Introduction to Value-Based Care Transformation
Healthcare leaders and physicians from University Hospitals convened at an Institute for Value-Based Medicine® (IVBM) event in Cleveland, Ohio, on October 23, 2025, to discuss groundbreaking advancements in value-based care and population health. The event focused on critical chronic conditions including diabetes and chronic kidney disease (CKD), bringing together medical professionals to share innovative strategies for improving patient outcomes.
Led by program chairs Ian Neeland, MD, and Patrick Runnels, MD, MBA, the conference emphasized practical solutions to reduce postoperative hospitalization lengths and demonstrated how fee-for-service resources can integrate with value-based care models. University Hospitals, partnering with The American Journal of Managed Care®, showcased their revolutionary approach through five systems of excellence (SOEs) designed to reshape patient care delivery.
These SOEs target five major chronic conditions: CKD, diabetes, chronic obstructive pulmonary disease (COPD), heart failure, and hypertension. The conference spotlighted two critical programs—diabetes and CKD management—through detailed presentations from their respective directors, offering insights into transforming healthcare delivery.
Addressing Diabetes Through Systems of Excellence
The Diabetes Crisis in America
Diabetes ranks as the seventh leading cause of death in the United States, presenting a significant healthcare challenge. University Hospitals, located in Ohio where diabetes diagnosis rates are among the nation’s highest, treats thousands of patients with prediabetes and diabetes annually. Despite remarkable advancements in medications and treatment protocols, diabetes management remains inadequate, according to Betul Hatipoglu, MD, medical director of the Diabetes & Metabolic Care Center at University Hospitals Cleveland Medical Center.
Improving overall health in diabetic patients can reduce their risk of microvascular complications by 37%, Hatipoglu emphasized. Beyond microvascular issues, diabetes correlates with severe conditions including kidney failure, hemodialysis requirements with hypertension, blindness, and nontraumatic below-knee amputations.
The Endocrinologist Shortage Challenge
Hatipoglu attributed inadequate diabetes management to a critical endocrinologist shortage affecting the entire healthcare system. She personally oversees diabetes care for 4,000 patients, yet nationwide, 37 million people have diabetes while only 6,500 adult endocrinologists practice in the United States. This dramatic imbalance creates unsustainable physician-to-patient ratios.
“We’re already working into population health this diabetes system of excellence, to redesign how we take care of diabetes in the ambulatory space,” Hatipoglu explained during her presentation.
Implementing Multispecialty Team-Based Care
University Hospitals administrators and providers designed SOEs utilizing multispecialty collaboration to improve follow-up care, enhance diabetes management, and relieve overwhelming physician burdens. Patient care teams now include diabetes educators, primary care physicians, nurses, certified diabetes care and education specialists, and PharmDs working collaboratively.
“Diabetes is a team effort. You cannot anymore, in this day and age, treat diabetes as a one-man show. It’s not going to work anymore,” Hatipoglu stated. “The patient goes in and sees the primary care physician and is then taken care of by the other team members, step by step, depending on what they need, whether it’s their medications optimized or adjusted, their risk factors controlled, or their educational needs met.”
Tackling Chronic Kidney Disease Management
Primary Care Physician Burden and CKD Prevalence
Sarah Lang, MD, director of the CKD SOE and a primary care physician, provided firsthand testimony about PCP burnout and the demanding workload facing primary care specialists. She referenced recent analysis revealing that managing every metric and closing every care gap would require primary care physicians to work 27 hours in a 24-hour day—an impossible standard.
Approximately one in seven adults has CKD in the United States, yet 90% remain unaware of their condition. Medicare beneficiaries with CKD account for a quarter of Medicare spending alone, while CKD maintains the highest admission and readmission rates among chronic conditions.
Expanding Pharmacist Roles in Patient Care
As part of the SOE multidisciplinary collaboration, pharmacists assume significant roles in reducing physician burden and comanaging patient care. At University Hospitals, pharmacists can initiate, discontinue, adjust, and titrate medications; order laboratory tests; and prescribe medications under initial PCP referral.
“The goal is to provide continuity of care between the PCP, the pharmacist, and the specialty visits,” Lang explained. Pharmacists at University Hospitals meet with patients more frequently than PCPs, significantly reducing care gaps and improving patient outcomes.
