Nashville Medical News June 2014

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For Practice Managers, the Only Thing Constant is ChangeIn her 16 years with Old Harding Pediatric Associates, Jerrianne Allen has witnessed her fair share of change in the continuously evolving fi eld of medical practice management ... 9

Council Fellows Celebrates a Successful Second ClassNow in its second year, the popular Nashville Health Care Council Fellows initiative is set to graduate its second class on June 6 at the Noah Liff Opera Center. Launched in 2013, the program engages healthcare executives tasked with leading the industry through an era of unprecedented change in an educational setting ... 11

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FOCUS TOPICS RURAL HEALTH PRACTICE MANAGEMENT

Divya Shroff, MD, FHM

PAGE 2

PHYSICIAN SPOTLIGHT

ONLINE:NASHVILLEMEDICALNEWS.COMNEWS.COM

Catching Fire: Lean Healthcare TransformationsJoan Wellman Pioneered Application of Toyota Principles in Healthcare; Helps Complex Health Systems Facilitate Large-Scale Change

Limited AccessRural Communities Risk Losing Hometown Healthcare

By CINDy SANDERS

At the end of April, Franklin-based Community Health Systems (CHS) announced plans to turn Haywood Park Community Hospital, located in Brownsville in the western part of the state, into an urgent care clinic. Plans call for the county’s only hospital to cease inpatient admissions and emergency services at 11:59 p.m. on July 31.

According to a release from the hospital, inpatient admissions had dropped from 1,300 in 2009 to less than 250 in 2013. Additionally, the Emergency Room had also seen a sharp decline with 15 or fewer patients per day over the past several months. The release went on to cite changes in guidelines for inpatient admissions and federal reimbursement cuts under the Affordable Care Act that have not been offset by Medicaid expansion in Ten-nessee as contributing factors to the hospital’s demise. In light of the new reality, Haywood Park CEO Joel Southern said maintaining a full-service hospital was simply not sustainable. Residents of the agricultural community must now drive close to 30 minutes to hospitals in Covington, Ripley or Jackson for inpatient and emergency care.

Although the latest to make a news splash, Haywood Park isn’t the only hospital that has closed in Tennessee or been reassigned as an outpatient clinic in recent months. Craig Becker, president of the Tennessee Hospital As-sociation, noted two others have closed in West Tennessee and that Scott County in East Tennessee has recently reopened without obstetric care after being shuttered for several months.

(CONTINUED ON PAGE 4)

By LyNNE JETER

Last June, healthcare leaders from around the country – Stanford’s Lucile Packard Children’s Hospital, Oregon Health & Science University, UCLA Health, the University of Michigan Health System, and Vancouver Coastal Health – converged on the campus of Nemours Children’s Hospital in Orlando to see lean healthcare transformation in action.

As usual, Joan Wellman, president of Seattle-based Joan Wellman & Associates (JWA Consulting), worked quietly and diligently behind the scenes, connecting hospital


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Catching Fire: Lean Healthcare TransformationsJoan Wellman Pioneered Application of Toyota Principles in Healthcare; Helps Complex Health

2 > JUNE 2014 n a s h v i l l e m e d i c a l n e w s . c o m

By KELLy PRICE

When she was working for the Vet-erans Administration, fellow physicians used to teasingly call Divya Shroff “Dr. Blackberry.”

In the days when portable technology was new to the halls of medicine, Shroff was constantly looking for ways this tool could be used to help her patients. Early on, she knew her way around the ground-breaking, and ubiquitous, little black device and recognized its potential for im-proving the practice of medicine.

“I’ve always been action-oriented, and I wanted to be a conduit to explain to the tech people how devices could be most useful. I guess I wanted to explain why the fonts on the screen needed to be green,” she recalled.

Shroff’s reputation as an innovative leader in medicine and clinical change management has only grown during her tenure with two of the country’s larg-est healthcare systems — the Veterans Health Administration and Nashville-based Hospital Corporation of America. Last December, HCA announced Shroff had been appointed chief medical offi cer for TriStar Centennial Medical Center, the company’s 657-bed fl agship facility in Nashville.

Prior to joining HCA, Shroff served as associate chief of staff for Informatics at the Washington, D.C. Veterans Affairs Medical Center. There, she played a piv-otal role in the development of projects that gained national recognition, such

as Blackberry EKG transmission for off-site cardiologists, an electronic providers hand-off tool, and inpatient interactive bedside televisions that could communi-cate with the hospital’s electronic medical records system. “I was so proud to work for an organization that was literally on the cutting edge of technology and medi-cine,” she said.

When she was offered a new position as chief clinical transformation offi cer and vice president in the Clinical Services Group for HCA in Nashville, she laughed and asked, “What’s the job description?”

Her role at HCA was designed to support the development and innovation

of the clinical merger of technology and healthcare. She had responsibility for the clinical implementation of the electronic health record system across the HCA enterprise, clinical leadership for mobile health technology development and tele-health deployment for patient and pro-vider engagements and improved clinical workfl ow, as well as other projects to fa-cilitate communication and collaboration among physicians.

Shroff executed and extended the strategic employment of a physician leadership program into 70 HCA hospi-tals, resulting in the successful utilization of Meditech’s EMR, and along the way, created a website in use by 11,000 clini-cians today. Additionally, she focused on improving the physician experience with patient care and technology by placing an emphasis on how mobility could trans-form care delivery and clinical workfl ow.

Her depth of technological skills, knowledge and experience should stand her in good stead as CMO where she is playing a signifi cant role in improving quality and patient outcomes in partner-ship with the hospital team. She is respon-sible for overseeing medical affairs and providing leadership to the more than 1,000 physicians on staff.

Shroff brings experience as a physi-cian executive with strategic vision in healthcare to her new position. Her skill set includes understanding trends regard-ing healthcare reform, quality, safety and physician/provider engagement and em-ploying technology to harness innovative

solutions. She also brought with her a treasure trove of insight into geographic variations, market diversities, and multiple lines of business operations.

Known as a leader in social media and mobile health technology develop-ment for patient and provider engage-ment and clinical workflow, she has intimate knowledge of multiple EHR sys-tems, which focus on driving implementa-tion optimization and future functionality development across complex patient care models and transitions in care.

In announcing her appointment last fall, TriStar Centennial President and CEO Heather Rohan said, “Her lead-ership and ability to engage providers utilizing innovation and technology to transform quality and access to patient care will be a tremendous asset to TriStar Centennial.”

Shroff said she is excited about the direction that medicine is taking in terms of technology, and she anticipates data collection will enable physicians to move more confi dently into population health. “The data should be able to show us trends in disease states, behavioral pat-terns, and provider relationships in ways we have not been able to previously ana-lyze,” she said.

Shroff has been published in a vari-ety of scientifi c journals and recognized in publications like TIME Magazine, The Washington Post and CIO Magazine. But long before she was a nationally rec-ognized physician and health informatics leader, Shroff was a curious, bright child growing up in Chicago. Her family moved to Illinois from India to work with Abbott Labs in the late 1960s. She lived in her family’s native country when she was in the fourth grade before returning to the United States for the rest of her education.

Always interested in science, Shroff said, “Sally Ride was my childhood hero.

Divya Shroff, MD, FHM: Innovative Leadership in Clinical Change Management TriStar Centennial CMO Focused on Improvement through Partnership

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By CINDy SANDERS

Everyone needs an advocate … some-one who truly understands the unique is-sues you face and is willing to go to bat for you.

For healthcare providers and the citi-zens they serve in small towns all across the state, that ‘someone’ is the Rural Health Association of Tennessee.

Celebrating 20 years of service at the annual convention in Pigeon Forge this fall, RHAT is exclusively and specifically focused on Tennessee’s rural communi-ties … advocating for and educating about all things healthcare. At the helm is Joellen Edwards, PhD, RN, FAAN, who serves as the 2014 presi-dent and was a member of the organization’s founding board.

As the association prepares to enter its third decade of ser-vice, the board is in the process of hiring RHAT’s first executive director. “We have had a wonderful executive assistant, Susan Veale, but she has been our only paid employee all these years,” said Ed-wards. After commissioning the Center for Nonprofit Management in Nashville to conduct an organizational assessment, RHAT decided the time was now to take

the next step in growth.“We have a wonderful advocate for

our organization – Bill Dobbins,” Edwards noted of RHAT’s active lobbyist, “but we would also like to have an executive direc-tor to make sure the voice of rural health gets heard in all kinds of venues across the state, and we want to build our partner-ships.” Edwards added RHAT also wishes to expand their educational offerings to rural healthcare providers and to identify additional grant writing possibilities.

The timing is right as the challenges facing rural health providers have only become more pronounced as community and critical access hospitals face uncertain futures in a changing healthcare environ-ment. A handful of hospitals have closed over the past year (see related article on page xx) and a significant number of other facilities and services are so endangered that there is mounting concern over widespread ac-cess to care issues across the state.

