Organizations are working on a multitude of initiatives to prepare for greater contractual risk for population management, while also moving toward value-based care initiatives. In this new era of accountable healthcare, a new role, the chief integration officer, is beginning to take shape to link hospitals and providers in the care continuum.
The chief integration officer, which is going by many titles, such as the VP of population health, VP of integration, chief accountable care officer, and VP of the continuum of care, is beginning to formulate the organizational design for population health management, juggling an overwhelming number of projects in a short time frame without many dedicated team members, says Amanda Berra, practice manager, research and insights, at The Advisory Board Company, who identified this role in a recent research brief. [Click here to see an infographic further exemplifying the position.]
“I think the thing that is driving it is the growing industry commitment to a future in which providers are going to handle a lot more population-level risk,” says Berra. “Between the passage of the ACA [Accountable Care Act] , the emergence of a lot of commercial ACO contracts, the number of new Medicare programs for ACO and ACO-related demonstration projects, you definitely sense a momentum in the industry.”
Berra says she started seeing this position emerge a year ago, and it now is beginning to proliferate as hospitals are integrating and aligning with physicians to build care management platforms that allow for risk segmentation, the ability to reach out proactively to high-risk patients, avoid preventable readmissions, and focus on chronic care management. Berra says she has been finding this chief integration officer in organizations that are committed to change.
“The more clear-cut that ambition is to become a capable population manager at a health system, the more those health systems have taken early steps,” she says.
New Role, New Responsibilities
Ellis “Mac” Knight, M.D., senior vice president of physician and clinical integration at Palmetto Health (Columbia, S.C.), and executive medical director of Palmetto Health Quality Collaborative (PHQC), has been in his integrator role for a year now. He is an internist by training, and 10 years ago transitioned to the administrative side of medicine, after getting a business degree. He’s worked in a variety of roles: vice president of medical affairs at Palmetto Health Richland, senior vice president of ambulatory services for the health system, and now the head of the PHQC.
Knight’s clinical integration responsibilities fall into several buckets, which include overseeing the affiliation of the 1,100-member hospital medical staff; creating mechanisms for physician alignment; facilitating the creation of an accountable care organization (ACO); and negotiating for group contracting with payers.
It’s very important that each step along the way that we facilitate integration and wire and connect these physicians together, both with each other and with the hospital system,” says Knight. “Part of our strategy with the employed physician network is that we have everyone up on the same EHR.”
The health system currently has an inpatient EHR provided by the Kansas City, Mo.-based Cerner, and is currently implementing Cerner on the ambulatory side to provide connectivity. Through the PHQC, Palmetto Health’s physician-led, patient centered, independent medical ACO, a discounted Cerner EHR will be offered to non-employed physicians. Knight says that the ACO will be focusing on effectively managing certain populations like its own employee population of more than 10,000 and patients within its own zip code, which has one of the highest percentages of diabetic amputations in the country.
At Baptist Health System in Birmingham, Al., Scott Fenn is the first person in the chief integration officer role (he also holds the title of vice president), and he is responsible for inpatient and ambulatory clinical strategies and for creating the Baptist Physician Alliance Organization, which is a clinically integrated network of 400 affiliated physicians that will provide the opportunity to share data across many Baptist Health ambulatory clinics located throughout north and central Alabama, four hospitals, and aligned post-acute providers.
“[We’re] really working on collaboration with our doctors through our IT infrastructure committee, which includes the key hospital IT leadership [who envision] how the data should flow, what that looks like with the master patient index, so we can effectively know and manage those we’re going to be covering in the future,” says Fenn.
Fenn previously worked at Memorial Hermann Healthcare System in Houston, Texas for 17 years, serving in numerous leadership positions in hospital operations, physician practice management, and managed care contracting.
Currently, Fenn is working on many projects: creating order sets for Baptist Health’s system-wide inpatient EHR (Epic; Verona, Wis.), creating a master patient index, implementing ACO infrastructure, and implementing a business intelligence platform (from the Waltham, Mass. -based MedVentive) that will produce physician scorecards to show performance based on quality measures.
