WINTER 2017
FIXING THE SYSTEM
Experts, execs debate solutions at Mayo Clinic event
THE FIGHT ON OPIOIDS
Deploying resources, tech to produce some ‘bright spots’
PREDICTION POWER
At the intersection of data, diagnostics and ethics
BLOCKCHAIN
REACTION
L oc a l le a ders a re pl a ying a k ey role in b ringing distri b u ted ledger tech to he a lth c a re
BROADER
DEFINITION
Community health workers are playing increasingly important roles
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OPEN
CONTENTS
21
DEPARTMENTS
04 YOU SHOULD KNOW
closing the gap
180 Health Partners supports opioidaddicted mothers
Danielle Torrez’s EXPHealthcare stresses employee training
06 THE RULES
Why court decision on patent litigation venue rules matter
07 MAKING STRIDES
Nashville General’s Joseph Webb maximizes resources
07 PUSHING ON
LifePoint’s quality initiatives gain steam
39 INTERCONNECTIVITY
Oscar Health platform focuses on customer data
40 HCA VS. VUMC
Will employers catch crossfire as local stalwarts battle?
42 REMARKABLY STABLE
Unlike ACA plans, job-based coverage premiums rise modestly
10 DATA BANK
47 NUTRITIONAL F OCUS
Saurabh Sinha guides emids into new markets
A look at some key numbers
12 THREE QUESTIONS
Raiven’s Jim Stefansic on AI-predicted treatment
16 DEPLOYING DEVICES
Local leaders bring distributed ledger technology to health care
VU scientist ponders predictive modeling
44 HEALTH OF A COMMUNITY
Blockchain reaction
08 THE JOURNEY
32
36 PROMISE OF PREDICTION
JourneyPure, iThrive target with technology
f eatures
18 SOME BRIGHT SPOTS
How area providers are addressing the opioid epidemic
22 REDUCING RELAPSE
CaredFor tackles patient engagement for opioid treatment
23 POT BY PRESCRIPTION
Two lawmakers seek to stem opioid tide with medical cannabis
24 ROOT CAUSE
Axial uses analytics to address problematic opioid practices
A look at the Intelligence Squared discussion at Mayo event
26 TERMINALLY BROKEN?
35 ‘ACTION GETS ATTENTION’
Outreach workers help with advocacy, coordination
Savor Health simply approaches cancer fight
48 TAKING IT F URTHER
Sketches to summarize Health:Further discussions
52 INDUSTRY TITANS
Tennessee Health Care Hall of Fame inducts third class
58 ORTHOPEDIC CONSTRUCTION
TriStar Centennial creates ‘hospital within a hospital’
60 ROLL ’EM UP
Nashville consolidators target niche sectors
61 INTERNATIONAL EFF ORT
U.K. learns from Nashville’s health care models
close
62 READING CORNER
IQuity RNA research advances
64 THE BIG QUESTION
What’s the fastest way we can (re) build trust?
Center for Medical Interoperability seeks innovation standards
daniel meigs
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EDITOR’S LETTER
OPEN
editorial Editor Geert De Lombaerde Managing Editor William Williams Contributing Writers Lena Anthony, Ayumi Fukuda Bennett, Linda Bryant, Stephen Elliott, Caroline Leland
art Art Director Christie Passarello STAFF Photographers Eric England, Daniel Meigs
production Production COORDINATOR Matt Bach Graphic Designers Amy Gomoljak, Abbie Leali, Liz Loewenstein, Melanie Mays
publishing advertising director Heather Cantrell Mullins bUSINESS DEVELOPMENT director Jennifer Trsinar ACCOUNT EXECUTIVES Maggie Bond, Rachel Dean, Nicole Graham, Michael Jezewski, Carla Mathis, Marisa McWilliams, Hilary Parsons, Mike Smith, Stevan Steinhart, Keith Wright Sales Operations Manager Chelon Hill Hasty Account Managers Gary Minnis, Olivia Moye, Annie Smith
marketing EVENTS DIRECTOR Lynsie Shackelford PROMOTIONS MANAGER Josephine Wood
circulation Subscription Manager Gary Minnis Circulation manager Casey Sanders
SouthComm 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 210 12th Ave. S., Suite 100 Nashville, TN 37203 www.nashvillepost.com Nashville Post is published quarterly by SouthComm. Advertising deadline for the next issue is Friday, Feb. 2, 2018. For advertising and subscription information, call 615-844-9307. Copyright © 2017 SouthComm, LLC.
BREADTH, DEPTH I was lucky enough in October to be able to say a few words to a select and successful crowd at a reception honoring this year’s inductees into the Tennessee Health Care Hall of Fame. (Read all about them starting on page 52.) My remarks included a comment that one of the perks of our work at the Post — both daily via our website and in these quarterly magazines — is having the chance to talk to smart and hungry entrepreneurs who may well be honored as Hall of Famers in future decades. On these pages, we have brought together a great number of those terrific people. There are data wranglers looking to shift the battle lines in the war on opioids, big thinkers devising promising blockchain networks and caregivers developing new approaches to delivering better care to more of our fellow citizens. There is no shortage in Middle Tennessee of health care professionals thinking about things differently, stacking innovation on top of knowledge or layering new technologies on top of proven methods to create positive change. Simply put, the breadth and depth of resources across Nashville’s health care sector never cease to impress. Also impressive is Nashville’s overall growth, which shows few signs of slowing in 2018. One of the ways we chronicle that growth is with our annual In Charge list of movers and shakers that will again be part of the Leaders issue we’ll publish in early March. Do you think this year’s list missed a deserving someone? Do you know of a new power broker who moved to town this summer? Let us know about them by sending a note to incharge@ nashvillepost.com. We look forward to hearing from you and wish you a terrific holiday season. Geert De Lombaerde, Editor gdelombaerde@nashvillepost.com
We owe a big thank you to the advisory board that helped us shape many of the stories in this pub. Their experience, insights and candor were of tremendous value as we sorted through ideas. Craig Boerner VUMC Ashby Burks Baker Donelson Amanda Cecconi Punching Nun Group Brandon Edwards ReviveHealth Shane Reeves TwelveStone Health Partners Ben Ross American Physician Partners Tom Wylly Brentwood Capital Advisors
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OPEN
YOU S HOUL D KN OW
YOU SHOULD KNOW Danielle Kimmey Torrez EXPHealthcare
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As alternative health care payment models have grown in prevalence — a recent report says they accounted for 29 percent of all health care payments in 2016 — so has the emphasis placed on patients’ experiences with providers, be they behemoth hospitals or small physician groups. That has led to several reactions, including the emergence of chief experience officers across large health care provider organizations. It also has created an opportunity for Danielle Torrez and her team at EXPHealthcare, which is preparing to launch a web-based suite of assessment, online learning and consulting services centered around company culture and customer experience. EXPHealthcare is an offshoot of Experience Global, which was founded on the five principles of service and relationship excellence of Walt Disney Co. — where Chief Experience Officer Bruce Loeffler spent a decade — and also focuses on other industries. Torrez and her team this summer secured funding from former Guidant Partners CEO Steve Burgess and his wife Michelle while presenting at the IdeaCon entrepreneurship conference early this year. “We’ve found the biggest opportunity in health care,” says Torrez, a former fashion marketer and member of the music group Out of Eden. Since the summer, the EXPHealthcare team has been building out its software platform — paid pilots are tentatively scheduled for early next year — and cementing the case for how employee experience scores correlate with patient satisfaction. “The biggest effect is in the way leadership treats employees,” she says. “As soon as someone in leadership treats you better, communication becomes better in your teams. And the patient experience goes up very quickly.” And possibly in a big way: A California health system working with EXPHealthcare boosted its HCAHPS patient satisfaction survey score by 14 percent in the first quarter following implementation and has sustained a double-digit increase from its baseline score.
ERIC ENGLAND
11/7/17 3:07 PM
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MARKETING
DIGITAL
PUBLIC RELATIONS
ISSUES & CRISIS
11/7/17 3:20 PM
OPEN
THE RULES
Earlier this year, The U.S. Supreme Court issued a unanimous opinion that overhauled patent litigation venue rules. Since a 1990 opinion from the Federal Circuit, patent cases had been following general venue rules, meaning that plaintiffs could bring a case in any district where the defendant was deemed to be present. In practice, that led to about 36 percent of all patent cases launched in 2016 to be filed in the Eastern District of Texas, where juries are viewed as being more favorable to plaintiffs. The Supreme Court’s ruling this year stated that a corporation can only reside for legal purposes in the state where it was incorporated. We asked Nate Bailey, a partner at Waller Lansden Dortch & Davis, a few questions about the ruling’s possible impact. Why does this matter? There are numerous “patent trolls” out there who buy patents just for the sake of suing. Many readers of the Post are likely either familiar with the patent troll problem or have been hit with a lawsuit by a patent troll. Historically, the defendants in patent troll litigations have settled to avoid a costly lawsuit. How will patent litigation change as a result of this? Many more cases will be filed in the District of Delaware because so many companies are incorporated there. Also, patent cases will increase in jurisdictions like the Middle District of Tennessee where companies have a physical presence.
THE RULES Nate Bailey waller
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How much of impact should we expect here in the Middle District, where courts already are dealing with severe case backlogs? Historically, a large percentage of patent troll litigations were filed in the Eastern District of Texas because of its aggressive local patent rules. But, the new Supreme Court case has changed how the Patent Venue Act is interpreted, making it harder for the Eastern District of Texas to find venue. It is likely that the Middle District will see an increase in patent cases filed. The district only has a handful of patent cases a year, so instead of two to four, you might see four to six or even more if a patent troll decides to hit several local companies at once, which often happens. As it relates to Middle Tennessee’s health care sector, this seems like something IT companies should be watching closely. Is that an area where you’d expect more action? The Supreme Court’s TC Heartland opinion is industry-agnostic.
daniel meigs
11/7/17 3:08 PM
TOUCHING BASE
OPEN
Making strides
Nashville General CEO Joseph Webb makes most of modest resources by William Williams Joseph Webb
Joseph Webb has enjoyed multiple milestones since his tenure as CEO of Nashville General Hospital at Meharry Medical College began in 2014. However, for all the successes, Webb and his team might be most worthy of recognition for handling as best as possible the difficult challenges associated with budgets and expenditures. Last March, in a bit of a surprise, Nashville General asked that the city’s annual subsidy to the safety-net hospital be hiked to nearly $56 million from $35 million. This after the Metro Council in February approved $16 million in emergency funding. Metro approved a $35 million subsidy only. “We are currently working with the city and Meharry Medical College on a plan to reconcile that budget with our projected needs,” Webb says. The work is paying dividends. In 2016, the hospital received a strong rating from nonprofit accrediting organization The Joint Commission, bouncing back from a previous bad review. Webb is encouraged, noting, “Delivery of high-quality care and ensuring the safety and satisfaction of our patients is our highest priority. We have been working hard to keep building on the progress and growth evident in that review. The Joint Commission will return by next fall, and we fully ... look forward to receiving another strong report.” As to this year, Webb says he recently received confirmation that the hospital’s cancer program was awarded a three-year accreditation with commendations by the American College of Surgeons’ Commission on Cancer.
Webb says Nashville General has “made strides” in strengthening its operations. “We have cut costs and improved our billing and collections practices,” he notes. “As we continue to focus our hospital around the principles of patient-centered care, we are also proud to have achieved National Committee for Quality Assurance recognition in our patient-centered medical home.” Webb says 2017 brought a redesign of Nashville General’s emergency department into three separate zones: fast track, urgent care and emergency. Additionally, the facility received a level two award by the Tennessee Center for Performance Excellence. The Nashville General Foundation has done “an exceptional job” this year, he says, hosting an open house art show in January (showcasing original work received by Bridgestone and the Metro Arts Council), creating a series of three jazz brunch fundraisers and receiving an Astellas Foundation grant that allows no-cost prostate screening exams to men (insured or uninsured) over 40. Progress aside, the need for more funding cannot be over-emphasized. “We are making strides in cutting costs and increasing collections, but having resources to meaningfully invest in our hospital is a real challenge,” Webb says. “We also fight long-held misconceptions or concerns about Nashville General that are not always accurate. That is why I invite anyone interested to come by the hospital and see first-hand what has changed recently. I’m confident the people of Nashville will be pleasantly surprised. Our doors are always open.”
Pushing FORWARD
LifePoint’s quality initiatives gain steam by Geert De Lombaerde Rusty Holman
With the cover story of this magazine 12 months ago, we shone the spotlight on a wide-ranging quality program LifePoint Health executives have built on the foundation of a Centers for Medicare and Medicaid Services initiative the company was part of early this decade. Focused on clearer communication and closing the distance between hospital leaders and those tending directly to patients, the push evolved into the LifePoint National Quality Program (developed in collaboration with Duke University Health System), which folds in health care stakeholders in the company’s hospital communities. A year ago, three LifePoint hospitals were recognized for meeting a variety of quality and safety benchmarks under the quality program and were named Duke LifePoint Quality Affiliates. In January, the company’s 58-bed Bourbon Community Hospital near Lexington, Kentucky, joined them; in May, the 100bed Meadowview Regional Medical Center in Maysville, 45 miles northeast of Bourbon, did as well. Executives say up to five others could earn the accolade before year’s end, and another five are in line to be review in 2018. Near the end of 2016, LifePoint executives also announced that 35 of their hospitals had that year earned Chest Pain Center Accreditation from the
American College of Cardiology. Their successes lifted to 63 the number of centers with that distinction. This year, another two have been certified and the remaining six are expected to join them before 2017 is through. (Seven of those also have achieved heart failure accreditation, the first for LifePoint facilities.) Another priority on the quality front has been certifying providers and executives as certified professionals in patient safety, a designation administered by the National Patient Safety Foundation. After having 50 employees meet the CPPS standard in 2016, another 93 people have since done so. It’s worth noting that only about a third of them are actually patient safety officers or patient safety leads; 46 percent are members of hospital leadership teams and 19 percent are front-line leaders such as nurses or infection preventionists. Looking ahead to 2018, Chief Medical Officer Rusty Holman and his charges are looking to build on those successes while also, among other things, branching the National Quality Program into ambulatory and physician practice settings, building more patient advisory councils in their hospital communities and work to standardize physicians’ work when it comes to clinical processes as well as working with supplies, equipment and pharmaceuticals.
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OPEN
THE JOURNEY
THE JOURNEY Saurabh Sinha emids Technologies
The year 2017 will go down as a notable one for emids Technologies, which in May opened a London office and during the summer acquired Encore Health Resources from publicly traded QuintilesIMS. The latter move brought the Nashville-based company about 200 employees and opened doors with providers. Here, CEO Saurabh Sinha talks about some of the biggest drivers of change in health care and how the Encore deal sets emids up to be a part of many more important conversations. As we see it, there are three big drivers of change in health care today. The first is that the pace of regulatory change is accelerating. And the purely political side of that today means the change itself might change; look at how CMS is no longer mandating payment bundles as before. Two: Consumers are more in charge. They are increasingly at the center of decisions and driving changes in behavior by other stakeholders. And three: The tech transformation is huge and that’s obviously affecting us most directly.
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THE JOURNEY
When it comes to regulatory change and specifically value-based care agreement, only in the how is there debate. The big question is, “Who gets to decide what value is?” And because the consumer is involved, the digital element of how that’s presented needs to be designed with customer-facing features. The history of emids has been in working with tech platforms on the payer side. But with value-based care models emerging, a gap appeared in our client ecosystem where cooperation is happening. A number of big insurers are forming joint ventures with health systems. That’s why we wanted to move into the advisory and consulting services Encore delivers. It was important for us to be where our clients will be in the future. Regarding consumers taking control: I have no doubt that, in the long term, the consumer will decide what value is. Look at how so many insurers are rebranding — Aetna created Healthagen for its technology business, United has Optum and the Florida BlueCross organization has organized itself under the GuideWell brand — because they want to position themselves to be the ones guiding and
oPen
are leaders, some are followers and some are laggards. And the organizations are very self-aware about which category they belong to. Where emids comes in is — whether it’s via an app, a portal or a device — combining engagement with the customer and enablement of the data these organizations have. Here’s an example: A doctor’s visit that leads to a prescription that leads to a pharmacy visit can touch up to 40 systems in the back of an organization. There’s a lot of value in synchronizing those systems and their data. That’s the enablement piece of what we bring to the table. Any successful process has four stages: Think, design, plan and do. The emids organization we have built over the years covers the plan and do. Adding Encore gives us much more talent for the think and design phases. There was some overlap between those two talent sets before, but now it’s a very smooth process bringing both together. The big question for so many health care organizations going forward is, “Do you know your customers?” We have the analytics to help companies better in-
‘The big quesTion for so many h e a lT h c a r e o r g a n i z aT i o n s going forward is, “do you know
Legends Bank is opening a brand new location in Midtown, so we can serve your business even better. This isn’t just another branch, but a center dedicated to meeting the unique needs of our local business community. We’re open to partnership and solutions. We’re open to listening to the ideas, goals and challenges you have for your business. Meet our team to discover what legendary service feels like. We also have locations
your cusTomers?”’ coaching the consumers who will make the decisions. They have apps for pricing comparisons that are improving the transparency of the process and adding options. It’s all about making the quality transparent and the plans are way ahead of the game because they’ve been managing the risk. They’re 20 years ahead of providers in that respect. The providers are squeezed and they need to make investments to catch up. There’s an element of handholding that comes with that. As is the case just about everywhere, some organizations
Open for business.
in Green Hills and Brentwood. teract with their clients. With Encore on board, we’re now one of the few to cover both the payer and provider spaces. So many organizations are focused on one or the other. Having both, that’s our clarity of thought. In the future, health care will be very regional and highly personalized. That’s where the industry is headed. You’re seeing a more results-oriented approach from CMS and those in the industry will be motivated to share more data. The quality has to come from the ground up. We have to get our hands on the raw data to interpret where things are going.
LegendsBank.com eric england
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OPEN
DATA BANK
A LOT OF WANT-TO A survey of more than 300 CEOs and other innovation leaders showed that there is very broad acceptance of the need for digital innovation in hospitals and health systems. But there’s also a big gap in how to translate that understanding and desire into meaningful action.
DATA BANK Make no mistake: The long-term challenges for the U.S. health care sector haven’t changed. There still looms a huge shortfall in skilled labor at a time when demographic trends will produce large demand growth. And for every source of pressure on costs, other factors are pushing up prices elsewhere. Still, there are several signs that — via technology, cooperation, transparency and otherwise — health care in the United States is becoming smarter and more efficient. Here’s a partial snapshot of the landscape.
76%
of leaders say digital innovation is essential to meeting long-term goals
SENIORS AND JOBS Mirroring broad demographic trends, the Middle Tennessee population of seniors rose by more than a quarter between 2011 and 2016. But that was still less than employment growth in the health care sector.