Edwards, who is a professor and the associate dean for research at East Tennes-see State University’s College of Nursing, said ensuring rural patients have access to providers was a main reason RHAT was so involved in a telehealth bill that passed this year. Introduced by RHAT and sponsored by Sen. Doug Overbey (R-Maryville) and Rep. Kelly Keisling (R-Byrdstown), SB2050/HB1895 codifies ex-pectation of payment for services delivered

via telemedicine communication tools.“It fortunately passed, almost unani-

mously, requiring insurance companies to pay for telehealth visits,” said Edwards. She noted some payers already reim-bursed for such services but the new law is meant to preserve access uniformly across the state no matter who carries coverage on the patient being seen.

Getting the bill passed and signed into law by the governor was only the first step, however. Edwards said the law is now in the rulemaking phase, and RHAT contin-ues to be active and vigilant in ensuring the rules being developed don’t under-mine the intent of the law. One concern, among several, is that individuals might be required to see a provider or specialist in a direct face-to-face meeting before being allowed to take advantage of telehealth technology.

“That might result in non-utilization, and i’s contradictory to the idea of tele-health,” Edwards pointed out. “We are absolutely dedicated to patient safety, but we do want the rules to be effective.”

The association also closely moni-tored the recent legislation meant to curb methamphetamine production in Ten-nessee. Edwards readily admits it’s a bal-ancing act between substance abuse and access to medications.

“Rural areas are primary sites for meth production. When you’re in an iso-

lated area, it’s harder to discover,” she noted of meth labs. However, Tennessee’s natural beauty, which is so abundantly displayed in small towns across the state, also plays havoc with allergies and asthma. Edwards said it isn’t always as easy or cost efficient as lawmakers might believe to get a prescription. “We’re not promoting drug use by any means, but to us, it’s an access issue,” she said, adding the compromise legislation that passed wasn’t “as bad as it could have been … kind of a lukewarm victory.”

RHAT is also working to increase access to oral health through a resource directory outlining providers that will see patients without dental insurance. A pilot program in the eastern part of the state has worked well, but now RHAT would like to expand the reach statewide.

Similarly, Edwards hopes to see ex-panded behavioral health services to areas lacking population density. “In terms of access, you’re not going to find mental health providers in rural areas at nearly the level you will in urban areas,” she stated. She is particularly excited about a relatively new program at ETSU that of-fers a doctorate in psychology with a spe-cific rural focus.

A Mountain City rural clinic staffed by ETSU’s College of Nursing utilizes the psychology students, supervised by

RHAT: Fighting for Healthcare Close to Home

Dr. Joellen Edwards



Humboldt General Hospital and Gib-son General Hospital both closed earlier this year. Humboldt now offers an Emer-gency Department plus outpatient clinical and rehabilitation services. Gibson Gen-eral has been rechristened Trenton Medi-cal Center and offers urgent care, primary care, lab and X-ray services, behavioral health and physical rehab. Another hospi-tal in Upper East Tennessee is currently on life support.

A common theme among the recently departed inpatient facilities and the more than 50 others that have been deemed ‘in danger of closing’ is their rural location. Becker said, “These rural areas are the most vulnerable. We’re going to have to fi gure out how to keep a medical presence in these communities, and right now it’s hard to en-vision how that’s going to happen.”

Joellen Edwards, PhD, RN, FAAN, president of the Rural Health Association of Tennessee (RHAT), concurred, noting hospital closures have a ripple effect. “You lose your prenatal care. You lose your pri-mary care because they just can’t make it when the hospital closes.”

Edwards, whose research focuses on rural populations, is a professor and as-sociate dean at East Tennessee State Uni-versity’s College of Nursing. Looking at a number of the threatened hospitals in the state, she said, “Some of these are criti-cal access hospitals, which means there is not another hospital for a minimum of 30 miles – or it could be even further away ...

and probably is.”She continued, “In East Tennessee, if

you live in our mountains, 30 miles is not an easy drive. Not having a hospital avail-able in minutes … rather than an hour or more away … makes a difference literally to life and death.”

In addition to losing access to care, Becker said the economic impact of losing a hospital is a topic that has been glossed over. “These are often some of the best paying jobs in these communities,” he said.

Edwards pointed out hospitals are frequently the economic driver in rural communities and are sometimes one of the few jobs in the county that come with health benefi ts. Losing those jobs only ex-acerbates the problem of uninsured and under-insured rural populations.

“I can guarantee you Brownsville is hurting right now because of losing those jobs,” Becker said. He added CHS couldn’t be blamed for their decision to cease emergency and inpatient services … it’s simply an economic real-ity. “It certainly isn’t that the community doesn’t deserve to have a hospi-tal. The reality is now you can’t afford to have one.”

Even in communities that don’t close hospitals, Becker said he anticipated seeing service lines that are not typically profi t-able … such as oncology and obstetrics …

cut loose. “Cutting services isn’t much of a strategy, but we’re going to see a lot of that,” he predicted.

When the Supreme Court struck down the ACA’s state mandate to expand Medic-aid, hospitals were left with severe cuts and the loss of a signifi cant source of offsetting reimbursement. The funding cuts, such as DSH payments, are back loaded. Becker said Tennessee hospitals face $1 billion in cuts in the year 2019 alone.

“Even with (Medicaid) expansion, it’s going to be diffi cult,” he said of the fi nan-cial stressors hospitals face. “But without expansion, we’ll lose even more hospitals and defi nitely see more services cut.”

He added lawmakers have, at times, accused the THA of ‘crying wolf’ as the association leaders have discussed the im-minent danger to numerous hospitals in the state. “This is the kind of thing we’ve been predicting,” Becker said of the recent closures, adding he wasn’t happy to be proven right.

The current closures, however, are feared to be the tip of the iceberg. With-out expansion of the Medicaid rolls (TennCare), Becker doesn’t foresee a happy ending for a lot of other hospitals. “One-third of the hospitals in the state are losing money,” Becker said, adding they

couldn’t indefi nitely continue to operate in the red. “I see other hospitals on the bor-der … on the brink,” he noted.

The Tennessee Plan proposed by Gov. Bill Haslam as an alternative to the Medicaid expansion program rolled out by the federal government and accepted by 26 states plus the District of Columbia so far, is still stalled … although not yet dead. During the 108th General Assembly, however, state lawmakers added another hurdle to getting funding to Tennessee hos-pitals by passing a bill requiring Haslam to obtain legislative approval before accept-ing any expansion dollars.

Under the federal Medicaid expan-sion plan, states would receive 100 per-cent of the cost to ensure individuals with incomes up to 138 percent of the federal poverty line for three years from 2014 through 2016. Beginning in 2017, funding phases down over the next four years to a permanent match rate of 90 percent by 2020 … signifi cantly higher than the 65 percent provided for current TennCare enrollees.

Becker, who called himself an eternal optimist, said he still believes the Tennes-see Plan could pass. Unfortunately, he said it might take having more hospitals close to drive the message home. “Maybe there is going to be some pressure on some of these rural legislators when they realize they are losing part of the social fabric of their com-munities,” he said.

If a deal is struck soon, Tennessee still has a chance to receive one full year at the 100 percent match rate. “I think there’s defi nitely a possibility … we’re not going to give up,” Becker stressed.

From RHAT’s standpoint, Edwards said, “We have a stance that uninsured people in Tennessee should have an oppor-tunity to be covered just like in Maryland where they chose to expand Medicaid.”

Although she said the association doesn’t take a political stance as to which expansion plan is implemented, Edwards concluded, “We in the Rural Health Asso-ciation do want to see a reasonable expan-sion of services to people in this state … it’s what they deserve.”

Limited Access, continued from page 1 From the Release Announcing Haywood Park’s Closing:

Rural hospitals such as Haywood Park are particularly impacted by new cuts in federal program reimbursement as part of the Affordable Care Act. These cuts were based on more people having insurance, whether through Medicaid expansion or the insurance exchanges. Tennessee has forgone the option to cover more individuals with Medicaid, leaving many of the state’s most vulnerable citizens without access to health insurance, and with no means to address the unsustainable burden of uncompensated care.

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clinical faculty, through telehealth and onsite clinical rotations to address mental health needs. Edwards said the integrated program has worked wonderfully well … providing convenience to those already coming to the primary care center and taking away some of the stigma of access-ing behavioral health services.

As always, almost every area of focus for RHAT circles back to access. “We are the organization that started the Ten-nessee Rural Partnership, which is now housed inside the THA,” she said. The partnership, originally set up specifi cally for physicians, now extends to nurse prac-titioners and physician assistants interested in working in rural settings. “It’s been very successful. They have matched up many, many physicians and providers with the communities that need them,” she noted.

Although there are many obstacles

providers face in delivering quality care to rural areas, Edwards said there are also many rewards.

“If you’re practicing in a smaller com-munity, you have fewer patients … which can compromise your fi nances … but you really get to know your patients. There’s a lot of joy in that,” she concluded.

