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Planning for the Future

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LOUISVILLE On September 13, Norton Healthcare broke ground on a new 100,000 sf tower to convert the old Suburban Hospital into a comprehensive women’s and children’s services center for the St. Matthews area. MD UPDATE digital publisher Megan C. Smith sat down with Norton’s Kenneth C. Wilson, MD, system vice president of clinical effectiveness and quality, to discuss how the new hospital fits into the organization’s accountable care model. This is Part One of a two-part series on the overlapping trends of healthcare reform and the expansion of hospital-based services into suburban populations.

Megan C. Smith: I wanted to start by asking you about your job title – a real sign of the times. What does “clinical effectiveness and quality” leadership mean to Norton Healthcare physicians and administration?

Dr. Kenneth C. Wilson: You will see the term “clinical effectiveness” around with a number of healthcare organizations. The concept is that as we move from our current reality into a more value-based future, providers will have to be accountable not only for the quality and safety of care, as they always have been, but also accountable for the economic side of healthcare. The broader value equation will be increasingly important, so the purpose of clinical effectiveness is to assess whether we are providing good outcomes in the context of reasonable, sustainable cost.

How does your prior experience in clinical practice influence your work as a physician leader today?

My training and 20 years’ experience as a primary care physician inform the work that I do every day. When I made the transition to this kind of work about 15 years ago, it occurred to me that as a practicing physician there is no question whether you impact the lives of your patients. But, you do that one patient at a time such that at the end of the day, or the end of the week, the month, or the year, you have touched a finite number of individuals in terms of their healthcare and their quality of life.

In the role as a physician executive, a physician manager, a physician leader, we are working to develop processes and systems of care for entire populations. While I’m not the one on the sharp end of care, the work that I and my colleagues in leadership do impacts many more people, multiply your impact through the work. I feel strongly, as do the other leaders and our organization, that physicians are crucial in moving all healthcare organizations to a place that will allow us to be more effective in the future.

Physicians spend at least the early parts of their lives training and learning to do their craft, and they invest lots of time and energy. What I did as a physician gives me perspective on what we do as provider organizations and helps to inform my perspective on what we’re trying to accomplish.

How is your work tied into the development of Norton’s new ACO model of care?

Broadly, my role with the ACO is to work with Dr. Steven T. Hester, our chief medical officer, around the Brookings-Dartmouth Accountable Care Pilot Sites program, in which we are partnering with Humana. We were in the original group of three, expanded over the first year into five organizations, partnering with the Brookings-Dartmouth folks to study strategies in the development of commercial ACOs. Now certainly there are lots of healthcare organizations that are working in the ACO space, if you will, through the Pioneer ACO in the Center for Medicare and Medicaid Innovation, to the Medicare Shared Savings Program at the Innovation Center as well. Premier has a large collaborative. That the Accountable Care Act actually contains the language “accountable care organization” probably has a fair amount to do with that.

There is a saying out there that if you’ve seen one ACO then you’ve seen one ACO. As I talk to folks around the country, I discover there are lots of different ways people are designing their accountable care organizations with varying parts, principals, and partners. We at Norton Healthcare come to see that accountable care is less about organizational design – though there are components of organizational design that really promote and help provide accountable care – and more about accountable care being more of an idea or a concept that you bring to the provision of healthcare.

Let’s discuss Norton’s new Women’s and Children’s Hospital, not in a brick-and-mortar sense, but rather on the topic of specialized or comprehensive service lines and their role in the ACO. What does it mean to Norton to have this new Women’s and Children’s Hospital going forward into accountable care?

What our organization is creating is not only the bricks and mortar, but the infrastructure, the “systems of care” of the organization. At the core of our Women’s and Children’s Hospital program are two concepts: a system of care approach and a team-based approach, which are very sympathetic with accountable care models.

A lot of the conversation in the healthcare reform world is around how we are organized. There have been hospitals and physicians who until the last five years or so were for the most part independent business people. Entrepreneurs who worked in a fee-for-service system.

One of the problem areas is how the interests of physicians and interests of hospitals are not always closely aligned. In our market, a preferred and predominant mode of physician alignment is employment, so the Women’s and Children’s Hospital is employing specialty physicians central to the care of women and children in our area.

A couple of early examples are from our Norton Neuroscience Institute. We’ve been able to create a real critical mass of neuroscience specialists: a neurologist, neurosurgeons, and other specialists. We’ve been able to create a Headache and Migraine Program whereas this level of expertise in our area was previously unavailable – the closest place for people who struggled with chronic headaches with Chicago, to the Diamond Headache Clinic.

Another example is eating disorders. While eating disorders do affect men, it is predominantly a female issue. So, again, folks who needed really intensive support and care had to travel outside the area. If I’m looking at it, if I’m running an ACO and I have to be accountable for the total cost of care for the population, having to send people out to Philadelphia for eating disorders or Chicago for migraines would increase the cost for that population. Because of the creation of the Women’s Program, we have been able to bring and strong services to women.

The other big thing about this program is early intervention. If you look at any population of people, a relatively small percentage of that population, say 5%, are responsible for an inordinate amount of the cost of healthcare. These are people typically with multiple, chronic medical problems that are fairly well along the path of disease progression. One of the things about American healthcare is that we haven’t generally placed a lot of emphasis on wellness and prevention in the fee-for-service system.

One of the key strategies of the Women’s and Children’s Hospital’s programs is care centered around early intervention. Specifically, early diagnosis and intervention to bone health issues such as osteoporosis, osteopenia, things like that, so as to prevent more costly and more quality of life impacting problems like pathologic fractures, orthopedic issues, and so on.

Another example is a strong urogynecology program. Childbearing puts a lot of women in a situation where they develop bladder problems, so an ability to diagnose bladder problems early provides an opportunity for intervention that is less invasive, improves quality of life, and greatly impacts the total cost of care for the population. So, clearly, I think that the women’s care agenda through these types of examples is very compatible with the big picture of accountable care.

One the pediatric side, Norton has had Kentucky’s only freestanding pediatric hospital, Kosiar Children’s Hospital, for a long time. Our pediatric physician alignment is with the Department of Pediatrics at the University of Louisville, although with a few exceptions they are not employed. Still, the pediatric story is much the same.

We know that, for example, if you look at imaging for children, there is evidence in the literature that suggests that non-pediatric systems of care would probably create more frequent issues with radiation exposure for kids. Our associated physicians create diagnostic imaging protocols for children that go a long way to reducing the radiation exposure and the risk of cancer due to pediatric imaging. Branching out from our downtown location at the Kosair Children’s Hospital to the Women’s and Children’s Hospital in suburban Louisville provides us an opportunity to expand specialty pediatric services for folks who may not have had access to that level of comprehensive specialty care previously.

“If I’m looking at it, if I’m running an ACO and I have to be accountable for the total cost of care for the population, having to send people out to Philadelphia for eating disorders or Chicago for migraines would increase the cost for that population. Because of the creation of the Women’s Program, we have been able to bring and strong services to women.”