Top 12 takeaways from the 2018 JP Morgan Healthcare Conference — while the destination is uncertain, the direction is clear

The recent breathtaking flurry of mega-mergers coupled with increasingly challenging market forces and an ever shifting political landscape has cast a cloud of confusion regarding where the U.S. healthcare delivery system is heading.  

So, where do you go to find the map?

Every year, the JP Morgan Healthcare Conference provides an incredibly efficient snapshot of the strategies for large healthcare delivery systems, the hub for healthcare in the U.S. Most of these organizations are also the largest employers in their respective states. The conference took place this week in San Francisco with over 20 healthcare systems presenting, including Advocate Health Care, Aurora Health Care, Baylor Scott & White Health, Catholic Health Initiatives, Geisinger Health System, Hospital for Special Surgery, Intermountain Healthcare, Mercy Health in Ohio, Northwell Health, Northwestern Medicine, Partners HealthCare System, WakeMed Health & Hospitals and many of the other big name brands in the market. Each provided their strategic roadmap in a series of 25-minute presentations from their “C” suite. If you’re looking for the GPS on strategy and a gauge on the health of healthcare, this is it.  

How do their strategies differ? What direction are they heading in? There is a great line from Alice in Wonderland that goes, “If you don’t know where you’re going, any road will take you there.” You would think that line applies perfectly to the U.S healthcare system, but the good news is it actually doesn’t.

While the exact destination for everyone is TBD, the direction they are heading in is actually pretty clear and consistent. It turns out that they are all using a very similar compass, which is sending them down a similar path.

So, what are the roadside stops health systems consider absolutely necessary to be part of their journey to creating a more viable and sustainable value-based business model?

Based on the travel plans for over 20 of the largest and most prestigious healthcare delivery systems in the country, here’s your GPS and list of 12 things you “must do” on your journey.

1. You Must Scale

Clearly the headline at #JPM18 was the flurry of major announcements regarding major mergers. With that said, two of the mergers were front and center: teams were there to present from Downers Grove, Ill.-based Advocate and Milwaukee-based Aurora, which will be a $10 billion organization with 70,000 employees, as well as San Francisco-based Dignity Health and Englewood, Colo.-based Catholic Health Initiatives, which will be a $28 billion organization with 160,000 employees. The size and scale of these mergers is pretty stunning. While the announcement of these and the other recent mega-mergers has forced many into their board room to determine what the deals mean to them, the consensus at the conference was this: There are a number of different paths forward to achieve scale. Some, like Baylor Scott & White in Texas, have aggressive regional expansion plans. Others are betting on partnerships to provide the same or even more value. Taking a pulse of the room, two things were clear. The first is there is no definition of scale any more in this market. The second is that, despite this flurry of mergers, “getting really big” is not the only destination.  

2. You Must Pursue “Smart Growth” and Find New Revenue Streams

Running counter to the merger narrative in the market, Salt Lake City-based Intermountain provided a good overview of the movement to what is called an “asset light” strategy of “smart growth.” This is a radically contrarian approach to the industry norm, which is the capital intensive bricks and mortar playbook of buying and building. As part of their strategy, Intermountain will open a “virtual hospital” delivering provider consultations and remote patient monitoring via telehealth. The system will also launch a number of healthcare companies every year, leveraging their considerable resources in a manner they believe will produce a higher yield. Other health systems outlined a similar stream of initiatives they have in motion to diversify their revenue streams and expand their business model into higher margin, higher growth businesses. One example is Cincinnati-based Mercy Health, which achieved strong growth and leverage via their investment in a revenue cycle management company. Advocate in Illinois formed a partnership with Walgreens. Together, they now operating 56 retail clinics and Advocate has seen a significant impact on driving new patients and downstream revenue to their system. The bottom line is all now recognize that they must think and act differently to be able to continue to fund their clinical mission and serve their community.

3. You Must Measure and Manage Cost and Margins

While some are moving aggressively to get scale, everyone is looking to more effectively use the resources they have and get more operating leverage. Margin compression was a consistent theme, with many systems now moving into consistent, stable operating models around managing margins versus launching reactionary initiatives when they find a budget gap. What is emerging is a new discipline and continuous process around managing cost and margins that is starting to look similar to the level of sophistication we have seen in the past for revenue cycle management. To that end, there has been major movement in the market to implement advanced cost accounting systems, often referred to as financial decision support, which provide accurate and actionable information on cost and help organizations understand their true margins as they take on risk-based, capitated contracts. Some during the conference referred to it as the “killer app” for the financial side of driving value. Regardless of what you call it, all are moving aggressively to understand the denominator of their value equation.

4. You Must Become a Brand

Investing in and better leveraging their brand has become a strategic must for health systems. The level of sophistication is growing here as providers shift their mental model to viewing patients as “consumers.” Aurora in Wisconsin cited their dedicated Consumer Insights Group and outlined their “best people, best brand, best value” approach that has been incredibly effective both internally and externally. At the same time, the bigger investments for many health systems relative to brand are more on brand experience than brand image, with a focus on understanding and radically rethinking the consumer experience. As an example, at Danville, Pa.-based Geisinger, close to 50 percent of ambulatory appointments are scheduled and seen on the same day. And every health system is making meaningful investments in their “digital handshake” with consumers, creating and leveraging it via telehealth as well as mobile applications to enhance the customer experience.