RHAT: Fighting, continued from page 3

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By CINDy SANDERS

Will the Affordable Care Act help or hurt Americans living in rural areas? As is true of many complex laws, there probably isn’t going to be a single, simple, clear-cut answer. Some of the elements should be benefi cial; others could have unforeseen or unintended consequences that ultimately limit access to care.

Noted rural health expert Keith Muel-ler, PhD, head of the Department of Health Management and Policy for the University of Iowa College of Public Health and direc-tor of the Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis, has been an integral part of pre-paring two policy briefs focused on ACA’s impact on rural America. Mueller also serves as chair of RUPRI’s Rural Health Panel, which released “The Patient Pro-tection and Affordable Care Act of 2010: Impacts on Rural People, Places, and Pro-viders: A Second Look” in late April. The new review is a follow-up to the original analysis released shortly after the legislation was signed into law.

“Like a lot of people, we were pleas-antly surprised at the level of enrollment,” Mueller said of the panel’s reaction to re-cently released health exchange numbers. He explained that on top of the 8-plus mil-lion that was widely reported, there has also been a fair amount of enrollment in qualifi ed health plans (QHP) on the open market. At this point, Mueller noted, it isn’t clear what the urban/rural breakdown is among enrollees.

However, Mueller continued, the number of uninsured individuals in rural areas is generally about the same or a little higher than in urban areas. “Small em-ployers in rural areas are less likely to have made an employee plan available than small employers in urban areas,” he noted.

While having more people insured is a positive, Mueller pointed out coverage comes with a presumption that someone will actually be there to deliver care. “You have to address both the fi nancial access and the availability of services,” he contin-ued. “You’ve increased the demand so you also have to increase the supply.”

Mueller continued, “In rural areas where there’s already a shortage of pro-viders, you’ve exacerbated the situation. There are still many more counties that are primary care shortage areas than there ought to be … and that’s a fundamental service.” In addition, he said there are pockets where there is a shortage of emer-gency services and general surgeons. Muel-ler said the health delivery system has to be integrated locally across the full continuum of care from primary through quarternary care. “You need to have a system where no matter where I live, there is a point of entry for me to get all those services,” he stated.

On a more positive note, Mueller said Title 5 of ACA, which deals with workforce issues, did increase funding for the National Health Service Corps. There has also been increased attention regarding how provid-

ers could be used more effi ciently in fed-erally qualifi ed health centers, including a push to have non-physician providers prac-tice at the top of their licensure.

Even before ACA, Mueller pointed out, healthcare systems were already evolv-ing with pilot programs testing innovative payment and delivery models. Technology, he said, will provide a critical role … par-ticularly the use of telehealth in rural areas. Instead of having to bill for each discreet service, Mueller said newer payment mod-els allow for bundled services, “leaving it up to doctors to fi gure out the best way to get to the value proposition.”

That is a win for telehealth, he noted, since the service is often left out of tradi-tional payment plans. Another plus for tele-health is that patient satisfaction also plays into reimbursement … being able to ‘see’ a specialist at home using technology to as-sist in a consult rather than driving to an urban market, should increase convenience and satisfaction for rural patients. It allows them to receive the care, albeit differently, that would be found in a much larger city.

“That, to me as a researcher and ana-lyst, is the most exciting direction because it means that people will get the care they need when they need it no matter where they are living,” Mueller said.

Of serious concern, however, is the fi -nancial fallout in states that did not opt to expand Medicaid as was intended by ACA to help offset payment reductions in other areas, such as those to disproportionate share hospitals. “The states that did not ex-pand Medicaid are states with larger rural populations so the non-expansion has a dis-proportionate rural effect,” Mueller said.

He added, “So far there hasn’t been a huge effect because those reductions are scheduled to happen over time.” However, Mueller continued, “The longer those states don’t expand (Medicaid), the greater the impact.” He noted the fi nancial strain would be felt more sharply in rural areas because those hospitals tend to have much thinner operating margins in the fi rst place.

Mueller noted, “We have put in place over the last couple of decades various ways to sustain service delivery in the rural areas. The scary scenario would be because of fi nancial pressures, we pull the rug out from under (them). If that happened, there would be places in rural America where ac-cess would be severely limited.”

He concluded, “You don’t stop what has been working, even if it isn’t perfect, until you have a better solution in place. I think we’re working on a better solution right now … but it’s not in place, yet.”

The Changing Rural Health Landscape

Access “The Patient Protection and Affordable Care Act of 2010: Impacts on Rural People, Places, and Providers: A Second Look” under the quick link for the Rural Health Panel at rupri.org.


By CINDy SANDERS

While a practice’s focus is on the pa-tient, significant attention also has to be given to financial considerations like work-ing capital, planned growth, and invest-ment in new equipment. After all, practices that neglect their own financial health often find they aren’t around too long to care for their patients’ physical well-being.

Nashville’s prominence in the health-care industry has fostered a number of fi-nancial institutions with specific industry knowledge. Recently, Steve Jaynes, director of Medical and Professional Private Banking for Av-enue Bank, and Blake Wilson, head of TMA Medical Banking – a divi-sion of INSBANK, shared their insight and expertise regarding money issues facing practices.

Working CapitalWhile ‘working cap-

ital’ is a broad category, Jaynes and Wilson both quickly honed in on ICD-10 and its potential im-pact on practices. Jaynes said a key concern over the implementation delay is that it might cause practices to hit the pause but-ton. “ICD-10 has such a potentially huge cash flow impact. I think resting or stepping back is a mistake,” he said.

He and Wilson both expressed a hope that practices would use the next 16 months to train and test the new coding system to minimize disruptions to reim-bursements. However, as Wilson pointed out, “Everybody has to be on board for the process to work … everybody in the chan-nel from vendors to payers.” Given the complexity and room for error, he contin-ued, “Some experts are recommending up to six months of working capital either on hand or with access to borrow.”

He added access to debt might be a bet-ter business option than stockpiling cash … but included the caveat that practices vary so any decision would ultimately depend on a specific practice’s capital structure. “With interest rates as low as they are today, hav-ing access without necessarily putting your capital on the sidelines makes a lot of sense. That covers the risk component but doesn’t necessarily sacrifice the primary line of busi-ness … taking care of patients.”

Jaynes noted, “Where (practices) have a working capital line of credit with their financial institution, it’s probably not a bad idea to have a backup plan in place.” He suggested requesting a temporary increase for 60-120 days to guard against cash flow

interruptions. He added the better pre-pared a practice is for ICD-10, the less disruption to cash flow. However, he con-tinued, it’s almost inevitable that there will be some disruption. “We’re advising out clients to be prepared for that.”

Expansion & Changing Practice Structures

Jaynes said there has been recent movement in terms of practice consolida-tions, mergers, expansions and purchases of capital equipment. “The combination of the recession and the implementation of ACA had, I think, sort of a dampening ef-fect with many practices taking a ‘wait and see’ attitude,” he said. However, Jaynes continued, “You can only delay so long. I think the gates are starting to open.”

He added it’s a two-way street with funding becoming more readily available. “We do look at things with an eye to a brighter economic future,” he said. “I think the financial services industry is much more open to helping clients access capital as compared to what it was when things were really tight in the recession five years ago.”

Among their client base, Jaynes said, “We’re seeing activity around consolida-tion as practices start to try to get bigger for the benefits of scale.”

As for physicians purchasing into a practice, Wilson noted, “Our main goal is to line up the cash flow streams with a prudent … but not overly conservative … repayment stream.” He added that tradi-tionally a practice might have floated the cost of the new physician’s share while the amount was paid back over time. “But that’s again putting capital on the side-lines,” he pointed out. In general, he said, debt is cheaper than equity in today’s mar-kets.

Both Jaynes and Wilson said they are also seeing clients diversify to add new rev-enue streams by investing in ambulatory surgery centers, medical office buildings, and new service lines.

As for purchasing or refinancing prop-erty, Wilson remarked, “With commercial rates near historic lows, we’ve seen good activity on refinancing, and that mirrors the residential market.”

In Praise of ProactivityToday in America, healthcare deliv-

ery is undergoing sea change. A number of factors … at least in the short-term … have combined to squeeze working capital. “Be proactive in your planning,” coun-seled Wilson. He said to not only consider where your practice is going but where the industry as a whole is moving. “Put pencil to paper to look at stress tests … different scenarios … and how you would or could

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By CINDy SANDERS

“Billing has morphed into a mon-ster,” stated Kathi Carney, CPC, senior coding auditor for STAT Solutions, a division of Crosslin & Associates.

For practices trying to get a handle on coding and billing, it often feels like battling the mythi-cal hydra … every time you think you are get-ting somewhere, another issue rears its ugly head.

