position to be an epicenter for health care technology. I’m proud to have watched that emerge and I’m excited about the blockchain community forming, because I think it’s a key to positioning Nashville as a hub of health care technology.”

As much as the health care industry depends on Nashville, the city depends on the revenue the sector generates even more. Almost 400 health care companies

Aside from the concerns of increasingly exorbitant spending, there are other causes for anxiety in health care. The industry is designed for episodic care, addressing illness and injury as they occur. As we’ve increasingly become a nation with unhealthy habits and lingering illnesses, it’s done little to adapt itself.

“The state of being healthy being hard has made us a nation with chronic conditions,” Chris Kay, chief innovation officer at Humana, said in a presentation following that of Bass. “[The health care] mindset doesn’t work anymore when you have people suffering from longtime conditions. That requires a relationship.”

In an age where information is more readily available than ever, data regarding the cost of care still remains perplexing for consumers.

“The complexity inside an insurance company about claims and payments is profound,” Kay said. “Health care is one of the few markets where the service we receive — the patient and the doctor — is disconnected from the payment.”

Finally, the caregivers themselves often lack data on patients and it can be frustratingly difficult to pass relevant patient files between doctors and information systems, Kay said.

“Doctors want to have a full record of our data but they don’t,” he said. “Interoperability is a core problem in health care.”

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TECH

FEATURES

Keeping pace with the healthcare industry.

But hundreds of health care and technology innovators didn’t gather at the Schermerhorn to hear the things they probably already knew to be problematic in their field. Rather, they were drawn by the promise of a new technology with the potential to address these problems and revolutionize the industry. They wanted a closer look at blockchain.

A disruptive promise

Blockchain technology was popularized by the bitcoin market, with companies like Deloitte and Microsoft recently having invested in it.

In a blockchain, security is guaranteed as each piece of data is blocked with others and then verified at each point in the network of connected databases. As blocks are increasingly chained together, the data gets buried and harder to manipulate. This system replaces the need for single-point, third-party fiduciaries.

“At its core, the reason why blockchain is valuable and interesting is that you trust users in the network less and the system more,” Jeff Garzik, an original developer for bitcoin, told the opening audience. “Data in transactions is fully verified by every single network participant… Every node in that network is checking the rules.”

This level of security could make blockchains a method for storing health data, one that would be easily tapped and transferred by those with permission.

Proponents argue this could be a way to give patients constant access to their wellness data and promote healthy habits in the face of chronic maladies.

“Fundamentally knowing your score as an individual, as a consumer, is the root of our ability to control our own health,” Kay said. “Imagine having your own health and wellness records available throughout your life and being able to control who sees what.”

Kay went on to paint a future where the navigability of data on blockchains leads to “zero friction points between the time a patient sees a doctor and the time the payments and settlements are made.”

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On the caregiver side, blockchain is most promising in its potential to transfer relevant patient data from one place to another and provide interoperability.

“Health care is the only vertical market that has not agreed upon an interoperability program at this point,” Ed Cantwell, executive director of the Center for Medical Interoperability, said during an afternoon panel session. “If they put their money where their mouth is and they adopt platforms that are standards-based… and trust-worthy, then that’s the foundation for blockchain to be wonderful.”

Serving Nashville’s healthcare industry for more than 50 years.

Potential pitfalls

There are, of course, obstacles to blockchain becoming widely adopted throughout health care.

Perhaps the main barrier will be the industry itself, which is notoriously resistant to major change. The most prominent insurance companies have little financial incentive to make the marketplace more navigable for patients as it stands now, as they benefit from the treatment of individual illnesses rather than the full spectrum of health.

Then there are the stringent regulations regarding matters as sensitive as health care. The Health Insurance Portability and Accountability Act (HIPPA) may not account for a major disruption in the way patient information is stored before it is thoroughly vetted.

“If we were to wait for the U.S. government to mandate specific technology around blockchain, it would be at glacial speed,” said Stephanie Fetzer, a project architect at IBM and conference panelist.

Lastly, it might be the patients themselves who are most resistant to the adoption of blockchains.

It will be hard for average people to put the faith of their medical records into something they don’t understand.

In short, blockchains may have to establish themselves in smaller capacities before igniting a full-scale health care revolution.

Lucy Carter

615-346-2497

Scott Mertie 615-782-4292

krafthealthcare.com

11/9/16 2:34 2:31 PM

FEATURES

TECH

Promise vs.

Privacy with Blockchain emrs If blockchain databases were widely adopted in health care, they would change the way people store, protect and share electronic medical records.

EMRs are a patient’s online portfolio, constituting her or his allergy information, lab results, personal statistics, billing data and other pertinent medical history as it exists digitally.

While their digital nature makes it possible to share EMRs, the system has evolved in a way that has largely prevented that from happening.

“What EMRs have not gone through their full potential on is [that they require] the use of [various] silo systems that are written in languages that are not compatible with each other and with different standards that emerged,” Matt Spoke, founder and CEO of Canada-based technology company Nuco, said during a panel about EMRs at the recently held Distributed:Health conference.

In particular, patients do not typically access their own EMRs. Hospital and health care records are owned by the providers.

And while patients have the right to a copy of their information, it is not easy to obtain. A distributed database of EMRs could change that.

“I don’t think blockchain will change the ownership,” said Jodi Daniel, partner at the Washington D.C. law firm Crowell & Moring. “But if the patient can access the record … then blockchain can help facilitate the patient’s ability to control the flow of data that they hold for themselves and the purposes for which they want that data to be used.”

EMRs available on blockchain networks will be easier to share between health care providers and patients, but they may also be visible to others.

Blockchain advocates argue that the networks are more secure than traditional databases because they rely on every point in the system for security, instead of a single, fallible server.

However, this introduces infinitely more points of access to the data they hold, a potentially concerning characteristic.

“It is more secure to a certain extent… but we’ve also introduced multiple points of visibility for that data,” said Spoke.

“You’ve removed the ability for someone to change information, but you give 10, or 100, or a 1,000 points of access to read that information.

“There’s a trade-off when we talk about privacy and security.” > Peter Chawaga

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11/9/16 2:35 2:31 PM

TECH

Hacking health care

Volunteer programmers help Faith Family Medical Center move into the future

by Stephen Elliott

At Faith Family Medical Center, leaders are using the tech industry as a model for how to make life easier for their patients.

During the mid-October Hack for the Community event, that approach was evident.

“The on-demand society that we are now in, where there is an expectation that most things are viewable and available in real time… I’ve looked at that as much from other industries as from the health care industry,” Joshua Southards, Faith Family operations director, said during the hackathon, presented by HCA and the Nashville Technology Council.

Also present at the event was a longtime Faith Family patient, herself a driver for Uber and Lyft, who Southards said typifies why the medical center was seeking the help of the dozens of gathered computer programmers who were divided into groups to develop tech solutions for more than 20 area nonprofit organizations in 36 hours or less.

“Everyone has an internet connection now. The majority of even our patients have it,” Southards said, in reference to the fact that Faith Family serves the working uninsured and under-insured. “Five years ago, that was not the case. But now a majority of people have a smart phone.”

For Faith Family patients — many of whom work jobs at which stepping away for a minute to make or take a phone call is simply not possible — the new online scheduling system developed by the volunteer programmers during the hackathon will be of particular benefit. The system will allow patients to see when appointments are available and book them, all on a cell phone, without having to “play phone tag” with the Faith Family scheduling staff.

FEATURES

Hack for the Community event attendees work at the Noah Liff Opera Center

daniel meigs

NASHVILLEPOST.COM

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Mark Miles, a computer programmer volunteering at the hackathon, said a goal is to “complete the circle, where their front-end system will be aware of what they have available because it’s talking to the back-end system.”

The new system could soon be replicated at other Nashville-area medical centers for the underserved or uninsured. Southards said multiple local medical centers use the same patient records software and likely could benefit from the online patient scheduling system.

“If this works for us, it’s a shareable thing for some of the other safety net clinics in town,” Southards said.

The Hack for the Community event brought more than 20 nonprofits — including the Council on Aging of Middle Tennessee, Gilda’s Club of Nashville and St. Luke’s Community House — to the Noah Liff Opera Center for 36 hours of computer work with volunteer programmers.

Each nonprofit had a specific tech need and was assigned a group of volunteers, and a hum of activity filled the room, converted for two days into a buzzing operations center with soda cans and coffee cups scattered atop tables, charging cable spider webs winding around chair legs and white boards, and notepads graffitied with ideas both discarded and accepted.

Miles, one of those volunteers, said one goal of the hackathon was to limit expenses for the nonprofits.

“A lot of the work has been to try to grasp what they have, what they are using now and how much of that we can leverage to be able to try to achieve their goals quickly — not only achieve it quicker but achieve it without any additional investment,” he said. “Can we make use of what they have — the applications and infrastructure — so that we can get them what they need to help streamline their operation and not have to go to greater expense?”

The online scheduling system sounds simple, but Alfred Francis, another volunteer programmer working on the Faith Family project, said there was a little more to it.

“With a new system, it’s pretty straightforward,” he said. “But we are working with something that’s existing that has its own limitations.”

A couple of days after the hackathon, Southards said the event had resulted in “enormous strides” toward developing an online scheduling system. And while that system wasn’t quite ready for immediate deployment, Faith Family patients should soon be able to avoid phone tag when setting up medical appointments.

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11/9/16 2:35 PM

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A SATISFIED PATIENT Health care providers begin to place emphasis on customer satisfaction

by Linda Bryant

Responding to reliable consumer feedback quickly and using it to improve the customer experience is a cornerstone of good business practice.

For most businesses, that is.

Until fairly recently, health care providers — hospitals, clinics, outpatient centers and the practitioners who work in these facilities — likely existed in a separate universe regarding customer service. And that was understandable.

Though it’s easy enough to request a refund when a restaurant bungles your order or return an item to Target, you probably would not walk out of a health care facility refusing to pay the bill, for example, due to a rude x-ray technician or after a long emergency room stay.

These days, however, providers are paying far more attention to patient satisfaction. In fact, leaving a positive impression on patients and their families is a top priority for many, if not most, providers as seen by their efforts to ramp up efforts to collect, track and apply feedback.

Specifically, 64 percent of health care organizations ranked improving patient satisfaction scores as a top issue, according to a 2016 report by San Jose, Californiabased health care communications company Vocera.

Saint Thomas Health, a nine-hospital network of nonprofit hospitals in Middle Tennessee, is among that majority.

“Listening to our patients is incredibly important,” says Dawn Rudolph, STH chief experience officer.

“Anytime you are receiving feedback from the people you care for, it’s a good thing. We want patients to feel we are meeting their needs.”

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Why this increased focus on patient satisfaction and customer service?

Rudolph says a major contributing factor came when the Centers for Medicare and Medicaid Services (CMS) started to judge hospitals on the quality of their patient care and experience and subsequently began tying the results to reimbursement.

One key government metric is The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS and pronounced “H-caps”). The standardized 27-item HCAHPS survey is distributed to a random selection of patients between 48 hours and six weeks after discharge.

Scoring consists of patients’ responses to, for example, a facility’s noise level throughout the night, a doctor’s bedside manner or a willingness to recommend a facility to friends and family.

HCAHPS scores were conceived of and initiated in the mid-2000s, but providers’ scores weren’t tied to reimbursement until 2010. A provider’s reimbursements are penalized — up to 30 percent — when patient satisfaction scores fall below the 50th percentile.

“We’ve been reporting on our HCAHPS since 2006,” Rudolph says. “It has [accelerated what we call] a ‘culture of always’ at Saint Thomas.”

Rudolph describes that culture as yielding the consistent serving of patients with compassion, respect, informativeness, competency and safety. Creating and maintaining a culture of always is complex, with many people and factors involved. Furthermore, a 24/7 hospital environment can’t produce perfect results 100 percent of the time. As such, much of patient satisfaction hinges on effective — and sometimes unabashedly honest — communication with all involved.

It often means something as simple as a facility admitting and apologizing for a mistake or ensuring a patient is given enough time for questions.

11/9/16 2:43 2:42 PM 11/3/16 10:19 AM

MANAGE

“It has taken hospital leadership to create intentional training and tactics so that we can keep that ‘culture of always’ going and to continually make sure our staff is aware of it,” Rudolph says.

What do patients complain about?

Rudolph says most concerns relate to interpersonal communication rather than clinical care. A recent Journal of Medical Practice Management study supports Rudolph’s observation. It showed overwhelmingly that patients’ most frequent complaints involve a lack of satisfaction at the front desk and not a physician’s clinical skill or expertise.

In fact, 96 percent of patient complaints in the survey were about customer service and only 4 percent involved care quality and accuracy.

“The pressure points occur when patients feel their time isn’t being respected or someone is making them feel like their needs are less than important,” Rudolph says. “Anxiety increases. They feel they don’t have a voice.”

Providers such as Saint Thomas Health are focused on patient satisfaction beyond wanting to make sure they receive maximum reimbursements. They want to ensure patient loyalty.

A recent study by global consulting firm Accenture found that hospitals that deliver superior patient satisfaction scores experience a net increase of repeat patient visits up to 50 percent higher than do average performers.

Rudolph says that technology is key to sustaining STH’s “culture of always.”

For example, the hospital system recently deployed Pulse, a patient feedback tool that allows the prompt gathering of responses regarding the final 24 hours of care. This lends an immediacy and specificity to the data, making it less “perceptual” than info collected for HCCAPS survey questions, which query patients after they leave the hospital, Rudolph says.

The Accenture study supports Rudolph’s point.

Indeed, the need for quicker — and increasingly more relevant — patient feedback also is driving entrepreneurial solutions in the free market nationally as well as in Middle Tennessee.

For example, local patient-care communication technology company Amplion Clinical Communications has found that collecting real-time data from health care professionals, particularly nurses, is yielding promising results for clients wanting improved patient satisfaction scores.

“Technology is a really promising tool when it comes to improving patient satisfaction,” says Brenda Aubin, Amplion clinical integration manager. “You just need to make sure you have the right technology and have folks on board who know how to use it.”

Like Saint Thomas, Amplion is increasingly focused on collecting realtime data from patients and health care professionals rather than afterthe-fact “perceptual” data as required by HCAHPS. Aubin says Amplion’s research is yielding some “eye-opening” results that should help providers continue to improve patient satisfaction.

A recent Amplion-sponsored study found that the caregiver who accompanies a patient during an overnight hospital stay is likely far more critical in judging patient satisfaction — and, therefore, affecting reimbursement and long-term image/reputation of the hospital — than hospitals might have suspected.

The study revealed that 60 percent of patients have family, friends or professional patient advocates actively supporting them during hospital stays.

In nearly every category surveyed in the Amplion study, the caregivers graded the nursing staffs lower in meeting patients’ needs than the patients did.

“This is sobering news to health systems and suggests important process changes all of us in the industry will need to make if we want to be known for delivering superior care,” Aubin says.

“Nursing teams will need to focus on patient caregivers almost as much as the patients themselves in order for both patients and caregivers to recognize a high-quality patient experience,” she adds. “Hospitals will need a strong and passionate nursing staff, as well as current technology designed to help deliver on that expectation.”

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QUALITY CARE AT LOW COST

Rural state physician group benefits from accountable care organization model

by Peter Chawaga

As health care has evolved into big business, many smaller practices have faced the threat of being left behind.

Those practices have battled with the rising tide of regulations and cost increases by banding together via accountable care organizations. And ACOs — coordinated groups of health care providers that agree to tie revenue to quality standards determined by the Centers for Medicare and Medicaid Services (CMS) — often have proved helpful.

For example, the Cookeville, Tennessee-based Cumberland Center for Healthcare Innovation (CCHI) comprises about 180 independent primary care doctors across 50 counties in rural Tennessee. It has functioned as an ACO model to access more resources than would otherwise be the case while treating patients as per usual.

CCHI looks at the approach, much like other ACOs do, as a way to connect payment to performance, allowing care management to be maximized and eliminating unnecessary expenditures.

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Because ACOs (some are collections of hospitals while others are groups of independent physicians) are primarily paid for by Medicare, they allow health care providers across different specialties to share Medicare data on patients. This increases efficiency and reduces both paperwork and the chance of repeated testing. According to CMS, a combination of its 400 Medicare ACOs generated $466 million in program savings last year.

“The two goals of CCHI are to increase the quality of care to our patients in these rural communities and to decrease the overall cost of health care,” says Dr. Brent Staton, CCHI’s CEO and operator of a family practice in Cookeville.

Originally founded through word of mouth between its members, CCHI has evolved to serve nearly 150,000 patients a year, Staton estimates. According to CMS performance data, CCHI generated savings of more than $4.2 million in 2015 while outperforming most other ACOs in several care categories.

Staton credits the wide access to patient data afforded by ACO membership for CCHI’s success. CMS provides that data on patients through what are known as a Claims and Claims Line Feed and an Admit, Discharge and Transfer Feed, empowering members to serve their patients more effectively than they could previously.

“Having access to data that we’ve never had access to before, we’re able to understand where dollars are spent in the system,” Staton says. “That’s essentially what has happened with the ACO. We understand now how we’re going to be measured, and we understand how to reduce costs because we can tease out those high-cost patients and fo-

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cus on giving them higher-quality care. We’re able to predict who may be high-risk patients in the future, and we’re able to intervene more rapidly.”

Fueled by the data it gets from CMS, CCHI has developed relationships with local hospitals to bolster its knowledge of patients and respond more quickly to their needs following discharge.

“Some of the hospitals are starting to provide information back to the practices about when their patients were actually in the hospital and when they went home,” says Dr. Ty Webb, CCHI’s chief medical officer and a family practitioner based in Sparta. “As a result, instead of the patient getting follow-up within three weeks from being [released from] the hospital, they can get follow-up within three days.”

This in-depth knowledge of patients also helps ACO members combat one of the major challenges that health care faces today: the prevalence of chronic conditions.

“At the ACO, we can provide data to the practice that tells them if a chronically ill patient was just in the hospital or the emergency room, so the practice can very rapidly reach out to the patient,” says Webb. “Now the patients have contact with the physician that they trust to try and get them better. It’s showing that there is less utilization of high-cost health care, meaning that people aren’t sick as much with these chronic conditions and they’re not in the hospital as much. That’s good for the patient and good for the system.”

ACOs are not without detractors.

Critics fear that by reducing the quality of care to a number and adding oversight to the work of independent physicians, ACOs only impede caregivers’ efforts to serve patients as they see fit. It’s a concern that CCHI has been built to avoid.

“Another layer of complexity, another layer of bureaucracy… that is a fear that, if not addressed by the organization, becomes a reality,” says Webb. “Our structure is actually aligned so that we provide a minimal burden on a practice and become an enabling partner with them, to help them and not hinder them.”

CCHI uses processes that capture quality measures within the standard workflow of its members, so as not to weigh them down with extra tasks.

It helps members analyze their data, pointing to areas where revenue can grow and quickly identifying patients who are at risk of becoming chronically ill. CCHI’s care coordinators are directly in touch with the care coordinators at member practices, working one-on-one to implement the measures that can help the practices themselves.

“We’re very aware of that potential to impede because we practice as well, and we don’t want another layer of requirements on top of us without any support,” says Webb. “So we’re careful to actually be here in a supporting capacity.”