72%
29.2%
26.8%
growth in health care jobs
growth In 65+ population
of hospitals have built or are planning to build an innovation center
Source: CBRE
52%
SUPPLY LAG
of leaders are holding back on innovation due to a lack of capital
But that growth pace isn’t at all the same for doctors specifically. By 2030, one industry group expects the nationwide shortfall of physicians could top 100,000. Here’s how that number breaks down.
Primary care doctors Medical specialists
70%
Surgeons
of leaders don’t think their IT teams have the resources to support innovation
Other specialists 0
10k
20k
30k
40k
50k
Source: Association of American Medical Colleges
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Source: Avia and American Hospital Association
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DATA BANK
A PATH TO LOWER COSTS
SLOWER IS BETTER
Researchers this summer asked more than 9,000 consumers in 15 states as well as 450 doctors from around the country about what they think is needed to lower the costs of health care.
It appears the days of health care prices comfortably outpacing the overall economy’s inflation are behind us — with one exception. Since the last recession started in late 2007, health care prices are up 19.7 percent versus the GDP deflator’s 15.7 percent. Here are, as of the past three Augusts, the annualized price changes of various components of the health care system.
Increase costs for poor health habits
consumers
physicians
28%
Have insurers offer catastrophic plans
40%
23%
Lower payments for drugs, chronic treatments
Reduce services insurers must cover
11%
12%
0.9%
1.2%
1.3%
-1.0%
0.1%
0.5%
Prescription drugs
4.7%
6.2%
2.7%
Nursing home care
1.9%
3.2%
1.9%
Dental services
2.7%
2.8%
1.6%
Home health care
1.1%
1.2%
1.1%
-0.6%
0.9%
0.0%
1.1%
2.0%
1.2%
Physician/clinical services
20% 16%
2015 2016 2017
Hospital care
23%
21%
Encourage doctors to follow practice guidelines
Type
Durable medical equipment
6%
Overall index Source: Texas Medical Center Health Policy Institute
AT A PREMIUM The cost of job-based insurance coverage also has grown at a slower pace in recent years. Here are the average annual increases in premiums for family coverage.
Source: Altarum
15% 10% 5%
Source: Kaiser/HRET Survey of EmployerSponsored Health Benefits
2000
2002
2004
2006
2008
2010
2012
2014
PAYER PREFERENCE
TECH TRENDING
Moving to a single-payer system — i.e. the government — very likely wouldn’t notably cut costs. But a majority of the more than 1,000 doctors surveyed this summer by Merritt Hawkins say they’d favor such a system primarily for clarity and stability.
Investors continue to pour money into digital health companies. Through the first half of this year, their funding was on track to outpace 2016’s record year by more than 50 percent.
8 6
42%
Somewhat support
14%
4
Neither support nor oppose
3% 6%
2
Somewhat oppose
35%
0 2010
2011
2012
2013
2014
2015
2016
Source: Merritt Hawkins
*Annualized
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2016
$10 billion
Strongly support
Strongly oppose
OPEN
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2017* Source: StartUp Health
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OPEN
THree questions
THreE questions Jim Stefansic Raiven Healthcare
Jim Stefansic serves as president and chief executive officer of Nashville-based health care artificial intelligence and data analytics solutions provider Raiven Healthcare. Prior to founding the company (which previously was called Faros Healthcare) in 2016, Stefansic oversaw Pathfinder Therapeutics Inc., helping the company he co-founded bring to market two image-guided surgical products and raising more than $17 million in venture capital and Small Business Innovation Research program funding. Stefansic once served as the director of commercialization at Launch Tennessee, leading the statewide SBIR program and assisting numerous technology businesses in their growth. He was also a research professor at Vanderbilt University Medical Center. There, he helped initiate technology used within the Vanderbilt Vision Research Center. Following are some of Stefansic’s thoughts regarding what works well at Raiven Healthcare.
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THREE QUESTIONS
How does the core technology work to build on merely flagging at-risk patients and actually recommending treatment plans? We use advanced artificial intelligence techniques including Markov decision processes and dynamic decision networks to determine the optimal pathway of care for a patient, much like a GPS determines the optimal route to get between two points. Our pathway can include multiple types of interventions. For example, an individual suffering from depression might respond best to therapy, medication or some combination that can be adjusted over time. Our AI software learns over time and can recommend a change in treatment if the current intervention is not effective. We can also include cost in the analysis. So if two treatment plans lead to similar outcomes but one is 50 percent less expensive than the other, this can be indicated to the provider, who may be in a risk-based contract and not aware of this. The more complex the condition, the more useful our technology — and, of course, the most complex patients are the hardest to treat effectively at an optimal cost. Another great thing about our technology is that it is programmed to learn like a human. So it can fill in the gaps when data is missing, which is common in health care analytics today. You’ve been working with Centerstone for more than a year now. What are some of the results you can share from that collaboration? With Centerstone data, we have demonstrated 40 percent better outcomes at a cost reduction of 60 percent for AIpredicted treatment versus treatmentas-usual for patients suffering from comorbid chronic and mental health issues (for example, patients that have both diabetes and depression). Now our focus with Centerstone is on working with high-risk, mentally ill TennCare members who are part of case management. It is important to note that more and more in today’s health care environment, both public and private payers are recognizing that “health” occurs both inside and outside the clinic. In the TennCare Health Link program, case managers at
OPEN
Centerstone are tasked with the great responsibility of tracking members’ overall well-being outside the clinic with cost constraints and risk management. So it is important that they find the right intervention at the right time. Our technology is well suited to solve this problem because we consider in our analysis social determinants of health, which reflect a person’s social, economic and environmental factors that influence health status and are critical to determining what treatment works best for individuals suffering from mental health disorders. How, if at all, could Raiven’s platform and approach be expanded into other areas of health care? Our technology is completely health care agnostic — or, for that matter, completely subject matter agnostic. For us, the goal is to find the 10 to 12 variables or “predictors” in the vast amount of data that help the machine-learning engine “learn” over time and provide the optimal answer to the question it is trained to solve. The key is to ask the engine the right question. This is where many health care organizations struggle. They know who their highest-risk patients are, but they don’t know what the best outcome is to optimize or treatment pathways to consider to improve care. This is where our decades of experience in mental health come into play. We are not just data scientists. We are the subject matter experts that help make data actionable at the point of care by asking the right questions of the data. We are applying this diverse knowledge to develop an advanced analytics platform to treat mental health issues for the military and their family members through the Cohen Veterans Network. Our initial work in this space is very promising, as we can demonstrate with 72 percent accuracy the effectiveness of treatment for veterans suffering from mental health issues such as post-traumatic stress disorder. We are also working with accountable care organizations in the management of their chronic disease patients, where we can demonstrate potential savings of $1,800 per member per episode of care when the right interventions are prescribed.
In Tune with Healthcare Audit, Tax & Advisory Human Resources Information Security Mergers & Acquisitions Physician Compensation Risk Assessment Staffing Valuation MSO www.lbmc.com/tennessee Nashville | Knoxville | Chattanooga
eric england
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Slack takes the hardest part of all our jobs — communication — and makes it simpler, more pleasant, and more productive. Whether you’re collaborating, brainstorming, striking deals, approving expenses, standing up with your team or sitting down with a new client, you can do that all in Slack. And then everyone is in the loop, no one’s in the dark, and it’s all time-stamped and searchable. Research, sell, forecast, design, negotiate, deliberate, merge, deploy, resolve, secure, facilitate, build and create in one place. Slack. It’s where work happens.
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Try it with your team at slack.com
11/7/17 3:42 PM
S PON S OR E D PROFIL E
COMPA N Y PROFIL E Slack Technologies, Inc. is an enterprise software platform that allows teams and businesses of all sizes to communicate effectively. Slack works seamlessly with other software tools within a single integrated environment, providing an accessible archive of an organization’s communications, information and projects. Slack
REALTIME FEEDBACK FOR BETTER CARE How the Johns Hopkins Sibley Innovation Hub uses Slack to communicate
Hospital staff at the Johns Hopkins Sibley Innovation Hub in Washington, D.C., don’t have to wait weeks or months for the results of hospital surveys to tell them how patients feel about the service they received. Now the team of design experts, doctors, nurses, hospital staff, and administrators use a combination of Wi-Fienabled tablets and Slack—a team communication platform—to gauge patient satisfaction instantly throughout the duration of their stay. “Getting feedback in real time means we can respond in minutes and not miss the opportunity for service recovery,” says Nick Dawson, Executive Director of Innovation at Johns Hopkins Sibley Innovation Hub. With conversations neatly organized into Slack channels by different topics, team members are able to easily find and access important information like requests from patients and see whether patients are getting their needs met. A dispatch system for delivering nonclinical care Patients use their tablets to secure creature comforts— like movies or ordering food from a favorite restaurant— but they can also use a concierge app to request things like a warm blanket or a book from hospital staff. And rather than have their simple requests get lost in the shuffle of everyday hospital operations, on the back end of the app, the patient’s request triggers an alert in a Slack channel that’s monitored by the team of on-call staff. Since all on-call team members have access to the channel, they “can all see when a request was completed, and by whom, or offer to help cover for people,” adds Dawson. Similarly, when new visitors arrive at the Hub and check in using the Envoy app, an alert pops up in a
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Slack channel notifying the team of their arrival and who they’re there to see. Sourcing real-time feedback from patients Tablet home screens feature expressive faces—from happy and smiling to sad and frowning—that patients can tap to submit comments with details about how they’re feeling. That information immediately gets funneled into a Slack channel with the help of a Zapier integration—a service that makes it easy to automate tasks between apps—for the whole team to review. The team can then discuss issues right there in the channel and, together, address them as they arise. More communication leads to better care “By putting tablets in patients’ hands so they can make requests and tell us how we’re doing, we’re able to pull patients into the team more actively and help them see that we’re invested in their care,” says Dawson. He has also observed the ease with which hospital staff communicate with one another in Slack, and how being able to exchange information quickly and informally allows them to do their jobs, and tackle challenges, faster. Slack has become their real-time feedback and dispatch system, and a central part of their approach to delivering better care. “The biggest benefit is the hardest to describe or quantify,” says Dawson. “It’s culture. Slack is both faster and more efficient while being more human and less formal. I don’t think I can go back to an email-first work environment.”
Website Slack.com Locations San Francisco London Dublin Melbourne New York Toronto
S PE C I A LT IE S Simplifying team communication Slack brings all your team’s communication together, giving everyone a shared workspace where conversations are organized and accessible, creating a searchable, transparent archive of work. Bringing all your work into one place Slack integrates all your tools and apps, bringing data into your conversations so your team can make quick, informed decisions. Choose from over 1,000 apps in Slack’s App Directory or build your own custom integrations to connect your company’s proprietary systems to Slack.
CON TAC T Phone: 1.855.980.5920 Email: feedback@slack.com
Find out how Slack can create better alignment and shared understanding across your team at slack.com/ customers.
11/7/17 3:42 PM
OPEN
TECH @ WORK
TECH @WORK DEPLOYING DEVICES JourneyPure, iThrive target addiction treatment patients and teens, respectively, with technology
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Every year, we spend more and more time on our phones and computers. It only makes sense, then, that companies, including some based in Nashville, are using the devices that are almost always in our hands to treat intractable health problems and foster well-being for at-risk populations. Local addiction treatment company JourneyPure uses its Coaching mobile app to keep patients engaged after they leave in-patient treatment facilities. According to the company’s internal tracking, 60 percent of patients treated this year are sober and healthy, “and this means that our app, which is part of the JourneyPure Coaching service, is working,” says CEO Kevin Lee. The app includes questionnaires, activities and educational material, and entries are sent immediately to a patient’s coach. “The app focuses on daily activities that encourage positive behaviors and is built on a wellness plan that is professionally developed to address each person’s needs,” Lee adds. “If the former patient misses a meeting, a physician appointment or other activity, the coach knows. So, we can stay ahead of the negative behaviors that indicate relapse to drug abuse.” Lee says the company expects app users to grow from about 1,200 people currently to “many thousands within a couple of years.” Another local project seeks to help a different at-risk group: teenagers in the process of developing life skills. Backed by the D.N. Batten Foundation and the Centerstone Research Institute, iThrive Games builds video games with the goal of enhancing teenagers’ “overall well-being by building social and emotional skills and positive mindsets and habits that can last a lifetime,” says Michelle Bertoli, director of content at iThrive. One benefit of the project, according to Bertoli, is that games produced by iThrive are easily scalable to multiple student populations. This contrasts with more conventional attempts to teach social and emotional skills in schools, which can require heavy resource investment from teachers. In one iThrive project, a mod for a popular computer game, players take on quests that require them “to look at conflicts from different perspectives and to practice regulating fear and anger.” “We already accept that other mediums like music, film and books influence and move us,” Bertoli says. “Games also create incredible worlds and tell fantastic stories. And beyond that, they involve their audience in a more tangible, interactive and complicit way that can prompt reflection and shift mindsets.”
courtesy of JourneyPure
11/7/17 3:14 PM
INDEX
A-E
Donald Pinkel 54
Justin Lanning 21, 45
Sarah Cannon Cancer Institute 58
Dorothy Lavinia Brown 53
Kaiser Family Foundation 42, 53
Saurabh Sinha 8
180 Health Partners 21, 45
Drew Altman 42
Kevin Lee 16
Savor Health 47
Aaron Symanski 32
D’Yuanna Allen Robb 45
Launch Tennessee 12
Scott Cihak 58
Accenture 32
Ed Cantwell 35
LifePoint Health 7, 18
Siloam Health 44
A.J. Bahou 32
Ed Miller 35
Marquee Dental Partners 60
SMG Catalyst Healthcare Research 64
A.J. Kazimi 19
Elisa Friedman 44, 46
Marty Bonick 60
American College of Emergency Physicians 18
Elizabeth Ann Stringer 24
Maternal Infant Health Outreach Worker 45
Southern Joint Replacement Institute 58
Aspire Health 53
emids Technologies 8
Elliott Green 39
Austin Madison 39
Erik Pupo 32
Axial Healthcare 24
EXPHealthcare 4
Bahou Law 32
F-M
Barbara Clinton 45 Belmont University 52 Beth Harwell 23 Bill Frist 53 Bill Southwick 60 Black Book Market Research 32
Stanford Moore 54
McWhorter Society 52
Steve Dickerson 23
Meharry Medical College 7, 53
St. Jude Children’s Research Hospital 54
Meharry-Vanderbilt Alliance 45
Stryker Warren 47
Mercer 32, 43
Surgical Care Affiliates 53, 60
Metro Public Health Department 45
Susan Bratton 47
Frist Cressey Ventures 21
Micah Winkelspecht 32
Gartner 32
Michael Warren 23
Gem 32
Michelle Bertoli 16
T-Z
General Care Corp. 53
Monroe Carell Jr. Children’s Hospital 40, 54
Giles Ward 32
TennCare Health Link 13 TennCare Kids 45 Tennessee Department of Health 20, 23
BlueCross BlueShield of Tennessee 40
Harry Jacobson 54 Hashed Health 32
N-S
Brandon Edwards 64
Hayley Hovious 61
Nashville Entrepreneur Center 47
CaredFor 22
HCA Healthcare 35
Nashville General Foundation 7
Center for Medical Interoperability 35
Health:Further 32, 48
Nashville General Hospital 7
Centers for Disease Control and Prevention 18
HealthSouth 53
NashvilleHealth 53
Healthways 21
Nashville Health Care Council 52, 61
HealthWise of America 53
Nate Bailey 6
Heritage Medical Associates 19
Neil de Crescenzo 32
Hope Through Healing Hands 53
Oscar Health 39
Humana 39-40
Parker Polidor 22
IQuity 62
Parthenon Pavilion 58
iThrive Games 16
Pathfinder Therapeutics 12
Jay Gunter 60
Paul Gentuso 19
Jeff Levin-Scherz 43
Peter Fuchs 32
Jeremy Faison 23
PhyMed Healthcare Group 60
Vanderbilt University Medical Center 12, 19, 35 40, 53
Jim Stefansic 12
QualDerm Partners 60
Vanderbilt Vision Research Center 12
Jim Usdan 60
Raiven Healthcare 12
Waller Lansden Dortch & Davis 6
Joel Gordon 53
Ray Herschman 32
Willis Towers Watson 43
John Bass 32
Renal Care Group 54
Joseph Webb 7
ReviveHealth 64
JourneyPure 16
Rusty Holman 7, 18
Centerstone Research Institute 16 Cerner 32 Change Healthcare 32 Chase Spurlock 62 Cigna 29 Clayton Associates 21 Colin Walsh 38 Craig Morrison 58 CredenceHealth 21 Cumberland Pharmaceuticals 19 Dan Prince 64 Danielle Kimmey Torrez 4 David Edwards 19 David Reagan 20, 23 David Shifrin 32 D.N. Batten Foundation 16
Tennessee Health Care Hall of Fame 53 Tennessee Hospital Association 20 The Crichton Group 39 The Wondr’y 47 Thomas Frist 58 TriStar Centennial Joint Replacement Center of Excellence 58 TriStar Centennial Medical Center 58 TriStar Health System 58 United Derm Partners 60 Vanderbilt Opioid Stewardship and Safety Council 19 Vanderbilt University 12, 19, 23, 35, 40, 47, 53
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OPIOIDS
‘Some bright spots’
How some Middle Tennessee providers are responding to the opioid epidemic by Lena Anthony
ach year, the Centers for Disease Control and Prevention collect and report data on opioid prescribing rates. In 2016, Tennessee pharmacies dispensed 107.5 opioid prescriptions for every 100 residents — a rate surpassed only by those in Alabama and Arkansas. But another takeaway from the data is this: Tennessee’s prescribing rate dropped 11 percent since 2014. That’s when the majority of providers first became tuned in to the prescription opioid epidemic and started asking, “Is there a better way to treat pain? ” Resoundingly, the answer was yes. And increasingly, provider organizations across the nation are changing the pain management paradigm by prescribing fewer opioids, using non-opioid alternatives and providing education about the dangers of opioid use. Before there were staggering statistics of overdoses or studies showing that the probability of long-term opioid use increases with just a fiveday prescription, there was pain as
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Mitch Evans
the fifth vital sign — a concept developed by the American Pain Society in the mid-‘90s that quickly took hold in health care. “We were taught to inquire about pain and the goal was to eliminate it,” says Rusty Holman, chief medical officer at LifePoint Health. “At the same time, we had this publicly reported measure of patient satisfaction that, to some degree, hinged on how well we managed patients’ pain.” Understandably, providers responded by prescribing opioids. “For years, we systematically worked against ourselves, and now we have to unwind and unravel that entire pain management framework,” Holman says. At Brentwood-based LifePoint, which owns and operates 72 hospitals in non-urban and rural communities in 22 states, that unwinding and unraveling has been occurring at the regional level for years. But in 2016, opioid stewardship became a national initiative, after members of the compa-
ny’s Emergency Department Physician Guidance Council — all emergency physicians — reported a significant increase in the number of patients coming into EDs to request opioids. “We dove into the data and found wide variability in the prescribing patterns coming out of our emergency departments,” Holman says. “Based on that information, we put together a guidance document, some of it mirroring guidelines and recommendations from the CDC and American College of Emergency Physicians, to distribute to our hospitals.” The document covers non-opioid alternatives, recommended dosages of opioids to limit dependence and diversion and educational information that can be printed out and given to patients and their caregivers.
