10_How Shared Expertise and Best Practices Keep Organizations Strong

Hosted by Quint Studer with special guest Tim Gronniger

Caravan Health helps clients align their efforts in three key areas: clinical needs, operational execution, and business realities. In this podcast Quint talks with Tim Gronniger, CEO of Caravan Health, who unveils his company’s highly successful model for helping healthcare organizations thrive in an incredibly tough environment.

His company shares the expertise and best practices clients need to navigate the complex Accountable Care Organization (ACO) system while reducing administrative risk and freeing themselves to do what they do best: practice patient care. Not only does Caravan help create the ACO, they stay with clients long-term and offer ongoing guidance. Tim explains how players of all sizes can better understand and leverage their data and implement survival strategies like sharing resources, expertise, and technology…while reaping the benefits of scale.

Quint Studer 0:57
It is just wonderful to have you on today. I have such great respect for Caravan. I remember meeting Lynn years ago, and she just got named one of the most influential women in healthcare who’s of course, I think the founder of Caravan have good friends at Caravan last year, one of my highlights of my year was doing a presentation at your conference because you provide such great services to people who are in such a need of it. And it’s just so obvious the difference you’re making for people. But for those of you that really don’t know, as much as I know about Caravan, why don’t you describe what caravan is and what it does?

Tim Gronniger 2:29
Yeah, absolutely. And I want to thank you Quint, for for having me on today and for your participation in last year’s symposium. And this year’s all virtual symposium, we’re really excited about that coming up in a couple of weeks. Like you say, Caravan was Caravan health is a company that was founded over five years ago by Lynn Barr, our who’s who’s still our board chair and is still very involved. We grew up in, in rural healthcare in parts of the country where these are, these are not the the parts of the country where all the technology gets adopted first, where we have tons of resources and where we are able to just throw money at a problem and solve it. We, you know, our founding members weren’t large enough to form their own Accountable Care Organization at the time. And so they had to work together, by necessity and by requirements of the program, to be able to get access to data on their patients and to have the opportunity to participate in the program. And, you know, Medicare Shared Savings Program in this context was a new program at the time that offered providers the opportunity to to be rewarded for providing high quality care for their patients and managing the total cost of care of their patients, which was very new at the time and was built around some of the work I had done on Capitol Hill and CMS and Medicare agency, general idea trying to step away from from fee for service only medicine and step more towards population health based medicine where you do better by keeping your patients healthier over time, until Caravan grew out of that are those early days of needing to support rural providers working across state lines at our early clients were based in Michigan in the state of Washington and Mississippi, all in the same ACO, which is really a radical idea that Lynn had, but the concept was, it didn’t matter where you were. But that’s providing more preventive care for patients and providing better management for chronically ill patients. Those are problems in every state in America. And if you’re working on those same problems together, you can share resources and you can share technology and you can share best practices across state lines across the country and to take advantage of getting larger and getting scale together. And caravan facilitates that and so what really differentiates us we’ve grown a lot since then we are still rural, but we are also in urban areas and suburban areas with the real focus on safety net facilities, County Health Hospitals and hospitals and health systems that are serving patients that they don’t have as much as other parts of the country. What differentiates us is our our focus on aligning that clinical needs operational execution and business realities. So it’s not enough to say that primary care is broken, we need to do better. We need more prevention and care management for high risk patients more data and insight and panel management, that’s all true. But we also need to implement change in a way that’s practical and sustains itself financially. Otherwise, our champions in our communities will lose their jobs, because they’re pursuing programs that are going to lose the money, lose money, and put their facilities out of business. So we try to always keep our focus on the combination of those three, clinical, operational, financial, and that’s what helps our clients be successful in these programs. And that’s what allowed us to, to serve all of these facilities across the country, and have them be very successful in Medicare Shared Savings Program last year, 70% of them received shared savings payments versus the national average of 50% in the program, so we’re very proud of that. And we’re very proud of the quality improvements that they’ve been able able to achieve getting much higher rates of vaccination than is typical in their communities before joining the program, just as one example.