That personal knowledge of medicine within management is another key to CCHI’s success, according to Staton, who earned a business degree from Tennessee State University before attending medical school in Australia.

“You have some ACOs that are run by purely business people, hospital administrators or MBAs who don’t participate in patient care,” he says.

“And then you have ACOs that are run by doctors who are laser-focused on just quality of care. Then you have ACOs like ours that are doing both.

“You focus on quality or you focus on cost to the exclusion of other things,” Staton adds. “You have to focus on both.”

A dual focus between quality and cost is simply going to increase in importance as health care fees and regulations grow, Webb says.

“Because of the burdensome and multiple regulations that have come along in medicine, it’s much more difficult now for physicians to have flexibility to maintain independence to treat their patients as they were trained and as they feel best,” says Webb. “The business of medicine has gotten to be so complex that there needs to be support for that physician. That is where an ACO structure becomes beneficial. It lets you maintain independence and then the ACO provides support.”

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Endangered species

Rural hospitals risk closures, rely on entrepreneurial relief

by Linda Bryant

While hospitals in urban areas and suburbs face formidable challenges regarding crunching the numbers, navigating complex regulations and serving the public, the overwhelming majority of them are survivors.

Rural hospitals, however, are an endangered species.

Seventy-six of these facilities — often referred to as critical-access hospitals (CAHs) — have closed nationwide since 2010. And 30 percent of the country’s 2,000 rural hospitals are likely to cease operations during the next two years.

According to Leawood, Kansas-based nonprofit National Rural Hospital Association, 673 rural hospitals, or about one-quarter of all such health care facilities, are “vulnerable or at risk for closure” during the next decade.

The numbers are disturbing considering rural hospitals are often the only places that provide health care within a 50- to 100-mile radius of their respective communities. In addition, many are a significant source of employment for the communities they serve.

Six rural hospitals in Tennessee have shuttered in the past six years, according to industry publication Becker’s Hospital Review. They are Gibson General Hospital in Trenton, Haywood Park Community Hospital in

Brownsville, Humboldt General Hospital in Humboldt, Parkridge West Hospital in Jasper, Starr Regional Medical Center in Etowah and United Regional Medical Center in Manchester.

“Like a lot of things in health care, issues surrounding rural hospitals are complex and have a lot of players and regulations,” says Bill Anderson, CEO and president of Medhost, a Franklin-based IT company that offers a cloud-based health care management system involving clinical and financial solutions for hospitals.

“Rural hospitals face an economic squeeze and resource shortages,” Anderson adds. “Because of [increased] regulation and more sophisticated treatment options, fixed costs are increasing — sometimes dramatically because of federal regulations requiring technology.”

Indeed, factors negatively impacting rural hospitals are intensifying. Throughout America, small towns and rural communities are losing population, which dissuades physicians from feeling comfortable about their prospects of establishing viable practices and careers in such places.

Even more glaring, CAHs increasingly — compared to their urban counterparts — must treat a disproportionate number of low-income, indigent and aging patients, many with chronic conditions such as diabetes, and heart disease. And they must do so with a modest number of doctors and specialists, no less.

Furthermore, revenue at most rural hospitals is stagnant — or dwindling — because so many patients are on Medicare or Medicaid or are either uninsured or underinsured. Even when they are insured, many folks don’t seek help until health conditions have deteriorated because their insurance policies have high deductibles, Anderson says. katie turner

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“Plus, many health care plans encourage treatment outside of walls of the hospital,” he adds. “That means the percentage of inpatient health care being delivered is declining. It means shorter hospital stays and more services delivered outside of the hospital setting. Many of these hospitals are in a very difficult place.”

Alan Morgan, CEO of the aforementioned National Rural Hospital Association (NRHA), agrees that the situation surrounding rural hospitals “appears to be going in the wrong direction.”

But Morgan points out the crisis is motivating health care innovators, entrepreneurs and visionaries to invent “new models, systems and solutions” he believes will eventually help stabilize rural hospitals. He sees a lot of promise in “telehealth,” which refers to advanced technologies that deliver health care education and support via computers.

“One of the most successful applications [of telehealth] is the teleconsultation,” Morgan says. “We’re seeing a widespread application of teleradiology and telepsychology. These are the kinds of applications that show a lot of promise. For example, just think about how telepsychology can help with the opioid addiction crisis.”

Morgan points to physician-to-physician teleconsultations and virtual patient support groups for everything from weight loss to depression as a part of the solution.

“Rural doctors are now able to link with peers [via technology] and discuss procedures and protocols,” Morgan adds. “This is a great way to have access to top specialists. As we move forward to address problems, I believe telehealth solutions will thrive, and we’ll move towards direct patient access (for example, a rural patient talking to a health care professional remotely via a computer).”

Industry veteran Clare Moylan agrees.

“Telehealth will play a significant role in rural health care,” says Moylan, managing director of Healthcare Management Partners, a Nashville-based consulting firm that specializes in engineering turnarounds at distressed hospitals.

Moylan sees the rural hospital of the future changing from a primarily inpatient facility to an “important emergency/ambulatory care/outpatient providers for communities.”

“They may have ‘swing’ beds for skilled nursing patients, but inpatient care will primarily be provided by larger regional ‘hub’ hospitals,” she says. “The best rural hospitals will know their core services and do very well by eliminating other services. Most back office operations will be outsourced.”

Moylan is certain the disruption surrounding rural hospitals will cause growing pains.

“There will also be fallout from the distress we currently see in the market,” she says. “Hospitals will be put through bankruptcy. Some may close, others may be successfully restructured. The goal is to protect healthcare services in rural areas, recognizing that the traditional rural hospital model is changing, whether we like it or not.”

Medhost’s Anderson offers a similar take, noting nonurban hospitals are “going in two directions.”

“Hospitals that are situated well geographically and have good leadership will start to expand their communities of care,” he says. “Other hospitals — by virtue of

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competition or because of the market they’re in — will end up looking for alternative operating models. They will be less of a full-service hospital and more of an immediate care facility. Unfortunately, I do believe you are going to see a number of hospitals go out of business.

“The reality today is the country cannot afford to deliver health care the way it has in the past,” Anderson adds. “There are inefficiencies and some excess capacity in the system. There are better and worse operators. As a result, we’ll see some of the capacity taken out, and the operators who are left will be more efficient.”

Anderson also sees some creative “repurposing” on the horizon.

“Take the example of behavioral health care,” Anderson says. “Many states have shortages of inpatient care. I think we’ll see situations in which existing [underutilized] facilities will be repurposed for different types of health care.”

Anderson predicts that many solutions — particularly those based in technology — will rise from the private sector.

Indeed, Medhost is on the front lines addressing the problem with free-market solutions. Anderson says the company’s rural health division, which provides consultation, marketing and technology products for the rural health market, is among the firm’s fastest growing.

Despite the innovation and restructuring needed to bolster rural hospitals, many proposed changes won’t occur unless laws are changed at the federal level, says Maggie Elehwany, vice president of government affairs and policy at NRHA. Elehwany, the association’s main lobbyist, says current regulations pertaining to rural hospitals are restrictive and outdated, and don’t allow providers to establish new and more flexible models.

Elehwany is working to improve the outlook for rural hospitals by promoting the Save Rural Hospitals Act. The bipartisan bill, co-sponsored by Republican and Democratic members of the U.S. House of Representatives, is aimed at adjusting how rural hospitals are reimbursed and setting guidelines for the creation of innovative delivery models.

“Rural hospitals have also endured Medicare cuts for years,” Elehwany says. “If Congress doesn’t intervene, we almost certainly will lose a quarter of our rural hospitals in the next 10 years. One in three rural hospitals are under financial risk, and 69 percent of rural hospitals operate at a loss.”

Elehwany says there are now “health care deserts” caused by rural hospital closures. She describes a domino effect that often occurs when a community loses a hospital.

“The hospital closes, which means the physicians leave and the pharmacist leaves,” she says. “Health care is not the only thing that shrivels up. You see home values fall and families stop wanting to move there. People get stuck and you see the erosion of an entire community.”

Elehwany and her NRHA colleagues are optimistic that the Save Rural Hospitals Act will pass in 2017.

“We are just trying to stop the cuts and stabilize the system; we’re not trying increase reimbursements,” she says. “The bill will offer much-needed regulatory relief and stop the bleeding. Maybe we can’t save all rural hospitals, but we can create a path forward for hospitals that don’t need inpatient beds anymore.”

‘Issues surrounding rural hospitals are complex.’

Bill Anderson

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Rule change

The fight against sepsis is ready for data science approach

by Ray Guzman

Remember in “A Charlie Brown Christmas” when Lucy — folding her fingers and thumb into a fist — gives brother Linus five good reasons why he should go through with his role in the Christmas play?

For patients battling sepsis — and the physicians racing against time to cure them — the infection packs a far more devastating punch.

There has been no real change in the protocol for managing sepsis (a condition spurred by the body’s response to infection as it injures its own tissues and organs) during the last 40 years. So it’s time hospitals pick up new tools to combat the infection. We’ve come up with five good reasons why using a data science approach to combating sepsis can deliver the knockout punch needed to save lives.

Before we go into how data science (another term to explain the term is “machine learning”) relates to sepsis, we should discuss how it works. Rather than leveraging another piece of software or hardware to integrate into existing technology, this type of technology-based strategy relies on super computers that have the ability to learn. Instead of relying on software, the power is in the algorithms used to train the computer, which is focused exclusively on the problem of sepsis and in which the technology grows and improves over time when it’s fed with data from various sources.

That said, following are five good reasons to deploy a data science approach:

1. There isn’t a human expert — academic or otherwise — on the subject of sepsis.

Many honorable and talented people are working very hard to understand sepsis. Yet it’s still unclear as to what triggers the body to develop this runaway response to infection. Untreated sepsis progresses so fast that clinicians struggle to get ahead of the curve, and often a diagnosis is confirmed very late, and sometimes too late.

2. The best clinicians cannot explain their expertise.

Suppose you have two patients treated at the same time for the same illness with the same treatment protocol.

One develops sepsis and the other doesn’t. Over time, many clinicians develop a “sixth sense” about who will be diagnosed. But it’s hard to quantify, much less instruct, on the basis of a “sixth sense.”

3. Sepsis definitions, protocols and staff change over time.

Solid protocols are in place in many hospitals. But between nursing staff changes and the communication breakdown among hospital staff and physicians, additional time is added to a process for which every hour counts. With sepsis, the time between identification and treatment has major consequences in terms of lifelong chronic health conditions and, at worst, mortality.

4. There is no such thing as an average sepsis patient.

Sepsis patients are like snowflakes — no two are alike.

That’s why it’s hard to get ahead of the sepsis curve.

Sepsis can be masked by more than 84 diagnostic codes from bacterial meningitis to bronchitis to a simple urinary tract infection. Clinical indicators, beginning with a rise in blood pressure, occur on average 15 hours into the 36-hour decline from infection to death. But electronic health records-based alert systems generally require additional validation, resulting in even more time before the initiation of an aggressive sepsis treatment protocol.

5. Much of the low-hanging fruit of process improvement for sepsis has already been put into play.

The clinical indicators and protocols have been fine-tuned to the point that maximum benefit has been achieved.

TREWScore (targeted real-time early warning), modified early warning scores and routine screening identify approximately 70 percent of patients who fall in the area under the curve but do not take into account the precious value of time in the sepsis treatment equation.

Every hour of delay in the application of effective antibiotics increases mortality by 7.6 percent. The combination of those patients missed by traditional screening coupled with the 24-to-26 hours wasted for clinical identification leaves a trail of lives lost and expenses that have risen precipitously. With more than 258,000 sepsis deaths annually in the U.S. — and at a staggering cost of more than $32 billion per year — surely we can do better.

To put this in perspective, consider the fact that what is happening in America is tantamount to two jumbo jet crashes with no survivors — every single day. If that were happening, would the airline industry be looking for new approaches?

Taking the best of what data science can offer to develop a truly new approach for combating sepsis is the right thing to do. For providers who are committed to reducing in-hospital and post-discharge sepsis mortality without an additional cost burden, it’s time to look at new solutions to a vexing and all-too-devastating problem.

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Ray Guzman is CEO of WPC Healthcare. wpchealthcare.com

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Self-care is more self-directed than ever before Ease of use, tailoring, motivating are keys to changing habits

by Chandra Osborn

Chandra Y. Osborn is vice president of health and behavioral informatics at One Drop, a diabetes management platform. onedrop.today

When I was expecting my first child, I wanted to learn anything and everything that was going to happen to my body and my baby over the next nine months. Sure, I had prenatal care appointments — 13, in fact.

But my pregnancy apps? I looked at them every day.

Usually several times a day. I used one app to follow my body’s and baby’s physiological changes, track my weight and store my health data. I used the other app to get advice about what to eat, what activities to avoid and even what over-the-counter medications I could take.

Here I was, experiencing my first baby — arguably the most important thing to ever happen to my body — and the vast majority of how I took care of myself was directed and informed not by a qualified medical team, but by health apps on my cell phone. No doctor told me to use those apps. I chose them. I searched for them, I selected them (based on app store reviews, nonetheless), I downloaded them, and I decided they were good enough.

After entering some personal data, my apps knew my due date, when my prenatal appointments should be and what foods I should eat based on my weight changes… and I could store my sonogram photos and belly selfies. Just what I needed and wanted!

And I’m not alone in having these requirements.People expect to use technology to meet them where they are and where they want to be, especially when it comes to their health. Many folks often ask me how I got into tech. My answer: “To educate people and promote health.

Technology isn’t an option, but a requirement to working in this field.” Phones, trackers, tablets and computers are delivering health information more than ever before.

Everyone has to be able to access, understand and apply that information to become and stay healthy.

As a Vanderbilt University Medical Center scientist, my research studies found that certain types of people use technologies to take care of their health. These people have health literacy skills — they can understand and apply health information. We also found that having health literacy skills means you’re more likely to have a cell phone and be savvy in how you use it. People without these skills may not be taking advantage of the more than 200,000 health apps that now exist.

Earlier this fall, Dr. Michael Mackert at the University of Texas in Austin published a study of nearly 5,000 Americans that found people with health literacy skills are in fact more likely to use health apps as well as activity trackers and patient portals. They’re also more likely to believe these technologies are easy to use and useful.

So that raises a few key questions, each of which has a number of answers:

1. How can we get more people to use health tech?

• Engage users of all types in the design, development and refinement of digital health solutions.

• Leverage what people use. That includes iOS and Android devices and even feature phones.

• Use familiar channels to communicate. Text messaging is the No. 1 cell phone activity for everyone.

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• Make the first impression say, “I’m easy to use.”

• Make the user interface and user experience intuitive.

• Be interoperable with other platforms.

2. Once people are in, what’s the most effective way to educate and change behavior?

• • • •

Health education and support must be data-driven.

Personalize health messages. Tailor. Tailor. Tailor.

Simplify messages but make them engaging and compelling.

Develop and/or enhance users’ knowledge about the importance of the health behavior. Correct any misinformation and create accurate heuristics.

• Develop and/or enhance users’ personal motivation towards the health behavior. Deliver content to promote favorable attitudes by saying something like “Doing the behavior will make you feel good in these ways.” Also, promote favorable beliefs about performing the behavior and the outcomes of doing so. Let people know there are more benefits than costs to performing this behavior.

• Develop and/or enhance users’ social motivation about doing the health behavior. Make social normative support accessible by showing people others like them or the people they care about think they should do this or are doing it, too. Then give concrete advice on how to get practical support. That can include saying things such as, “This is how you can ask your partner to join you for a walk.”

• Finally, develop and/or enhance users’ skills for performing the health behavior regardless of the situation. Help people build the infrastructure to be successful regardless of what life throws at them. For example, this calculator will help you determine how much medication you need to bring on your next trip.

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So what does health literacy- and behavior change-friendly health tech look like? In 2013, Dr. Shelagh Mulvaney and I developed and tested a mobile health program called MED for people with diabetes receiving care at safetynet clinics. MED sends one data-driven, personalized text message each day at a random time during waking hours. This message educates, motivates or helps build skills around taking medications and/or insulin. MED sends a second text at the end of the day asking, “Did you take all of your meds today?”

MED also calls people at the end of each week to give self-care feedback and encouragement.

In our research, all users said MED was easy to use and useful and were engaged in 84 percent of the text messages over three months — the highest engagement we’ve seen in the scientific literature. Users also improved selfcare, reduced barriers to self-care and improved glycemic control.

If MED produced such great results, one can only imagine the potential of technologies at the forefront of hyper-personalized support. My next project is working with One Drop, a health tech startup revolutionizing diabetes care.

Unlike MED’s automated, data-driven text messages, One Drop supports people with diabetes and prediabetes via personalized coaching and a digital therapeutics program delivered entirely through a mobile app. Users enter self-care data — most of which is entered automatically, greatly reducing the burden on the user — and receive health literacy- and behavior change-friendly insights.

We’re harnessing technology to make living with diabetes hyper-personalized and simple. We’re meeting people where they are and where they want to be. The best health tech is all of these things. It’s easy to use, personally relevant, empowering and actionable. For people with chronic health conditions, it’s comprehensive, interoperable, engaging and ongoing. The secret sauce is health literacy- and behavior change-friendly, but also dynamic and continuous.

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As the country, propelled by the Affordable Care Act and other changes in the health care landscape, moves toward value-based care, the time has come to find new ways to lower costs and boost positive outcomes. Pulling social determinants of health (SDH) data into population health management (PHM) platforms is a step in the right direction. To accomplish this task, we first need to define our terms.

What are SDH?

MANAGING A POPULATION’S HEALTH

Leveraging social determinants of health can yield positive results

by Justin Neece

The United States spends $3 trillion on health care annually, yet the nation lags many developed countries in health outcomes.

Based on a meta-analysis of nearly 50 studies, researchers found that social factors — including education, racial disparities, social support and poverty — accounted for more than a third of total deaths in the United States in a year, according to a U.S. Health Care from a Global Perspective piece by David Squires and Chloe Anderson.

In addition, we often treat illnesses but do not address the conditions that contribute to them. And doing so is futile.

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Social determinants of health are the factors and environments that a given population is born and grows into.

They include economic stability, education, social and community context, health and health care and the built environment (whether country roads in a rural setting, sidewalks in a city or something in between).

While economic instability has an obviously negative impact on health care, social networks can reinforce unhealthy behaviors such as smoking and drinking. Similarly, a patient’s social and community context is also vital to combatting depression or social isolation. In a more practical respect, SDH also include addressing language differences and transportation, which are directly connected to the impact a health care provider can offer.

For clinicians who acknowledge the impact of social determinants on health, it’s difficult to know where to begin. Emergency medical records generate a great deal of raw data, but making that data accessible, user friendly and actionable can be a challenge. Very few EMRs incorporate space for social data, and the vast majority of primary care practices lack processes for capturing and integrating such data, according to an American Academy of Family Physicians article by Michael Laff.

Claims data is helpful, but not timely. Clinical information is better but may be missing critical information.

The combination of these information sources is critical to transforming data into actionable insights.

Population health management tools must go beyond the individual patient record to help providers visualize the general performance of the organization. A strong platform also should allow each staff member to customize the data to suit her or his workflow needs. Finally, bringing in geographic and demographic data creates the most robust PHM experience for both providers and patients.