In mythology, Hercules ultimately defeated the monster by settling on a methodical process for attacking and eliminating each head. In practice man-agement, a similar dis-ciplined approach helps conquer billing and cod-ing woes. “It’s all about process and accountabil-ity,” said Rhonda Sides, principal, Healthcare Services & Forensic/Val-uation Services at STAT Solutions,

“Right now, a lot of what we’re being

sought out to help physicians with is the financial impact of various decisions they face,” Sides continued. While there are many areas that impact profitability … from recruitment to M&A decisions to patient engagement … perhaps no area is so directly linked to the bottom line as bill-ing and coding. Closely akin to that is the need for a robust internal auditing pro-gram to evaluate compliance efforts and billing efficiencies.

“Money is being left on the table be-cause things drop through the cracks,” Sides said of what they discover when asked to audit practices. “Sometimes what we find is documentation that is not ever captured in billing. They did the work and didn’t get paid.”

But it doesn’t have to be that way. “There are controls and processes that many, many practices could really im-prove … simple processes that create ac-countability all the way through the trail from the patient walking through the door to posting money received,” she contin-ued.

Both Carney and Sides agreed that technology is a double-edged sword. “Technology is not making it easier … it’s making it more difficult,” Carney said. In

part, she continued, because it’s easy to as-sume the technology has all the answers. “People are letting the system do the work, but it still requires a human,” she noted. Verifying the amount received matches contracted prices, following up on denials, and checking fee schedules all need the human touch.

Carney added, electronic records often sort entered items into different pockets, which can make it easier to miss a piece of documentation or billable action. She said practices have to be particularly vigilant when first switching to an elec-tronic system. “With EHR conversions, it’s imperative to do a pre- and post-coding and chart review,” she stressed. “The doc-tor is used to documenting a certain way on paper, but it’s different in the EHR so you have to make sure the documentation is captured appropriately.”

Sides added, “EMR systems have changed the way that documentation is done, but it also, by default, has changed some of the coding patterns.”

Another place where the consultants have seen technology make practices somewhat lax is in reconciling books … particularly when payments come into the practice electronically. “There are

so many things you have to check and balance to make sure you are tying your actual cash received to what you posted to the billing system,” Sides said. “Basic, simple things are missed all the time.”

Sides and Carney said one of the best ways to find and correct those ‘misses’ is to engage an outside consultant to review charts, coding and billing, and compli-ance. Sides pointed out, “Independent eyes pick up a lot of things you don’t see.”

Carney added, “By having their cod-ing looked at, it can improve the bottom line.” She went on to say that although au-ditors might find inappropriate reimburse-ments that could cost money in the short run, ultimately those catches could help the practice avoid future fines by correct-ing processes. Additionally, an audit could highlight billable services that aren’t being captured.

Without a firm grasp of the compli-cated coding and billing process, which will only get more complex with ICD-10 implementation, the two-headed hydra could quickly become a practice man-ager’s worst nightmare. Carney summed up, “You can end up with a monster of a mess in your computer system … and no money.”

Taming the Two-Headed Hydra: Billing & Coding

Kathi Carney

Rhonda Sides


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HealthcareEnterprise

W Squared’s Strategic Approach to ProcurementBy LARRy MCCLAIN

For nearly a decade, W Squared, a Brentwood-based business process solu-tions company, has provided a shared ser-vices model of back-offi ce support to some of the fastest growing healthcare compa-nies in Nashville.

With offerings that include fi nance and accounting, human resources and payroll, procurement, information tech-nology, and EMR/EHR systems assess-ment and implementation, the company has become a resource for healthcare or-ganizations requiring a scalable infrastruc-ture. W Squared feels that “outsourcing” is a dated term and prefers to use the more dynamic expression “business process partnering.” This emphasis on forming a close strategic relationship with clients has helped fuel dramatic growth in its health-care procurement group, launched just one year ago.

“For decades , healthcare procurement has typically been a tac-tical endeavor rather than a strategic one,” said Deborah S. Long, W Squared’s vice presi-dent of procurement and supply chain manage-

ment. “For example, a physi-cian practice often doesn’t buy something like an X-ray ma-chine until they need it – and then it’s too late to enjoy any negotiated savings. Joining a group purchasing organiza-tion (GPO) doesn’t fully solve the problem, either. When or-ganizations ride a GPO’s coat-tails, they realize savings on items that are under contract, but there are often hundreds of items that aren’t under con-tract.”

The newest trend in healthcare purchasing is what’s often called “aggregated pro-curement” – a discipline that turns passive participation in a GPO into an active attempt to bring all needed items under contract and control – everything from blood pressure moni-tors to waiting room chairs. According to Long, healthcare organizations of all sizes are often shocked to see what they could save when they negotiate and manage all their spending, not just medical/surgical supplies. Negotiated savings can be size-able on things like offi ce supplies, lab con-sumables, small parcel shipping, travel, and offi ce renovations.

Unlike a typical GPO, an aggregated procurement partner like W Squared takes a soup-to-nuts approach to negotiat-ing and managing costs. W Squared’s fee structure is based on the number of loca-tions served, not dollar volume, so it’s an arrangement that is cost effective for group practices, urgent care clinics and other or-ganizations that need to scale quickly.

“We’re able to provide each of our clients with a dashboard showing before-and-after results that track total procure-

ment spending, savings achieved, and ROI,” said Long. (See the sample dash-board above.)

“We’re a lready achieving ROI of 500 percent or higher with our typical client. That’s be-cause we actively negoti-ate contracts in areas that most GPOs won’t touch. For example, we recently renegotiated a contract for online clinician train-ing, saving the client 40 percent,” she continued.

W Squared is adept at fi nding suppliers whose strengths align well with its clients’ needs. In the

case of physician practices, W Squared negotiates special terms that help prevent inventory from piling up. Some suppliers are willing to consign inventories, which helps control expenses in pricey categories like pharmaceuticals. And some distribu-tors are willing to deliver products several times per week to ensure that the practice is never overstocked or depleted. Long said the strategic supplier relationship is as important to W Squared as the client/


W Squared’s Strategic Approach to Procurement

Although the company has been de-identifi ed and rebranded ‘NewCo,’ the dashboard shows actual procurement savings and ROI recently achieved by one W Squared client.

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By CINDy SANDERS

In her 16 years with Old Harding Pediatric Associates, Jerrianne Allen has witnessed her fair share of change in the continuously evolving fi eld of medical prac-tice management.

Operations manager for the large pe-diatric practice and current president of the Nashville Medical Group Management As-sociation, Allen knows her experiences mir-ror those of colleagues throughout the city, state and country who are grappling with trans-formative change. One of the biggest challenges, she said, is simply keeping up with all the criteria prac-tices have to meet in the highly regulated healthcare industry.

“I think the biggest change I’ve witnessed was from paper to EMR and then the guidelines that come along with EMR,” she said of OHPA’s transition from paper to electronic records, which now includes proof of mean-ingful use, increased specifi city of documen-tation and transitioning to ICD-10 codes. “The changes that have come affect the front all the way to the back,” she added of the impact on everyone in the practice.

“All the changes that we’re faced with … all the criteria and all the guidelines … affect how we treat and manage patient care,” Allen said. “For us, the challenge is keeping our connection with the patient and continuing to engage with them and not become so distracted by the requirements that we lose our initial focus,” she noted of a universal concern facing practices across the country.

“We can’t stare at a screen to make sure we hit all the requirements and not look up and engage patients and parents. When

they walk out of our offi ce, we want them to feel like they were listened to and treated with compassion and had a good experience … and not that we were just focused on our documentation and charting,” she said.

Despite the growing pains while tran-sitioning to an EMR and the lure of focus-ing on a screen instead of the patient, Allen said the benefi ts of technology far outweigh the regulatory burdens that come with it. In fact, she added, practices that don’t embrace technology are at real risk of being left behind.

As a pediatric offi ce, Allen noted OH-PA’s target audience is young to middle-age parents and their toddlers and teens. “Our patients (including parents) are smart. They know technology … it’s second nature to them,” she said, adding social media pro-vides the practice another tool for enhanced engagement.

The patient portal is central to the practice’s online communications efforts. Through the portal, Allen said parents can ask questions, set appointments and request prescription refi lls or forms at their conve-nience … whether that’s 3 o’clock in the afternoon or during a 3 a.m. feeding. It also plays a central role in meeting certain facets of meaningful use.

Allen said one of the biggest advantages of the EMR is the reporting capability that allows the practice to tailor information to meet the needs of specifi c populations. Whether it’s an email blast to all patients with broad-based reminders or a sorted communiqué to a specifi c age group with a notice that it’s time for a vaccine, the tech-nology supports the practice’s commitment to well care and prevention.

“Sometimes I’m surprised by practices that don’t have an EMR,” she added of those still reliant on paper records. Allen said at this point everyone should at least be plan-ning to convert to electronic records and budgeting for the change.

The next great challenge for practices, she continued, is conversion to ICD-10 cod-ing. “I think it’s important to still keep mov-ing forward and use the extra time to our advantage,” Allen noted, adding practices should be assessing software and then test-ing processes to minimize reimbursement disruptions.

