Managing Population Health and Managing to Stay in Business
Dr. Grace Terrell, President and CEO of Cornerstone Health Care, recently visited LDI and shared her experience of directing a physician-led health system through health care reform. Terrell, a primary care physician and a good Southern storyteller, told us about ‘Julia’, her patient of more than 20 years:
Julia had just gotten a huge medical bill [from] this place in the local community that could cure all sorts of knee pain and back pain. What she got was a $1,500 bill that her exchange product paid about 60 percent of, for care she absolutely did not need. It was unnecessary, expensive, inappropriate care at the wrong place, for the wrong price, at the wrong time. Unfortunately, that’s the way a lot of health care is still in this country. The story of our organization is confronting that and dealing with that and trying to innovate around that in the middle of being in just a regular old medical practice.
Cornerstone began in 1995 as a multidisciplinary group of 42 physicians in 15 practices in central North Carolina. It focused on early adoption of new technology and practice innovations, including: electronic medical records in 2005; weekend hours in consolidated, multi-specialty facilities in 2007; and certification of its primary care practices as so-called “medical homes” in 2008. In 2015, Cornerstone had a high national rank among Medicare Shared Savings Program participants, and its spinoff CHESS has been selected to become a Next Generation ACO. More than 300 physicians are now part of the group.
Gauging from her storytelling, Terrell is clearly passionate about designing new models of care to deliver greater value in health care. Some examples of Cornerstone’s initiatives:
- Cornerstone invested in population health analytics software and reached out to patients who had lost touch with their doctor. According to Terrell, Cornerstone had “better results with blood pressure, cholesterol and blood sugar from just this one maneuver than we had from hiring our new endocrinologist at $300,000 a year!”
- In a “look at the whole picture approach”, Cornerstone set up two clinics with an internist, a nurse practitioner, a care navigator, behavioral medicine specialist and a pharmacist.
- Cornerstone established a heart function clinic with embedded behavioral services since “the number one indicator for heart failure readmission to the hospital is actually depression.”
- In its oncology clinic, Cornerstone embedded a general internist who could preserve continuity of care for patients’ medical needs beyond cancer.
- For Medicare and Medicaid dual eligibles, Cornerstone created a concierge practice with full assessment of psychiatric needs.
- To support the neediest and sickest patients, Cornerstone built an extensivist practice with a focus on medication management.
However, the outcomes they achieved did not translate into a stable financial base. Terrell observes: “It has been an up-and-down, yin-yang experience for our organization where the finances have never been there as we had thought they were going to be…The payers have never been as quick to move as we thought they were going to move.”
For much of the past year, Cornerstone has been “trying to keep the place open and pay the lights and doing things like pay chemo bills and things like that…It required a significant amount of working with the physicians who said ‘we thought this was going to work by now.’” In early 2016, Cornerstone was acquired as a wholly-owned subsidiary of Wake Forest Baptist Medical Center, an academic medical center based in Winston-Salem, NC. It will continue to operate as a separate business unit.
Looking ahead, Terrell ties up her story about ‘Julia’: “I don’t know where the rest of things are going, but I do know it’s the right thing to do. We’ve got an incredible problem in this country: a sixth of our economy is giving health care to one another. We don’t invest in anything else much, and we don’t give good care – or we give care like we did to Julia. The $1,500 got spent on something of absolutely no value, when she’s having all sorts of other medical issues that are not being addressed because we haven’t had the infrastructure to do it.”