Curbing the crisis
Earlier this year, LifePoint formed a multidisciplinary opioid stewardship committee, with rep-
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OPIOIDS
Rusty Holman
is used by the Vanderbilt Opioid Stewardship and Safety Council to better identify patients who are at risk of complication or opioid misuse disorder. “Our committee notifies providers of these at-risk situations and provides specialty advice for how to treat their pain most appropriately,” he says. Identifying and monitoring high-risk patients will �ecome mandatory for Joint Commissionaccredited hospitals beginning Jan. 1, 2018, when new and revised standards related to pain assessment and management take effect. Other requirements include designating a leader to oversee safe opioid prescribing, educating staff on safe prescribing and facilitating prescriber access to prescription drug monitoring databases.
‘We have to unwind and unravel that entire pain m a n a g e m e n t f r a m e w o r k .’ Dr. Paul Gentuso
resentatives from clinical informatics, multiple service lines and its national quality program, among others, to organize various initiatives to address the opioid epidemic. Similar to the ED guidance document, the committee plans also to create a document for perioperative pain management. Eventually, the committee will be responsible for tracking and monitoring prescribing patterns across the enterprise and sharing those numbers with individual facilities, with the expectation that they will encourage discussion and changes to prescribing habits. The committee is also tasked with educating about pain and the dangers of opioid use disorder to all stakeholders, including community members, patients, their caregivers, clinicians, senior leadership and even the board of directors. At Vanderbilt University Medical Center, Dr. David Edwards, assistant professor of anesthesiology, leads a team that tracks opioid prescribing and the use of opioid alternatives in near real-time. The information
Rusty Holman, LifePoint
With the exception of Missouri, all states maintain these state-specific electronic databases that track controlled substance prescriptions and offer a view into patients’ prescribing histories. States vary on what they require providers to do with these databases. Tennessee prescribers, for example, must register for the web-based Controlled Substance Monitoring Database, but they don’t have to consult it every time they prescribe opioids. Checking the CSMD is now standard practice at Heritage Medical Associates, which has 140 providers across a dozen sites in three Middle Tennessee counties. “Our providers routinely check the database,” says Dr. Paul Gentuso, chief medical officer for Heritage. “It gives us a full look into what prescriptions they’ve filled and uncovers people who might be doctor shopping.” Because it’s web-based, however, checking the database can add another layer of administrative burden to an already burdened clinical practice. And in situations when it’s not required, such as when prescribing a course for fewer than seven days, many prescribers may opt out of checking it. Nashville-based AffirmHealth is trying to solve that problem with its software platform, Dash,
that automates the process of checking the database and can pull that information just before a patient’s office visit. In addition, the platform delivers key insights such as daily morphine milligram equivalence (MME) and can alert providers when the MME seems too high. The platform can be used as a standalone tool or incorporated into the practice’s electronic health record management system. “We saw the movement of states imposing guidelines, and a lot of them are really helpful,” says Mitch Evans, CEO of AffirmHealth. “But we also saw providers having a challenging time complying with them while still running a practice. We built this platform to help them stay compliant and make sure they can practice responsible prescribing as efficiently as possible.” To address the opioid epidemic, providers are also relying more heavily on pain management specialists. Vanderbilt offers several pain-related consultation services, including for chronic, acute, perioperative and palliative pain. At Heritage, primary care providers now routinely refer patients with chronic pain or comorbidities to pain specialists outside of the organization. “We believe it’s important to have a single prescriber of pain medication,” Gentuso says. “Our primary care providers continue to attend to the other conditions, but they co-manage pain with an outside specialist.” But there’s a challenge. With certified pain specialists in short supply, Heritage has struggled to find local practices willing to see these patients. LifePoint, meanwhile, is looking at telehealth as a way to better connect its rural communities with qualified pain specialists.
But there’s still pain
Prescribing fewer opioids is one way to combat the prescription opioid crisis, but it does nothing to address the pain that patients experience. Multimodal pain management now includes not just opioids, but also non-opioid medications, like nerve blocks, injections, TENS (transcutaneous electrical nerve stimulation) units, topical analgesics, and ancillary treatments, such as physical therapy. Nashville-based Cumberland Pharmaceuticals has seen double-digit annual growth — to $4.1 million in 2016 — in the sales of Caldolor, the non-opioid ibuprofen injection that was developed at Vanderbilt and approved by the FDA in 2009 to be used in conjunction with opioids to reduce severe pain or instead of opioids in cases of mild to moderate pain. CEO A.J. Kazimi says it has been the compa-
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OPIOIDS
ny’s fastest-growing drug, which he partially attributes to the heightened awareness of the opioid epidemic. When surgery occurs, providers are setting expectations up front that some pain should be expected — which is a cultural shift from the heydays of pain as the fifth vital sign. The goal of multimodal pain management is to minimize pain, but also to minimize the use of opioids, which carry the risk of dependence and also are linked to longer hospital stays and more complications.
A treatment desert
In September, the Tennessee Department of Health released its latest data related to the opioid crisis. The MME rate for Tennessee prescribers has dropped 22 percent since 2012. And while 2017
isn’t over yet, the rate of decline appears to be accelerating, says Dr. David Reagan, chief medical officer for the Department of Health. But the numbers also reveal the potential fallout from prescribing fewer opioids: Despite the decrease in MME, the number of overdose deaths has risen dramatically — and much of that rise can be attributed to heroin, fentanyl and other illicit drugs that are obtained outside of the health care system. To screen for opioid use disorder, the state encourages emergency departments to use the SBIRT protocol, which stands for screening, brief intervention and referral to treatment. Both TennCare and private insurers reimburse providers for performing this evidencebased practice that was developed by the World Health Organization. But when many providers get to
the RT part, Reagan says, they’re at a loss of what to do. “Traditionally, emergency room physicians have said, ‘This is an ER, not a substance abuse treatment center,’” he says. “That’s true, but they are also a critical link in the chain. What we need to think about doing in health care is initiating that treatment before they leave.” Instead of stabilizing patients and sending them home, where the cycle of abuse can more easily resume, Reagan says hospitals should think about mobilizing a crisis team to evaluate them and discharge them with a treatment plan in place. At Vanderbilt, pain management specialists are encouraged to complete the training required by the Drug Enforcement Agency to prescribe the opioid antagonist buprenorphine for the treatment of opioid use disorder. Once certi-
HEALTH & WELLNESS KEY TO REGION’S FUTURE SUCCESS This region is recognized for economic vitality and quality of life. The Nashville Region’s Vital Signs report is a collaborative process led by the Nashville Area Chamber of Commerce that allows Middle Tennessee to forecast emerging issues and challenges, while we still have time to develop regional solutions. Good health in Middle Tennessee starts in our homes, schools, workplaces, neighborhoods and communities. Poor health brings a significant personal cost, but also damages the economic competitiveness of our region. With a tight current labor market and an unprecedented number of workers expected to retire in the coming decade, health plays a vital role in determining Middle Tennessee’s future productivity. Employers play an important role in helping to address health issues through innovative programs for their employees and by building a culture of health and wellness in the workplace. To learn more about the health of this region and how you can get involved, visit nashvillechamber.com/vitalsigns or nashvillehealth.org.
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fied, however, there are strict limits on how many patients they can treat per year. To help close the gap on treatment, Vanderbilt also has created a one-year fellowship program in addiction medicine. At press time, a super summit of opioid stakeholders, including the Department of Health, the Tennessee Hospital Association, Tennessee Healthcare Association and representatives from provider organizations across the state, was set to convene in Nashville. “If you look across the state, there are some bright spots where great progress is being made,” Reagan says. “But these ideas don’t spread quickly enough. It’s both remarkable and telling that the medical community is coming together to collaborate on how to more effectively and rapidly respond to this epidemic.”
Nearly one in 10 persons in the region lacks health insurance (9.7%)
Smoking rates Nashville region: 18.2% United States: 15.1%
More than $500 million is lost annually in productivity for the Nashville region due to absenteeism and presenteeism associated with diabetes, obesity and hypertension in the workforce.
Good health requires policies that actively support health:
Health
Transit
Housing
Work
Nutrition
11/8/17 11/7/17 11:41 3:16 PM PM AM 11/3/17 2:43
OPIOIDS
FEATURES
Closing the gap
180 Health Partners takes an entrepreneurial path to supporting opioid-addicted mothers by Lena Anthony
mong the alarming statistics related to the opioid epidemic, few demonstrate the cost to the health care system as well as this one: The average hospital stay for a baby born with neonatal abstinence syndrome (NAS), which occurs when the mother uses opioids during pregnancy, costs $66,700, compared to $3,500 for those without NAS. Justin Lanning, a former Healthways executive and co-founder of CredenceHealth — which sold to Xerox in 2011 — has witnessed firsthand the toll of addiction and NAS in his own extended family. With backing from Clayton Associates and Frist Cressey Ventures, he launched 180 Health Partners to develop an entrepreneurial approach to closing the cost gap in treating NAS. The company pairs expectant mothers with a dedicated care team to achieve safe medication stabilization or medically supervised tapering during their pregnancies. Care team members include a behavioral health supervisor, counselor, social worker, nurse, resource advocate and a peer advocate who, by definition, is a local mother who previously used opioids. The goals of the program are two-fold: Get mothers off opioids for good and reduce the pain, suffering, cost and mortality of babies born with NAS. Since its launch in 2016, the company has served nearly 100 mothers, and Lanning says babies born to mothers in the 180 Health Partners program are having significantly shorter hospital stays, with hospital costs that are about 85 percent lower than the average cost to treat NAS. Additionally, 100 percent of mothers enrolled in the program receive behavioral health support
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and 74 percent elect to receive immediate postpartum long-acting removable contraceptives, which Lanning says is much higher than typical Medicaid adoption rates. The company goes at-risk with managed care organizations — many of them working on Medicaid contracts — to achieve these savings and outcomes. As a payback to the communities it serves, 180 Health Partners donates money to community organizations through its 180 Impact Fund. In a nod to the tech backgrounds of Lanning an��� thers on 180 Health Partners’ senior staff, much of the support to mothers is enabled or facilitated by technology, namely Salesforce Health Cloud. “Technology plays a major role, but it’s not the upfront role,” he says. “When we’re engaging with mothers, it’s all about the relationship. We maintain eye contact and look for natural breaks in the conversation to record information. No one has their face in a computer screen.”
The 180 program launched in East Tennessee, expanded into Middle Tennessee this fall and will soon spread west toward Memphis. Next year, Lanning says 180 Health Partners services will begin its nationwide expansion, starting in Florida, Kentucky and Arizona. Lanning says the company was built to scale. As it enters new markets, market managers find local staff and develop and maintain a network of health care providers and other community partners. The biggest challenge, he says, is erasing the stigma with every new community it enters. “There is absolutely an opioid epidemic, but oftentimes we report on it as if it’s bad people doing bad things,” he says. “When we enter a new market, we work hard so that mothers feel like it’s OK to talk about it and know they won’t be shamed when they do go to talk about it. Everything about a business is challenging, but above all we want to make sure there’s love and compassion for these mothers.”
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Reducing relapse
CaredFor tackles patient engagement for opioid treatment programs by Lena Anthony
arker Polidor is not in recovery, but he knows people who are. “I never knew what to do or what to say,” the entrepreneur says. “Oftentimes, I wouldn’t do or say anything at all.” Now he has a better response: CaredFor, the Nashville-based company that Polidor and his brother, Colin, founded last year to help addiction treatment programs provide better longterm recovery support for their alumni and their families. The company licenses its platform to treatment programs for delivering personalized content, discussions and calls-to-action in a branded app. By letting alumni provide reviews, testimonials and referrals, the platform doubles as a sales tool. Providers also can track engagement with an analytics dashboard, revealing in real time how often users are logging in and what types of content they are accessing, while helping them identify who might be at risk of relapse. CaredFor launched in April 2016 and started marketing its product in the first quarter of this year. At press time, it had approximately 20 customers in various markets, including in Nashville. “We haven’t really seen a trend yet,” Parker Polidor says. “We’re seeing all sizes and types of providers using it.” The brothers are serial entrepreneurs by trade. In 2001, when Colin was still in college, they started their first venture — a valet parking service for ski resorts in New Hampshire. They sold it in 2004 and took the year to develop their next startup, Cell Journalist, which turned
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From left: Colin and Parker Polidor
everyday citizens into content creators for local media outlets. That company sold to Torontobased ScribbleLive in 2014, and the brothers left the company early last year. “After our last exit, we were really looking at ways to make a difference for those who were struggling with addiction,” Polidor says. “What we kept hearing was once people get out of treatment, that first year is really hard and the risk of relapse is highest. They go home and feel alone, isolated and ignored, which is in stark contrast to how they feel supported, encouraged and part of a community while in the early stages of recovery.” When CaredFor launched last year, the opioid epidemic was gaining national attention, but it wasn’t necessarily on the company’s radar. When the Polidors launched, they were focused on alumni engagement — specifically, former patients of addiction treatment centers. Now, Polidor says, the company has expanded its reach and is being marketed to the grow-
ing number of outpatient medication-assisted treatment programs for opioid misuse disorder. “The vast majority of people who are addicted to opioids are not going into a residential program,” he says. “They’re much more likely to be in a long-term outpatient program, but statistics show that more than a third of them drop out after three months. Statistics also show that if these providers can keep them engaged for 90 to 120 days, the odds of them sticking with the program are significantly higher.” Polidor says the Health Insurance Portability and Accountability Act-compliant platform should be particularly useful for office-based opioid agonist treatment (OBOT) programs, which often couple medications like methadone or buprenorphine with ancillary psychosocial services. Parker says OBOT programs can use the platform to conduct group counseling sessions, a feature that would be especially handy in rural communities where access to such services might be limited.
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OPIOIDS
FeAtUReS
Pot by PrescriPtion
Keeping pace with the healthcare industry.
Two Republicans continue quest to stem tide of opioids with medical cannabis by Stephen elliott
Sen. Steve Dickerson
s each legislative session comes and goes, two Tennessee legislators’ quest to legalize cannabis for medical use seems less and less quixotic. State Sen. Steve Dickerson, a Nashville Republican, has been pushing the medical cannabis legislation for three years. The anesthesiologist is currently conducting hearings along with co-sponsor Rep. Jeremy Faison, R-Cosby, in anticipation of introducing a bill once again for the 2018 session. “I’ll keep sponsoring it until it passes,” Dickerson says, echoing a statement he first made three years ago. “It continues to look more and more likely every year. But at this point, it’s still a flip of the coin.” The two tout cannabis as a safer alternative to opioids, but they’re facing pushback from fellow Republicans in the legislature, state health officials and representatives from law enforcement agencies. “We’re having to break some really longstanding, firmly and fervently held beliefs, and those things don’t change overnight,” Dickerson says. Their efforts could get a boost from a more mainstream wing of the ruling party. Beth Harwell, a fellow Nashville Republican who is a candidate for governor and serves as speaker of the House of Representatives, convened a special task force earlier this year to consider opioid abuse in the state.
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The group’s recommendations, published in September, include encouraging health care providers to consider “alternative pain management options.” Though the task force recommendations did not specifically mention medical cannabis, Harwell earlier this year said she was open to the prospect of legalizing the drug in Tennessee, in part because her sister, who lives in Colorado, successfully used cannabis to treat her back pain. Meanwhile, on Dickerson and Faison’s special committee, several Republicans with medical backgrounds pushed back, claiming cannabis should face the same federal Food and Drug Administration scrutiny that other prescription medicines face. Among the skeptics were Joey Hensley, Rusty Crowe and Richard Briggs. Michael Warren, deputy commissioner for population health at the Tennessee Department of Health, espoused some of the same concerns when testifying before the committee. “We really think that the FDA approval process and pharmaceutical-grade manufacturing assures that medications that Tennesseans or anybody else has access to are safe and effective,” he said at the time. For reasons articulated by a Vanderbilt University law professor at the hearing, there are unique challenges facing those attempting
Serving Nashville’s healthcare industry for more than 50 years.
Rep. Jeremy Faison
to gain FDA approval for medical cannabis. There was one thing medical cannabis advocates and Department of Health officials could agree on: The FDA should reschedule marijuana. Because it is part of the FDA’s most serious scheduling regime, cannabis can be extremely difficult to study. Dickerson says a rescheduling would be “a game changer,” while David Reagan, chief medical officer at the Department of Health, says the agency has advocated for rescheduling the drug. But Faison argues the harm caused by opioids in Tennessee every year is enough to warrant unique accommodation for cannabis. “I want us to realize that in 2016 in Tennessee, opioid abuse deaths [were] right at 2,000,” he says. “If we’re going to hold marijuana use for medical use to a standard, then compare it to what’s going on right now that’s legal and that’s encouraged by a lot of doctors.”