Quint Studer 6:14
I think, Tim, you hit something really important. Um, I was talking with David Schneider. He’s the CEO of Dixon Hospital in Dixon, Illinois. It’s an 80 bed hospital last night. And I started out as a 35 bed hospital. So I sort of used to joke, you know, whoever who your switchboard is, whoever’s closest to the phone in those days. Yeah. And I think David told me that, like 120, small hospitals are essential hospitals, whatever, rural hospitals have gone out of business. So when I look at caravan, in many ways, you’re providing services that if you didn’t provide it, some of these organizations might not be able to provide the care to their communities. Is that true?

Tim Gronniger 6:58
Yeah, absolutely. And, and there are a million reasons why rural hospitals are struggling and closing and, and we address and try to provide solutions for some of them. Not all of them, right. But our clients are rural hospitals are figuring out ways with us to develop new ways of caring for their patients to generate new business models for them that are that weren’t available 10 or 15 years ago. So you can, if you get good at managing your patients longitudinally, not just when they show up, but keeping track of them, keeping them healthy, you can now generate revenue based on that in ways that weren’t possible before. And that can help sustain rural hospitals. There are, there are important new innovation center models always coming out from CMS focused on rural facilities. And figuring out how to use those effectively is important for for rural hospitals as well. And that’s, that’s something that we spend a lot of time with our clients on is translating policy into, to practical business implementation. And so keeping you know, keeping access to two primary care to urgent care to obstetrics in rural communities requires a lot of work and a lot of investment from different parts of the ecosystem. And we try to bring it all together as much as possible for our clients.

Quint Studer 8:17
Welcome. I think that’s why Caravan was so smart and bringing you on. Because you know, your background with CMS, your background was on the policy side, and then to bring it back, because usually if somebody understands policy, but they don’t operate, something that operates and understand policy, the fact that you have skill set and both and I know you do not because you’ve told me that, but because people who work with you have told me that. And I think that’s the value that you have brought to care of them. It’s been been really, really unique and really special for them. What about this is a question I have, if I’m a small hospital, and I’m part of a big system, can I still benefit from caravan or not?

Tim Gronniger 8:56
Yeah, absolutely. We work with different structured systems, we work with rural hospitals, we work with combinations of referral centers in their their rural satellite centers and their rural health clinics. For us, it’s really about figuring out for every system and every community hospital out there, figuring out an approach to, to governance into to look how they look at their data, how they look at their patients, that’s going to work with organization and it’s going to take what they have and and get them somewhere better in the future because they we haven’t ever and as you know, from all of your work, in your experience, even the best organizations inevitably have a lot of room to grow or they have future challenges that they need to prepare for. And so we we early on, in all of our engagements, we do detailed assessments and reviews of their local environment and develop a strategic plan for where they need to get to to be well positioned for the future.

Quint Studer 9:53
Yeah, it seems to me you you help some hospitals stay more independent because you sort of partner with them. They’re there, you help some hospitals become strong enough. So when they do joint go to join the system, they have bring a little more leverage to the table and you help some that are in the system get a little more attention that they would. Because, you know, again, I’ve talked to a lot of people and sometimes you’re part of a big system, but you’re one of the smaller players, you just might not get the attention or the strategy for the big system might not be the right strategy for your individual hospital.

Tim Gronniger 10:26
Yeah, that’s right. And we, um, you know, like you say, I still stay in touch with the policy world here in DC a lot. And there’s always a lot of concern about well, are we going to be facilitating consolidation and monopoly behaviors if we are creating larger SEOs? From our perspective, stitching together collaborative SEOs of composed composed of rural and community hospitals, safety net facilities, cuts against consolidation. So you know, I’m in the DC area, and I have six hours drive from Pittsburgh, just to name a specific example. If I drive a couple hours outside of town, I start to see UPMC clinics from the from the, you know, the excellent facility in Pittsburgh that is growing, sort of inexorably every direction, right. UPMC is not a client, I certainly would be open to working with him on certain projects, but our facilities would be much more likely to be our clients would be the ones that are trying to find strategies to survive in a world where the major behemoths are sort of constantly encroaching upon their service areas. And they need to be able to share resources, share expertise, share technology, to be able to, to, to create new, to create new models and to to survive in that environment.

