‘Kids were put in a position of being pawns in a bigger game’

Bill Considine doesn’t mince words when it comes to the political brinkmanship over the Children’s Health Insurance Program that threatened coverage for children across the U.S. “We started using kids as a pawn in this game, and we violated a trust relationship with 9 million children and their families,” said Considine, who has led Akron Children’s Hospital for 39 years. He’s equally passionate about the role children’s hospitals can play in a value-based environment and the need for more engaged leadership. He spoke recently with Modern Healthcare Managing Editor Matthew Weinstock. The following is an edited transcript.

Modern Healthcare: As you talk to lawmakers, whether it’s in Columbus or in Washington, what’s been your message about the impact these protracted debates on CHIP and other health programs have had on your patients?

Bill Considine: Why aren’t children a top priority?

I know they don’t vote, but society is really measured by how it treats its most vulnerable, and our children depend on adults to make decisions for them; our elected officials, quite honestly, are not stepping up to that responsibility when it comes to kids, and many of them don’t even understand the infrastructure—the federal infrastructure and the state infrastructure—relative to healthcare for children.

Many of the elected officials I have talked to will argue that my numbers are wrong when I say that 31 million children in this country depend on Medicaid, and another 9 million depend on CHIP.

We have 70 million kids in this country and 40 million of them are in those two programs. In Ohio, we have 2.5 million children and 1.3 million are on Medicaid. Medicaid is not a welfare program for kids, yet our elected officials, and for that matter I think our public, view Medicaid as a welfare program. It has the word “aid” in it.

I guess a plus that came out of the (January) spending bill, and the fact CHIP got attached to it, is for the first time we started hearing the word “children” mentioned. Kids were put in a position of being pawns in a bigger game. We wouldn’t do that to many of the other populations in the country. We wouldn’t do it with our military. We wouldn’t do it with adults. We wouldn’t do it with veterans. But we did it with our kids.

MH: If we move outside of the political space and look at the shift that’s taking place in payment, how are pediatric hospitals affected? What’s your role in the move to value?

Considine: Children’s hospitals have been working on this value formula for a long time. There’s an entity—the Solutions for Patient Safety. It started here in Ohio. I give Cincinnati Children’s all the credit for pulling us together and saying, “Let’s not compete around quality. Let’s work together on quality and learn from one another.” And we developed a solution for patient safety. We’ve received money from the CMS and the Center for Medicare and Medicaid Innovation.

We’ve now brought another 100 hospitals into our collaborative from around the country and also North America. We learn from one another about central-line infections and adverse drug events and serious safety events and codes outside the ICU and surgical-site infections. The improvement around that has been enormous and it has saved millions of dollars that principally ended up with the insurance companies because of the contracts, which are based on past utilization rates.

I have said to our state officials that we would be willing to take risk and responsibility for 500,000 Medicaid kids. Just assign them to us and you can give us a per-child per-month rate that is within your budget—what you spend now—and we’ll plug those kids into our primary-care network and follow them. They’ll all have medical homes. We’ll follow those kids through our School Health Service. We’re in 30 school districts with our school nurses and school aides. We’ll have our home-care entity going into the homes of these kids to make sure that environment is conducive for their well-being. And if they need hospitalization, they can come to one of our sites. If we can keep it closer to home for our satellite facilities, that’s better for everybody. And if they happen to be on vacation when they need to go into a hospital, we’ll pay that bill.

MH: How receptive has the state been to that?

Considine: It puts them in a tough spot because we’re a Medicaid managed-care state. There are managedcare companies that have contracts with the state and I think all of them probably made money on Medicaid last year, but it gets back to the political arena again.

Some of the steps to get there are, “OK, let’s go into partnerships with these Medicaid managed-care companies. Let’s have some value-based components to our contracts. Incentivize us to continue to enhance quality and incentivize us relative to readmissions.” We’ll take on that risk.

MH: Have you entered into those contracts with managed-care companies yet?

