Nashville Post Vitals

WINTER 2015

SEEKING THE BEST WAY Saint Thomas’ Karen Springer isn’t waiting on others to create needed change

DOCTORS DISCUSS

CHALLENGES, COSTS

DIFFICULT PROBLEMS, CREATIVE SOLUTIONS

TACKLING TECH

INTEROPERABILITY DIFFERENT PATHS

TO POPULATION HEALTH MANAGEMENT

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WHAT COMING HOME FEELS LIKE.

LIMITED RESIDENCES REMAIN

FROM THE

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CONTENTS FROM THE EDITOR

INTRO

13

32

OPERATE SCHOOL

10 Brawn and brains

CONNECT PLAN

DATA

grow

layer of growth

Pharma’s pipeline to growth

20 Layer upon

30 DATA BANK

Nashville for-profits find strategic opportunities with academic medical centers

Analytics player Stratasan has big plans for ’16 and beyond

Health care has a shortage of several things — but not big trends

13 Area pharmacy

DOCS

22 ‘The challenge IS doctor and patient INTERFERENCE’

hall

schools flourishing

Expanded facilities, programming an indication of high demand

14 Taking shared

Four doctors discuss the patient relationship, the young guns they work with and a greater sense of antagonism in the industry

Four-school training program dumps silos for a broader view of care

COVER

responsibility

LAW

16 ‘Medical

judgment is being subsidized for profit margin’ U.S. Attorney David Rivera on combating ‘increasingly creative’ fraud

26 ‘We’ve got to get outside of ourselves’

Saint Thomas’ new CEO opens up about how a truly integrated system can help shape an updated paradigm in patient care

32 Tennessee HEALTH CARE HALL OF FAME

The inaugural class of eight — whose achievements span more than a century of medical and corporate progress

38 Cumberland

Firm’s partnership with VU on its way to producing two more products

39 Jumpstarted via Nashville

Minneapolis-based Reemo using funding from Jumpstart Foundry to fuel future

TECH

40 Simulation education

Belmont health sciences students use mannequins, replica spaces for training

42 Tackling interoperability Two industry groups address the problems of health care’s complicated connectivity

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CONTENTS FROM THE EDITOR

INTRO

48

64 CHANGE

47 The cost

INSURE

56 A Cold War in

of health care hackery

Data breaches growing but still not on enough radars

Assessing the impact of health insurer consolidation

48 Appy days

SOLVE

BUILD

solutions to difficult problems

A peek at some technologies that promise to make medical life simpler for providers and consumers

50 Healthful

development

mANAGE

60 Rankings

52 The nuances

and priorities

of orderly development

What to listen for in certificateof-need cases

DATA

53 DATA BANK

New technologies are forever working their way into the health care system

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57 Creative

A look at how some promising new approaches are improving outcomes and lowering costs

oneC1TY project to offer a ‘health-centric’ flavor

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a hot industry

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Chamber report outlines where our public health indicators are coming up short

63 The numbers are in — and they’re not all good Fixing the fact that ZIP codes are better predictors of life expectancy than genetics

64 Who is the

72 In senior care

Stakeholders take different approaches to trying to deliver lasting wellness improvements

A peek inside NHC Place at The Trace being built in Bellevue

FURTHER

74 Can the rise

quarterback of population health?

68 First-year

success

Jumpstart Foundry to brand Health:Further as a yearly event

SETTINGS

70 Coordinate or stagnate

design, little things can MAKE big changes

KICK

OF treatment companies alleviate the opiate crisis?

An industry matures but other factors need to fall into place

The journey from volume to value will require smarter systems

ON THE COVER Karen Springer photographed

by Michael W. Bunch. Read more beginning on page 26.

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Healthcare.

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CONTENTS FROM THE EDITOR

INTRO

editorial Editor Geert De Lombaerde Managing Editor William Williams Contributing Writers Linda Bryant, Emily Kubis, Cindy Sanders Copy editor Dana Kopp Franklin

art Art Director Derek Potter Photographers Michael W. Bunch, Eric England CONTRIBUTING Photographer Nicholas Sala

production Production COORDINATOR Matt Bach Marketing art director Christie Passarello Graphic Designers Katy Barrett-Alley, Amy Gomoljak, James Osborne

publishing PUBLISHER Jamie McPherson bUSINESS DEVELOPMENT CONSULTANTS Maggie Bond, Rachel Dean, Todd Gash, Michael Jezewski, Carla Mathis, Marisa McWilliams, Hilary Parsons, Ellen Skrmetti, Jennifer Trsinar, Mike Smith, Stevan Steinhart Sales Operations Manager Chelon Hill Hasty Account Managers Gary Minnis, Sarah Richmond, Annie Smith

marketing MARKETING DIRECTOR Heather Cantrell EVENTS DIRECTOR Lynsie Shackelford PROMOTIONS MANAGER Wendy Deason

circulation Subscription Manager Gary Minnis Circulation manager Casey Sanders

SouthComm Chief Executive Officer Chris Ferrell Chief Financial Officer Ed Tearman Chief Operating Officer Blair Johnson Executive Vice President Mark Bartel Director Of Financial Planning and Analysis Carla Simon Vice President of Production Operations Curt Pordes Vice President of Content/ Communication Patrick Rains Controller Todd Patton 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 Wednesday, February 10th, 2016. For advertising and subscription information, call 615-244-7989.

Copyright ©2015 SouthComm, LLC.

LEARNING, STRETCHING The Nashville region is fortunate to have so many vibrant and thriving industries fueling its growth and prosperity.

With an economic impact of nearly $40 billion, health care is certainly a heavy hitter in that regard.

Recognizing the immense local and national reach of Middle Tennessee health care leaders, the Post team — led by the terrific Emily Kubis — has taken another deep dive into the issues facing them. Throughout these pages, you’ll hear from key players sharing insights about how far they and the sector as a whole have come and what they expect is coming next.

Are you looking to learn more about population health management and the promise of reducing health inequities while still keeping an eye on providers’ financial health? We’ve got that covered. Ever been frustrated by having to once again fill out that form at your doctor’s office and wondered why we can’t have a system that better shares such data? You can learn more about the goals and challenges of the new Center for Medical Interoperability. And if you’re looking for creative approaches to long-standing conundrums, we have a few of those, too.

Not surprisingly, a thread running through many of our stories is that change is ongoing and inevitable. The good news is that Nashville is full of thoughtful, strategic leaders who are not afraid to stretch their teams to find viable solutions and remain relevant.

Whether you’re in the industry or not, we hope you enjoy reading this edition of our quarterly series and we look forward to reconnecting with you in print early next year. That’s when we’ll bring you another Leaders issue featuring the seventh iteration of In Charge, our annual and definitive list of the business and civic leaders moving Nashville forward. Until then, we wish you and your organization a very healthy end to 2015.

A Special Thanks to our Vitals Issue Partners:

Jamie McPherson, publisher jmcpherson@nashvillepost.com Geert De Lombaerde, Editor gdelombaerde@nashvillepost.com

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PARTNER letter

I

n just seven years, CapStar Bank has grown from our initial $88 million equity raise to an institution with assets of more than $1 billion. A large part of our growth has been propelled by financing opportunities in Nashville’s healthcare sector. CapStar’s healthcare division grew organically out of our focus on meeting the needs of small to medium-sized businesses in middle Tennessee and our goal to address the personal banking needs of their owners and associates. Today our Healthcare Banking Group represents one of our largest client segments and is an area with significant growth opportunities in the years ahead.

Our Healthcare Banking Team collectively has more than 60 years of healthcare finance and operational experience; each of us has spent our entire working careers in the Nashville community. While working with healthcare companies across the country, we continue to be reminded and tell the story of the significant role the Nashville community has in the growth and development of healthcare delivery throughout the U.S. and around the world. CapStar combines big-bank know-how and small-bank personal attention with hands-on operational experience to create customized funding solutions. We’re not just providing valuable senior debt capital; we can also provide counsel and guidance to local healthcare companies striving to grow their businesses in a rapidly evolving healthcare delivery system.

Why are we bullish on healthcare? Consider the following statistics contained in a report recently released by the Nashville Health Care Council: • The Nashville healthcare industry has a $39 billion impact on the local economy.

• The healthcare industry accounts for 250,000 total jobs locally.

• Nearly 400 healthcare companies have operations in Nashville.

• By 2022, one in every 11 new jobs in Tennessee will be in healthcare.

• 95 percent of Nashville Health Care Council members indicate that having a headquarters in Nashville is important for their company’s performance.

• Nashville Health Care Council member companies gave nearly $215 million in philanthropic contributions in Nashville during 2014.

No wonder we’ve invested so significantly in our Healthcare Banking Team. Our strength is delivering personalized solutions designed to meet the specific financial needs of healthcare companies in Nashville and beyond. Our healthcare clients are our partners, and their success is our success.

Let’s celebrate Nashville, and let’s celebrate the contributions Nashville is making to further development of the healthcare delivery system locally and across the globe!

Mark D. Mattson

Director of Healthcare Banking CapStar Bank

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hange, change, and more change. A new budget deal, headline grabbing whistleblower settlements, new Stark regs – it seems like a game changing development is on the horizon before we can swallow the first sip of morning coffee. The Bradley Healthcare Team changes with the industry – adding new practice areas, opening new offices, bringing in new talent. As one of the top 20 healthcare law firms in the country as measured by the leading healthcare trade magazine, we focus on nearly every subsector of the industry, handling transactions, dealing with regulatory developments, defending whistleblower suits, and interfacing with the government.

We are fortunate to be part of the vital healthcare community that is Nashville. It seems that every day a new operating model is devised, fresh capital breathes new life into startups, and talent flocks to the city. We have been excited to be part of that growth. We know that what happens in Nashville doesn’t stay in Nashville – it spreads across the country and becomes the new norm.

We look forward to serving our industry and our community for many years to come.

Jay Hardcastle

Chair, Healthcare Team Bradley Arant Boult Cummings

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N

ever before has our nation’s healthcare system experienced such a time of change, transformation and opportunity.

With healthcare spending comprising 17.4 percent of the GDP – that number is slated to grow to 19.3 percent by 2023 – the impact of this transformation is highly complex and not to be underestimated.

For Nashville, the capital of our nation’s healthcare delivery system, this disruption presents an opportunity for entrepreneurs, policy makers, business leaders and physicians to further strengthen our city’s role as a healthcare innovator and industry change agent.

As healthcare transforms, our nation is searching for scalable solutions to increase access to care, control costs, consistently measure quality, define value, discover cures to diseases and transition to a consumer-based industry.

The answers are within these pages. In this healthcare issue of the Nashville Post, you’ll find stories about and interviews with many of the Nashville area entrepreneurs and leaders who are helping redefine America’s healthcare industry.

Jarrard Phillips Cate & Hancock, Inc. is proud to be a part of Nashville’s vibrant healthcare community, and we strongly believe in our city’s entrepreneurial spirit, collaboration and problem-solving to transform – and redefine – healthcare.

As one of the nation’s leading healthcare strategic communications firms, we understand the power of stories and their ability to inspire, create and sustain change. We hope the stories in this issue of the Nashville Post will help you and your business succeed, answer the challenges ahead and capitalize on opportunities to make healthcare better.

David Jarrard

President & CEO Jarrard Phillips Cate & Hancock, Inc.

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NEW TAB NEW TAB

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Brawn and brains

Nashville for-profits find strategic opportunities with academic medical centers by Emily Kubis Health systems have to be more creative today than ever before. Facing the new expectations and incentives of value-based care, providers are forging new alliances across the industry — including with hospitals that have traditionally been competitors with very different approaches to operating.

Whether a hospital is part of an academic entity, owned by a county government, a public company or a nonprofit system, reimbursement and quality measures have created very familiar challenges around sustainability and profitability. To capitalize on new payment models, hospitals must play to their varied strengths and associate with new partners for the specialities they lack.

“In the era of value-based care, the lines between for-profits and nonprofits are exponentially blurred,” says Michael Wiechart, CEO of Franklin-based Capella Healthcare. “We all feel the same reimbursement pressures. The typical nonprofit no longer has the luxury of standing on its mission, and the for-profits can no longer stand on their bottom lines. They all have to stand on quality.”

To provide the full range of coordinated care that government and commercial payers require, provider groups of all sizes have constructed networks of regional partners. Those alliances range from urgent care clinics and primary care doctors to community hospitals and academic medical centers, and the partnerships can be loose affiliations or official joint ventures. But they all seek to streamline operations and build an efficient spectrum of health care services.

Among the various new associations, partnerships between academic medical centers and for-profit hospital companies have seen particular success. One of the earliest to develop such a relationship is Brentwood-based LifePoint Health.

The company’s JV with Durham, North Carolina-based Duke University Medical Center, Duke LifePoint, has its roots in a LifePoint acquisition a decade ago of a Virginia hospital in Duke’s service area and the subsequent resurrection of an old relationship between the two entities.

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“We saw the landscape changing in the markets around us,” says Jeff Seraphine, president of LifePoint’s Eastern Group. “Duke was getting calls from community hospitals struggling to think about health reform and regulatory changes and how to keep up. Operating those community hospitals was not something Duke was doing, and was probably more suited for our strengths as an organization, and that’s where the discussion started.

Can we leverage those things we both do well in a new value proposition for hospitals trying to adapt to a changing industry?”

Community hospitals have capital needs that for-profit companies can take on, but they also need operational expertise to develop cost-effective service lines. That means finding the right balance of services that can be provided on-site, and the right partners for those that cannot. Developing a continuum of care that spans from the lowest acuity to very complex and specialized medical procedures — a strength of big academic medical centers such as Duke’s — is a key piece of these clinical affiliations.

Finding that balance is also a cornerstone of the Capella-MUSC Health Network, a partnership between Capella Healthcare and the Medical University of South Carolina. Wiechart says the alliance allows both entities to “borrow each other’s strengths for the betterment of the whole.”

“You have to find the right level of complexity of care to be doing locally,” Wiechart says. “A fairly classic example is that [smaller communities]

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OPERATE should not be doing significant heart procedures or neurosurgery. That’s why to be seen whether other academic medical centers you have to have a relationship with the right partner for that level of care that will seek that type of joint venture or look to build wider, more regionally based designs. also supports their academic mission.”

On a local level, Vanderbilt University Medical Inversely, the academic mission behind that clinical expertise can be expensive. Academic medical centers host large research divisions, expensive equip- Center is actively pursuing the growth of a regional ment, specialized physicians and unique caseloads that come with cost pressures strategy called the Vanderbilt Health Affiliated their smaller counterparts may not have. As such, they can also Network. With more than 3,400 use an assist from a for-profit partner. physicians and 50 hospitals, the “We don’t have access to capital that for-profits might have,” physician-led, population healthsays Dr. Mark Lyles, MUSC chief strategy officer. “As a state based network offers a different medical school, we are going to have to collaborate with others way of approaching the challenges — not only to provide the full continuum of care, but to mainand opportunities of extending tain the range of services we provide. That’s been the driving a strong brand and building a reforce of this partnership.” gional continuum of care system.

The Capella-MUSC partnership has provided opportunities Last year, VUMC split operational and financial ties with for the university medical center to expand its clinical efforts as well as research and training objectives. Lyles says getting phyVanderbilt University, which sicians and nurse practitioners to train in community facilities gives the system more flexibillike Capella’s can create opportunities that may funnel them toity in developing strategic partward those types of hospitals upon graduation, making an imnerships and other operational models. Vice Chancellor Dr. Jeff pact of physician shortages.

Further, the connected facilities allow physicians to creBalser told the VUMC Reporter ate and implement more direct, coordinated and expansive that functioning as an indepenpopulation health efforts and other community-oriented dent agency will give the hospital care initiatives. the ability to “build its network “These models start with clinical enterprise and medical staff of affiliated hospitals into an endevelopment,” Lyles says. “The evolving structure of these parttity that can thrive amidst the nerships gets into those population health models, and it’s pochallenges and uncertainty of the sitioned to grow into economic alliances and taking economic new health care economy.”

Harry Phillips, Duke LifePoint But these new models have risk in partnership.” their share of complications, from Different models, same questions regulatory issues to financing The growth of these partnerships could include more innovative economic challenges and unknown best practices. Five years models, but it also means adding market share. Capella-MUSC recently added a ago, these approaches were practically nonexistent, second system to its South Carolina network, and the local company also has a and Seraphine says the integrated care systems similar partnership with UW Medicine, the Seattle-based medical division of the may eventually need more than what any single University of Washington. partner in the relationship can provide — whether Duke LifePoint has expanded notably, growing into a 12-hospital network that’s capital to invest, physicians to recruit or oththat includes markets in Pennsylvania and Michigan. Harry Phillips, the joint er priorities. Even so, the trend of collaboration is venture’s chief medical officer, says these efforts create research opportunities expected to increase as various entities respond to and a brand extension that has furthered the partnership’s reach. health reform’s challenges.

“We have not been surprised by the recognition and preference for the Duke “We are really fascinated with all these creative brand in our regional markets, but we have been pleasantly surprised that it reso- collaborations that have sprung up,” Phillips says. nates well in remote markets,” Phillips says. “We’re very enthusiastic about the “It’s great these organizations are coming together, benefits we’re seeing in our national partnerships.” but we know it is very challenging to enhance qualThese collaborations include three important pieces — an academic medical ity while reducing costs. In these loose affiliations, center capable of handling the most complex cases, a community hospital with how successful is it going to be? Are any of these which to partner and a for-profit system with the capital to help tie it all together. new creative collaborations going to be the answer?

But that is just one concept among many integrated care models and it remains The story remains to be told.”

‘We have been pleasantly surprised that [the Duke LifePoint brand] resonates well in remote markets.’

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photo courtesy belmont university

Area pharmacy schools flourishing

Expanded facilities, programming an indication of high demand by Cindy Sanders A decade ago, students interested in a health care career as a pharmacist had to look outside Middle Tennessee to pursue their education. Today Nashville is home to two programs that are continuing to expand and innovate.

Lipscomb University’s College of Pharmacy and Health Sciences has recently debuted a new sterile compounding lab and has added over the past couple of years dual-degree programs that add informatics and management skills to a pharmacist’s clinical competencies. At Belmont University’s College of Pharmacy, programming has been put in place to make transitions along the continuum of education easier — from early assurance into the doctoral program for qualified pre-pharm undergrads to newly announced residency and fellowship partnerships.

Lipscomb doubles down Tennessee was hit hard in 2012 by the devastating fungal meningitis outbreak that claimed more than 60 lives nationally and 16 here at home. The tainted injections were traced back to improper procedures at the New England Compounding Center in Massachusetts.

“With the meningitis outbreak, the nation got focused on the quality and preparation of those products,” says Roger Davis, dean of Lipscomb’s College of Pharmacy.

While the school already taught aseptic technique in a small laboratory, the 2012 national tragedy underscored the consequences of making mistakes.

“We made the commitment at that point that even though we were doing a competent job of preparing our students in this particular area of compounding, we needed to do even more,” Davis says. “We increased the intensity of the training and expanded the lab capabilities and deepened our assessment of the training. We can 12 VITALS

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train more students in a better environment and assess their technique in a much more progressive way.”

