This content is sponsored by Optum.
Readmissions, quality reporting, population health — hospital and health system CMOs have more on their plate than ever. Here, five CMOs share their thoughts on the biggest challenges facing the modern CMO, and advice for 2014 and beyond.
[Responses have been edited for length and clarity.]
Question: What is the biggest challenge facing you right now? Do you think it's the same challenge that is facing most CMOs around the country?
H. David Arredondo, MD, CMO of Presbyterian Delivery System and Executive Medical Director of Presbyterian Medical Group (Presbyterian Healthcare Services, Albuquerque, N.M.): Our biggest challenge is how to most rapidly and effectively implement the ever-increasing volume of evidence-based practices and guidelines, and to do this in a way that does not overwhelm our physicians, providers and nurses. We need to make this easy for our clinicians, and we need to be able to track compliance. We will be challenged to sustain improvements and determine what care processes must be "highly reliable" and achieve 100-percent compliance every time.
Usamah Mossallam, MD, Associate CMO of Henry Ford Health System (Detroit): It’s figuring out how to best place ourselves in an age of unknowns in healthcare. For us in particular, it’s reimbursement challenges and changes. Everybody is interested in paying less for healthcare. We struggle with large numbers of under- and uninsured patients, and we wonder, as the [Patient Protection and Affordable Care Act] takes effect, what that will do to those numbers… There’ll be an increase in Medicaid patients, but Medicaid isn’t a great payer and doesn’t cover our expenses, so we’ll continue to have reimbursements less than our costs.
Jeremy Orr, MD. CMO at Humedica: One of the biggest is having a thorough understanding of the population. Many hospitals have grown by acquisition so they have disparate pieces — hospitals, clinics — that are on different IT systems and have different ways of billing, clinical operations. That means they have islands of data and can’t see across to get a sense of the population that moves between. This is the greatest challenge for them as they move into risk-based contracts. To make good, executive decisions they need access to this information, and right now they don’t have it.
M. Michael Shabot, MD, CMO of Memorial Hermann Health System (Houston): The greatest challenge is the conversation of our practice, both the inpatient and ambulatory sides, from volume to value, moving our goal from the number of procedures and tests we can do to doing what we can to improve the health and healthcare of the patients we serve. It’s a very different focus. We have spent a lot of time and energy here at Memorial Hermann in reflection about this volume-to-value transition and how to optimize the value of the healthcare our patients receive.
I think it’s more of a cultural challenge, and not a technical challenge. Sometimes, the technical challenges are easier — setting up patient-centered medical homes, providing our ambulatory practices with electronic monitoring for high-risk patients at home. Those are specific things we can do, but changing the culture of the organization is more challenging.
Anthony Slonim, MD, CMO at Barnabas Health (West Orange, N.J.): The biggest challenge is trying to figure out how to integrate our organization with our physician colleagues while we attempt to understand the numerous relationships that can be formed in the process including employment, integration, joint ventures or simply IT integration. This is especially important as we transition from volume to value-based healthcare. We have to be thinking more about how we work with our physicians to manage large populations of patients, reduce the clinical variation in care and the cost structure if we will be successful. No one quite has the skill set for that yet; but, one thing that is for sure is that we cannot do it without our physician partners.
Q: What are the toughest clinical areas to maintain in terms of quality, and why?
Dr. Arredondo: We have found that some of the surgical and medical specialties are challenging with respect to tracking quality. Since evidence-based guidelines are less well-developed for these specialties than they are for primary care, in many situations it can be difficult to determine how to measure quality. Though we can readily track complications and other parameters, it is not easy to know when care is suboptimal. More standardization of care in the procedural areas is our best bet to learn how to track quality and then to improve it.
Dr. Mossallam: I don’t know if there’s one that’s tougher than the others. Obviously, the emergency department has always been a tough area to maintain because of the rapid turnover of patients and the unknowns with which the patients present. The ability to manage surges and provide the highest quality care when you’re being squeezed in several areas is important.as we are all running lean operations, we might not have the excess to handle increases in volume readily [in the ED] — that’s always been one of the challenges in maintaining quality. The [Patient Protection and Affordable Care Act], based on the lessons learned from Massachusetts, will likely result in an increased number os patients seeking care in our ED as well as requiring inpatient care.
Dr. Orr: The Achilles’ heel is patient behavior. We have a fair amount of control over how the hospital or system is organized and we can incentivize doctors. But if the patient doesn’t go along or adhere to recommendations and treatments it will all fail. We have guidelines on diabetes and hospital acquired infections, but we don’t know how to get patients to change their behavior.