Data aggregation is a key challenge for organizations of all sizes. EMRs were not designed for the type of analytics that guide improvement, patient satisfaction and cost reduction.

Practical strategies to take action

• Getting better prepared for patients via huddle reports With a data warehouse and proper analytics tools, the PHM platform gets down to the nitty-gritty of patient care and coordination. Daily huddle reports are generated for providers and case managers to easily access important information such as the patient’s homeless status or prior incidences of domestic violence. Clinicians can use the information prepping for a visit and also act accordingly when following up on missed visits.

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• Education and communication for a diverse patient population Social determinants also have a direct impact on patient education and communication. La Maestra, a large community health clinic located in southern California, leverages its PHM platform to improve health literacy and bridge communication gaps. The clinic serves a community where 74 percent of the population speaks a language other than English. Staff — from physicians to the receptionist — speak more than 20 languages and dialects. When someone from this multilingual population arrives for an appointment, a coordination effort is put in place that goes far beyond a basic scheduling system.

• Going outside the clinic walls to improve health Knowing your patient is homeless or having multi-lingual physicians may not be enough. The health care system is beginning to develop extra-clinical solutions that go beyond the doctor’s office to influence social determinants and create a more positive feedback loop. Examples include the following: * In New York City, a medical/legal partnership helped resolve legal issues involving housing, resulting in a 91 percent decrease in hospitalizations and ER visits; * A coalition and care management program addressing patient complexity in Camden, New Jersey, has seen monthly hospital charges drop by 56 percent; * Seattle saw a $334 monthly drop in urgent care costs per child when it brought community health workers to asthmatic children living below the poverty line. Instead of the children and their families having to wrestle

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with transportation barriers, and clinicians coping with no-show appointments, the community health workers came to them.

The promise of data science for effective PHM

Social determinants of health are critical in terms of the retrospective analysis necessary to better prepare for patient visits or the launch of meaningful outreach to address gaps in care or maintain care plans.

But there is increasing value in leveraging true predictive insights that harness the power of SDH to achieve additional benefit to an end-to-end PHM program. Deploying data science is vital to achieve broader improvements in health and greater health equity. It can help gauge the impact of social determinants on patient risk factors and outcomes and further strengthen population health management tools.

Data science allows PHM tools to use pre-clinical data to build a social determinants profile that would, for example, help predict who is more or less likely to end up in the emergency room, who is at risk for a negative cardiac or diabetic event and/or who is likely to be a readmissions risk.

The value is clear and — with large data sets coming together from a variety of sources in a manner that is accessible for analysis — we are on the cusp of tremendous opportunity.

In terms of how the industry will evolve to leverage the deep insights related to this information, the possibilities are truly endless. It is time to apply what we know to get aggressive about population health management.

Justin Neece is president and COO of i2i Population Health. The company’s i2i Tracks system of population health management tools serves more than 2,000 organizations across 35 states.

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LEARNING, GROWING LifePoint’s big drive to improve quality has it much better positioned to help patients outside hospital walls

by Geert De Lombaerde

‘A community’s health is much more than what is happening in the health care system.’

Rusty Holman

Reaching a goal ahead of schedule is worth celebrating. So is topping a target you’ve set for your team. So what do you do when you surpass expectations and do it nine months ahead of schedule?

If you’re LifePoint Health and you’re working on the quality of your hospitals’ patient care, you double down and push on.

In late 2011, the Centers for Medicare and Medicaid Services (CMS) chose Brentwood-based LifePoint to be one of just 26 organizations nationwide that would take part in its Hospital Engagement Network program, which aimed to slash the amount of certain hospital-acquired health conditions — such as drug complications, falls and blood and urinary tract infections — by 40 percent over three years.

Leaning on a partnership with Duke University Health System that started in 2005, LifePoint almost met that threeyear goal in less than two and a half years and has since cut the number of the targeted adverse events by 50 percent.

Similarly, Tennessee Hospital Association members that took part in the Hospital Engagement Network program avoided nearly 14,000 adverse events or readmissions over four years. Not having those things go wrong produced savings of more than $104 million across the state. Nationally, CMS says four-year savings reached nearly $20 billion.

Such heartening statistics aren’t the result of innovative new treatment methods or scientific breakthroughs, though. Hospital-acquired infections have long been a source of frustration for providers and regulators as well as a source of pain and anxiety for patients. Many in the industry long saw such incidents as — in the words of a U.S. Department of Health and Human Services agency — “an inevitable hazard of hospitalization.” But it became clear years ago that clinicians don’t have to reinvent the wheel to drastically reduce the number of infections their patients pick up while under their care. It’s a matter of prioritizing patient safety and proper processes.

For LifePoint Chief Medical Officer Rusty Holman and his team, maximizing the improvements their more than 70 hospitals and numerous outpatient and post-acute facilities could generate under the Hospital Engagement Network program came down to four key areas: leadership, culture, process improvements and staying focused on the patient. That required both top-down initiatives and the

opening of bottom-up communication channels. One of the most successful features combines both approaches and can be seen in all LifePoint facilities every day.

It’s a simple white board.

The white board is divided into three columns. The first lists hurdles, inefficiencies and problems nurses and other front-line staff have pointed out — and have been given explicit permission to point out. Those can focus on workflow issues between the patient floor and the pharmacy, for instance, or single out shortcomings such as, “The nearest photocopier is in another wing two floors away and it takes 10 minutes to get there.”

The second section is for managers to list what action they’re taking to resolve the issue. They’re empowered to address the concerns however they see fit, and sometimes their response is a mere “We’re looking into it” for a while. But the expectation is that there will be an answer and an action. That goes back to staying focused on what will make this better for the patient above all.

The third column is the simplest. It gets filled in only when the issue has been resolved.

Another initiative that builds on what the learning boards are doing are CEO weekly patient safety rounds.

The top executives of LifePoint’s hospitals have standing times on their calendars to walk the halls, visit with patients, look over work areas and, yes, check in on the learning boards — all with an eye to pushing down the number of preventable errors. Holman says this approach helps get CEOs out of their offices more effectively and gets them more involved in the clinical aspects of their facilities. (See our story on Saint Thomas Health’s dyad model on page 62 as another take on this concept.)

More broadly, the learning board has closed the distance between layers of the organization charts for LifePoint hospitals. Executives and team leaders find themselves more closely involved with what front-line workers are doing, and those workers have a more efficient path to create changes that help them aid patients.

“It has created a transparency that says it’s safe to bring up problems,” Holman says. “That’s a big positive in creating a teamwork safety culture.”

Reaching out

These initiatives and the other work done as part of the Hospital Engagement Network program helped build a platform for Holman’s bigger goal, the LifePoint National Quality Program. Unveiled in early 2015 as the Hospital Engagement Network reached its three-year milestone, the program is more comprehensive and longer-lasting, incorporating more measurements and focus areas.

All of LifePoint’s hospitals are now fully on board with the program, and three already have been recognized for reachdaniel meigs

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ing key benchmarks. Among them is the tiny Riverview Regional Medical Center in Carthage, which in 18 months slashed its hospitalacquired infection rate to about 0.5 percent from a 2014 average of more than 1.5 percent. (See the accompanying top sidebar for more details.)

But the National Quality Program is more than a beefed-up version of the CMS program from which it evolved. By widening its vision to include the continuum of care beyond hospital walls, it has become a bridge that extends LifePoint’s connections to the health care ecosystems in the areas where it does business. Most of the company’s hospitals are the sole providers in their communities, which makes them natural conveners for broader discussions on health care quality. (And with hospitals increasingly being measured — and penalized — on quality measures such as readmissions, improving relationships with other health care stakeholders also stands to benefit the company’s bottom line.)

Around the country, almost 10 LifePoint hospitals have assembled community coalitions that include key players such as area pharmacists, paramedics, home health professionals, skilled nursing providers and community education centers. Holman says the broader vision, dialogue and cooperation those efforts have produced are creating “dramatic” changes in culture at the company’s hospitals, where workers better see the bigger picture and how they can help their patients. One striking example of that is in Arizona, where Havasu Regional Medical Center executives convened a coalition to build on a promising partnership with local paramedics. Among other things, that approach has improved care for high-risk and home health patients and cut the hospital’s readmission rate to less than 7 percent versus a national average of more than 15 percent. (See the second sidebar for more details.)

“A community’s health is much more than what is happening in the health care system,” Holman says. “Readmissions issues could be due to transportation, the cost of medicines, education or other demographic factors.”

To get a better handle on what those issues are and how LifePoint can continue to respond, Holman set up the Patient and Family Advisory Board and recruited Chairman and CEO Bill Carpenter to help him organize its meetings. The two meet regularly with community members to talk about quality and safety priorities, patients’ experiences and the impact of technology on what happens in LifePoint’s hospitals.

Holman says the group’s feedback has helped shape how LifePoint’s leaders communicate success, share stories of patient experiences and reinforce the good behaviors taking place. And the board has helped improve a key element of the patient experience: Based on members’ feedback about nurse interactions, shift changes are now handled at the bedside, where patients and family members get updates in layman’s terms and questions are heard and answered by multiple members of the care team.

Such changes, Holman says, are having “a distinct cultural impact” — to the point that executives at 15 LifePoint hospitals have come forward this year looking to set up their own regional patient safety councils. Holman and his team are working on a toolkit that provides guidance and coaching for how to best go about doing that. Developing more of those networks will help set up LifePoint for a future in which much more health care is paid for via so-called bundles that need to be divvied up among the various providers who touch a patient.

“Risk-based models have been focused much more in urban markets so far,” Holman says. “Their impact on us is still limited — but we want to be prepared for when they become more of a reality.”

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case study

Building a community coalition

Focused on quality and by a shift in payment models, many hospitals are playing a leading role in setting up in their communities partnerships that improve health outcomes beyond the hospital’s walls.

The leaders of LifePoint’s Havasu Regional Medical Center in Arizona set out to build on a successful collaboration with a group of paramedics there by convening representatives from other providers, including pharmacists, home health and nursing caregivers, medical equipment vendors and community education centers.

Together, they set out to identify common factors that lead to hospital readmissions and come up with ways to reduce them.

So far, so good. Through its first six months, the joint effort made the following progress: • Better use of home health services: Home health professionals began joining daily department team meetings where clinicians identify potential patients who could qualify for home health services, then check to see if they are eligible. As a result, about 86 percent of patients are now being screened and home health assignments are up 36 percent from 2015.

• More follow-up appointments: Before the formation of the coalition, 80 percent of high-risk patients were discharged without follow-up appointments. Now, hospital unit clerks schedule followups with all patients before they are discharged. Additionally, a transitionof-care nurse loops in paramedics who visit the patient at the hospital prior to discharge. Paramedics then visit the patient at home within the first 48 hours after discharge, checking on medications and safety checks and answering questions, including about the follow-ups, while assessing for the potential for home health services. The results: All highrisk patients are being discharged with appointments and 87 percent of those follow-ups have been kept as scheduled.

• No-doc home health services: The coalition figured out that 15 percent of patients who qualified for home health care did not receive those services because they don’t have a primary care physician. For them, Havasu Regional built a “no doc” list in coordination with an emergency department case manager.

Over the past four months, 10 patients on that list have received needed home health care.

Combined, those small individual gains can snowball into big improvements: Havasu Regional’s readmission rate now sits below 7 percent, less than half the national average.

case study

Fighting off infections

Early this decade, LifePoint’s 25-bed Riverview Regional Medical Center in Carthage had several quality improvement plans in place but was still struggling with hospital-acquired infections. After being well below 0.5 percent in 2011, the rate of infections topped 2 percent in the third quarter of 2014 — right after the hospital enrolled in LifePoint’s National Quality Program.

Soon after, the tide turned definitively. Since October 2014, the infection rate at Riverview has dropped an average of 24 percent per month and is now back near 0.5 percent.

Those improvements have generated positive momentum elsewhere: Riverview’s HCAHPS patient satisfaction scores for pain management have risen 21 percent in less than two years, and the hospital’s score on LifePoint’s Culture of Safety and Engagement survey has gone from 45 percent in 2013 to 92 percent this year. The latter is one of the highest average CoSE Index scores in the company.

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VIRSYS12 TRANSFORMING THE BUSINESS OF HEALTHCARE Firm bridging technology gap in evolving healthcare market

As the business of healthcare continues to evolve, Virsys12 is partnering with clients and leaders in healthcare using technology to unify care around the patient and track the journey from sickness to managed to improved health outcomes.

With Virsys12’s focus on healthcare IT innovation, the awardwinning certified Salesforce® Silver Consulting Partner is breaking new ground in how integrated cloud technology is being used to help organizations operate faster and more efficiently, close the gaps in care, and increase engagement across the healthcare continuum—from providers to payers to patients, and everyone in between.

Virsys12’s CEO and Founder Tammy Hawes notes that the transition from volume-based to value-based care is significantly affecting the way healthcare organizations do business. Their ability to successfully adapt to this new reality will hinge on having access to real-time data and analytics as well as a single source of truth for coordinating care both inside and outside the clinical environment. This is one of the key reasons Virsys12’s clients are moving to Health Cloud, powered by the Salesforce platform. As an all-encompassing “patient success platform,” it eliminates the silos between the many disparate players now working together seamlessly to improve outcomes. And because patients can easily access the plat-

form from their device of choice to take more control over their own wellness, it promises to help prevent and limit the progression of common diseases while reducing overall costs to providers.

According to Scott Hultstrand, Manager of the Quality and Data Integrity Team at Care Coordination Institute, Virsys12’s contribution has been instrumental in their work to help transform Greenville, South Carolina’s MyHealth First Network (MyHFN) to a value-based model.

Together, they’ve been able to think through their healthcare technology strategy and, more importantly, translate technology into application to patient care.

The combination of the Salesforce Platform, Virsys12’s V12 ACO app, and Virsys12’s ongoing consulting work has made a huge impact at MyHFN, Hultstrand emphasizes, and providers and patients alike are feeling the benefits.

Physicians are getting the information they need in a timely manner and staying more engaged with important quality measures, resulting in patients getting the attention, care and sense of connection they need to take control of their health.

“Many have been skeptical the transition from volume-based to value-based care will really happen,” reflects Hawes. “Our clients are showing that not only can it be done, it is already making a difference in people’s lives.”

Virsys12 is an award-winning, certified Salesforce® Silver Consulting Partner focused on healthcare innovation nationwide. With success providing transformative technology solutions for large, small, public and private enterprises, the individually certified team maintains top customer satisfaction ratings and excels in lean business process. We solve your hardest problems by making the complex simple, guaranteeing our work for implementation, integrations, applications and technology strategy.

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FEATURES

XXXXXOF FAME HALL

Jack O. Bovender Jr. Tennessee HEALTH CARE

hall of fame The Tennessee Health Care Hall of Fame was created in 2015 by Belmont University and the McWhorter Society with support from the Nashville Health Care Council as founding partner. The body serves to honor the health care pioneers, innovators and practitioners who have helped make Tennessee a major player in the nation’s health care sector.

Selected by a multi-member committee, the second annual class of six individuals follows 2015’s inaugural class of eight.

For more information about the process and how to nominate someone for the 2017 class, visit tnhealthcarehall.com. > William Williams

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A 40-year health care industry veteran, Jack O. Bovender, Jr., began his hospital administrative career in 1969 as a United States Navy lieutenant.

Later, Bovender served as chief executive officer at two Hospital Corporation of America-owned Florida hospitals. He held several senior-level positions with HCA before retiring as chairman and CEO in 2009.

At HCA, Bovender fostered a patients-first culture.

His commitment to expand diversity among health care leadership led to HCA’s executive development program, which focused on mentoring young professionals, many of them minorities.

Long before passage of the Affordable Care Act, Bovender was a strong advocate for national programs that benefited the uninsured and underinsured. He established HCA’s charity care and uninsured discount policy.

Bovender helped lead the rescue of patients, employees, staff and patients from New Orleans-area hospitals during Hurricane Katrina. From Nashville, he oversaw HCA’s massive effort to send supplies and relief until a full evacuation could be launched.

Thousands of lives were saved and his actions became a model for disaster response for hospitals.

Bovender, who received his bachelor’s degree in psychology from Duke University in 1967 and his master’s degree in hospital administration from Duke in 1969, was the 2007 recipient of the American College of Healthcare Executive’s Gold Medal Award and Duke University’s 2012 Distinguished Alumni Award. He is a founding member of the Nashville Health Care Council and was lauded by Institutional Investor as “Best CEO in America” for health care facilities in 2003, 2004 and 2005.

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HALL OF FAME

FEATURES

Stanley Cohen

Colleen Conway-Welch

Henry Foster

Dr. Stanley Cohen served as professor of biochemistry at Vanderbilt University for 41 years, mentoring and educating graduate students, postdoctoral fellows and fellow faculty members.

Cohen received his PhD. degree from the University of Michigan before attending Washington University in St. Louis for his postdoctoral fellowship in the laboratory of Martin Kamen. There, he learned techniques using radioisotopes, a new technology at the time.

Also during this time, Dr. Victor Hamburger, an expert in zoology, enlisted Cohen to handle work in mouse embryology with Dr. Rita Levi-Montalcini. They would characterize what would be known as nerve growth factor. At the same time, Cohen isolated a substance known as epidermal growth factor (EGF).

When Cohen came to Vanderbilt in 1959, he continued work on the characterization of EGF and its receptor. Other groups discovered that mutations in the DNA of the receptor for EGF caused many kinds of cancer. Now, pharmaceutical companies have developed 87 medicines to treat many of these cancers.

Cohen’s work illustrated the importance of basic science research — knowledge for the sake of knowledge — in advancing clinical human treatment.

For his efforts, Cohen shared the 1986 Nobel Prize in Physiology or Medicine with Dr. Levi-Montalcini for the isolation of growth factors. He also was an American Cancer Society professor for his entire career, was elected into the National Academy of Sciences and received the National Medal of Science from then-President Ronald Reagan.

Cohen, a recipient of the Lasker Award (often referred to as the “American Nobel”), retired from Vanderbilt in 2000.

Born in Iowa, Colleen Conway-Welch earned a B.S. degree in nursing from Georgetown University in Washington, D.C., in 1965.

After next receiving her M.S. degree in nursing from the Catholic University of America, she studied nurse midwifery at Catholic Maternity Institute in Santa Fe, New Mexico.

Welch would earn a Ph.D. degree in nursing from New York University in 1973, after having served nationwide in numerous clinical positions including staff and charge nurse, parent-child nursing instructor and clinical nurse specialist.

Welch moved to Nashville in 1984 to join the Vanderbilt University School of Nursing as a professor and dean, eventually serving as the second-longest sitting dean of nursing in the United States .

While at Vanderbilt, Welch met and married the late entrepreneur Ted Welch, with the two to become one of the city’s most beloved couples. She began the university’s hybrid Bridge Program, through which college graduates complete 12 months of a “bridge” (accredited as a B.S.N. equivalent) before completing a 12-month master’s degree in nursing. She also began Vanderbilt’s nurse-midwifery major in the master’s program as well as the Vanderbilt University Medical Center’s nurse-midwifery service.