Quint Studer 11:41
Yeah, it’s interesting in my book, Building a Vibrant Communities, it’s really geared toward those smaller mid market cities have lost so much talent. So when you’re talking about the communities I’m thinking of, you know, this year before COVID, I’ve been in Chillicothe, Ohio, you know, Elkins, West Virginia, the daily in Georgia, just exactly the type of places that that you talk about. So it’s really, really neat. Tell me for those of you that might just be a little bit unfamiliar. Give me a quick, as quick as you can a description of an ACO?

Tim Gronniger 12:15
It’s a great question. And it’s really important not to glide gloss over this. So just a historically, organization and financing of Medicare and all healthcare, claims payment really is a provider up provides a service, whether it’s a surgery or a test, they’re reimbursed for it, and you go on with your merry way. There’s nothing that follows whether whether it was well done, not well done, whether the patient benefited from it or not backing up, say 20 years, there’s been a long known problem with that structure, which is that it is it tends to be inflationary, and it doesn’t provide a lot of attention to the quality of care that patients are receiving. The classic example being a hospital discharges a patient of with chronic heart failure, congestive heart failure, patient is readmitted three times in the next four months, hospitals paid more under that cycle. And maybe they could have done something that would have better manage that patient’s care at home. But why would they because investing in that would deplete their revenue, they have no way to recapture any of that revenue because of the structure fee for service, accountable care organizations or contracts. structure that was created through the Affordable Care Act in Medicare and adopted by many payers outside of Medicare as well. There’s more than 1000 ACO contracts in operation today, commercial Medicare otherwise general idea of an ACO contract says we want to we the payer and we the patient’s care about how the patient is cared for over the course of a year. And you know longer but it’s usually measured in a year. And so if you do a good job managing total cost of care for the year, you the health system, or you the physician can share in some of the savings from that. And that’s measured against annual benchmark, or, or other metrics. Sometimes, we’re also going to because we don’t only care about money here, we’re also going to track clinical quality measures. And so we’re going to track how you do on prevention. We’re going to track how we do on diabetes management, we’re going to track how you do on depression screening. And if you don’t do a good enough job on those you aren’t eligible for any shared savings. And so this is meant to flip the consideration flip the incentive on those readmissions, say where? Well now, rather than spending those resources on inpatient care that, you know, maybe the patient needed to be admitted two out of those four times. Let’s invest in post acute care and let’s invest in sending a nurse to visit with the patient at home more routinely. Or let’s invest in care management services where we’re staying in frequent touch with the patient or providing remote monitoring services, a scale that’s Bluetooth enabled, say with an iPad that will transmitted back to us so we can catch a patient who’s spiraling out of town. Before they have to be readmitted. So the general general restructuring of the relationship between the payer and the provider with a goal towards getting more alignment with what patients actually care about, which is managing their own health in their own costs that they are paying and co pays and coinsurance over the course of years.

Quint Studer 15:20
On Yeah, I learned this again, last year at your symposium, I got to meet so many great people. And they’re so grateful to what Caravan’s bringing to them in their community, because these are things that they might not be that they would not be able to do without the services that you offer, how do you help up a hospital that sort of, you know, some small hospitals, particularly, are pretty risk adverse, because, you know, that bad month, they can’t make up, they’re not the big as they became, and that can have a bad month? And make it up? How do you get them sort of through that transition period, where they want to be involved, but they’re sort of afraid of taking the risk?