5. You Must Operate as a System, Not Just Call Yourself One

One clear theme at #JPM18 is different organizations were at different points along the continuum of truly operating as a system vs. merely sharing a name and a logo. There are a number of reasons for this, but you are increasingly seeing tough decisions actually being made vs. just kicking the can down the road. There has been a great deal of acquisitions over the last few years coupled with a new wave of thinking relative to integration that is more aggressive and more forward-looking. This mental shift is actually a very big deal and perhaps the most important new trend. Many health systems are heavily investing in leadership development deep into their organization to drive changes much faster.   

6. You Must Act Small

The word “agile” is quickly becoming part of everyone’s narrative with health systems looking to adopt the principles and processes leveraged in high tech. Chicago-based Northwestern Medicine is an example of an organization that has grown dramatically in the last five years, now approaching $5 billion in revenue. At the same time, they have still found a way to operate small, leveraging daily huddles across the organization to drive their results. The team at Raleigh, N.C.-based WakeMed has achieved a dramatic financial turnaround over the last few years, applying a similar level of rigor yielding major operational improvements in surgical, pharmacy and emergency services that have translated into better bottom line results.

7. You Must Engage Your Physicians

Employee engagement was a major theme in many of the presentations. With the level of change required both now and in the future, a true focus on culture is now clearly top of mind and a strategic must for high-performing health systems. That said, only a handful articulated a focus on monitoring and measuring physician engagement. This appears to be a major miss, given that physicians make roughly 80 percent of the decisions on care that take place and, therefore, control 80 percent of the spend. One data point that stood out was a 117 percent improvement in physician engagement at Northwestern. Major improvements will require clinical leadership and a true partnership with physicians.

8. You Must Leverage Analytics

Many have reached their initial destination of deploying a single clinical record, only to find that their journey isn’t over. While health systems have made major investments big data, machine learning and artificial intelligence, there was a consistent theme regarding the need to bring clinical and financial data together to truly understand value. Part of this path is the consolidation of systems that is now needed on the financial side of the house with a focus on deploying a single platform for financial planning, analytics and performance. The primary focus is to translate analytics not just into insights, but action.

9. You Must Protect Yourself

As organizations move deeper into data, there is increased recognition that cybersecurity is a major risk. Over 40 percent of all data breaches that occur happen in healthcare. During the keynote, JP Morgan Chase CEO Jamie Dimon shared that his organization will spend $700 million protecting itself and their customers this year. Investments in cybersecurity will continue to ramp up due to both the operational and reputational risk involved. Cybersecurity has become a board room issue and a top-of-mind initiative for executive teams at every health delivery system.

10. You Must Manage Social Determinants of Health in the Communities You Serve

Perhaps the most encouraging theme for healthcare provider organizations was the need to engage the community they serve and focus on social determinants of health. As Intermountain shared: “Zip code is more important than genetic code.” To that end, Geisinger refers to their focus on “ZNA.” They have deployed community health assistants, non-licensed workers who work on social determinants of health and have implemented a “Fresh Food Farmacy,” yielding a 20 percent decrease in hemoglobin A1c levels along with a 78 percent decrease in cost. Organizations like ProMedica Health System in Ohio have seen similar results with their focus on hunger in Toledo. WakeMed has an initiative focused on vulnerable populations in underserved communities that has resulted in a significant decrease in ER visits and admissions and over $6 million in savings.

11. You Must Help Solve the Opioid Epidemic

The opioid issue is one that healthcare professionals take very personally and feel responsible for solving. It came up in virtually in every presentation, and it’s an emotional issue for the leaders of each organization. This is good news, but the better news is that they are taking action. As an example, Geisinger invested in a CleanState Medicaid member pilot that resulted in a 23 percent decrease in ER visits and 35 percent decrease in medical spending, breaking even on their investment in less than 10 months. While many would rightly argue that the economic rationalization isn’t needed for something this important, the fact that it’s there should eliminate any excuse for anyone not taking action.

12. You Must Deliver Value

The Hospital for Special Surgery in New York is the largest orthopedics shop in the U.S. and a great example of how value-based care delivery is taking shape. Perhaps the most revealing stat they shared is that 36 percent of the time patients receive a non-surgical recommendation when they are referred to one of their providers for a second opinion. This is exactly the type of value-based counseling and decision-making that will help flip the model of healthcare. Some systems are farther along than others. Northwestern currently has 25 percent of its patients in value-based agreements, but other systems have less. As the team from Intermountain re-stated to this audience this year, “You can’t time the market on value, you should always do the right thing, right now.” Well said.  




