There’s no place like Louisiana, which flaunts its cultural diversity and the richness of its artistic traditions in the kitchen, on the bandstand and in its urban and rural communities. But Louisiana’s many problems from entrenched poverty to poor public education; high rates of smoking, obesity and low-birthweight babies; and a crime rate triple the national norm all pose big challenges for health care providers.
Their work is complicated even more by accelerating change in health care. Payment reform, technological innovation, performance improvement mandates, a heightened emphasis on prevention and efforts to cut costs by keeping people out of the hospital whenever possible all complicate an already daunting task.
Dr. David Carmouche, senior vice president of Ochsner Health System and president of the Ochsner Health Network, spoke to U.S. News about his transformation from a preventive cardiologist to the leader of one of Louisiana’s nascent population health networks, built on a tradition of top-quality care.
Before he arrived at Ochsner a year ago, Carmouche served as an executive vice president and chief medical officer at Blue Cross Blue Shield of Louisiana in Baton Rouge, where he led initiatives designed to better organize care, improve quality and lower cost. He is scheduled to speak at the U.S. News Healthcare of Tomorrow Conference in Washington on Nov. 3.
I think of Louisiana as a state unlike any other, with big implications for public health. Is that true?
Absolutely. On average it’s a fun-loving group of people that really live life hard. They celebrate with food, they celebrate with drink, they love their sports, they love family, and they hold festivals all the time. It’s a culture that’s full of life. I remember there was a survey about the happiest places to live in the United States, and I think several cities in Louisiana were in the top 10. All that poses challenges when you combine it with a relatively impoverished state, relatively low health care literacy and relatively low access to health care insurance. The challenge for those of us in population health is to manage all that. If you can do something important in Louisiana, it’s a national story, because it’s the hardest place to be successful in that work.
You’re from Louisiana, aren’t you?
I was born here but grew up in Charlotte, North Carolina. My family moved there when I was a kid. We all moved back after high school. I went to Tulane and Louisiana State University medical school. I went away to the University of Alabama Birmingham for four years to do my residency I was chief resident there and then came back.
How did you get into population health?
I’m a board-certified internist. When I came back to Louisiana, I joined a large physician-led multispecialty group that’s relatively large for Louisiana, the Baton Rouge Clinic, with about 100 physicians. I practiced internal medicine for the first five years. For 10 years after that, I ran a preventive cardiology clinic. I have some special training in hypertension and cholesterol disorders and built a team of nurse practitioners, diabetes educators and nutritionists. Patients were referred because they had high-risk conditions. We did a great job of taking care of them.
Why did you leave the practice?
Our reimbursement model was all fee-for-service, and I found that I was making $100,000 to $150,000 less than my colleagues who were practicing internal medicine. Our patients’ complexity precluded us from seeing a large volume of them, whereas my colleagues were seeing lots of patients with minor ailments or who just needed physicals.
It was an awakening to me that fee-for-service reimbursement doesn’t work for unique care models that create significant value. It’s really what led me to Blue Cross. Blue Cross is the major carrier in Louisiana, with 65 percent of the market share. The way I looked at it was that if we were ever going to align payments with the type of care that would create value for patients, we would have to work with payers like Blue Cross.
What’s your role with Ochsner?
Ochsner is a large system with nine owned or managed hospitals and 1,100 employed physicians. I’m director of the Accountable Care Organization, and I also preside over the Ochsner Health Network, which is our statewide clinically integrated network. Each of our metro areas has a representative entity that falls under the network’s umbrella. It’s relatively new, announced in June of last year.
Ochsner’s network has grown relatively fast in such a short period of time, hasn’t it?
It’s growing. How fast depends on how you define it. If you measure it by hospital members, there are 30. That’s a lot. If you think of it as aligned physicians, you could include all of the members of the hospitals’ medical staffs, which would be 3,300 to 3,400 physicians.
We focus more narrowly on the physicians who are involved in clinical integration and are deeply committed to it.
By the end of the year we estimate that we’ll have 2,200 physicians who fit that description. They include the Ochsner-employed physicians and a like number of physicians in communities that have joined the Ochsner network.
How does integration play out in patient care, as it relates to population health?
It starts with the realization that, when you have the analytic capability to assess how care is delivered for different conditions, you can see that similar patients can have significant variation in how they’re treated and how much their care costs. Two people with knee pain can have a sixfold or eightfold difference in the cost of their care without necessarily having any appreciable difference in their outcomes.
When you start to understand that these are very smart doctors with patients who have similar problems but who manage their patients very differently you can see the potential to improve outcomes and lower health care costs. And, if you believe that Medicare and the insurers are marching away from paying for widgets and individual services and moving toward one payment for an episode of care, you understand that developing models to deal with variation has to be a core strategy.
For me it’s really just making the best use of the evidence. What do we know from the scientific literature about the best practices for treating certain conditions? How do we assure that these best practices are applied more often than not? If you do this correctly, you’ll be applying the best science to help people get better care, and, at the same time, avoiding waste, duplication and excess cost.
How do you make these changes happen in each doctor’s office and clinic?
We’re leveraging electronic health records, which connect all of our systems. We have created some 20 registries identifying groups of patients with certain diseases and conditions, and we’re reaching out to them proactively, to make sure they’re getting the care they need, when they need it. We’re realigning physician compensation for Ochsner-employed physicians, moving away from fee-for-service payment to higher payment for high-value, high-quality care. We’re looking at physician preference items, trying to consolidate down to one or two knee implants, or one or two cardiovascular implants, so that we can get better pricing from manufacturers.
And we’re looking at alternative care models. We have 500 or so nurse practitioners and physician assistants. We’re trying to organize them into care teams, rather than just delivering care through physicians. We’re also building out care-management capabilities that are broader than we’ve had before. Our goal is to more carefully manage the care of the small percentage of patients whose costs we’ll have to cover if they exceed the amount reimbursed by Medicare or insurers. The best way to keep costs down will be to provide high quality care, so patients can go home quickly and recover fully.
How do physicians respond to these changes?
Historically, there were two barriers to standardization of care. One is the physician’s sense of autonomy and control. Standardization is a challenge to that. That’s a change management issue, figuring out how to get physician leaders to help develop new care paths. The second is that we have not had a financial incentive to standardize care. It’s been OK to allow variation. In fact, physicians and care teams that drove costs higher created more revenue for health systems.
That’s changing. Physicians are starting to understand the science of care delivery. They’re hearing about unwarranted variation, and we have better analytics to paint the picture for them. They’re starting to get that. This has created a major upheaval for doctors, who now are relearning how to practice medicine every day. I’m 49 years old. For those of us who trained before 2010, you weren’t really expected to think about the cost of health care.
Any thoughts on how this will play out?
I have three children that are being raised in Louisiana. At the end of the day, I want them to be able to live and thrive in a state that is not only happy, but healthy. I want them to be able to actually afford the health care they need. And when they receive it, I’d like it to be world-class. So this is what we are trying to do, and I couldn’t be more optimistic that we can get there, even in Louisiana.
Date: September 30, 2016