Tim Gronniger 16:01
Yeah, so the most important thing we can do is put examples in front of them of other rural hospitals that have done this and done it well, right. And at this point, we have, you know, scores of case studies and, and data runs, showing that that a rural hospital, even with very limited resources can make this work financially can make it work operationally, can make it work for their patients, we also spend a lot of time walking them through very discrete implementation plans and project plans that will show them, it’s not just us saying that, if you, if you provide more wellness visits to your Medicare patients, that’s going to fund the investment in primary care require the staffing required to do this work, you know, we’ll show you in practical terms, what you need to do to make it happen will show you a job description will show you the trainings that they’re going to receive from us. And we’ll show you the tools and educational templates that they’ll be using. And so we walk them through it in very practical terms. And then when it comes time to, you know, fortunately, none of these models require a downside financial commitment, that is a promise to pay the government if the if cost of the population go up until year three, typically. And at that point, we’ve we’ve either had enough experience with them, where they’ve been able to build up reserves to fund their portion of the risk requirement, or in some cases, they may be eligible with us to take for us to take all of their downside risk, if we’ve been able to, to prove the program with them, and have confidence that they’re going to be able to, to perform at a good level going forward in the program. And so we have made that, that option available to some of our clients. And that has been in some cases, that’s what you’ve got to do. Because there’s just like you say, there’s there’s such risk aversion and small facilities, understandably, because they need to stay open, they can’t take the risk of writing a check to CMS at all. And so in some cases, we will take that final backstop for them.

Quint Studer 18:00
Thank you, Tim. When ACOs first came about, you know, you read all this stuff well, these hospitals signed up and it didn’t work for them or these they lost money on it. And I think what happened is ACO became a general term and people just thought they’re all the same and they’re not I know what I was just blown away at what you bring to your the hospitals you serve was almost like a feeling of everybody was on the trip together the teamwork between the hospitals, the it’s a partnership you have with with your with your hospitals that you serve, so you provide such a great service to them. And I hope the listeners if they’re part of an ACO I think they can learn a lot from how Caravan doesn’t if they’re not I’m just know this if I was president of a small hospital right now, I would not be walking to Caravan I try to be running the Caravan or virtually connecting with Caravan. Because not only it’s just the expertise you bring to the table, and it’s so beyond what most organizations have equitable, any organization I think has even big organizations can learn a lot from smaller organizations, because smaller organizations sometimes have to be even more creative than the big ones. So I want to thank you for what your caravan is doing for patients. And that’s really what we’re talking about is you’re helping those that help the patients. So with COVID and you’re very virtual anyway, has caused, you know, tell me what does it what’s the impact it’s had on Caravan and those that you serve?

Tim Gronniger 19:37
Yeah, obviously a really tumultuous year and just a really difficult year for the healthcare system. And right now, I fear we’re getting the worst of it at this point. And we’re just hearing stories that will break your heart honestly of what what are the clinicians and the staff are going through at our clients right now. We’ve had just in the Last week, we’ve heard a number of a physician at one of our, one of our clients passed away from COVID. Same, you know, same reports for a pharmacist and other clients and, you know, scores of staff, you read, you know, Mayo Clinic, not not a client, but you know that you see, they have 900 staff infected in the last month. So that the year has been very trying for our clients. First and foremost, I wanted to, you know, really center that in the discussion. And so our immediate reaction to that, as, as an employer, ourselves, our first, when this happened, our first need was to ensure the safety of our employees. And we are not providers, we have nurses and physicians on staff, but they’re in educator roles. They’re an expert roles. And so we had to immediately not just secure the safety of our employees, but then reconsider how our teachings and our work fit in the context of what our clients are going through this year. And so, you know, we aren’t going to be pushing our clients to bring in in March, this is to be bringing in all of their patients for annual wellness visits, when we still don’t have an understanding of what’s what the epidemiology of the viruses and how it’s how it’s safe to see patients in person in person. And so we had to very quickly like the entire healthcare system. But again, working for our clients who don’t have the same resources, as many others, figure out how we can serve them and help them adapt to the new reality of the need to implement tele-health programs overnight, essentially, they need to adapt to changing recommendations from CDC and other health authorities, local public health authorities rapidly to figure out how to get their patients access to care, you know, the patients you read stories of