The No. 1 takeaway from the 2019 JP Morgan Healthcare Conference: It’s the platform, stupid

If you want to understand the shifting sands of healthcare, you’ll find no better place than the nonprofit provider track during the infamous JP Morgan Healthcare Conference that took place this week in San Francisco.

Over 40,000 players were in town from every corner of the healthcare ecosystem. However, if you want to hear the heartbeat of what’s happening at ground level, you needed to literally squeeze into the standing room only nonprofit provider track where the CEOs and CFOs of 25 of the most prominent hospitals and healthcare delivery systems in the country shared their perspectives in rapid-fire 25 minute presentations.

This year those presenters represented over $300 billion, or close to 10 percent of the annual healthcare spend in U.S. healthcare. These organizations play a truly unique role in this country as they are integrated into the very fabric of the communities that they serve and are often the single largest employer in their respective regions. In other words, if you work in or care about healthcare, understanding their perspective is a must.

Every year I take a shot at condensing all of these presentations into a set of takeaways so healthcare providers who aren’t in the room can share something with their teams to help inform their strategy. So what do you need to know? Glad you asked, here you go.

Shift Happens — Moving from Being a Healthcare Provider to Creating a Platform for Health and Healthcare in Your Community

Trying to synthesize 25 presentations into a single punch line is pretty stressful. I listened to every presentation, debriefed with other healthcare providers in the audience afterwards and then spent the next 48 hours trying to process what I heard. I was stumped.

But then, finally, it hit me. To take a new spin on an old phrase, “It’s the platform, stupid.” To be clear, even though I’ve been in healthcare for close to 30 years, “stupid” in that sentence is absolutely referring to me.

So the No. 1 takeaway from the 2019 JP Healthcare Conference is this — for healthcare providers, there is a major shift taking place. They are moving from a traditional strategy of buying and building hospitals and simply providing care into a new and more dynamic strategy that focuses on leveraging the platform they have in place to create more value and growth via new and often more profitable streams of revenue. Simply stated, the healthcare delivery systems of today will increasingly leverage the platform and resources that they have in place to become a hub for both health and healthcare in the future. There is a level of urgency to move quickly. Many feel that if they don’t expand the role that they play in both health and healthcare in their community, someone else will step in.

Folks in tech would think of this as the difference between a “product” strategy (old school) and a “platform” strategy (new school). Think of this as the difference from cell phones (Blackberry) to smartphones (iPhone and Android devices). One was a product, the other was a platform. Common platforms that we’re all familiar with such as Facebook, Amazon, Google, Apple and even Starbucks have always 1) started with a very small niche, 2) built an audience, 3) built trust and 4) then added other offerings on top of that platform. By now there is no need for a “spoiler alert.” We all know that this strategy works and these companies have created a breathtaking amount of value. The comforting news for hospitals and healthcare delivery systems is that many have already completed the first three steps and have many of the building blocks they need to leverage a “platform” as a business strategy. The presentations at the JP Morgan Healthcare Conference made it clear that most are now actually taking that fourth step to separate themselves from the pack.

There is enormous upside to those who understand this pivot and take advantage of this change in the market. Dennis Dahlen, CFO of Mayo Clinic, shared his perspective on this: “Thinking differently in the future is essential. In many ways, at Mayo, we are already operating as a platform today, but we have to continue to leverage this approach to uncover additional ways that we can be a hub for both health and healthcare in our community.” Mayo’s platform includes leveraging research, big data, expert clinic insights and artificial intelligence to create new value for Mayo’s clinical practice as well as new opportunities for Mayo’s partners.

To be clear, the mental shift here is massive. It’s the difference of being on defense (where most healthcare providers are) to be being on offense (which is where they know they need to be). Executive teams have focused their time, energy and resources on driving and supporting inpatient admissions via a traditional bricks and mortar presence coupled with the acquisition of physician practices. The difficulty of thinking through what it means to truly be “asset light” and taking a different approach shouldn’t be underestimated. The good news is that the recent financial results of many health systems have improved, providing a little breathing room for investments to enable this shift in strategy. Those who don’t may fall way behind.

A New Way of Thinking — What it Means to be a Hub

Being a hub is essentially bringing together people with common interests to spark innovation and facilitate work getting done more efficiently. Examples include Silicon Valley as a “tech hub,” Los Angeles as an “entertainment hub,” New York as a “financial hub,” Washington, D.C. as a “hub for politics” and how essentially every college town is or can become a “research hub.”

Given that hospitals and health systems are the largest employers in their community, they are already set up to become a hub. In the past, they leveraged that position to simply care for the sick. Increasingly in the future, these organizations will be health and healthcare hubs for innovation and building new companies, for bringing the community together to tackle issues like hunger and homelessness, for education and training, for research and development partnerships, for coordinated, compassionate and longitudinal care delivery for treatment, for support groups for specific chronic conditions, for digital and virtual care, and for thoughtful and effective support for mental and behavioral health. Changes in the care delivery market over the last 10 years have put the right building blocks in place to make this happen.

