The Responsibility of a Big Provider in a Small State

Interview · February 27, 2018

Janice Nevin and Tom Lee

Thomas H. Lee, MD, interviews Janice E. Nevin, MD, MPH, President and Chief Executive Officer for Christiana Care Health System.


Tom Lee:  This is Tom Lee from NEJM Catalyst, and we’re talking today with my friend and colleague Janice Nevin, who is a physician and the CEO at Christiana Care in Wilmington, Delaware. Janice has been doing some very forward-looking things with her organization, and we’re going to talk about what and, even more important, why. Janice, I’ve followed Christiana for a long time for a variety of reasons, including the fact that I grew up right nearby, but not everyone in our audience will be familiar with Christiana. Can you tell us a little bit about your system and the role it plays in Delaware health care?

Janice Nevin:  Absolutely, Tom, and it’s great to talk with you. We’d love to have you back for a visit next time you’re around. Christiana Care Health System is a regional, community-based, academic health system, and we have the great privilege of serving people throughout the state of Delaware as well as in the contiguous counties of Pennsylvania, Maryland, and New Jersey. But it’s because of our presence in Delaware that we have a unique opportunity because the work that we do always has a statewide impact.

We’ve got four campuses, a couple of acute care hospitals, a freestanding emergency department, and multiple outpatient facilities throughout the state, although we are concentrated in the largest county. We are absolutely focused on achieving the highest, the best outcomes that we can, and so have been nationally recognized by multiple organizations as a leader in quality, safety, innovation, and health equity. We sponsor multiple academic programs in all the different health professions.

Everything that we do is rooted in the Christiana Care way. It is our promise to those we serve, and it starts with the words “we serve.” We talk about serving our neighbors because Delaware is a small state, and we care for people as though we live next door to them. And we do that as respectful, expert, caring partners in their health by creating innovative, effective, affordable systems of care that our neighbors value. That last word, value, is very important to us. When we think about our impact, the value that we bring is not simply to those who come to us, those we serve directly, but as importantly, the impact that we have on the people who live throughout the state of Delaware.

Lee:  Your point that Christiana is the biggest provider in a small state is an important one because health policy tends to happen at a state level. That’s where Medicaid policy is made [for example], so the impact is tremendous. My understanding is that managed care in general and value-based payment in particular have not come to Delaware as quickly as, say, Massachusetts. What is the current situation regarding insurance coverage, payment reform, and the ACA in Delaware?

Nevin:  That’s an important question. Delaware is a Medicaid expansion state, and my perspective is that the state did a terrific job of rolling out all the elements of the Affordable Care Act, including the exchanges, and we had a considerable number of Delawareans who got access as a result of both of those initiatives. The state has also been very successful in getting funding from the Center for Medicare and Medicaid Innovation (CMMI) and we are a State Innovation Model (SIM) test state. We were successful in being awarded funding to create a plan and now we are in the final year of implementing that plan.

We started from a place of a great deal of opportunity, particularly in terms of payment reform. The state historically has been very much a fee-for-service payment state. It’s very hard to find any evidence of capitation, total-cost-of-care arrangements. I will say, as a result of the SIM funding and the emphasis that’s been placed on creating value, and committing to reform, we’ve seen some changes start to take place.

We are the owners that helped create a statewide accountable care organization, as an example. We’re in our third year of a Medicare Shared Savings Program ACO. We’ve had the privilege of caring for about 50,000 Delawareans, and not just those in New Castle County, or those who come to Christiana Care, but because we’ve partnered with the other hospitals and health systems in the state we are truly able to deliver that approach to care statewide.

We also were fortunate to partner with Aetna beginning last July of 2017, and we’re caring for close to 30,000 state employees and their dependents. That is in a version of a total-cost-of-care model, meaning that if we are successful in helping the state achieve the spending target for that population, if we exceed their goals, there’ll be an opportunity for sharing.

But what’s new for us, and what’s new in the state, is that if we are not successful, and we do not help them achieve their spending goals, then Christiana Care, in partnership with Nemours, our children’s health system here, we’re on the hook for that difference. If we don’t deliver, the governor will be getting a check signed by me for the difference in that cost.