In addition to the challenges inherent in running physician offi ces, Allen said savvy practice managers also must recognize there is increased competition for patients. Not-ing we live in a ‘fast food world,’ Allen said practices have to demonstrate their value and be accessible to patients since there are now walk-in clinics on just about every corner. It’s important, she said, to help patients under-stand the benefi t and need for continuity of care.

Rather than just being an isolated ap-pointment, Allen said the goal is to use per-sonal knowledge aided by technology to help patients optimize their time and health. “Hey, we see you’re behind on this vaccine. Or you’re in for an ear infection today, but how is your asthma?” she said as examples of ways of ways to maximize the value of each appointment to the patient’s benefi t.

“We want them to walk away feeling like they got something they couldn’t get elsewhere,” she concluded.

For Practice Managers, the Only Thing Constant is Change

react to those fi nancially.” Wilson said the best option is to take a proactive stance to both creating a savings cushion and garner-ing access to debt. “With those two crite-ria, you should be able to weather storms in this volatile and changing healthcare climate,” he said.

Being proactive applies to bankers, as well. Both Jaynes and Wilson said their in-stitutions make it a priority to keep up with healthcare issues impacting their clients’ practices. “We’re never going to be an ex-pert in the practice of medicine,” noted Wil-son, “but we want to be as knowledgeable and in tune as possible with the trends, chal-lenges and opportunities in the business of healthcare.” Jaynes echoed that sentiment, adding medical bankers try to anticipate is-sues that could impact the fi nancial health of client practices and look for viable solutions across a range of services.

Jaynes, who is credited with creating

the medical private banking department at SunTrust 20 years ago, came out of re-tirement in 2013 to launch Avenue Bank’s targeted medical practice. He said one of the key attractions for him to return to work was the opportunity to join a bank with local decision-making. “Not only does it effect the quality of the decision … but equally im-portant, it’s a much faster process. It doesn’t take two weeks to get a decision made. Many times, it’s in a matter of hours.”

Both Avenue Bank and INSBANK are headquartered in Nashville. Avenue assists clients with business and personal banking throughout Middle Tennessee and has fi ve physical locations in Nash-ville and Cool Springs. INSBANK focuses more specifi cally on the commercial side of medical banking and covers practices and healthcare businesses across the state through their partnership with the Tennes-see Medical Association.

Following the Trail, continued from page 6

Jerrianne Allen

Tapping into NMGMA

Jerrianne Allen said the Nashville Medical Group Management Association welcomes both practice managers and affi liate members including consultants and vendors. “Our goal is to be a valuable organization for practice managers to gain knowledge and information, but we also provide the resources needed to help them accomplish all their goals,” said Allen, who serves as the 2013/14 NMGMA president.

Upcoming programs include information on communicating with millennials, providing outstanding customer service, addressing fraud and abuse, and exploring the intersection of medicine and technology. Programming, which is held on the second Tuesday of the month at Saint Thomas West Hospital, is open to members and guests.

For more information on NMGMA or to register for an upcoming program, visit nmgma.com.


By CINDy SANDERS

Value-based reimbursements, ICD-10 re-boot, meaningful use, clinical integration phy-sician alignment, transparency, PQRS, 5010 implementation, e-prescribing, staffi ng and train-ing, compliance, audits … oh yes … and caring for patients

There’s no question the American healthcare system is in the midst of sea change as foundational rules are rewrit-ten and a new infrastructure for care delivery is being put in place. While pro-viders, practice managers and admin-istrators are supportive of many of the concepts, it doesn’t make the transition any easier.

With wave after wave of change washing over practices, it’s certainly ‘sink or swim’ time. For those trying to navigate the rough waters, the Medical Group Management Association’s ex-tensive resources, advocacy and insights on critical issues help shore up practice managers as they fi ght to keep afl oat.

Laura Palmer, FACMPE, a senior in-dustry analyst and sub-ject matter expert for MGMA, said practices across the country are facing unprecedented change. While much of it is tied to the Afford-able Care Act, a move to restructure the delivery and payment

system was underway even before the landmark legislation was set in motion but has since been greatly accelerated. Today’s practice managers are being asked to alter ‘business as usual’ on most every front.

Benefi ts & EligibilityReferencing the ACA impact,

Palmer said it’s about much more than just expanding coverage. “It’s really a change in how insurance plans work,” she noted. Keeping up with who covers what, where, with whom and at what point has become increasingly complex as staff members drill down through eligi-bility requirements and benefi ts to fi gure out the bottom line for patients.

While access might be expanding as more people join the insurance rolls, Palmer noted there has actually been a trend of narrowing networks. Not every physician or service provider is on every plan level under a payer. Adding to the confusion, not every family member is on the same plan.

“We’re starting to see more differ-entiation, and it’s more diffi cult for the patient and provider, who needs to know where to send someone for referrals,” she noted.

Whereas traditionally a lab company would have been on every plan under a payer, that’s not necessarily true today. A platinum plan might have more options than a gold or silver plan. “It’s a lot more complicated,” Palmer said. “You can’t

depend on what you knew in the past to be true.”

Therefore, she continued, it’s critical to regularly check coverage parameters and limits. Verifying benefi ts annually used to be pretty common. However, Palmer said that no longer works. “Best practices say we really need to check eli-gibility and benefi ts every single visit for every single patient,” she said.

Although patient benefits tied to large employers or government entities still aren’t likely to change more than once a year, the same isn’t necessarily true for smaller employers. And, Palmer pointed out, people change jobs much more frequently now so even if a com-pany’s plan hasn’t changed, the patient’s job status might have.

Appropriate Staffi ngTrue access to care doesn’t mean

simply having the coverage in place to allow a patient see a provider. The sec-ond part of the equation is having pro-viders available to meet appointment demands within a reasonable time frame.

“The days of a doctor’s offi ce being closed for two hours over lunch are long gone,” Palmer said. In fact, she noted, many practices are looking at evening and/or weekend hours, group care set-tings and adding non-physician extend-ers to meet demand.

From a reimbursement standpoint, practices must see enough patients to keep the doors open. From a quality

standpoint, which now ties to reimburse-ments, it’s critical to meet best practice parameters. Palmer noted evidence-based standards might call for a patient with a specifi c complaint to be seen within 48 hours. Practices have to fi g-ure out how to do that or risk the con-sequences … both of missing quality benchmarks and of lowered patient sat-isfaction scores, which also will soon tie into reimbursement rates.

“You don’t want patients to go to the Emergency Room because they couldn’t get an appointment,” Palmer said. She added, “Practices need to make sure they have adequate staff coverage and a triag-ing system in place to ensure patients are getting the right care in the right environ-ment in the right time frame.”

Making New Friends“Practices that in the past might

have been competitors in a particular community are now having to play nice with each other,” Palmer pointed out of new coverage rules and clinical integra-tion models.

Tied to the narrowing network trend, providers are fi nding payers and plans increasingly dictate referral pat-terns. Palmer said new payment models, such as the formation of accountable care organizations, also are forcing more col-laborations encouraged by both the fi -nancial setup and patient need.

She added that while this kind of col-laboration across care settings is gener-ally viewed as a good move for quality patient care, it is different than tradi-tional practice silos and will take time for providers to adjust to creating more community-based care than has been available in the past.

Adjusting to New Payment Models

Although the vast majority of reim-bursements remain in the fee-for-service world, the switch to a value-based sys-tem is already underway. “The practical aspect of how we deliver care is already changing,” Palmer said.

Practices have begun investing in changing technology and staffi ng models before reimbursements have caught up to the new way of doing business. Case managers, nutritionists and non-physi-cian providers are being added … even when those services aren’t clearly reim-bursable across most payers … because of the value they add to patient care.

Currently, Palmer noted, only about 3-5 percent of a practice’s reimburse-ments are tied to quality metrics. While those numbers have remained pretty steady for the past few years as reported to MGMA, Palmer said she was eager to see if there is a change indicated in this year’s data. Anecdotally, she said MGMA staff members have heard from more practices that contracts are being

Drowning in Sea ChangeMGMA Tackles Tough Issues to Help Practices Stay Afl oat

Laura Palmer


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By CINDy SANDERS

Now in its second year, the popular Nashville Health Care Council Fellows initiative is set to graduate its second class on June 6 at the Noah Liff Opera Center. Launched in 2013, the program engages healthcare executives tasked with leading the industry through an era of unprec-edented change in an educational setting focused on exploring innovative ideas to address some of healthcare’s greatest chal-lenges.

Over the course of eight daylong sessions held between January and June, the 32 executives selected for the Class of 2014 had the chance to participate in the unique curriculum based on three founda-tional elements:

Engagement in a forum for thought leadership and collaborative dialogue,

Experience of issues facing healthcare through immersion activities, and

Exploration of personal leadership styles and development.

The program is co-directed by former U.S. Senate Majority Leader Bill Frist, MD, and Larry Van Horn, PhD, associate professor of Economics and Management and executive director of Health Affairs at Vanderbilt University Owen Graduate

School of Management. In unveiling the participants chosen

for this second class last December, Frist noted, “This Fellows class includes some of the nation’s strongest healthcare talent and represents a broad spectrum of the

industry, incorporating provider, payer, technology, finance, policy and other sec-tors.”