Welch was elected to what is now the National Academy of Medicine, a health-related advisory entity working with Congress. She was appointed to the advisory committee to the National Institute of Health and was appointed by then-President Ronald Reagan to the Presidential Commission on the Human Immunodeficiency Virus Epidemic.

President George H.W. Bush appointed Welch tothe Kennedy Center for the Arts and the Presidential Commission on Emergency Preparedness board.

An Arkansas native, Dr. Henry Foster graduated valedictorian of his high school class, earned a B.S. degree from Morehouse College in Atlanta and received his M.D. degree from the University of Arkansas in 1958, where he was the only AfricanAmerican admitted in his class of 96.

Foster went on to serve as a medical officer in the United States Air Force from 1959-61 and then completed his residency training in surgery in Massachusetts and in obstetrics and gynecology at Meharry Medical College.

From 1965-73, Foster served as chief of obstetrics and gynecology for Tuskegee Institute’s John Andrew Hospital. Despite the challenge of being the only OBGYN in a seven-county area, Foster and his team delivered more than 17,000 babies and performed approximately 1,200 major surgical procedures for an underserved population.

In 1973, Foster moved to Nashville to work in academia at both Meharry and Vanderbilt University.

Foster has served on numerous boards and task forces. With his staunch commitment to health care having led to his induction into the National Academy of Medicine (formally the Institute of Medicine).

Foster founded and directed Meharry’s “I Have a Future Program,” an initiative that noticeably reduced teen pregnancy among inner-city Nashville youth. For that work, then-President George H.W. Bush honored the program with one of the nation’s Thousand Points of Light Awards.

In 1993, the University of Arkansas awarded Foster an honorary doctorate degree, the first of what would be many. And in 1995, then-President Bill Clinton nominated Foster to serve as U.S. surgeon general.

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FEATURES

HALL OF FAME

Frank Groner

Paul E. Stanton Jr.

Tennessee HEALTH CARE

hall of fame 2015 inductees

The inaugural eight-member class, named in 2015, of the Tennessee Health Care Hall of Fame.

Thomas Frist Sr.

Frank Groner graduated from Baylor University in 1934 and then embarked upon a noteworthy 46year career as a health care executive.

The Texas native served as the chief executive officer of Southern Baptist Hospital in New Orleans before assuming the leadership of Memphis-based Baptist Memorial Hospital in 1946. Groner helped transform the hospital, which today ranks among the South’s top medical facilities.

During his career, Groner exhibited leadership recognized nationally and abroad. For example, he was selected as chairman of both the American College of Health Care Executives and the American Hospital Association. In addition, he received the Justin Ford Kimball award for his work with Blue Cross Blue Shield. In 1983, he was honored as a Baylor University distinguished alumnus and was, in 1988, a charter inductee of the Health Care Hall of Fame.

Groner endowed a professorship at Baylor and created the Frank S. Groner Fellowship in Health Administration at Baptist Memorial Health Care Corp. He established residencies and fellowships at Baptist Memorial in 1950. Because of his dedication, more than 70 health executives launched their careers, including former CEOs at Baylor Health Systems, Yale New Haven Medical Center, Baptist Hospitals of Kentucky, Carolinas Health System in Charlotte and the aforementioned Baptist Memorial Health Care Corp.

Of note, Groner is the only person to have received the top three national awards in health care: the Kimball Award in 1964, the Distinguished Service Award (from the American Hospital Association) in 1966 and the Gold Medal Award (from the American College of Hospital Administrators) in 1988.

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Born in Atlanta, Dr. Paul Stanton Jr. graduated with a bachelor’s degree in chemistry from Emory University in 1965.

Shortly after, he earned an M.D. degree from the Medical College of Georgia. With an internship, residency and fellowship in Florida, Georgia and Illinois, respectively, Stanton began his career as an attending physician at Atlanta’s Georgia Baptist Medical Center and spent the next 10 years as residency education program director and as professor and chief of surgery, among others, at various statewide facilities.

In 1985, Stanton relocated to Johnson City, Tennessee, and began a career in health care and education that would span more than 30 years.

Beginning as East Tennessee State University chief of vascular surgery and associate professor, then chair of the department of surgery, then professor and dean of medicine and vice president for health affairs, in 1997 he was named ETSU president.

Stanton was responsible for ETSU’s largest grant to date, $6 million from the Kellogg Foundation for Interdisciplinary Health Care Education. He also established the Gatton College of Pharmacy and oversaw the creation of 10 doctoral programs.

During his 15 years as university president, Stanton awarded more than 31,000 diplomas.

Stanton served on the Governor’s TennCare Committee on Graduate Medical Education, the Governor’s TennCare Roundtable and the Southern Regional Education Board. He is also the recipient of Business Tennessee’s “100 Most Powerful,” the Medical College of Georgia’s Distinguished Alumnus Award and the Johnson City-Jonesborough-Washington County Chamber of Commerce’s Hall of Fame designation.

Thomas Frist Jr.

Ernest Goodpasture

Jack Massey

Clayton McWhorter

David Satcher

Mildred Stahlman

Danny Thomas

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HALL OF FAME

FEATURES

The Event

The Tennessee Health Care Hall of Fame inducted its 2016 class at an October ceremony held at Belmont Universityâ&#x20AC;&#x2122;s Curb Event Center. Hosted by Susan Dentzer, the president and CEO of the Network for Excellence in Health Innovation, the second annual event honored a six-member class of pioneers who have contributed to Tennesseeâ&#x20AC;&#x2122;s health care community and who have encouraged future generations of health care professionals.

Courtesy of belmont university

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CHECKUP

TOUCHING BASE

touching base

Fast start

‘artificial intelligence will change health care as we know it in the move to value versus volume of care’ Dr. Jim Stefansic

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FULLY CAPITALIZED

Faros forges future with strong first year

Contessa preps for strong 2017 with funding in place

by william williams

by william williams

It has been a busy 2016 for Faros Healthcare.

Now, that intensity is about to increase for the Nashville-based health data analytics and artificial intelligence company.

After having added veteran industry executive David E. Young as its board chairman in October, Faros is prepping to land patents and is focused on expanding its customer base, which includes accountable care organizations and providers in gainsharing agreements.

The moves come as the fledgling company — which markets a predictive analytics platform for complex health treatments and bills itself as being able to improve outcomes while simultaneously cutting costs by 40 percent — was formally established a mere 10 months ago.

Dr. Jim Stefansic, Faros president, chief executive officer and co-founder with Dr. Casey Bennett, says progress is being made.

“Health care organizations are now collecting large quantities of data but are not effectively utilizing it to drive decision-making,” Stefansic says. “Faros’ technology supports care providers in making the best treatment decisions for a specific patient at the optimal cost.”

Specifically, Faros was launched out of Nashvillebased Centerstone Research Institute but acts as an independent company whose cloud-based AI engine integrates with existing electronic health records and population health software.

The platform was licensed from Centerstone, a nonprofit provider of community-based behavioral health and addiction services, and Indiana University Research and Technology Corp., a nonprofit agency that helps Indiana University bring discoveries and projects to market.

Stefansic says Faros has received funding (the amount and the investors’ identities are not being disclosed) and is evaluating additional funding options.

Faros maintains strong relationships with both Centerstone and IURTC, Stefansic says. For example, the aforementioned Bennett also serves as the company’s chief scientific officer and invented the analytics and artificial intelligence engine as a graduate student in Indiana University’s School of Informatics and Computing.

Bennett also served as a data architect, research fellow and data scientist at Centerstone, at which his contributions to analytics and data warehousing were nationally recognized, including in IBM’s Smarter Planet series.

“Artificial intelligence will change health care as we know it in the move to value versus volume of care,” he says. “Our technology will produce better outcomes and bend the cost curve.”

Contessa Health is poised to enjoy a robust 2017.

And that is noteworthy given the Midtown-based home hospitalization company recorded a strong 2016.

In October, Contessa announced it had raised $7 million from a group that includes three investment firms, including the Nashville Capital Network (NCN). That funding came after the company landed $3.5 million in December 2015, capital that will help it scale services built around bundled payments and delivered so as to minimize health care costs.

Leading the $7 million round was Noro-Moseley Partners of Atlanta, which was joined by NCN and Wisconsinbased Marshfield Clinic Health System, Contessa’s first partner. Existing investors BlueCross BlueShield Venture Partners, Martin Ventures and Sandbox Advantage Fund also chipped in.

Travis Messina, Contessa chief executive office and co-founder with David Coppeans, says the company is on very solid footing and not needing to pursue additional funding at this time.

“Given the increased focus on episodic risk arrangements and receptivity to our model, we are excited to close this financing so that we can build out the resources needed to capitalize on the numerous opportunities we have in front of us.”

The remainder of the year, Messina says, will be spent continuing to enhance the functionality of ContradoClaim and expanding the protocols of ContessaCare, the company’s proprietary clinical model through which it is reimbursed only in a prospective (i.e., a single payment for all providers of care) bundled payment.

“As to ContessaCare, we recently completed cardiac protocols,” he says. “This is particularly timely given the [Centers for Medicare and Medicaid Services] announcement to make select cardiac episodes of care mandatory.”

Messina says receptivity has been strong with ContradoClaim, which allows Contessa clients to administer prospective bundled payments without disrupting existing claims processing workflows. Via ContradoClaim, provider and payer partners process claims according to existing workflows, with Contessa managing the rest of the effort.

Messina says Contessa is prepped to finish the year strongly after having added several key employees. Likewise, preparations for 2017 are underway.

“We will continue to focus on building the best team possible,” he says, “so that we can successfully bring to market several new programs that we are in the midst of implementing.”

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11/9/16 3:09 PM

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Nashville Post speaker offers tips for using data to grow and improve business

More than 2.5 quintillion bytes of data are created every day.

And did you know that 90 percent of the entire world’s data has been generated in just the past three years?

It’s no wonder business leaders see tremendous opportunity in what we can euphemistically but earnestly refer to as BIG data. It’s also no surprise 62 percent report feeling overwhelmed by it.

What follows is advice from Alcott Marketing Science, a data-based marketing firm with experience in industries such as healthcare and financial services. Alcott’s founder, Jim Alcott, is a speaker at this year’s Nashville Post Vitals Healthcare Summit on Nov. 17.

Using data to understand customers Appending demographic data to customer data will paint a portrait of precisely who a business’ customers are.

For example, are the biggest spender’s empty nesters, or are they families with children at home? Where do they live? What are their hobbies?

What other brands do they support?

Using data to divide customers into segments is smart for a number of reasons. It offers the marketing, product, and experience teams a chance to tailor messaging in an effective and cost-efficient way. It also allows analytics teams an opportunity to determine which customers are most likely to purchase or take other steps in a customer journey.

Monetizing customer data “It can be tremendously valuable to mine the data you already have,” Alcott said. “Looking at your existing customer information is almost always an opportunity to further monetize your base.”

Customer data shows how much money a business’ consumers are spending on various product or service lines, when they’re spending it, and how often they spend. Carefully analyzing this data opens up opportunities for cross-selling other product lines, developing loyalty programs, and understanding seasonal marketing opportunities.

Locational data critical to success “Too often, companies think of their trade area in terms of specific counties or zip codes,” Alcott said. “Or in some cases, they will simply draw a radius around their location and call it a day.”

But data about traffic patterns, natural and man-made boundaries, competitor locations, and other factors will have a significant impact on convenience and trade area, he said.

For more information on how data can impact business decisions, visit the Alcott blog at Alcott.Marketing, or attend the Vitals Healthcare Summit on Nov. 17. Go to NashvillePost. com for details and RSVP.

Alcott Marketing Science leverages data to build and execute strategic marketing and business solutions.

For 25-plus years, founder Jim Alcott and his team of data scientists and marketing professionals have served clients in fields such as healthcare, banking, and education.

Website Alcott.Marketing Twitter @AlcottMarketing Email info@alcottmarketing.com Phone 615-905-9000 Offices Nashville, Tenn.

Portland, Ore.

SPECIALTIES Data-driven strategy Data-driven audience profiles and targeting Multi-platform, intuitive advertising campaigns Insightful creative Personalized campaign delivery Trackable, iterative analytics Automated, nurturing customer communication Measurable ROI for marketing Tools and accountability for sales teams Social responsibility The Alcott team distributes half the company’s annual profits to charitable, non-political causes aligned with employee passions and community needs.

11/9/16 9:48 AM

CHECKUP

DATA

WORKERS’ GROWING SHARE Consumers are continuing to feel more of the strain of rising costs. The share of people enrolled in a high-deductible plan has more than doubled since 2010, and nearly a quarter of people with such coverage now have deductibles of at least $2,000. People at companies with fewer than 200 employees are two and a half times more likely to have a deductible above $2,000.

DATA BANK

FADING EFFECTS

The research team at Hedgeye — which since this spring includes former Metro Council member Emily Evans, who also is a member of the advisory board of this magazine — have for more than a year built their investment thesis around the idea that the positive effects of the Affordable Care Act’s rollout are quickly diminishing. Here are a look at some of the statistics they’re pointing to.

More than 4 million people joined the ranks of the insured in 2015. That pushed the uninsured rate into single digits but it was less than half the number from 2014.

16.6% 16.3% 15.7% 15.4%

Share of covered workers with an annual deductible of $2,000 or more

Source: U.S. Census Bureau

9.1%

2015

2014

2013

2012

2011

2010

2010 20% 2011 28%

3-199 workers 200+ workers

3% 4% 5% 7%

2013 31%

13.3%

2009

2008

2007

2013...............................................20% 2014...............................................20% 2015...............................................24% 2016...............................................29%

2012 27% 10.4%

2006

2009................................................. 8% 2010...............................................13% 2011...............................................17% 2012...............................................19%

2009 16%

EBBING ENROLLEE WAVE

15.2% 14.7% 14.9%

Share of covered workers with a high-deductible health plan

8%

2014 34%

11%

2015 36%

12%

2016 41%

16%

Source: Kaiser Family Foundation

NOT AS HUNGRY FOR HELP Starting in the spring of 2014, health care employers ramped up hiring quickly to cope with the influx of newly insured patients. Hedgeye’s crunching of the numbers on a rolling 12-month basis shows the trend peaked this past March.

On a recent conference call, Managing Director Tom Tobin said, “We are on the last months of this growth phase.”

500 400 300 200 100

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DATA

CHECKUP

Addiction in the workplace affects more than your bottom line

PAYING UP From May 2012 to May 2015, the average hourly wage for U.S. workers rose 5.5 percent to $23.23. The health care sector topped that pace by 30 basis points but the gains haven’t been at all uniform.

All health care practitioners and technical occupations

8,021,800 Jobs

$37.40

Hourly wage

Home health aides

820,630 Jobs

$11.00

Hourly wage

+4.9% +5.7% -2.3% +4.9% Nurse practitioners

136,060 Jobs

Increased Injuries and accident rates Higher absenteeism and turnover Loss of productivity and efficiency

Nursing assistants

$48.68

Hourly wage

1,420,570 Jobs

$12.89

Hourly wage

+28.6% +10.7% 0.0% +4.6% Registered nurses

Pediatricians

28,660 Jobs

$80.07

Hourly wage

2,745,910 Jobs

$34.14

Hourly wage

-6.2% +9.3% +3.1% +4.5% Pharmacists

Psychiatrists

24,060 Jobs

$93.12

Hourly wage

295,620 Jobs

$57.34

Hourly wage

-0.6% +9.1% +5.0% +3.7% Physician assistants

98,470 Jobs

Family practitioners

$47.73

Hourly wage

127,430 Jobs

$92.36

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Substance Use Assessment Pre-Treatment Consulting Sobriety Coaching Family Support Services

Hourly wage

+17.7% +7.4% +15.8% +3.7% Source: Kaiser Family Foundation

This is not the bottom.

This is the beginning.

615.208.6671 HELP@MusicCityInterventions.com www.musiccityinterventions.com 11/9/16 3:12 3:11 PM

CHECKUP THREE QUESTIONS

David Jarrard Jarrard Phillips Cate & Hancock

David Jarrard and his partners launched their firm more than a decade ago on the idea that important health care organizations live in “a dynamic political environment that savvy leaders use to their advantage and others ignore at their peril.”

Since then, the changes in health care have come thicker and faster. Here, Jarrard talks about how leaders can do more than cope with them.

Why is it important that health systems take a political approach to communications?

During times of great transformation — which certainly defines health care today — politically smart communications are a fundamental element of successful change management. They are not deployed merely to describe changes underway as dictated by internal or external forces. Instead, they shape the change itself and facilitate its reception to the people who can make or break its success.

As in winning political campaigns, leaders present their constituents a compelling vision and clear action that rallies support. It speaks to emotions and motivations. It lays out evidence and builds a case. It engages in true conversation. It drives to a win in which important “voters” cast ballots by their actions and attitudes. It’s a unified, comprehensive, all-out campaign.

Is it a lot of work? Absolutely.

However, to effectively transform health

systems with thousands of employees, massive infrastructures and decades of traditions, no lesser effort will suffice.

As health systems adapt to this trend, what are the most significant pain points these organizations face?

What health systems have done for 100 years will not work anymore. That’s painful. Health systems are grappling with a fear of the unknown and the untested. A new story is being written, a prospect that is simultaneously frightening and terribly exciting.

Who will write health care’s new story? Successful leaders are already on it. They are defining what health care will look like tomorrow and how care will be offered through them.

They will shape the future of care and accelerate the transformation of their organizations.

What do these big-idea changes and trends look like day to day when they’re being communicated?

It looks like an ongoing, smart conversation between people on a mission to make care better, relevant and sustainable.

It looks like everyone is in it together.

Practically, we see leaders engaging with their stakeholders in real dialog in the earliest stages of a change management effort. As they move through change, they relentlessly use a multitude of communications vehicles and consistently evaluate the data to determine what’s most successful. Through that work, true change is not a program or an initiative.

It’s a new definition of who they are and how they serve.

Daniel Meigs

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INSIGHT

Statute — and increased review of claims for reimbursement by an army of government contracted auditors. In addition, the Affordable Care Act added a new wrinkle to the False Claims Act, requiring health care providers and suppliers to investigate potential overpayments and report or repay identified overpayments within 60 days of learning of them or risk significant FCA liability.

In general, the penalties for noncompliance and the obligations to ensure and defend the integrity of all claims submitted for payment are higher than ever, and that has increased anxiety for physicians. Smaller physician group practices and solo practitioners, in particular, likely find it daunting to keep up.

Danielle Sloane

Q&A regulatory changes

‘The penalties for noncompliance … higher than ever’ Bass attorney Danielle Sloane sees challenges for health care officials by william williAMs

Danielle Sloane is a member with the Nashville office of Bass Berry & Sims. Her practice focuses on compliance, regulatory and operational matters; mergers, acquisitions and joint ventures, and government investigations.

Post Managing Editor William Williams chatted with Sloane specifically regarding changes to the health care industry’s “system of laws.”

What has changed related to fraud and abuse law?

The biggest change has been greater enforcement of existing laws — such as the Stark Law and the Anti-Kickback

How are changes in health care fraud and abuse laws affecting physicians?

Historically, fraud laws were focused on billing for services that were not rendered or where a physician was inappropriately incentivized in a way that jeopardized the independence of his or her clinical judgment. Today, audits, regulators and whistleblowers are increasingly holding health care providers and suppliers liable for the failure to meet any technical requirement, for example, a missing proof of delivery or lack of a signature. In the end, sloppy paperwork or poor recordkeeping can lead to significant liability, regardless of the necessity of the care provided. Moreover, there seems to be more willingness to second guess the medical judgment of physicians, particularly when documentation is lacking.

