‘This shift to ac­count­abil­ity and value is go­ing to come up in any re­form pro­posal’

Modern Healthcare - - Q & A -

On May 15, Mike Slubowski, cur­rently CEO of the $2.7 bil­lion SCL Health with a dozen hos­pi­tals in Colorado, Kansas and Mon­tana, be­comes chief op­er­at­ing of­fi­cer of Livo­nia, Mich.-based Trin­ity Health, a sys­tem about six times larger. He will be serv­ing CEO Dr. Richard Gil­fil­lan, who has pledged to turn the na­tion’s sec­ond-largest Catholic­spon­sored health sys­tem into a prov­ing ground for the value-based care mod­els he helped shape while lead­ing the CMS’ Cen­ter for Medi­care and Med­i­caid In­no­va­tion. Edi­tor Mer­rill Goozner spoke with Slubowski last week about the ma­jor chal­lenges in his new role and the spe­cial chal­lenges faced by ex­ur­ban hos­pi­tals such as the ones he ran at SCL dur­ing 6½ years there. The fol­low­ing is an edited tran­script.

Mod­ern Health­care: Why switch from be­ing the top per­son at SCL to sec­ond-in­com­mand at Trin­ity?

Mike Slubowski: Rick Gil­fil­lan has been think­ing for some time about how to or­ga­nize his se­nior team at Trin­ity to put an em­pha­sis on op­er­a­tional ex­cel­lence. Trin­ity is in 22 states and has about $17 bil­lion in rev­enue now. There’s a fair amount of com­plex­ity when an or­ga­ni­za­tion spreads that far.

Fo­cus­ing on op­er­a­tional ex­cel­lence across the score card—qual­ity, safety, care ex­pe­ri­ence, com­mu­nity ben­e­fit, im­prov­ing the health of the com­mu­ni­ties they’re serv­ing, fi­nan­cial stew­ard­ship and, of course, align­ment with their peo­ple and clin­i­cians—is crit­i­cal. It’s an ex­cit­ing op­por­tu­nity.

MH: You pre­vi­ously worked at Trin­ity. What’s changed since you left?

Slubowski: I am en­tirely aligned with the shift to risk-based ar­range­ments and the value they’ll pro­vide. Trin­ity has launched an ACO in nearly ev­ery one of its mar­kets early on as a re­sult of Gil­fil­lan join­ing the or­ga­ni­za­tion. They’ve gone be­yond train­ing wheels in that re­gard.

Re­gard­less of where health re­form goes, this shift to ac­count­abil­ity and value is go­ing to come up in any re­form pro­posal. So the po­si­tion­ing they’ve done to align clin­i­cians and the health sys­tem to de­liver care that is the high­est qual­ity in a cost-ef­fec­tive way and also mea­sure how they can im­prove the health of in­di­vid­u­als and pop­u­la­tions is spot on.

MH: Has SCL pre­pared you for wider adop­tion of value-based ap­proaches?

Slubowski: We’ve done some of that work here at SCL Health. We have ACOs. We were early in the Medi­care Shared Sav­ings Pro­gram in our mar­kets. We’ve got some well-de­vel­oped physi­cian group prac­tices in each of our com­mu­ni­ties. We’ve ex­panded our con­tin­uum of ser­vices in­clud­ing home care.

We’re do­ing a lot of vir­tual health ini­tia­tives. In Mon­tana and Colorado, we were the first to part­ner with Doc­tors on De­mand for video vis­its, for ex­am­ple. I think Rick’s vi­sion for trans­for­ma­tion and mine are very much aligned.

MH: What are the is­sues af­fect­ing ru­ral hos­pi­tals to­day, and how will the changes be­ing pro­posed in Wash­ing­ton af­fect them?

Slubowski: We con­sider all our min­istries in Mon­tana ru­ral, but Billings is more ur­ban than our hos­pi­tal in Miles City, which is a very large crit­i­cal-ac­cess hos­pi­tal. The things that are com­mon to ru­ral ar­eas are the chal­lenges, for both med­i­cal and tech­ni­cal staff, of at­tract­ing clin­i­cians com­mit­ted to those ar­eas who will stay there.

Other is­sues are hav­ing a crit­i­cal mass of vol­ume to demon­strate pro­fi­ciency in what­ever clin­i­cal ser­vices

“Many ru­ral hos­pi­tals have been in­ven­tive in con­vert­ing many of their beds to nurs­ing beds and in ex­pand­ing their home care pro­grams.”

you’re of­fer­ing, as well as the abil­ity to spread fixed costs over a larger base of rev­enue.

De­vel­op­ing a con­tin­uum of care can be more chal­leng­ing in ru­ral mar­kets be­cause peo­ple pre­fer to have their pri­mary ser­vices in their own back­yard. But it is not cost­ef­fec­tive to pro­duce the spe­cialty ser­vices in ev­ery mar­ket or ev­ery hos­pi­tal. So deal­ing with is­sues such as trans­porta­tion and con­ti­nu­ity of care is a huge chal­lenge.

We’re do­ing a lot now with tele­health as are many providers in ru­ral com­mu­ni­ties: from eICUs and con­sults on video vis­its to hav­ing tel­era­di­ol­ogy and in­ter­pre­ta­tion ser­vices trans­mit­ted elec­tron­i­cally. Those will all be tools that will help ru­ral com­mu­ni­ties im­port some of the spe­cial ser­vices we need with­out peo­ple hav­ing to ac­tu­ally be in those com­mu­ni­ties.