in April and May of even missing appendicitis as much less than missing cancer patients in in health care facilities. And how can we support our clients in reaching patients who still need care, but aren’t presenting themselves in the same way? Because they are, they’re terrified. And so for us, it was a dramatic pivot. And we sort of did a hard read of all of our teachings, all of our work with our clients, refocused our, our frequent touch points with our clients to be to be entirely focused on COVID issues where appropriate, you know, produced 100 new teaching resources around virtual care around tele-health and made those available freely to the public on our website. And to organizations like AAFP, and state based Primary Care Organizations that pick them up and use them that are really focused on what our core strengths are as a company, which is practical implementation of new technologies, new workflows, and focused on how do you do it? What is your staff need to know? What do patients need to know? And how do you get paid for it? Right, and that that’s something that we spent all of our time in the spring on. And then over the course of the year, and some things returned to normal in the summer, and some things ebbed and flowed in our client sites. And you know, our footprint is National. So we always had different clients going through different phases of this epidemic. But consistently, we needed to adapt to not being able to be on site nearly as much as we used to be really at all with a couple of exceptions this year. And so we we adapted all of our workshops to two virtual formats. We made them focused on recovering preventive care. You probably have seen the data but acute care services have over through October, this is probably falling off again, acute care services rebounded to their prior year levels on a monthly basis. Still with a big cumulative gap. Preventive care services have not caught up at all. And so patients have not been able to to get flu vaccines at the same rates and vaccines not happening at the same rate screenings not happening at the same rate. So we’ve been focusing on where clients have capacity, helping them get back to where they need to be in population health and prevention. And doing all of that in a virtual environment ourselves as, as you talked about earlier, the you know, we do a lot of educational events, we have our annual symposium coming up, we’ve had to learn how to do massive virtual conferences, for the first time ourselves as a company. And that actually opens up some opportunities, right? Because you can reach people who don’t have to fly to Arizona or don’t have to fly to Florida. And so we’ve tried to be smart in in taking advantage of some of these new technologies because it has enabled us to do things we couldn’t do if we were trying to be only in person.

Quint Studer 24:48
I think to me, right? Again, being in rural, you know, when when I was involved with this tutor group, we had 200 rural hospitals and for them to travel for them to find the backup Staff now, before COVID, but even with COVID, you know, because they’re not they don’t have an airport right in town. You know, I mean, this is a long process. So I think the services you’ve always offered are exceptional. And I’m just sitting here thinking what a gift you are to the smaller hospitals, because you are bringing one, it’s almost like a virtual system to them. But what you’re also bringing is just such intellectual capital. I know really, so much of the time when I was in a 35 bed hospital, we know we’re doing the best we can, but it’s that access to the intellectual capital. And then when you read all these articles, they’re always about these big places, these big places or not a big place, you actually bring the best practices for somebody that looks like me, somebody that has the same issues of me. So I just think the wealth of intellectual best practices you have and the intellectual capital you bring to the table, just so vital, and no one limb, what I also love about it, it’s all about doing it for the right reasons. It’s doing it because you truly want to make a difference in healthcare and after getting to know you also, so what’s what’s your biggest learning this year? I mean, you came from Capitol Hill and policy, and you’ve now been in the in the, in the, you know, in the trenches here. And now the then you get into the trenches that are very tough time to be in the trenches. What some some of your biggest learnings from this this past year? Yeah, well, you,

Tim Gronniger 26:29
you, you hit the nail on the head that our client in our orientation has been really trying to bring to bring best practices from all over to places that might not otherwise have it and credit to to Lynn and some of our founding members like Tim Putnam, in Indiana, and Chris Baumgartner in Michigan for, for that approach. And, you know, I’ve continued to learn at all my stops along my career, and this year, surprising learnings for all of us in the country, I think, in a lot of ways. But certainly, we can do a lot from home, you know, we’ve been able to do far more than I would think possible with, with a fully remote workforce and used to be, you’d think you can’t close a deal, you can’t close a sale, without being in person. Well, it turns out, you can, if the if, if you can develop trust, and if you’ve got the if you’ve got something that the client needs, then being in person isn’t a requirement, it turns out, I think as a company, it’s also underlying something we were really focusing on. Towards the end of last year, you really can’t communicate enough during periods of uncertainty and change. We were we were sort of early on communicating on a daily basis with our employees about what was happening and doing all hands calls, you know, three, four or five times a week. Whereas before, we might have done it once a month. We’ve been you know, we’ve kept up a pace of about every other week through this and, and that really translates through in communicating what the company’s strategic vision is, we use the objectives and key results framework ourselves. And you’re constantly coming back to what is our mission, vision and values, and reinforcing that with with staff and managers so that it’s easy for people to get lost, when it may be clear for you and me and our clinical leaders, why we are changing our teachings on a particular clinical workflow, why we’re changing our opinion about a particular technology or implementation solution. But if we don’t, if we don’t communicate and train on that, then the people who actually are talking to our clients are not going to be able to explain what we’re doing, they’re not going to be able to communicate any rationale. So we’ve had to really increase the frequency of our communication through this through this year.