Although very similar in scope to the inaugural programming, Van Horn said there were some small tweaks for 2014.

“We spent a little more time on ACA implementation this year given the timeli-ness,” he said. “We’ve added more inter-national perspective to this year’s content and curriculum and allocated more time to the discussion of wellness and popula-tion health.”

Van Horn noted, “There’s a lot of learning and cross-pollination amongst the seasoned executives that constitute the Fellows class. We learn from each other and broaden our perspectives.” In fact, he continued, a new addition to 2014 is a teaching module led by the Fellows and fo-cused on the subcomponent of healthcare in which they operate. The short presenta-tions, called Life in the Trenches, gave the executives the opportunity to share a point of view from their industry sector.

Beth Bierbower, president of the Em-ployer Group Segment for Humana and

Council Fellows Celebrates a Successful Second Class

Clockwise from top left: George Barrett addresses the 2014 Fellows class; Sen. Bill Frist (L) and Vanderbilt University School of Medicine Dean Dr. Jeff Balser participate in an interactive discussion; Guest speaker Marie Golden shares a point with participating healthcare executives; Council Fellows is ably led by healthcare experts Dr. Larry Van Horn (L) and Dr. Bill Frist.



system administrators with companies in a strategic way to build a more reliable healthcare system using lean manufacturing principles.

“A lean transformation is excruci-atingly patient-focused,” said Wellman, who pioneered the application of Toyota principles in healthcare and helps com-plex systems facilitate large-scale lean healthcare transformations. “Every activ-ity in the organization is assessed, relative to whether it adds value for the patient. As waste is removed, more time and re-sources are paid to the patient. It’s a very smart move to use these principles in a highly competitive environment because if you can do more for your patients with the same resources, you obviously have competitive advantage.”

Wellman’s lean transformation jour-ney began in the early 1990s, when she was consulting with Boeing on its lean manufacturing effort.

“We were taking executive teams from Boeing to Japan,” explained Well-man. “In the course of two weeks, we took them by Toyota, Honda, Fuji, Xerox and other prize-winning com-panies to see how their manufacturing processes work. They saw the same prin-ciples in action at all these companies.”

In 1994, Wellman recalls a Boeing executive, who served on the board of directors of a Seattle hospital, pondering whether lean principles could apply to healthcare.

“At that time, none of us were healthcare consultants, but we saw the appeal,” she recalled. “We took a group of clinicians to Boeing’s final assembly line in Everett, Washington, and trained them in lean principles alongside opera-tors on the line. Then we went back to the hospital and scratched our heads, try-ing to figure out how to make it palatable to healthcare professionals so the same principles could be applied. We looked at the waste and problems in hospital pro-cesses as we would in a lean manufactur-ing line.”

Wellman spent a year at the hospi-tal, better understanding the healthcare sector and the application of lean manu-facturing principles to a healthcare set-ting. In 1996, Wellman became involved in delivering a series of lectures at Seattle Children’s Hospital about concurrently improving patient flow and quality while also reducing costs.

In 1998, “it was time to put our big toe in the water,” said Wellman, who es-tablished JWA Consulting in 2000. A few years later, her book, Leading the Lean Healthcare Journey: Driving Culture Change to Increase Value (CRC Press), was published with co-authors Pat Hagan and Howard Jeffries, MD. The book chronicles healthcare improvements at Seattle Children’s Hospital, Memorial Care, The Everett Clinic in Washington, and Children’s Hospitals and Clinics of Minnesota.

“I don’t see the lean principles movement slowing down at all because

of the Affordable Care Act,” said Well-man, whose firm has grown to 22 asso-ciates. “I see an increased commitment and attention to building a more reliable system – with better quality, better safety, and better patient flow – at a lower cost. Applying the lean production system to healthcare is one of few models any-where that simultaneously addresses all of those issues.”

A lack of time, attention, and leader-ship passion are the primary barriers to lean principle implementation in health-care systems, said Wellman.

“Mainly, it’s the lack of time,” she said. “Money is not the issue because it’s rare for organizations to look back and say they aren’t getting financial gains from doing this work.”

The application of lean principles is also aggressively being used in another segment of the healthcare industry: the design of healthcare facilities around the world, said Wellman, whose firm is be-coming well known for its work in what JWA Consulting refers to as Integrated Facility Design, applying lean principles to the design and construction process.

“We just finished up some work in the Netherlands, and helped design a healthcare facility in Saudi Arabia,” she said. “We’re also doing work in Canada and the U.S., whose clinical processes are fairly similar but social systems are quite different. All those factors have to be taken into account. One thing’s for sure: With the healthcare industry facing financial challenges and other market pressures, lean healthcare transformation is catching fire.”

Catching Fire: Lean Healthcare Transformations, continued from page 1 I wanted to be just like her.”

In college, she participated in a six-year, integrated BA/MD program and graduated with a degree in biology with a minor in Spanish, as well as her medi-cal degree, from the University of Mis-souri – Kansas City School of Medicine. Shroff completed her residency in Internal Medicine at Barnes-Jewish Hospital and Washington University School of Medi-cine in St. Louis.

The board certified internist is a Fel-low of Hospital Medicine and a member of the American Medical Informatics As-sociation. She created physician leader-ship curricula and physician engagement/alignment strategies in matrix organiza-tions utilizing cross discipline teams for the successful operational and clinical best practice outcomes.

In the community and beyond, she

also has taken on the role of active vol-unteer. Shroff sits on a number of local boards including the Nashville Adven-ture Science Center and Nashville Pub-lic Radio WPLN Community Advisors and serves as a chapter director for TN HIMSS. She also has participated in med-ical mission work through the Dominican Republic Primary Care Clinic Volunteer MD program.

Recently, she assumed another new role — that of bride and now newlywed as she celebrated her marriage to music label executive Matthew Hargis in a festive des-tination wedding this spring. Always a great communicator, Shroff designed a special logo for their wedding invitations, combin-ing a medical caduceus with a cleft note.

“We’ve got Nashville covered … music and medicine,” she said with a laugh.

Physician Spotlight, continued from page 2

partner relationship and is one of the pri-mary reasons results are so compelling.

W Squared’s contract specialists can also negotiate volume incentives and well-designed warranties. Simply by structuring a tiered pricing structure in a flu vaccine purchasing program, W Squared helped lower one organization’s total spending in that category by more than 12 percent. This is accomplished by consolidating the total disparate rep-resented volume and creating a delivery model that meets the business needs for each client partner.

W Squared continues to introduce value-added services where GPOs seldom venture. Long’s team recently created a travel and rental car portal for a health-care client. It works almost identically to

online consumer sites like Travelocity, ex-cept that all the contracts have been nego-tiated on behalf of that single client.

“The services we offer are intended to augment, rather than replace, GPOs,” added Long. “A typical GPO doesn’t help a client create an optimized formulary – and then stand guard over every procure-ment contract and decision. That’s the extra value that we provide, whether it’s renegotiating a contract with a phone and Internet provider or lowering the cost of medical waste disposal.”

Long said she is confident that W Squared’s documented procurement sav-ings would continue to win new clients. “Our goal is to transform tactical health-care purchasing into strategic healthcare procurement.”

W Squared’s Approach, continued from page 8

negotiated with quality metrics in mind.Despite payments lagging a bit be-

hind, Palmer said practices have really embraced the concept of value-based care. “It’s the right thing to do,” she stated. “I think physicians and practices know to really manage care, the best way is to look at total patient care.”

ICD-10Recognizing that not every pro-

vider in every setting is on the same page about the latest ICD-10 delay (with a new implementation date of Oct. 1, 2015 as confirmed by CMS in May), Palmer said it cropped up as the number one concern for 2014 in MGMA’s annual Medical Practice Today survey.

Chief among worries are cash flow concerns, vendor issues, testing, and ad-equate staff training. Palmer noted, “The delay in implementation is going to allow for more testing, and that’s got to be good for everyone.” She added, she thinks it will give vendors the needed extra time to re-solve software issues and practices time to get the technology and training in place.

However, Palmer acknowledged

there would be some practices that once again put ICD-10 on the back burner only to panic again next year instead of using this time to really prepare.

Practice Setup“Integration and alignment issues

are still a big topic of conversation,” Palmer said.

What is the most effective practice model? Should practices merge? Sell to a hospital? Specialize or become multi-discipline? The ‘correct’ answer, she said, truly varies depending on circumstances and location.

“Healthcare is local,” Palmer pointed out. “What would work in Maine won’t necessarily work in Arizona.”

The MGMA LifelineMGMA’s resources can serve as

a lifeline to practice managers who are treading water as fast as they can. Palmer stressed the organization’s role is not to make decisions for practice managers but to put them in a position to proactively make thoughtful choices based on their own unique set of circumstances.