Hiding in Plain Sight — The Single Biggest Change in Healthcare We May Ever See Has Already Happened

Taking advantage of becoming a hub and leveraging the strategic concept of being a platform requires new thinking, new structures and new skill sets. The great news for healthcare providers is they have already made the toughest move of all in order to set this in motion.

Over the last decade, there has been a massive level of consolidation with hundreds of hospitals and thousands of physician practices being acquired every year. While more mergers and acquisitions will still happen, this stunning and fundamental restructuring of healthcare delivery has taken place and there is no turning back. This is likely the single biggest shift relative to how healthcare is structured in this country that will take place during our lifetime, and it barely gets mentioned. The strategy many were chasing was primarily being driven by a “heads in beds” pay-off that was both based on offense (“an easier way to grow”) and defense (“we better buy them before someone else does”). That said, as this consolidation happened most healthcare delivery systems were really just an amalgamation of stand-alone hospitals set up as a holding company that provided no real leverage other than more top-line revenue.

During the JP Morgan Healthcare Conference, it was clear that most have made the shift from a holding company into a single operating entity. Chicago-based Northwestern Medicine shared a very refined playbook for quickly bringing acquisitions onto their “platform,” and the results are pretty stunning as they have transformed from a $1 billion academic medical center into a $5 billion regional healthcare hub in a handful of years.

And over the last few years, these organizations have gotten super serious about making the toughest decisions right away. The mega-merger of Advocate Health and Aurora Health, the largest healthcare delivery systems in Illinois and Wisconsin respectively, was accompanied by a gutsy decision to fast-track the implementation of Epic at Advocate to get the leverage of a single EHR platform across the system. While many focus on the cost of the transition and the shortcomings of some of the applications, what gets missed is the enormous long-term leverage this provides regarding communication, integration, continuity of care and, of course, access to data and the potential to improve clinical and financial performance. This creates a “platform-like” experience for both employees and customers. 

So, the twist in the story is that the pay-off for consolidation will likely be very different and perhaps much better than many had originally intended. They have the building blocks in place to be a health and healthcare platform for their community. But now they need to figure out how to truly take advantage of it.

Your Action Plan — 6 Ideas from 25 Healthcare Delivery Systems on How to Leverage Your “Platform”

During their presentations the 25 non-profit provider organizations opened up their playbooks on how others can leverage their platforms and the idea of becoming the hub for health and healthcare in their respective communities. Here is what they shared.

1. Create the Digital Front Door — or Someone Else Will

The big shift in play right now is the moving away from traditional reliance on transactional face-to-face interactions with individual providers. Building relationships and trust is something that has been a core competency and core strategic asset for hospitals in the past. In the future, this simply won’t be possible without leveraging digital platforms as we do in every other aspect of our lives today. As Stephen Klasko, MD, CEO of Philadelphia-based Jefferson Health, shared, the real strategy will be to deliver “health and healthcare with no address.”

Many provider organizations are moving aggressively to create digital front doors. Kaiser Permanente delivered 77 million virtual visits last year. Intermountain introduced a virtual hospital that provides over 40 services and has delivered over 500,000 interactions. Nearly every health system leverages MyChart or a similar personal health record platform. There is an enormous amount of risk for hospitals and health systems that don’t take action here, as traditional healthcare providers will be competing with more mainstream and polished consumer brands for the relationships and trust of the folks in their community.

As the team from Spectrum Health shared, “87 percent of Americans measure all brands against a select few — think Amazon, Netflix and Starbucks.” Google, Apple and Facebook as well as Walgreens or CVS are all going after this “digital handshake,” and are big threats to healthcare providers. There is no question that some of these organizations will be “frenemies,” where they are both competing and collaborating. Healthcare organizations will need to approach any partnerships mindful of that risk.

2. Drive Affordability and Reduce Cost — or Risk Being the Problem

As the burden of the cost of care increasingly shifts to the patient’s wallet, healthcare providers will need to play in driving affordability. Coupled with the recent federal requirement to post prices online, there is a great deal of visibility around the price of care, even if the numbers are way off the mark. Understanding and reducing the total cost of care is now viewed as a requirement. As legacy cost accounting applications relied on charges as a proxy for cost and were limited to the acute care setting, most provider organizations have or are now in the process of deploying advanced cost accounting applications with time-driven and activity-based costing capabilities including a number that presented during the conference, such as Advocate Aurora Health, Bon Secours Mercy, Boston Children’s Hospital, Hospital for Special Surgery, Intermountain Healthcare, Northwestern Medicine, Novant Health, Spectrum Health and Wellforce.

This was one of the hottest topics during the conference, and there was significant buzz regarding having a single source of truth for the cost of care across the continuum. Vinny Tammaro, CFO of Yale New Haven Health, commented, “We need to align with the evolution of consumerism and help drive affordability in healthcare. How we leverage data is mission critical to making this concept a reality. Bringing clinical and financial data together provides us with a source of truth to help both reduce the cost of care as well as reallocate our finite resources to high impact initiatives in our community.” Organizations like Intermountain Healthcare, which implemented a 2.7 percent price reduction in exchange pricing, are taking the next step in translating cost reduction into lower prices for consumers. And now healthcare systems are starting to work together to create additional leverage via Civica Rx, which now includes 750 hospitals joining forces to help lower the cost of generic drugs.

