Episode 28: LifeBridge Health’s Focus on Community with Neil Meltzer

What’s it like competing for business as an integrated delivery system—sandwiched eight miles between the University of Maryland Medical System and Johns Hopkins Health System—in a global budget environment within the state of Maryland? Find out this week in John’s conversation with LifeBridge Health CEO Neil Meltzer, a dynamic and inspirational leader serving his community and the stakeholders of LifeBridge with purpose.

Interview highlights include:

• How LifeBridge thrives in the intensely competitive Baltimore market
• Using patient data analysis to identify hotspots
• LifeBridge’s vision for the future

John:  I guess the best place to start is to tell me a little bit about yourself and your system, Neil. I’ve found that that Life Bridge is fascinating on a number of fronts, which is one of the reasons why I wanted to talk to you about some of the things that you’re doing there. Why don’t you kick us off today by talking a little bit about yourself and Life Bridge?

Neil:   Sure. My name is Neil Meltzer. I’ve been at Life Bridge for thirty years into what was going to be a five-year plan for me. When I began at Life Bridge, Life Bridge was just one hospital—Sinai Hospital of Baltimore, which had its roots back in 1866 really for the purpose of teaching individuals who are being discriminated against and couldn’t get residency programs elsewhere.

Over the past 150+ years, we’ve grown into a 2.1 billion dollar integrated delivery and financing system comprised of primarily: 4 hospitals, 38 urgent care centers, 4 nursing homes, an living facility, and a whole variety of entities which really span from wellness all the way through hospice.

We serve primarily the central Maryland region. But we go as far north as southern Pennsylvania, and as far east as the northern part of Delaware.

My background personally is actually in health physics or nuclear physics where I was studying the impact of nuclear power on the environment. And [I] somehow managed to find my way into running a health system through the concept of public health.

Recognizing, when I graduated doing nuclear physics, that there weren’t a whole lot of jobs for world savers at the time… I was offered an opportunity to work in a hospital at the time and realized that I could still have an impact on the environment and the community we serve through that mechanism.

John:  In your market, Neil, you have some pretty big competition. Who are you going up against?

Neil:  Yeah, we’re in a very dense market. Within eight miles from us we must have… I would say probably eight or nine hospitals. The biggest competition is Johns Hopkins health system eight miles to the southeast and University of Maryland medical system, which is eight miles to the south-west. They have facilities or satellite hospitals surrounding us as well.

So it’s in a kind of unusual situation. When I began at Sinai hospital almost thirty years ago, Sinai was considered one of the hospitals most likely to close, in part because the community felt that it wasn’t necessary to have a Jewish hospital in this day and age… and secondarily, there was a sense that we were over-bedded. And in fact, if you take a look at the number of beds per thousand in Maryland, and you compare it to some other states, we are probably over bedded by a 1000-1200 too many beds. But I think the unique reimbursement model in Maryland is beginning to move us in the right direction.

John:   I want to get to that that reimbursement model in a second. I think one of the questions that that other executives listening to this are thinking about in your unique market is “How do you compete?” How do you differentiate yourself when you’ve got a Johns Hopkins on one doorstep and in the back door, you’ve got University of Maryland pretty much equidistant? How do you differentiate yourself? How do you compete in that environment?

Neil:   I think that’s a good question. It’s an important point and something that we talk about frequently here. I really feel that every organization has its own unique personality. When I take a look at Hopkins, I think they do a wonderful job treating the esoteric and their market is really the world. I take a look at University of Maryland, which is fairly close to us, and they’re a wonderful training ground and they train number of primary care physicians for our community.

But when I take a look at Life Bridge, what I’ve tried to do is create a purpose for the organization. So I’ve had our employees work together to come up with a purpose statement, which is really the filter through which we make all decisions. And the purpose statement which they came up with, which I happen to endorse, is creating healthier communities together. And when we talk about communities, we talk about not only the community surrounding the organizations that we serve, but the internal communities as well.

So it could be a community of a department. It could be a community of the hospital. It could be a community of neighborhood that we serve, but it’s important to recognize that our culture is one that focuses really on making the folks around us better, if you will. We don’t have a national perspective, although we would like to be nationally recognized in one or two areas. Our focus is really on the community.

We like to say that we’re the organization with a social conscience. We’re the community conscience. We are the community’s health system and we care for the people around us. What’s kind of unique is if you take a look at the flagship hospital—Sinai hospital—although we’re located in a fairly urban area, there’s not an ounce of graffiti around the organization.

When I took over as the president of the hospital, the first thing I did was take the fences down from around the organization. In opening ourselves in some symbolic way to the communities that we serve, we sent a subliminal message (or not so subliminal message) that we are here for those around us. We’re not here to put a fence up between us and the community.

I want people to feel comfortable that we we’re a neighbor, that we were an organization that welcomed everyone regardless of where they live or their ability to pay.

And one of the things that we’ve done, which I think makes us somewhat unique is we’ve been heavily focused on population health for decades. Even before it was called population health. I think population health has become a bit of a buzzword now. When I started, we used to call it prevention.

But for all intents and purposes, we have been developing services that really support some vulnerable communities that seek our services.

We’re spending probably somewhere in the vicinity of 22 million dollars a year, with over 200 employees, on 45 different programs ranging from pediatric HIV, to programs that assist unwed fathers, to programs such as housing upgrades that benefit seniors—really in an effort to keep people well, keep people healthy (or healthy as they can be) out in their local communities.