Lucy Carter
615-346-2497
Scott Mertie
615-782-4292
krafthealthcare.com
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FEATURES
OPIOIDS
Root cause
Axial Healthcare uses data analytics to intervene in problematic opioid practices by Stephen Elliott
t a recent health care and technology conference in Nashville, Elizabeth Ann Stringer shuns success stories to pitch her company’s potential. Instead, she turns to a missed opportunity. The chief science officer at Nashville-based Axial Healthcare calls up the anonymized health information of a recently deceased 43-year-old woman from East Tennessee. The woman had a history of sleep apnea yet was prescribed respiratory-depressant opioids. She was prescribed opioid doses well beyond guideline limits; she had been co-prescribed sleep aids. The woman died of cardiac arrest just one day after receiving her final opioid prescription. “She was receiving very substandard care,” says Stringer, who holds a PhD degree in neuroscience from Vanderbilt University and did postdoctoral work on the effects of opioids on the brain at Stanford University. “This should never, ever happen, but it happens every day.” The impact of the late woman’s interaction with the health care system reaches beyond her tragedy, however. The collective effects of opioids and other drugs on her body led to compounding costs — and opportunity costs — in the health care system in general. “Resources are being diverted from other people and going to this individual who’s receiving poor care,” Stringer says. “It is a major [financial] drain when p eople are not properly cared for.” Instead of returning to academia, Stringer joined Axial Healthcare, in part to address the problems illustrated by the case at hand. The
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Elizabeth Ann Stringer
company, founded in 2012, has built analytical platforms that take health insurance claims data and other inputs and turn it into guidance for health care providers, patients and insurance companies, particularly concerning opioid usage and prescribing habits. According to Axial Healthcare statistics, one company product (through which pharmacists talk to providers about opioid prescribing patterns and at-risk patients) resulted in multi-prescriber activity dropping 2.4 percent and the number of patients on opioids dropping by 1 percent. Part of the problem, Stringer says, is lack of education. Pain is not taught thoroughly in medical schools, she notes, even though many patients present to providers for exactly that reason. “Very often, providers don’t know how to treat pain,” she says. “What they do understand is that this medication — opioids — can help address the pain complaints, and patients are going to be happy when they leave the doctor’s office.” The opioids do not address the underlying cause of the pain, but rather mask it. And in the
process, acute pain can morph into chronic pain, leading to a cascade of problems for the patient and costs for everyone involved. Axial Healthcare aims to reverse that dynamic. In some cases, it’s as easy as alerting a health care provider to a problematic prescription practice he or she might use but not recognize. In other cases, the analytics can identify pill mills or high-risk patients and initiate an intervention. “It’s not just enough to analyze a problem,” Stringer says. “We want to build out capabilities that are able to intervene, move the needle and improve care.” While the company’s work relies heavily on insurance claims data, the platforms are engineered to build on themselves, according to Stringer. “The claims data is foundational, but all of our products produce their own data that then feeds back in,” she says. “The outcomes fed into the system help us tailor our models to become more specific and more effective with our recommendations.”
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Thanks, Nashville! Best Weekend Getaway!
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Debate: The U.S. health care system is terminally broken
Mayo Clinic conference hosts Intelligence Squared discussion on how to create meaningful change
an the U.S. health system as we know it today be “fixed” and become better, smarter and more compassionate? That was the question debated in September as part of Transform, the annual conference of the Mayo Clinic Center for Innovation. The discussion was moderated by ABC News correspondent John Donvan and can be viewed in full at www.intelligencesquaredus.org. On one side and arguing that yes, the U.S health care system is terminally broken, were Shannon Brownlee, visiting scientist at the Harvard School of Public Health and senior vice president at the Lown Institute, and Robert Pearl, a former CEO of The Permanente Medical Group in California. Opposing them and arguing that there is still time to fix the system were Ezekiel Emanuel, a bioethicist and vice provost for global initiatives at the University of Pennsylvania, along with David Feinberg, president and CEO of Geisinger, an integrated health system in Pennsylvania widely viewed as a model for innovation. Here are edited excerpts from their debate.
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Brownlee: You’re going to vote on a single premise, but in fact there are two ideas in that premise. And one of them is that you have to ask yourself the question, “Just how broken is the system, anyway”? My partner Robby Pearl and I agree that it is incredibly broken. If it were a patient, if the health care system were a patient, we would have put it in the ICU long ago. But the second thing you must decide is whether or not the reforms that are in place can revive that patient. It can’t. It is in worse shape than our opponents are going to argue, and we think the reforms are less than adequate. Now I warn you the picture I’m going to paint isn’t very pretty. We have fragmented care. We have burned-out physicians and nurses. A quarter of a million patients die every year of
errors, nosocomial infection and adverse drug events. We’ve had a record number of drug recalls in the last decade, in part because we have an FDA that is a captive agency. […] And don’t get me started on medical devices. We have tragic care for the elderly. We’ve almost killed primary care. And we’re still paying fee for service even though we know that fee for service rewards more care, not better care. It’s kind of like paying for a car based on the number of parts in the car. And we still do not have universal coverage. Meanwhile, costs are out of control. And it’s not just drug companies that are the problem. It’s that everybody is charging what the market will bear. Costs are also out of control because of how much we waste on fraud, on adminis-
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Donvan: Thank you, Shannon Brownlee. […] Our next debater will be speaking against the motion. […] Ladies and gentlemen, please welcome Zeke Emanuel.
tration, on inefficiency and on my special interest, overtreatment. We spend about $300 billion a year on services that patients don’t need. And when you add it all up the waste is about $1 trillion. So costs are also out of control because we have massively overinvested in the hospital sector and underinvested in primary care and communitybased care. And hospitals are now consolidating the fastest they can in order to capture market share and drive up prices even higher. They are investing in technology and specialty care, not because that’s good for the community, because it’s good for their bottom line. Every one of these problems is fixable. But they should be seen not as isolated ailments. They’re systemic failures requiring systemic
solutions. But the majority of actors out there, what Robby calls the legacy players — the hospitals, the drug companies […], the device makers, the insurers — they a� en’t going to like systemic solutions very much. And they are resisting a lot of these solutions. And they won’t fix the problems that exist until they have to. Now, our opponents are going to give you examples of incredible care, fantastic primary care, fantastic medical records. Many, many wonderful innovations. But the problem is these are million-dollar solutions to a trilliondollar problem. And they are not going to scale up. They are one-offs. So given this, I think that you have to vote in favor of the premise. The American health care system is terminally broken. Thank you.
Emanuel: Everyone agrees that the U.S. health care system is broken. There’s $800 billion, $1 trillion of waste, at least $200 billion of unnecessary care, and $130 billion of inefficiently delivered care. The quality of the American health care system is not great almost no matter how you measure it, whether it’s infant mortality [or] survival for acute myocardial infarctions. Even cancer treatments that we pound our chest on as being the best in the world. Childhood leukemia: We’re exceeded by Germany by four percentage points. Breast cancer: France does better than us. We are generally underperforming, no doubt about it. But the key word in the proposition is terminally broken. Are we beyond fixing? […] If you go around the country, there are multiple points of light — much more than Shannon says — and not only reserved for places like Mayo Clinic, Geisinger and Kaiser. There are many, many places. You go to CareMore, which is a Medicare Advantage plan in Southern California, and has now branched out into Medicaid and other programs around the country in places like Tennessee and Iowa. They care for chronically ill elders, much sicker than the average Medicare patient, and they do phenomenally well. They have 45 percent fewer hospital admissions than Medicare — regular Medicare. If you go to a small group in Hawaii, they’ve addressed behavioral health problems by co-locating a lot of psychologists in their offices. They treat depression, anxiety, smoking cessation problems, insomnia and even patients who are noncompliant with medical disorders, and have substantially improved their performance. Palliative care — another area where we have underperformed for many years. I’ve been studying it for 35 years. We now have interesting groups. A for-profit company based in Nashville, Tennessee, Aspire, that begins palliative care not in the last month or the last two weeks of life, but 12 months before. They identify patients, send out a nurse to the home and they’ve seen 25 percent savings and are keeping patients in their homes over that period of time. […] These are but a handful of thousands of examples around the country. So how do we scale them? Well, let’s be honest: The key is behavior change. How are we going to get doctors and hospitals, skilled nursing facili-
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ties, home health care agencies and all the rest to change? We know. We have to change the financial and nonfinancial incentives. There is no disagreement between our side and the affirmative side that we need to change off the fee-for-service system. The fee-for-service system rewards doctors for doing too much. I’m an oncologist. It rewards us for giving chemotherapy. We already are moving off the fee-for-service system. […] We’ve seen tremendous change in bundled payments, in creating efficiency, in bringing down the cost and […] making quality the same. We don’t sacrifice at all. We have Medicare bundles, we have private insurance bundles and we have states like Arkansas and Tennessee introducing bundles broadly. They are going to expand because they actually bring returns relatively quickly. Yes, we can transform the American system. It’s not terminally ill. But we need to be careful about the timeline. It takes four years before you begin to see change and then 10 years before change sets in. 2030 is the right timescale. This is not like flipping the switch. This is change over time of a $3.4 trillion industry. We are not terminally ill. We can save the American health care system. Donvan: Thank you, Zeke Emanuel. […] I want to welcome to the stage Robert Pearl. Pearl: The American health care system is terminally broken. Shannon’s told you the magnitude of the problems. And the solutions that exist are simply inadequate. […] The reason is simple: What’s in place today is a compromise, a political compromise, to get the Congressional votes and to avoid the ire of the hospital systems, the health plan systems and the drug industry. It is simply inadequate to be able to overcome the shortcomings. […] Ninety-two percent of physicians get paid on a fee for service
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basis. They get rewarded for a splenectomy. They don’t get rewarded for thinking about how they can make sure [the patient] got the vaccine that is needed. If we’re going to address not just quality but also address cost, we have to move from fee for service to capitation. It’s difficult but anything less will be incomplete. Zeke talked about bundled payments. The evidence says in bundled payments, costs come down on a unit basis but doctors do more. When hospitals and doctors consolidate, what do we see happening? They don’t use it to improve efficiency and effectiveness of care. No. They use it to raise the price by controlling the marketplace. Every American needs to have the totality of the medical information available to every physician, hospital at every point of contact. It can
‘2030 is the right timescale. T h i s i s n o t l i k e f l i pp i n g t h e s w i t c h .’
Robert Pearl
be done. But it won’t get done. Why is that? Because the people who manufacture and sell the electronic health records are not going to open up what’s called APIs, the application processing software that’s necessary for third-party developers to come in, because they know it will break the stranglehold they have on those who have purchased the systems already. And we need to make sure we address the issue of drug prices. Drug costs are rising three times more rapidly than medical inflation, five times more rapidly than overall inflation. It used to be that drug companies spent all their money on R&D. That’s not happening anymore. A lot of them are simply acquiring competitors, creating monopolistic control of that marketplace. And primary care: 20, 25, 30 patients being seen every single day. We talk about primary care, but we still train more specialists than primary care physicians. The 15-minute [visit] has got to become a thing of the past. The changes that are happening, the Medicare changes are making the life of primary care [doctors] worse. What we know today is that the American health care system is terminally broken. All the small fixes you heard about from Zeke will make a small degree [of difference]. One-offs, people in one area will do it, but not another area. We’ve got to change all of American medicine, how it’s
organized, how it’s reimbursed, how it is led, how it’s technologically supported. It is terminally ill. It does not have to be. Donvan: And here is our final debater in making opening statement against the motion, David Feinberg, the president and CEO of Geisinger. Feinberg: So let’s talk about behavioral change. We could fix every problem we have in health care immediately — 50 percent of the cost — if we ate right, we didn’t use illegal drugs, we drank alcohol in moderation, we wore our seat belts, we didn’t shoot one another and we prevented adverse childhood situations that we know we can prevent. Overnight, we fix the health care debate. Our opponents will tell you that the United States spends more on health care than most industrialized countries and our outcomes aren’t as good. But that graph is actually misleading, because the United States spends the least amount on social services compared to those other countries. And when you combine social service spend and medical spend, we’re kind of just in the middle. So we have an option. We can either start spending as a country on social services, or it’s up to the health care system to fill that gap. So we’ve done some things at Geisinger. We’ve sequenced 100,000 people’s entire DNA for free. We look at their DNA, and about 4 percent of those people have medically actionable conditions that we could intervene with before the bad thing happens. And in those cases, there’s probably about four first-degree and second-degree relatives that are also affected. Health care is not just about getting to the doctor and getting to the hospital. It’s understanding your genetic code and also your ZIP code. And what we looked at [were] ZIP codes where we provide care. We have towns like Shamokin, Pennsylvania, where 80 percent of the kids are on subsidized lunch. The rates of diabetes are one in four to one in five. Food-insecure people with great health care through Geisinger still have measures of blood sugar that are out of control. Guess what happens when we bring those people in and we say to them, “Here is food, fresh fruits, vegetables, lean meats, legumes. And if you’re living in a motel, we’ve got spatulas for you, and we have microwaves and hot plates. We’re going to teach you about your diabetes, and you’re going to give you and your family this food to eat.” Every single patient has had a decrease in their hemoglobin A1C, in their blood pressure, in their weight. If this was a pill, it would be a multibillion-dollar pill.
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I believe health care reform begins with the docs, the nurses, the patients, the moms, the brothers and sisters, the communities coming together, taking care of one another, scaling these great ideas and making sure that every patient gets the exact kind of care that you’d want for everyone in your family. Thank you very much. Donvan: Thank you, David Feinberg. Shannon Brownlee: Your opponents are taking issue with your argument that the points of light, the islands of excellence, cannot be scaled. They are saying sure they can. Argue that point with them. Brownlee: We’ve seen periods of ferment in health care before, and each time there are these incredible points of light and I don’t argue them at all. They are fantastic and there are a lot of them. But somehow, the existing legacy players somehow manage to beat it back. Why is this time different? Emanuel: So let’s look at the mid-‘90s: We had a big push to control health care costs after the failure of the Clinton health care reform. [I]t was managed care, and it basically was 1-800-JUSTSAY-NO. And the public did revolt against that and did want more choice and not drive-through deliveries. And the consequence was we got rid of any management and costs did go up. Now we have a different problem. Now the problem the public is upset about is affordability. It is the inefficiency and unnecessary care of the system and the public, the various people who can control the system, are responding. […] You have the public that is pushing, you have employers that are pushing and you have changes in policy throughout the system. Feinberg: And we have something else that we didn’t have back then. We have data. We now have an electronic health record, as clunky as it is and tough as it is. We now have data to help make these decisions that we didn’t have in the ‘90s. Pearl: So, a couple of things. First, in terms of bundled payments: What does the data show? Bundled payments work very nicely to lower your unit price. What have we seen? We’ve seen two things. Physicians doing more total joints now and spine surgeries that are more complex. The cost increase for the complexity that has been put in place in response is more than the dollars that have been saved. But I want to address something that David said, which is, he’s absolutely right: We have
places like Geisinger and Kaiser and Mayo that do things very well. […] The question is, how do you take a broken fee-for-service system, and 19th-century cottage industry with doctors scattered across the community, small hospitals in every town, and now put that together into a Geisinger or Kaiser? We believe that that’s not going to happen without major force. Emanuel: We’ve had states adopt payment transformation for their Medicaid programs. I mentioned Arkansas and Tennessee as but two examples. Ohio is doing stuff and so are other states. Oregon’s doing some interesting things with its Medicare population. In addition, we have private payers that have entered this space and are using various different payment mechanisms to shift. I’m
80 percent of the market. The fact is, you have big insurers across the country. You have Cigna and many others that are trying to move to capitation, moving to steering patients to efficient providers. You have the Massachusetts BlueCross BlueShield plan which introduced the AQC, alternative quality contracts which brought down costs and improved the quality. But it took four years of working hard at it. And it has to be sustained. […] And you’re lifting up the pot and saying, after one year, “Is it boiling yet?” That is too early. Change takes time. It takes four years before you get the maximum change and then 10 years. Brownlee: Number one: Zeke, I’m not saying that you look after a year and you say, “Oh, not working. It’s terminal.” That’s not true. That’s not what we’re saying. It’s that it is a massive, massive problem. Number two, it does take time. And number three, we have one state that’s globally budgeted all of its hospitals. And it’s going along pretty well. It’s not like everybody’s at risk instantly. They’re moving slowly.
‘ T o [ g o a t r i s k ] i m m ed i a te l y , t o t u r n t h e s w i t c h , w o u l d be a d i s a s te r . So you’ve got to start it with u p s i de r i s k o n l y .’ working with the BlueShield firm in Hawaii. They’re trying to move all their primary care doctors in the state of Hawaii to capitation. It’s not easy and it takes time. And those changes are happening throughout the country. Brownlee: By the way, Hawaii is a very, very interesting place because there’s really only two insurers. Well, there’s Medicare. But there is HMSA, which is the BlueCross BlueShield, and there is Kaiser. And that actually makes a difference. Emanuel: Shannon, that’s true of many states. Alabama, the BlueCross plan has 80 percent of the market. Tennessee, the BlueCross plan has
David Feinberg
Donvan: I want to pick up a point […] that Shannon made, while it’s still out there. She said that change is going to have to come from the top. And you made an argument in your opening, David, that the change actually has to come from the bottom […] Respond to her point on that. Feinberg: When I was at UCLA, we diagnosed the first case of AIDS. We did more organ transplants than any hospital in the United States. We invented Herceptin. Those things don’t come from Washington, D.C., right? Those innovations happen in our academic medical centers. They happen in a place that’s trying to figure things out differently. And this health care reform thing is going to happen the same way. And it’s because communities, people like our audience are going to say, “You know why we have to do it this time? Because we can’t afford not to do it. Because if we
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don’t do it, we don’t have money for roads, we don’t have money for schools.” It’s a different day. I think we have a moral imperative to get it right. And I think it’s going to get pulled by our communities. Emanuel: I think it’s synergistic. It’s partially from below, with innovative doctors and hospitals. It’s partially from above, [with] changes [to] the financial incentives. Let me give you a very good example of where we’ve had massive change in the system. It’s far from perfect, but before the Recovery Act in 2009, […] 9 percent of hospitals had electronic health records. No doctors had electronic health records. We put in incentives to say you had to have electronic health records. I’m not saying it’s nirvana. I’m not saying it was rightly done. I oppose many of our regulations and thought they should be different. But today, seven years later, every hospital has an electronic health record. All doctors are getting on board with it. And we are going to see, in the next generation, those APIs are opening up. Pearl: You’re absolutely right; hospitals have done it. But fewer than 20 percent of physicians’ offices can communicate with that machine even though it’s next door. And that is going to be the big leap. Brownlee: The piece that’s really important that you just said, Zeke, which is that the innovation has to bubble up from underneath. But there are some things that have to be imposed from above. And the shift in payment has to be imposed. So who’s going to do the imposing? Medicare hasn’t done it yet. I’m hoping at some point it’s going to move to some kind of global budgeting for hospitals, and that it’s going to start putting physicians at risk. But are the private plans really going to move this direction? Are they going to do it?