We’ve also seen, more globally, a shift to some of the initial stages of value-based payment. Pay-for-performance has taken root, and increasingly many of the contracts that we’re looking at both inside our organization and with what we know is happening with the private practice community, more and more of the revenue that we earn is grounded in value.

For us, that’s the important piece of all of this, our opportunity to create value, and create value in the way that we’ve defined it, which is, how do we help people achieve the outcomes that are important to them, and how do we do it in a way that respects cost and creates portability? By committing not only to driving the best performance in terms of how we deliver care, but also to thinking about how that care gets paid for, when that comes together we have the greatest impact for change.

When I talk to folks about where we are as a system, and our opportunity in the state, I talk about the past as being a successful hospital system, and we were that. We are currently, I believe, a successful health system in that we’ve started to build those components, the infrastructure that will support value-based care, risk-based payment. So where we are going, and where we must be, is a system that truly impacts the health of the people of Delaware. And it means taking responsibility not only for those who seek out care with us, but for all the people who live in the communities throughout Delaware.

Lee:  As someone who’s been watching and, frankly, admiring what you’re doing, my take is that you’re not just reacting thoughtfully to market challenges. You’re actually trying to show leadership. You’re trying to pull the system in the right direction as opposed to fending off change that would disrupt things for as long as possible. Is that take right, and then the follow-up question is, why? Why are you doing it? So many other folks I know are trying to delay disruption to the status quo because it does make life that much harder.

Nevin:  It’s in our DNA that we’re never satisfied with the status quo. I firmly believe that we need to lead, and to take responsibility to disrupt ourselves, and so we have been committed to that and remain committed to that. I have said, not only inside the organization but at the board level and publicly, that I am desperately seeking capitation. If we sit back and wait for things to change, we lose a great opportunity to shape our own future. More importantly, doing this work gives us the opportunity to do what needs to be done to transform the delivery system, and make a difference in how we care for people, and then how people experience health.

I’m a family physician. I spent the first part of my career working at Thomas Jefferson in Philadelphia and throughout my career have always taken care of vulnerable populations. And I know I don’t have to tell you — it’s the social determinants of health. It’s behavioral health, access, that have a much bigger impact on health and the cost of care, than the delivery system itself. By reforming how we get paid we create an opportunity to address those issues that have such a significant impact on health and how people live their lives.

One of the tools we have developed that gives me confidence about the disruption we’re creating is something called Carelink CareNow. We at Christiana Care were recipients of a CMMI grant and used those funds, as well as our own investment, to create a unique data platform that uses artificial intelligence and machine learning to help us as we ingest data from multiple different sources, to help us learn how we can care for people and how we can be more effective.

We’ve got a very powerful HIE (health information exchange) here in the state called the Delaware Health Information Network, so our data platform is agnostic to EPIC, Cerner. In fact, we can take in data from multiple different electronic health records, home devices, claims data, and then that data feeds to a predictive analytics tool, which in real time is able to let our virtual care team know who is at risk today, in this moment, and it’s allowing us to reach out to people who are at risk and intervene, and potentially change the trajectory of that care.

We have 104,000 lives that we’re managing on this platform, about half from our Medicare Shared Savings ACO, the population of about 30,000 I mentioned from the state, as well as our own employees, and then many of the other programs that we’ve invested in such as Independence at Home, and the bundles. And what we’re learning about this approach, a provider-based approach to population health management, is fascinating.

We have partnered deeply with physicians throughout the state who now have access virtually to a behavioral health consultant, a social worker, a clinical pharmacist, a nurse, and specialty physicians. It’s been amazing. Imagine being a solo family physician in rural western Sussex County, and now you have access to all of these resources for your patient. You can start to make some decisions that ultimately not only impact health, but that also help to make care more affordable, take out costs.

The other thing that we’re learning about, and I know you’re not surprised at all about this, is some of those specific social issues that are driving multiple ED visits, readmissions, lack of access to care. We have been, to some extent, not surprised, but occasionally have had some unexpected learnings because of our ability to go deeply into the circumstances of a particular patient.