The goal, she said, is to “bring people vetted information – good information from reliable sources – so practice man-agers can make informed decisions.” She continued, “There isn’t one right answer. The joke around here is if you’ve seen one practice … you’ve seen one practice.”

Although new delivery models are building local alliances, there is certainly still a competitive relationship among practices in a given geographic area. Palmer said a key benefit of MGMA is that it provides a safe environment for peer networking to allow the exchange of information across regions. Where a prac-tice manager might not ask the competing cardiology practice down the street how they are handling benchmarking or suc-cession planning, MGMA membership provides a forum where that manager could talk to cardiology practices outside the market catchment area to find out how they are addressing those issues.

Finally, she noted, MGMA offers the tools to allow managers to excel in their careers. “We provide professional devel-opment so we grow the next generation of practice managers,” Palmer stated.

Drowning in Sea Change, continued from page 10


a 2014 Fellow, said, “It’s exciting to meet with others in the industry and network, but more than that to gain an understand-ing of what their issues are. You get a dif-ferent view of the system.”

For her Life in the Trenches pre-sentation, she said she took a broader industry perspective. “This industry is at an infl ection point – the point and time the fundamentals of your business change.” She added premiums are ris-ing, the number of peo-ple living with chronic conditions continues to increase, costs are up … all of these issues make business as usual unsus-tainable over the long haul. Once you recognize an infl ection point, Bierbower said the next step is to ask, “How do you take advantage of the of the challenges that ensue?” She contin-ued with evident enthusiasm, “Technol-ogy has the ability to change the game.”

In addition to sharing the inherent knowledge of the co-directors and Fellows housed in the classroom, the participants also benefi ted from presentations by a host of nationally recognized healthcare leaders, policymakers, educators and au-thors. The depth and breadth of the 2014 speaker’s roster underscored the respect the industry has for this unique program.

“We’ve had fabulous speakers and case studies,” Bierbower said, adding the interactive nature brought the informa-

tion to life.Tapping into the immense local tal-

ent, the 2014 Fellows heard from a host of leaders including hospital operations gurus Richard Bracken and Jana Davis (HCA), Bill Carpenter (LifePoint), Mike Schatzlein, MD (Saint Thomas Health), and Jeff Balser, MD (Vanderbilt Univer-sity Medical Center). Other local leaders operating on a national and international scale including Joey Jacobs (Arcadia Healthcare), Ben Leedle (Healthways) and Gene Boerger (Emdeon) shared perspec-tives on everything from integrating men-tal and physical healthcare to population health and wellness to product innovation.

The class also attracted experts from further afi eld. Toby Cosgrove, MD, CEO of the Cleveland Clinic; Princeton Univer-sity Professor Uwe Reinhardt; Dean Ornish, MD, founder and president of the Preven-tive Medicine Research Institute; political pundit Frank Luntz; George Barrett, CEO of Cardinal Health; and National Geo-graphic Fellow and best-selling author Dan Buettner were among the visiting speakers.

“There hasn’t been a session that hasn’t been extremely valuable,” Bier-bower noted. One speaker that made a big impression was Frank Luntz. “He talked to us about language and how the language you use really makes a difference. It’s not what you say but what people hear.”

Another highlight this year was a fi eld trip to the Entrepreneurship Center. “We exposed the Fellows to approaches for structuring innovative organizations,”

noted Van Horn. The executives, he said, had the opportunity to engage in hands-on visioning and strategy exercises with the entrepreneurs launching companies that seek to provide solutions to some of healthcare’s toughest issues.

Van Horn said the makeup of the 2014 Fellows class also helped further broaden perspectives. “This year we had more di-versity in the classroom. We had more lead-ers who are with smaller companies, seven women, two physicians, a PhD.”

What hasn’t changed at all from the inaugural program is the energy and in-terest among the participants. “It’s such a vibrant classroom experience when you have these seasoned and successful ex-ecutives focused on the same problem … which is how do we transform our health-care industry to create sustainable value in a world of declining resources,” Van Horn said. “We just have these incredible discussions. I look forward to being there every class we have,” he added.

Frist, Van Horn and the leadership of the Nashville Health Care Council soon will turn their attention to planning for the Class of 2015.

The Fellows initiative is presented in partnership with BlueCross BlueShield of Tennessee, Community Health Systems, HCA, Healthways, LifePoint Hospitals and Vanderbilt University’s Owen Graduate School of Management. For more information about Council Fellows and future offerings, go online to healthcarecouncilfellows.com.

Council Fellows, continued from page 11

On May 15, the Nash-ville Health Care Council hosted Dan Buettner, New York Times best-selling au-thor of “Blue Zones,” and Dean Ornish, MD, founder and president of the San Francisco-based Preventive Medicine Research Institute, for a discussion on health and well-being. Wayne Riley, MD, adjunct profes-sor at Vanderbilt University Owen Graduate School of Management, moderated the conversation, with Ben Leedle, president and CEO of Healthways, providing opening remarks.

“We’ve learned that environment plays a vital role in creating a healthier lifestyle. Surrounding oneself with natu-ral opportunities for better health choices empowers a person to make the effort to lead a healthy life,” said Buettner, who is a National Geographic Fellow.

He pointed out that, in addition to eating healthy food and getting plenty of exercise, people in the healthiest commu-nities in the world have a sense of purpose and a strong social network.

“Over the years, we have reexamined

the factors that incentivize a person to make good, healthy decisions. Fear is not a sustainable motivator … what enables people to make sustainable life changes is not fear of dying but joy of living,” said Ornish.

Additionally, Ornish highlighted nu-trition, fi tness, love and support, and stress management as key factors in a person’s health and well-being. The physician has directed clinical research demonstrating the positive impacts of comprehensive life-style change on chronic disease for more

than 35 years. The pair of wellness ex-

perts gave Council executives insight on best practices to health and longevity, under-scoring public policy strate-gies to improve the health of communities and the trans-formative impact of choice on controlling healthcare costs.

“In Nashville, we are seeing collaborative efforts among government and busi-ness leaders to encourage and enable healthier living.,” said Council President Caroline Young. “The improvement of the health of our com-

munity will be a critical piece to ensure Nashville’s future growth and prosperity,” she added.

The May program was presented by Healthier Tennessee, an initiative of the Governor’s Foundation for Health and Wellness that strives to increase the num-ber of Tennesseans who are physically active for at least 30 minutes fi ve times a week, promote a healthy diet, and reduce the number of people who use tobacco. Adams and Reese served as supporting sponsor for the program.

Health Care Council Hosts National Health & Well-Being Experts

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Dr. Dean Ornish (L) and Dan Buettner discuss longevity and the motivating factors to live a healthier lifestyle with local healthcare executives at a recent Nashville Health Care Council program.

The New Group of Council FellowsCongratulations Class of 2014

Elizabeth Bierbower: President, Employer Group Segment, Humana

Marty Bonick: President, Division 1 Operations, Community Health Systems

Charles W. Byrge II: President & CEO, Harpeth Capital

Phil Clark: VP, Finance & CFO, EnableComp and Complete Holdings Group Systems

Will Clark: SVP, Strategy and Brand, Brookdale Senior Living

Phillip A. Clendenin: EVP, Operations, AmSurg

John Dreyzehner, MD, MPH: Commissioner, Tennessee Department of Health

David Duckworth: CFO, Acadia Healthcare

Mitch Edgeworth: COO, Vanderbilt University Medical Center

David Frederiksen: President & CEO, PatientFocus

Robert Gallagher: Division VP, DaVita

Paul Gilbert: EVP & Chief Legal Offi cer, LifePoint Hospitals

Meaghen Greene: SVP, Strategy & Marketing, American HomePatient

Robert Harris: Partner, Waller

Daniel Hart: VP, Corporate Development, MEDHOST

Scott Huebner: President, Operations, Cigna-HealthSpring

Angela Humphreys: Member, Bass Berry & Sims

John Maki: VP, Sales, BlueCross BlueShield of Tennessee

Will Morrow: VP, Development, HCA

Eric Paul: SVP & Chief Managed Care Offi cer, IASIS Healthcare

J. Edward Pearson: SVP & COO, HealthStream

Rosemary Plorin: President, Lovell Communications

Kirk Porter: SVP, Bank of America Merrill Lynch

Ed Powell, PhD: Chairman, eMD

Paul Rein: CFO, Sarah Cannon Research Institute

David Rogero: Principal, Cressey & Company

Tammy Stephens: SVP, Operations Finance, Healthways

Cathy R. Taylor, DrPh, MSN, RN: Dean, College of Health Sciences, Belmont University

Martha Thorne: General Manager, Allscripts

David Vreeland: Partner & Co-founder, Cumberland Consulting Group

Michael Wiechart: President & CEO, Capella Healthcare

Herman Williams, MD: CMO, RegionalCare Hospital Partners

Beth Bierbower


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GrandRounds

Let’s Give Them Something to Talk About!Awards, Honors, Achievements

As part of the Healthy Tennessee Ba-bies Are Worth the Wait initiative, North-Crest Medical Center has been recog-nized by the Tennessee Hospital Associa-tion’s Tennessee Center for Patient Safety for its leadership in reducing the number of babies born electively between 37 to 39 weeks. NorthCrest successfully met its goal of decreasing the number of babies in this delivery category to 5 percent or less and has maintained this goal for a minimum of six consecutive months.

