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Making the Leap to Accountable Care in a Physician-Driven Organization at Carilion Clinic

April 25, 2014
by Mark Hagland
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Carilion Clinic’s journey towards accountable care and population health management

In his presentation at the Atlanta Health IT Summit on April 16, Stephen Morgan, M.D., senior vice president and CMIO at the Roanoke, Va.-based Carilion Clinic, spoke extensively and in detail about “Carilion Clinic’s Journey with Population Health Management and Health IT.”

Dr. Morgan shared with his audience at the Health IT Summit, sponsored by the Institute for Healthcare Technology Transformation (iHT2), and held at the Historic Academy of Medicine at Georgia Tech, in downtown Atlanta, regarding the experiences of the eight-hospital, 600-physician integrated health system around accountable care and clinical transformation. (Since December 2013, iHT2 has been in partnership with Healthcare Informatics and its parent company, Vendome Group LLC.)

Stephen Morgan, M.D.

After putting into context the broad shift towards accountable care in U.S. healthcare, Dr. Morgan explained the core drivers pushing the Carilion Clinic towards accountable care, and creating an accountable care organization (ACO) under the Affordable Care Act (ACA). Indeed, the Roanoke, Virginia-based Carilion organization joined the Medicare Shared Savings Program (MSSP) for accountable care organizations (ACOs) in January 2013, and that step in itself has helped to spur the development of more coordinated approaches to care delivery and the acceleration of the creation of IT foundations to support the ACO financing and delivery model.

What’s more, the avoidable readmissions reduction mandate embedded in the Affordable Care Act (ACA), as well as implied in sharing risk with the federal Centers for Medicare & Medicaid Services (CMS), has further spurred activity already underway at Carilion Clinic to improve the management of such chronic illnesses as congestive heart failure (CHF), coronary artery disease (CAD), diabetes, and chronic obstructive pulmonary disease (COPD).

Morgan explained that, shortly after the Carilion organization reorganized itself as a physician-governed clinic in 2006, the organization’s leaders came up with a strategy to move forward on population health management, a strategy that is still being refined based on early experiences so far.

“Among the key questions we faced,” he told his audience, “was, are you able to manage risk? We had gotten into the Medicare Advantage program fairly early on, but realized that we did not understand how to manage risk, and actually had had to back out of that program quickly.” Among the issues besides the ability to manage risk, that Carilion Clinic’s leaders have faced, are: what kind of strategy is being developed for the integration of clinicians? How has the organization engaged physician leaders? How will the organization handle the necessary culture shift involved in moving from a fee-for-service-based reimbursement system to a payment system based at least partly on risk? What are the fundamentals for effective health IT and data management? How will the organization effectively manage the pace of change?

In fact, Dr. Morgan said, “We’ve been undergoing a huge culture shift. In fact,” he said, “we’ve found that culture has been one of the biggest issues for us. We’re getting through it, but it’s hard. And having an effective HIT and data management strategy,” he said, is also incredibly important. Related to both and equally challenging, he says, is the fact that “We have one foot on the dock and one in the boat” when it comes to reimbursement. “We’ve still got most hospital payment under fee-for-service; so it’s really tough, in terms of what we tell our doctors” about how to best manage the utilization of resources in a mixed-payment environment.

Among the steps that the Carilion Clinic leaders have taken since 2006 that have moved things forward, Dr. Morgan cited the following

> They developed a multispecialty medical group

> They focused strongly on nurturing physician leadership within the organizatio

> They have created substantial quality, safety, and process improvement

> They have implemented an electronic health record (EHR) enterprise-wide

> They constructed the Riverside campus

> They opened a medical school in partnership with Virginia Tech University

> They have implemented medical homes at all primary care sites

> In partnership with Aetna, they have created a commercial HMO, Whole Health, and a Medicaid HMO, MajestaCare; and Carilion has become a Medicare Shared Savings Program (MSSP) accountable care organization (ACO)

> They’ve built a culture of collaboration

“All of our primary care sites, around 40, are on the patient-centered medical home model, as defined by Carilion Clinic,” Dr. Morgan noted. “Initially, we worked to get all of our primary care sites certified as level 3 PMCHs,” according to the certification standards of the National Committee for Quality Assurance (NCQA), he noted. “But,” he added, “we moved away from that approach, because we found it was more process-oriented, and it was driving our physicians—and our nurses—crazy. So we tried to move instead towards creating PCMH elements that were more ‘value-added.’ But all of our outpatient locations now have a patient-centered medical home, with care coordinators.”