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‘ W e ’ v e s ee n pe r i o d s o f fe r m e n t i n h ea l t h c a r e bef o r e [ … ] b u t s o m e h o w , t h e e x i s t i n g l e g a c y p l a y e r s s o m e h o w m a n a g e t o bea t i t ba c k . W h y i s t h i s t i m e d i ffe r e n t ? ’ Feinberg: You know, Shannon, I’ve had an opportunity to work in an academic medical center and now in an integrated delivery health system. It’s a culture and an understanding that takes years to develop. And to do it immediately, to turn the switch, would be a disaster. So you’ve got to start it with upside risk only. Audience member: For scaling up, do we need a uniform national person identifier for health care? And if we do, is that politically feasible? Brownlee: I don’t think it’s necessary, but I don’t think it’s a bad idea. You could have all your banking information on a little card. Pearl: Yeah. What’s essential is that we have everyone’s electronic information available to every physician and hospital at the point of contact. Unfortunately, we’re a long way away from that. We disagree on how likely it’s going to be. I think a small card with all that information won’t be enough. You need to know whether [the patient] had his vaccine or not. And that requires every physician. Interconnectivity is not going to be enough. We need to actually drive a single national IT system like we have ATMs. Feinberg: Come back to this conference in three years and everyone will have, on their iPhone, all their medical records and be able to share it with anyone. It’ll be completely interoperable and usable. I think you can probably even be able to sell some of your information — de-identified or identified — because there’s value in that data. Audience member: The question that I have — and I would enjoy a healthy debate on — is, if all the providers in this country become good at managing risk and become risk-bearing entities, will that solve our fundamental issue and turn the health system around? Pearl: If it actually works, if we’re actually able to change it, it will have a very good impact
Shannon Brownlee
upon the health of the country. I’m just still very skeptical that people will do it. They’ll fill out the checkboxes and make the things happen. I don’t think they’re really going to change the underlying social determinants, the other wellness factors, all the other things that go on, unless every one is a checkbox. And now you’re going to totally swamp the primary care physicians of the United States, of which we already do not have enough. Feinberg: Your question is a great one. And if everybody did the right thing, we solve another problem. We have a provider shortage. And if everyone does the right thing, all of a sudden, we don’t need as many doctors as we currently have. So I think that that’s an important piece in all of this. […] Especially in some rural areas and in underserved areas, trying to find primary care [and] specialty care is almost impossible. Donvan: The votes are in. Here’s how it works: You voted twice. It’s the difference between the first vote [before the debate started] and the second vote; whoever went up the most will be named our winner. The motion again: The U.S. health care system is terminally broken. On the first vote, 42 percent of you agreed with the motion, 34 percent of you disagreed and 24 percent were undecided. Those were the first results. Let’s look at the second result. The team arguing for the motion the U.S. health care system is terminally broken, their first vote was 42 percent, their second vote was 45 percent. They picked up 3 percentage points. That is now the number to beat. Let’s see the team against the motion: Their first vote was 34 percent, their second vote was 51 percent. They pulled up 17 percentage points. The team arguing against the motion that the U.S. health care system is terminally broken is our winners. Congratulations to them.
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Digital strategy, design,
PointClear Solutions is a leading digital health consulting company that provides enterprise software and mobile and web-based application strategy, design, development, and management services for clients worldwide, including industry powerhouses like McKesson/Change Healthcare, Walgreens, Philips, Nuance, and the CDC.
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Begin by clearly defining your project scope – what’s in and what’s out, what’s essential and what would be nice to have, and what needs to be delivered when (and for what cost). All major stakeholders and team members need to be aligned on this. It’s also important to take this time to look beyond the build and develop a 1-3 yearplan, clarifying how your software will scale; who will monitor and maintain it; and the total cost of ownership over the long-term.
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11/7/17 3:24 PM
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COVER
Blockchain reaction Local leaders are p l ay i n g k e y r o l e s i n bringing distributed ledger technology to h e a lt h c a r e b y S t e p h e n Ell i o t t a n d Geert De Lombaerde Giles Ward
est known as the platform that birthed bitcoin and other cryptocurrencies, blockchain has grown widespread over the past year — to the point that Gartner analysts this summer published a paper outlining the hype cycle around various uses for the distributed ledger technology. But as Gartner’s researchers themselves put it, this innovation with “the potential for substantial change in technology development and delivery as well as in how the economy, business and society operates” shouldn’t be ignored. Walmart is using blockchains to better track food as it travels to its stores. Property insurers are creating smart contracts that securely and transparently vet and adjudicate claims.
B
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And in Estonia, considered one of the world’s most digitized countries, shareholders of companies listed on the Tallinn Stock Exchange use a blockchain-based service to electronically vote at annual meetings. When it comes to health care, blockchain similarly promises to eliminate much of the friction and waste that has been created by the growth of the industry and the intermediaries, vendors and “solutions” that growth has created. Those players emerged to create a level of trust between counter parties, says John Bass, CEO of locally based Hashed Health. But they won’t be needed if distributed ledger technology is widely adopted in health care.
“The distance and the complexity between the two endpoints — between the pharma company and the patient, between the hospital and the consumer, between the two ends of the supply chain — has grown more and more complicated and more and more costly,” Bass told Health:Further’s David Shifrin during this summer’s Health:Further conference. “What blockchain does is it moves that trust issue to the software and eliminates the need for those middlemen […] You don’t need those relational databases with those applications on top to solve all the manmade issues that we’ve created over time.” Not surprisingly, there is tremendous interest in removing some of the accumulated tech
daniel meigs
11/8/17 1:00 PM
COVER
‘ T h e e a r ly a d o p t e r s are the ones that g e t r e w a r d e d .’ Micah Winkelspecht, Gem
clutter: A Black Book Market Research survey published in October showed that 76 percent of insurance company executives were either already deploying or in the process of implementing some blockchain solutions sets and 70 percent expected blockchain to be integrated into the systems by early 2019. It could be, says Nashville attorney A.J. Bahou of Bahou Law, that blockchain in health insurance becomes analogous to streaming services and the music industry — a case of follow quickly or be left behind to struggle. Things look set to move quickly and in many different directions within health care. On these next few pages, we’ve assembled a few ideas to give you a sense of that imminent change. Let the blockchain reaction begin.
In the revolutionary vanguard
For some in the blockchain world, the language is more about what’s possible and less about what’s in the way. They talk about “fundamental changes” and “grand ideals” and presenting their view of the world to everyone else. “[Blockchain] technically makes it possible to have a single version of the truth and for society to technically organize all the information about an individual in a secure and consistent way,” Peter Fuchs, a senior corporate strategy consultant with Mercer, told the crowd at the Distributed:Health conference in September. “That’s going to fundamentally change everything.” Fuchs was joined in the conversation at Distributed — which was held at the Schermerhorn Symphony Center and organized by locally based BTC Inc. — by Micah Winkelspecht, founder and CEO of blockchain application developer Gem. Winkelspecht said the changes Fuchs envisions could hit health care soon. “In the next year, what you’re going to start to see is the first production deployments of real working code processing real transactions with real customer data,” Winkelspecht said.
A.J. Bahou
the European Union. The General Data Protection Regulation, Fuchs and Winkelspecht said, is some of the strictest regulation ever. “The purpose of the regulation is to really reassert the rights of the individual around their data, and this regulation actually gives it some teeth that will force organizations to adopt a new standard much more quickly than they would otherwise,” Winkelspecht told the Distributed crowd. “Blockchains can provide the rails for these organizations to be able to comply with this new regulation.”
Building decentralized systems of truth
Neil de Crescenzo
“And then nobody will ask if blockchains work in the health care industry. The early adopters are the ones that get rewarded the most and then the laggards are going to start to fall behind.” Fuchs and Winkelspecht predicted a world in which entities warehouse our personal data like a bank warehouses our money, and provide a financial return in exchange, like interest on a bank account. “Your data is being bought and sold all the time, for real money,” Winkelspecht said. “You never see the economic benefit of that data. Only they do, because the data belongs to them and not you. If we can shift the ownership rights back to the individual, perhaps this is a way for people to monetize their own data, or at the very least receive the personal benefits like personalized medicine.” One development that could boost blockchains and their role in shifting those ownership rights is a set of new data privacy rules slated to go into effect next year in
A small Germantown-based team has begun laying down some of those rails and connecting them to other railroads in the health care world. Launched last year and backed by local investment firm Martin Ventures and Chinese blockchain specialists Fenbushi Capital, Hashed Health is building a consortium of health IT firms, consultants, educators and more to think through, build and support blockchain solutions on a shared (and money-saving) basis. One of the consortium’s first projects has focused on streamlining the credentialing process for doctors licensed in Illinois or active there with credentials from other states.
‘It’s not disruptive on its own but what it allows people to do will b e d i s r u p t i v e .’ G i l e s W a r d , H a s h e d H e a lt h
“We create a decentralized system of truth,” Bass told Health:Further’s Schifrin. “It solves a problem in today’s world but it also sets up the system to tackle future issues.” That approach, says Hashed Health Executive Director Giles Ward, typifies what Hashed is looking to do — while leaving the more audacious goal setting to others. Ward, a former DSI Renal executive, acknowledges that some people see perfect electronic health records as a holy grail of sorts but argues that it’s more important in the coming years to prove blockchain’s worth in more narrow — yet still
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‘ T h i s i s a j o u r n e y. What we’re trying to do i s e n a b l e t h e f i r s t s t e p .’ N e i l d e C r e s c e n z o , C h a n g e H e a lt h c a r e
eyeopening — ways. The technology, he says, can provide an elegant solution to many problems deemed at least mildly intractable today. “We say to people, ‘We don’t know your problems the way you do but let us give you this tool to help,’” Ward says. “It’s liberating to think of it as a data structure. It’s not disruptive on its own but what it allows people to do — securely track opioid distribution, for example — will be disruptive.” For a good example of how blockchain can create transparency and trust where there is little these days, Ward says to pay attention to what some insurers are testing. Their projects, he says, could drastically slash the time it takes to adjudicate claims by quickly verifying that the patient is covered and has received treatment, posting that information to the appropriate records systems and agreeing to a payment — eliminating the need for an explanation of benefits statement and the potential for nasty surprises.
‘This is a journey’
Hashed has this year welcomed to its consortium a number of notable names, including payment processor and IT services company Change Healthcare, which processes 12 billion health care-related transactions annually that comprise more than $2 trillion in claims. Change Healthcare CEO Neil de Crescenzo announced at Distributed that his team will before year’s end launch a blockchain-based platform to process transactions linking providers and insurers — bringing real muscle that can push open the door to widespread blockchain adoption. That news came a few months after the company said it was joining the Hyperledger project hosted by The Linux Foundation as well as Hashed. At Distributed, de Crescenzo echoed Hashed’s incremental ethos.
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“We are building from the inside out so as not to get too far ahead of our customers,” de Crescenzo said. “This is a journey. What we’re trying to do is enable the first step. We’re ready to work with every company in this room, across the industry and outside the industry.” Change CTO Aaron Symanski says many companies will over the next two years develop a much clearer understanding of how they can use blockchain platforms and what they can bring to the table. Similarly, he adds, issues around regulation and liability also will be largely settled. “None of those questions are show stoppers,” Symanski says. At a Distributed conference panel, Symanski and others outlined how blockchain technology can help the industry redefine its underlying “unit of accounting.” Health care payments can get complicated quickly because a patient (and her insurance carrier) don’t often pay a single fee to be treated for a broken arm. Instead, those procedures are broken down by line item: this much for the X-ray, this much for the plaster, this much for the pain prescription. That involves multiple parties needing to check off on their part of the treatment, a process that plays right into the strength of blockchain. “You need to introduce a different way to ensure that both the services are being provided and received and [that] there’s trust in the transaction and ultimately funds flow to the right people at the right time,” Symanski said. “And that, in fact, is what blockchain can help solve.” Ray Herschman, vice president of accountable care strategy and business development for health IT giant Cerner, is optimistic major changes could come to health care payment structures in the next couple of years, driven by some large early adopters. “There’s a new language that we have to get a common understanding of,” he said during that Distrib-
uted panel. “Bundled payments is not a new idea. The question is, ‘Are we at the tipping point where that’s going to become a common form, not an exception or a science project?’ I think we’re there.”
Pumping the brakes just a bit
Not everyone in the blockchain arena — even those who see the potential for quick and meaningful changes — think the shiny new technology will sweep away all the cumbersome legacy technologies. Questions still linger about its scalability and security and even the most fervent boosters say a worst-case scenario would be for someone to go too big too quickly and suffer some sort of failure. Erik Pupo, managing director of Accenture’s health client service group, told Distributed attendees he sees plenty of opportunities in care coordination, management applications and “some sort of personal health record” managed by the patient to some degree. “But what I cannot see,” he added, “is an EHR on blockchain. I don’t foresee that potentially ever happening. Not because it’s a bad idea, but because we’ve made a tremendous investment in health IT. We don’t see any interest in using blockchain to replace existing classical database approaches.” Bahou says it’s been striking to see how quickly the consensus around blockchain uses in health care swung from 2016 — “The customer should be in control of his health record” — to this year, with the thinking centering much more on transactions that use records pulled primarily from databases. The dynamic of powerful stakeholders clinging to existing business models is perhaps the biggest obstacle to blockchain’s swift rollout across the health care landscape. It will take courageous CEOs deciding to share their data — “Storing data is just a cost,” de Crescenzo says — and that could take a while. Hashed’s Ward says the end-of-the-rainbow scenarios being described by some boosters these days could end up taking 25 years to materialize. “It’s dependent on the big players changing their models,” he says. Even with CTOs and CIOs convinced of blockchain’s technical merits, that could take a while — and for a very old-school reason: The same Black Book Market Research study that had seven out of 10 insurance execs thinking they’ll have blockchain on board in 18 months also showed that 88 percent of respondents say an unclear cost is stopping them from committing to a time frame.
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TECH
‘Action gets Attention’
The Center for Medical Interoperability is moving closer to setting standards that will drive innovation by Geert De LombaerDe
How do you go beyond admiring the problem?” asks Ed Cantwell, CEO of the Center for Medical Interoperability, a nonprofit research lab founded in the spring of 2015 to rally the buying power of some of health care’s biggest names behind improving the sharing of data. For Cantwell and his team based in the oneC1TY development a stone’s throw from HCA Healthcare’s headquarters, the answer is clear. Backed by HCA, Vanderbilt University Medical
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Center and other big names, they are drawing up a common set of technical standards and building a certification center to verify that health devices and systems will run on those platforms. “Action gets attention,” Cantwell says. And the Center for Medical Interoperability’s first notable action should become public soon in the form of draft specifications for medical devices used in hospitals. The plan is for those specs, written in conjunction with vendors and equipment makers, to align the basic system principles for the manufacturers. From there, those companies can develop software updates that put their machines on the same technological footing. And the third step will bring the process back to the Center for Medical Interoperability’s testing lab, where technicians will run a strict certification program to give everyone involved in treating the patient with this equipment peace of mind that the data collected will be shareable. “We are not trying to replace any standards that are out there,” says Ed Miller, the center’s chief technology officer. “We don’t really need to invent anything. We’re working with the community to
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define the standards better.” Miller once worked at Colorado-based CableLabs, an R&D center. There, he developed similar frameworks to guide the cable industry’s response to emerging technologies and the need for better security and authentication procedures. Miller and his team have done some early testing of the foundational specs they’ve drafted and have made some refinements. He says that there’s no specific timetable in place to take the next steps and get full-fledged certification processes set up. Cantwell says the team has the benefit of a tailwind stemming from the realization by many in the industry — even those profiting most from today’s arrangements — that big tech changes are coming and that their business models are at risk. Also potentially at risk over the medium term, Cantwell adds, is Nashville’s status as a primary hub for health care innovation. It’s time to get on board to help drive change and help define the terms of a better way to treat health care data. “Liquidity is the currency of innovation,” he says. “And Nashville had better lead the change to create that liquidity.”
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by Stephen Elliott
and first published in an April issue of the journal Clinical Psychological Science, promises a new way to treat patients who exhibit signs of selfharm and ideation. Furthermore, it provides an example of what predictive analytics and machine learning could do for diagnostics in other areas of medicine. But his research also begs some ethical questions, and Walsh does not shy away from them. He sat down with the Post to discuss his research, the intersection of diagnostics and technology and medical ethics. This transcript has been edited for length and clarity.
olin Walsh — a practicing internist, medical professor and data scientist at Vanderbilt — found that it was possible to take simple information about patients at the Vanderbilt University Medical Center, build an algorithm and predict with startling accuracy which patients would attempt suicide within the next week. The computer model, developed with scientists from Florida State
What are the limits of using traditional health care data in your predictive model? The typical model is that people like us at a big academic medical center will often start with the kind of data that we collect through routine care, and that’s what we did. So when I see my primary care doctor, and I have a visit with that doctor, that person will write a note, maybe they’ll send a cholesterol test, maybe they’ll order a prescription, and that’s the kind of data that we tend to work with when we start. But the reality is now people are living more and more of their lives with technology, things like smart phones, which are always within
Promise of prediction A Vanderbilt scientist considers the possibilities of predictive modeling in health care
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hand’s reach now. We are representing more and more of our lives in things like social media and our personal technology, which in the past didn’t have quite such a big footprint in our lives. The problem always comes first, and the problem we’re trying to work on is suicide risk. One of the things we realized is there is a really significant proportion of people who either attempt suicide or die from suicide who may not have many touches with a system like Vanderbilt hospital. To reach those people, we need to think a little bit more broadly. For example, there are lines of research in mental health and many other parts of health care using Twitter data. Twitter has been very open with their data and will share it in an anonymized way for people to do research. There’s some growing research that people are actually willing to share social media data with people like me, with physicians as well as researchers, because they understand that the tools that come out may be useful and may help people and may actually save lives. How does wearable technology fit into your research? When you talk to somebody who thinks a lot about the data science, we tend to be interested
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in thinking through lots of types of data, and we tend to be pretty open about the types of data that might apply. As I always tell my students, the key is to put the problem first. So think about what you’re trying to do, and is it worth trying to obtain data you don’t have now, trying to get data we don’t typically collect, or to think through how would Fitbit data or how would iWatch data or phone data help you. There’s a growing number of areas where we think it probably will, and there are more and more people who are actually integrating that data. Imagine we can get Fitbit data, just as an example. That opens some real research opportunities. It also creates some potential ethical dilemmas. One of the easy examples I can think of is location. There are so many devices now that are feeding our location, and it’s really easy to accidentally collect data that people didn’t mean to share with you. What are some challenges confronting the use of big data in diagnostics? There are challenges around the promise in what we can do with things like machine learning and artificial intelligence as we begin providing recommendations on things we never could before. With respect to things like suicide risk, what does it mean if we can take any clinical data and theoretically come up with some measure of risk, and maybe it was never part of the conversation in the first place. Is there a potential for causing harm in doing that? How can more information be harmful? If you have someone coming in and their chest hurts and I’m worried about the potential for a heart attack, we have really good clinical diagnostics around that. But now imagine we can use data to try to come up with an even better prediction, and we make a recommendation. We want to be cautious about the fact that that might lead to testing down the line. And there are costs to testing, and not just financial. We need to think through the data that we’re giving to people at the time they’re making decisions. The power of data is that we can move more quickly and more flexibly than we ever were able to before. Also, we can do that on a population of millions, instead of [just] the person who’s sitting in front of me in a clinic. Is it necessary to have a human in the room? That’s part of it. Medication is an easy example. You can imagine a model — and we have those models — that basically can recommend a treat-
ment pathway or a medication that someone might be eligible for. It’s really important to put that into context. And right now, we still can’t do much better than having a person in the room who can take the information from a machine, put that into the context of the conversation that you and I are having, and also bearing in mind that there’s always going to be those factors that aren’t measured necessarily by the data we’ve got. I can evaluate preferences or values of what somebody really cares about that I may not have typed into a machine for the machine to learn. All those things are going to help weight our decisions. What sort of preferences or values could come into that equation? Something we don’t routinely collect. I ask a lot of my patients as I get to know them whether they feel like they want a new prescription or whether they want to try a new gym membership. And those aren’t necessarily things I type because that’s not a question that happens in clinical workflow. But if I know that a patient is very interested in doing their best to prevent a new prescription and they want to minimize the amount of medication that they take, I may not have a place to record that in the system today. Perhaps the suggestion is I should have that place. But in the meantime, it’s really important for me to know that I don’t necessarily push them to think about a prescription. A lot of the reason people come to the doctor is to have that connection with someone you trust. Does putting a number on a diagnostic prediction make it seem more concrete to a patient? That is one of the big challenges. Sometimes adding more numbers either makes no difference or compels us to think about something we weren’t weighting as highly. Screening is a place where there’s real potential benefit. Our goal is not really to tell people what to do but to give people the opportunity to say what can I do before something has happened. If we add a number to an already crowded clinical encounter with lots of data, sometimes that can be challenging to know what to do with. Doctors in training when they can think of 10 possible causes of something and one of them is really scary — even if it’s very likely to not be the case — people weight that scary thing really highly. And they’ll do a bunch of extra stuff because they’re really worried about that scary thing. As we get better in medicine and get more experience, we say, “OK, you’re worrying about
the scary thing” but weighting that properly is really hard. We can build models really quickly, but a lot of the hard work is then taking that model and putting it into a context in which it’s useful. There’s science around that, there are engineering problems around that, and there are also ethical problems around that. In what direction is this technology heading? It’s inevitable that we’re going to try and learn more from data and design useful, helpful tools that basically help us deliver care safer, cheaper. That’s where I’d really like to see us go. I’m not sure if that’s a five-year proposition, but I’d really like to see that. Health care often is reactive to illness as opposed to moving toward wellness and prevention, but I think I’m seeing that change. We’re going to see more and more of those models integrated into clinical practice. Is there a disconnect between physicians and data scientists? That’s a big challenge, and there are various reasons for that. As somebody who wears different hats, I feel those reasons and I try to understand those reasons. It’s also easy to forget those reasons and get excited about the fact that I can sit in this office and build the model in an afternoon and I think we’re going to save the world because we’ve got risk predictions now. But then the reality is I have patients who can’t get to clinic and I don’t have a model that fixes that problem. There’s a lot of nuance in clinical medicine and so it’s really important to acknowledge the limitations. If we don’t show that we are sensitive to that nuance, then we get the blank stare and we lose the people who we actually are trying to reach — whether that’s doctors or patients. What more could wearable technology do? One of the first things we find when we start measuring things more is we find patterns that may or may not be helpful. We find patterns that look really interesting and maybe it looks really important, but it turns out to be a pattern that’s what we call the noise, as opposed to that signal that we’re looking for. Imagine a watch that’s measuring your blood pressure throughout the whole day. We’ve never been able to measure your blood pressure for 24 hours. We’re going to find a lot of really interesting patterns that may or may not be important. First of all, we’re going to get deluged with data. There will come a point where we are trust-
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me as a provider, it’s good for their family, it’s good for the community, and it’s certainly good for the health care system.
