A year into his tenure as president and CEO of Nemours Children’s Health System, Dr. Larry Moss wants to position the Jacksonville, Fla.-based system as being at the forefront of the shift to value-based care. But that can’t happen until providers, payers and policymakers adopt a broader definition of health and fully rethink reimbursement, he said. Moss joined Nemours in October 2018 after serving seven years as surgeon-in-chief at Nationwide Children’s Hospital in Columbus, Ohio. Nemours, which operates in five states, has more than 1.7 million patient encounters annually. Moss recently met with Modern Healthcare’s editorial board. The following is an edited transcript.
MH: You’ve talked a lot about accelerating the growth of risk-based contracting and incorporating social determinants. How are you doing that?
Moss: It all starts with the definition of health. What Nemours is doing is a more comprehensive, holistic and expanded vision of what health actually means. There’s tons of data saying that health is about 15% medical care and about 85% everything else, which is education and literacy and safety and freedom from poverty and avoidance of adverse childhood experiences.
We can’t envision creating a healthy generation of children by focusing on only the 15%. We’ll always do that and we’ll do it at a high level, but our move with an expanded definition of health begs the question of how we get paid.
As a country, we’re spending $3.5 trillion for the opposite of what we want, which is health. We pay for volume and we pay for complexity. In my 25 years as a surgeon, it bothered me every day that our financial incentives are the opposite of what our families and our patients need. We want to be the system that leads the transformation in kids where all the incentives are aligned.
MH: Can you give us an example of how Nemours has been able to shift accountability back onto the organization?
Moss: Nemours was fortunate in 2012 to get a $3.7 million grant from the Center for Medicare and Medicaid Innovation to do some work around asthma. The vision was to not look at asthma based on the subset of patients who show up in the emergency department or show up in the hospital. We wanted a broad, population-based approach.
We used the support to develop a two-pronged approach called integrators and navigators. Navigators involved everything around the patient—community health workers and care coordinators, people who would go out into the home and see what the triggers were. The integrators were more about the environment and the population—what’s going on in the school, what do smoking ordinances look like, what is the community environment? Is that community your friend or your obstacle in the disease process?
At the patient level, after three years, we had reduced the population-based incidents of ED visits for asthma in pediatrics by 60%. That’s not just the patients that were in our system, that’s the whole population of interest that we were looking at, which is pretty profound. Hospital admissions dropped by 44%. Also very significant.
One of the integrators made the observation that the only inhaler on the state Medicaid formulary, this was in Delaware, was one without an indicator of when the inhaler was empty. Tons of kids were ending up in the ED because the parents thought they were doing the right thing and administering the dose, but there was no indicator that the canister was empty. As a result of this program, the state changed its formulary and countless kids were saved from visiting the hospital.
Another interesting example is, it turned out that all the school buses, when they would wait for the kids outside of school, had their engines running. A little bit of digging and research work (showed that) bus exhaust fumes in high concentration were a massive asthma trigger. The school district changed its policy and the drivers had to wait with the ignition turned off.
We learned that partnerships are key. We’re not the experts in how to deliver (social services). We also learned that the irony of this is the better it works, the worse for the health system financially in our current model. Because right now, we make our money by having the intensive-care unit full of kids with asthma and the ED full of kids with asthma, which is the opposite of what we want.
MH: You want to be capitated?
Moss: We want to be capitated.
MH: Are you prepared to provide the full range of care in a capitated model?
Moss: Our vision is to be able to do that.
We’ve created a value-based service organization. It’s about three things: people, processes, data. And with respect to people, we’ve brought all the relevant stakeholders in our organization under one roof to try to align their viewpoint on delivering care—primary-care doctors, nurses, finance, the billing office, care coordinators. If you put those people in the same room with the same incentives under the same roof, culture starts to change.
With respect to processes, the most fundamental shift for a doctor or a nurse or a practice is what do the words “your patient” mean? If your patients are the ones on your clinic schedule or the ones that come into your hospital, or the ones that are in your unit, that’s not what we’re talking about.
That viewpoint of, “I am responsible for the health of a population of kids,” as opposed to, “I’m responsible for who shows up in my hospital and my office,” is a real fundamental shift and it gets you out of bed doing things very differently.
MH: How do you envision partnering with organizations outside of healthcare? Are you splitting the risk and reward with them?
Moss: We’re starting to have conversations with government. We’re a little farther along in Delaware than we are in Florida.
Why should a social services agency care about keeping people out of the hospital? They’ve got their own problems to worry about. Why should the people spending the medical dollars care about meeting social needs that’ll ultimately make a healthier population? That’s the conversation we’re starting to have with states. Maybe we can take Medicaid dollars or dollars allocated for medical care, pair that with dollars allocated for social services, put them all together in one bucket and say, “Those dollars are for health, let’s spend them appropriately.”