3. Tackle Social Determinants of Health — or You Won’t Be the Hub for Health in Your Community

It is always less expensive to prevent a problem than it is to fix it. The good news is that the economic incentives for hospitals and healthcare delivery systems to both think and act that way are beginning to line up. They are certainly there already for providers that are also health plans such Intermountain, Kaiser Permanente, Providence St. Joseph Health, Spectrum Health and UPMC. They are also in place for providers that have aggressively taken on population-based risk contracts such as Advocate Aurora Health. With that said, it feels like every health system is starting to lean in here — and they should.

Being the central community hub for these issues makes a ton of sense. The way that Kaiser framed it is that while they have 12 million members, there are 68 million people in the communities they serve. Taking that broader lens both allows them to make a bigger impact but also broaden their market. Many organizations, such as Henry Ford Health System, are taking on hunger via fresh food pharmacies. Geisinger shared how a 2.0 reduction in Hemoglobin A1c reduction leads to a $24,000 cost reduction per participant in their fresh food “farmacy.” So while hospitals are perfectly positioned, have the resources and know it’s the right thing to do, they are now also beginning to understand the business model tied to targeting the social determinants of health. There is also strong strategic rationale associated with taking on a broader role of driving health versus only providing healthcare.

4. Create Partnerships for Healthcare Innovation — or Lose the Upside

Spectrum Health has a $100 million venture fund. Providence St. Joseph’s Health announced a second $150 million venture capital and growth equity fund. Mayo Clinic Ventures has returned over $700 million to their organization. Jefferson Health has a 120-person innovation team focused on digital innovation and the consumer experience, partnering with companies to build solutions. These are all variations on a theme as virtually every organization that presented is leveraging their resources to make a bigger impact and drive additional upside from their platform. “We have close to 900 agreements with over 500 partners,” stated Sanda Fenwick, CEO of Boston Children’s Hospital. “Our strategy is to be a hub for research, innovation and education in order to help evolve how care is delivered. This can only be done by collaborating with others.”

5. Become the Hub for Targeted Services and Chronic Conditions — or They Will Go Elsewhere

Perhaps the best example here is the work of Hospital for Special Surgery, the largest orthopedics shop in the world. It is has become a destination for good reason — fewer complications, fewer infections, a higher discharge rate to home and fewer readmissions. The most compelling data point is that when patients come to HSS for a second opinion, one-third of the time they receive a non-surgical recommendation. The same type of shopping is increasingly going to happen for chronic conditions.

Healthcare delivery systems that take a more holistic yet targeted approach have significant potential. They will need to think more deeply about the end-to-end experience and become immersed within the community outside of the four walls of the hospital. Other players in the community, such as CVS Health and Walgreens, would say they have a platform — and they would be right. The platform that healthcare providers have built and are building will absolutely be competing against other care delivery platforms.

6. Leverage Applied Analytics — or You’ll Lose Your Way

In order to enable everything listed above, the lifeline for every health and healthcare hub will be actionable data. Applied analytics is a boring term that is actually gaining traction and starting to dislodge buzzwords like big data, machine learning and artificial intelligence relative to its importance to healthcare providers.

Similar to how analytics are being used in a practical way in baseball to determine where to throw a pitch to a batter or position players in the field, healthcare providers are pushing for practical data sets presented in a simple, actionable framework. That may seem obvious, but it is simply not present in many healthcare organizations that have been focused on building data warehouse empires without doors to let anyone in. Many organizations, such as Advocate Aurora Health, Bon Secours Mercy and Spectrum Health, have deployed more dynamic business decision support solutions to access better insight into performance and care variation. This allows them to assess opportunities to reallocate resources to invest in more productive ways to leverage their platform.

While leveraging a platform as a business strategy is new to healthcare providers, the good news is that building blocks are already in place. It’s time to leverage that platform to drive better outcomes and more affordable care in the community. And now is the time to get started.


A hospital without patients

Nurse Veronica Jones speaks with patient Richard Alfermann, who suffers from Chronic Obstructive Pulmonary Disease, during a video call on Thursday, Nov. 2, 2017, at the Mercy Virtual Care Center in Chesterfield, Mo. Jones says that she and other nurses who work with homebound patients like Alfermann feel like they have “50 grandparents.”


Located off a superhighway exit in suburban St. Louis, nestled among locust, elm and sweetgum trees, the Mercy Virtual Care Center has a lot in common with other hospitals. It has nurses and doctors and a cafeteria, and the staff spend their days looking after the very sick―checking their vital signs, recording notes, responding to orders and alarms, doing examinations and chatting with them.

There’s one thing Mercy Virtual doesn’t have: beds.