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ing devices to make more suggestions; maybe it’ll be guidance at first. In the beginning, I think what you’re going to see most short term is more recommendations. What’s your goal when seeing patients? I see my job, certainly in primary care, as trying to help people become who they want to be, at least from a health perspective. And I know that can sound grandiose; it’s not intended as such. It’s important to understand where people are and figure out where they want to be. If you tell me it’s really important to you to be on as little medication as possible, for whatever reason, then I want to try and help you get there. Part of the reason I spend so much time applying data science methods to mental health is because it’s a really important problem. It hurts people. We know that. When we treat it, it drastically can improve quality of life. And in the case of suicide, it’s such a highstakes example. People die from that every year. The longer-term goal is to course correct earlier, before you even get to that point where we’re reacting to a problem but when we’re preventing that problem in the first place. We know if we can prevent people from ever getting to the point where their blood pressure is so bad they have a heart attack, we’ve saved that person so much harm. And it’s good for everything: It’s good for that person, it’s good for
How can models help with more practical problems? One of the areas we’re seeing models being used more and more now is actually figuring out why someone is missing appointments, and maybe we can find them because we see in their pattern of data they’ve missed a lot of clinic appointments, their address is 200 miles from our hospital, they don’t have a emergency contact in the chart. One of the places where models have really amazing power — and part of the reason they’re so popular right now — is because they can process a lot of data in a very short period of time, more so than a human being could ever do. A well-designed model might be able to look at the right pieces of data in many different places that might take me a half an hour to do myself if I think to do it. It can say, “Hey look, this person has missed the last four appointments with you. Did you put all those facts together?” And maybe I didn’t. That’s an easy example, and I think there are a lot of low-hanging fruit examples like that. When we can build a tool that allows people to do easy stuff like that and have that little light bulb go off… We don’t see that enough, and that’s what we shoot for now. I’m a believer in that hybrid model, the idea that we want to build these tools to augment decisionmaking but never to just take the reins away from someone, to be totally autonomous. The real art of it is figuring out how those tools can help make the interactions we’re already having better. I would love to spend less time talking about managing numbers sometimes and more time getting to know that person and figuring out what their quality of life factors are, what their drivers are, what their goals are.
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Interconnectivity as an asset
Oscar Health’s tech platform allows openness toward customer data by Caroline Leland
imple. Easy. Understandable. These are not words most people would use to describe their health insurance. But New York-based health insurance startup Oscar Health wants to see those words used to characterize its customers’ experience. And soon the unusually user-friendly health insurance experience the company offers will be available to some Nashvillians through Oscar’s new partnership with Humana. “Oscar has had the opportunity to start in an era where we can build from the ground up without a lot of the legacy issues that have unfortunately plagued health care,” says Elliott Green, Oscar’s vice president of expansion and strategic partnerships. Green is spearheading Oscar’s partnership with Humana to offer plans for businesses in Nashville. He says interconnectivity is one of Oscar’s key product assets. Conventional health insurance companies primarily concern themselves with managing
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their customers’ data, including medical information and claims, but don’t emphasize making that information easily accessible to providers or patients. Oscar, on the other hand, is designed to connect patients directly with their providers and with their own data. And that data flow goes both directions: The providers on the platform also have easy access to their patients’ full medical history — freeing those patients from the burden of managing and sharing that set of information with every clinician they see. Remarkably, this system obviates much of the need for an electronic health record integration. This openness toward data puts an inherent limit on the providers Oscar can work with. The company spins this limited set of providers as a “curated” list. “Do you want to innovate?” Green says Oscar asks its potential provider partners. “Do you want to open your scheduling systems to our members? Do you want to look into whether
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or not you can exchange clinical notes so [that] your physicians are able to receive more information before the patient even arrives?” Austin Madison, vice president and partner of Nashville-based insurance agency The Crichton Group, says Oscar’s fresh approach to health insurance is exciting. “What’s intriguing about their program,” Madison says, “is that they’re trying to do what everybody’s been talking about for a while: to reach the consumer where they are. To provide transparency, providing concierge help, explaining how their plans work.” Green says most customers use the company’s concierge system, which consists of a team of a nurse practitioner plus three “care guides” who are intimately familiar with each Oscar user’s account. When you contact Oscar for customer support, you talk to one of the same four folks every time. Though the company is tech-focused — with its high levels of transparency and its ergonomic mobile app — Green says Oscar sees itself as “age-agnostic.” “In the individual age brackets, our biggest segment is 56-64,” he says. “We’re not just technology; we also want to help.” Oscar’s insurance plans will be available for individuals and small businesses in Nashville to purchase this fall, with coverage starting in early 2018. “Nashville is one of the most exciting [U.S.] cities,” Green says. “It’s a hotbed of entrepreneur activity. When you start talking about health care, people will usually tell you to be quiet. But in Nashville, people ask you more questions — which is very odd for us, but very exciting.” Still, Green admits that it would be premature to declare Oscar’s model the future of the health insurance sector. It’s an industry that is difficult to break into. It’s expensive. And under the current federal administration, the industry is particularly volatile. After five years in existence, Oscar’s leaders are not sure when the company might become profitable. “We raise a lot of money because it’s an expensive business,” Green says. “We’re investing a lot in the future. We’re a growing business so… we’re not concerned.” The Crichton Group’s Madison wonders whether Oscar could maintain its character if it were bought by a larger company. “In a town like Nashville, everybody’s trying to figure out that [health care] solution,” Madison says. “It’s an interesting time to buckle your seatbelts.”
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HCA versus Vanderbilt
Will employers get caught in a battle between two hometown health care stalwarts? by Alex Tolbert
CA Healthcare and Vanderbilt University Medical Center are industry giants on a global scale. Tension between these two Nashville institutions will see a critical event next year as an insurance startup from New York City helps drive volume to TriStar Centennial’s increasingly visible pediatrics facility — and away from Vanderbilt’s Monroe Carell Jr. Children’s Hospital. The startup is insurance company Oscar Health. It recently formed a joint venture with Humana to bring its technology-powered offering to employers for the first time. The joint venture is using a new provider network, the first ever offered to employers in Middle Tennessee that does not include coverage at any Vanderbilt facilities, including Monroe Carell Jr. Children’s Hospital. Industry insiders are interested to see what happens. Vanderbilt’s position in the market is dominant and it is an open question whether a group insurance product that excludes Vanderbilt will be accepted by employers.
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HCA and Oscar’s offering
HCA’s TriStar brand has invested significantly over the last several years to build a rival pediatrics hospital, even pulling physicians from Vanderbilt and building out a suite of children’s physician and surgical services, including a Level III neonatal intensive care unit. It has seen
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volume growth but it is still the underdog in Nashville pediatrics. That is why it has partnered with another underdog — New York City-based Oscar, which is offering lower premiums for local employers (and also has partnered with Saint Thomas Health). Premiums are reputed to be 10 percent less than similar plans on BlueCross BlueShield of Tennessee’s S network. Again, though, the catch is that the plans don’t include Vanderbilt. Employees would have no coverage — not even “out-of-network” coverage — at Vanderbilt.
The risk of no Vanderbilt
On a macro scale, Oscar could disrupt Vanderbilt’s ownership of the pediatrics market and bring more pricing competition to the region. This could be a positive development for employers, given the high premium increases they have seen over the years. But it all arguably hinges on one factor — how effectively TriStar’s Children’s Hospital can compete with Monroe Carell. According to TriStar representatives, Centennial will be able to offer 96 percent of what Vanderbilt can by next year. That sounds pretty good. But then, some would argue that the reason people buy insurance is to have coverage for the four percent TriStar will not be able to provide. What will TriStar not have yet? It will not have pediatric cardio-
vascular or neurosurgery in 2018. It won’t have an extracorporeal membrane oxygenation unit until 2020 or be able to provide hepatology, rheumatology or trauma services. Any child needing those services will be transferred to Vanderbilt and will be fully responsible for the costs. Oscar may make some payments to Vanderbilt if it makes a network adequacy determination but Vanderbilt is under no obligation to accept those payments as payments in full. This will be true for pediatrics but also for any other specialized services only provided by Vanderbilt. This is why coverage at Vanderbilt has always been the floor of employer-based health insurance in Nashville. No employer wants to risk an uncovered child at the region’s pre-eminent academic medical center and an employee under the threat of bankruptcy. Which is to say, Vanderbilt’s dominance is deserved and its high quality of care and specialized services have ensured it. But this dynamic also illustrates how the academic medical center’s hold
‘Oscar could disrupt V a n d e r b i lt ’ s o w n e r s h i p of the pediatrics market and bring more pricing c o m p e t i t i o n .’
on the market inhibits price competition, for payers and providers alike. Until now, small employers haven’t had a choice to exclude Vanderbilt from their group health plan. We will soon see whether HCA has made enough investments in its pediatric service lines to make that choice compelling. Otherwise, employers may decide to save 10 percent through other means. There is no doubt that HCA will keep investing in its pediatric offering, though. This is likely just one chapter in Vanderbilt and HCA’s efforts to be seen as the most trusted resource for Nashville pediatric care. Alex Tolbert is the founder and CEO of Nashvillebased Bernard Health. bernardhealth.com
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s pon s or e d profil e
compa n y profil e The Nashville Technology Council exists to be a catalyst for the growth and influence of Middle Tennessee’s technology industry. NTC’s vision is to establish Nashville as the nation’s creative tech destination by connecting, uniting, developing, and promoting the region’s tech community.
THE EPICENTER FOR NASHVILLE’S TECH COMMUNITY
Nashville Technology Council 500 Interstate Blvd. S, Suite 200, Nashville, TN 37210 Website technologycouncil.com
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From its inception in 1999, the mission of the Nashville Technology Council was to be a catalyst for the growth and influence of Middle Tennessee’s tech industry. Today, the NTC supports the local technology industry and its nearly 400 member companies, by coordinating local technology workforce development, connecting professionals to cultivate a collaborative community, uniting around policies that nurture expansion and attract both talent and businesses, and promoting Middle Tennessee as the nation’s Creative Tech Destination. Few issues are as important to the health and growth of our economy as ensuring the continued development of a trained and talented technology workforce. The NTC is actively laying the groundwork for the 2018 debut of ApprenTech Tennessee, a technology focused apprenticeship program. ApprenTech Tennessee combines paid on-thejob training, classroom education,
and placement in a high paying, high-skill occupation. Learn more at ApprenTechTN.com This spring, the NTC launched Tech Hill Commons, a 9,500 squarefoot facility designed specifically to be a place for the region’s tech community to come together, innovate, and grow. The space houses the NTC’s new HQ and makes available two executive board rooms, 150-person event space, and a tech learning center for launch events, off-site team retreats, usergroup meetups, professional development, and student tech-enrichment. Learn more at TechHillCommons.com On January 25, 2018, the 9th Annual NTC Awards will be held at the Wildhorse Saloon. The evening is dedicated to celebrating Middle Tennessee’s rich community of developers and technology entrepreneurs, enthusiasts and institutions with awards in 14 categories. Tickets and tables are available at NTCAwards.com
Twitter @NashTechCouncil Facebook facebook.com/NashvilleTechCounci LinkedIn linkedin.com/company/nashvilletechnology-council linkedin.com/groups/51917 Number of Employees 7 Number of Company Members Nearly 400 Founded 1999
s pe c i a lt ie s ApprenTech Tennessee: The NTC is creating ApprenTech Tennessee, the first technologyfocused apprenticeship program in Tennessee and will debut a pilot project in Nashville in 2018. Learn more: ApprenTechTN.com Tech Hill Commons: A hub where Nashville’s tech community comes together. Located at 500 Interstate Blvd. S., the beautiful new space offers two executive board rooms and a 150 person event space. Room rentals available. TechHillCommons.com
con tac t Phone: 615.873.1284 Email: info@technologycouncil.com
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FeatUres
INSURE
SMART. RELEVANT. ENGAGED.
RemaRkably stable
In stark contrast to ACA plans, premiums for job-based coverage show modest rise by Phil Galewitz, Kaiser health News
amily health insurance premiums rose an average 3 percent this year for people getting coverage through the workplace, the sixth consecutive year of small increases, according to a study released in September. The average total cost of family premiums was $18,764 for 2017, according to a survey of employers by the Kaiser Family Foundation and the Health Research & Educational Trust. That cost is generally divided between the employer and workers. (Kaiser Health News is an editorially independent program of the foundation.) While overall premium increases remain modest, workers are picking up a greater portion of the tab — this year $5,714 for family coverage, about a third of total cost.
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Employer-provided coverage for a single person rose on average 4 percent, to $6,690. Those individuals pay $1,213 on average. Still, the employer market looks remarkably stable compared to the price increases seen in the Affordable Care Act’s insurance marketplaces for people who buy their own coverage. Premiums on those plans spiked on average about 20 percent this year, and many insurers dropped out because of financial concerns. For all the media attention and political wrangling over the Obamacare exchanges, their share of the market is relatively small. They provide coverage to 10 million Americans while 151 million Americans get health insurance through their employer. The continued slow rise of employer health premiums identified in the Kaiser survey surprised some analysts who have expected the trend to end as the economy picked up steam, leading to a jump in use of health services and health costs. Drew Altman, CEO of the Kaiser Family Foundation, said it’s “health care’s greatest mystery” why health insurance costs have continued their slow pace even as the economy has picked up the past few years. “We can’t explain it.” Another unexpected result was that workers’ deductibles — the health bills that workers must pay before their insurance coverage kicks in — remained stable this year at $1,221. Since 2010, as companies sought to keep premiums in check, deductibles have
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November TALE OF TWO MARKETS The cost of employer-provided coverage has grown far less than that of insurance purchased through the non-group market. 20%
Source: Kaiser Family Foundation
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nearly doubled. Higher deductibles can limit premium increases because costs are shifted to workers and it gives them greater incentive to cut spending. “Increasing deductibles has been a main strategy of employers to keep premiums down and we will have to watch if this plateauing is a one-time thing … or if this portends a sharper increase in premiums in future years,” said Altman. “It could be deductibles are reaching their natural limit or could be the tighter labor market” that’s causing employers to back off, he added. Meanwhile, a second employer survey released in September by Mercer, a benefits consulting firm, suggests a modest increase in health costs coming next year, too. Employers said they expect their health costs to increase by an average of 4.3 percent in 2018, according to the survey. To deal with higher medical costs — notably big increases in the prices of prescription drugs — employers are using multiple strategies, including continuing to shift more costs to workers and paying doctors and hospitals based on the value of the services rather than just quantity of services.
Jeff Levin-Scherz, a health policy expert with benefits consultant Willis Towers Watson, said there is a limit on how much employers can shift costs to their workers, particularly in a tight labor market. “Singledigit increases doesn’t mean health care costs are no longer a concern for employers,” he said. The 19th annual Kaiser survey also found that the proportion of employers offering health coverage remained stable last year at 53 percent. But the numbers have fallen over the past two decades. The survey highlights that the amount workers pay can vary dramatically by employer size. Workers in small firms — those with fewer than 200 employees — pay on average $1,550 more annually for family premiums than those at large firms. The gap occurs because small firms are much more likely than large ones to contribute the same dollar amount toward a worker’s health benefits whether they’re enrolled in individual or family coverage. More than one-third of workers at small employers pay at least half the total premium, compared with 8 percent at large employers. That’s the case at Gale Nurseries in Gwynedd Valley, Pennsylvania, where health insurance costs rose 7.5 percent this year. Its 25 workers are paying nearly half the cost of the premium — at least $45 a week for those who choose the base coverage plan offered through Aetna. Employees also have deductibles ranging from $1,000 to $2,500.
