Chief medical officers roundtable: Addressing the entire continuum of care

The move to value-based care is transforming the role of the chief medical officer.

Long gone are the days when a CMO focused solely on inpatient care.

Now, CMOs are being called on by their colleagues in the C-suite to brainstorm new ways to care for patients beyond the hospital walls to prevent pricey readmissions.

CMOs are also amping up efforts to encourage doctors to factor in costs and use quality data to achieve better outcomes.

Modern Healthcare reporter Maria Castellucci recently conducted a roundtable conversation with Dr. Robert Jansen, chief medical officer of Grady Health System in Atlanta; Dr. Todd Shuman, chief physician officer of Roper St. Francis in Charleston, S.C.; and Dr. Patrice Weiss, chief medical officer of Carilion Clinic in Roanoke, Va., to discuss the evolution of their roles and the challenges they face. The following is an edited transcript.

Modern​ Healthcare:​ How​ is​ the​ shift​ to​ value-based​ care​ transforming​ your​ role​ as​ chief​ medical​ officer?

Dr.​ Todd​ Shuman:​ The traditional role of the CMO is not the role most people play now. The traditional role of the CMO was totally hospital-based. A lot of the focus now is of course how you handle patients outside the hospital. There's much more of a focus on the outpatient settings. That's a good portion of what's driving strategy for most healthcare systems. But most systems can't own the entire compendium of services offered to patients, so the question is: How do you begin to partner with people outside in order to develop care coordination across the entire continuum for patients? It's a totally different focus on what people need to do in order to achieve value-based care.

Dr.​ Robert​ Jansen: We are the large safety net hospital in Atlanta, and given our population and the mission that we serve, value-based care takes on an entirely different connotation for us. Part of it starts with how you define it in an environment where revenue is scarce, since a large percentage of our population is uninsured or insured by either Medicare and primarily Medicaid. We are trying to get our faculties—and we have two medical schools that serve as our medical staff—to first of all begin to understand what the relationship between quality and cost really is. That has continued to be part of our discussion because the cost side of the equation has never been particularly highlighted.

Shuman: I agree. Ten years ago, I was concentrating on our mortality rates after coronary bypass surgery or something that's really facility-based. Now the majority of my time is spent on how I can take care of patients who are utilizing the emergency department at a high level and should be utilizing other facilities, or I need to figure out their social aspects to make sure they have the support they need to not use the ED. It's a community- and continuum-based focus, compared with just a hospital-based focus.

Dr.​ Patrice​ Weiss: There's a true recognition across our organization that to reduce redundancy and waste, you absolutely need to have physician engagement and buy-in, and one of the best ways to get that is to have the physicians at the table where the decisions are being made. We pride ourselves on being a physician-led organization. In addition to that, we have a dyad leadership role where we have a physician leader and an administrative vice president. Most of our administrative VPs have clinical backgrounds. Many have been nurses, pharmacists or respiratory therapists, so they do have a solid background in clinical care. We really do charge the physician-administrative dyad with the care that we deliver, our clinical operations, our clinical initiatives, and also the responsibility of engaging others.

MH:​ So​ how​ do​ you​ engage​ with​ physicians​ to​ talk​ about​ cost​ and​ quality?

Jansen: We confront two different areas in that discussion. One is the utilization of resources with patient flow, length-of-stay discussions, because a large component of our cost really centers around finding accessible places for people to be discharged and also safe environments for follow-up. We have an entire focus now on trying to identify resources in the community so we can safely discharge patients and know that they will get services they need. We're also trying to reduce the length of stay for those patients who are just very difficult to find placements for. That's driven primarily by the behavioral health and homeless populations. The second aspect that we have finally started addressing is the acquisition cost of supplies. We have put together a physician-run value-based purchasing committee to look at bringing in new resources, new supplies, new requests, and adding the cost component to the discussion as opposed to it always be centered purely on clinical utilization. Those discussions are beginning now, because the acquisition cost of drugs and equipment has become very important to the system and, therefore, the physicians. It's a little different slant on value-based care, but it is particularly targeting that cost component of the equation.

Shuman: As Dr. Jansen said, first you have to get physicians to believe that you can achieve higher-quality care at lower cost, and there's no doubt that is true and it's been proven multiple times. I think our medical staff certainly believes that. Once you achieve that, then what we've tried to do is have absolute transparency marry with quality outcomes. So, for instance, right now we have an ability for the surgeons at the end of the case to know exactly how much they spent during that case. They get it sent to their phone, and so when they walk out of the operating room—not right out of the operating room but at least by the next morning—they know exactly how much they have spent. And on a department level, we're totally transparent about that. This doctor spends this much to do a gallbladder operation. Because of that transparency and doctors being able to come together and talk about it, we've been able to drive down the cost. On the outpatient side, like we've talked about, primary-care doctors are usually farther along the curve and thus figuring out costly care because they know hospitalizations, ED visits and so forth are costly, so they engage very quickly. Again, if you can produce that data, they respond, and that's what we give them: percentage of ED utilization for their patient population and percentage of hospitalization for their patient population.