Effective January of last year, the Tennessee Board of Pharmacy required all licensed pharmacies to comply with applicable sections of the U.S. Pharmacopeia 797 standards. Davis says the Lipscomb University lab not only meets those standards but exceeds them, continually exposing students to best practices prior to experiential practice in the community.

Co-opting space from another lab that had been moved, the Lipscomb School of Pharmacy built a new sterile compounding lab that opened in the spring and was put into full use with this fall’s incoming class. At just over 1,000 square feet, the new $500,000 facility offers the same equipment and technology that students will find in professional compounding pharmacies. Additionally, audiovisual equipment allows faculty to observe, capture and assess aseptic practices including gowning and garbing, compounding, and cleaning and disinfecting.

The lab features six laminar airflow workbenches, allowing students to prepare non-hazardous sterile products, and a biological safety cabinet to prepare hazardous sterile products including simulated chemotherapy drugs.

“We added the capability to compound the chemo drugs, which is a different process, because you have to protect the pharmacist who is preparing the product, as well as the patient who will consume it,” Davis says.

He says the School of Pharmacy will also work with

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OPERATE the community to create continuing education opportunities to enhance the training and skills of those already working in the community.

Along those same lines of preparing students to meet “real world” needs, Davis says the university has added new dual-degree programs over the last few years to better enable doctor of pharmacy students to manage people, patients, data sets and outcomes.

In addition to the clinical component in pharmacy, students have the option to earn a master’s degree in health care informatics or in management.

“Both of these can be completed within the four years that is required of the doctoral program,” Davis says. “There’s a huge need in the health care industry for people who can handle large amounts of data. It’s the underpinning for population health.”

The impetus behind the new lab and dual degrees is really the same, Davis notes. At the core of the programming is a desire to prepare practitioners at a higher level of competency to meet the nation’s increasingly complex health care needs.

“We try to prepare our students so they move into the marketplace in a very quick and productive manner,” he says.

there were 32 percent more pharmacists desiring such a residency than there were training sites nationally.

“This helps create jobs in Rutherford County, where the Christy-Houston Foundation focuses, helps the hospital expand its clinical and administrative services and helps Belmont establish additional training sites,” says Phil Johnston, dean of Belmont’s College of Pharmacy. “Together, this partnership will benefit recent graduates, the patients of Saint Thomas Rutherford Hospital and the residents of Rutherford County.”

The Christy-Houston Foundation provided $123,740 as seed money for the tworesident program. In addition to the gift, the foundation has provided funding for state-of-the-art equipment for Belmont’s School of Occupational Therapy and the

Belmont looks to help fill fellows gap Over the last few months, the Belmont University College of Pharmacy has announced several additions to the continuum of education. In July, Belmont and Nashville-based Aegis Sciences announced the launch of a pharmacy fellowship program. The fellows will complete an intensive two-year postgraduate training program focused on drug information, evidencebased practice, teaching and research.

The program is one of about 60 postgraduate pharmacy fellowships in the country and offers a unique training experience in areas not widely available in pharmacy training. Katie Miller, board certified pharmacotherapy specialist, was named the fellowship director.

In August, Belmont announced a postgraduate pharmacy residency at Saint Thomas Rutherford in partnership with the Christy-Houston Foundation.

Citing the ever-increasing complexity and fast pace of health care service innovation, Belmont officials say there is an increasing demand for pharmacists with postgraduate residencies that provide training in management, clinical service provision, alternative therapies and budgetary controls. However, last year

photo courtesty lipscomb university

Christy-Houston Drug Information Center at Belmont’s College of Pharmacy, a center that is utilized continuously by 300 students, 30 full-time faculty and more than 700 volunteer pharmacists.

However, before students can get to post-graduate work, they must first successfully complete the doctor of pharmacy program. Belmont has recently announced an “early assurance” program for qualifying incoming freshmen to the pre-pharmacy undergraduate degree program.

Students must meet a number of requirements out of high school, indicate an interest in the program as an incoming freshman, and complete a successful interview with the College of Pharmacy during a Belmont Preview Day or campus visit prior to enrollment. Once accepted to the university, additional requirements must be met and grade point averages maintained.

However, those who meet all the requirements are assured admission to the College of Pharmacy. Other benefits include being assigned a faculty adviser from the doctor of pharmacy program while still an undergrad, preferred access to available volunteer and shadowing opportunities, and an open invitation to begin attending lectures, seminars and other special events by the College of Pharmacy to increase exposure to the field from the beginning of a student’s college career.

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OPERATE Taking shared responsibility

room. Of course, the med student zeroed in on the examination, and the pharmacy student got a deFour-school training program dumps silos for a tailed history of medication.” broader view of care by Linda Bryant Shoal’s team member Joshua Cockroft, a A groundbreaking program at Vanderbilt University is tackling an age-old prob- second-year medical student at Vanderbilt Unilem in medicine — getting health care professionals from different disciplines to versity School of Medicine, called the home visit “eye-opening.” actually collaborate on patient care.

“It was a very unique opportunity,” Cockroft The Vanderbilt Program in Interprofessional Learning is one of the first of its kind in the country. Those close to the five-year-old program describe it as says. “We were able to figure out more about how ultimately transformative and believe the model represents the future of patient the patient’s health had waxed and waned over care — particularly as the industry’s payment models continue to change and time. We were able to treat the patient in a truly holistic way. […] VPIL breaks down the old hierreward collaboration.

VPIL participants include students who are in training to become physicians, archies. I gain insight into my colleagues’ decision nurses, pharmacists and social workers. Rather than spending their entire school making, and it also shows me just how comprehenexperience learning about their individual disciplines in isolation, VPIL students sive and holistic health care can be.”

VPIL is a competitive program and spend two years working together with patients in teams. They typically admits about 40 students even make home visits together as a team and accompany many a year. Participants meet in clinic or of the same patients while they are in the program. classroom settings once a week for two Christine Shoal, who is studying to be a family nurse practiyears. Some of the biggest challenges tioner at the Vanderbilt University School of Nursing, calls the of the program include the complex program “rich in knowledge and life-changing.” scheduling required, finding more “Medicine is extremely specialized now, and that’s one of the practice sites in the community and exreasons why VPIL is so important and unique,” Shoal says. “In panding the program, Davidson says.

VPIL, we learn to take shared responsibility for the patient. EvWhile the program may be relativeeryone sets their ego aside, and together we work to understand ly small in terms of numbers of stuthe patient. We get to see this person change and grow over dents, it has a larger impact because time, and I think we provide much better care because of it.” the model is so innovative, says Roger The VPIL program not only represents collaboration across Davis, dean of the College of Pharmacy health care disciplines. Four universities are also partnering — and Health Science at Lipscomb. the College of Pharmacy and Health Science at Lipscomb Uni“The VPIL program has for one of versity, the University of Tennessee College of Social Work, the the first times accomplished a learnTennessee State University School of Nursing and the School of ing system that is sustained over an Medicine and School of Nursing at Vanderbilt University. extended period of time,” Davis says.

“VPIL is training for the next generation,” says Heather Da“Most interprofessional programs in vidson, assistant professor of medical education and adminthe past have not succeeded because istration and director of program development at VPIL. “We Heather Davidson, the organizational commitment could know that being trained in a silo is not the most helpful ap- Vanderbilt Program not be sustained. proach. But traditionally, that’s how most health care profes- in Interprofessional “This program prepares students for sionals have been trained. We are teaching students in a less Learning true team practice,” he adds. “Students fragmented way.” are better prepared because the learnHow does the VPIL approach actually impact the patient?

Shoal describes a patient with complex health problems who was also living in ing begins from Day 1. They have the opportunity for immediate application through their clinic extransitional housing for the homeless.

“We made a home visit and all of us were able to talk to the patient for almost periences. Most importantly, students learn that two hours,” Shoal says. “Our team identified different things about the patient. better patient outcomes are the result of team efI was focused on his meal and exercise plan. The social work student was con- fort through utilization of the unique expertise of cerned about mental health and also noticed that the patient had a bike in his each health professional.”

‘We know that being trained in a silo is not the most helpful approach.’

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photo by eric england

‘Medical judgment is being subsidized for profit margin’ U.S. Attorney David Rivera on combating ‘increasingly creative’ fraud

fice approach to combating health care fraud, and what the investigators have learned along the way.

How did health care fraud come to be a district priority?

We recognized a couple of years ago the surge in the health care industry in this district and the Midstate. It’s clear that Nashville is the “It City” for health care, so how do we respond to that, and what is the responsibility of the U.S. Attorney’s Office? If we were in New York, our priority might be investment fraud. If we were in Chicago, it might be gang violence. r in Miami or Texas, it might be the smuggling of drugs. In this district, a big priority is health care fraud, because with growth in industry comes growth in fraud.

Compliance with health care regulations is always on the minds of health care executives, especially as the number of legal cases and settlement figures continue to grow. According to local law firm Bass Berry & Sims’ annual Healthcare Fraud and Abuse Review, the federal government recovered $1.9 billion more in fiscal 2014 than in the year prior. Look for that figure to stay high: More than 1,400 qui tam cases, also known as whistleblower suits, have been filed in the past two years.

“This is an area that is extremely important to this district,” says David Rivera, United States Attorney for the Middle District of Tennessee. “We’re doing a considerable amount of work in this area, and we’ve had a considerable measure of success.”

Are there particular types of health care fraud that The Post’s Emily Kubis sat down with Rivera to discuss the U.S. Attorney’s Of- are more common here?

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OPERATE The types of health care fraud we’ve observed in the office run the gamut of unnecessary medical procedures, so it’s not just a victimless crime. We’ve seen unnecessary hospital admissions, unnecessary CAT scans — exposure to radiation for profit purposes. We’ve seen scams with adulterated drugs, we’ve seen unqualified and non-licensed care billed to Medicare and Medicaid like it is compliant. It erodes consumer confidence, and it has a direct impact on the money available now and in the future in federal health care programs.

How did the U.S. Attorney’s Office approach the issue?

We recognized this is something we needed to double down on, and in a couple of years, we did just that. We doubled and then tripled the size of our civil unit and increased our affirmative civil enforcement program threefold. We hired very talented lawyers with experience in this area, and we reinvigorated our white-collar section and added attorneys focused on health care fraud.

What result did those efforts have?

On the civil side, between 2006 and 2009, civil recoveries averaged between $400,000 to $1 million per year. In the last three years since we’ve applied our additional resources and focused our investigative efforts, we’ve recovered roughly $200 million. Last year alone, we recovered about $155 million.

So you can see how our efforts have uncovered that there is considerable health care fraud that must be addressed. On the criminal side, we’ve increased prosecutions at least fivefold — and that’s not just charges, but convictions. Those are convictions on individuals, health care providers and doctors who are convicted of health care fraud.

Is the Middle District of Tennessee seeing the national increase in whistleblower cases?

Yes, the amount of qui tam cases that have been filed in this office have increased significantly.

Most of the False Claim Act cases have come to us through the filing of qui tam cases by whistleblowers. We’ve had considerable success in our ability to investigate these cases, intervene and obtain recoveries. Recoveries through the False Claims Act are actual checks cut by corporations settling cases and go directly to replenish our Medicare and Medicaid funds.

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OPERATE Nationally, we know approximately 20 to 25 percent of cases filed by whistleblowers see government intervention, which is an indication of how cautious and judicious the government is in looking at these qui tam cases. In our district, I suspect we are well above that 20 percent in the number of cases in which we intervene.

Are there other trends you’re seeing in health care fraud investigations?

What we found, and what I see throughout the country, is that health care corporations involved in fraud are becoming what I would call increasingly creative. They create a methodology that is successful in generating considerable amounts of profit. A trend I’ve seen is individuals without medical training making patient care decisions. Medical judgment is being subsidized for profit margin.

Another big area is when you look at the Anti-Kickback and Stark Law. Once upon a time, it might have been cash or a bonus payment of some type, and now we see lease arrangements and other more creative avenues of funneling benefits to that provider. That’s much more difficult on the part of law enforcement agencies that might be investigating. One trend that is clear on the part of the Department of Justice and this U.S. Attorney’s Office is our very public emphasis on our intent to pursue individual accountability for these crimes.

How does that differentiate from company settlements?

We want to be clear to the health care industry that paying off settlements and damages and fines will not be business as usual. This office and the Department of Justice will be pursuing the people who are responsible for the fraud — whether it’s the CEO, COO, executives, folks responsible for marketing — if we can find criminal culpability of those individuals. The corporate entity doesn’t create the scheme.

It’s created by individuals in the organization, and we will continue to pursue the individuals and criminal liability of those individuals.

Are there other areas your office is emphasizing?

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We do a lot of work in the area of prevention as well. We make great efforts to get out in the industry, provide seminars and speakers so we can inform the industry of what’s happening. We can be available and accessible so there can be transparency about what it is we do.

We want to see this industry grow and flourish, but the biggest enemy of industry is fraud. We’re not just doing work in the area of enforcement, we are also mindful of prevention. Because with every prosecution or enforcement action, it would be better for everybody if it had never happened.

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Marshall Martin and Jason Moore Stratasan

photo by eric england

Layer upon layer of growth

Analytics player Stratasan has big plans for ’16 and beyond by Geert De Lombaerde Pity your average hospital executive for a little bit. Just for a few seconds, promise.

Think about how her hospitals aren’t getting paid at the rate they used to. Picture her having to deal with the doctors who have set up a surgery center nearby to lure away some of her most profitable customers. And her biggest corporate priority for the next two years is figuring out which service lines — orthopedics, freestanding emergency departments or urgent-care clinics? — are deserving of parts of her precious capital budget.

For more than 600 hospitals in 40 states, the potential headache of weighing those dynamics is alleviated by Stratasan, a five-year-old software and analytics venture based near downtown’s First Tennessee Park. The company — which takes its name from the Latin words for layers and health — has amassed mountains of demographic, market share and financial data that gives customers greater confidence in making planning, marketing, physician relations and acquisition decisions.

And in a world where sticky customers mean so much, here’s a thought: Stratasan’s services steadily get better over time as its technology and people interact with clients making front-line decisions.

“We’re learning at a rapid pace because all of the inputs we have,” says cofounder and COO Jason Moore. ”There are a lot of meaningful conversations with clients to fold into what we’re doing.”

Moore launched what is now Stratasan as Health Data Source. Initially, he expected his core customer base would be smaller hospitals without dedicated planning staffs. But it turned out larger organizations more eagerly wanted the 20 VITALS

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chance to crunch — and validate — their numbers.

Absorbing all that data over time has more recently proved useful for Moore and his team as they go back to smaller hospitals with more refined models and databases.

“It’s a race to adapt to change, and people are willing to look at all the tools available to them,” CEO Marshall Martin says. “It’s no longer just about filling beds. Bringing in the wrong patients may not be the answer in a fee-for-value world.”

Stratasan has steadily grown its staff to 21 people but 2016 is setting up to a be big. Martin, who came on board about 18 months ago, says he can see the company hiring between eight and 12 people in the coming year. Key drivers are the recent formal introduction of Spark, the company’s concierge analytics service, and the upcoming rollout of the first in a series of niche products under the Pathways brand.

Spark is a more formal, packaged evolution of three years of work with Stratasan’s service tools, which now account for about 40 percent of the company’s revenues. The company’s team of specialists are in a position to translate clients’ goals and priorities and run them through a virtual implementation process. The question that results is usually a variation of, “Is this still the decision you want to make?”

The Pathways line’s premise is that Stratasan’s main planning tools can be too cumbersome and wide-reaching for certain purposes and audiences.

Picking a smaller focus area can let Stratasan deliver a clearer value to smaller groups with more specific questions. The first product, to be rolled out in January, will focus on the key dynamic of physician recruitment and retention.

Stratasan has positioned itself to be at the table for a lot of the important questions being asked by health care executives these days. The market is in flux and reliable data is at a premium as various stakeholders figure out how to stake their claim to a world dominated by value-based reimbursement and population health management.

“We’re not sure how long the transition will take. There are specific questions to answer during that process, but the underlying question will still be the same,” Moore says. “What are the right services to provide in the right place? It’s all about understanding the communities you’re in.”

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‘The biggest challenge is the continued interference between doctor and patient’

Four doctors discuss the patient relationship, the young guns they work with and a greater sense of antagonism in the industry compiled by Emily Kubis Nashville is full of health care executives ready to tackle health reform’s main challenges and we love covering their big ideas. But just as important are the physicians who deal with policy and reimbursement changes on a day-to-day basis. Getting their perspective sheds light on how the health care industry affects clinicians and patients alike at ground level.

So as we did last year, we asked several Tennessee physicians for their take on being a modern M.D. They are: Dr. Laura Lawson, a breast surgeon at Saint Thomas Medical Partners; Dr. John Hale, a family physician in Union City; Dr. Michel McDonald, a Nashville dermatologist; and Dr. Doug Springer, a gastroenterologist in Kingsport We think you’ll find their answers frank, enlightening and at times provocative.

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How are changing reimbursements affecting your practice?

Lawson: We have definitely noticed that reimbursements and payor mixes have changed over the last few years. To be honest, one of the main benefits of being employed by the health system’s physicians group, Saint Thomas Medical Partners, is that I don’t have to worry as much about that on a day-to-day basis. I am involved in both the administration of my practice and of the larger group, but I am able to focus my attention on patient care. I am able to provide care for all and don’t have to stop and think about what kind of insurance, if any, that my patients have.

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OPERATE The biggest thing we’ve seen over the last year or two is the effect on patients’ deductibles. Everyone’s deductibles have gotten pretty outrageous. We see fewer patients earlier in the year when their deductibles are not met, and then when they do meet their out-of-pocket obligations, they want to pile on preventive care before the end of the year.

While I understand why more patients allow cost to drive their health care decisions, it’s really ill-advised from the physician’s perspective. Too often, we see patients wait until something really bad happens or put off care for so long that they don’t have any choice. What may have been a minor illness initially turns into a more complex medical condition that costs everyone more and carries more long-term effects.

We also still don’t really know the full effects of ICD-10 but should find out in the next few months.

Hale:

I have not noticed a great effect on how I practice other than drug costs.

A lot of medications that I prescribe have skyrocketed in price lately because of pharmaceutical industry M&A, patients’ changing prescription benefits in their health plans and other factors.

Patients are calling back to request different medications because they can no longer afford the same ones I’ve prescribed for a long time. It affects my practice because I have to make sure to keep up with the changing prices and adjust my prescribing habits to make sure my patients can afford it.

McDonalD:

We are seeing greater patient financial responsibility with the continuing shift to high-deductible health plans. Collections is more burdensome and expensive for providers; it’s getting more difficult to collect in a timely manner that allows us to pay our business obligations. We also have to jump through hoops related to perceived quality markers — not necessarily investigated and proven quality — in order to get paid for services.

As a result, overall documentation has increased, staff time has increased and related expenses have all increased. It’s becoming more difficult for private-practice physicians to remain profitable, especially if you have a large population of government payers like Medicare and Medicaid.

Springer:

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OPERATE What do you wish your payers understood better?

Lawson: I wish that payers understood that most providers are very thoughtful about what tests to order for patients and try to be good stewards of our health care dollars. If we do order something, it is because we really think it is in the best interest of the patient.