“We’re building the patient-centered medical home network with both our employed and aligned doctors,” says Fenn. “So there are 78 physicians in over 40 practices that are working to achieve the NCQA [National Committee for Quality Assurance] patient-centered medical home status by 2013, so we will have geographic points of access for all of those patients that we are going to be held responsible for in the future, whether that be for readmissions, or chronic condition management, or ACO.”
Reporting Structure and Staff
In many cases the chief of integration reports to the health system CEO, says Berra, like Fenn does at Baptist Health. Knight, on the other hand, reports to Palmetto Health’s CMO, who reports to the CEO. As executive director of PQHC, he also reports to the board, which reports to the system board of Palmetto Health.
Berra says that many times this role is staffed with a “skeleton crew” of a few direct reports, and many dotted line or indirect reports, which requires the chief integration officer to have good persuasion skills to address concerns on various organizational levels.
“[One of my] goals would be to further develop the culture of these organizations,” says Knight. “I’ve always said you can talk about economic integration, you can talk about clinical integration, but cultural integration trumps all of those things. Like minded physicians develop in a culture that fosters behaviors and vision that we’re looking at together, otherwise we’re not going to be successful. It’s a big change for a lot of physicians.”
Knight has three direct reports that include the vice president of clinical integration, the vice president business operations, and the vice president of clinical affairs for the employed physician network.
Fenn agrees that the integration officer must earn and build trust within the organization to align various physician groups across the healthcare system. “Our employed doctors should be our largest supporters when it came to why the independent medical staff would want to work collaboratively with the hospital system team,” he says. “If the employed doctors weren’t able to effectively communicate that they thought it was a good idea, then no one else in the medical staff would do it. We spent a good year and a half repositioning and refortifying the relationship with our employed doctors before we started in on the alliance.”
Fenn has 10 direct reports that include the CMO, CIO, the president of medical group, and leaders in managed care contracting, graduate medical education, outpatient services, and quality/case management.
Berra says that in interviews she did with about 30 executives with integration-related job titles, many had a relatively long tenure at the organization, worked on both the provider and the payer side of healthcare, had clinical credentials (oftentimes as a nurse leader), and had experience with care management and clinical IT roll-outs.
“You’re definitely looking for someone who has a lot of experience working on administrative teams and administrative initiatives,” says Berra. “There are a lot of nursing positions that have a significant administrative and leadership component to them, so potentially that is why this person is getting pulled. I think it depends on the organization and where this position is living.”
The person in the chief integration role must understand the clinical and business side of healthcare, and Fenn believes that a physician with an MBA would be a good fit. “Some experience in working closely with physicians and organizing the delivery systems of care that achieve real clinical results, but in a way that’s collaborative with the hospital and physician staff,” says Fenn. “I spend a lot of time building consensus with hospital teams and physician teams, and helping lead them to come up with the right answer.”
Knight agrees that the position requires solid clinical background, but is not sure a formal business degree is needed, but rather an understanding of the economics of healthcare and a strong management skill set to get physicians “to march in the same direction”.
Financial and Culture Challenges
Executives with direct responsibility for transitioning health systems into a risk-based world face some significant challenges, notes Berra. She adds that these leaders are faced with an overwhelming number of projects to complete in a short time frame, and therefore, have to prioritize. “The setting up of this care management platform so that it does the basics of care management, which would [create] some sort of risk segmentation capability and ability to reach out proactively to higher-risk patients and get them into care coordination [programs],” she adds.
Additionally, Berra says that because the chief integration officer and its team is so new, budgetary input, or even having a dedicated budget, is not always clear. Fenn agrees saying that most health systems in the country don’t have the financial wherewithal to pay for the tremendous cost of clinical alignment that necessitates EHRs, health information exchange technology, patient kiosks, and more.
“It’s going to take some ingenuity in the way we construct these contracts with payers and employers that they step up and pay for the infrastructure that could save healthcare dollars and provide a better healthcare product for the patient,” adds Fenn.
Knight says his biggest challenge is to help create that cultural shift for providers in today’s mixed reimbursement environment. “Hospitals and physicians are both providers of healthcare, and I don’t think we need to be in an antagonistic relationship,” says Knight. “I think we should work together, and it will not only help quality of care, but bring down some of the costs [as well].”