Emdeon (#11), M*Modal (#29), Experian Health/Passport (#44), Med-Host (#46), HealthStream (#56), and Cumberland Consulting Group (#96) have been named to the Top 100 Health-care Information Technology companies in the nation by Healthcare Informatics.

Hospice Source, LLC, a hospice-fo-cused durable medical equipment (DME) company headquartered in Plano, Texas, recently announced the installment of its new board of directors including Michael E. Collins, managing member, founder and CEO of Nashville-based merchant-banking firm 2nd Generation Capi-tal, LLC.

Middle Tennessee hospitals recently celebrat-ed being head of the class when it comes to safety. The Leapfrog Group recently released their spring 2014 hospital safety scores. The following area hospitals received an A. Maury Regional, NorthCrest Medi-cal Center, Saint Thomas Midtown, Saint Thomas Rutherford, Saint Thomas West, TriStar Centennial, TriStar Hori-zon, TriStar Skyline, TriStar StoneCrest, and Vanderbilt University Hospital.

Using data from McGraw Hill Dodge Analytics, the May issue of Architectural Record magazine, ranks Earl Swensson Associates (ESa) third in the nation of the Top 5 Design Firms for healthcare construction starts January 2011 through February 2014.

Hospice Compassus achieved high-est honors as a Healthy Challenge: Plati-num Seal Winner among 95 other work-places that participated in Nashville’s sec-ond annual Mayor’s Workplace Challenge over the past year. The program encour-ages and recognizes workplaces to excel in three areas: being green, healthy and involved in the community.

Carol Penterman, the owner and CEO of Interim HealthCare of Middle Ten-nessee, was presented with the Tennessee As-sociation of Home Care Outstanding Homecare Leader Award for 2014.

Jill Howard, COO of TriStar Skyline Madison Campus, is featured in a new series of statewide television advertise-ments speaking on behalf of WGU Ten-nessee, the school from which she earned her master’s degree.

Middle Tennessee was well repre-sented during the annual awards pre-sentation as part of TMA’s 179th Annual Meeting. David Vanderpool, MD, was honored with a Dis-tinguished Service Award, presented annually since 1963 by the TMA Board of Trustees to exemplary members of the associa-tion for their notable achievements dur-ing the past year. As founder and CEO of LiveBeyond, a nonprofit organization that provides medical care, clean water and nutritional support after disasters, Van-

derpool helped build hospitals, orphan-ages, secondary school, and vocational schools in Haiti after the earthquake of 2010. Last year, Vanderpool and his wife sold their house and most of their belong-ings to permanently relocate from Brent-wood to Haiti. Sally Killian, MD, received an Outstanding Physician Award, given annually by the TMA House of Delegates to member physicians who through their illustrious medical careers make an im-pression among their colleagues, peers and on the profession of medicine in Ten-nessee. Killian recently retired after more than 30 years in practice as an internist. Siloam Institute of Faith, Health and Culture was named a Community Service Award winner.

MedAssets, Inc. recently announced W Squared as the recipient of its 2013 Cost Management Performance Award.

John Deane, president of Advisory Board Consulting hosted a reception last month honoring Faith Family Medical Center (FFMC) for its care of the working uninsured in Middle Tennessee. Deane, a former FFMC Board member, said it was important everyone in the local health-care community know about Faith Family … particularly in light of the Affordable Care Act and vote to not expand Med-icaid in Tennessee. He noted employed people who either don’t qualify for ACA insurance or who can’t afford it, are left with few options for primary medical care.

Cumberland Consulting Group, a national technology implementation and project management firm, recently announced the selection of partner Jeff Lee to Consulting Maga-zine’s 2014 Top 25 Consul-tants list. The honor recog-nizes the 25 most influen-tial consultants of the year.

Middle Tennessee School of Anes-thesia recently hosted its inaugural Mis-sion & Awards dinner. Local honorees at the May event included Kent Price, CRNA, APN from Summit Medical Center, who won the Clinical Excellence Award; Wayne Winfree, CRNA, MS, APN, president of Cumberland Anesthe-sia in Carthage, who won the Mary Eliza-beth DeVasher Distinguished Alumni Ser-vice Award; Hampton Bisalski, CRNA, MS, APN, who has served as an MTSA instructor and alumni association trust-ee, who was honored with the Mission & Heritage Award; and the posthumous presentation of the Philanthropy Award to founder Bernard V. Bowen, CRNA.

The National Rural Health Associa-tion (NRHA) recently announced TriStar Ashland City Medical Center as one of the top 20 Critical Access Hospitals (CAHs) in the United States for patient satisfaction.

Michael E. Collins

Carol Penterman

Jeff Lee

Dr. David Vanderpool

More Grand Rounds Online


Meharry Graduates Largest Class in HistoryThe largest graduating class in the history of Meharry Medical College received

their diplomas at the College’s 139th Commencement on May 17 at Nashville’s Grand Ole Opry House. The School of Graduate Studies and Research awarded 78 diplomas across four degree programs — PhD, MHS, MSPH and MSCI. The School of Dentistry awarded 41 diplomas and the School of Medicine 97.

Commencement speaker, Norman C. Francis, JD, president of Xavier University of Louisiana, told the graduates the nation owes a debt of gratitude to Meharry, which was founded in 1876. He added, “Meharry graduates have a very special re-sponsibility to lead. You are going to have to stand for people who cannot speak for themselves and make their case clearly.”


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GrandRoundsTriStar Skyline Approved as Provisional Level II Trauma Center

On May 20, TriStar Skyline Medical Center announced the State of Tennes-see had approved their application to become a Provisional Level II Trauma Center.

“The trauma program is going to satisfy a significant need for trauma care in our community, said Roger Nagy, MD, trauma medical director. “Middle Ten-nessee, which encompasses eight coun-ties, is projected to reach a population of 1.6 million by 2016. The American College of Surgeons recommends hav-ing one or two high-level trauma cen-ters for every 1 million people.“

One-in-Six Americans Miss Work Due to Oral Health Issues

A new Delta Dental Oral Health and Well-Being Survey confirmed one out of six Americans (16 percent) said they have missed work due to oral health issues beyond regular treatments and clean-ings causing an estimated loss of more than 164 million work hours annually.

Other findings from the survey that was released last month included:

• Stronger reported oral health was linked with income, education and age. The survey found 86 percent of Americans making $100,000 a year or more visit the dentist at least once annually compared with 46 percent of Americans making less than $25,000.

•More than a quarter of Americans (27 percent) said they have open oral health issues they’d like to re-solve. The biggest reasons for not addressing the problem was abil-ity to pay for the work (cited by 62 percent) and fear of treatment (23 percent).

“It is essential that we take care of our oral health,” said Phil Wenk, DDS, president of Delta Dental of Tennessee. “These are decisions that affect our health and our productivity at work.”

Ker Joins Allergy PartnersDan S. Sanders, III, MD, of Allergy

Partners of Middle Tennessee recently announced the addition of Jennifer P. Ker, MD, to the practice in treatment of allergies, asthma, ecze-ma and immunology for both children and adults.

Board certified in Al-lergy and Immunology, as well as Pediatrics, Ker received her medical degree from the Medical College of Ohio. She complet-ed both her residency in Pediatrics and fellowship in Allergy & Immunology at Vanderbilt.

Avondale Adds Senior Analyst

Investment banking and wealth management firm Avondale Partners recently announced the addition of Donald Ellis, PharmD, as a senior ana-lyst covering the specialty pharmaceuticals and bio-pharmaceuticals sectors for the firm.

Ellis spent 10 years in medical practice as a clinical pharmacologist with the VA

Medical Center and Kaiser Permanente hospital systems in California, followed by 16 years in equity research and four years in financial service consulting. El-lis earned his undergraduate degree in Chemistry and Doctorate in Pharmacy from the University of Southern Califor-nia. He also holds an MBA from the Uni-versity of San Diego.

Aspen Dental Opens New Area Office

On June 5, a new Aspen Dental of-fice is opening in Murfreesboro at 2711

Medical Center Parkway. Meharry gradu-ate JoKeidre Butler, DDS, will serve as lead dentist for the new office, which of-fers a full range of services from exams and hygiene services to treatment of periodontal disease, extractions, fillings, oral surgery, dentures, crown and bridge work, and whitening. The Murfreesboro practice is one out of 19 Aspen Dental-branded locations in Tennessee, a state where 94 percent of the counties have dental health professional shortage ar-eas as designated by the U.S. Depart-ment of Health and Human Services.

Dr. Phil Wenk

Dr. Jennifer P. Ker

Donald Ellis

Nothing shall be impossible.

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