Hale: I think they understand us extremely well. They know how our system works. They know what drives us. They are fully aware of their financial leverage over the typical medical practice and regularly use it in contract negotiations and other interactions. I think both sides would be better off if we could sit down and have some sort of cooperative effort and not an antagonistic situation.

‘Patients are calling back to request different medications because they can no longer afford the same ones I’ve prescribed.’

McDonald: I wish they understood the hassle factor for patients. For example, as a specialty practice, we put protocols in place for appropriate use so we don’t have issues getting them approved from payers. But we still see too many patients who take off work and drive long distances to come in to our office to have a procedure that we know is going to be approved, but end up having to leave and come back because the insurance company says they need another pre-certification and we can’t get anyone on the phone or they can’t deliver it that day. If the payers were more efficient, then they could eliminate these hassles for the patients — their customers.

At the same time, when I stop to think about the generation of doctors before me, I realize they went through a lot of hardships that I did not have to endure, making house calls and working extremely long, hard hours. Malpractice and changes in medicine changed that.

My generation is used to working a lot and running a good business. The younger generation is more tech-savvy. They also are more likely to practice in employed environments that give them more of a quality of life without having to deal with the business side of medicine.

I definitely see more of a focus on work-life balance. When I started practicing 17 years ago, we didn’t see a lot of talks at conferences about this issue. Doctors are much more aware of it now. We’ve also seen a shift in physicians taking on more leadership roles and driving the boat more in health care reforms — within their practice, their hospital and even at the state and federal levels through organizations like Tennessee Medical Association.

McDonald:

The younger generation of doctors approaches the business of medicine as an employed model. They demand quality of personal life much more than senior physicians experienced early in their careers. The younger physicians’ expectations may be to work an eightSpringer: Everything has a cost.

The more dochour day and then go home to their families, Dr. Michel McDonald umentation, phone calls and emails that are re- hobbies and interests. quired to get a patient scheduled and treated, the more expensive the patient becomes, without ad- What is your greatest challenge on ditional reimbursement for the provider. If payers could become more efficient and consistent, then physicians could quickly complete the patient encounter a day-to-day, operational basis? and save health care dollars for everyone.

Inversely, has there been a notable

Do you see generational differences among doctors and their approaches or priorities?

Springer:

operational improvement in any area due to health reform?

Lawson: The greatest challenge on a daily basis is the paperwork. Sometimes it seems to take longer to fill out the forms, document in the chart, dictate and then approve notes or sign my name five or six times in different places than it actually takes to care for the patient. I want to spend more time Hale: I think every generation — people of any profession, not just physi- with my patients, not working on the computer. cians — looks at the one following them and sees a different work ethic.

They see benefits that the current generation has that they wish they had. Hale: The biggest challenge is the continued in-

There are some generational differences, mainly regarding prioritization of family life. It is now much more common for a physician to have a spouse that also works outside the home, which necessitates more shared responsibility, especially of children.

Lawson:

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OPERATE terference between doctor and patient. There are positives with electronic medical records when you look at moving information and being able to access data quicker and easier. But it does slow us down, limiting the number of people we can see, and it puts a barrier to building a rapport with the patient.

When you look at insurance networks, we have to hire people just to confirm what type of plan a patient has, check network referrals, prior authorizations and all sorts of other requirements. We live with these things daily. These barriers, along with employment contracts, have decreased collegiality in the profession. Doctors used to be a lot more connected with each other, and that’s a shame.

McDonalD: The answer to me is one and the same — electronic health records. There are day-to-day operational challenges trying to keep up with all the rules and regulations, which are

constantly changing. There is no standardized record. It’s a challenge to remain efficient and stay focused on patient care and avoid always looking at the computer. Conversely, e-prescribing cuts down on errors, and it’s much more efficient than what we used to do on paper charts. Overall it’s certainly an improvement I believe will ultimately make health care more seamless. But it is coming with a cost.

The biggest challenge of practicing medicine today is providing a high-quality patient visit, including a meaningful outcome, with drastically reduced reimbursement. In prior years, most health care organizations have been able to succeed because commercial insurance companies reimbursed at higher rates to offset governmental programs that often reimburse less than the actual cost of care.

Unfortunately, a large part of health care reform is shifting insured patients from commercial insurance to government programs such as the exchanges, Medicare and Medicaid. As this shift occurs, reimbursement shrinks and the cost of providing care increases over the patient population.

Furthermore, the cost of doing business goes up each year with rising costs of medical supplies, staff wages and our own personal health insurance, without any increased reimbursement to offset these costs. In my opinion, health care reform has made no notable improvement to patient care.

Springer:

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OPERATE ‘We’ve got to get outside of ourselves’

Can we partner with them? How do we ensure that all those partners know the needs of that person?

As a nonprofit, we do self-assessments in the communities we serve. So if we’re doing what we Saint Thomas’ new CEO opens up about how a say we’re supposed to, we should see that needle truly integrated system can help shape an updated move. We should see obesity go down, we should see diabetes issues resolve, we should see healthier paradigm in patient care children. If we’re not, then we’re just kind of filling One of the biggest players in Nashville health care is in a period of transition in in the boxes. We’ve got to get engaged. both leadership and operation. Nonprofit health system Saint Thomas Health this summer overhauled its C-suite almost entirely, and those new leaders also What steps do you have to take operationally to do that effectively? are transforming how their providers deliver care.

Leading that charge is the system CEO Karen Springer. Previously Saint The worst secret about health care is that none of Thomas’ COO, Springer is moving the nine-hospital network toward becoming this talks to each other electronically. We have to a “clinically integrated delivery system,” which involves pushing care out of the have an integrated network of this patient visible hospital, into the community and through partnerships with other Nashville to every entity. The banking industry can do it. The providers. Amid massive overhauls to the health care sector as a whole, Saint Veterans Administration has done it. Why can’t we Thomas has emerged as a leader not only in caring for the underserved, but also do it?

The only way we can reduce the amount of in being honest about health care’s shortcomings and the innovations needed redundancy and wasted dollars in health care is to overcome them.

The Post’s Emily Kubis spoke to Springer about her new role, her aspirations to have visibility in our own facilities and others’ facilities so we don’t ask patients to know what’s and her system’s future. happening in their care. It’s not fair for us to ask What are your goals as CEO? a patient to be responsible for that. We should be The vision and mission that we started under Mike Schatzlein about four years responsible for that. Waiting for someone else to ago is the same journey we’ve been on, and my role now is to take it to the next take that lead is not the right place for us to be as level. We’re organizing ourselves to become one Saint Thomas. The change of Saint Thomas, so we’re going to step into and take our name was just one part of that, and sets us up for what we really want, the lead. which is to be a clinically integrated health care delivery system.

That takes coordination of our own entities and facilities, but also partnering Why do you feel Saint Thomas is poised to with community service providers and physicians who may or may not be take a leadership role in this work? employed with us. And that’s the next level. The next level is to really be not I think it goes back to [Catholic missionaries] just a system of hospitals but to be a system of care. That’s my charge and that’s the Daughters of Charity and the founders of Ascension. Ascension has taken this on and said what I’m undertaking. to all of our ministries, “We’ve got to change the delivery of health care. It’s just not sustainable What does the “clinically integrated health system” entail?

Our mission in Catholic health care is to serve persons where they are, and we and, as a branch of the church, we’re not asking. probably have not been doing that if we look really and truly at ourselves. We’ve We’re telling you we must change how we do been doing that when they come to us — they get great health care when they’re things.”

But since it’s all so new, each of us in different in our hospitals. But that’s not enough. If we’re really going to fulfill and change ministries are attacking it in different ways to see the way health care is delivered, we’ve got to get outside of ourselves and try which is the best way, and we’ll share it with each to make a difference in these communities where people live. And it’s not that other.

I’m grateful we’ve been pretty innovative this work isn’t going on, but none of it is really integrated around the patient. and advanced here, and Ascension supports How do you make so much more of your work patient-oriented? that and looks to see how successful we are, and The foundation is neighborhoods. We look at our neighborhoods and say, “Do we supports us if we fail. have a medical home there? Should we put one there? Are they underserved?”

We’ll take those best practices and share with That’s your foundation, and then you look for urgent care, retail pharmacies. Michigan or Austin or Jacksonville. We’ll share NASHVILLE POST

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Keeping pace with an ever-changing industry.

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OPERATE what we’ve learned. That’s what the Daughters would have done.

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

Lucy Carter Member KraftCPAs PLLC Healthcare Industry Team

615-346-2497

Scott Mertie President Kraft Healthcare Consulting, LLC

615-782-4292

Leadership at Saint Thomas has been very forthcoming about health care’s strengths and weaknesses. Where do you think that openness comes from?

I would hope that part of it is we’re a missionoriented organization. Just because someone fails or doesn’t meet expectations doesn’t mean you throw them out. How can we help them?

It’s a forgiving environment and it should be.

If someone is missing the mark, how do we get them there? Do they not have the right tools or education?

Errors happen, mistakes happen, and we should learn from them. We can’t hide it in health care. It’s people’s lives, and we have to own that and hold ourselves accountable. In health care in general, we are not really where we should be. Compared to other countries, we spend more money and our quality outcomes are not as good.

The bigger part of it is how we’ve set up our payment structure, so what are we going to do?

How do we make sure it’s sustainable for the generations to come? I started as a nurse and I remember sending patients home after surgery and thinking, “I’m not sure this is going to be OK.” But I didn’t know what else I was supposed to do. I don’t ever want my nurses to feel that way.

Speaking of the payment structure, how is Saint Thomas operating in the changing landscape?

They pay us for the work we do, not for the work we should be doing. But [this work is] our call, and we will find resources within the work we do get paid for to pay for these efforts. Just like we did for MissionPoint; we used the dollars we were able to be paid for and applied the population health [tools]. And we will do the same thing for clinical integration.

There’s not a big magical bucket of money.

We’ll work together and make it happen. That’s the beauty of becoming a system of people who care about what we’re doing.

Who’s on the bench?

This summer’s changes to Saint Thomas’ leadership team began with the promotion of CEO Dr. Mike Schatzlein, who took a vice president position at Saint Thomas’ parent organization, St. Louis-based Ascension Health. His vacated spot was filled

by Saint Thomas COO Karen Springer, a promotion that set off a chain of openings that the system filled with new leaders.

Here are some of the system’s smartest, most innovative pioneers who are taking Saint Thomas into a new era of care delivery. > Emily Kubis Bernie Sherry, COO, Saint Thomas Health Sherry was formerly the president and CEO of Saint Thomas Midtown and West hospitals in Nashville. He led the strategic integration and service allocation of the two facilities when the system rebranded all of its hospitals under the Saint Thomas name in 2013.

Amber Sims, chief strategy officer, Saint Thomas Health Sims was named to her position in September after having held several different roles throughout the Saint Thomas system. She was COO of Saint Thomas Physician Services as well as vice president of the Saint Thomas Health Alliance, an organization focused on strategic partnerships.

Fahad Tahir, CEO, Saint Thomas Medical Partners As head of Saint Thomas’ multi-specialty physician group, Tahir is at the forefront of care coordination and integrated delivery. He led the more than 60 medical practices in linking together under the Medical Partners name earlier this year.

Blake Estes, executive director of strategy and planning, Saint Thomas Health Formerly a financial analyst and the director of strategic operations for Saint Thomas Midtown and West hospitals, Estes took on a system-wide role in 2014. He is a leader in operational finance as well as strategic finance and planning.

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DATA BANK

In the same boat Tennessee is no outlier when it comes to growth in health care spending. Here’s the average annual increase the Volunteer State and its neighbors experienced from 1991 to 2009.

Health care has a shortage of several things — but not big trends.

From our usage of various facilities to how we’re splitting the costs with our employers and the people who will help heal us, here are some snapshots of the industry’s evolution.

North Carolina..........................................................................7.9% Virginia........................................................................................6.9% Kentucky.....................................................................................6.7% Missouri......................................................................................6.7%

Just visiting

Arkansas.....................................................................................6.6%

America’s community hospitals these days book a third fewer inpatient days per 1,000 people than two decades ago. By contrast, our collective per-capita use of outpatient facilities has soared by more than half.

Tennessee..................................................................................6.6%

Georgia........................................................................................6.6% Alabama......................................................................................5.9%

2.5k

Carrying the load Workers with employer-based insurance are today shouldering a larger part of the cost of that coverage.

2.0k

Average annual health insurance premium

1.5k Outpatient visits

1.0k

Employer contribution

10.8K $17.5K

$

2005

8.6K $12.5K

$

2005

Inpatient days

0.5k

ED visits ‘93

Worker contribution ‘97

‘01

TennCare trends

‘05

‘09

The frequency of Tennesseans’ visits to their doctors has shifted slightly over the past decade. Among both the population as a whole and those with TennCare coverage, the number of people who see their doctor monthly has dropped, while those who visit yearly has risen. Here’s how the numbers broke down this year among the different populations.

Weekly

Monthly

2015

2.7K $4.9K

$

2005

‘13

2015

2015

Every few months Yearly or rarely

All heads of households

2%

11%

46%

41%

TennCare heads of households

3%

26%

49%

22%

Weekly

Monthly

Every few months Yearly or rarely

All children

1%

7%

47%

44%

TennCare children

1%

13%

51%

33%

Sources: American Hospital Assocation, Kaiser Family Foundation, UT Center for Business & Economic Research, staff research

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OPERATE Market value Earlier this year, the Nashville Health Care Council reported that the health care sector has a $39 billion impact on Middle Tennessee’s economy. Here’s another benchmark number: The combined value of the 17 publicly listed companies headquartered in the area tops $50 billion — and that’s after October profits from some major names led investors to sell big for several days. Here, as of Oct. 23, are how the companies’ market capitalizations rank.

27,440

HCA Holdings

4,080

Acadia Healthcare

4,000

Brookdale Senior Living

3,160

AmSurg

3,110

Community Health Systems

2,720

Healthcare Realty Trust

2670

LifePoint Health

2,320

National Health Investors National HealthCare Corp.

921

Surgery Partners

844 774

HealthStream

575

AAC Holdings

371

Healthways Community Healthcare Trust

2,670

138

Cumberland Pharmaceuticals

96

Symmetry Surgical

90

Diversicare

60

Coming up short A lot of those companies are big employers of nurses. This forecast from Project HOPE and Health Affairs suggests they’re going to have to pay up to attract and retain nurses in the coming years. Below are the numbers for the projected shortfall between the FTE supply of registered nurses and the demand for them.

2018........................................................................................................................-15,895 2019........................................................................................................................-55,159 2020........................................................................................................................-97,669 2021..................................................................................................................... -137,284 2022..................................................................................................................... -174,820 2023 ..................................................................................................................... -203,597 2024..................................................................................................................... -234,659 2025 ..................................................................................................................... -258,597

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Tennessee HEALTH CARE HALL OF FAME The Tennessee Health Care Hall of Fame was created this year 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.

The inaugural class of eight — whose achievements span more than a collective 100 years of medical and corporate accomplishments — was selected by a 12-member committee.

For more information about the process and how to nominate someone for the 2016 class, visit tnhealth-

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Thomas Frist Sr.

Thomas Frist Jr.

Committed physician, savvy businessman

Dedicated businessman, lifelong philanthropist, devoted father and grandfather

A native of Meridian, Mississippi, Dr. Thomas Frist Sr. attended the University of Mississippi, where he started a transportation company that eventually employed 17 other students. But Dr. Frist’s passion lay in caring for people, shaped from his early experiences working as an orderly at Meridian’s local hospital. Dr. Frist studied medicine at Vanderbilt University School of Medicine and completed his residency at the University of Iowa.

In 1935, Dr. Frist opened a medical practice in Nashville. During World War II, he served in the U.S. Army Medical Corps as the chief of medical services for a 1,000-bed hospital. Discharged as a major at the war’s end, Dr. Frist returned to his Nashville medical practice.

In 1957, he was appointed to the American Medical Association Committee on Aging and subsequently established the Tennessee Commission on Aging. During this time, Dr. Frist envisioned creating a hospital where patients came first and where funding was not dependent upon government sources. This dream led him to set up Park View Hospital with several other medical professionals and businessmen. The success of Park View served as the seed of inspiration for Dr. Frist Sr., his son Dr. Thomas Frist Jr. and friend Jack Massey to form Hospital Corp. of America in 1968.

Dr. Frist served as chief medical officer and chairman of the board for HCA. He is the namesake for the HCA’s Frist Humanitarian Award.

A Nashville native, Dr. Thomas “Tommy” Frist, Jr. is a graduate of Nashville’s Montgomery Bell Academy and Vanderbilt University. An entrepreneur at heart, Dr. Frist created a collegiate advertising company and earned his pilot license while at Vanderbilt. In 1965, he graduated from the Washington University School of Medicine in St. Louis and then returned to VU for his surgical residency.

His residency was interrupted by a two-year term as a flight surgeon at Robins Air Force Base in Georgia during the Vietnam War. While in the military, Dr. Frist had an idea for a company that would bring hospitals together to share resources.

In 1968, Dr. Frist, his father Dr. Thomas Frist Sr. and Jack C. Massey formed Hospital Corp. of America.

As one of the nation’s first investor-owned hospital companies, HCA modernized the way health care was delivered in the United States. Dr. Frist served HCA in various leadership roles including president, CEO and chairman. He remained on the board of directors of HCA until 2009 and currently serves as chairman emeritus.

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Ernest

Jack Goodpasture Massey

Clayton McWhorter

Decorated pathologist, passionate educator, dedicated public servant

Lifelong entrepreneur, savvy investor, devoted philanthropist

Celebrated businessman, respected mentor, dedicated philanthropist

Born in 1886 near Clarksville, Ernest Goodpasture was a Tennessee native and 1907 graduate of Vanderbilt University. Dr. Goodpasture then attended Johns Hopkins Medical School and served as a faculty member at Johns Hopkins and Harvard medical schools. In 1924, he was invited to join the new Vanderbilt Medical School as the Department of Pathology’s first chairman.

He spent the most of his career at Vanderbilt before serving as scientific director of the Armed Forces Institute of Pathology in 1955.

Dr. Goodpasture’s scientific accomplishments led to his recognition as one of the world’s foremost pathologists. His interest in infectious agents and viruses led to the development of the chick embryo technique used for the cultivation and study of a number of viruses. This work provided the foundation for the successful development and improvement of vaccines against yellow fever, typhus and influenza, saving thousands of lives.

In recognition of his scientific work, Dr. Goodpasture received honorary degrees from Yale University, the University of Chicago and Washington University. He was elected as a member of the National Academy of Sciences and the American Philosophical Society, among others. He also was nominated for the Nobel Prize in Physiology and Medicine.

Jack Massey was born in Georgia, attended college in Florida and eventually relocated to Tennessee to build a career steeped in health care, business and investment. After selling a chain of six drug stores, Massey founded Massey Surgical Supply Co. in the 1930s and supplied area hospitals and doctors with medical equipment. In the 1940s, Nashville’s Protestant Hospital was experiencing significant financial challenges that would likely end in the facility’s closure. Massey became the principal behind its development to the Tennessee Baptist Convention and in 1948, the hospital was renamed Mid State Baptist Hospital.

