“If you are going to do a good job in case management and the more efficient management of patients with chronic diseases, the first thing you have to come to grips with is that is largely not institutional work. It is about the practice of medicine,” Murphy says. “It creates the reality that hospitals—large and important as they are—are not really the focal point of healthcare. Hospitals are ancillary services. They are important ones, but they are ancillary to the practice of medicine. Real value-driven disease management is physician work. It’s outpatient work, and it’s about support personnel.”
Carilion has invested heavily in its physician group, doubling from 300 physicians to more than 600 in three years. A heavy investment has been made in an inpatient and ambulatory electronic medical record from Epic Systems, an essential piece of infrastructure for an ACO, Murphy says, but a costly investment of $100 million over a decade.
The expansion of the medical group comes along with a cultural transformation to make what Chief Medical Officer Mark Werner, MD, calls “an accountable group,” with an emphasis on team-oriented, interdisciplinary care.
“We have focused very intently on our culture,” Werner says. “From the beginning we recognized culture was the key to our success and that a failure to build and protect our culture was the biggest threat in our efforts to develop an accountable and integrated group.”
Werner says there are technical challenges in getting reliable, timely information on disease registries, clinical outcomes, and costs. There are cultural challenges in changing physician behavior. And the financial challenge will be how to balance the need to reduce hospitalizations while still managing the hospital bottom line.