‘We Will have to Watch if this plateauing [of deductibles] i s a o n e - t i m e t h i n g .’ D r e w A l t m A n , K A i s e r F A m i ly F o u n D A t i o n
A decade ago, the nursery paid the full cost of the premium. “It’s crazy — we keep paying more and getting less,” said Comptroller Candy Koons. At the Westport (Connecticut) Weston Family YMCA, health insurance premiums rose about 7 percent this year, leaving its 50 full-time employees to pay a $156 premium for individual coverage. “It’s not problematic, but it’s one of our bigger costs associated with payroll,” said Joe Query, the human resources director. Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation. khn.org
Nonprofit SIG Thursday, November 9 7:30-9:30am November Mixer INDUSTRIOUS Nashville:Gulch Tuesday, November 15 5-7pm Get to Know AMA Nashville Coffee Thursday, November 16 8-9am Deep Dive: B2B Search Marketing Tuesday, November 28 7:30am
December December NAMA Holiday Mixer Tuesday, December 5 Time TBD
January January Lunch
Thursday, January 11 11am-1pm January Mixer Tuesday, January 16 5-7pm Get to know AMA Nashville Coffee Thursday, January 18 8-9am B2B SIG Tuesday, January 23 7:30-10:00am Marketing Tech SIG Thursday, January 25 Time TBD
February February Lunch Thursday, February 1 11am–1pm February Mixer Tuesday, February 6 5-7pm Get to know AMA Nashville Coffee Thursday, February 15 8-9am Nonprofit SIG Thursday, February 22 7:30-9:30am
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Community health workers join the triple aim team Key group of workers help with outreach, advocacy, coordination by Lena Anthony
roviders have long known that controlling costs, improving health outcomes and boosting quality ratings require a multidisciplinary approach and participation from the C-suite, supply chain, technology and beyond. Recently, they have started adding another player into the mix — the community health worker. The community health worker model is thought to have originated in China. By the middle of the 20th century, that country’s population was booming and medically trained professionals were refusing to settle in the country’s rural areas, creating issues of health care access for millions of residents. Farmers were trained as so-called barefoot doctors to provide basic health care services. Even today, in underserved regions such as Bangladesh, Brazil, India and sub-Saharan Africa, trusted community members play the role of health care provider for their neighbors.
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From left: Elisa Friedman and Consuelo Wilkins
There’s no shortage of modern and specialized medical resources in the United States, but the community health worker (CHW) model is still relevant. These individuals help with care coordination, health education, patient engagement and treatment adherence — all essential ingredients to reducing health care costs, improving outcomes and boosting quality ratings. Locally, Siloam Health’s community health worker program started in 2015, after the nonprofit health clinic for local refugees and immigrants received a private grant from a family foundation. Today, the program consists of
two full-time and seven part-time CHWs serving four refugee and immigrant communities across Nashville. In addition to serving as translator and interpreter, the role also entails teaching health education classes, transporting patients to and from health appointments and making house visits with a focus on helping patients set and achieve health goals. These community health workers also coach providers on having culturally appropriate interactions with these patients. Amy Richardson, community health outreach director at Siloam Health, has collected
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baseline data to help determine the effectiveness of the organization’s CHW program. A follow-up study is expected next year, so for now she leans on anecdotal evidence that it’s working — both on an individual level and for broader groups. In one case, a longtime Siloam Health patient was struggling to lower her A1C level, an important indicator of diabetes control. After engaging for just three months with a CHW, it had dropped from a 10 to 8. (A level of 6.5 percent or higher indicated diabetes.) In another community served by Siloam Health, a CHW had a positive impact on the rate of children enrolled in dental care. For the past decade, the Metro Public Health Department has employed community health workers, which it calls outreach workers, to help encourage participants, from birth to age 21, in the TennCare Kids program to get their annual preventive physical. The goal is three-fold, says D’Yuanna Allen Robb, director of maternal child and adolescent health for the department. “TennCare is interested in prevention first,” she says. “From a cost standpoint, medical issues can be identified and treated earlier, before they escalate. Getting young people in for their physical also helps establish a medical home and relationship with a provider. Finally, it’s helping to change the culture and set the expectation that routine physicals and health are important.” Outreach workers also are part of the health department’s immunization program, reaching out directly to families whose immunizations records are not up to date before the beginning of the school year. “A lot of what goes into a family’s decision to immunize can be cultural,” she says. That’s why the health department is intentional about employing a diverse range of community health workers. In many cases, culture and language are prerequisites for employment as a community health worker. At Franklin-based 180 Health Partners, a startup that connects pregnant women who use opioids with a multidisciplinary support team, experience is what matters most. The company’s full-time peer advocates are all formerly pregnant opioid users. “Being an outsider and forcing a social stigma on somebody doesn’t work,” says Justin Lanning, president and CEO of 180 Health Partners. “We need to be motivated by people who are like us, people to whom we can relate. I see the community health worker as someone who can coordinate and navigate the unique and complex intersection of the social determinants
of care for each patient. They also reinforce directions from a higherlicensed professional and engage in a meaningful, trusting relationship, which results in the highest likelihood of results.” The 180 Health Partners support team assigned to each mother includes a peer advocate, as well as a behavioral health supervisor, counselor, social worker, nurse and resource advocate. Together, they create a care plan that may
a baby born to a 180 Health Partners mother is 85 percent less than the average $66,700 cost of treating a baby born with NAS. Return on investment studies on community health workers are hard to find, but they’re out there. One is from Molina Healthcare, a Medicaid managed care organization that operates in 11 states: The company launched a community health worker program in New Mexico in 2011 to find and support its most difficult-toreach Medicaid-eligible members. It conducted a retrospective claims analysis and found a 4:1 return on each dollar spent. But another study,
I think we will have a large pool of people who are interested, but if there is a c e rt i f i c at i o n p r o g ra m, h o w d o w e pay fo r i t?’ C o n s u e l o W i l k i n s , M e h a r r y- V a n d e r b i lt A l l i a n c e
involve medication stabilization or medically supervised tapering, behavioral and mental health assessment and counseling, as well as food, shelter, employment and transportation. “It is crucial that our whole care team is connecting well with our moms and understands their individual care plan,” he says. “The peer advocate offers guidance and experience to the mom and, through genuine relationship, she makes sure the mom is accomplishing her care plan goals. The peer also picks up on any challenges or difficulties the mom is facing that may not be captured in the care plan.”
Making a business case
Lanning’s company is just a year old but he says his team already is seeing positive results. Outcomes are improving — the length of stay in the neonatal intensive care unit for babies born to mothers working with 180 Health Partners is 70 percent shorter than that of the average baby born with neonatal abstinence syndrome (NAS). Costs are lower, too — the cost to treat
published in the Journal of Clinical Outcomes Management, assessed the impact of a community health worker-led diabetes education program and found that, after one year, the cost of the program outweighed cost savings by a ratio of 2.28 to 1. The researchers concluded, however, that longer-term cost savings may be achieved due to reduced complications from diabetes. Therein lies one of the challenges with getting community health workers on the team working to achieve to the so-called Triple Aim of improving the patient experience, improving the health of populations and lowering the per capita cost of providing care. The evidence isn’t there yet in sufficient amounts. “It takes a while to get the studies done, and it can take forever to raise the money for them,” says Barbara Clinton, a Nashville-based public health consultant and former director of the Maternal Infant Health Outreach Worker program at Vanderbilt. Funding is the biggest challenge facing the community health worker model, says Siloam Health’s Richardson. “Right now, most of these positions are funded by grants. We need a funding model that is more sustainable, and that is definitely a part of the CHW conversation happening across the country.” In Middle Tennessee, that conversation is only beginning. The Volunteer State is one of
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18 states that does not yet have a state association for community health workers. According to the Bureau of Labor Statistics, there were approximately 52,000 community health workers in the U.S. last year, which was a 7 percent increase over the previous year. Tennesseans accounted for 890 of those workers, a number that had actually dipped since 2014. “One issue is most people are not familiar with community health workers as a concept,” Clinton says. “An association can help to bring the information to the general public and to policymakers, letting them know that community health workers are a relatively low-cost and effective approach to impacting health on a lot of different dimensions.” The Meharry-Vanderbilt Alliance is leading efforts to establish a state association by bringing together key players from across the city to form a collaborative. Their first meeting was in September 2016. Earlier this year, Clinton prepared a national survey of community health worker associations to help the collaborative better understand what these associations do. “One of the things that came out of that report was the importance of identifying a champion,” she says. “It seems to be easier if there is a commissioner of health who loves the idea. Another question that came up is where should it be based, in the public health department, at a university or as a standalone nonprofit?” By the end of the year, the group expects to send out a statewide survey to all organizations that utilize community health workers to better understand their needs and get a more accurate headcount of just how many CHWs there actually are in the state. That will include workers with titles such as community health advisor, community health representative, outreach worker, patient navigator, peer advocate, peer counselor, lay health advisor, peer health advisor
and, in Hispanic communities, promotores de salud. “I think more organizations are using them and don’t even realize it,” says Elisa Friedman, director of planning and community engagement for the Meharry-Vanderbilt Alliance. “But until we have a common definition and standards on what the role entails, it will be hard to know. A state association would help solve the problems around nomenclature, establish standards for training and competence, and advocate for reimbursement for community health worker services.” Consuelo Wilkins, executive director of the Meharry-Vanderbilt Alliance, believes many people will be interested in a career as a community health worker. “I think we will have a large pool of people who are interested, but if there is a certification program, how do we pay for it?” she says. “Many of these individuals will be from communities with disparities and they may be unable or unwilling to incur debt for additional training.” To address that question, 180 Health Partners executives provide tuition support to help their peer advocates become certified as peer support specialists. Gaining the certificate also comes with a pay raise. “Those mothers who have found stabilized living often want to pay it forward, and we are excited to help them do that with a great job, full benefits and growth opportunities,” Lanning says. Outreach workers at the Metro Public Health Department, meanwhile, receive the same core benefits package as other Metro employees and, based on performance, are eligible for scheduled raises. “If the individuals we employ as community health workers look like and are members of these under-served or at-risk communities, then we also have the responsibility to build out the economic opportunities for them,” says Allen Robb. “This should absolutely be a career trajectory.”
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Nutritional focus
Savor Health takes simple approach to helping fight cancer by William Williams
avor Health offers a simple motto: Cancer starves the body of nutrition. Savor Health uses nutrition to fight back. The approach is straightforward enough. In short, Savor offers individually customized, prescriptive nutrition solutions designed to increase the effectiveness of cancer patient treatment. The goal of the company is to drive reductions in hospital admissions, readmissions and lengths of stay. Savor offers a roster of oncology dietitians and what it bills as a “custom technology” to determine an optimal nutritional profile for each user. “Proper nutrition improves adherence to treatment, reduces treatment toxicity and complication rates, and overall improves patient quality of life,” says Susan Bratton, who founded the New York-based company in 2011 after she lost her husband Eric to cancer. Of note, Savor Health has significant Nashville ties. For example, in September, the company announced the hiring of Stryker Warren, who is based in the city, as executive vice president for corporate partnerships. Warren served as CEO of publicly traded medical device company Urologix from 2008 to 2012 and has been a master mentor at the Nashville Entrepreneur Center and The Wondr’y, Vanderbilt University’s innovation center. In addition, Bratton spent upwards of 20 years working in the local market as a health care services investment banker, establishing multiple industry relationships.
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Stryker Warren
“Stryker will be able to work with leaders in the Nashville health care market,” Bratton says. “We recognize Nashville is one of the epicenters of innovation in the health care world.” Warren joins former Pfizer executive Andrea Day, recently added as vice president of business development, and radiation oncology professor Dr. David Raben, who will serve on the company’s scientific advisory board. Bratton and Warren say Day, with her business development background, could prove helpful in the company’s Nashville-area work and relationship building. “We’ve begun exploring a variety of relationships with existing health care companies seeking to
add a nutrition focus to their offerings,” Warren says. “The literature would suggest with growing evidence the importance of nutrition in the care continuum. “In other words — the recognition that food is medicine,” he adds. The additions will be helpful, as Bratton says Savor Health expects to “more than triple” the number of its biopharma clients within a brief time span. A key question Bratton and Warren face is how the Savor Health model can be applied more broadly — to address, for example, the nutritional needs related to diabetes treatment, elder care and professional sports. “Savor health is a platform technology that relies on evidence-based science and clinical best practices beginning in oncology but with plans to expand into other therapeutic areas such as diabetes, kidney disease and the autoimmune diseases, to name a few,” Bratton says. As to a timetable to scale up the model, she says Savor is already addressing areas related to diabetes and kidney disease. “Many cancer patients experience multiple co-morbid conditions,” she explains. On this theme, Bratton says the company will be adding employees during 2018 as the model grows. Bratton and Warren note that the commitment to evidence-based science has resulted in relationships with prestigious companies such as Merck and Celgene. “We are optimistic that the willingness to innovate and embrace innovation in Nashville bodes well for Savor Health,” Warren says.
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coming in 2018 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 and preview what’s next.
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.
Taking iT furTher
A few sketches from this summer’s Health:Further gathering
ugust’s third annual Health:Further conference brought more than 1,000 health care experts to the Music City Center for four days of presentations and panels centered around the group’s central tenets that health is a human right and that it must be supported affordably and sustainably. We asked Ayumi Fukuda Bennett, our former collaborator on Southern/ alpha and founder of Startup Southerner, to summarize a few of those sessions for us in the illustration style she has popularized across Nashville and elsewhere in the Southeast. For more summaries from Health:Further as well as podcasts and other thought-provoking content from the Health:Further team, you can visit medium.com/healthfurther.
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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 disrupting and adapting.
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HALL OF FAME
Tennessee HEALTH CARE
hall of fame 2015 inductees Thomas Frist Sr.
Clayton McWhorter
Thomas Frist Jr.
David Satcher
Ernest Goodpasture
Mildred Stahlman
Jack Massey
Danny Thomas
2016 inductees
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Henry Foster
Stanley Cohen
Frank Groner
Colleen ConwayWelch
Paul Stanton
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 third annual class of six follows 2016’s class of six and 2015’s inaugural class of eight. For more information about the process and how to nominate someone for the 2018 class, visit tnhealthcarehall.com. > WILLIAM WILLIAMS
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Dorothy Lavinia Brown
Bill Frist
Joel Gordon
Dorothy Lavinia Brown has enjoyed a life of firsts. She was the first African-American woman representative in the Tennessee General Assembly, the first single adoptive mother in Tennessee and the first woman to practice general surgery in the South. Not bad for somebody who grew up at a New York orphanage. Brown was born in Philadelphia in 1919. She eventually would graduate at the top of her class at Bennett College before coming to Nashville to attend Meharry Medical College. Brown then interned at Harlem Hospital in New York but, after applying for a surgical residency, was rejected due to race and gender. Undaunted, she turned to Dr. Matthew Walker, Meharry’s then-longtime chief of surgery, for help. Against his staff’s advice, Walker offered Brown a faculty position she would hold for more than 20 years. She went on to become the first female chief of surgery at Nashville’s Riverside Hospital and the first African-American woman to be made fellow of the American College of Surgeons. Brown’s personal life included great accomplishments, too. In 1966, via her seat in the state legislature, she helped pass a law that allowed single women to adopt children. Among her many honors are the Dorothy L. Brown Women’s Residency at Meharry College, the Humanitarian Award from the Carnegie Foundation and the prestigious Horatio Alger Award. As Brown often said, she was humbled to be a role model “not because I have done so much, but to say to young people that it can be done.”
Dr. William “Bill” H. Frist has impacted Tennessee (and beyond) as a physician, public servant and humanitarian. A Nashville native, Frist graduated from Montgomery Bell Academy, Princeton University and Harvard Medical School, and then completed a fellowship in cardiothoracic surgery at Stanford University School of Medicine. Soon after, Frist joined Vanderbilt University Medical Center, helping start a heart and lung transplant program and serving as founder and director of the Vanderbilt Multi-Organ Transplant Center. He would go on to perform more than 150 heart and lung transplants. In 1994, Frist was elected to the U.S. Senate and represented Tennessee from 1995–2007. Of note, Frist served as Senate majority leader from 2003– 07, a position to which he was elected after having served fewer total years in Congress than any other person previously chosen to lead that body. Since his Senate work, Frist has helped lead public education reform through his work with the State Collaborative on Reforming Education while simultaneously contributing to global health care efforts. For example, he founded nonprofit Hope Through Healing Hands and NashvilleHealth. Frist also serves as partner and chairman of Cressey & Company’s executive council and as cofounder of Aspire Health, a non-hospice, community-based palliative care organization. Frist currently serves on the boards of the Robert Wood Johnson Foundation, The Nature Conservancy, the Kaiser Family Foundation, AECOM, Teladoc and Select Medical Corp.
Joel C. Gordon has always been at the forefront of change. After graduating from the University of Kentucky with a B.S. degree in business management in 1951 and then spending three years as a United States Air Force officer stationed in Europe, Gordon began his business career in Tennessee in 1955 with Cain Sloan Co. as a merchandise manager. In 1969, he co-founded General Care Corp. (a hospital management and operating company later purchased by HCA) and, then, Surgical Care Affiliates in 1982, an outpatient surgery center operator later acquired by HealthSouth. He also was a key architect of HealthWise of America, later acquired by United Healthcare. Gordon was one of the first health care entrepreneurs to introduce the concept of physician ownership/joint ventures as a business model in hospitals and surgery centers, now commonplace within the industry. He was an early pioneer of freestanding outpatient surgery centers. Gordon served as an original founder of the Nashville Health Care Council. He was named a distinguished graduate of both University of Kentucky and the to U.K. Business School Hall of Fame. He was also one of the original members of the Alexis de Toqueville Society of the United Way in Nashville. Gordon received the United Way’s Alexis de Toqueville Award, the Community Award from the National Conference of Christians and Jews, the Community Foundation’s Joe Kraft Humanitarian of the Year Award and the Tennessee Performing Arts Center’s Applause Award.