MH: How do you fund these ser­vices?

Slubowski: Crit­i­cal-ac­cess hos­pi­tals have been get­ting spe­cial, cost-based re­im­burse­ment for many years. They are just like the rest of the health­care sys­tem was years ago. That can pro­vide per­verse in­cen­tives. The more you spend, the more you get. The flip side is be­cause it is ser­vice-based re­im­burse­ment, it doesn’t gen­er­ate cap­i­tal for in­vest­ing in op­er­a­tions for the fu­ture.

There’s a lot more ag­ing pop­u­la­tions, largely Medi­care, Med­i­caid and unin­sured, in those com­mu­ni­ties. In some states they use provider fees, where the state taxes hos­pi­tals to achieve ad­di­tional fed­eral fund­ing. That will run into chal­lenges as we re­visit the ACA. A lot of those ru­ral hos­pi­tals are very de­pen­dent on get­ting provider fee pay­ments be­cause of their dis­pro­por­tion­ately high share of Med­i­caid pa­tients.

Some crit­i­cal-ac­cess hos­pi­tals have fund­ing from their com­mu­ni­ties. A lot of those com­mu­ni­ties are chal­lenged fi­nan­cially. Many of those hos­pi­tals can’t make it on pa­tient­care rev­enue. They’ve de­pended on those sub­si­dies for many years. So there are a lot of chal­lenges.

On the flip side, many ru­ral hos­pi­tals have been in­ven­tive in con­vert­ing many of their beds to nurs­ing beds and in ex­pand­ing their home care pro­grams. Those are ways to pro­vide needed care in those com­mu­ni­ties that aren’t nec­es­sar­ily in­pa­tient or tra­di­tional out­pa­tient ser­vices at hos­pi­tals.

But the big­gest is­sue is how do you cre­ate a crit­i­cal mass of med­i­cal and tech­ni­cal staff. It’s not only try­ing to at­tract peo­ple to those mar­kets, but hav­ing enough vol­ume to gen­er­ate rev­enue and main­tain com­pe­tence in do­ing pro­ce­dures and pro­vid­ing ser­vice.

MH: Im­mi­grants help staff many ru­ral hos­pi­tals. Has the de­bate in Wash­ing­ton af­fected your abil­ity to re­cruit physi­cians?

Slubowski: Many of the grads who come here for ad­di­tional train­ing and place­ment are very con­cerned about what’s go­ing on right now. It’s def­i­nitely go­ing to af­fect the sup­ply and de­mand equa­tion, not just for ur­ban cen­ters. Many ru­ral hos­pi­tals have de­pended more on for­eign med­i­cal grad­u­ates and im­mi­grants who come here to train.

MH: Are you see­ing a chill­ing ef­fect on their de­sire to come here?

Slubowski: I don’t know what the fi­nal out­come will be on the im­mi­gra­tion ques­tion and how much recog­ni­tion there will be for needs like spe­cial la­bor forces. For me, the jury is still out. But it has got a lot of peo­ple con­cerned.

You’ve seen the anec­do­tal ex­am­ples of peo­ple who were turned away dur­ing the first im­mi­gra­tion ban, who had sim­ply trav­eled back to see fam­i­lies. It def­i­nitely cre­ates bar­ri­ers.

The flip side is if there is a way to sup­port bring­ing them, there’s still a lot of in­ter­est for med­i­cal grad­u­ates and can­di­dates to come to the United States for train­ing and place­ment in med­i­cal roles.

MH: How do you view the pos­si­ble shift to Med­i­caid block grants?

Slubowski: I’m not ex­cited about block grants. If it were go­ing to move to ship­ping money to the states, I’d rather see a per capita ap­proach or an in­no­va­tion grant ap­proach to fig­ure out how to help peo­ple who are poor and un­der­served. But if the per capita rate is too low, or it doesn’t deal with ex­oge­nous costs like drugs, it’s a prob­lem. They should be part of the equa­tion.

We be­lieve very strongly in the orig­i­nal prin­ci­pals of the ACA that health­care is a fun­da­men­tal right that ev­ery Amer­i­can ought to have ac­cess to a ba­sic level of health cov­er­age. Med­i­caid is an im­por­tant part of that equa­tion.

MH: What is­sue do you think isn’t be­ing ad­e­quately ad­dressed by health­care lead­ers or the health­care me­dia?

Slubowski: What there has not been a lot of dis­cus­sion about is how to en­gage con­sumers about how to have more skin in the game. Whether we live in an en­vi­ron­ment of poor so­cio-eco­nomic cir­cum­stances and health dis­par­i­ties, or we’re for­tu­nate not to be in those cir­cum­stances, ev­ery­body has a role in some way to im­prove their own health or take re­spon­si­bil­ity for their chronic con­di­tions.

That’s an area that needs more dis­cus­sion— about how we en­gage each of us in ev­ery way pos­si­ble. Ob­vi­ously peo­ple with means have more ways to do that. But ev­ery­body can do it and that has to be part of the equa­tion.

“I’m not ex­cited about block grants. If it were go­ing to move to ship­ping money to the states, I’d rather see a per capita ap­proach or an in­no­va­tion grant ap­proach to fig­ure out how to help peo­ple who are poor and un­der­served.”

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