Instead, doctors and nurses sit at carrels in front of monitors that include camera-eye views of the patients and their rooms, graphs of their blood chemicals and images of their lungs and limbs, and lists of problems that computer programs tell them to look out for. The nurses wear scrubs, but the scrubs are very, very clean. The patients are elsewhere.

Mercy Virtual is arguably the world’s most advanced example of something gaining momentum in the health care world: A virtual hospital, where specialists remotely care for patients at a distance. It’s the product of converging trends in health care, including hospital consolidation, advances in remote-monitoring technology and changes in the way medicine is paid for. The result is a strange mix of hospital and office: Instead of bright fluorescent lighting, beeping alarms and the smell of chlorine, Mercy Virtual Care has striped soft rugs, muted conversation and a fountain that spills out one drop a minute. The mess and the noise are on screens, visible in the hospital rooms the staffers peer into by video—in intensive care units far away, where patients are struggling for their lives, or in the bedrooms of homebound patients, whose often-tenuous existence they track with wireless devices.

The virtual care center started as an office in Mercy’s flagship St. Louis hospital in 2006, but got its own building and separate existence two years ago. It is built on many of the new ideas gaining traction in U.S. health care, such as using virtual communication to keep chronically ill patients at home as much as possible, and avoiding expensive hospitalizations that expose patients to more stress, infections and other dangers.

But perhaps the most important factor driving Mercy Virtual isn’t technology or new thinking but new payment systems. In the near future, the hospital’s administrators believe, instead of earning fees for each treatment administered, insurers and the government will pay Mercy Virtual to keep patients well. A visit to the hushed carrels and blinking monitors is a glimpse into a future in which hospital systems are paid more when their patients are healthy, not sick.

Even now, Mercy Virtual is in the black, because of existing Medicare payment reforms that have already converted some of the agency’s payments into lump sums for treating specific illnesses. Mercy can get its patients out of the hospital much faster than average, so it pockets the money it doesn’t need for longer stays, says Mercy Virtual President Randy Moore.

The hospital is well placed, he adds, for the full transition to a payment system based on efficiency and preserving wellness. “Our idea is to deliver better patient care and outcomes at lower cost, so we can say to an insurer, ‘You expect to spend $100 million on this population this year. We can do it for $98 million with fewer hospitalizations, fewer deaths and everyone’s happy,’” says Moore. “It’s a very strong future business model.”

One weird thing about thinking this way is that it radically reimagines traditional notions of medical care—not just how it’s delivered, but when. Most hospitals wait for a sick person to walk through the doors or come into the ER. Mercy Virtual reaches out to patients before they’re even aware of symptoms. It uses technology to sense changes in hospitalized patients so subtle that bedside nurses often haven’t picked up on them. When the computer notes irregularities, nurses can turn a series of knobs that allow them to “camera in” on the patient; they can get close enough to check the label on an IV bag, or to observe a patient struggling for breath or whose skin is turning gray.

There are those who say that even an intensive care unit could, in principle, be brought to a patient’s home. But for now, the future looks like this: Hospitals will keep doing things like deliveries, appendectomies and sewing up the victims of shootings and car wrecks. They’ll also have to care for people with diseases like diabetes, heart failure and cancer when they take bad turns. But in the future, the mission of the hospital will be to keep patients from coming through their doors in the first place.

Racing the Symptoms

On a recent Monday morning, nurse Veronica Jones touched a button on a screen in front of her to make a video call with Richard Alfermann, a retired 75-year-old banker living on a wooded acre outside Washington, Missouri, 50 miles west of the center. A lifelong smoker until 10 years ago, Alfermann suffers from chronic obstructive pulmonary disease, or COPD. He has trouble breathing and even slight exertion can floor him. The most minor illness, in the past, was enough to force him into the hospital.

Seated on a couch in his home, Alfermann happily greets Jones, with whom he has spoken through video at least twice a week since entering the virtual care program in August 2016. The previous year, he was hospitalized three times. Since then, Alfermann has managed to stay in his home.

One paradox of care at home is this: Monitoring patients from afar with regularity can create more intimacy between patient and his caregivers than a sporadic, once-every-three-months visit in person. Jones and the other nurses on the virtual ward say they feel like “we have 50 grandparents now,” she says. In addition to the touchless warmth, regular interactions enable more individualized care. For example, many COPD patients have such high pulse rates on a good day that an unsuspecting doctor might immediately send them to an ICU. A tele-doctor in regular contact, however, can distinguish a true crisis from a baseline reading that might seem alarming but is normal for that patient.

In Alfermann’s case, if he shows signs of failing health, his physician―Carter Fenton, an emergency medicine doctor with 450 patients under his care—can call in home health care nurses, who can examine Alfermann more closely, take X-rays and EKGs and blood samples if necessary. In a sense, Mercy has given Alfermann his own hospital, a home hospital.

And that’s the main purpose of the “engagement at home” program—to keep very sick patients out of the hospital, where their care runs up enormous bills and is laced with dangers to the patient, ranging from nasty bacterial infections to misplaced drug orders to the disorientation of constant alarms, tests and injections. “A telemedicine visit is never going to be as good as having a doctor and his or her team at your bedside,” says Moore. “But 99 percent of the time we can’t make that happen. With virtual we can at least see any patient just like that―rather than tomorrow or next week. And that can be a life or death thing.”