Quint Studer 28:51
So what are you looking back? And if I was, Tim, I’d be sitting here thinking, you know, when you’re on Capitol Hill, doing your great work there when you were at CMS, doing great work there. That’s wonderful. But sometimes you’re not as close to actually getting the reward and recognition because as close to the actual action, you certainly are now, what do you feel best about when you look at your transition to caravan and what what the organization is doing right now?

Unknown Speaker 29:22
Well, you know, I’ve

Tim Gronniger 29:23
um, as I was looking in preparing for today, looking at this question, in particular, and I’m not to derail the topic, I will say that this this year has been hard on everyone and in particular, it hit home for me this week. My mother was admitted to the hospital with coronavirus last night and so I don’t feel great about anything right now to be honest. But I will say she seems she’s in ok shape. She we think it’s going to be fine. It’s been such a traumatic year for the country. And this is something you’ve talked about that we’ve got a lot to do. To recover from as a health health care system at this point, and I feel great about the people, I work with a caravan and the the commitment that they have to serving our clients all over the country and the work that they put in this year. You know, you have parents of young children in your life, we have, you know, about 30 40% of our staff is dealing with children at home while they’re working, including myself, and it’s just been, it’s, it will drive anyone crazy as, as anyone who has looked at our consider that situation, well, we’ll know. But I feel like we have people caravan and in our clients who are, who really care and who are going to get through this and then recover from this rapidly now, now that we see a vaccine in the near term. So I’m very optimistic about what the start of 2021 is going to bring for the health care system and for the country as we start to recover from this.

Quint Studer 30:59
You know, Tim, I just had this conversation the other day. And I don’t think you know, people, I think they don’t mean it, but they’ll say something like, Well, some good things have come out of coal, but I think you really, yeah. And then they’ll say tele-health, so by the time we get done with that sentence, everybody’s already so sad. So it’s not, it’s just we were doing the best we can with what we’ve got. And just, you know, I know this is audio, so they won’t be able to see your face. But I can tell talking to you this morning, your mother’s on your mind, I can see the emotion in you. And the one thing, Tim, as we wrap up, I think you should feel best about is your employees love you and your leadership. And I know people at caravan and I know people aren’t going to tell me something to tell me something, or tell me something because I’m going to share it with you. I think the leadership that you and your executive team have brought out to show that you put their safety first the understanding of you’re an employee, and you’ve got kids and you’ve got virtual and you know, everybody in your extended family and neighborhood things because you work in healthcare unique, you’re the expert. And I think what I will tell you what I think you should feel best about is the unbelievably compassionate and empathetic leadership that you brought to caravan in the past. And you certainly brought it this year. So I’m really excited to be at coming to your symposium here, December 10. You know, I’m just thrilled. And I think what you brought up is a lot of what I’m going to talk about, what do you do as a leader today, when your employees are feeling such trauma, that you’ve got to lead much differently than you’ve ever led before. And you’re one of those examples of a leader that’s figured out and has done it the right way. So thank you for what you’ve done for caravan thanks caravan for what you’ve done to make healthcare better, which means you make patients better, which means in essence, you’ve made communities better. So someone has been kicking around health care for a long, long time. You’re one of my heroes. So thank you so much for being on the busy leaders podcast today.

Tim Gronniger 33:05
Likewise, thanks so much Quint. I really enjoyed it.

Unknown Speaker 33:07
Thank you.