One of the things that has surprised us is the issues that exist with literacy. Not just health literacy, but with literacy in general. Imagine if you’re someone who can’t read, you can’t recognize numbers, and every time you interact with the health care system everything that you get is either written down, or in numbers. We’ve developed some clever approaches using pictures, for example, to help folks who have trouble with reading and interpreting. At the same time that we provide them information in a way that they can use it, we’re also providing them support in the community for literacy issues, or whatever they need.

Why do this? It’s why I came to medicine. It’s why I became a family physician. I really do think that we’re in a moment in time where the challenges are enormous, but the opportunities to create something that will be lasting and truly make a difference in people’s lives is even greater than the challenges. That’s why we’re in it. If we disrupt ourselves, move away from depending on emergency department visits and hospital admissions, and focus on giving people everything that they need, nothing that they don’t — doing it in low-cost facilities, ideally doing it in their home and in their community, partnering with community organizations to address those social determinants — [we can] get people the access to behavioral health that’s so important.

If we do all of that, we will make a difference in the health of those we serve, and I think we’ll be successful financially. It’s a challenge. We’ve got to get the payment model that’s also tipped, but by demonstrating our commitment, by partnering with payers, and with the state, showing them our results, we’re starting to see that payment can also change.

Lee:  Maybe it’s too soon to tell, but the last question I want to ask is, how’s it going? I guess that boils down to three sub-questions: Are there any data yet to show that quality is improving? Are there any data yet to show that the cost curve is being bent? And then there’s the morale of the troops. You’re a very forward-looking, big-picture [person], and it’s great that your board is, but not everyone is out there, so are our clinician colleagues coming along?

Nevin:  The answer to the first two questions is yes, and yes. We are seeing some remarkable impact in terms of our focus on clinical pathways driving quality. For example, we have reduced admissions to our neonatal intensive care unit — and I don’t have to tell you, one baby that’s low birth weight, or has serious issues, that’s a huge cost to the system. That’s one example, as well as reducing readmissions, reducing utilization of the emergency department. And we know because we’re managing our own employee population that we’re seeing the impact on cost.

Again, we’re connecting more people to care management for their chronic illness. I just saw some outcomes for the work we’re doing with our employees. Not only are we under what we had budgeted, but I believe that we will end the year spending less on our employees this year than we did last, even though we’re covering more lives —  certainly some early metrics that give me optimism about what we can accomplish in the future.

This is certainly a new world for caregivers, and the good news is that the work that we have done inside our organization around engaging our caregivers in coming back to our values and behaviors has had impact. We embarked, last year, on a system-wide initiative to engage everyone in the organization around redefining values and behaviors. It comes from a place of me believing that organizations that not only survive, but thrive, in times of change are organizations that understand their values and consistently live those values through behavior.

So we did that work, and our new statement is “we serve together, guided by our values of excellence and love,” and it’s already having an impact. It gives us an opportunity to have a conversation about why we came to health care, the importance of the work that we’re doing, so helping connect people back to the purpose of being a caregiver. The work that we’ve done in our ACO, again, we’re able to show physicians in the community that we want to partner with you, we want to learn from you. How can we support you caring for your patients?

I do think there’s a lot more work to be done. We are, in many ways, just getting started. Engaging physicians, partnering with physicians, is a major focus for us. Many people are feeling overwhelmed and overburdened, and the issue of burnout has now gotten national recognition, and so we are addressing that through our Center for Provider Wellbeing, which is becoming a national leader in addressing issues of burnout.

Back to engagement, my view is that it’s the people who do the work who can help us identify the real problems and then be the problem-solvers, the innovators, who will allow us to create an environment in which they can deliver all the care that needs to be delivered, and create an experience both for them and for those we serve that is truly exceptional.

Lee:  I’m rooting for your success, and I’m glad you’re moving your system toward redesign when you’re in a position of strength, rather than facing a crisis. I hope we can continue to tune in from time to time and see how it’s going.

Nevin:  That would be great. I’m very privileged to lead this organization, to have the opportunity to serve the state of Delaware, and I think this is a great time to be a leader in health care. The opportunity to make a difference, from my experience, has never been as great as it is right now. Thank you for your leadership, and your inspiration for all that you do.

Lee:  Thanks so much.

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