In response, physicians are spending much more time on paperwork and devoting more practice resources to billing and compliance teams. An alternative response for physicians is to sell their practice to a larger group or a hospital or partner with a management company to gain the capital and infrastructure necessary to keep up with the increasingly demanding regulatory environment, as well as the data collection and reporting that are increasingly tied to payments.

What about the Stark Law and the Sunshine Act? Put simply, the Sunshine Act is about transparency. The Act (called “Open Payments” by CMS) requires most manufacturers of prescription drugs — or FDA-approved devices, biologicals or medical supplies covered by government health programs — to report to CMS (1) any and all transfers of value to a physician who is not an employee and (2) all physician ownership or investment. Beyond penalties for failing to accurately report information, the Sunshine Act did not create new prohibitions; rather, it provides public access to information about industry financial relationships with physicians.

The data can be used by government authorities and the public, including the media, to highlight, investigate and identify significant industry relationships.

While preserving physician clinical judgment is certainly a noble cause, so is innovation. Physician input remains important to these manufacturers — especially device makers — and, of course, physicians’ time is valuable, so there has been concern that the act may stifle physician input necessary for innovation. daniel meigs

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INSIGHT

Clare Moylan

Q&A troubled hospitals

Diminishing distress Healthcare Management’s Clare Moylan helps hospitals tackle turnarounds by linda bryant

Healthcare Management Partners moved its Philadelphia-based operations to The Gulch this year with an eye on growth and accessibility to clients.

And in steps Clare Moylan Moylan serves as managing director of the Nashville office for the company, which specializes in turnaround work with distressed hospitals and senior living facilities. At press time, she was working on the Chapter 11 bankruptcy of Oneida, Tennessee-based Pioneer Health Services.

The Post spoke with Moylan about the fine details of assisting small hospitals struggling to stay stable.

When you start working with a hospital, how much of the effort is truly financial vs. the processes in place that might be wasteful and impeding success?

In theory, you can have an efficient company that is over-

leveraged and only needs financial (debt) restructuring.

But in companies we work with, there are always huge opportunities for operational improvements. Typically, those operational deficiencies have driven the company to financial distress.

The first thing we do is assess the business to diagnose what the problems are and set up an action plan to turn things around. Management teams are often focused on the [profit and loss statement], whereas it’s a cash shortage that turns it into a crisis. So, in a crisis we focus on cash flow, which is real, instead of profitability, which can be misleading. The key is prioritizing your initiatives to make the most impact and pulling together the right team to implement them.

How often are a hospital’s troubles primarily clinical?

And do patients get a sense of when a hospital is not working well and, as such, take their business elsewhere?

Financial and clinical problems don’t always go hand in hand. Though in a struggling organization, it is much harder to keep your top clinical talent. In most distressed situations, the hospital’s troubles are not primarily clinical. The health care environment is changing rapidly and financial pressures, particularly on standalone providers, are extreme. There are many “links in the chain.” And one ERIC ENGLAND

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INSIGHT

broken link — such as a failed electronic health record installation or ineffective billing and collections processes — can bring the organization to its knees.

Patients certainly “vote with their feet.” That’s why communication and transparency is such an important part of what we do. The community — and certainly hospital staff and physicians — generally have a strong interest in seeing their local hospital do well. We come in and lay out our findings because we need everyone to understand what the issues are and help work together towards their resolution. Building up trust between different stakeholders is critical to putting the hospital back on track and improving financial and clinical performance.

You have worked with various rural hospitals. How different are the problems at a struggling rural hospital compared to those at an urban facility?

Rural hospitals face several issues that many urban facilities avoid. Rural populations are declining as young people migrate to cities, which means the local hospital’s market is declining. This is somewhat offset by an aging rural population and the higher use rates of health care in those over 65. Nonetheless, [health care] markets in general, are trending away from rural areas.

This has a serious impact on the talent pool, too. The recruitment and retention of experts needed — for example, physicians, nurses, IT techs, billing specialists and executive management — is a real challenge in rural areas. The younger generation of newly qualified doctors do not tend to like the idea of being a sole practitioner in their specialty area, which historically was the way things were done. Rural hospitals need to assess opportunities for some type of clinical integration with larger hospital systems in order to address these staffing challenges.

How much of a share of Healthcare Management Partners’ revenues are from its financial advisory and expert witnesses services?

It fluctuates year to year. When we get a litigation support job, they tend to be large, complex cases. Scott Phillips is our guru in that department. This year we worked on a very large case where a hospital system claimed damages against a national health insurer for being locked out of network for over 20 years. We calculated damages of over $600 million and the case settled before going to trial. So this year, the litigation work makes up about 25 percent of revenue. Financial advisory is usually less than 20 percent, and the majority of our work is in turnaround, or chief restructuring officer, engagements.

You offer a proprietary data analytics service called HMP Metrics. Thoughts?

HMP Metrics is a data warehouse of the HCRIS cost reports filed by every Medicare-certified hospital in the country. We have data for each quarter from 2015 going back to 1996, so it’s a monster on the server. The most powerful use of this data is in benchmarking and trending key operational metrics. It very quickly points us to where opportunities lie. We rely heavily on this data for our expert testimony work, and it is also used by private equity firms and banks to source

opportunities and conduct due diligence.

In addition, HMP Metrics contains the hospital Medicare claims data (MedPAR) for several states, which enables us to run patient migration studies showing where patients in a certain market are choosing to go for their hospital care. Outmigration of patients (i.e., patients choosing not to use their local hospital for care) is often an issue for many hospitals that we deal with.

Our director of HMP Metrics, Dr. Aaron Wells, is working diligently to relaunch the product on a new server and revamp the code so that it works faster. The most exciting part is the addition of data from other health care disciplines. We are working now on a test product that matches the Medicare hospital and skilled nursing facility claims data to trace patients through the care continuum. This establishes a level of market understanding that we haven’t seen before. And with the move toward bundled payments, this kind of analysis will be very powerful. We are in discussions with a clinical care group that can analyze the HMP Metrics data from a quality standpoint, which will bring a new angle to the analysis.

What might a turnaround process look like for a client?

I’ll give you an example of a Tennessee client we helped turn around this year. The company is a large provider of post-acute care services (skilled nursing, behavioral health, rehab, homecare, hospice, pharmacy, etc.) with over 4,000 employees and around $300 million annual revenue. When we first looked at the company, it was on the verge of bankruptcy with only eight days’ cash on hand and in default on loan covenants. We were engaged to conduct an assessment and develop a turnaround plan. In an unprecedented move, the company’s board unanimously voted to support our recommendation to replace the entire executive team.

We needed to send a message to the organization that the culture was really changing, and it was the right decision. We brought in a new CEO (Bruce Buchanan) and CFO (Derek Pierce), and I was project director. I later took the role of the head of home health and hospice. Within a matter of weeks, we identified necessary staff cuts and implemented them quickly. Then we could reassure the rest of the staff that they were the “go forward” team.

In this case, we made no significant cuts at the facilities, but there was huge overspend on overhead. We pulled together the leadership of every department and strategized together about the key areas of dysfunction. They worked in inter-disciplinary teams to develop initiatives. Some of these people didn’t know each other’s names — such silos had built up over time. We encouraged cooperation and empowered leaders to “right their own ship.” Many had just been waiting to be told what to do, but we encouraged them to figure out their own solutions and become leaders.

After getting through the cash crunch, operations quickly turned around and the company went from (earnings before interest, tax, depreciation and amortization ) of $11 million in the year before we arrived (2014) to EBITDA of $50 million and 83 days cash on hand in 2015.

In the meantime (and into 2016), we refinanced the distressed debt with a new lender and, at the end of our engagement, transitioned to a new management team.

‘In most distressed situations, the hospital’s troubles are not primarily clinical’ Clare Moylan

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CHECKUP

BUILD

ON TOP OF THINGS Vanderbilt Children’s Hospital undergoes high-tech addition at highest level

Vanderbilt University Medical Center officials have enlisted New York-based Blair + MUI Architects to handle design of what will be a four-story addition to the existing Monroe Carell Jr. Children’s Hospital at Vanderbilt structure. The Nashville office of Turner Construction is constructing the addition, which will require specialized building methods given the unusual nature of the project.

Patient rooms will serve critically ill children but offer the flexibility to be re-configured to maximize the safety and comfort of any type patient.

The work stations (sometimes called “nurses stations”) will have access to an on-site telemedicine center. With its high-tech communications equipment, the center will enable the hospital’s physicians to connect with patients and referring physicians worldwide.

courtesy of Blair + Mui Dowd Architects

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BUILD

MAKING MEDICAL SPACE MATTER

Healthcare Realty completes major Midtown project

This image shows the lobby of the new-look structure, for which an expanded 10-operating room ambulatory surgery center will be relocated to the top floor. Also, Elite Sports Medicine and Orthopaedic Center will operate from expanded offices in the facility.Â

Nashville-based Healthcare Realty will soon unveil its new medical office building and a renovated adjacent building, with the two acting as one structure and called Midtown Medical Plaza I and II. The effort also includes a new 640-space parking garage. With a project value of about $50 million, the buildings are located at 21st Avenue, Church Street and Hayes Street in Midtown. The tenant roster includes entities involved in oncology, infusion services, imaging, orthopedics, ENT, colorectal, plastic surgery and general surgery.

With spacious and energy efficient hallways, the reinvented Midtown Medical Plaza I and II will be home to an MPower Performance Institute facility to feature high-tech offerings and an indoor/outdoor sports turf area.

ERIC ENGLAND

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FEATURES

REFORM

An End to Malpractice?

Legislative push seeks to quash patients’ ability to sue regarding medical mistakes

by Cari Wade Gervin

‘We’re practicing too much medicine in courtrooms and not in our hospitals’ Sen. Jack Johnson

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Health insurance premiums are skyrocketing in Tennessee, but one organization may have a partial solution — end medical malpractice lawsuits.

Entirely.

January will mark the second time Alpharetta, Georgia-based nonprofit advocacy group Patients for Fair Compensation will introduce legislation in Tennessee (via sponsors Sen. Jack Johnson and Rep. Glen Casada, both Williamson County Republicans) to ban malpractice lawsuits, both minor and major.

“We’ve got a health care system from an affordability standpoint that’s just unsustainable,” says Wayne Oliver, PFC executive director. “It’s time for some kind of drastic action.”

Oliver’s plan would create a patients’ compensation system for those who feel they had received injurious medical treatment. Instead of filing a lawsuit, a patient would apply for compensation based upon his or her injuries.

“The existence of the litigation system causes doctors to do some irrational things they know are not necessarily in their patients’ best interests,” Oliver says. “They know [the things] add no diagnostic value to the patients and are simply ordered to protect from the potential of being sued.”

Oliver cites a Gallup study noting one in four health care dollars is spent on “defensive” medicine, estimating it costs the U.S. health care system $650 billion annually. Remove the threat of malpractice, he says, and you eliminate that unnecessary spending, while minimizing insurance costs.

Modeled after worker’s compensation and not dissimilar to arbitration panels, the plan is similar to those used in other countries, Oliver says. Compensation claims would be funded by a pool of annual fees from every state physician.

Oliver says a licensed physician unconnected to the case would review a patient’s injury claim to assess sufficient evidence to move forward, at which point “three physicians in the same specialty practice” — i.e., three orthopedists if the patient was filing over a mishap during hip surgery — would then study the redacted case file and determine if the claim is legitimate and, if so, the payout.

However, according to the Johnson and Casada legislation (called the Insurance Costs Reduction Act ), an administrative law judge would make that first decision.

That judge would be appointed by a board overseeing the

entire patients’ compensation system (which would itself fall under the aegis of the Tennessee Department of Health). Appointed by the governor, the lieutenant governor and the speaker of the House, the 11-person board would consist of at least three physicians, two patient advocates, one business executive, one hospital administrator, one accountant and one lawyer — not exactly neutral oversight.

Moreover, the legislation states, “If the judge determines that the medical treatment conformed to national practice standards for the care and treatment of patients, then the application shall be dismissed and the practitioner shall not be held responsible for the applicant’s injury.”

And if a patient is eventually found worthy of compensation, it “shall be offset by any past and future collateral source payments” — i.e., any insurance or disability payments.

Still, Johnson says that whatever the wording, the bill is needed.

“We’re practicing too much medicine in courtrooms and not in our hospitals,” says Johnson, who believes he has the votes to win Senate approval.

But House Democratic Caucus Chair Rep. Mike Stewart says the legislation — PFC is also pushing similar measures in Florida and Georgia — is a terrible idea.

“Sadly, I don’t anymore make predictions about whether really bad bills will progress because, unfortunately, we’ve seen under the Republican supermajority, they often do,” Stewart says. “But … this particular bill — which is designed to take away the right to trial by jury — is unconstitutional under the Tennessee constitution. The founders of this state, the makers of our constitution, had a very strong belief that the citizens should ultimately make these important decisions. So the right to a jury trial is extremely strong.”

Johnson says he has had preliminary discussions with Attorney General Herb Slatery’s office about the legislation. If it begins to advance, he will ask for an official opinion as to its constitutionality.

Understandably, the legal community opposes the legislation. But last session, the Tennessee Medical Association also raised concerns about it. During a November 2015 Senate Commerce Committee hearing, TMA general counsel Yarnell Beatty questioned PFC’s statistics and called the system “speculative.”

Reached by email before press time, Beatty says he still opposes the legislation.

“Tennesseans do not want or need an unproven healthcare liability system,” he says. “Our present system is working well and is fair and transparent. Tennessee has significantly reduced frivolous lawsuits while maintaining accountability for providers who are negligent.

Throwing out our current system in favor of an untried and unproven experiment will be costly and cause undue stress on our medical system, both for patients and providers. And there is no guarantee of cost savings or any other benefits.”

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FEATURES

INCUBATE XXXXX

Senior-level innovation

Brookdale looks to incubate new ideas via entrepreneur program

by Caroline Leland

When 30-year-old entrepreneur Mike Eidsaune — his health care-oriented technology product in tow — stepped out of his car for a week in residence at a Brookdale Senior Living community in Ohio, he wasn’t sure what to expect.

At the time, that product was a communication tool for families with a close relative in a senior living community — and not designed for use by the seniors themselves. After a week living and interacting with people five decades older than he, Eidsaune realized his company was going to change fundamentally.

“We did change our name about three months after that stay, and that name change was in line with the new release of the application we put out,” Eidsaune says. “A lot of the changes we made were as a result of my stay at Brookdale.”

Eidsaune’s company, Carely (formerly known as Care Monster), now includes assisted living residents in its user base. In the year since Eidsaune’s stay at Brookdale, Carely has grown from two to six employees and raised $600,000 in angel funding.

“All of our growth is a result of that week in residence,” says Eidsaune, who serves as Carely CEO and co-founder.

Andrew Smith, Brookdale director of strategy and innovation, believes that openness to new technology is key for senior wellbeing.

When Brentwood-based Brookdale — which bills itself as the nation’s largest senior-living company — doubled in size after a merger in 2014, the company’s leaders realized their need to emphasize innovation.

“As the leader in the industry, we saw how important it would be to stay connected to and to continue to support entrepreneurs in the industry,” Smith says.

With input from Eidsaune, who was Brookdale’s first entrepreneur in residence, Brookdale set out to build a program to include seniors in the innovation process for products its facilities might use.

After an online application and an interview with Brookdale staff, selected entrepreneurs win full room and board at a Brookdale living facility for five consecutive days. More than 50 entrepreneurs have applied for the program since it was announced publicly this year.

And as of October, Brookdale has hosted seven entrepreneurs in communities throughout the country. The products represented range from full-body driers to virtual reality programs to adaptive clothing. Because these companies are still developing their products, Brookdale has yet to adopt any of the technologies iterated through the Entrepreneur in Residence program.

Entrepreneur Dayle Rodriguez, whose company Syntab enables communication between devices like smartphones and TVs to connect people across generations, was the Entrepreneur in Residence at a Brookdale community in Torrance, California, in mid-October. He says he was happy to see that age was not a limiting factor for how technologically savvy someone might be. At Brookdale, he met a 97-year-old who loved — and was skilled at using — Apple products.

“Syntab wasn’t really for him,” says Rodriguez, adding that the week in residence showed him the importance of pushing the envelope technologically while remaining user-friendly for seniors without a technology background. courtesy of brookdale

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FEATURES

Brookdale, aging 2.0 partner to aid seniors Making the lives of senior adults more manageable is a noble goal, one that Aging 2.0 is trying to achieve.

The San Francisco-based company brands itself as “a global innovation network on a mission to accelerate innovation to improve the lives of older adults around the world … through community, events, startup programs and content.”

Now four years in operation, Aging 2.0 comprises more than 40 volunteerrun chapters and has hosted more than 300 events. Its efforts have caught the attention of Brentwood-based Brookdale Senior Living, which serves as a sponsor to the company.

Andrew Smith, Brookdale director of strategy and innovation, is working with Aging 2.0 affiliates to find startup partners, host panels and continue facilitating innovation with input from seniors.

“It’s important to design products and services with seniors, not [simply] for seniors,” Smith says, noting Aging 2.0 does just that.

For Brookdale’s Entrepreneur in Residence program (which enables those companies seeking innovative ways for the aging to live side-by-side with seniors by moving into a Brookdale community for five days), Smith says Aging 2.0 is helping “drive innovation” within the senior care space.

“Aging 2.0 has been an important part of this movement, raising awareness for the category and bringing together passionate people from all areas to collaborate and partner,” Smith wrote in a guest blog for Aging 2.0.

Smith says Brookdale is “only a piece” in the effort but is optimistic an “immense impact” looms.

“Hopefully the Entrepreneur in Residence program can be a valuable resource for those brave, passionate and crazy entrepreneurs out there trying to help us achieve our goal of bringing new life to senior living,” he wrote. > William Williams

“I think the important thing is to not be patronizing when we develop these products, to not dumb things down,” he says.

Smith says that residents of Brookdale facilities are excited by new technology.

“People aren’t afraid,” he says. “They love having the first look.”

Brookdale Kettering (Ohio) resident Mary Lou Busch says the program hasn’t been as exciting for her because she’s been using a computer for over 30 years.

“I’m an unusual person,” she says. “I’m used to using technology. I do see the point for a place like Brookdale. It gave us a chance to see some new technology and to see what people are thinking about for the future.”

Brookdale isn’t the only senior living company prioritizing technological innovations. The company is a key sponsor of the four-year-old company Aging 2.0, which brands itself as “a global innovation network on a mission to accelerate innovation to improve the lives of older adults around the world … through community, events, startup programs and content.”

Aging 2.0 comprises more than 40 volunteer-run chapters and has hosted more than 300 events. Smith says Brookdale works with Aging 2.0 affiliates to find startup partners, host panels and continue facilitating innovation with input from seniors.

“You hear it in industry conferences, in the language that we’ve been saying for a couple years: It’s important to design products and services with seniors, not [simply] for seniors.”