Massey later entered the food industry as owner of Kentucky Fried Chicken. He served on Baptist Hospital’s board as it became the largest hospital in Middle Tennessee in 1968 and, with Thomas Frist Jr. and Thomas Frist Sr., co-founded what is today HCA. Throughout his years of success, he was quick to comment on the joy he found from learning and accomplishing those improvements: “Lots of people have more than I do, but not many have as much fun. The fun is in the accomplishing.”

Clayton McWhorter began making an impact on the health care industry as a pharmacist after obtaining his B.S. degree in pharmacy from Samford University.

Upon noticing the expansion of services he could provide patients by moving into the business side of health care, McWhorter became a hospital administrator, honing his leadership and management skills. Years later, McWhorter would go on to become president, chairman and CEO of HealthTrust Inc., chairman and COO of HCA and most recently, founder and chairman emeritus of Clayton Associates, a firm created to invest in and advise health care entrepreneurs in the health care industry.

McWhorter and his family have greatly contributed to education in Nashville and beyond through the creation of the McWhorter School of Pharmacy at Samford and Belmont’s McWhorter Hall and McWhorter Society. He has also received many awards in recognition of his service, including the United Way’s Tocqueville Award and the Joe Kraft Humanitarian Award.

McWhorter has mentored countless leaders throughout his career and continues to offer his four guiding principles to all mentees: “Be prepared. Find a mentor and be a mentor. Act like an owner. Give back.”

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David Satcher

Mildred Stahlman

Danny Thomas

Dedicated public servant, celebrated advocate, lifelong educator

Scholarly physician, passionate educator, health care pioneer

Dr. David Satcher has devoted his career to advocating for the health and safety of all Americans by tackling issues not previously addressed nationally, including obesity, health disparities among minority populations and mental illness. Satcher served as president and CEO for Meharry Medical College, where he oversaw the merger of Hubbard Hospital and Metro Nashville Hospital. At Meharry, he also led the plan for academic renewal, which included a national fundraising campaign and the rebuilding of faculty. Dr. Satcher would then go on to serve as director of the Centers for Disease Control and Prevention, the 16th Surgeon General of the United States and the 10th Assistant Secretary for Health in the Department of Health and Human Services.

Throughout his career, Dr. Satcher has received a number of top awards. He also received more than 50 honorary degrees from universities and colleges — including Emory University, Harvard University and Georgetown University. Dr. Satcher, his wife Nola and their four children have been active in the Nashville community as he served as a deacon at First Baptist Capitol Hill Church and taught youth in Sunday school.

The mother of modern neonatology, Dr. Mildred Stahlman is a native Tennessean and longtime Vanderbilt University student, educator, researcher and physician. Graduating from Ward-Belmont College for Women, she matriculated to Vanderbilt University in 1943. Dr. Stahlman then graduated with honors from the Vanderbilt School of Medicine in 1946 as one of only four women in a class of 50.

She completed internships in Cleveland and Boston, a residency year in Chicago and was a research fellow in Sweden, ultimately leading to a 60-plus year career at VU and its medical center.

Throughout her time as an instructor, professor and practitioner of pediatrics and neonatology, Dr. Stahlman had more than 150 peer-reviewed publications and assisted in the training of more than 80 post-doctoral fellows from approximately 20 countries.

During her career, Dr. Stahlman revolutionized the care of high-risk newborns by creating the world’s first modern neonatal intensive care unit in 1961 and was later asked to be the godmother of the first infant she helped save. She also promoted the (then) novel concept of regionalized neonatal critical care and helped establish the first Angel Transport Mobile Intensive Care Unit.

Committed humanitarian, celebrated entertainer, lifelong health care advocate

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An entertainer and producer, Danny Thomas was born in Michigan in 1912 after his parents immigrated to America from Lebanon. Thomas began his career working in radio and eventually branched out to film and TV. As a struggling actor working towards his big break, Thomas made a vow to St. Jude, patron saint of hopeless causes, saying, “Give me a sign that I am going in the right direction and someday I’ll build a shrine in your name.” He never forgot that promise. After finding success, Thomas founded St. Jude Children’s Research Hospital, a research and treatment hospital devoted to curing catastrophic diseases in children.

The hospital opened in 1962 in Memphis. In the ensuing half century, St. Jude has treated children from all 50 states and all over the world and continues to lead the way understanding, treating and defeating childhood cancer and other life-threatening diseases. To this day, the hospital stands by Thomas’ founding promises that no family pays St. Jude for treatment, travel, housing or food and that St. Jude freely shares its discoveries. Thomas is quoted as saying, “No child should die in the dawn of life.”

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The Event

The inaugural eight-member class of the Tennessee Health Care Hall of Fame was inducted at an October ceremony held at Belmont’s Curb Event Center. The ceremony was hosted by Susan Dentzer, senior policy advisor at the Robert Wood Johnson Foundation, and also included comments from Belmont President Robert Fisher, BU Provost Thomas Burns, Nashville Health Care Council Chairman William Gracey and McWhorter Society Chairman Harry Jacobson. photos courtesy of belmont university

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RE !

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Could Stem Cells Be The Next Penicillin?

David Ebner

Lung Writer Institute Staff Writer Staff

Chances are that you have heard about stem cells—they have been in the news for years. But did you know that stem cells are being used right now in the United States to treat debilitating lung diseases?

Sufferers of diseases like COPD and pulmonary fibrosis are receiving life changing stem cell treatments that just a few short years ago had not yet been thought of as possible.

With further advancements in the study of stem cells, the question is posed: are stem cells the next penicillin? Stem cells and penicillin both come from humble beginnings and accidental discovery, they are both used to treat life threatening conditions and diseases, and just like penicillin, stem cell biologists have won Nobel Prizes due to the practical uses of their discoveries.

Consider the history of penicillin. Originally discovered in 1928 by the Scottish biologist, Sir Alexander Fleming, the full potential of the medication was not seen until its wide use in WWII. It wasn’t until 1945, 17 years after its discovery, that Sir Fleming received the Nobel Prize. By that time, the medication had saved millions of lives.

Stem cells have also been studied extensively over time and have crept into the national dialogue as a buzzword, particularly the stem cells found in fetuses. However, the actual stem cells that are now being used to treat diseases in the United States, and the same cells that warranted the 2012 Nobel Prize in Medicine, are adult stem cells. This type of stem cell is found in fully developed individuals and flourish in all people—regardless of age or health.

Most cells found in the body have developed into a specific type of cell, like a skin cell or a brain

cell. At the turn of the 20th century, biologists discovered that some cells that reside in the body have not yet been assigned as a certain type of cell. Stem cells are simply blank cells standing by to meet your body’s needs. The use of these cells to treat diseases traces back to 1968 when the first bone marrow transplant was performed.

The result of placing healthy stem cells into a sick individual’s body is the creation of healthy blood cells that are not infected with the disease. In turn, these cells replace the diseased ones and start to heal the patient.

Today, a clinic called the Lung Institute is using adult stem cells harvested from the patient’s own fat, blood or bone marrow to provide similar healing results for people with lung diseases. Their website, www.lunginstitute.com, states that they have treated over 1000 patients to date. The physician gives the patient a growth factor that multiplies the stem cells into millions of healthy cells and extracts the stem cells from the patient, then they separate the cells and reintroduce them into the patient’s body. The result is that the healthy cells replace the damaged ones found in the lungs.

Not only can this slow the progression of the disease, but it also works to restore lung function.

Just as penicillin was recognized by the scientists that award the Nobel Prize in Medicine, so have stem cell developments. If the number of people who have already been successfully treated with stem cells is any indication of the future, then it will undoubtedly be heralded as one of the ground-breaking medical technologies of its time.

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photo courtesy cumberland pharmaceuticals

Cumberland Pharma’s pipeline to growth

Firm’s partnership with VU on its way to producing two more products by Geert De Lombaerde Cumberland Pharmaceuticals has made its money over the years on niche products other drug companies won’t or can’t commit to. The West End-based company finished 2014 with almost $37 million in revenues, a net profit of $2.4 million and a product pipeline with the promise to substantially grow those numbers. Through the first six months of this year, CEO A.J. Kazimi and his team ramped up their research and development spending to lay the groundwork for the next phase of growth. Their goal is to bring to market one new product every year — they have five now — whether via internal development or by acquiring the medicine from another company.

Here’s what Kazimi told investors about the clinical development portion of his team’s plan this September via a virtual presentation hosted by Better Investing and PRNewswire:

We have a four-pronged strategy to expand our portfolio and drive future growth. […] We want to continue to expand the indications for our existing products. You see, we believe an FDA-approved brand is a valuable asset and that low-risk growth opportunities lie in exploring label expansion and making these products available to additional patient populations.

Second, our development team has successfully developed and registered two of our approved brands and we continue to actively seek late-stage development opportunities that represent a good fit for Cumberland that our development team can then advance.

Third […], our commercial organization has the capacity to promote additional products and we are seeking to acquire approved products that can leverage this capacity and augment our near-term growth.

And finally […], in order to be successful over the long term, we believe it’s important to have a pipeline of innovative new product opportunities. And we formed Cumberland Emerging Technologies, or CET, for just that purpose. CET is working with some of the leading academic research centers in our part of the country to identify their breakthroughs and team with their scientists to advance new product candidates. Noted here are existing academic collaborations [with Vanderbilt University, the University of Mississippi, the University of Tennessee, Washington University 38 VITALS

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and the University of Virginia] which have led to a growing group of innovative projects funded by a series of NIH grant awards secured by CET. We acquired the rights to ifetroban, a new chemical entity or NCE, together with Vanderbilt University, from a large pharma company through CET. We have successfully transferred and manufactured ifetroban and initiated clinical development under the brand name Hepatoren. Hepatoren is an intravenous formulation of ifetroban for the treatment of hepatorenal syndrome, or HRS, which is a potentially life-threatening condition for which there is no approved treatment in this country. We completed enrollment in the Type II HRS patient cohort in our Phase II study at the end of last year, and four dose levels were enrolled and evaluated. We announced top-line results earlier this year indicating that ifetroban was well tolerated in HRS patients at all dose levels, and no safety concerns were identified.

Importantly, we also found that patients receiving the higher doses of ifetroban were more likely to produce increases in their urine output compared to patients who received a placebo. This signal of an improvement in kidney function is encouraging and certainly warrants the continuation of this development program. Next steps include further analysis of the full data set, completion of enrollment of the Type I patients in this study and then the design of a followup study based on all of these findings.

Earlier this year, we announced the addition of a new Phase II development program initiating clinical development of Boxaban, an oral formulation of ifetroban. We’re evaluating this product candidate for the treatment of patients with aspirin-exacerbated respiratory disease, or AERD. AERD is a respiratory disease involving chronic asthma and nasal polyps that is worsened by aspirin. Approximately one in 20 asthmatic adults — which is about a million patients in this country — suffer from AERD and the awareness of this disease is growing throughout the medical community.

Current treatments remain a challenge as novel and effective treatment modalities are lacking for this poorly met medical need. We have completed manufacturing of Boxaban oral capsules and have received clearance from the FDA for our request to initiate the clinical program for this product candidate. As a result, a Phase II multi-center study is well underway, and we look forward to reporting on the results of this study later this year.

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CONNECT Jumpstarted via Nashville

Minneapolis-based Reemo using funding from Jumpstart Foundry to fuel future by William Williams Reemo operates its offices in a city known for cold weather.

But the Minneapolis-based company has a Nashville tie that could allow for a fast acceleration of sales and visibility that could rival in heat intensity an August day in Music City.

From May to August of this year, Reemo participated in an accelerator program at Jumpstart Foundry’s Trolley Barns offices on Rolling Mill Hill. The company — whose software applications are used in wearable mobile devices that aid in the assisted living process — was one of five non-Nashville entities to land funding. As with all Jumpstart participants, Reemo received $100,000 in seed funding.

Al Baker, Reemo chief executive officer and co-founder, says working with Jumpstart Foundry has been positive. During the program process, company officials took five trips to Nashville, spanning the equivalent of about two months.

“We’ve continued to partner with Jumpstart and they have been very supportive since we graduated,” Baker says of the aftermath of the program.

“Nashville is our sister community,” he adds. “It is on our radar for future expansion.”

Reemo bills itself as providing the world’s first software solution that transforms Internet of Things (IoT) devices for assisted living.

Specifically, the company makes software that enables users to conveniently control technology devices in their homes, while simultaneously giving their care providers information regarding their well-being. With pointing and hand waving, users of Reemo software-powered devices can control, for example, their lights, televisions, stereos, door locks and thermostats. The company recently partnered with Samsung — known for its mobile, smart home and wearable products — to bring IoT to mobile health, Baker says. Other companies with which Reemo is working including LG, Apple and Microsoft.

“We’re empowering people to live in their homes longer [than otherwise] using products already on the market,” Baker says.

In addition to the Jumpstart Foundry funding, Reemo has landed $400,000, money that will fuel the software project and increase the company’s visibility with assisted-living facilities.

“There are all types of ways to monitor folks in home to be safe but not a way for them to improve the quality of life,” Baker says in explaining the need for the Reemo software.

Launched in 2013 and now with six employees, Reemo has since “continued to learn and explore the market,” Baker says.

“We’ve built out of the proof of concept for the technology,” he says. “And we’ve begun to find partners that could help us improve the design and the scalability of the product.”

Baker says an early milestone was the company’s joining a Microsoft acceleraphoto courtesy reemo

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tor program in Seattle in fall 2014.

“We graduated from the program and are still seeing the benefits of the design improvements we made,” he says. “The strength of the Microsoft brand is very helpful to a new company. We have access to the best software designers and engineers in the world.”

Reemo joined four other out-of-town companies for which Jumpstart Foundry provided funding: Life Detection Technologies (San Jose, California); Community Health TV (New Orleans); Care.

IT (Spartanburg, South Carolina); and Vital Metrix (Huntsville, Alabama).

Marcus Whitney, Jumpstart Foundry president, describes Reemo’s technology as “really compelling.”

“And while we believe it has broad consumer possibilities, the value to persons with limited mobility is significant,” Whitney says.

Baker says Reemo’s focus since its founding has been “to learn where our technology can fit.”

“That said, for the next six months, our goal is to pilot the technology so that in mid-2016 we can grow, scale and sell en masse to the U.S. market.”

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connect A healthy child is the best gift of all.

Support Monroe Carell Jr. Children’s Hospital at Vanderbilt this holiday season by purchasing a Holiday Project items.

Belmont student Ashe Tiedt works on SimBaby

Holiday cards, photo cards, contribution cards, gift tags, holiday gifts and our 2015 ornament.

Simulation education

Belmont health sciences students use mannequins, replica spaces for training by William Williams

Purchase items online at ChildrensHospital.

Vanderbilt.org/ holidayproject

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The use of mannequins originated in the 15th century.

At Belmont University, their usage — and that of other simulation tools and spaces — is very 21st-century.

Specifically, Belmont is increasingly using simulation and replication for health education, and the students are embracing the effort, according to Dr. Beth Hallmark, director of simulation for the BU Gordon E. Inman College of Health Sciences and Nursing.

Both the Inman Center, which houses the aforementioned college, and McWhorter Hall (home to the BU schools of Pharmacy and Physical Therapy, and the Department of Psychological Science) offer simulation labs.

“The space in McWhorter offers four individual patient rooms, used primarily by pharmacy students to do inter-

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photo by eric england

viewing and patient counseling training,” Hallmark says.

According to Hallmark, an important key in replicating a hospital is that as Belmont students interact in the lab, they are able to experience a situation or a case study in an environment similar to what they will see in an actual hospital.

“Each of our simulation labs replicates a true acute-care environment,” says Hallmark, who began her Belmont career in 2007 as lab director for the School of Nursing. “Within each lab, we have equipment that is currently utilized in [Nashville-area] acute-care facilities.”

For example, Hallmark says the simulation labs are outfitted with fully functional head walls with pressurized air and suction. The IV pumps are “smart” pumps that incorporate technology to help prevent medication errors. Electronic health

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o

records enable students to use a computer labs are helpful to other education efforts at the university. to document their findings and review the “All our students have the opportunity to work with other patient situation. academic disciplines and participate in one interprofessional In addition, Belmont students are simulation,” she says, noting students studying occupational exposed to clinical situations for which therapy, physical therapy, social work or pharmaceutical studthey must make “real life decisions,” ies are involved.

Hallmark says.

“In the past, we trained in silos … and each discipline “Training students using simulation trained within its own curricular requirements,” she says. “But provides a safe place for them to learn — now the students have the opportunity to experience working where mistakes are reflected upon and with other disciplines. The research indicates that training inlearning is the goal,” she says. terprofessionally helps with critical communication and thus On the mannequin theme (technically, decreases error.” they are known as “manikins”), Belmont Funded by the Memorial Foundation and Belmont, the new uses SimMan, an adult mannequin; Sim- four-bed lab at the Inman Center offers digital video capability Mom, which actually delivers a baby; and and includes obstetrics and pediatrics components. Hallmark SimBaby, a life-size infant says the addition of video has been invaluable. used to train pediatric stu“The most important part of simulation is dents. Norway-based Laerdal the reflection and debriefing that occur after makes the mannequins. the simulation,” she says. “The true learning “We have many different takes place as the students are able to view variations of mannequins in their videos and see what they have actually our labs, but the most sophisdone; this is often an eye-opening experience ticated are referred to as highand allows for impactful learning. The faculty fidelity mannequins,” says simply facilitates the learning by helping the Hallmark, who also serves as students reflect on their action and construct program director of the Tentheir own learning. nessee Simulation Alliance.

“We sit with them and talk through with “The mannequins are comthem,” she adds. “The videotape allows us to puterized and the instructor help them reflect on their actions, leading to can alter vital signs, like blood meaningful learning.” pressure and heart sounds.

Hallmark says the students can watch the They also exhibit other symp- Dr. Beth Hallmark, simulation live in a room that has been outfitBU College of Health toms such as the respiratory Sciences and Nursing ted with flat screens. rate and color. The students “They can have an assignment, watching must assess the mannequins live, during the time their peers are using as if they were real patients. the simulation labs,” she says. “Subsequently, The mannequins can communicate ver- they all debrief together and learn from one another.” bally with the students, providing a great Hallmark says Belmont has been on the forefront of simuopportunity for the students to learn criti- lation equipment acquisition and facilities. cal communication skills.”

“The pedagogy of simulation is, frankly, still a fairly new in In addition to “talking,” the manne- terms of research and faculty development,” she says. quins can have urine output, can bleed, “It’s a small world in terms of simulation,” Hallmark adds. can have rise and fall of the chest, and can “We are a founding member of the Tennessee Simulation Alhave an intravenous line started to infuse liance (a networking and training organization for both acaIV fluids, Hallmark says. demic centers and medical facilities) and an affiliate under the “We try to make the labs as real as pos- Tennessee Hospital Association.” sible for the students,” she says. “Their deHallmark says Belmont takes a serious approach to health cisions are based on real data.” education via simulation.

Hallmark says the Belmont simulation “We don’t say we’re pretending.”

r t

‘We don’t say We’re pretending.’

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Tackling interoperability

Two industry groups address the problems of health care’s complicated connectivity by Emily Kubis One of the most frustrating things patients deal with when interacting with the health system is attempting to share medical information among new specialists or facilities. From filling out the same form multiple times to potentially life-threatening delays in treatment due to crossed wires on prescriptions or referrals, patients may not know interoperability by name. But they certainly know its impact.