One major aspect of the hospital of the future, it seems, is “less hospital, more future,” says Robin Cook, a former ophthalmologist and the best-selling author of medical thrillers that feature things like roboticized hospitals and killer apps that actually kill their patients. People will continue to go to hospitals—or, increasingly, outpatient surgical centers―to get operations, but their stays will be shorter. “It’s going to be progressively more procedure-oriented, with a lot less parking people to monitor them,” says Cook.

As Alfermann, his nose fitted with a cannula bringing him 100 percent oxygen, pops up on the monitor in front of her, Jones is examining his vital signs, which include blood pressure, pulse, temperature and blood oxygen readings that feed wirelessly into the system from devices that Alfermann attaches to himself at home.

Most medical interventions take place when a patient presents himself at a doctor’s office or an emergency room. Because “frequent flyers” hate going to the hospital—often a traumatic place for the old and infirm–they’re often in denial about any symptoms they may have, which, ironically, raises the risk that things will get to a critical point if no medical staff are watching.

“A lot of times they’ll say, ‘I feel fine,’ but I can see on the monitor that they are struggling to breathe,” says Fenton. “I remind them that this is how things got started the last time they were hospitalized. There’s a trust factor at first. Sometimes it takes a trip to the ER to vindicate us.”

Today, the concern is Alfermann’s pulse. It’s been above 100 beats per minute twice the last three mornings, from its usual level around 85. Pulse is “a big clue that he may not know what’s happening but something may be about to happen,” Fenton says. He and Jones worry that with cooler weather and drier air, Alfermann might be developing a cold that could exacerbate his COPD.

“Any shortness of breath or changes in your cough?” Jones asks. “Any fever or chills?”

“I don’t think so,” responds Alfermann, a fan of bowling, fishing, and the St. Louis Cardinals. “Yeah. Nothing better, nothing worse. Same old shit.”

“If anything changes with that you know you got to call me right way.”

Jones and Fenton monitor Alfermann carefully over the next several days to make sure there’s no incipient problem. But by Wednesday his pulse is back to normal. Until the next time. “I don’t feel super, but I’m OK,” he tells Fenton. “I haven’t felt good in so long I don’t know what good is.”

Reassured for the moment, Fenton knows there’s always an escape valve. “We always tell the patients, if you feel like you’re getting worse, you need to just go to the hospital,” he said.

Virtual ICU
On the other end of the second floor at Mercy Virtual Care, which is a maze of desks and computer screens, nurses and doctors have their fingers deep in the business of colleagues at hospitals across the country, from North Carolina to Oklahoma. They run a series of programs —TeleICU, TeleStroke, TeleSepsis and TeleHospitalist — all aimed at keeping hospitalized patients from growing sicker and at getting them home faster.

In part, the virtual ICU is dealing with a problem that technology created. All the beeping monitors in the patient’s hospital room crank out massive amounts of information, presented in too cumbersome a way for nurses and doctors on site—at least in typically understaffed hospitals―to deal with quickly. So Mercy Virtual provides nurses and doctors who can focus on monitoring and digesting these data streams, looking for signs of trouble. That way the nurses and doctors on site can pay more attention to the patients and less to the machines.

Electronic health records, which most hospitals started using over the past decade, “inundated us with data,” says Chris Veremakis, who runs Mercy’s TeleICU program. “The EHR has become a thing of its own, and you find people spending so much time in front of the EHR instead of spending time with the patient.”

A layer of backstopping colleagues, watching the data roll in in real time, can improve the quality of treatment by making sure good care standards are being met and catching signs that a patient is going downhill, Veremakis says: “We let the nurses on the floor do their regular work and not be pulled in a million different directions.”

One of the intense professionals doing this is Tris Wegener, who was an ICU nurse for 22 years before a snowmobiling accident wrecked her arm and led her to virtual nursing. Now she spends most of her days at Mercy seated in front of a bank of computer screens. She’s waiting for the appearance of a little red flower icon, which means that a computer program, after taking in data from the monitors in the patient’s room, is warning of a danger of sepsis, an immune response to a bacterial bloodstream infection that is the No. 1 hospital killer.

Sepsis can be hard to spot, manifesting itself in irregular symptoms. It’s on the increase among chronically ill patients who are living longer than before―about 1.5 million people get sepsis in the U.S. every year, and 1 in 6 die. When one of the red sepsis flowers pops up, Wegener makes a series of inquiries to rule out false positives. If the patient meets all the criteria—typically very low blood pressure, high fever, infection and high levels of lactic acid—she calls the nurse or doctor on duty. The hospital might be in High Point, North Carolina, Joplin, Missouri, or a dozen other places.