Weiss: We have reduced our cost of OR devices without sacrificing quality, and we've done it by decreasing redundancy, so instead of having five different devices, we've had the physician leaders come together and decide that we're going to have three devices, and we're going to agree upon those three. By doing that, the OR staff is much more comfortable knowing three devices rather than five. I wish it was just as simple as five because it was actually more than that. It's important to say that our physicians led that charge. They came to us and said, "We want to decrease the redundancy. We want to decrease having eight of something."

MH:​ Is​ it​ easy​ to​ engage​ physicians​ in​ this​ way​ and​ get​ their​ buy-in?​ Are​ they​ motivated​ on​ their​ own​ to​ look​ for​ improvements?​

Weiss: I wouldn't say it is easy, but I think when you speak with providers about patient-centered care and the best outcomes for patients, that theme is the most successful one in having physicians buy in and become engaged. I don't think it would as effective if the approach is to just say, "Well, we're going to do this because it will save dollars." While that is very, very important, we all went into medicine because we want to help patients, and we want to have the best outcomes.

Shuman: You can't just show cost data. You've got to show quality data; you've got to build a case for what you're trying to do. Intellectually, I think physicians understand that high-quality care is less expensive, so again, if the patient isn't readmitted to the hospital, it's less expensive. If the patient doesn't get an infection, it's less expensive. If the patient is not hospitalized the first time, it's less expensive. You need to be able to show that the higher-quality care is related to cost, and you need to engage them with transparent data. Physicians go through sort of the stages of grief. You show them the data initially, and they don't believe it. It's got to be wrong. You're penalizing me. Our approach has been that we're just trying to make everybody better, and we're trying to have better outcomes for the patient. If you take that approach and are transparent about the data, people respond to that.

MH:​ How​ are​ you​ addressing​ physician​ burnout?

Weiss: We've actually changed the way we talk about the Triple Aim; we talk about the Quadruple Aim and recognize that the health and well-being of all of our providers is an additional very important aim. We've had several conferences, meetings, discussions about burnout with the physician leadership throughout the organization. We did an internal survey, which pretty much confirmed the national findings. Over 50% of our physicians and nurses test positive for burnout. We've tried to put things into place to help with that. We have a mindfulness study, and we've talked openly about what folks think is contributing to burnout. Part of the work that's now required in healthcare has taken people away from what has brought them into healthcare, which is that direct patient care, the bedside care. People will tell you, "I feel like I spend more time on electronic health records, more time on administrative duties than I do on my clinical duties." We have a Fourth Aim Committee to tap into our front-line doc concerns, prioritize them and recommend solutions. We have a long way to go, but at least we're actively talking about it.

Jansen: Burnout has little to do with that physician-to-patient or nurse-to-patient interaction. It's all the noise around you and all the requirements, the EHR, or, in our environment, dealing with the socio-economic challenges of the patients. That's what causes our folks to have difficulty. We've done focus groups for physicians and nurses. We have a rapid-response team to deal with catastrophic events. If you have bad outcomes or deaths, we meet with the nursing staff and the physician staff to help them deal with their loss because those events take a toll on the provider as well as the family. We've started a well-being committee. I like your phrase, the Fourth Aim Committee. I may have to go back and try to rebrand it.

Weiss: You can have it. We recognize that providers can be very much affected when there's an unanticipated outcome or a medical error. We put together a trust team, which is made up of peers, and it's a rapid response for emotional support when there is a medical error or an untoward outcome. Further, we know that physicians who are burned out are potentially more likely to have a medical error, so we're also incorporating the work of the trust team and calling out and again recognizing the whole second victim concept.

MH:​ The​ Medicare​ Access​ and​ CHIP​ Reauthorization​ Act​ is​ dramatically​ going​ to​ change​ physician​ reimbursement.​ How​ are​ you​ talking​ with​ physicians​ about​ that?​

Weiss: Honestly, we are spending less of our time talking about MACRA and more about talking about value. We feel that if we're just speaking narrowly about any particular payment program, ultimately that can be very confusing and less effective. But what we're really trying to talk about are our strategies and principles that drive value. We don't know what healthcare is going to look like five years from now. MACRA may not be around five years from now, but value is here to stay.

Jansen: We are still trying to figure out if after the current administration gets through, if MACRA will still be around. That's a political statement, but there is some validity to that. We participate in a Medicare Shared Savings Program. We're able to meet most of the MACRA requirements at the present time based on the activities that were already engaged. But I agree, we don't really sit down and talk about MACRA. We talk about how to deliver good care, and if we're able to do that and meet the needs of the patients, I think we're going to be fine with regard to the requirements under MACRA.