A study conducted by medical research organization West Health Institute found that the American health system’s lack of interoperability resulted in excess of $30 billion in costs, which includes the tab for mistakes and inefficiencies contributing to poor results for patients. With dollars and outcomes on the line — and in an era during which even secure financial data can be transmitted wirelessly — patients and many of the providers who care for them recognize that a serious change is needed.

While there are technical and regulatory challenges to sharing medical information among providers, experts say the issue is less about creating the necessary technology, but more about breaking down the business barriers to implementation and scale.

“The technology components are there, and I believe the industry has proven, while not at scale, there is sharing that is occurring,” says Bob Robke, vice president of interoperability at tech giant Cerner Corp., which is on track to book more than $4 billion in annual revenues this year. “Most of our issues today are how we can scale that and make it an expectation of both providers and patients.”

To scale interoperable technology, the industry has to unite the software vendors and the providers who buy their products. The two groups have traditionally had a transactional relationship, but are now faced with coordinating toward a common achievement.

Two industry groups have sprung out of this dynamic. On the vendor side, there is CommonWell Health Alliance, an interoperability network for information technology companies. The group was founded in 2013 by five big players in the IT world 42 VITALS

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— Cerner, McKesson and Allscripts among them. By September of this year, the group had grown to 33 members, including locally based Medhost.

On the provider side, the Nashville-based Center for Medical Interoperability was launched in April of this year. With five local executives and seven national health care leaders, the group represents a big chunk of the provider industry’s procurement power, which Center Executive Director Ed Cantwell calls “the most valuable asset” in the free market.

“We launched with the Nashville five — LifePoint, Community Health Systems, HCA, Ascension’s Saint Thomas and Vanderbilt University Medical Center,” Cantwell says. “What’s unique about those five is that they’re almost the surrogate for the entire nation. You have your prestigious academic, your rural hospitals and the national mega-presence of HCA. We don’t have to invent new technology. It’s more of developing the techno-economic model for these providers to say, ‘I’m just not going to tolerate the current system.’”

While interoperable technology exists, the real need is in developing standards for vendors to build on and for which hospitals can be certified. Presently, interoperability standards are built around “Meaningful Use,” the federal incentive program for providers to implement and use certified electronic health records.

But because Meaningful Use Medicare payments, for example, began in 2011 and end next year, certification has been oriented around existing standards.

That’s a low achievement bar, according to Bill Stead, VUMC’s chief strategy officer and a biomedical informatics professor.

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CONNECT “Current standards do not require that the two parties or systems actually under- in selling standardization services,” Schatzlein says. stand the information in a way that allows it to be used,” Stead says. “It’s a bit like “We’re standardizing to get the proprietary nature requiring the Postal Service to use standard envelopes and standard addresses and out of this information. If there’s a profit-making standard paper, but when you open it, it’s written in Chinese, and you need an inter- proprietary approach, that’s no different than the preter. That’s the current level of interoperability built into the current regulations.” vendors making everything different on purpose.”

The interoperability landscape includes all the technology involved in patient Naturally, the vendor community largely rejects care, from medical devices to the electronic health records that hold a patient’s that characterization. Misaligned incentives likely charts and medical history. Presently, none of these elements communicate with did contribute to technology fragmentation, but each other, causing expensive complications and inefficiencies. that glosses over the millions of dolThe Center for Medical Interoperability’s goal is to connect the lars spent by health systems over nation’s network of devices and software by building a “plug-andmany years to internally optimize play” system that collects data in a standard, non-proprietary way. non-interoperable technology. Did Developing interoperability standards will improve certificagovernment regulations keep hospition processes, care coordination and product development, Stead tals from demanding interoperable says, with engineers able to compete on a standardized, rather technology until now? Did vendors than vendor-specific, playing field. conspire to tap the brakes on develop“That would be the first big win for the development commument? Were providers wary to share nity,” Stead says, “And also a big win for the government, because it patient data and slow to invest in makes interoperability certification scalable and doable.” technology that could do so?

The provider-oriented center is more focused on connecting Perhaps a better way to think about and standardizing medical devices, while the vendor-based Cominteroperability is as a co-morbid pamonWell has spent more time building out the shared infrastructient. There were many causes of the ture of interoperable health records. condition, and a coordinated response The splitting of that work was an unofficial, but natural, diviis the only cure. sion of labor, according to Dr. Mike Schatzlein, center board mem“There are a lot of good organizaber, and Ascension Health senior vice president. Many expect that tions and good efforts in all aspects,” as the health record industry continues to consolidate, it will be inStead said. “We’re doing pieces of creasingly incentivized to solve its own interoperability challenges. what needs to be done, but we’re not Meanwhile, the much more fragmented medical device industry actually doing it in a coordinated fashcan be better impacted by the center and its provider expertise and ion. The real secret is to take those awareness of connectivity needs in an acute-care setting. steps together.”

But siloing software development is partially to blame for the Developing CommonWell and nation’s current lack of interoperability, and leaders on both sides Bill Stead, VUMC the Center for Medical Interoperaof the coin say they are ready and willing to share data and inforbility pushes the vendor and providmation as the process unfolds. er industries toward breaking down “We connect over 1,000 medical devices,” says John Gresham, vice president of their sector-specific competitive barriers to inCerner’s DeviceWorks division. “That’s why the Center for Medical Interoperability teroperability. Representatives from both groups and Cerner, that’s such an important relationship. The work we’ve done with medical note that a neutral, collaborative effort has been devices has been in the absence of any standards, and if new ones emerge out of the necessary to build a trust framework among secMedical Interoperability group, we’ll look to adopt those standards as they occur.” tor peers. As that work evolves, the ultimate test Nevertheless, tension remains between vendors and providers. There is a sug- will be whether the industry as a whole — health gestion among providers — both implicit and explicit — that vendors are, at worst, systems, vendors, individual physicians and othpurposefully blocking interoperability efforts and, at best, not actively contributing ers — can move forward in a coordinated fashion to their success. It is not profitable, some say, for vendors to make their systems toward true interoperability. communicate with competitors. It makes better business sense for them to bind “We have big things to solve around the patient, users to their own network of products. And even in this move toward improved and the barriers keeping that from happening need standards, some providers worry that certification represents an additional profit to be addressed,” Robke says. “I think when you look opportunity for vendors. at it from the patient’s eyes, things get really clear on “We just don’t want the vendor community to think there is money to be made what we need to do.”

‘It’s a bit like requiring the Postal Service to use standard addresses but when you open it, it’s written in Chinese.’

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CONNECT ‘Pulling the data together in one place isn’t enough’

VUMC, LifePoint talk through the challenges of interoperability The Center for Medical Interoperability features five big Nashville names: Vanderbilt University Medical Center’s Jeff Balser and former Saint Thomas CEO and Ascension Health executive Michael Schatzlein as well as Bill Carpenter, Wayne Smith and Milton Johnson, the respective CEOs of LifePoint Health, Community Health Systems and HCA Holdings.

“We’ve got this window where the provider strength from Nashville, plus the national nature of board, can really do some historic things,” says Ed Cantwell, executive director of the center, which was launched earlier this year.

Balser and Carpenter answered a few questions for the Post about their organizations’ approaches to interoperability and their involvement in the Center for Medical Interoperability.

What are the biggest interoperability challenges for your specific organization?

The challenges facing VUMC when it comes to large-scale data sharing outside our system aren’t that different from those of other health systems. To help address issues of interoperability, we are making a substantial investment in new information technology that, when fully implemented, will enable providers, hospitals and health systems from across the Vanderbilt Health Affiliated Network to efficiently share data. This invest- ment is a necessary step in the process to scale up and sustain our population health initiatives.

Carpenter: Like any provider organization, our greatest challenge is ensuring that our clinicians have access to all the information they need when, where and how they need it. This includes data from disparate sources, including electronic health record systems and data generated from various medical devices and equipment. However, just pulling the data together in one place isn’t enough. It has to be available and presented to clinicians in a way that makes sense and fits within their workflow as they care for patients.

Balser:

How should patients think about interoperability?

Balser: While

the average citizen may not be familiar with the term our industry has adopted to characterize perhaps the most pervasive problem confronting health care delivery today, they’re very familiar with the issues of interoperability from a consumer’s perspective. Who hasn’t experienced difficulties with the portability of their medical records? A task as simple as seeing a specialist

for the first time or visiting an out-of-town emergency department can be frustrating or perhaps even dangerous if vital medical information can’t be obtained.

A majority of the public wonders why physicians and hospitals can’t communicate with each other more effectively when you can get a mortgage or do just about anything else online. However, I think the public should understand that regulations intended to ensure the privacy of their health information make the challenges we face even more difficult.

Carpenter: For patients, interoperability is really about improving care. It is a vital part of expanding patient-centered care models. Most people see many health care providers working across many settings — annual appointments with a primary care doctor, consultations with a specialist or two, that unexpected visit to an ER. Interoperability ensures that each of these providers has the best, most up-to-date information on a patient and that that patient is receiving informed, optimal care.

Interoperability also can give patients and families ways to be more engaged in the care they receive through technologies like patient portals. If we share information with patients, we improve their ability to be an active member of their care team. This is an important step for empowering patient accountability and encouraging better health.

How are the physicians in your organization approaching this issue?

Balser: Because we are a tertiary referral center, the physicians at VUMC are more frequently encountering issues related to access of patients’ prior records. There is no lack of awareness among our providers about the difficulties surrounding the transmissibility of health information. Having long been the beneficiaries of IT tools that were created in-house which afford an array of options and conveniences in the clinical setting, our clinicians understand the institutional priority we place on having the best of these offerings. And many are actively engaged in making our capabilities more interoperable and available across the country and around the world.

Carpenter: For providers, interoperability means a timely, comprehensive view of a patient’s health

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CONNECT status. It can improve a clinician’s ability to make the best possible clinical de- portant to the success of provider organizations cisions and enhance their ability to engage patients in care. By breaking down as well as health IT and device innovators across barriers that exist, it also can enhance provider collaboration. the country. We are fortunate that many of these health care provider and technology organizations What is the impact of the Center for Medical Interoperability on the industry are based in Nashville. These organizations, includand Nashville? ing LifePoint Health, benefit significantly from beBalser: The center brings a national voice and focus to the problems we all need ing in close proximity to the center. It allows us to to work together to solve in order to move health care forward in a way that will actively participate in the center’s activities and infully deliver on the imperatives of improving service and controlling costs. I’m fluence their work and how it takes shape. proud to have a role on the center board and believe that VUMC and the center We all understand the great potential for techcan work together in many ways. nology to transform patient care and make our For example, we are working with the center on a project to upgrade our wire- health care system more efficient and effective. But less network to medical-grade for all mobile devices. The center’s presence here there are a lot of barriers to this potential being in Nashville is logical. In addition to a top academic health system, we have a achieved right now. Health care is rife with records host of other large, successful nonprofit and for-profit hospital systems based systems that can’t share data and devices that can’t in our region. As a city, we are an incubator that represents all aspects of health communicate with one another. We have to fix this. care. The center will thrive in Nashville due to the many favorable conditions To achieve its full potential, technology needs to be and diversity of perspectives that will contribute knowledge toward solving in- developed with the perspective of those who proteroperability’s challenges. vide patient care. And it needs to be developed with Carpenter: The Center for Medical Interoperability really exists to improve the some kind of industry standard in mind. The Censafety, quality and affordability of health care. This means that its work is im- ter is making sure that this happens.

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CONNECT

The cost of health care hackery Data breaches growing but still not on enough radars

Research firm Ponemon Institute published a report earlier this year on data breaches in the health care sector that included some startling numbers. Among the data points: >C riminal attacks on health care organizations are up 125 percent from five

years ago

> 2.3 million adults were victims of medical identity theft in 2014 >7 8 percent of health care organizations and 82 percent of their business associ-

ates have suffered web-borne malware attacks

> The average data breach costs a hospital $2.1 million > But only 40 percent of those health care organizations are concerned about

cyber attacks Parker Rains, a vice president at Fisher Brown Bottrell Insurance in Nashville, says health care data is much more valuable to hackers than credit card numbers because the health care info has a long shelf life and can be used to access other data such as Social Security numbers. It also often takes longer for victims to realize they’ve been hacked.

But, says Rains, companies can help themselves in a number of ways, many of them easy to put in place. Here are his tips for company leaders: > Establish and enforce strict password policies. > Also set up and enforce strict policies for taking home laptops and storage devices. >D evelop a disaster recovery plan to respond to and recover from an attack. That

includes a communications plan identifying a spokesperson, laying out talking points as well as a plan to notify customers.

> Look into buying cyber liability coverage, which

could save millions in fees and other costs. General property insurance doesn’t cover cyber crimes. It also doesn’t protect disk drives and other computer software, the data stored on them or computer programs in general.

Breaking down cost We asked Fisher Brown Bottrell’s Parker Rains to price out some standard hypothetical cybersecurity policies for two different types of care providers. Here’s a snapshot of what he came up with:

Outpatient provider

40M $14K

$

Revenue

Annual premium

Home health care company

15M

$

Revenue

3K

$

Annual premium

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CONNECT Appy days

A peek at some eye-catching technologies that promise to make medical life simpler and cheaper for providers and consumers by Emily Kubis In a 2014 report on the evolution of digital health care tools, analysts at consulting firm Oliver Wyman wrote the following: “As Health Market 1.0 gives way to Health Market 2.0, we expect to see an industry dramatically different from today’s: 24/7, convenient, enhanced by technology, holistic and personalized, with prediction and prevention making us much less reliant on cures. We will use hospitals less, clinics and telehealth more. The line that has long separated health care from retail will be more and more difficult to see as retailers, wellness coaches, pharmacies, tech companies, and others start to play a far more significant role in keeping us well — and, in the process, capture a trillion dollars or so of annual health care expenditures.”

With that in mind, it’s probably a good idea for us to become more educated about some of the online tools that are available to both patients, physicians and new health care consumers. Here’s a quick overview of just a few apps we think show a great deal of promise.

Epocrates

iTriage

Medical reference app Epocrates hosts a wealth of clinical information at a provider’s fingertips. With diagnostic, safety and treatment information, providers are able to access the facts they need quickly and at the point of care. A service of cloud-based electronic health company athenahealth, Epocrates lets users look up all kinds of drug information, such as pill identification and interactions or alternative treatment recommendations. It has a ICD code search function and clinical practice guidelines and actionable recommendations, as well as disease information developed with the publishers of the British Medical Journal. In addition to all the clinical reference data, the app also allows physicians to communicate securely with one another and access patient lab records and health history.

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This medical reference app provides the patient alternative to the more clinical apps for providers. Users can look up symptoms, conditions, medications or procedures on everything from acetaminophen to neurosurgery.

Patients can get up-to-date information on their health and what to expect when they visit the doctor or get a diagnosis. The app also has a doctor search-and-book function as well as a health record component that allows patients to track and manage their conditions and appointments.

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CONNECT My Pain Diary

Stride

A tool that allows users to input and track their chronic pain conditions and symptoms. Featuring several innovative widgets that add important details to pain symptoms, the data can be then shared with clinicians. Users can also specify triggers, pain duration and sleep quality as well as other associated symptoms. The app even has a weather function that matches local weather data to each entry, allowing patients to track environmental factors that may be affecting their conditions. Interactive graphs combine all the data, making it easy to spot patterns, trends and correlations.

Stride Health is an app and company for the new wave of health insurance purchasers — those buying on the federal health exchange. Though a wide range of demographic groups use Healthcare.gov, many are young, healthy, without children and looking for a good deal on insurance.

Stride Health outlines your estimated cost of insurance and selects a plan offered on the federal exchange that fits your needs.

After taking in your age, income, location, current medications and any medical conditions, it develops a “total coverage and care forecast” that can even include your preferred physicians.

Noom

ZocDoc

Billed as an app for preventing chronic diseases like obesity, diabetes and hypertension, Noom uses behavior change programs to help users get healthier. The health coaching app has tracking functions for patients to log their meals, weight, blood pressure and other indicators. And the company’s analysis system creates personalized and disease-specific health plans with customized daily tasks. Providers can use the app to monitor adherence and see which patients need additional interventions. Users are able to connect their behavior to their outcomes, getting feedback on what’s working and coaching for what isn’t.

Think of this as applying OpenTable’s approach to securing dining reservations to the process of seeing a doctor.

The app compiles open appointment times with doctors and specialists in a given area that can be booked with the touch of a button. Patients can filter their list by insurance network or specialty, and the company currently books more than 1,800 types of medical procedures across 50 specialists. Patients typically see a doctor within 24 hours, far less than average wait times. The company also has ZocDoc Check-In, which allows patients to fill out medical forms just once and have them sent to enabled doctors’ offices.

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Healthful development

oneC1TY project to offer a ‘health-centric’ flavor It would not be fair to describe oneC1TY as fully focused on health care.

But the distinctive development — still fledgling but quickly redefining the 28th/31st Avenues Connector on Nashville’s vibrant west side — clearly has a “health-centric” feel with its businesses, patrons and approach.

Home to, for example, the city’s first raw foods restaurant and a sand volleyball court for the active crowd, oneC1TY eventually will feature multiple buildings, many of them accommodating companies, businesses and organizations involving the health sciences, health care technology, the fitness industry, environmental sustainability and the like.

Ryan Doyle, the oneC1TY general manager overseeing the effort for developer Cambridge Holdings Inc., describes the massive project as a business ecosystem of sorts.

“We are creating the public square for Nashville’s next generation of health care innovators,” he says. “A place where proximity to our urban anchors in health and education pair with the region’s growing technology workforce to appreciate the historical foundation of our economy while shifting towards the business models that will continue to evolve and grow Nashville as the nation’s health care capital.”

Doyle says oneC1TY will offer an alternative perspective on the integration of the lifestyle decisions Nashvillians make each day.

“Whether you work, live or just visit our community, you will have the opportunity to experience the craft of fresh food, communal spaces to relax or be active, and a neighborhood focused on your environment, both indoors and out. Simple things that support the people we become.”

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CONNECT The nuances of orderly development

What to listen for in certificate-of-need cases

by Mike Brent Tennessee has used the certificate of need process to assist in regulating the development of health care facilities and services since the 1970s, when — at the urging of the federal government — many states created health planning departments in an attempt to control increases in health care costs. Today, about two-thirds of the states, including Tennessee via the Health Services and Development Agency, still utilize some form of a CON process.

Tennessee’s statutes governing the CON process start with a declaration from the legislature that public policy requires that “the establishment and modification of health care institutions, facilities and services shall be accomplished in a manner that is orderly, economical and consistent with the effective development of necessary and adequate means of providing for the health care of the people of Tennessee.” Of the three primary components of the process, “orderly development” may often be the most complex question for the members of the HSDA to consider.

In making that determination, HSDA members are instructed to consider how a proposal would relate to the existing system, whether it duplicates or competes with other services and whether it meets quality standards. As is often noted in agency presentations, both by those proposing and opposing CON applications, these are “guidelines,” not mandatory requirements. Therefore, orderly development is addressed in varying approaches by applicants.