“I get the data as soon as it enters the system,” she says. “The nurse on duty might have three other patients. Is she aware of the problem? Sometimes, sometimes not. She might have another patient who’s coding in the emergency room. They don’t have time to check out this patient whose X-ray looks clear, but we know that tomorrow, if this isn’t taken care of, he’s going to code with pneumonia.”

It’s not unusual for the entire staff of a small ICU to rush into a patient’s room when a patient crashes. When that happens and Mercy is watching, its remote nurses can keep an eye on the other patients while those at the scene take care of the most critical case.

Working on a single shift not long ago, Wegener and two other virtual nurses had to sort through 136 sepsis alerts from hospitals around the country. Each one takes as long as 40 minutes to resolve. “It keeps your mind going,” she said.

“The job isn’t physically demanding but mentally, oh gosh,” says Lindsey Langley, whose expertise is in diagnosing and ordering treatment for stroke—a condition in which speedy diagnosis and treatment can be the difference between a minor tic and death, or a grave, lifelong disability. “You go home every day exhausted. You are tapped out.”

Most of Mercy’s telehealth and remote monitoring covers patients and hospitals inside the small Catholic hospital system, which has facilities in Missouri, Arkansas, Oklahoma and Kansas. But it also partnered with hospital systems at the University of North Carolina and Penn State. Part of the attraction is the backup Mercy provides to hospitals that serve uninsured or low income patients and can’t afford to staff up to levels that might be desirable.

“Mercy runs 24/7 in the background collecting analytics on our patient population,” said Dale Williams, chief medical officer at 351-bed High Point Regional hospital in North Carolina, which is part of the UNC system. As they gather vital signs, EKG data and so on, the Mercy staff can alert brick-and-mortar staff to any significant changes. If there isn’t a nurse or doctor in the room, they intervene.

Of course, a nurse in St. Louis can’t fill an IV fluid bag in North Carolina, but she can use a camera in the room to see that an IV bag is almost empty—then call and instruct a nurse on the floor to refill it. The telemedicine cameras are powerful enough to detect a patient’s skin color; microphones can pick up coughs and gasps and groans.

Making that order from far-off St. Louis can be a delicate matter until the virtual nurses and doctors establish good working relationships with their partners in the flesh-and-blood world. Unsurprisingly, when Mercy starts its virtual relationships with these hospitals, the professionals on site often aren’t exactly enthused to be getting instructions from afar.

“People just think that they can put the technology in place and get amazing results,” said Moore, who estimated that Mercy had spent $300 million to create the virtual care center. But acculturation is key to the process. At most ICUs and other hospital services, physicians and nurses already think they are operating at top capability. It takes work to convince them that their services would be better with help from outside.

“We’ll spend time with them and say, ‘This isn’t Big Brother looking over your shoulders: We’re partners,’” he said. “But doctors don’t necessarily want other doctors writing their orders, and if they won’t accept it, it doesn’t work. If a nurse ignores our team because she’s too busy and not used to TeleICU, nothing happens.”

Sometimes the cultural shifts required may be a bit too much to work. Tampa General Hospital piloted a TeleICU relationship with Mercy Virtual for six months, but ended the agreement Nov. 15. The hospital gave no explanation for the decision.

Longer term partners, however, seem to have converted to the concept. “A decade ago I would have said, ‘I don’t know that that can work,’” said Williams, who has been working with Mercy Virtual for about two years. “I’ve been convinced. It would be ideal to have a doctor in each unit 24/7, but even then they can’t be looking at the analytics the way these people do. They have critical care-trained nurses and doctors looking at this stuff all the time. They can camera in and count the pores on someone’s nose.”

Williams’ hospital has two critical care doctors who take care of the 28-bed intensive care unit from 7 a.m. to 6 p.m. each day, with “Mercy running in the background,” he said. After 6 p.m., nurses on the ward continue to do their thing, but Mercy is in charge.

“This allows our guys to go home on backup call,” he said. If needed, the doctor can always drive back to the hospital, but most nights Mercy’s intensivists take care of problems. “This allows us the best of both worlds. We have constant analytics and if something is changing that’s not seen by nursing staff, they’re right there monitoring it in St. Louis.”

The relationship has improved outcomes at High Point, Williams said. Doctors who used to get burned out and quit after a year or two tend to leave less often. And the hospital’s care has improved year after year—fewer hospital infections, fewer patient days on ventilators, fewer readmissions and better patient survival, he said.

For now, Mercy and its partners have one foot in the old payment system and the other in the new world, where best outcomes and money align. But there are still administrators at Mercy hospitals who see fewer admissions and days in the hospital and “aren’t particularly happy about it,” Veremakis said. “There is an awkwardness in this time. But enough people with vision recognize this is the right way to go.”

Mercy Virtual’s ICU nurses, most of whom had years of experience before coming here, are sometimes a bit nostalgic for the bedside, with its immediacy and adrenaline. “You’re used to being in charge. Here you’re part of a team,” said Wegener. “If you think something is not being done you have to be polite.

“And there’s no way I can put a price on being able to put my hand on a patient and say, ‘My name is Tris.’”