The other is herding the doctors. They’re like cats; the only way is by using a lot of tuna. The tuna is the incentive for the doctors. Transparency is also an important piece of the puzzle. When you publish doctors’ data side by side, they’re professional and will respond accordingly.
Dr. Shabot: Anything in which the emphasis is on patient-centered care is in conflict with traditional care. Those can be very difficult to change. We’ve seen some of these challenges, and we’re doing well, but they’re not easy. All of us on the CMO side, we love technical challenges, where we can just program something differently. Those are the easy changes — the difficult ones are the ones that cut across culture. But as CMOs, that’s our job, to change culture.
Dr. Slonim: The biggest challenge at the moment is in the ambulatory environment. Up to this point, we have had large volumes of data to assist us in improving inpatient care, but we have not had the data available to understand the ambulatory environment. Now, through our accountable care organization, we are finally tapping into data about physician performance in the outpatient arena. With that comes a realization of all of the improvement opportunities that exist in ambulatory healthcare to fulfill the triple aim.
Q: What are your thoughts on the current federal quality reporting requirements and reimbursement reductions for readmissions? How has your job changed in the past few years because of these changes?
Dr. Arredondo: The quality reporting requirements are a fact of life, and we cannot escape them. As an integrated system with hospitals, a medical group, a health plan, homecare, etc., the sheer volume of required measures to report upon is daunting — more than 200 — and the resources required to develop the capacity to report these and improve upon them is costly. Our organization has devoted significant resources to understanding these requirements and has committed to succeeding with these measures. We find ourselves spending much more time understanding and prioritizing the requirements. We then have to engage our providers and support staff in executing on processes that have been designed to meet requirements.
Dr. Mossallam: The federal quality reporting requirements and initiatives are well-intentioned. Obviously, a lot of work goes into compiling the data and the metrics and that changes some of our processes, but it’s often change for the better. As painful as they are, they have led to process improvements for us and others [hospitals].
As for the readmission issue, it’s been something we’ve been working on for the past couple of years. Here in Detroit, it’s a socioeconomically depressed area, and a lot of what prevents readmissions isn’t about healthcare. It’s about ensuring patients get home safely, that they have transportation to their follow-up appointments and are able to keep them. It is about ensuring that they do not have to choose between spending money on medications versus food and shelter. It's made us rethink the ‘episode of care’ — it doesn’t end at discharge, but at the safe handoff of the patient to the next care team. We can argue about whether or not that’s fair on us, but it has shifted our focus and caused us to engage more with our community partners.
Dr. Orr: There are benefits from this, and that’s standardization of what is important. We’re behind other industries because we saw medicine as special. Doctors had judgment and didn’t need standards. It’s a welcome change to hold doctors to standards like in other industries and have them prove the work they do. However, this policy lags behind technology by 10 to 15 years. We can tell how well doctors perform from EHR data but the current requirements are based on claims data. These reporting requirements need to catch up to technology so we’re measuring things that matter.
Dr. Shabot: I’m in favor of quality reporting requirements. Any CMO will tell you there are some requirements that are not well-thought out and complying with those does not ensure the best care for the patient. An example is a finally retired core measure that required community acquired pneumonia patients to receive antibiotics within four hours of arriving in the ED. For patients with pneumonia, that’s a good thing. The problem was that we were doing diagnostic testing and getting X-rays and lab work back, and completing that within four hours was challenging, especially with other emergency patients arriving in the ED at the same time. The net effect was that many patients who ultimately didn’t need antibiotics were getting them anyway, forced by compliance with that measure. The reporting measures, along with transparency about them, are important.
I also think the reimbursement reduction for excess readmissions is fair; other CMOs might disagree. At Memorial Hermann, we’re different from most hospitals and systems in that we started a campaign to reduce readmissions eight to nine years ago, long before it became a national quality measure. We identify patients at high risk for readmission and have case manager assigned to make a timely follow-up physician appointment, and follow up with them at home to make sure they are taking their meds and doing well.. To do this well you need to have started long before readmission reduction became a requirement.
Dr. Slonim: Anytime we’re faced with new reporting requirements, it focuses a large segment of our industry on specific bodies of work. Unfortunately, the number of new regulatory requirements becomes burdensome if not organized effectively. In addition, there is an opportunity cost that accompanies new mandates. More measures means less time in the day to manage other important elements of patient care that are operative in our hospitals. I believe that there needs to be a balance between the things we have to do in quality improvement and the things we know we need to do to help our hospitals provide better care.