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HALL OF FAME
Harry Jacobson
Stanford Moore
Donald Pinkel
At age 4, the family of Dr. Harry Jacobson immigrated to the United States from Germany. Growing up in Chicago and completing medical school at the University of Illinois, Jacobson trained in medicine at Johns Hopkins and in nephrology at Texas Southwestern in Dallas, where he specialized in kidney failure and diseases. He later spent two years as a major in the Army Medical Corps at Fort Sam Houston in San Antonio. After seven years as a faculty member at Texas Southwestern Medical, Jacobson moved his family to Nashville to join the Vanderbilt University faculty. There, he grew VU’s nephrology program into one of the nation’s top 10. In 1997, after 12 years building the program and launching what became one of the world’s largest dialysis companies, Renal Care Group, Jacobson was named Vanderbilt’s vice chancellor for health affairs. During his tenure, Vanderbilt University Medical Center saw it budget grow more than 300 percent, became a top 10 funded research university and was named as a Fortune magazine top 100 places to work. Of note, Jacobson’s favorite achievement was helping to create the Monroe Carell Jr. Children’s Hospital. Since retiring, Jacobson has focused on growing health care companies. He is past chairman of the Nashville Health Care Council, has received the Crystal Leaf award (recognizing Nashville’s top health care leaders), was elected to the National Academy of Sciences Institute of Medicine and remains active with the American Red Cross and The Family Foundation Fund.
Dr. Stanford Moore is a decorated scientist, lifelong educator and dedicated academic. Born in Chicago in 1913, Moore would graduate from Nashville’s Peabody Demonstration School (now the University School of Nashville) and Vanderbilt University, where he earned summa cum laude honors and was a member of Phi Kappa Sigma. Moore received his doctorate in organic chemistry in 1938 from the University of Wisconsin before going on to become an accomplished scientist and professor. During his career, Moore developed many significant scientific breakthroughs that changed the way the world conducted research. In 1949, he published the first method for the complete analysis of the amino acid composition of a protein, redesigned an automated amino acid sequencing system for ribonuclease and contributed to the then-growing understanding of how protein functions on a structural and chemical basis. That work ultimately resulted in his 1972 receipt of the Nobel Prize for Chemistry in Stockholm and changed the field of genetic medicine worldwide. Moore spent the majority of his career as a biochemist and professor at the Rockefeller Institute (later Rockefeller University) in New York. Of note, he served in the U.S. military during World War II, the only time during which he was not at active at Rockefeller Institute in some manner. Moore was the recipient of the Founder’s Medal at Vanderbilt University and was chosen as USN’s first distinguished alumnus. Moore is also the namesake of Vanderbilt’s recently completed residential college, Moore College.
Dr. Donald Pinkel is a key figure in St. Jude Children’s Research Hospital history. His path to Memphis was equally noteworthy. Born in Buffalo, New York, Pinkel joined the U.S. Navy in 1944 and attended Cornell University as a pre-med student officer candidate before graduating from the University of Buffalo School of Medicine in 1951. He would serve as a pediatric resident at the Buffalo Children’s Hospital, helping start a clinic for hematology-oncology patients. Soon after, Pinkel resumed active service during the Korean War and served as a pediatrician, eventually contracting polio. During his rehabilitation, he was recruited to develop pediatric service at Roswell Park Cancer Center in Buffalo. There, he established research and clinical programs. In 1961, Pinkel was recruited to Memphis while St. Jude was under construction. The facility’s principal focus was research of management of childhood malignancies and blood disorders. Over the next 11 years, the institution became a world leader in pediatric hematology and oncology, with Pinkel and hospital founder Danny Thomas pioneering racial integration of staff and patients. For his decades of service, Pinkel was awarded the Lasker Award and the Kettering GM Medal for his contributions to pediatric research. After leaving St. Jude in 1974, Pinkel went on to develop pediatric oncology programs at various hospitals across the country. In 2001, Pinkel semi-retired in California teaching in the biology department of Cal Poly State University.
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FEATURES
HALL OF FAME
the event The Tennessee Health Care Hall of Fame inducted its 2017 class in October at Belmont University’s Curb Events Center. Hosted by John Seigenthaler, senior counsel at Finn Partners, the third-annual event honored a six-member class of pioneers who have contributed to Tennessee’s health care community and encouraged future generations of industry professionals. Belmont and its McWhorter Society created the entity with Nashville Health Care Council input. belmont university
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FEATURES
BUILD
Orthopedic construction TriStar Centennial Medical Center creates ‘hospital within a hospital’ by William Williams
n November 2016, executives with TriStar Health System sought a rezoning to allow for a vertical addition to their Centennial Medical Center campus on Midtown’s western fringe. A year later, that effort has progressed notably. The main hospital building, which rises eight stories and anchors the northwest corner of 23rd Avenue North and Patterson Street, is now boasting a skeleton of four extra stories. Spanning 145,000 square feet, the vertical addition yielded a structure that is visible for miles. It’s a $96 million project being undertaken to accommodate the TriStar Centennial Joint Replacement Center of Excellence. The center currently operates from space within the existing facility. “There is no doubt that our city is growing and this center will allow us to continue to ensure that our patients have access to safe, highquality and compassionate orthopedic care,” Scott Cihak, TriStar Centennial’s president and CEO, says of the project. “The new orthopedic center will improve patient and provider experience and position our hospital to better serve the growing orthopedic needs of thousands of more patients who seek our hospital and our talented physicians for their care.” When completed in the third quarter of 2018, the project will add of 29 patient rooms, 10 operating rooms, 17 post-anesthesia care unit bays,
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20 early-morning admission rooms and a 10bank elevator upgrade. Dr. Craig Morrison, orthopedic medical director of TriStar Centennial Joint Replacement Center of Excellence and chair of orthopedic services at TriStar Centennial, says the facility has a “longstanding history of providing patients with high-quality orthopedic care utilizing the latest innovations in joint replacement procedures. “Our new ‘hospital within a hospital’ design will meet the unique needs of joint replacement patients by offering highly personalized care, ensuring a superior patient experience,” says Morrison, who also works as an orthopedic surgeon with the campus-based Southern Joint Replacement Institute.
The multi-building TriStar Centennial Medical Center complex spans 43 acres and is home to a collective 657 beds in the main hospital, a heart and vascular center, Parthenon Pavilion (behavioral health), a women’s hospital, a children’s hospital and the Sarah Cannon Cancer Institute. As significant — in terms of height and mass — as the addition to the main hospital is, it is perhaps the symbolic meaning of the project that is most noteworthy. “As amazing and impressive as this space will be once completed,” Cihak says, “I’m quickly reminded of what truly makes our hospital special and impactful through the words of our founder, Dr. Thomas Frist: ‘It’s not bricks and mortar that make a hospital; the people do.’”
courtesy of TriStar Centennial Medical Center
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BUILD
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FEATURES
ROLLUPS
Roll ’em up
The latest crop of Nashville consolidators targets niche sectors
ince the founders of HCA began buying hospitals nearly five decades ago, Nashville has produced numerous variations on the idea of a centralized business office supporting clinical sites across the country. Some have worked well, others didn’t pan out as planned. In the past few years, a number of seasoned local management teams have formed ventures looking to consolidate several specialty segments that haven’t received a lot of corporate attention — at least not out of Nashville — over the years. Here’s a snapshot of those ventures and the people running them.
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Compiled by Geert De Lombaerde
Jim Usdan
Marty Bonick
Bill Southwick
Jay Gunther
Marquee Dental Partners
PhyMed Healthcare Group
QualDerm Partners
United Derm Partners
• Veteran health care CEO Jim Usdan launched his latest company with a $35 million commitment from Chicago Pacific Founders a little more than two years ago. Since then, the company has acquired 28 dentist offices — more than half of them in the Nashville market — and taken over the billing and administrative operations.
• Launched in 2012 when Excellere Partners backed Anesthesia Medical Group, PhyMed now does work at 47 locations in four states. Two years later, the Ontario Teachers’ Pension Plan acquired a majority stake in the anesthesiology company, which has since steadily brought on board doctor groups in several states.
• Formed in early 2015, this company announced itself about a year later when it secured almost $32 million in backing from Cressey & Co. and New York-based Apple Tree Partners. After starting with three skin care practices in North Carolina, the QualDerm team has closed on a number of acquisitions since and now runs 15 practices.
• The youngest of this group, United came to market 2016 with funding from Frazier Healthcare Partners out of Seattle, which specializes in pharma investments but previously also backed DSI Renal. Following an acquisition of eight Austin-area clinics this year, the company now runs 12 locations that treat about 130,000 patients per year.
• CEO Jim Usdan (formerly with Council Ventures and Castle Dental, among others), COO Fred Ward (DentalOne Partners), Chief Development Officer Nathan Cox (Benco Dental)
• CEO Marty Bonick (CHS, Ardent); CMO Patrick Forrest; CFO Sam Daniel (Comprehensive Pharmacy Solutions, American Pathology Partners)
• CEO Bill Southwick (Rehab Documentation Company, USPI, HealthMark Partners), CFO Susan Brownie (Cogent, HealthStream), COO Todd Falk (DaVita)
• CEO Jay Gunter (LifePoint, DSI Renal), CFO Beth Workman (DSI, Ernst & Young), Chief Development Officer Dan Conroy (Surgical Care Affiliates)
• Tennessee, Kentucky, Maryland, Pennsylvania
• Tennessee, Ohio, North Carolina, Virginia
• Texas, Nevada
• Tennessee, Alabama, Kentucky
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LESSONS
International effort U.K. seeks to learn from Nashville’s health care models by Caroline Leland
ost Nashville residents realize the city is a health care hub — but few likely are aware that a European country is studying our city’s health care models for learnings. Philip Dunne, Great Britain’s minister of state at the U.K.’s Department of Health, visited Nashville recently to gain a deeper understanding of how the United States health care system uses big data to improve patient care. “You’ve impressed upon me how significant Nashville is to the U.S. health care market,” Dunne told an audience of about 25 — mostly health care-related bankers and lawyers — at a panel the Nashville Health Care Council hosted in partnership with local law firm Baker Donelson in late September. “The [U.K. National Health Service] for the second year running was accorded the accolade of the best health system in the world,” Dunne added. “But we know that we can always do things better, especially with data management.” Dunne explained that his team is particularly interested in using data to improve the predictability of health care challenges and performance. The focus of his visit to Nashville was on elevating National Health Service information technology systems and software solutions to the world-class standards exhibited in Music City. “We have attempted a top-down solution, which was successful, in part, but has not led to
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the degree of digital data capture and use that we know requires many systems here,” Dunne said. “And we’re looking at internal organization: We want to encourage NHS organizations to work more closely together to form more integrated systems for the patient experience.” To that end, the U.K. also is seeking to restructure its procurement processes to make opportunities for innovation easier to identify. In addition to seeking learnings on digital solutions for utilizing data, and improvements to overall system integration, the U.K. recently announced a new science innovation partnership with 31 countries, including the United States. “We are funding collaboration between the best research institutions around the world,” Dunne said. “This will unlock and unleash a flow of talent and opportunity from other nations.” The program, called the U.K. Science and Innovation Network, supports joint funding proposals, research papers and formal partnerships. So far, the partnership’s main accomplishments have included supporting a research collaboration between Cancer Research U.K. and the U.S. National Institutes of Health and National Cancer Institute; fostering vaccine development research funding granted jointly to the University of Liverpool, the Liverpool School of Tropical Medicine and the U.S. Centers for Disease Control; and facilitating the publication of joint research papers by the U.K. Meteorological Office and the U.S. National Oceanic and Atmospheric Administration. Dunne also pointed out that the U.S. market demonstrates an effective “rapid test and learn” model that the U.K. could emulate. Dunne’s team is pushing for more rapid introduction of regional initiatives so that the country can enable its own “rapid test and learn”
approaches to making improvements in its health care system. Recently, that included regionally managed mobile-application tools for processing nonurgent patient inquiries. NHS was able to evaluate how each regional solution performed in comparison with its peers in order to choose the most effective tool for national implementation. Hayley Hovious, Nashville Health Care Council president, said it is fitting that Dunne would choose Tennessee’s capital as a place to gather learnings for the U.K. “Nashville is a great model for methods that work and taking them to scale,” she explained. In April, the council sponsored a trip to the U.K. with 30 delegates to learn about the health care system there. On the journey, the group met with Dunne, establishing a relationship that led to his presence on the Council panel in September. “The Nashville Health Care Council mission recently shifted from establishing Nashville as the health care capital of the nation to making
‘Nashville is a great model for methods t h a t w o r k .’
H ay l e y H o v i o u s ,
N a s h v i l l e H e a l t h C a r e C o u nc i l
Nashville a catalyst for global collaboration for better health care everywhere,” Hovious said. The council’s U.K. trip and its event with Dunne both stem from the organization’s new, expanded mission. Simultaneously, Great Britain’s 2016 decision to leave the European Union has allowed for a new national budget for health care policies, programs and other spending. Dunne said he is certain he’ll be returning again to Nashville in the near future. “It’s been five years since the last visit, and I’m sure it’ll be less than five years ’til the next visit,” he said with a laugh. And Nashville will be going back to the United Kingdom much sooner than that: The next council trade mission is slated for the last weekend of April 2018 — with the group to return, no less, on British Airways’ inaugural direct flight connecting London and Nashville.
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CLOSE
READING CORNER
Retrospective promise The principals of local diagnostics and analytics company IQuity outline some encouraging research
bout four years after being founded, downtown-based diagnostic testing company IQuity early this year raised more than $2 million from a group of 15 investors. Combined with several National Institutes of Health grants, the funds helped the company’s leaders open a lab in The Baggage Building adjacent to Union Station. Here, Chase Spurlock, IQuity’s CEO, and Thomas Aune, the company’s co-founder, provide an overview of research material — layering some machine learning on top of classic diagnostics work — that they presented at neurology conferences around the country this year.
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IQuity’s IQIsolate technology is the product of more than 12 years of research at Vanderbilt University Medical Center and IQuity, with over $4 million in funding from the National Institutes of Health and additional private investment. This research found that differences in RNA expression patterns can be detected in blood samples from patients with a variety of human conditions including complex, inflammatory diseases. Building on this principal finding, IQuity’s work has been focused on developing diagnostic tools that provide accurate, actionable information to health care providers at the earliest stages of disease. It is generally accepted that early diagnosis and early treatment of autoimmune disease leads to optimal patient outcomes. Capturing a snapshot of RNA uncovers the communication occurring inside the cells and tissues of the body. IQuity has harnessed the power of cutting-edge technologies like RNA sequencing to identify RNA targets that exhibit large changes in autoimmune disease. The reproducibility of current sequencing platforms using gold-standard approaches including quantitative reverse transcription PCR (RT-qPCR) is quite high. We identified and validated RNAs capable of distinguishing specific diseases from healthy
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individuals and patients with other diseases with accuracy levels surpassing 90 percent. Our research has focused on a new class of RNA — the long, noncoding RNAs (lncRNAs). Differences in lncRNA expression values found in the peripheral whole blood in autoimmune disease are greater than what we observed in previous studies that focused primarily on protein-coding genes. The use of lncRNAs as the foundation of our Isolate test panels enhances the confidence of disease determinations using our analytical approaches built upon machine learning. Through clinical collaborations in the United States and Europe, we have recruited more than 2,500 subjects that were used to validate the RNA targets in our Isolate tests. These data sets were used to build computational models capable of distinguishing disease and non-disease samples. IQuity offers gene expression-based panels for multiple sclerosis, gastrointestinal disease (irritable bowel syndrome versus inflammatory bowel disease — Crohn’s or ulcerative colitis) and rheumatologic disorders (fibromyalgia, rheumatoid arthritis and systemic lupus). The IsolateMS algorithm has been validated using an independent group of subjects. IQuity’s algorithm was tested using data from blood samples of healthy subjects, patients with multiple sclerosis and inflammatory (i.e. optic neuritis, transverse myelitis, neuromyelitis optica) and non-inflammatory (i.e. Parkinson’s and Alzheimer’s) neurologic diseases.
Significant finding, looking to the future
Through a collaboration with the Accelerated Cure Project, IQuity was able to obtain blood specimens from patients with a clinically isolated syndrome who later developed multiple sclerosis. A clinically isolated syndrome (CIS) is the major clinical precursor to multiple sclerosis. Patients are often diagnosed with a CIS months to years before a diagnosis of MS can be made using the McDonald criteria. Our CIS blood samples were obtained years before a clinical diagnosis of MS was made. Using our algorithm, we were able to make a positive MS determination at the time of a patient’s CIS event in 95 percent of the patients enrolled in the study. This retrospective study highlights that examining RNA levels in a patient’s blood sample can accurately identify MS at the earliest clinical time points. Had our test been utilized at the time of a CIS diagnosis, the attending physician would have had additional information to confirm a suspected case of MS. As IQuity looks to the future, applications of data science and machine learning analytics present rich opportunities for discovery. From analysis of large data sets generated through genomic studies to health care claims data analysis, IQuity plans to leverage its existing team of data scientists to uncover insights in these hard-to-decipher data sets. In 2018, IQuity plans to expand its offerings to include this analytics platform technology to stakeholders in academia and industry.
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CLOSE
THE BIG QUESTION
What’s the fastest way we can (re)build trust? I want to deal with the insurance company they show in their advertising.” That quote was culled by market researcher Dan Prince of SMG Catalyst Healthcare Research and Brandon Edwards of the ReviveHealth agency from the responses to questions posed as part of the ReviveHealth 2017 Trust Index. Another, juxtaposing, comment from an insurance exec about some large health systems: “Skyscrapers are being erected out of the windows where you are being told they have no funding for investment.” The Revive report showed that trust among the main players in health care is eroding. In a time of tremendous changes and uncertainty, that spells big trouble. The
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provider-payer relationship, which has long been characterized by a binary power struggle, needs to evolve into a far more equitable dynamic as value-based payments grow in importance. Oh, and by the way, patients should probably feel more empowered in their care and how they pay for it. We have a long way to go before we hit that big goal. On the pages of this magazine, we’ve highlighted local entrepreneurs’ efforts to chip away at the trust question by improving employee culture and patient experience, to get a better and more productive handle on the masses of data being generated by the system or to corral the immense potential of blockchain to unclutter processes, free up information and — by its very public and shared construction — build trust. We can’t put it any better than how The Economist did in October 2015: “The blockchain lets people who have no particular confidence in each other collaborate without having to go
through a neutral central authority. Simply put, it is a machine for creating trust.” In reporting our cover story, we lost track of the number of times we heard the phrase “condition precedent” when discussing trust. Without trust, there can be no effective interoperability. Without good interoperability, there can be few new insights. And without those insights, there will be far less meaningful innovation — ideas that can literally save lives — than is possible. So allow us to put out this call to action to Nashville’s vaunted health care sector: Commit to ways you can build trust in other stakeholders you deal with and continue to invest in ways to improve their potential trust in you. Providers: Reach out to patients and others in your universe in transparent ways and ask questions that might make you feel vulnerable. The team at LifePoint Health will tell you the feedback and ideas you get are very valuable. Payers: Work like crazy to shed the label that you’re unfair to providers and patients by lifting the veil and sharing more of your data in productive ways. Look at what Oscar Health is doing for a start. And technologists: Continue to look for inefficiencies you can fix and systems you can connect. The more we know, the better — and healthier — we can become. Fight the good fight because we need all the help we can get to get over this trust hump.
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