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2017 H E A L T HCARE INNOV ATION C OL L A B ORATION C E L E B RATION

AUGUST 2017 HEAL THF U R T H E R . C O M

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FACING THE TRUTH

Some sobering news about the cost of addiction to your business by ryan cain

Many business professionals seem to have it all together.

For a time, I was no exception.

As president and CEO of a medical device distributorship at 34 years old, I was already an expert in molding myself into who my audience needed me to be. On the surface, who could argue? I had more money than most of my friends. I ran a team of several dozen people whose job security rested on my shoulders. I had a nice car, a comfortable house and a beautiful family. I lived the life that society demands.

However, that was nothing more than an illusion. In reality, my life was a series of silos designed to let me be whom I needed to be to get what I wanted from others. I had my employees who knew me as the boss who worked hard/played hard. I had my vendors who knew me as a professional, wellspoken, over-achiever who could make my business partners money. I had my family who knew me as a hard worker willing to work long hours to help secure our financial well-being.

And I had my secret silos. I had a group of friends who drank alcohol like me. They stayed separate from my other silos. I had a group of friends who occasionally participated in illicit drug use like me. I kept those friends sepa-

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rate from everyone. My life was spent not working towards growing a business or raising a family but, rather, managing to keep all these silos functioning to support me while keeping knowledge of what I was doing silent.

What was real was my addiction to drugs and alcohol. I used opiate pain medication or alcohol every day for almost 17 years. It ran my life despite my best efforts to manage it — and hide it from everyone. When I would be confronted by a friend or loved one concerned with my use, I could always deflect by saying, “How could I have a problem? Look at what I have? Look at how successful I am?”

The truth is I did have a problem. But as many executives and business professionals know, there are various reasons why we cannot face this truth. First, we typically are high-functioning over-achievers. We aren’t the homeless, living-on-the-street types. We are VPs, sales representatives, marketing managers, C-suite executives. We still have our cars, our houses and our families. For now.

Second, we are “too busy” with our careers to shut down for 30 minutes, let alone 30 days, to seek help. How can the world I know function without me? Third, and most important, we cannot accept the fact that perhaps we are not running the show. Many of us have been successful because we were the go-getters, the win-at-anycost types. Just hit the numbers, make the quota and show a profit. Nothing else matters. The hardest thing for me to admit was that I had a problem. But until I was willing to do that, I could not find a solution.

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TREAT

My addiction cost me dearly. I was arrested. I lost my wife and children. I lost my best employees. I lost my friends. But there was also a significant cost to my business. I faced several lawsuits, had high turnover and had generally poor production due to my absenteeism as a result of drugs and alcohol.

Since 2012, I have educated myself. I have learned that I am not alone in this scenario. Many of us are “functioning” addicts or alcoholics; and executive-level positions are a perfect hiding place for people like me where time is easily explained away, opportunities for secrets are everywhere, and the depths of pain are covered up by titles, money and power.

The stats support much of my personal story: According to the Office of the National Drug Control Policy (ONDCP), 67 percent of drug users are full-time employees. They aren’t the homeless. They are your co-workers, your employees or your VPs. The stats say one out of every 12 of your employees uses illicit drugs every month.

With alcohol, the frequency of use and abuse is even higher. According to NCAAD.org, 24 percent of all employees report having used alcohol during the workday within the past year. WhiteHouse.gov estimates that 70 percent of the costs of alcohol abuse are due to loss of productivity in the workplace, amounting to nearly $120 billion in costs annually.

For people who may have a problem, there are warning signs that can be spotted at work. Depression, irritability, mood swings, absenteeism and turnover are all

clues. According to the ONDCP, addicts and alcoholics are twice as likely to miss work compared to those who do not use. They are also twice as likely to have undergone multiple job changes within the last 12 months. Easier to spot are other indicators such as office holiday party behavior, smelling alcohol on a person or neglecting responsibilities at work.

But what can you do to help someone you are concerned about? Employers can serve an important role offering workers options to face the problem and serving as a place to turn for help. A 30-day visit to a treatment center may be daunting to some. Inpatient treatment is always an option, but it is not the only option. There are other available treatment modalities that allow employees to continue a relatively normal work schedule while simultaneously treating their substance use issues.

Outpatient treatment, sober coaching, education, awareness and prevention are tools that can help mitigate these habits into something treatable. Too often we wait until the inevitable “bottom” hits. Sometimes employees need sober companions, detox, drug testing or clinical therapy. If you are concerned for yourself or others within your organization, take action. Say something to offer help and guidance. An intervention with someone suspected of having a problem should be done with compassion and care. They need to know you care about them too much to underreact to the situation. Help can come in many forms. But the first step is to address the problem so that you can work towards a solution.

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Ryan Cain is a co-founder of Music City Interventions (musiccityinterventions.com).

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11/9/16 3:23 3:19 PM

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‘Simple nudge that makes a big difference’

MissionPoint CEO talks progress, ponders new partners and payment methods

‘you’ll see more and more companies like ours in the landscape.’

Jason Dinger

With health care spending expected to continue growing faster than the economy, the pressure on providers to improve their quality and cost efficiency is stronger than ever and still intensifying.

Jason Dinger, CEO of MissionPoint since the organization’s launch in 2011, knows this better than most in Tennessee. Dinger leads an accountable care organization that started under the umbrella of the local Saint Thomas Health system and now operates as a subsidiary of parent company Ascension. MissionPoint serves more than 250,000 members (90,000 of them in Nashville) and manages $1.5 billion in health care spending.

Post contributing writer Caroline Leland sat down recently with Dinger to hear his take on population health management and the evolution of health care in Nashville and nationally.

How do you define a population health management organization? How does it differ from a more conventional model?

Population health management is managing health care needs for a defined set of people. Typically that defined set is either employees and beneficiaries of a given company, or … members for a payer. So we’re essentially helping improve the health outcomes for a large population of people, and those populations are defined by our clients — whether a payer or employer.

How has your influence helped shape the trajectory of MissionPoint?

[Our] success is entirely due to our ability to listen to the needs of the people we serve and to our team members who constantly innovate to meet those people’s needs. We are in a new sector of health care that continues to grow and evolve quickly. We’ve been successful because we listen to a lot of the non-clinical needs that people have that prove to be barriers to their health care — whether that’s how you get to the doctor’s office or who cares for you at home.

How do you respond to those non-clinical needs?

We have a group of associates, nurses, social workers and others who are visiting people in the hospital; they’re do-

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ing health visits; they’re meeting with family members; and they’re developing plans of care for people to really remove the barriers they’ve had for getting better.

How common is this type of holistic approach?

Traditionally, companies like ours have not existed because we haven’t bitten into the pay-per-service world that dominates health care. But as we partner with providers and others to take on risk [to address these] populations, you’ll see more and more companies like ours in the landscape.

Is MissionPoint the only company of its kind in Nashville?

As far as I know, there’s nobody else who’s taking on broad populations and all of their needs. I think you will see companies that focus on really discrete populations.

Aspire Health will do what we do for folks in need of palliative care. So we’ll partner with somebody like Aspire to meet those specific needs for people in our population.

Who are your main customers?

We manage the health care needs for self-insured employers, Medicare Advantage, Medicaid, Medicare feefor-service… It’s a wide array. We’re in eight markets throughout the country, nine starting in January.

How did your previous experiences shape your vision for MissionPoint?

My first job in health care was as a hospital administrator in rural Zimbabwe. While we were taking care of acute needs of that population, I really began to understand how the wider ecosystem affects people’s health on a dayto-day basis. So in many ways, MissionPoint is going back to that first body of work in trying to [remove] all the barriers that may be creating these acute conditions that people are trying to manage.

What exactly does it mean to “localize health system delivery?” What are the challenges and solutions you’re researching toward that end, and how are they relevant to MissionPoint?

There has always been an emphasis in the health care system to standardize across diagnoses. So we think about people like a condition in many ways: just a heart failure, COPD (chronic obstructive pulmonary disease) or pneumonia. On a micro scale, we’re localizing issues that are going to impact people’s health care choices and treatments.

If you don’t have a sidewalk outside your house, you’re not going to walk 10,000 steps, as an example. If you’re reliant on an hourly wage worker to get you to the doctor’s office, there’s a good chance you won’t make it to the doctor’s office. So part of what we’re doing is identifying micro indicators that are needing to be managed to help improve the health outcomes for a population of people.

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Does MissionPoint’s work spill into city planning or urban design?

We’re just getting started on the environmental side. What’s exciting about the work we do is that the longer we do it and the more interactions we have with members, the more patterns and trends we see. As we look to the next few years, we’re just going to get smarter and smarter about those environmental factors that right now are not obvious but will become clear in helping solve people’s long-term issues.

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What are examples of a challenge that you’ve researched and a solution you’ve designed?

Early on we found that we had a group of children that had filled their asthma medication prescription but were still presenting to the ER for an asthma attack, which just didn’t make a lot of sense. When we engaged with the families, it turned out that the little plastic spacer for their asthma was more expensive than the medication. So to save money, they were buying the medicine, which makes sense, but they weren’t buying the plastic spacer — not realizing that the plastic spacer was actually the key to taking the right dosage and the ease of taking the dosage. So we just paid for the plastic spacer, and we saw their ER visits drop to almost zero.

So it seems like a lot of this work might be to identify the root causes of an issue.

Yeah, they don’t need to be complicated. We tend to believe that, in many cases, more complex solutions and more technology are the path to better health. Our experience has been that [often] it’s the simple nudge that makes a big difference.

What is the future of charitable health care in Nashville both in terms of payment structures and trickle-down policy?

As we continue to engage in this journey, we’re going to find that the effects of social determinants of health are going to become more and more predictive. Issues of housing, transportation and food security are going to start to inform the ways in which we can better improve outcomes and lower the cost of care. I think you’re going to see new participants in health care, some folks who we wouldn’t have traditionally associated with supporting health care improvement start to participate in health care. You’re going to start seeing new payment methods by the government and commercial payers who incentivize working on those social determinants of health.

What is the future of federal health care policy? What are your thoughts on the Affordable Care Act and its successes or failures?

The Affordable Care Act is with us and the new administration will need to be focused on short-term and long-term amendments to that act — which we would have quite honestly expected previous to now.

There will be changes to shore up the federal marketplace, as an example. I think they will preserve that, but there will be some material changes to risk pooling and other policy-driven supports to preserve the marketplace.

The advent of MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) will be the other sort of big policy wave in terms of changing the way physicians get paid and how they work more broadly with the wider health care ecosystem.

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A new model

Updated Saint Thomas leadership structure focuses on clinically integrated care via dyad

by Peter Chawaga

Karen Springer and Greg James

The health care industry is distinctive in its mission to simultaneously do good and do well. It is dedicated to the welfare of its patients as well as the interests of its shareholders. Traditionally, the dual tasks are segmented, with clinicians focused on care and administrators making business decisions.

Saint Thomas Health, one of Nashville’s largest health care players, is changing that segmentation as one of the first members of the massive Ascension Health network to have adopted the dyad model of management — which pairs a chief physician with an administrative leader.

The dyad model gives both physician and administrator equal responsibility for decision-making and has emerged as a way to better involve clinical interests in systems that could benefit from their input but traditionally have left them out.

The model is noteworthy given the size of Saint Thomas Health, which is part of the aforementioned Ascension network (a faith-based Missouri-headquartered national health system with more than 1,900 sites of care). In addition to its three hospitals in Nashville, STH counts six throughout Middle Tennessee, as well as laboratories, various specialty

centers and its physician organization, Saint Thomas Medical Partners, with 500-plus physicians across 92 sites.

The net patient service revenue for fiscal year 2015 was more than $1.2 billion, according to Fahad Tahir, CEO of Saint Thomas Medical Partners. Last year, the nine hospitals handled 235,000 emergency room visits, 63,000 discharges, 42,000 surgeries and 9,500 births, he says.

Dr. Terrence McWilliams, a clinical consultant for Healthcare Strategy Group, says the dyad structure evolved as the nature of health systems and their relationships with physicians did likewise.

“The traditional operations administrator approach did not historically garner significant employed physician engagement with organizational goals, objectives and initiatives,” McWilliams says. “Faltering relationships and systemic dysfunction were not uncommon.”

The thinking is that when physicians become more engaged throughout operations, the system as a whole benefits. McWilliams points to a 2014 Medical Group Management Association survey that indicates close collaboration between physicians and administrators can lead to more than 20 percent medical revenue per physician.

“Buy-in is accomplished as part of normal operations, rather than being separately sought and striven towards,” McWilliams says. “Trust in the system is enhanced and the group is able to move forward more effectively.”

Saint Thomas Health’s shift in its approach to leadership comes as it undergoes significant change. STH expanded considerably last year, buying four hospitals in the eastern part of its footprint from Capella Healthcare. daniel meigs

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Meanwhile, Ascension is implementing a major change in how its members administer care.

“Saint Thomas Health — and all of Ascension for that matter — is moving to a more integrated care delivery system focused on prevention, early detection and treatment,” says Karen Springer, STH president and CEO. Ascension found success implementing the dyad model at its local ministries. And with these changes at Saint Thomas Health, it decided to apply the structure there as well.

“More than ever before, we need clinical leaders at the table to ensure that every decision we make supports our commitment to compassionate, personalized care,” says Springer. “When it comes to executive leadership, I am a firm believer that gaining a different perspective can provide the advantage needed to successfully steer an organization through any amount of change.”

Springer credits Ascension’s dyad model expertise for Saint Thomas Health’s ability to implement the structure effectively. She also has relied on her experience as Saint Thomas Health’s former chief operating officer, though all she knew firsthand was the old way of doing things.

“I had to step back and shift perspectives to imagine how the position would operate in a new format,” she says of searching for candidates to fulfill the model. “It was beneficial to have the COO background as we looked for talent and skills that would blend into that position from a clinical standpoint.”

Earlier this year, Saint Thomas Health hired Dr. Greg James, a neurologist with decades of experience in private practice and on the medical staff of an Ascension branch in Alabama, to fill its newly created chief clinical officer position. It then hired Paul Cleckner, a former financial services executive and vice president of operations at LifePoint Health, to work alongside James as the COO. “Together, we have mutual oversight and accountability for all care delivery at Saint Thomas Health,” James says of his pairing with Cleckner. “As health care becomes increasingly complex, it is difficult for one leader to have the perspectives that he or she needs to make the best decisions.

The dyad’s mutual oversight brings that expertise together in a way that can be more synergistic. It has been said that in a dyad model, one plus one can equal more than two.”

James explains that the wider goal is to create more clinically integrated systems that go beyond a physician’s focus in the hospital to places like inpatient, outpatient, ambulatory and post-acute care.

“We now have dyads of physicians and administrative leaders at multiple levels of the organization, hospital facilities, medical group and service lines,” says James. “It gives both parties the support they need to lead with more confidence. Physicians feel empowered because they have more say in decisions, and administrators feel as though they now have the necessary clinical perspective and support to make better, less adversarial decisions.”

As the model is implemented up and down operations, Springer has seen positive changes throughout clinical and administrative staff.

“The physicians enjoy seeing their peers influence the hospital’s decisions and strategies,” she says. “Admin-

istrators are energized by the new perception that the clinical voice brings. I find that administrators may have thought they were inclusive and comprehensive all along.

But with the clinical voice, they realize pieces that were missing before.”

The structure has been employed at Saint Thomas Medical Partners, where Tahir is partnered with Dr. James Ward, its first chief medical officer.

“We bring together the skillset of our physician leaders with administrative staff to actively participate in every step of the decision-making process so that our decisions are truly collaborative, patient-centered and include the knowledge and expertise of our clinical experts,” Tahir says. “We’ve committed to integrate physicians and administrative staff more often and in more venues to ensure we make intentional decisions agreeable to the best knowledge and perspectives within the dyad.”

Now that physicians have a stronger voice, Saint Thomas Health believes its patients benefit. Those physicians now have oversight within the Saint Thomas Medical Partners board and are embedded in the STH Board of Directors. Tahir credits physician quality committees for the system’s recognition as a patient-centered medical home by the National Council on Quality Assurance.

“The future of health care increasingly invites coordination across the continuum of care and requires intentional collaboration,” Tahir says. “Who better to lead the charge than our physicians along with administrators together?”

There are concerns among some that dyad leadership adds another bureaucratic layer that hinders the ability to get things done quickly. It may also muddy the leadership hierarchy in the minds of employees.

“Of course, all management structures have inherent pros and cons,” says McWilliams. “In the dyad structure, what is gained in alignment and engagement may be offset by a seemingly slower decision-making process and potential ambiguity regarding authority.”

The Saint Thomas Health leaders did not encounter any such concerns, though Springer did acknowledge that adding new positions required some effective budgeting.

However, an expected return on investment will come as Saint Thomas Health is increasingly positioned to deliver high-quality care at a low cost to patients, she says.

“We continue to see growth,” James responds when asked how implementing the model has affected the bottom line. “We are creating even more bandwidth to lead important clinical initiatives around quality, patient safety and efficiency. It has been demonstrated time and again that great care not only creates better outcomes but also cost savings ... Furthermore, it should enable us to more easily partner with our affiliated physicians and providers to better meet the new challenges of valuebased health care payment models.”

The hope is that by establishing itself as an early adopter of the dyad model, Saint Thomas Health will become a frontrunner in the field.

“Without this type of model, it will be difficult to be a leader in health care at any point in the future,” says Springer.

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Primary choice

Joseph Webb

New clinic a key factor in Nashville General’s turnaround efforts

by Geert De Lombaerde

Joseph Webb has some milestones to point to in his twoyear tenure as CEO of Nashville General Hospital at Meharry, which he has admitted was in something of a crisis mode when he stepped in.

The city’s safety-net facility earlier this year received a strong rating from The Joint Commission, an accreditation body, bouncing back from a previous bad review. It has launched a hospitalist program to improve inpatient care. And it opened, in conjunction with Meharry Medical College, the Nashville Healthcare Center, a primary care clinic adjacent to its Albion Street location.

It hasn’t all been forward progress, though. Early this year, Webb and his team went before Metro Council to ask for $10 million in emergency funding — on top of

the $35 million subsidy already in the city’s budget. More than half of those extra funds were earmarked for paying overdue bills and fixing problems The Joint Commission had identified. And the hospital still collects only about one fifth of its patient charges.

Webb sees the Nashville Healthcare Center, which is staffed by three doctors as well as a team of nurses and a care coordinator, as a key player in growing that number — both by bringing in more insured patients and by lowering the cost of care over time because fewer patients will have acute (and expensive) episodes that require emergency room care. A big task for the clinic team is to connect patients to community resources such as trauma counseling or substance abuse services and streamline their care all along the spectrum.

“Everyone has experienced disjointed health care where you visit many health providers, and despite filling out medical forms with the same information multiple times, none really have a total view of your health or life,” says Dr. Frank Perry, an internal medicine physician at the clinic. “Nashville Healthcare Center seeks to correct this unfortunate reality.”

ERIC ENGLAND

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HOSPITALS

Alongside Meharry, where President James Hildreth has been in office since mid-2015, Webb wants to keep looking for ways to integrate the provision of various types of care being provided at their facilities. He doesn’t expect it to require big sums but instead be focused on using technology to eliminate barriers.

“We don’t need a lot of clunkiness in systems,” he says. “And we also don’t need to stop what we’re doing.”