Reducing Hospitalizations with ERAS Program
Enhanced Recovery After Surgery Implementation
Heather McFarland, DO, a critical care anesthesiologist and system chief of the Anesthesia Value Network at University Hospitals, manages the Enhanced Recovery After Surgery (ERAS) program. ERAS has established 14 standardized guidelines across 111 service lines adopted by 13 hospitals. With approximately 350 patients enrolled monthly, the program achieves surgical site infection rates below 1%, while 30-day readmission rates haven’t exceeded 20% in the past year, reaching a low of 12% in December 2024.
The program generates millions of dollars in hospital savings by decreasing variation and improving standardization. “We are following the new NPO [nothing by mouth] guidelines, and so it took that first really specific group of people to be champions with us, and then it was those data coming after it that helped convert a lot of the rest with them,” McFarland explained.
Building Team Culture in Operating Rooms
ERAS success depends on operating room staff and clinical care teams remaining present and proactive during surgery and postoperative care. To encourage smaller roles in the operating room, the program displays affirmation banners reminding staff of their integral contributions to patient care.
“It helps you to think about what you’re doing when you come into that operating room space,” McFarland said. “We always talk about fractal management as this management system that we use where people can really feel like they belong in part of this initiative.”
Optimizing Hospital Length of Stay
Balancing Quality with Hospitalization Duration
Charles LoPresti, MD, system chief for hospital medicine at University Hospitals, discussed the delicate balance in hospitalization length. He emphasized concerns regarding quality with either excessively short or unnecessarily long hospitalizations.
“From the time of admission to the time this patient is discharged, that is the sacred timeline when everything is functioning as it should,” LoPresti explained. “But something comes up, and now all of a sudden, we get thrown off of this timeline, and now our discharge exceeds what our ideal discharge time is.”
Three Categories of Discharge Barriers
LoPresti categorized discharge barriers into three buckets: germane, intrinsic, and extrinsic. Germane represents the optimal length of stay required for quality patient care. Intrinsic delays involve extended stays due to physician practice variation, while extrinsic delays result from system inefficiencies like poor care team communication, hospital staffing issues, or limited resource availability.
By utilizing electronic health records and adhering to clinical practice guidelines, care teams can significantly shorten discharge delays, reducing hospitalization stays. “We just want to standardize the 85% we actually want to decrease. Take that off your plate, and then really focus on the 15% of patients that do need a very tailored approach to optimize postdischarge care,” LoPresti stated.
Implementing Patient-Centered Rounds
University Hospitals implemented patient-centered rounds—scheduled meetings among physicians, bedside nurses, and patients—to address timely concerns and procedures, ensuring comprehensive communication. Hospitalists more readily discharge patients when confident about timely follow-up care, leveraging post-follow-up appointments and the “Healthy at Home” virtual clinic.
Future of Population Health and Value-Based Care
Panel Insights on Healthcare Transformation
The IVBM event concluded with a panel discussion featuring George Topalsky, MD, president of University Hospitals medical practices; Valerie Reese, MBA, vice president of population health; and Jordan Winter, MD, director of surgical services. Panelists discussed ambitions to shift from reactive sick-care models toward prevention and early intervention.
Addressing Fee-for-Service Model Conflicts
Panelists acknowledged conflicts between population health initiatives and traditional fee-for-service models. “We are dependent, dare I say, addicted, to the demand for our services. In fact, our compensation is directly tied to our individual productivity,” Winters stated. “You get rewarded for unnecessary surgery; as long as you don’t get sued for it, you get rewarded for it. Until we figure out how to wean ourselves off this model and truly commit to change, there is going to be misalignment.”
Building Collaborative Healthcare Culture
Panelists concluded by acknowledging the essential move toward multispecialty collaboration in primary care to improve value-based care. These transformations require substantial education, adaptability, and continuous alignment from physicians and administrators.
“We’ve made a lot of progress by focusing on outcomes and building a culture of collaboration—explaining the whys and the hows, solving problems together,” Topalsky concluded. “It’s an ongoing journey, but as we continue to adapt, engage, and align around what truly matters, I’m confident we’ll keep moving forward.”