Considine: Yes. We have about 70,000 children under that kind of managed-care plan and we established a population health entity that’s getting more traction. We just had a meeting with a major commercial insurer—I won’t mention its name—about partnering on dependents who are in their insured group. They’re looking forward to possibly having that conversation.

MH: Let’s talk a little bit more operationally. You’re doing an expansion, bringing a lot of things under one roof and you’ll also have four satellite facilities. Talk about how you’re shifting to focus on outpatient demand.

Considine: We’re in about 80 communities with some type of pediatric arm. We want to be in the schools, in the churches, in the neighborhoods, and work with other agencies in those communities; when you do that and open your ears, you learn about their issues. You need to reach out even more beyond your walls and we’ve been doing a good bit of that.

We took two of our satellite ERs the past couple years and converted those to urgent-care centers. Now, that cost us. It was about a $3.5 million hit to our bottom line because we got better reimbursement when we called them ERs.

If you’re really trying to be part of a solution, those are the kind of things you have to do. We’re working very hard on telemedicine. We have telepsychiatry that we’re extending into all our primary-care offices, backed up by people who can support that. We’re doing telepsychiatry with some of the schools that we’re in— not just telepsychiatry but also basic telehealth. At one of the high schools, we’ve opened the Akron Children’s Hospital Health and Human Service Academy, so when freshmen become sophomores, they’ll choose various academy tracks and one of those will be an Akron Children’s Hospital Health and Human Service track. We’ll give them exposure to health career options.

MH: As you think about that shift to outpatient and urgent care, how do you view that growth in the retail space with CVS and Walgreens?

Considine: We can’t control what CVS is going to do or what Target is going to do. We can control what we do. We are a known and trusted and economical value-based entity and, like CVS and like Target, are also close to home.

Our primary-care network is in the region. Our satellites are in the region. We spend a lot of time focusing on patient experience and building on the trust relationship that we have. We’ve been here for a long time—128 years.

Some of these things, they’ve got to prove that they’re going to be sustained. If we can bring convenience to the table and also show quality, show competitive price that equals value, and put that on top of the good will that we enjoy and our focus on children, I think that’s a winning formula.

MH: Leadership is something else you’re passionate about. You wrote a book and obviously you believe there are some things missing in healthcare leadership.

Considine: I do think there is a leadership void, in a lot of settings. People who get the mantle of leadership, I oftentimes think they believe that gives them something that is more image than substance. We all know when we see somebody who might have a title but doesn’t bring with that title credibility or respect—it might be a bully, things of that nature—they manage by fear instead of managing through empowerment.

I’ve had good coaches; I’ve had bad coaches in my athletic days. I’ve had good teachers and bad teachers. And when I reflect on that a little bit, I’ve learned a lot from bad bosses, and what I’ve learned is what I don’t want to be, because I’ve seen the effect of what they do and how they do it.

“I have said to our state officials that we would be willing to take risk and responsibility for 500,000 Medicaid kids.”

MH: This obviously impacts your leadership—your board recently split the roles of CEO and president apart. Why was now the time to do that?

Considine: I give our board a lot of credit in terms of their stewardship. One of the things they requested of me on a regular basis was to give them some scenarios relative to succession planning. I started here when I was 32. I’ll be 71 this year. When I started, the hospital budget was about $35 million and we had around 900 people. Today, we have about 6,000 people and we’re a $1 billion enterprise.

The board put together a special committee about five years ago and one thing they did was a gap analysis. Should I get hit by a bus, what kinds of things would we need to cover right away? That led to a plan for us to build in a little depth.

They thought the president of the hospital and the enterprise could have more operational responsibilities and the CEO would have more responsibilities for strategy, public policy, fundraising. They wanted to work on that and other transitions up to the day I move on and retire, because that day will happen.

We’ve not set a date, but we thought the first move toward providing that kind of stability was to break the role in half. It’s worked exceedingly well. It’s been seamless. Grace Wakulchik, who has been here 26 years and was our chief operating officer, she went into the president’s role. She was also our chief nursing officer at one time. The woman who was CNO, Lisa Aurilio, is now our COO.