Q: What is the best decision you've made as CMO in the past year? The worst?
Dr. Arredondo: The best was the a decision to retain and continue support of a surgical specialty program that had been a collaboration between an independent physician group and PHS. This program had been in place for many years and, though the long-term financial implications were not entirely clear due to the complexities involved, we committed the resources to retain the program. This entailed some difficult negotiations and a willingness to commit, but in the end, the value to the community will be worth the work.
The worst was the decision (or lack thereof) not to move more forcefully and expeditiously with the scenario described above. Fortunately, this will play out well and we will preserve the program.
Dr. Mossallam: Fourteen months ago we created an internal physician advisory service here to perform secondary physician reviews for appropriate patient status [to better ensure that the patient is either an inpatient or outpatient (observation)]. We’re significantly ahead of the pack on this. We’ve also refocused on resource utilization, which has been helpful.
When we had to start rethinking readmission resources, there were a few problems when we directed resources not to where the problem was and had to redirect our efforts. It really is about engaging the right people to do the right work, the people who have the skill set you need.
Dr. Orr: All CMOs should take stock of the information they have available. They should make a list of all the data sources they have, clinical data, claims data, health risk assessments, etc., and start getting feeds from them either manually or automatically. Then the information can be used to make decisions. Sometimes it’s also a matter of getting the right people from different silos come in and meet once per week and make sure everyone is on the same foot. Then, once CMOs have the information they need to go out and communicate and make sure the organization is all on the same page.
Dr. Shabot: The best decisions we made were to set a goal of becoming a high reliability health system and to consolidate many different hospital-based quality, safety and infection control departments into a single systemwide department with a single management structure.. When we have initiatives for new measures we do them as a system and we develop the processes as a system. If there’s new technology or something new for the EHR, we implement it across the whole system.
Dr. Slonim: The best decision we made was to make assure that we were engaging clinicians in the conversation about healthcare reform.. By allowing the clinical voices to be heard, we are better able to identify alternative solution sets that advanced our redesign efforts . I think that the worst decision had more to do with the timing than the decision. I think we should have moved faster on some initiatives to achieve the full benefit of the intervention. Healthcare is moving very quickly, when you’re thinking about doing something, keep your priorities in mind and be aware of when it needs to be executed.
Q: What advice do you have for other CMOs for 2014 and beyond?
Dr. Arredondo: As leaders, we often underestimate the importance of communication and transparency when we face challenging issues. Important and difficult issues will have to be explained many times. Those whom we lead do not expect us to be perfect, and they understand that leaders are fallible because they are human beings. Don’t be afraid to admit errors or misjudgments, the trust and respect that you will earn for this painful admission will serve you in the long run.
Dr. Mossallam: I think you have to really look at utilization practices. With regulatory issues like the readmission reductions and the two-midnight rule, ensuring the best and most timely utilization practices would be key for any administrator. Engaging the physicians is also key. Moving to a team based approach is necessary to stay ahead of the curve.
Dr. Orr: You need a uniformed approach. It’s sometimes tempting to say OK to making a contract for 50,000 lives in an ACO and then deciding to throw quality programs in, add some of the top doctors and see what happens. That’s a mistake because it does nothing to prepare the rest of the organization and confuses the doctors. It comes down to treating all patients fairly and consistently, regardless of payer status. You need that consistency across the whole organization.
Dr. Shabot: Our healthcare system would be markedly improved if patient safety was the core value of all healthcare decisions. Memorial Hermann’s board has set safety as the organization’s core value. If we’re starting a new program, then doing it safely and at the right hospitals is what we do. If we can’t do it safely, we don’t do it. Memorial Hermann has won many national and state awards for quality and safety and has grown hand over foot all while complications and their associated costs have gone down. If we focus on quality and safety the finances and growth will follow.
Dr. Slonim: I think being a physician leader requires education, skills and experiences that are not taught in medical school. You have to be prepared for the job. My advice is to make sure you’re prepared and get in the game. Make sure your interests and the interests of the patients you represent are being heard at the table as healthcare is being redesigned.
More Articles on CMOs:
32% of CEOs Don't Think Their C-Suite is Built to Achieve Strategic Goals
Walla Walla General Hospital Names CMO, Interim CFO
10 Things to Know About Sheridan Healthcare