Webb and his team are looking to prepare Nashville General for a world in which many health care services are reimbursed via bundled payments. The Centers for Medicare and Medicaid Services has a goal to have 50 percent of its payments account for alternative payment models by the end of 2018. That means the hospital’s chronic care model needs to be entrenched and efficient soon, a transition Webb likens to some aquatic acrobatics.

“You’re going down a river with one foot in one canoe and one in another,” he says. “All the while, you’re trying to decide when to lift that foot and move into the other canoe.”

Succeeding in a world of bundled payments, Webb says, will require leveraging relationships with providers of services that once were performed in a hospital or managed by a hospital. It will be key to keep such partners close and on the same page.

Down the road, such partnerships could result in the Nashville General-Meharry alliance setting up primary care sites beyond its current footprint. Webb says that’s at least a few years — and solid increases in patient volumes — away. There will be more milestones to come.

‘CliniCal experienCes should start muCh sooner’

In his investiture speech this past April, Meharry Medical College President James Hildreth outlined his vision for Meharry, touching on the patientcentered medical home model and technological changes and emphasizing that medical education must evolve to keep up. Here is an excerpt.

“We are now training students who are millennials, digital natives.

They engage the world and each other in ways that are very different from previous generations of students. And they will leave Meharry and practice their craft in a world that’s very different from previous generations.

Therefore, we must transform our curricula to account for the new realities.

Our pedagogy must be transformed to employ active and engaged learning strategies. We must embrace and use existing and emerging technologies to best effect such as social media, virtual reality and on-demand content and programs.

The century-old Flexner model of two years of basic science and followed by two years of clinical apprenticeship may well have run its course. Clinical experiences should start much sooner in the process perhaps as soon as day one of year one. And to the greatest extent possible, integration of basic science and clinical science should run throughout the course of medical school.

These same principles should apply to our dental students as well. Part of my vision for the college is to build a state-of-the-art learning center that includes flexible teaching spaces, virtual reality programs, simulation centers and innovation suites.”

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SMARTER SPORTS

new blood on board

This summer, Neighborhood Health CEO Mary Bufwack stepped down as chair of the board of Nashville General Hospital even though her term would have run through 2018. In moving aside, Bufwack said she wanted to help “usher in a new day” for the hospital.

The move was followed soon after by a fourmember expansion of the board to 11 and the appointment by Mayor Megan Barry of five new directors, most of them with direct health care experience. The newcomers include a banker, a college dean and the leader of one of the more prominent health care nonprofits in the area.

Here’s a rundown:

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• Harry Allen, a senior vice president at Pinnacle Financial Partners who joined the bank as part of its acquisition of Avenue Bank earlier this year. Before joining Avenue in 2011, he was vice president of finance and administration for Big Brothers Big Sisters of Middle Tennessee.

• Former CVS legal executive Sara Finley, who now runs Threshold Corporate Consulting.

• Richard Manson, CEO of Brentwood-based medical equipment supplier SourceMark and founding partner of downtown firm Manson Johnson Connor.

• Frank Stevenson, dean of students at Tennessee State University and a former deputy director for the Office of Minority Health for the Tennessee Department of Health.

• Joel Sullivan, the regional CEO of the Nashville area chapter of the American Red Cross. A former CFO of SouthTrust Bank of Tennessee in the 1990s, he has since specialized in helping young or struggling companies refine their vision and process improvement.

11/9/16 3:33 3:28 PM

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Smart. relevant. engaged.

2017 Issue Line-Up

leaders | spring Good leaders make a difference. They set the tone, develop talent and find ways to capitalize on opportunities. In this issue, we will share stories about leaders, from leaders and for leaders. The magazine also will include our popular InCharge list and spotlight our CEO of the Year.

techie | summer Middle Tennessee’s diverse technology sector — ranging from health care to music to retail — has been a driving force in the region’s recent successes. We’ll take stock of this thriving ecosystem full of bright ideas and bright people. This issue also will feature a look back at five years of our Most Powerful Women and will explore where they are now.

boom | fall The ongoing physical changes in Nashville’s landscape have been stunning — and there’s more to come.

But growth also continues to change the MSA’s outlying areas. Those factors have created new development questions to answer and challenges to meet. Boom will tackle these topics and more.

vitals | winter Insurance reform has definitively changed the game for most of the stakeholders in Nashville’s $39 billion health care sector. Vitals will take stock of that continuing evolution, shine a light on new trends and rising players and pulse industry leaders about how they’re preparing for what’s next.

210 12th Avenue South | Suite 100 Nashville, TN 37203 615.844.9410

Creating ConCentriC CirCles

Expanded facilities, programming an indication of high demand The number of freestanding emergency rooms throughout the country has roughly doubled since 2009, and you can hardly drive five blocks anymore without seeing an urgent care treatment center. Players big and small are investing heavily in these newer forms of health care access points. Among them is hospital leader HCA. On the company’s recent third-quarter earnings conference call, COO Sam Hazen outlined HCA’s approach to developing these facilities. Here are his thoughts: “We have evolved our freestanding emergency room strategy over the past five years. I think five years ago, we had maybe 12 to 15 freestanding emergency rooms.

We have 56 that are operational today. And I think that by the end of 2017 or early 2018, we’ll be north of 70.

With that particular strategy, we feel pretty good

about how we place those. We see the urgent care as an additional wrap-around, if you will, of our existing emergency room strategy, where there are certain components of certain markets where urgent care is the best answer because of either competitive hospital systems or other freestanding emergency rooms. And it provides a component that wraps around our freestanding emergency room strategy or our hospital strategy.

So there’s a blend of what the right facility is for the right situation. There’s population, there’s traffic, there’s location of other hospitals and other freestanding emergency rooms. And we go through this process of mapping out the market and determining what exactly is the right fit and how do we go about building this network further.

In some respects, we try to build an urgent care strategy around our emergency room strategy, which is built around our hospital strategy. So it’s almost these concentric circles of facilities that create a fairly broad HCA network in these large markets, allowing our patients to enter the system in different forms or different fashions — and also creating relatively favorable price points, if you will, for our payors where they can direct where they feel they need to direct but keep them in the HCA system.”

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Good leaders make a difference. They set the tone, develop talent and find ways to capitalize on opportunities. In this issue, we will share stories about leaders, from leaders and for leaders. The magazine also will include our popular In Charge list and spotlight our CEO of the Year.

ad close: february 15 materials due: february 17 in market: march For details and pricing, please contact your account executive or Jamie McPherson at 615.844.9410 or jmcpherson@southcomm.com

Look for the eighth annual In Charge invitation to land in your inbox late January 2017. sponsored by

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M&A

august Holden and Envision boss Bill Sanger first discuss the possibility of combining their companies, agreeing that the idea is worth exploring some more. A few weeks later, Sanger tells Holden he needs to call time until Envision has announced its third-quarter earnings in October. september 19 At their regularly scheduled meeting,

AmSurg directors review the financials of Envision, TeamHealth and Company B and give Holden and his team the green light to contact TeamHealth about a possible merger. late september / early october Representatives of AmSurg and TeamHealth begin meeting to discuss a potential deal. later in october Sanger and other senior Envision executives have preliminary conversations with advisors for TeamHealth, who say the company is open to talks but not until 2016. october 20 AmSurg goes public with its first offer to buy TeamHealth.

An inside look at the M&A dance

Before AmSurg, Envision inked big deal, they had to handle an on-and-off suitor Compiled by Geert De Lombaerde

Shareholders of AmSurg and Envision will vote Nov. 28 on their companies’ proposed multibillion dollar marriage. The seeds of the deal were sown in the summer of 2015, when the companies’ CEOs first met to talk about the potential for a deal. In the 10 months that followed, there were plenty of backs and forths and stops and starts. A number of those came in the form of TeamHealth, the Knoxville-based physician services company that itself had shown an appetite for deals by agreeing to buy hospitalist company IPC Healthcare for $1.6 billion.

AmSurg’s search for more physician services business led it to bid nearly $8 billion for TeamHealth in October. TeamHealth’s board rebuffed that offer and AmSurg walked away two weeks later. But that wasn’t the end of their M&A interactions — not by a long shot. Here, based on documents AmSurg and Envision filed this summer, is a glimpse into how TeamHealth walked onto and off the dance floor with both AmSurg and Envision several more times over the course of the ensuing months. july 2015 AmSurg President and CEO Chris Holden talks to Guggenheim investment bankers about the possibility of deals with Envision, TeamHealth or an unidentified Party B. Holden also talks to JPMorgan representatives about the possibility of joining forces with another national physician services company.

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After TeamHealth says no to both its original and revised offers, AmSurg withdraws its bid. november 4 TeamHealth representatives contact AmSurg to ask about preliminary due diligence on a potential transaction. A week later and after signing an nondisclosure agreement, representatives of the companies sit down to talk numbers and the rationale for a merger. november 19 TeamHealth tells AmSurg it is not interested in pursuing a deal at that time. january 5, 2016 After re-establishing contact in No-

vember, Sanger and Holden start talking about possible transaction structures, including an acquisition of one company by the other or a merger of equals. Looking to limit post-deal leverage, they lean toward the latter. january 7 Financial advisors to TeamHealth tell Barclays bankers the company wants an NDA with Envision to move along the companies’ discussions. january 9 The Envision Board convenes via phone to get an update on Sanger’s talks with TeamHealth, AmSurg and Company B. Executives with the latter had told Sanger they were interested in a deal only if it was in cash so directors decide to continue talks with only TeamHealth and AmSurg.

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January 11

Envision and TeamHealth sign an NDA. january 12 Directors and executives of both Envision and AmSurg, along with bankers from Barclays, Guggenheim and JPMorgan, meet in conjunction with the JPMorgan Healthcare Conference in San Francisco to discuss their businesses and reasons for bringing them together. january 19 Members of Envision’s leadership team meet with peers at TeamHealth in New York City to get an update on TeamHealth’s business and financial performance. january 21 The Envision board meets via phone for an update on the various talks and a deeper dive into the merits of teaming up with AmSurg. After discussing their “perception of the operational and strategic challenges facing TeamHealth,” they put a deal with that company to the side and direct Sanger to sign an NDA with AmSurg.

On the same day, TeamHealth contacts AmSurg to talk about a potential transaction and sends along financial information about its business and prospects. january 26 AmSurg executives meet with some of

their TeamHealth peers. AmSurg representatives also sign the Envision NDA before AmSurg and Envision execs sit down again to talk some more about their financials and the potential for a deal.

February 8

Representatives of TeamHealth contact AmSurg to propose a merger of the companies. february 9 Representatives of Envision and AmSurg

talk via phone with bankers from Barclays, Guggenheim and JPMorgan to talk about “the strategic opportunities afforded by a potential transaction,” including cross-selling and cost-saving options. february 11 The AmSurg Board meets to talk about

TeamHealth’s merger plan. They tell Holden to respond with a revised proposal. TeamHealth turns down that revised offer the next day. later in february Sanger and Holden have multiple

chats about ownership ratios in the future combined company. Holden’s first proposal has Envision share-

holders controlling 51 percent of the stock, while Sanger’s calls for a 55 percent share. The men agree to set up meetings for some of their directors. february 28 AmSurg executives talk by phone with senior leaders of both Envision and TeamHealth. march 16 AmSurg and Envision directors meet to go over governance and stock ownership questions. Envision lead independent director Michael Smith proposes a 54-46 split in favor of Envision. march 18 AmSurg sends another merger proposal to TeamHealth. march 20 In a phone call with Envision’s Smith, AmSurg Chairman Stephen Geringer counters the 54-46 proposal with a 53-47 split. march 22 Geringer, Smith, Sanger and Holden meet in Nashville to talk about the deal structure. They agree to take to their boards a proposal that, among other things, includes the 53-47 split. Three days later, the Envision board meets by phone and decides to move forward with a deal on that ratio. The companies’ advisors begin putting in place data rooms and other due diligence structures. march 30 Holden meets with a director of TeamHealth

to discuss his March 18 proposal. He leaves the meeting with a counterproposal. april 5 A TeamHealth representative emails Sanger to say the TeamHealth board fully backs talks about a transaction with Envision. april 6 Meeting again by phone, the Envision board tells Sanger and his team to stop talking for now to TeamHealth and to move forward with the AmSurg project.

EPILOGUE October 31 TeamHealth — now led by former LifePoint Health CFO Leif Murphy — announces it will sell itself for $6.1 billion to investment firm Blackstone. The deal is for $43.50 per share. AmSurg’s first offer a year earlier was for more than $71 per share.

april 6-7 At their regularly scheduled meeting, AmSurg directors hear from their bankers and attorneys about the state of things with TeamHealth and Envision.

They tell Holden to halt discussions with TeamHealth and enter into exclusive talks with Envision.

April 8

Envision and AmSurg sign an exclusivity agreement.

TeamHealth is now out of the picture. june 15 After extending their exclusivity agreement, En-

vision and AmSurg executives meet in New York to finalize the merger paperwork. The boards of both companies approve the joining and the companies tell the world.

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the chemicals emitted by the microbes in our body can affect the way drugs are deployed or food is digested, and even how a disease develops within the body. Now, 2017 may be the year the microbiome becomes one of health care’s most promising developments.

2. Diabetes drugs that reduce cardiovascular disease and death

Next year could be fruitful for type 2 diabetes sufferers, many of whom die from complications with cardiovascular disease. A couple of new diabetes medications promise to improve heart outcomes for type 2 diabetes patients, and experts think 2017 could provide even more progress on that front.

3. Cellular immunotherapy to treat leukemia and lymphomas

TEN FOR THE FUTURE

Cleveland Clinic’s annual medical innovations list includes microbiomes, diabetes drugs, ketamine, among others

by Stephen Elliott

The Cleveland Clinic recently asked more than 100 doctors and researchers to identify and rank the innovations they think will transform health care this year and into the future.

In a move that helped yield the Ohio-based academic hospital’s 11th annual list of the top 10 medical innovations (released in late October and outlined below), the experts narrowed a list of more than 200 nominations.

“The combinations that lead to innovation are much more unusual,” Cleveland Clinic Chief Wellness Officer Dr. Michael Roizen said in a release. “We used to develop a drug to treat a disease. Now, we’re combining devices, drugs and imagination.”

1. Using the microbiome to prevent, diagnose and treat disease

The microbiome is the collective term for the trillions of bacteria in our body, most of them in our gut. What researchers have discovered in the last 10 years — that our microbes have a mind of their own — may be the key to this innovation. According to the Cleveland Clinic list,

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Cellular immunotherapy could one day replace chemotherapy, along with its serious side effects, according to some forward-looking medical experts. In fact, one of the first cellular immunotherapies will hit the market soon.

The therapy removes a patient’s immune system T-cells and genetically reprograms them to seek and destroy tumor cells. They attack foreign cancer cells and can stick around to help prevent relapses. In 2017, the Food and Drug Administration will consider this pioneering treatment for one form of leukemia, which could lead to further approvals for other types of cancer.

4. Liquid biopsies to find circulating tumor DNA

Several companies are developing testing kits for a new blood test known as liquid biopsies, set to hit the market by year’s end with forecasted annual sales of $10 billion.

The new tests can uncover signs of actual DNA, or cellfree circulating tumor DNA (ctDNA), in the bloodstream, leading to easier discovery of cancer. Some medical experts think these liquid biopsies, as well as other new technologies, mean diagnosing and treating cancer could someday be as routine as a yearly visit to the doctor.

5. Automated car safety features and driverless capabilities

Car safety may not seem like a health care issue, but medical costs for auto accident victims last year totaled nearly $23 billion nationwide, and leaders in both Detroit and Silicon Valley are working on ways to virtually wipe out car crash injuries and their resultant hospital costs. Collision warning systems, drowsiness alerts and adaptive cruise control are among the early innovations, but more are on the way. In addition to the aforementioned automatic safety features, there is a larger goal — to remove human error from auto travel altogether. Driverless cars could eliminate accidents of carelessness, and experts say 2017 could be the “beginning of the end of car accidents.”

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6. Fast health care interoperability resources

With medical care providers using varying computer systems, it can be difficult for a patient’s multiple doctors or other practitioners to communicate with each other. The inefficiencies have been inherent in the medical world for years, but an ambitious program set to hit health care in 2017 could ease some of that frustration: Fast Healthcare Interoperability Resources is a new tool, soon to be released by an international committee called HL7, that will serve as interpreter between different systems and offices with different languages. In addition to making life easier for care providers, the new technology efficiencies could result in new data-driven health care solutions, experts say.

Perimeter Security.

Peace of Mind.

7. Ketamine for treatment-resistant depression

Medication doesn’t work for about one-third of depressed patients. But recent studies have found that ketamine — a drug commonly used for anesthesia that induces a trance-like state while offering pain relief and sedation — has favorable results with a majority of those treatment-resistant depression patients. Researchers are now studying ketamine as a possible blueprint for future depression treatments, and the FDA granted fast track status to the development of new medications based on the ketamine profile, according to the Cleveland Clinic. With nearly 43,000 suicides every year in the U.S., the medical community is hoping such new treatments could be the future of mental health.

8. 3-D visualization and augmented reality for surgery

Surgeons, particularly in ophthalmology and neurology, are already experimenting with 3D technology as a replacement for microscope oculars or other camera systems, which require surgeons to depend on their own eyes with their heads down. Experts say the added comfort and visual information provided by the new technology has led to easier and more efficient surgery.

Some software companies are also working on augmented-reality glasses to help medical students learn about human anatomy without cadavers.

9. Self-administered HPV test

For women in far-flung rural areas, or those without access to a doctor, a human papillomavirus diagnosis can easily be missed. Particular strains of HPV result in 99 percent of cervical cancer cases and, according to the Cleveland Clinic report, most sexually active women can contract HPV. But in 2017, doctors and health organizations are working to promote selfadministered HPV tests so that women can administer their own test, mail a sample to a lab and be alerted if dangerous strains of HPV are present.

10. Bio-absorbable stents

Metal coronary stents put into chests to prevent coronary artery blockage often stay in place forever and long after is necessary. This may hinder natural blood flow. Every year, 600,000 people have metal stents put into their arteries, which can also close blood clots. This past summer, the first bio-absorbable stent was approved in the United States. It can be absorbed by the body after two years, leaving behind a healthy natural artery. Experts estimate market potential will reach $2 billion in six years.

To learn more about these innovations, go to clevelandclinic.org.

Est. 1958 • rgfence.com The commercial fence ProfessionalsTm

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virsys12 Event In October, local technology integration firm Virsys12 hosted its third annual Nashville Healthcare Technology Forum, which focused on using the Salesforce platform to improve the scope and quality of health care delivery. The event at the Bridge Building downtown included a keynote from Nadeem Ahmed, Salesforce senior area vice president of health care and life sciences. His talk focused on the need to better connect various players in health care as well as stakeholders outside the system.

Socioeconomic factors such as exercise and transportation, Ahmed said, are more important than clinical factors for some patients, and platforms such as Salesforce increasingly have links to services such as Uber or grocery stores tracking patients’ purchases. Factoring those features into patient care can produce big gains.