However, by reviewing agency members’ decisions to approve a CON application, one can see that when orderly development is found by the agency, it can often be categorized in one or more of four broad categories.

First, access to services is often mentioned in those motions. Phrases such as “provide patient convenience” or “provide accessibility to all patients and pay sources in the area” appear in multiple recent motions, along with wording about eliminating the need to travel a long way to get services. Second, the cost to patients and payors is a factor often mentioned, with language such as “provide a lower cost” or “lessen the financial burden on the health care system.”

Third, increases in efficiency are noted in some motions, such as “improving staff efficiency” and “provides space that is more functional.” Finally, the agency often considers how an application might affect the health care market in the particular service area, with motions including language about “remain competitive in the marketplace” and “not negatively impact other providers.”

Motions made by agency members for the denial of CON applications are often more brief, but will often include failures to meet this criteria due to “inadequate proof of orderly development,” “an unreasonable service area” or causing a “negative impact on [another provider].”

Simultaneous review applications may present a unique review situation for the agency because they will include similarities of the proposed location, facility and services, as well as the primary service area. When it is decided that simultaneous review is appropriate, both applications — and any opposition to them — are presented to

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the agency members before they vote on either. They can vote to approve only one application, both applications, or neither application.

While the simultaneous review process can apply to any proposed service or facility, in recent months it has been used by the agency when considering several applications for satellite emergency departments. In March, the agency heard simultaneous applications

by Saint Thomas Midtown and TriStar Southern Hills, both for EDs in southern Davidson County. Both were denied and one of them is currently under appeal. In October, the agency heard two more satellite ED applications, both proposed for Montgomery County, by Gateway Medical Center and NorthCrest Medical Center. The Gateway application was approved on a split vote, while the NorthCrest application was denied on a unanimous vote.

After the October hearing, HSDA General Counsel Jim Christoffersen was quoted in media reports as noting that the proximity of the projects to each other and to their respective hospitals was an issue, and that both Gateway and NorthCrest agreed in their presentations to the agency that neither project would be economically feasible if both were approved.

As well as the comments shared by Christoffersen, questions from agency members as well as comments during their discussion, emphasized that many factors are taken into account when orderly development is considered. While consideration was given to convenience and accessibility, there were also questions and comments about the use of technology between the hospitals and the satellite EDs, and about location and patient transportation — whether by emergency medical services or by a friend, family member or the patients themselves.

While the criteria of need and economic feasibility are equally important to a CON application approval, orderly development is often the most subjective factor and the one that will sometimes generate the most discussion. By carefully studying the guidance found in the statutes and rules, what the agency has found persuasive in previous applications, an applicant can be better prepared when starting the CON process.

Mike Brent is a Bradley Arant Boult Cummings attorney who regularly represents clients before the HSDA. The views expressed above are his own, and are not intended to reflect the position of any client with matters before the HSDA.

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DATA BANK

Using more A recent report from Deloitte suggests we are getting smarter at how we’re using technology to tackle health care questions and problems. But the consulting firm also says usage is rising much more quickly among younger and higher-income segments. If the industry wants to spread the benefits of IT to more people, it says, “layering and tailoring” valuable information to other parts of the population will be key.

New technologies are forever working their way into the health care system.

Some cater to consumers, others finetune providers’ operations and still others simply don’t fulfill their promise.

Still, the way forward in health care will include smart tech tools. Here’s a snapshot of some of the factors that will decide which ones they’ll be.

Using technology to measure fitness and health improvement goals

17% 2013

Consumers with chronic conditions using tech-based monitoring

28%

22% 39%

2015

2013

2015

Trust issues There is huge promise in telemedicine as a tool to increase access and cut costs. But realizing that potential and getting patients on board is going to take time and work, according to an online survey conducted this summer by TechnologyAdvice.

How do you feel about attending virtual appointments?

How much would you trust a virtual diagnosis versus an in-person diagnosis?

How likely would you be to conduct a virtual follow-up?

Very comfortable............................. 14.1%

More..................................................... 1.1%

Somewhat comfortable................. 30.8%

Equally................................................. 24.6%

Somewhat uncomfortable............ 18.4%

Less...................................................... 45.0%

Very uncomfortable........................ 36.7%

Not at all............................................. 29.3%

Much more.......................................... 29.6% Somewhat more............................... 35.4% Somewhat less................................. 5.3% Much less............................................ 10.4% No impact........................................... 19.3%

Money flows Venture capital funds plowed $2.1 billion into digital health companies in the first half of 2015, in line with the previous year’s pace — which was 125 percent more than 2013’s and four times the 2011 total. Of the 330 distinct investors active in the first six months of the year, 108 funded a digital health venture for the first time. Here are the subsectors receiving the most money.

387M

$

Wearables and biosensing

212M

$

Analytics and big data

128M

176M

$

$

Enterprise wellness

Consumer engagement

$

169M

$

74M

EHR and clinical workflow

Telemedicine

Sources: Deloitte, TechnologyAdvice, Rock Health NASHVILLE POST

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

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A Cold War in a hot industry Assessing the impact of health insurer consolidation by Austin Madison

Consolidation has become a constant in the news. Today competing corporations and their consultants often feel it is best to join forces and share in the spoils rather than continue to battle it out in the trenches for profits. While these deals excite investors and shareholders, they are often found to be better in concept than in reality.

Apple and Beats. AT&T and DirecTV. American and US Airways. These are just a handful of examples of household names that have recently gone through highprofile mergers. However, there are mergers happening every day with even greater implications — and to which the majority of the American public pays little or no attention. Massive consolidation has occurred and will continue in health care. Largely ignored outside of industry insiders, an arms race reminiscent of the Cold War has been waged since the passing of the Affordable Care Act. What exactly is at stake? If you enter “health care merger & acquisition” in any search engine, the answer is clear. Our country’s appetite and need for health care outpaces every other segment in our economy, while the number of health care providers and payers continue to decrease.

Currently, the big five insurers — United Healthcare, Aetna, Cigna, Anthem and Humana — sit atop the health care payer market. With the announcements in late summer of the acquisitions (pending Department of Justice approval) of Humana by Aetna — for $37 billion —and Cigna by Anthem — for $54 billion — the big five will soon become the big three. Likewise, many experts believe the next few years will see the national health care provider space consolidate to five or six large national systems. PwC’s annual U.S. Health Services Deals Insight showed a 16.3 percent increase in M&A deals in 2014 compared to 2013.

So what does all of this mean for consumers and businesses that provide health insurance to their employees? Proponents of health payer consolidation say consumers will benefit from a much broader network, more efficient and value-based care and lower premiums. The jury is still out. If approved by the DOJ, all we really know is the Anthem and Aetna deals would mean that nearly 42 percent of the American

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population would be covered by only three health insurance companies. This means less competition, and less competition may ultimately mean less disparity between the cost of purchasing insurance from any of the big three carriers.

At first, the idea of health care providers having fewer payers to negotiate with for reimbursement rates seems like a welcome benefit. However, providers may lose any leverage, knowing they could lose a very significant portion of lives covered by one of the big three payers. As a result, a broader network may not necessarily mean deeper discounts and most certainly will not mean lower premiums for consumers and plan sponsors.

As both provider systems and payers race to see who can figure out value-based care and accountable care organizations, a few things appear to surface.

First, we are in for a continued period of volatility and uncertainty in the health care space. Both payers and providers are competing for what appears to be the ultimate prize as a client: the federal government. Aetna and Anthem’s acquisitions are strategic because they significantly increase their presences in the Medicare and Medicaid spaces and provide them the needed volume, negotiating power and reach to compete on the federal and state marketplaces and exchanges.

Secondly, health care has historically been very local by nature. As the big national players — payers and providers — compete for profit and covered and treated lives, it would make sense that a tremendous opportunity is waiting to be capitalized on by local and regional providers and payers. The question is whether communities will partner with local providers and payers to be nimble and innovative in an effort to provide better care and value than their larger and less nimble counterparts.

Finally, one should expect that as the payers and providers consolidate, a Cold War to spend the other side into submission will ensue. This means that those who will most likely suffer most — at least until the arms race produces a victor — will be consumers. Let’s just hope the arms race and health care Cold War does not cause collateral damage that will leave employers, consumers and taxpayers footing a bill that cannot be paid.

Austin Madison is a principal and vice president of The Crichton Group, a Nashville-based insurance agency.

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Creative solutions to difficult problems

A look at how some promising new approaches are improving outcomes and lowering costs

by Emily Kubis Physician shortages. An increasingly sick population. Newly insured patients entering an already burdened system. Yes, the health care system faces enormous change and challenge, but to solve these issues, we don’t have to boil the ocean. Creative why-didn’t-I-think-of-that responses are often more effective than massive, costly overhauls. Here are three novel approaches to some of the biggest issues in the health care system.

Visiting as a group Vanderbilt Center for Women’s Health With a blend of group classes and one-on-one physician time over a two-hour visit, leaders of Vanderbilt University’s group visit program say the Expect

With Me model leads to more satisfied patients and providers. Vanderbilt has offered group prenatal care since 2008, but recently revamped the concept through the Expect With Me program, a partnership between Yale University and United Healthcare.

Susan Lewis, director of Vanderbilt’s Expect With Me program, says group visits have led to dramatic reductions in preterm births and low birth weights. Additionally, providers feel less rushed and more connected to their patients.

“It was alarming and amazing how the rate of preterm birth and low birth weights was reduced,” Lewis says. “That was the most stunning finding, which has led to further studies to see what other benefits might be coming out of the program.”

The Expect With Me program is still in its pilot stage, with other iterations in Springfield, Tennessee and Detroit. But Lewis says she expects the study to show that the group model leads to NASHVILLE POST

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Legacy ER & Urgent Care facility in Allen, Texas

viders, but many patients are still using the emerhealthier babies and moms at a lower cost.

“What we think we’re going to prove is that group-care patients have gency room inappropriately. A study by Truven fewer visits to the hospital and number of tests done throughout the preg- Health Analytics found that 70 percent of emergency department visits could have nancy,” Lewis says. “That can be costly, so it lessens the tax been treated in an urgent care site on clinical resources.” or prevented altogether.

Further, the community element is key to the success of The founders of Texas comthe group model. Lewis says patients feel more connected to pany Legacy ER & Urgent Care their physicians, as well as the other patients, who are all due witnessed this dynamic firsthand to give birth around the same time. The supportive environwhile working as emergency room ment has improved clinical obstetric outcomes, but has also physicians. They saw an opporallowed doctors to provide additional social benefits. tunity to improve wait times and “They tend to tell us things we probably would not hear poor customer service by weeding in a 15-minute appointment,” Lewis says. “We can connect out inappropriate ER use and ofthem to resources addressing living situations or abuse or fering side-by-side urgent care. chemical dependency, and all those sort of social issues that “They’re going in with a sore impact the pregnancy.” throat or the flu, and getting a Lewis says the group prenatal care program has already $1,500 bill,” says Keith Miller, Leginspired a gestational diabetes group class at Vanderbilt. The acy president. “Even with a broken class has seen good results in blood sugar management, which arm or stitches, patients think they suggests the group model might help treat other conditions have to go to the ER, but most things such as Type II diabetes or high blood pressure. that are pretty common can be han“I could definitely see it cross over to non-obstetric fields,” dled under urgent care rates.”

Lewis says. “The group model could have a broader scope in With extended urgent care other chronic health conditions.” hours, the company’s model solves Keith Miller, one of the drivers of inappropriCombining care options Legacy ER & Urgent Care ate ER use — common illnesses at Legacy ER & Urgent Care, Texas inconvenient hours. Further, the Improving emergency department use is a major tenet of opportunity to see an ER doctor at health reform, as much of the nation’s health care dollars walk-in clinic rates is ideal for insurers as well as paare spent in ERs, often for non-emergent or preventable conditions.

Affordable Care Act proponents are hopeful that an increasingly insured tients increasingly paying more of their own health population will result in better access to primary care and other lower-cost pro- insurance costs. A study by the Robert Wood John-

‘patients think they have to go to the ER, but most things... can be handled under urgent care rates.’

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son Foundation found that services rendered in the emergency room cost, on average, $580 more than the same care provided in a primary-care setting.

“It’s really hard for a patient to diagnose themselves,” Miller says. “The beauty of this is that no one has to be the doctor, no one has to worry about going to the wrong place. The biggest thing is being billed the right way every time. It’s very advantageous for the patient and the insurance companies.”

With just two locations in Frisco and Allen, Texas, Legacy is still in its very early days. The company wants more insurance network inclusion and to expand its portfolio of care sites in Texas and nationally.

“We’re trying to find the right locations, but we’re also considering joint ventures,” Miller says.

“If there are hospital systems that want to make their emergency departments or urgent care clinics more convenient, we would be a great partner.”

Smarter telehealth CoactionHealth from Centerstone Research Institute From teleconferencing robots in the emergency room to texting your primary care doctor, the combination of telecommunications and health care could be used to treat a wide range of demographics and acuities. The future of telemedicine is bright and shows great potential in improving the connection between patients and providers.

But, says Centerstone Research Institute CEO Tom Doub, many with chronic conditions still feel disconnected from their doctors despite their high utilization of the health system. The research arm of Nashville nonprofit behavioral health services provider Centerstone wanted to see if smartphones could — in 90 days, no less — improve patient engagement and lower costs through a program called coactionHealth.

“These are people who are typically not receiving very good care, even though they are the most expensive,” Doub says. “This is a very vulnerable population with significant need that is not very well served by the current health system.”

Verizon provided the hardware — iPhones for

Ginger.io

94 patients with chronic disease and behavioral health conditions. CRI then partnered with two mobile health care applications, data-tracking Ginger.io and HipaaBridge, a secure application for HIPAA-complaint health care communication.

Ginger.io pushes patient information to providers through a combination of self-reported health data and information pulled directly from the device. For example, if the patient was moving less or not at all, the phone’s GPS would sense that and alert the connected provider.

“It checks in with you and sends alerts for activity that doesn’t seem normal,” Doub says. “We usually don’t know something is wrong until you show up in the ER, but we can prevent the crisis with an early-warning system.”

The pilot outcomes support Doub’s claim. In the three-month period that CRI tracked the 94 patients, hospitalizations were reduced by 61 percent and ER visits dropped by 32 percent. A cost study conducted by CRI found that reduction translated to $578,000 a month in savings, which translates to $74,000 per person annually.

With the pilot completed, Doub says CRI is now working with payers to move into a broader implementation. He says innovation in telehealth technology is only just beginning, but smartphones could revolutionize health care.

“I haven’t seen pharmaceuticals develop like this in recent years. Psychotherapy hasn’t changed much, but this is an entirely new frontier of opportunity,” Doub says. “I sense that the tide is really beginning to turn.”

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photo by michael w. bunch

Rankings and priorities

to prove a comprehensive assessment of health care access. While Nashville-region residents have greater access to quality care than residents in peer regions, they fare worse on many health outcomes.

Here are some exerpts from the report:

Interest in public health issues and their effect is growing, even from the business community and stakeholders who aren’t part of the traditional health care system.

The Nashville Area Chamber of Commerce this fall published a comprehensive look at the region’s health indicators. We have excerpted parts of that publication here. To view the report in full, go to nashvillechamber.com/vitalsigns.

The Nashville region is known for the size and scope of its health care industry and its health services providers. Being a health care capital has meant that our residents have greater access to quality care than residents in other regions.

However, our residents fare worse on many health outcomes compared to peers — even when accounting for differences in demographics.

In 2014, the Nashville Area Chamber’s Research Center spearheaded a partnership with FTI Consulting’s Center for Healthcare Economics and Policy to assess the health status and the cost, quality and access to health care in the Nashville region compared to that of our peer regions. In addition to comparing the overall health status of these regions, the report made demographic adjustments to compare the health status of similar populations across the regions. The report also analyzed private commercial claims, along with Medicare information,

Health outcomes for the Nashville region and its peers

Chamber report outlines where our public health indicators are coming up short

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A comparison of the medical and health behaviors of this region with peer regions shows that while our region performs well in some areas, we fare worse than at least half of our peers in majority of areas, when accounting for differences in demographics: • The Nashville area has the lowest incidence of asthma compared to peer regions.

• Nashville-area residents experience levels of chronic obstructive pulmonary disease, obesity and stress levels that are moderate to high compared to our peers. When accounting for demographics, these levels slightly improve.

• Our residents experience levels of depression and diabetes that are moderate compared to our peers. These levels are unchanged when adjusted

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A strong commitment to customers makes for an extraordinary business.

And an extraordinary bank.

for population difference.

• Nashville residents experience very unfavorable rates of heart attacks, physical activity and smoking in both absolute and adjusted rankings.

Healthy living The health status and behaviors of a region have far-reaching implications, not only for residents’ quality of life, but also for our region’s ability to sustain a strong workforce, contain health care costs and grow. While the Nashville region is a leader regarding the number of insured residents, work remains to transform our physical environment to enable and promote health activities.

• Of communities in our region, Nashville fares as the most walkable, likely due to Davidson County’s investments in greenways, sidewalks and bicycle lanes. Davidson County leads the region on this measure.

• The Nashville MSA falls behind all but Knoxville and Charlotte on walkability, despite investments made in Davison County.

On our bike score, we fall behind every comparison region with the exception of Chattanooga.

• The Nashville region outperforms all but two peers — Louisville and Kansas City — with regard to the number of insured individuals in the region. We also lead for the number of insured children.

• Tennessee remains one of the most obese states in the U.S., with 33.7 percent of adults and 16.9 percent of children obese, and 34.7 percent of adults and 15.4 percent of children overweight.

• Health outcomes and health behavior vary widely throughout the region. As a region, we consistently fall behind the state average for the percentage of smokers, the percent of adults who do not see a doctor due to cost, the preventable hospital stay rate and the percent of residents with access to exercise opportunities.

Salem Emamalie Owner Brentwood Jewelry and Gifts

Takeaways for improving health outcomes in Middle Tennessee It is clear that much work remains to improve the health and well-being of Middle Tennessee residents. While the region’s residents experience low levels of asthma, other areas, such as heart attack, physical activity, smoking, COPD, obesity and high stress, demand attention and action. To guide action, Middle Tennesseans should: • Take advantage of our health care system to positively influence health outcomes in Middle Tennessee. Compared to peer regions, our residents are more likely to be insured and more likely to take advantage of health care services. With our residents now accessing services for chronic diseases, there are opportunities to engage with individuals around a broader

LegendsBank.com

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• Expand health insurance coverage to Middle Tennesseans without coverage.

There are 269,750 Middle Tennesseans without health care coverage, making it more difficult for them to access the quality care that exists in our region. It is imperative that the state and region work to expand insurance coverage to ensure that more of our residents can access preventive care and treat chronic health conditions.

• Strengthen partnerships between health departments and community organizations to better serve low-income Middle Tennesseans. Data suggest that poor health outcomes do not impact all Middle Tennesseans equally. Low-income individuals are twice as likely to report being in poor or fair health. Public health departments can play a crucial role in strengthening partnerships, through shared data and coordinated strategies, with community organizations that support populations that are disproportionately impacted by poor health.

