Q&A w/ Carilion Clinic president and CEO Nancy Howell Agee on moving towards value-based care

Nancy Howell Agee has been the president and CEO of Carilion Clinic, Roanoke’s largest health system, since 2011 and has guided its seven hospitals and other health care facilities through the COVID-19 pandemic, which has stretched into its 19th month. Agee also gained national recognition as the immediate past chair of the American Hospital Organization. In this Q&A, Agee speaks on staying resilient throughout the pandemic, the success of telehealth, and initiating a system-wide move towards value-based care.

 

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Nicole Pasia: How have your hospitals continued to respond to the pandemic? What might be different now, with the rise of new variants, than last year?

Nancy Howell Agee: “I think I’m numb to the question these days. This is now 19 months in, and I would say that everyone is more than a little tired. ‘Tired’ means you can go home at night and sleep and you can get over it. The general malaise, the fatigue, the exhaustion that our staff feels is real. Their distress, their frustration, their concerns are real, and it’s really a very difficult position to be in. They’re fantastic, they’re resilient, they’re just amazing. I made rounds last week, and personally gave booster shots in our COVID unit in the emergency department. It was just heartwarming because everyone was thankful for the boosters, but more importantly was just saying, ‘We’re all going to get through those together.’ 

I think the difference between the surge that we had over last January, February, and then the law that we had in July, thinking that we were coming out of it was almost a cause for celebration. Then to slam back into another surge has been painful. And the surge that we have currently is a bit different than the one we had in the winter. In the winter, it was largely older people. You saw more use of [progressive] level care than ICU level care. This time the population’s younger. The average age is in the mid-50s and the acuity is even greater. So we’re seeing heavy use of our ICUs, a lot of patients intubated, on ventilators, a heavy use of [extracorporeal membrane oxygenation] — so, really sick patients.”

NP: How has telehealth shaped your operations? I recall that Carilion Clinic had already been planning to expand its telehealth services pre-pandemic. 

NHA: “Prior to the pandemic, we were already doing a fair amount of telehealth. We cover a large geographic area including a heavily mountainous rural region, and so reaching into the rural region through telehealth was very helpful to improve access, particularly for psych, pediatrics, and neurology. Coming into the pandemic then, of course, we completely pivoted and did a tremendous amount of our access and care through telehealth. About 70% of our visits were through telehealth. So we were able to pivot quickly and we were able to really accelerate use of telehealth. 

The good news is what we found is that patients and providers alike enjoyed, and felt good about the kind of care that they were giving and receiving through telehealth. We worked on our strategic plan, despite the pandemic. Last year we went on and completed our strategic plan for the next five years. And of course a part of that was to expand, significantly, our digital health capabilities.  Where we are currently is that we are certainly seeing a lot more patients in person. You can’t do everything by telehealth, but continuing to expand our telehealth services, and our notion there is that we’re going to be pivoting, or thinking of care agnostic to site. So care at home for instance. Going forward, what my vision is over the next two to five years is that a lot of care will happen outside of the proverbial hospital walls, and what can we do in the home using digital capabilities.”

NP: That segues into my next question, which is improving the integration of health into the community, while placing the patient at the center of care. You’ve spoken on this topic before — in your view, what needs to be done to further enact this shift towards value-based care?

NHA: “I’ve been active nationally through the American Hospital Association and as the chairman of that board, my passion was around value-based care. And so for five years now I’ve focused a lot of my time and attention on value-based care. Talking about Carilion specifically, we reorganized our primary care practices into medical homes, going back as much as 10 years ago. We’re pretty bullish on the notion of value-based care. That is a shift from transactional, fee-for-service medicine to more comprehensive care, preventive care, and a community connection. From a financial standpoint, creating more risk that’s less transactional and more continuity of care. 

We’ve been an [accountable care organization] since it was first offered and gone through several iterations. We’re currently a next gen number, so we take both upside and downside risk. And so, I would be very clear that we’re bullish on [value-based care]. Having said that, I think that it has been a lot tougher to change things, as I would wish. And that’s nobody’s fault. It’s easy to blame providers or insurers or what have you. We have so much infrastructure set up for the transactional, fee-for-service services that altering that has proved very tough indeed. 

There’s been less ability to really move to value-based care in the short run. I still think that’s doable. I still think that we are evolving. And I think that, particularly at the federal level, CMS is interested in continuing the pursuit of Medicare Advantage programs, and in towards value-based care, and in general the commercial insurers follow. So I see some progress there, but it is more evolutionary than revolutionary, that’s for sure.”

NP: That being said, what is your ideal future vision for delivery models of care, not just at Carilion Clinic, but perhaps across all health systems? 

NHA: “I am so passionate, and love what we do in health care in general and I truly find great pleasure and joy in what Carilion does for the communities that we serve. Our mission is my North star. If I look out 10 years, let’s say, it is about serving our communities in ways in which they want to be served. I think that means more care given at home, in a comfortable setting. I think it is paying great attention to the value of the care that we provide, continuity of care. Then nationally maybe what we’re seeing [is] a real focus on provider wellness as well … Every day for every single person who works in healthcare to say that they find joy and meaning in the work that we do.

There are two areas, at least two areas —  many more probably — where I see important work to be done, and that’s to eliminate inequities in care, and in opportunity, and also sort of sharpen our focus on behavioral wellness, including provider wellness. Then lastly and interestingly, is to focus on infant mortality and healthy pregnancies. There’s a lot of work to be done going forward, and I think we’re up for it.”

This interview was edited for clarity and length.