Virsys12’s forum also featured a case study of how the Care Coordination Institute in South Carolina is using Salesforce as well as a panel discussion featuring three local executives — 180 Health Partners CEO Justin Lanning, Renova PCA CEO Steve Kress, Tennessee Justice Center Staff Attorney Rob Watkins — and Tim Riley, CIO of Network Health in Wisconsin. > Geert De Lombaerde daniel meigs

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‘A national hub for personalized medicine’ VUMC to use $71.5M grant for center related to federal precision medicine initiative by william williams

Within the nation’s health care sector, the rise of precision medicine has been fast.

But, perhaps not surprisingly, most folks are not aware of the term.

That could be changing, as precision medicine (also called “PM” and sometimes used interchangeably with “personalized medicine”) is garnering significant attention, fueled in large part by National Institutes of Health grants and various academic initiatives and research.

Clearly, the NIH — which defines precision medicine as “an emerging approach for disease treatment

and prevention that takes into account individual variability in genes, environment and lifestyle for each person” — has helped give PM a more mainstream approach. In fact, President Barack Obama mentioned precision medicine in his 2015 State of the Union Address, a noteworthy nod given PM essentially was unheard of by the general public prior to this decade.

And now academia is getting into the mix more than ever before, transitioning from small sets of studies to major mainstream research.

This past summer, Vanderbilt University Medical Center officials announced the NIH would provide a five-year $71.6 million grant to allow them to establish and operate the VUMC Data and Research Support Center for the federal Precision Medicine Initiative Cohort Program.

The initiative is being billed as a landmark study of genetic, environmental and lifestyle factors affecting the health of at least one million people. Specifically, the center’s role is to acquire and organize what will become a massive dataset of precision medicine indicators. In addition, the facility will provide research support and analysis tools to scientists.

Of note, the $71.6 million is the largest research grant VUMC has ever received from any one single source. courtesy of VUMC

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“The Precision Medicine Initiative gives urgency to our shared goal of making patient care far more personal — unlocking the key intelligence we need to tailor diagnosis and treatment for the genetic and environmental features of every individual,” says Dr. Jeff Balser, VUMC president and CEO and dean of the Vanderbilt University School of Medicine.

“Moreover, this competitive grant will generate substantial economic impact for Tennessee, while firmly anchoring Vanderbilt and Nashville as a national hub for personalized medicine,” Balser adds.

The NIH grants for fiscal year 2016 are valued at approximately $55 million, with the PMI Cohort Program expected to begin enrolling volunteer participants during the next 12 months. The hope is that the initiative can meet its enrollment goal of about one million by 2020. Work on protocols, infrastructure and piloting components is underway.

No doubt, the grant and the establishment of the center are huge deals, both for VUMC and for Nashville’s health care sector. But this is not unexpected, according to Dr. Dan Roden, VUMC senior vice president for personalized medicine and a nationally known pioneer in the field — not to mention the elder statesman of Vanderbilt’s PM effort.

Roden says officials within the health care and academic health sciences sectors were “not surprised” about the NIH grant announcement.

“When we landed the grant, the universal reaction in the communities in which I live and work was, ‘Oh, yeah, those guys do that,’” says Roden, whose work within the PM field began about 10 years ago.

Roden will work closely with Dr. Josh Denny, a Vanderbilt associate professor of biomedical informatics and medicine who will serve as director of the aforementioned data and research support center.

Roden says the path to securing the grant — and, now, creating the center — was spurred by “a combination of the right personalities.”

“I’ve known Dr. Balser and Josh for years,” he says, pointing as far back as the 1990s when VUMC began laying the groundwork for its health care informatics and health information technology future. “Jeff and the VUMC leadership have put money into PM.” Since then, Vanderbilt has seen grants arrive, money invested and high-profile talent hired related to its precision medicine efforts.

“My job [over the years] has been to drive those investments and to make sure these people developed their careers,” Roden says.

Denny, the grant’s principal investigator, will cochair the PMI Cohort Program steering and executive committees.

“The fact that were having a national conversation about the precision medicine initiative is a positive,” says Denny.

“There will be great things coming from how we share health data,” he adds. “We are creating technologies that will allow that electronic health records

data to flow, solving it first for the PMI. But if we solve it for the PMI, we can solve it for all of health care and that would be a huge win outside the PMI.” Denny says the precision medicine initiative “transcends” any particular clinical specialty, disease and/or patient type.

“There is a need for more effective precision medicine approaches,” he says. “The new PMI could positively impact health care — and individual health care in particular — in a way not yet seen.”

Denny says the goal is to create a research paradigm that places research participants at the forefront of biomedical discovery while allowing them to do so efficiently and on a huge scale.

“A key goal is to support the translation of data to discovery as fast as possible,” he says.

“Traditional health care research studies have always allowed for the asking of a set of questions that were predefined,” Denny adds. “In this study, we can ask the same questions — but with unstructured data for which those question have not been asked before and that we don’t even imagine asking right now.”

As to his colleague Dan Roden, Denny offers substantial credit.

“We certainly email daily and probably talk a couple times per week,” he says. “I couldn’t have had a better mentor amongst many wonderful mentors I’ve had before.”

VUMC will be aided by several collaborators, including the Broad Institute of Massachusetts Institute of Technology and Harvard University; Columbia University Medical Center; the University of Michigan School of Public Health; Northwestern University Feinberg School of Medicine; and the University of Texas School of Bioinformatics in Houston (read more in the accompanying story).

Verily Life Sciences (formerly Google Life Sciences), the health care and life sciences company of Alphabet Inc., will support the VUMC Data and Research Center.

In addition, a PMI All of Us Research Program biobank is being built by the Mayo Clinic in Rochester, Minnesota. The facility will oversee the collection, storage and analyses of blood and urine samples for crucial genomic and other biological information.

In short, the undertaking is staggering in its breadth, scope and potential number of participants — both patients and researchers alike.

Roden says two pieces of heavy lifting — the writing and securing of the grant — are completed. Now comes a greater challenge.

“This is the beginning of what we hope will be a minimum five-year and maybe a 20-year adventure,” he says. “The key decisions involve who we recruit and how we process the data. Our job has just begun.”

Denny puts in more bluntly, noting, “We may be actively recruiting participants for the next three to five years, but there will be researchers using the data set for decades to come.”

‘The key decisions involve who we recruit and how we process the data.’

Dr. Dan Roden

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‘A normalizer of care’

Ryan Macy

Satchel Health takes off via telemedicine pivot

by Cari Wade Gervin

When Satchel Health started operations in the summer of 2014 as Octovis Inc., it envisioned itself as bringing Google Glass into operating rooms and physical examinations to increase efficiency.

The thought was that the company’s proprietary software would integrate patient files and other medical information with the technologically advanced glasses.

But right away, says Satchel CEO and founder Ryan Macy, the company began to see wider applications for the software and workflow technology. And soon the company had pivoted to telemedicine.

This turned out to be an even smarter, and prescient, business move when Google killed off Google Glass in January 2015.

Now the Gulch-based Satchel (officially renamed last March) is growing, having doubled its employee count to 15 over the past year. The next two to three years will see the company grow to 60 to 80 employees.

“We’re exploding,” Macy says. “We have customers all over the United States, and we’re working on partnering with a number of health care companies in greater Nashville.”

Telemedicine is rapidly growing in popularity as a costsaving measure, but Macy says the benefits of a system like Satchel go far beyond the financial. A true telemedicine set-up isn’t just an opportunity for a Skype-like video chat between a patient and a doctor in a different city — it allows complete integration of devices with workflow while allowing for collaboration and data collection.

To date, Satchel has specialized in outfitting places like in-patient rehabilitation facilities, long-term care facilities, and nursing homes. The equipment and software — all provided and installed by Satchel for a monthly fee — allows nurses and other medical staff to communicate with doctors elsewhere to fully assess a patient’s needs.

This is valuable in rural facilities where specialists might not be easily accessible, but Macy says it’s equally valuable in urban settings, too.

“Even if you’re in the middle of Manhattan, it is still a struggle to get a physician to walk into your building if it’s not a hospital,” Macy says. “Telemedicine is a great normalizer of care.”

Although much of Satchel’s client base is involved in geriatric medicine, Macy says there hasn’t been much pushback from seniors concerned that their doctor is checking in on the them from another city (not the least because they don’t have to figure out the technology themselves).

“Is there an aversion to tech from the senior perspective? No, there’s an aversion to lack of care,” Macy says.

“Mostly we hear from family members who are thrilled with it because their parent or grandparent is getting access to a doctor immediately, instead of waiting a week for one to come assess the problem.”

Macy adds that the structure of Satchel’s business — providing and maintaining the equipment and software — makes it easier than otherwise for facilities to add telemedicine to their practices.

“The reason why this is such a positive concept is that there’s no large capital outlay,” Macy says. “When something breaks or gets lost, we take care of it.”

Macy adds that most users see a return on investment within three to six months, a much shorter timeframe than if a business were buying all the equipment itself.

As Satchel continues to expand, Macy hopes it will become a big part of Nashville’s growing health care IT sector.

“It’s a big opportunity for Nashville,” Macy says. “And it’s such a great chance for us to do good while also being great professionally.”

Daniel Meigs

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Trust issues

A new survey shows massive gaps between key health care stakeholders Local health care communications agency ReviveHealth recently published the 10th version of its Trust Index, which measures how key players in the industry view each other. The short answer: Not at all kindly.

“Hospitals don’t trust health plans. Health plans don’t trust hospitals. Physicians don’t trust either one. And in the absence of trustworthy data and information, patients are placing their bets with friends, family and the Internet,” Revive’s principals wrote in summing up their collaboration with Catalyst Healthcare Research.

The sorry headline numbers:

The Revive survey also brought to light a big gap in how providers and payors view the ongoing shift to value-based payment structures. The execs running insurance companies said they expect to pay 44 percent of their claims based on value arrangements. Health systems leaders are forecasting that only 13 percent of their 2016 commercial revenues will come from valuebased systems.

One bright spot in the survey: Both groups of leaders are almost exactly on the same page when it comes to identifying the factors holding back progress.

Forces that are “very important” to restraining the transition to a value-based payment structure

health systems

Lack of technology, processes 62% 61%

Health systems executives’ trust in health plans

Lowest-rated plan

Reluctance to assume risk

40.3

Mean rating

health plans

62%

54.1

Highest-rated plan

58% 63.3

Risk of losing competitive edge 49% 49%

Physicians’ trust in health plans

Lowest-rated plan Mean rating Highest-rated plan

Decreased trust

52.7

48%

55.0

Physician resistance

57.2

45% 47%

Health plan executives’ trust in health systems

Lowest-rated system Mean rating Highest-rated system

48%

56.7 67.6 73.3

For more info on these topics and a link to an indepth presentation by Revive President Brandon Edwards and Catalyst President Dan Prince, go to thinkrevivehealth.com/topic/trust

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Let’s be honest about the pushback to mandatory bundles Paul Keckley is managing editor of The Keckley Report, a health care researcher and a widely known industry expert. He formerly was, among other things, managing director of the Navigant Center for Healthcare Research & Policy Analysis and executive director of the Deloitte Center for Health Solutions. paulkeckley.com

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There’s no reason to claim new models will compromise patient care

by Paul Keckley

In late September, 179 members of the House of Representatives sent notice to Centers for Medicare and Medicaid Acting Administrator Andy Slavitt and Chief Medical Officer Patrick Conway that they’re not happy about Medicare’s decision to double down on its bundled payment programs.

At issue is Medicare’s proposed plan next year to implement mandatory bundled payment programs for heart failure and coronary artery bypass graft surgery akin to the joint replacement bundles it announced four months prior.

The essence of the House members’ complaint is this: Through its Centers for Medicare and Medicaid Innovation, Medicare has over-reached its authority in forcing hospitals and doctors to accept bundled payments for services. Their letter said mandated bundles have the potential to compromise patient care and more time is needed to get provider input before the new bundles become mandatory next summer. But the essence of the complaint is the legitimacy of CMMI, which was authorized and funded in the Affordable Care Act as the vehicle through which delivery system reforms that shift incentives from volume to value were authorized. One Democrat joined 178 GOP House members as a signee of the letter, lending to its partisan flavor.

Partisan politics aside, let’s put the larger issue of mandatory bundled payments in perspective: Bundled payment programs are not new nor is their legitimacy as a bona fide vehicle for changing incentives the issue. They attempt to align the financial incentives between all providers (for example, hospitals, physicians, and post-acute care providers) that touch a single episode of care. By rewarding coordination across multiple settings of care,

errors are fewer, outcomes are better and efficiency gains realized. That’s the theory and it’s central to Medicare’s effort to bend the cost curve for the program that covers more than 55 million seniors.

Initially, Medicare encouraged the bundled payment program via two voluntary programs: • Bundled Payment for Care Improvement Initiative (2013): a voluntary program wherein hospitals may choose from one or many of 48 episodes of care in a bundles payment effort, with shared savings achievable based on historic “unbundled” costs.

• Oncology Care Model (2016): a voluntary program (for physician practices) that targets chemotherapy and related care during a six-month period following the initiation of chemotherapy treatment. The OCM is a threepart payment model. Physician practices continue to bill fee-for-service and practices also receive a prospective per-beneficiary-per-month payment and have the opportunity to earn performance-based payments, if they meet quality and cost goals. There are 195 practices and 16 payers participating in the Oncology Care Model. CMS is also partnering with commercial payers in the model.

But recently, CMS doubled down on bundles by mandating them via two proposals earlier this year: 1. Comprehensive Care for Joint Replacement (2016): Targeting the 400,000 total joint episodes with costs ranging from $16,500 to $33,000, the CJR program is a mandated bundle for five years in 67 communities involving 800 hospitals. Costs and savings are calculated for 90-days post-discharge and regional costs factor into the cost basis calculation over the span of the program.

Note: 700 hospitals are testing the CJR bundle per CMS. 2. Cardiac Rehabilitation Incentive Payment Model (2017): These are bundled payment models for highquality, coordinated cardiac care for heart failure, coronary artery bypass graft bundles and cardiac rehabilitation. The heart failure and coronary artery bypass graft bundles will be mandatory in 98 communities. Notably, in years three, four and five of these programs, savings or penalties up to 5 percent of costs will be calculated against regional baselines instead of limiting comparison to the local community. The cardiac rehabilitation bundle will be accessible in 45 markets.

Both of these are mandatory for hospitals and physicians in many communities, and both anticipate implementation next year. That’s the issue; not the legitimacy of bundled payments per se.

In fact, voluntary provider participation in Medi-

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care’s bundles to date has been significant. As of January 2016, the BPCI initiative had 1,448 participants, including 409 acute-care hospitals, 700 skilled nursing facilities, 288 physician group practices and 100 home health agencies. And Medicare has shown they’re working, its most recent report noting “promising results on cost and quality” in 11 of 15 clinical episode groups evaluated.

So why the pushback from this group of House members?

Perhaps it’s a principled belief that Medicare has no authority to force a new payment model on providers or that CMMI is out of bounds. The view that Medicare should act as a benign payer on behalf of its enrollees is a debate that’s appropriate, but perhaps that discussion should be expanded to include private insurers who cover 155 million through employer-sponsored plans. In these, the insurers make the rules, define the networks, set their premiums and force providers to adhere if they are to be included in the plans. So their letter poses a larger question about the role of payers in making rules for providers: It’s a source of tension that’s been around for decades.

Perhaps it’s a legitimate concern about the risk-adjustment methodologies proposed in the mandated bundles proposed to date. The fact that the new mandated bundles were announced only four months after the CJR program seems a bit rushed, and the wide distinction between episodes involving joint replacement and heart issues were inadequately addressed in the proposed rules.

In many instances, the government’s not gotten it right on its first try.

For instance, the accountable care organizations were flawed initially: too many measures, faulty calculus for determining shared savings and dubious design that made two-sided risk too risky for most provider organizations.

In the cardiac bundle, for instance, there’s legitimate reason to do a re-do around its risk calculus, and thoughtful analysis by the American Hospital Association (AHA), Medical Group Management Association (MGMA) and others point out technical flaws that should be legitimately addressed. Rushing to implementation of mandatory bundles is poor public policy, especially since the issue is not the acceptance of bundles, but how.

Perhaps the House members’ letter is a response to political pressure from those who benefit from maintaining the status quo. After all, most physicians don’t like the concept of shared risk and distrust payers, so alternative payment programs like bundles, ACOs and others are unwelcome intrusions. The status quo has served many in the industry well.

But for sure, the rationale cannot be that bundles compromise patient care as referenced in the House members’ letter. Bundles force coordination across multiple settings and practices. Bundles force providers to create formal pathways for patient care management and methods for knowing when patients fall through their cracks. Bundles force hospitals, physicians, allied health professionals and post-acute providers to share patient information and measure outcomes and monitor costs. Protection of vulnerable patient populations is laudable, but that’s no excuse for reinforcing poor care coordination, uneven and inadequate access, and lack of transparency that’s systemic for Medicare enrollees.

There are legitimate reasons for providers to take a guarded but proactive approach to bundled payments. That’s the posture taken by AHA, MGMA and others. There are flaws in the proposed mandated bundles and we need to get them right.

But there’s no reason to claim they will harm our patients. Care coordination, transparency, team-based delivery, evidence-based clinical processes and an intense focus on outcomes and cost seem in everyone’s best interest, especially our patients.

Let’s be honest about the proposed mandatory bundled payment programs: The issue is how they’re implemented, not whether bundled payments harm our patients.

NASHVILLEPOST.COM

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CLOSE

BIG QUESTION

THE BIG QUESTION

How can we create a viable innovation path?

In conversations about innovation and business models, the word “disruption” gets bandied about a lot — probably far too much. (A quick search of our website shows we’ve used it (only?) eight times in that context in 2016.) But spare a thought for doctors and hospital CEOs these days: How they take care of their patients and get paid for it really is being turned on its head in so many ways.

More patients than ever before are being pulled (or pushed) into other settings and payment models are increasingly calling for better coordination between the many players involved in organizing, delivering and handing off care. At the same time, new consumer-oriented technologies are challenging patients and providers alike to think differently about their roles and responsibilities in well-being.

Talk to enough health care pros in town — investors, entrepreneurs, attorneys, advisors — and you’ll inevitably run into several people who say the old guard can’t keep up with the times. They’ll say innovation isn’t in the establishment’s

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blood, that its incentives are misaligned in a world of bundled payments and mobile apps.

We can point to solid arguments on both sides. We see total outsiders injecting radically different ways of thinking into parts of the system where change is happening too slowly. We also see innovative thinking and proactive executives in blue-blood C-suites. In this magazine, we’ve tried to deliver you a taste of both.

Nashville’s nearly $40 billion health care industry has the track record, the management expertise and the financial resources to hold its own in a topsy-turvy world. It also has the insider knowledge and the entrepreneurial energy to rock the cart where necessary. But on their own, each of those approaches likely won’t be enough to ensure lasting relevance in the design and delivery of next-generation health care.

So let’s figure out the best way to unite them.

A few big names already are trying out the waters. Brookdale’s entrepreneur-in-residence program is testing innovations in senior care products, while big names Community Health Systems and LifePoint Health are among those who have pumped almost $400 million into funds that will invest in technologies the companies will then test and refine.

Instead of focusing so furiously on the idea of disruption, we see potential for health care leaders of all stripes to engage more often in gentle interruption. The resulting conversations could help save lives.

11/9/16 3:41 PM

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