• Enhance the public infrastructure to promote healthy living. Neighborhoods are often separated along socioeconomic lines, with varying access to factors that promote, or if missing, deter healthy living. As the region works to develop and redevelop neighborhoods, opportunities for increased access to bicycle and pedestrian pathways, transit, healthy foods and services, and open space should take a priority.

photo by michael w. bunch

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Caroline Young and Bill Frist NashvilleHealth

photo by eric england

The numbers are in — and they’re not all good

Fixing the fact that ZIP codes are better predictors of life expectancy than genetics by Dr. William H. Frist I like to keep an eye on my hometown’s statistics. I love seeing Nashville listed among the nation’s best cities to launch a startup, raise a family and visit for a weekend away. According to some estimates, we gain 80 new Nashvillians each day, transplants from all over, drawn to our welcoming atmosphere and our healthy business environment.

But for many of Nashville’s residents, “healthy” is not an apt descriptor. I’ve been closely watching these numbers, too. Nashville’s citizens have some of the worst health outcomes on a national and global level. Tennessee is one of the unhealthiest states in the country: 45th out of 50. And Davidson County ranks 22nd out of Tennessee’s 95 counties for health factors, according to the Robert Wood Johnson Foundation County Health Rankings.

In Nashville, more than 30 percent of adults are obese, and 36 percent — one in three! — of our school children is obese. More than 20 percent of our population smokes. Heart disease is the county’s leading cause of death, and our infant mortality rates rank among the highest in the state and below that of countries with much lower standards of living.

A closer look reveals alarming health disparities among neighborhoods within close proximity. The simple truth is our ZIP codes are more powerful predictors of life expectancy than our genetics. Social determinants like local environment,

education, diet and culture can play a huge role in how long and how well we live, more so than our medical care.

Nashville is also not on par with its peer cities.

According to the Gallup-Healthways Well-Being Index, compared with Austin, Charlotte, Richmond and Raleigh, Nashville ranks fifth in the group of competitive cities. These are the numbers that companies consult when choosing where to set up businesses or expand current offerings. Frankly, we have no choice but to make changes.

Without transformation, our citizens’ health will deteriorate. And as a community, we could lose $10 billion to $20 billion over the next decade in health care costs and a less productive workforce, making it more expensive to live, raise families or operate a business. Already, Nashville has clinicians and public health leaders dedicated to turning this tide. But our city is large and our problems are complicated.

To address these challenges, I am launching NashvilleHealth to create a comprehensive and bold, community-supported culture of health equity in Nashville. NashvilleHealth will serve as a county-wide convener to open dialogue, align resources and build smart strategic partnerships to create a plan for health unique to Nashville’s needs, leveraging the rich resources of our city and region.

We seek to bring together a diverse coalition of community, business and faith leaders, clinicians, academic partners and government policymakers to set priorities and shared objectives, and determine a plan of action to address the most pressing issues. Importantly, the collaborative will actively measure and monitor progress to ensure success of execution.

The overall health of our population is poor and, if left unaddressed, threatens our long-term vitality. To ensure that Nashville continues to grow and thrive, we must create a bold culture of health equity that is supported by the entire community.

Through NashvilleHealth, together we will create meaningful change in the health of our people and our city. But for this initiative to be a success, we need your help.

Dr. William H. Frist is a heart and lung transplant surgeon, former U.S. Senate majority leader, chairman of the executive board of health service private-equity firm Cressey & Co., and founder of NashvilleHealth.

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Who is the quarterback of population health?

Stakeholders take different approaches to trying to deliver lasting wellness improvements

by Emily Kubis Population health management is often mentioned as the salve for many of the health system’s wounds. If only patients could be better managed, with fewer complications and more efficiency, health outcomes would improve and costs would evaporate from the system.

But the general consensus on population health management ends with that basic concept. There are so many different groups of patients to cover and multiple stakeholders bearing some kind of risk that nearly every model takes a different approach. Whether an insurer sees the greatest incentive to manage a patient or a

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physician pitches in on a shared savings model, each entity has its own perspective on how to best help patients navigate the complicated, often duplicitous health system.

Each group trying to take the lead on risk management has its particular strengths and weaknesses. And yes, true long-term success will likely come from a model that capitalizes on all of the strengths that different partners bring to the table.

But ultimately, someone has to play lead fiddle.

To get closer to an answer as to whom is well positioned to call the shots while managing patients, we asked executives from both sides of the payerprovider aisle and beyond a simple question: Who is — and who should be — the quarterback of population health management partnerships, leading the team and making adjustments as the game develops?

Here’s how they answered:

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the insurer

the provider

Danny Timblin

Kimberly Lamar

Onlife Health

Wellness solutions company Onlife Health is a subsidiary of BlueCross BlueShield of Tennessee and the Brentwood-based organization engages patients with a toolbox of population health management services for national health plans. Onlife President and CEO Danny Timblin says that, despite the often contradictory relationship between payers and providers, insurance companies hold the key to population health.

“I think the payer is best equipped, even though they’re often seen as a financial player,” Timblin says. “Now they’re morphing into more of an ‘air traffic controller’ role, where they can see the network, see what’s being coordinated. They’re the best person to have that holistic view of the patient and their interactions with providers.”

A traditionally contentious relationship between payers and providers could be a roadblock to health plans’ efforts to manage patient groups, but Timblin says that mistrust can be overcome.

“The payer needs to be seen as a true partner in the equation instead of a claims prevention service,” he says.

With a wide-lens view of a patient’s physician visits and prescriptions, some insurers make the argument that their data is more comprehensive and useful for care management than the info collected by physicians who may or may not be able to access records from other specialists or see which prescriptions have been filled.

Not to mention, by having the final say on patients’ bills — the role that helped earn them that ‘claims prevention’ reputation — insurers carry a lot of financial risk, which could give them the greatest incentive to meaningfully impact costs in the long term.

Nashville General Hospital Insurers certainly carry a lot of fiscal risk, but so do providers who face a challenging reimbursement environment. As the city’s safety net hospital, Nashville General Hospital has long had to carry a larger share of indigent care than other systems in the area.

This year, the city hospital added Kimberly Lamar to lead its population health initiatives. Lamar says the facility’s “unique” financial position and largely underinsured population might be just the incentive risk management needs to succeed at the hospital level.

“I think we’ll take the lead and be in a better position,” Lamar says. “We’re providing service to this population that is primarily indigent, and what we’re challenged with is getting high-cost patients to a lower cost and save those dollars we’re not being subsidized for.

We’re finding a model with which to save ourselves.”

Nashville General sees a younger population with chronic conditions than other systems in the city, Lamar says. The demographic differences means the hospital has to be creative in its interventions, as they aren’t focused directly toward the traditional Medicare population — or even an insured population at all.

Dr. Joseph Webb, CEO of Nashville General, says population health is an “all-hands-on-deck” situation. But when it comes to the quarterback question, he feels differently than his payer counterpoints. He says that providers have more touch points with patients than insurers or other industry players.

“When you look at pre-acute, acute and post-acute care, there’s not another entity out there that does what the care delivery system does,” Webb says. “A pharmacy, a third-party payer — none of those are going to be as equipped to engage in population health management as a hospital or provider system.”

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the employer

the community

Stuart Clark

Caroline Young

Brentwood-based Premise Health believes patients are the most important piece of the population health puzzle, but their approach is based on the incentives of self-insured employers. The company’s executives have built their model on changing patients’ behavior by meeting them where they are. For most of us, that’s at work.

Premise Health operates onsite health clinics for large, selfinsured employers across the country, and CEO Stuart Clark says being able to tailor wellness approaches to specific company cultures and health insurance benefits allows his team to better engage patients and improve outcomes.

“A group practice might have 4,000 employers or payers, but we have one employer, one culture and one payer,” Clark says.

“We can get very focused on the individual patient and determining their needs.”

In addition to providing onsite services for basic health needs for employees and their families, Premise Health also plays a role in the greater health system. Clark calls the company’s approach patient advocacy and his team assists in connecting patients to the right community resources. Given Premise’s relationship with the employer — which in this case is also the payer — navigating the system becomes less complicated.

“We don’t do MRIs, but we’re not just going to tell you where those providers are,” Clark says. “We’re going to book your appointment, make sure it’s in your network and our doctors are going to get those results.”

Large employers are seeing the benefits of taking health care costs vertical and managing them internally. But without health care expertise and infrastructure, the companies need a partner, and Premise Health is paid based on results.

“We’re not going to continue our relationships with these large, sophisticated customers unless they see the needle moving,” Clark says. “Our industry has always been held accountable for containing costs. The rest of the health care system has never really been held accountable in that fashion, but that’s where onsite health clinics have been living for the last decade.”

One of the tenets of wellness is that population health interventions cannot occur solely at a physician’s office. In order to improve patient health significantly, clinicians have to find ways to serve populations outside of the walls of the health system.

By pulling in faith groups, government entities and other philanthropic organizations, community health efforts seek to serve people in and around their interactions with clinicians. By supporting patients as they navigate their day-to-day lives, these efforts seek to break down structural and social barriers to wellness.

NashvilleHealth, founded by former U.S. Senator Bill Frist, is a new community-based initiative focused on the population health and wellness of Davidson County residents. The program was launched under the umbrella of the Community Foundation of Middle Tennessee and counts the Vanderbilt University Department of Health Policy and the Metro Nashville Health Department as partners.

“It’s looking really broadly at how much of people’s health is impacted by social behavior, and that there are many things to affect that from a clinical perspective,” says Melinda Buntin, chair of VU’s Department of Health Policy.

NashvilleHealth is still in development but will feature three pilot programs focused on hypertension, smoking and child health.

Another key partner in the effort is the Nashville Area Chamber of Commerce, which conducted a health study comparing Nashville to peer cities, says NashvilleHealth Executive Director Caroline Young.

“We looked to see if they found the same health issues, and they did, so we feel like we can springboard off of that and set the stage of more community-wide dialogue on these issues,” Young says.

Buntin says community population health efforts demonstrate that an increasing number of stakeholders are seeing wellness opportunities.

“When you hear insurers or systems talking about keeping populations healthy — that there are things that they can do apart from encounters between patients and clinicians — that really is a big change in thinking,” she says.

Premise Health

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The promise and The pain

As population health management evolves, Healthways looks to stay relevant For evidence that population health management is a tricky and evolving space, look no further than the southeast corner of Cool Springs Boulevard and Carothers Parkway.

There sits the headquarters of Healthways, one of the pioneers of what is now called population health management but not that long ago went by disease management or chronic care management and focused more on the mechanical processes of reminding people to take their pills. As the market for working with broad patient groups has matured, the company has struggled to maintain its middleman role — a topic we featured on our January 2012 magazine cover pictured here.

Only last year did Healthways’ revenues top those of its previous 2008 peak of $736 million. And during the six intervening years, the company posted a cumulative net loss — thanks mainly to a large 2011 writedown of its important contract with Cigna — of $106 million. Over the last 15

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quarters ended this fall, it has lost a total of $17.6 million.

In late October — two days before Chairman Donato Tramuto formally moved into the CEO seat — Healthways leaders announced a wide-ranging restructuring that suggests sustained profitability is still a few years away. Among the changes coming: The company’s five business lines will be trimmed to two, population health and network solutions, while a consulting subsidiary acquired in 2011 will be sold back to its former leader and costs will be cut from the payroll, real estate and IT lines in the budget. On top of that, Tramuto, CFO Alfred Lumsdaine and their team will write down almost $20 million of their investment in a joint venture with polling giant Gallup.

In response to that news, several analysts cut their price target for Healthways shares, which were changing hands around $11, to between $12 and $13. The promise of comprehensive population health management is still there. The risk-reward balance for Healthways investors still appears precarious. > Geert De Lombaerde

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Vic Gatto Jumpstart Foundry

photo by michael w. bunch

First-year success

Jumpstart Foundry to brand Health:Further as a yearly event by Linda Bryant By any measure, Health:Further — Nashville’s first full-scale health care industry innovation conference — was a major success. More than 600 participants were left wanting more after the late-August event, and the buzz still lingers.

Now the event’s sponsor, business accelerator Jumpstart Foundry, is branding the event as a yearly offering and moving forward with plans for a bigger conference in 2016. To be held at Music City Center Aug. 23-24, the next Health:Further will be supplemented during the year by half-day quarterly mini-conferences.

“Nashville is such a lightning rod for health care innovation,” says Colton Mulligan, CEO at Nashville-based digital marketing agency FoxFuel Creative and keynote speaker at the recently held event. “The city is clearly establishing itself as a place that wields authority in the health care industry. Now’s the time to finally leverage our reputation and create an event that’s going to bring together big industry players and venture capitalists, as well as the innovators and creators.”

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The goal of Health:Further is to spark relationships and conversations between established players on the front lines of innovation, including HCA, BlueCross BlueShield of Tennessee and Community Health Systems. Creating relationships with investors and innovative health care startups is also a priority.

Gretchen Napier, CEO of Life Links, a small Nashville-based health care company that helps coordinate and manage care for the aging, attended the first conference and pitched to investors in a manner similar to that found on reality television show Shark Tank.

“Getting all these different people in one place to focus on innovation in health care is just a brilliant accomplishment,” Napier says “We were able to deliver well and connect with key players. I think Health:Further will make health care better for a lot of people.”

Napier’s company, which is also a graduate of Jumpstart Foundry’s 14-week business accelerator, is attempting to expand to 20 cities in five

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CHANGE years. It is about halfway to its funding goal.

“There are a lot of events where you see health care industry players talking to themselves about health care,” says Vic Gatto, Jumpstart Foundry CEO and founder. “Then you have events where the tech startups and inventors get together. We want to cross-pollinate these two groups. That’s what will really separate us from other health care conferences.

“We especially want to hear from the creative class — the innovators, technologists and startups who’re doing very interesting and novel things,” he adds.

With this backdrop, Nashville Post chatted with Gatto, who also is a board member of Post parent company Southcomm, about his plans for Health:Further and about its unexpected success.

What was one of the biggest surprises of the event?

I’m a venture capitalist. I’ve never run an event before. I didn’t really know what to expect, so it was a bit daunting. We hoped to get 300 to 400 people to come, and we didn’t want to lose money. We sold out and filled a room at Omni Hotel that held 600 people. We had a waiting list and had to turn people away. I had maybe 100 people calling me in the last two weeks wanting tickets.

We knew we wanted to bring dominant health care industry players with innovators, but tapped into the heart of something remarkable. We tapped into this group of people who wanted to learn about what’s happening around innovation, technology and new approaches for the patient. We weren’t just talking about where health care wants to be in 20 years. We were talking about where it’s going in the next six months.

The conference was a phenomenal success and the energy in the room was very exciting. It was surprising, but a lot of fun, to see so many people sharing different perspectives and learning from one another. Now we want to keep the conversation going, not just with the yearly event but also with half-day quarterly events. We expect at least 1,000 people to attend in 2016.

Where did people come from?

Roughly 300 to 350 were probably from within a three-hour drive of Nashville.

There were large numbers of people from Huntsville, Birmingham, Memphis, Chattanooga and Louisville. But a lot of people flew in from places such as Los Angeles, San Francisco, Minneapolis, Boston and New York.

Where is Nashville in the hierarchy of health care industry epicenters? And how does the Health:Further conference “move the dial” for the city in terms of being seen as a major health care center?

Nashville is building momentum. Of course, we aren’t the only health care epicenter. There are five other cities that are tremendously strong in health care and for individual reasons — Boston, Minneapolis, New York, San Francisco and Chicago. Health:Further should help Nashville be more broadly recognized as a leading center for health care innovation. This conference is one of the ways we can claim more superiority when it comes to innovation, and we’ll be pushing that story.

I want Health:Further to be recognized and associated with Nashville.

Think of South by Southwest. It’s about music and technology for the whole country, but it happens in Austin, Texas. It’s part of that city, and it’s hard to think about it taking place in any place other than Austin. We wanted to be an industry conference that’s associated with Nashville in the same kind of way. People will want to come to it because this is where everything is happening.

Did you notice any significant trends at this year’s conference?

Health care is becoming much more personal and patient-focused. The existing health care industry is trying to figure out how to reorient itself around the benefit of the patient. Previously, it’s been more oriented around the physician. The patient has always been there, but so many of the innovators and disruptors are moving towards solutions and innovations, making the patient and the patient’s family happier.

Can you give an example of how a huge health care industry player might be impacted by a startup or small health care company?

Clay Phillips, vice president of innovation for BlueCross BlueShield Tennessee, was on a Health:Further panel with me. He came because I asked him very plainly to be on the panel, but he actually ended up getting very excited by all the innovative ideas and by all the great conversations taking place. Now Clay wants BlueCross BlueShield to have a much bigger role in the innovation space.

I don’t know exactly what it’s going to turn into, but he’s going to partner with Jumpstart Foundry to do something to bring better and more innovative solutions to customers. BlueCross has a huge market share in Tennessee, and they’d like to have greater access to technology, innovation and entrepreneurism. The company wants to deliver innovation to their customer base, but they haven’t known how to do it at the scale BlueCross requires.

Dr. Jonathan Perlin, the chief medical officer at HCA, did a keynote for us about how HCA is using data and technology to deliver safer and more effective treatment. I know he was flooded with a lot of new perspectives and solutions. He’s looking at how and where HCA can incorporate some of these platforms.

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CHANGE A healthy child is the best gift of all.

Coordinate or stagnate

The journey from volume to value will require smarter systems

by Kevin O’Neil

Support Monroe Carell Jr. Children’s Hospital at Vanderbilt this holiday season by purchasing a Holiday Project items.

Holiday cards, photo cards, contribution cards, gift tags, holiday gifts and our 2015 ornament.

Purchase items online at ChildrensHospital.

Vanderbilt.org/ holidayproject

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The Affordable Care Act enacted in 2010 has ushered in a major transformation in the American health care system. Not only is the ACA focused on expanding access to affordable and quality care, but also on reducing the overall costs of health care. Health care spending has been on an unsustainable path.

Medicare spending had been doubling every 10 years, but recent figures suggest a slowing in cost growth. Still, more than a third of health care spending has been deemed unnecessary.

Moving from a fragmented fee-for-service system that rewards volume to one based on value has not been easy, but is certainly necessary.

Such a system will require better care coordination across the entire health care delivery system. Nowhere is careful care coordination more important than in the older adult population. Older persons may have multiple complex medical conditions as well as physical and cognitive challenges. Transitions from one setting of care, such as an acute care hospital, to another setting such as a home, a nursing home, or an assisted living facility is an especially vulnerable time for an older adult.

It is unusual these days for an individual’s primary care practitioner to oversee care in the hospital. This is usually done by hospitalists. In skilled nursing facilities, care is often provided by “SNFists.” Other providers have limited their services to people residing in assisted living facilities while palliative and hospice care is usually provided by specialist physicians and nurses devoted to persons with severe chronic medical conditions and end-of-life care.

This fragmentation of the health care system creates many opportunities for miscommunication. Such communication gaps can result in adverse medication events, unnecessary emergency room visits and avoidable hospital readmissions.

Prior to the enactment of the ACA, an estimated 20 percent of all Medicare beneficiaries discharged from the hospital were readmitted within 30 days. The Center for Medicare and Medicaid Services estimated that 13 percent of these readmissions were avoidable — and cost the system more than $12 billion.

More recent research suggests that an even higher percentage of unplanned hospitalizations and readmissions are avoidable.

The tremendous growth in the number of accountable

care organizations and Medicare Advantage Plan enrollees is testimony to the government’s intention to control costs as well as to improve quality. For organizations to accomplish the Triple Aim of CMS — improved quality of care, reduced costs and improved care experience — meticulous care coordination is essential to reducing unnecessary hospitalizations, which is the most expensive care. Thus, there is a push to drive care to less expensive environments when appropriate, feasible and safe.

Home care and assisted living will become more and more important in the evolving health care marketplace. Research has shown that several medical conditions such as soft tissue infections and deep vein thrombosis (blood clots) can be managed at home with better outcomes and at lower cost than in a hospital. More widespread implementation of such programs has been hampered by the fact that Medicare and commercial payors have been reluctant to reimburse providers for delivering care in these settings.

That will likely change.

Assisted living represents an untapped opportunity in the mission to meet the Triple Aim. CMS is already implementing bundled payments for care episodes that include hospital care, physician services and post-acute care. Assisted living is a much less expensive option than skilled nursing, and the efficiencies of scale can make a respite stay in assisted living a less expensive option than home care. More and more assisted living organizations are moving toward an integrated care model with the availability of onsite home health and therapy services. Assisted living also provides an opportunity for socialization, which is extremely important for overall well-being.

Effective communication between these service lines is key. Miscommunication of important information is a common cause for readmissions. George Bernard Shaw once said, “The single biggest

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CHANGE problem in communication is the illusion that it has taken place.”

If important information about a person’s medical conditions or medication regimen is not communicated properly when a person transfers from one care setting to another, such as the hospital to home or to a skilled nursing facility, adverse events that trigger a readmission can occur.

Thankfully, innovative projects have been supported by CMS to improve care transitions and reduce the risk for adverse outcomes. In 2012, CMS provided funding to 107 organizations nationwide that had demonstrated or proposed innovative care models to achieve the Triple Aim. Brookdale Senior Living, in collaboration with the University of North Texas Health Sciences Center, was a recipient of one of the CMS Health Innovations Challenge Grants. Brookdale had previously created a care transitions program that significantly reduced avoidable readmissions from its skilled nursing facilities in Cleveland. (Subsequent replication of this program in Kansas City and Lexington suggested that this program could be disseminated to all of Brookdale’s skilled nursing facilities.)

An important component of this program was a quality improvement project called INTERACT — Interventions to Reduce Acute Care Transfers — which was created by Dr. Joseph Ouslander and colleagues at Florida Atlantic University. INTERACT consists of a variety of “tools” that include checklists, protocols and algorithms for identifying and managing changes in a person’s health condition and preventing important information from falling through the cracks.

Another important aspect of the CMS Health Innovations Challenge Grant was the modification of the INTERACT tools for application in the assisted living population. Many residents of assisted living have medical conditions that place them at high to moderate risk for hospitalizations and readmissions. The INTERACT program modified for assisted living was significantly associated with a reduction in hospitalizations for acute care and a reduction in total Medicare cost. Since improving population health and reducing avoidable hospitalizations and readmissions are top priorities of CMS, it was concluded that the modified INTERACT program can be successfully applied to residents in the assisted living setting.

These are challenging times in health care, but challenges create opportunities. We as a nation are in a unique position now to help bridge the quality chasm. The status quo is not acceptable. We can eliminate errors that occur daily in the care of older adults and enhance the wellness and health of those who entrust themselves to our care. But this will require systems innovations that will improve the lives of many millions of older Americans.

Kevin O’Neil is the chief medical officer at Brookdale Senior Living.

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CHANGE

In senior care facility design, little things can add up to big changes A peek inside NHC Place at The Trace being built in Bellevue

National HealthCare Corp. runs dozens of skilled nursing, assisted living or independent living centers in 10 states but the company has in recent years been working to expand its presence in Middle Tennessee, adding to its Cool Springs complex and inking a partnership deal with Maury Regional Medical Center, among other things.

The Murfreesboro-based company is expanding with a particular focus on building design and technology, looking to deliver a heightened level of care to a new generation of senior care patients. That approach is on display as its new center in Bellevue, NHC Place at The Trace, takes shape. There, as at NHC’s new centers in Sumner County and Tullahoma, the company and its design partners have incorporated elements that address everything from the length of hallways and the pattern of the carpet to the location of the kitchen to ensure patient care is enhanced wherever it can be.

One of the primary features of the new centers is the concept of a single campus offering multiple services. One area of NHC Place at The Trace is dedicated to assisted living, one to continuing care and another specializes in memory care. Senior Vice President of Corporate Relations Gerald Coggin says such an approach is based on the needs of today’s senior care customers, who are looking for a location where they can age in place.

“The senior care population has been growing and is only going to increase in size in the coming years,” Coggin says. “We have been preparing for it very deliberately and with a new vision for what that care looks like. Today’s senior care patients are different demographically, varied in their experiences and expectations, and looking for more choices for this part of their lives.”

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Murfreesboro. Here are some of its specific design features, the fruit of planning by Johnson + Bailey team members with NHC department leaders: >S horter hallways to provide closer proximity to patients for NHC employees and more comfortable spaces for the patients >S pecial carpets and furnishings in the memory care space that help patients recognize space and distance, all to soothe and reassure those with dementia >A more home-like design, with higher ceilings, nicer carpets and more décor >A large and centrally located gym for both rehabilitation care and resident use >A centralized, professional kitchen that can serve the entire center, which ensures consistency and quality of food service >A variable refrigerant flow mechanical system to improve the air quality for patients while reducing energy consumption >W i-Fi throughout, along with amenities like a garden, a theater and multiple group gathering places Coggin says that with NHC centers attracting a broader spectrum of patients — many of whom are there for a shorter time than they would have been in the past — these design and health care elements are enhancing the patient experience.

“We are now a first choice for rehabilitation care, particularly after orthopedic injuries or joint replacement,” Coggin says. “That not only means that we see patients at earlier stages of their lives, but it also means that they get to see NHC firsthand, which often changes their perception of a senior care center.”

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CHANGE Bistro-style assisted living

Staying close

Open, home-like gathering areas are designed to encourage community

Shorter hallways and more nurse stations put patients closer to the people caring for them

photos courtesy national healthcare corp.

Better food Getting fit

A centralized kitchen streamlines food planning and improves the appeal and nutrition of meals throughout the facility

A central gym and fitness area delivers more rehabilitation services

Welcome areas Hotel-like entries and community areas create more inviting gathering places

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CHANGE

Can the rise of addiction treatment companies help alleviate the opiate crisis?

An industry matures but other factors need to fall into place by Emily Kubis More Tennesseans died of opiate overdoses in 2014 than in motor vehicle accidents. The rate of fatal opiate overdoses has risen every year since 2011, according to the state Department of Health, and the increase of intravenous drug abuse has contributed to a Hepatitis C epidemic on top of the rising rate of addiction.

But the crisis is not Tennessee’s alone to bear. Nationally, more than 16,000 people died due to opiate painkiller overdoses in 2013, and nearly 7,000 people are treated every day in emergency departments for drug misuse, according to the Centers for Disease Control and Prevention.

“Oxycontin is probably the biggest offender,” says Michael Cartwright, CEO of addiction treatment services company AAC Holdings. “There’s too much prescription medicine being prescribed and abused. People are finding they can get heroin cheaper and easier, and a lot of our patients have switched over. Young kids — I’d never seen that in the industry, a 19-year-old college kid strung out on heroin.”

From this landscape has sprung a burgeoning addiction treatment services industry, with AAC aiming to become one of the first national players. But sub-

stance abuse treatment is a mosaic of providers, with most treatment facilities operating independently of each other and the rest of the health care system. Care can come from hospitals, outpatient clinics, community groups and faith-based efforts, creating a complicated web to navigate.

Companies both public and private continue to see opportunity in the space, which the Substance Abuse and Mental Health Services Association estimates represents a $35 billion industry. AAC is effectively the first addiction treatment services company to go public, and with several acquisitions under its belt since its IPO last year, the company expects to be operating 1,200 beds by the end of 2016.

On a smaller scale, another Brentwood venture, JourneyPure, entered the space this year, landing initial funding in the spring and soon after acquiring a four-facility portfolio. Of course, the giant in the behavioral health game is Acadia Healthcare, which has several substance abuse treatment options, including residential facilities as well as inpatient and outpatient services.

This fragmented market — research firm IBISWorld says almost 80 percent of all U.S. substance abuse treatment clinics have a single location — presents opportunity for consolidation, which investors seem inclined to support. A scalable addiction treatment model could lead to more comprehensive and coordinated services, which is good for patients and payers alike.

“There will be larger players like [AAC] that aggregate the space,” Cartwright says. “There are positives to mom-and-pop providers. They have a passion in helping individuals with addiction.

But I do think there needs to be a lot more professionalism and resources in training and education. HCA is a good milestone — what they did and where the hospital industry is today compared to the ’70s. I think that’s where we are now with the addiction industry.”

More and better drug treatment options are positive developments, but questions remain for investors, patients and payers on outcomes. Opiate addiction, like any substance abuse concern, comes with a very possible chance of relapse. With the development of value-based care, both government and commercial insurers are increasingly paying based on better results, which could challenge the profitability of these companies. continued on page 76

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CHANGE But Cartwright says AAC welcomes the growth issue, as it involves physical care and mental health treatment, as well as more of value-based care. He says relapse is a part of re- social aspects like family, employment, housing and often the legal and criminal covery, but adds that treating addiction is similar justice system. to treating diabetes or other chronic conditions: It A wide-scale approach has not yet been successful in uniting the disparate pieces requires major lifestyle changes that take time. To of the addiction puzzle, nor in tapering off usage statistics or overdoses. However, prepare for value-based reimbursements, the com- individual communities have seen some success with innovative approaches. pany is initiating its own outcome studies, and CartOne approach that has received particular attention involves the Gloucester wright says the addiction treatment industry needs Police Department in Gloucester, Massachusetts. Facing opiate overdoses as the increased funding and research to further its efforts. leading cause of death in the state, a city police department took an innovative “We’ve come a long way, but we have a long way stance on its role in treating the addiction crisis. Under the ANGEL Program, to go,” he says. “We do need more outcome studies. any addict who comes into the Gloucester PD with drugs or paraphernalia and We do need to look at the different components of seeking help will not be charged or arrested. The Department has connected with drug treatment and dig down and local providers at Lahey Health Behavioral Services to provide look at effective ways of treating the patient with an “angel” to walk them through the detox and people. This is one of the most unrecovery system. derfunded diseases out there, in The program has been in place since June and has received my opinion.” public support from the Office of National Drug Control. As of The profitability and success of late October, the city has directed 260 people into treatment the addiction treatment industry is and seen a 23 percent drop in quality-of-life crimes. According certainly an important piece of reto the Gloucester PD, initial statistics also show it costs the deversing the rising rates of addicted partment 75 percent less to direct addicts to treatment than it Americans. But beyond company does to arrest them. endurance are larger questions Compare that to a recent legislative approach in Tennessee: about the complicated nature of In 2014, the state passed a bill that permits law enforcement addiction, and addiction treatagencies to criminally charge new mothers who used illegal ment, in America. drugs while pregnant. The mothers could face jail time. The law Most drug treatment is still was highly criticized by health advocates, who said it actually based on 12-step programs, which incentivized addicted pregnant women to avoid treatment for are recommended by many leadfear of incarceration. Further, the law did not address prescriping addiction specialists, includtion opiate use, which a Vanderbilt University Medical Center ing the aforementioned SAMHSA. study found was behind many of the state’s cases of neonatal However, an increasing number abstinence syndrome. The law will face renewed scrutiny in of critics have studied the success the upcoming legislative session, when legislators must decide rates of these programs and many whether to adjust it or let it expire in 2016. have claimed they lack evidence But whether lawmakers take a tough-on-crime approach as and can even hinder patients’ in Tennessee or a more decriminalized course of action as in path to sobriety by eschewing Massachusetts, the opiate crisis will continue until the stigma medical approaches in favor of around addiction and treatment is reduced. moralistic methods.

The scaling of treatment services through companies such as “There are new medications for AAC looks like a step in the right direction, especially if the inaddiction treatment that 12-step Michael Cartwright, dustry is successful in its research and educational efforts. But programs are not embracing, but I AAC Holdings without a comprehensive approach that ties together the mediam,” Cartwright says. “Twelve-step cal nature of addiction with its substantial societal elements, the programs have helped many people numbers of addicts and overdoses may continue on their curget sober for many years, but I do think there’s a rent, upward trajectory. place for medication. They go hand in hand, as well “This is a societal problem and it’s taken over America,” Cartwright says. “I as with faith-based groups, and I don’t know why do believe if we focus our efforts and intentions on the best possible ways to they need to be separate.” treat someone, we’ll get better as a country and overcome this disease. But it Opiate addiction is a complicated public health is complicated.”

‘There are positives to mom-and-pop providers.

But I do think there needs to be a lot more professionalism and resources in training and education.’

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INDEX AAC Holdings...................................................................31, 74

Christy-Houston Foundation..................................................14

Aetna.....................................................................................56

Cigna...............................................................................56, 67

Affordable Care Act....................................................56, 58, 70

Clay Phillips............................................................................69

A.J. Kazimi.............................................................................38

Clayton McWhorter...............................................................33

Al Baker.................................................................................39

Colton Mulligan.....................................................................68

Amber Sims...........................................................................28

CommonWell Health Alliance................................................43

Anthem..................................................................................56

Community Foundation of Middle Tennessee........................66

Ascension Health........................................................28, 44-45

Community Health Systems.................................31, 43, 45, 68

Bass Berry & Sims..................................................................16

Cumberland Emerging Technologies......................................38

Belmont University..........................................13-14, 32, 35, 40

Cumberland Pharmaceuticals..........................................31, 38

Belmont University College of Pharmacy...............................14

Danny Thomas.......................................................................34

Belmont University School of Occupational Therapy..............13

Danny Timblin........................................................................65

Bernie Sherry.........................................................................28

David Rivera...........................................................................16

Beth Hallmark........................................................................40

David Satcher........................................................................34

Bill Frist............................................................................63, 66

Doug Springer........................................................................22

Bill Stead................................................................................43

Duke LifePoint.................................................................. 10-11

Blake Estes.............................................................................28

Ed Cantwell......................................................................43, 45

BlueCross BlueShield of Tennessee............................65, 68-69

Epocrates...............................................................................48

Bob Robke..............................................................................43

Ernest Goodpasture...............................................................33

Brookdale Senior Living...................................................31, 71

Expect With Me.....................................................................57

BU College of Health Sciences and Nursing..........................40

Fahad Tahir............................................................................28

Capella Healthcare................................................................10

Fisher Brown Bottrell Insurance.............................................47

Capella-MUSC Health Network.............................................10

FoxFuel Creative.....................................................................68

Caroline Young.................................................................63, 66

Gallup-Healthways Well-Being Index....................................63

Center for Medical Interoperability.................................. 43-46

Gerald Coggin........................................................................72

Centers for Disease Control and Prevention.....................34, 74

HCA.................................................... 31-33, 43, 45, 68-69, 74

Centerstone Research Institute.............................................59

HCA Holdings...................................................................31, 45

Cerner Corp............................................................................43

Health Data Source................................................................20

Certificate of need.................................................................52

Health:Further................................................................. 68-69

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INDEX Healthways......................................................................31, 67

Melinda Buntin......................................................................66

Heather Davidson..................................................................14

Metro Nashville Health Department......................................66

Humana.................................................................................56

Metro Nashville Hospital.......................................................34

iTriage....................................................................................48

Michael Cartwright................................................................74

Jack C. Massey......................................................................32

Michael Wiechart..................................................................10

Jason Moore..........................................................................20

Michel McDonald..................................................................22

Jeff Balser........................................................................11, 45

Mike Schatzlein..........................................................27-28, 44

Jeff Seraphine.......................................................................10

Mildred Stahlman..................................................................34

John Gresham.......................................................................44

Milton Johnson.....................................................................45

John Hale..............................................................................22

My Pain Diary.........................................................................49

Jonathan Perlin......................................................................69

Nashville Area Chamber of Commerce............................60, 66

Joshua Cockroft.....................................................................14

Nashville General Hospital.....................................................65

Jumpstart Foundry......................................................39, 68-69

NashvilleHealth...............................................................63, 66

Karen Springer................................................................. 27-28

Nashville Health Care Council....................................31-32, 35

Katie Miller............................................................................14

National HealthCare Corp................................................31, 72

Keith Miller............................................................................58

Noom.....................................................................................49

Kimberly Lamar......................................................................65

Office of National Drug Control..............................................75

Laura Lawson........................................................................22

Oliver Wyman........................................................................48

Legacy ER & Urgent Care.......................................................58

oneC1TY................................................................................50

LifePoint Health....................................................10, 31, 45-46

Onlife Health..........................................................................65

Lipscomb University......................................................... 13-14

Parker Rains...........................................................................47

LU College of Pharmacy and Health Sciences................. 12-13

Phil Johnston.........................................................................14

Marcus Whitney....................................................................39

Premise Health......................................................................66

Mark Lyles..............................................................................11

Reemo...................................................................................39

Marshall Martin.....................................................................20

Robert Wood Johnson Foundation............................35, 59, 63

Maury Regional Medical Center............................................72

Roger Davis...................................................................... 13-14

McWhorter Hall...............................................................33, 40

Ryan Doyle.............................................................................50

McWhorter Society.....................................................32-33, 35

Saint Thomas Health........................................................ 27-28

Meharry Medical College......................................................34

Saint Thomas Health Alliance................................................28

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INDEX

COMING IN 2016

Saint Thomas Medical Partners ......................................22, 28 Saint Thomas Midtown ...................................................28, 52 Saint Thomas Physician Services ..........................................28 Saint Thomas Rutherford ......................................................14 St. Jude Children’s Research Hospital ..................................34 Stratasan ..............................................................................20 Stride Health .........................................................................49 Stuart Clark ...........................................................................66 Substance Abuse and Mental Health Services Association..74 Susan Lewis ..........................................................................57 Tennessee Health Care Hall of Fame ..............................32, 35 Tennessee Hospital Association ............................................41 Tennessee Simulation Alliance .............................................41 Tennessee State University School of Nursing ......................14 Thomas Frist Jr. ............................................................... 32-33 Thomas Frist Sr................................................................ 32-33 Tom Doub..............................................................................59 TriStar Southern Hills ............................................................52 United Healthcare........................................................... 56-57 U.S. Attorney for the Middle District of Tennessee ...............16 Vanderbilt Center for Women’s Health .................................57 Vanderbilt Health Affiliated Network ..............................11, 45 Vanderbilt University ........11, 14, 32-34, 38, 43, 45, 57, 66, 75 Vanderbilt University Medical Center..................11, 43, 45, 75 Vanderbilt University School of Medicine .......................14, 32 Vic Gatto ......................................................................... 68-69

ALL NEW

Wayne Smith ........................................................................45

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West Health Institute............................................................43 ZocDoc ..................................................................................49

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cabana

NP_12-15.indd 85

11/4/15 6:31 PM

NP_12-15.indd 86

11/4/15 6:31 PM