And what we found through this effort is that we’ve been able to prevent close to 34 million dollars’ worth of either readmissions or admissions to the hospital by keeping people in their homes as healthy as they can be.

John:   Can you dive a little bit deeper into specifically how you do that? I’m thinking of some of your seniors’ initiatives. And I ask that question because a lot of systems will SAY that they’re community focused–they’ll do their community needs assessments and they’ll say they’re all about the community.

One of the things that strikes me from previous conversations that we’ve had is that Life Bridge really seems to be living that mission. So can can you get a little bit more specific?

Neil:  Sure. Beyond some of the larger programs, let me give you an example.

The way we really began using my public health background is we started hot spotting. I said to my team, “Let’s take a look at 100 patients who have been in the hospital or in the emergency department three or more times. Let’s see if we could find a pattern. Do they live in the same neighborhood? Do they live in the same block? In the same apartment building? They have the same diagnosis? Do they have the same the same physician? No. Is there any commonality?”

And what we found is that there were a number of areas that we needed to focus on that in some cases matched our community health needs assessment. Some cases were actually kind of unique. I’ll give you a couple of examples.

One… There was a woman who was in the hospital over 100 times in a year. Fragile diabetic. She was a single mom [with] three kids. We did a home visit (a site visit) at our expense for the first time and found that she didn’t have a working stove.

So we bought her a stove. She knew very little about the basics of nutrition, which was in part causing her difficulties with her diabetes. So we gave her three nutrition classes. We filled her refrigerator with food—all of this at our expense. And we have been now doing weekly house visits, and she has not been back in the hospital as a readmission or emergency department patient.

We recognize that there are many patients like her that need individual attention or individual intervention. On a larger scale, what we found is that there are certain commonalities with trip hazards and people’s homes, so we developed a program called housing upgrades to benefit senior’s hubs. We send individuals into patient’s homes or individuals homes to determine, “Are there trip hazards? Do they need grab bars? Do they have a broken stoop that needs to be fixed do they don’t trip on the way in the house?” We take care of these minor repairs for them.

The other thing that we’ve recognized is that our communities becoming more diverse and there are multiple ethnicities that we’re serving. So we’ve internally been focusing a lot on health equity and making sure that not only are we training our staff, but we’re training incoming residents and physicians on the essentials of understanding how someone’s background might influence their ability to receive information or to follow information.

And another example there: We had a patient who was from South America. She spoke Spanish. We had a translator in the room. She had a cardiac issue and the translator of the physician was a relatively young female cardiologist. She talked to the patient, told the patient what she needed to do, asked the patient through a translator if she understood. The woman shook her head up and down said, yes, she understood. And then asked the patient would she follow the directions? And she shook her head back and forth and said, no, she would not. This happened twice. We took the patient out of the room with the translator and tried to get an understanding. And she said, well, in her in her culture, doctors have white hair. They’re men. And what she was used to respecting for healthcare information was essentially a more senior male and until we were able to understand that and address that with her, we knew that we weren’t going to be able to maintain her health the way she needs to maintain her health.

It’s a variety of these things that need to occur throughout the organization at all levels to get the optimal health or to achieve optimal health for patients. We started a program in the community to try.

We’re actually sending paramedics to people’s homes to treat patients for minor injuries as well as to pre-medicate them, if they require infusion prior to coming to the hospital to prevent them from having to come to the hospital twice or to prepare them for the kind of service they may need. That happens oftentimes with a chemomtherapeutic patient.

And again, we don’t get paid for these services, but it reduces the total cost of care. And this kind of gets into the Maryland system because in Maryland, there is an incentive to reduce the total cost of care for Medicare patients. To the extent that we can reduce the total cost of care for Medicare, the state benefits by getting reimbursed at a slightly higher rate by Medicare than the rest of the country. But we’ve gotta meet 65 quality metrics and we’ve got to continue to reduce the total cost of care below the national average for Medicare patients in the country. And that could be a whole other discussion.

John:  Neil, I think a lot of folks listening to this may not understand the unique situation that Maryland is in. Can you talk a little bit about that reimbursement system and its origins and where you are today with that?

Neil:   Sure. This goes back to the 70s actually, I believe. There were four states that had what was called a Medicare waiver program. We were waved from the Medicare reimbursement program and they were Massachusetts, New York, New jersey and Maryland. Maryland is the only state that maintains this particular program.

Essentially, it’s a pilot program that allowed us to demonstrate that if we could reduce the total cost of care for Medicare patients, the Medicare program would pay more, commercial insurance would pay lightly less, and in doing so, the state and ultimately the hospitals benefited by not having to negotiate with the payers for any type of insurance because it is an all-payer system.

So all payers pay essentially the same thing for care. Our rates are set much like a public utility. There is a rate-setting commission—in our case, it’s called the Health Services Cost Review Commission—that determines the rates for each individual hospital. Those rates are determined based on prior history, whether it’s a teaching hospital, whether it treats a large number of uncompensated care. It looks at payer mix and things of that nature. So it allows us to focus on reducing total cost of care.

The model as it exists has an incentive not to really grow volume beyond five percent per year. We are essentially given rates based on historic performance. Our volume can go up by percent or go down five percent within our existing rate structure. If it goes much higher than five percent, we begin to lose money. If it goes lower than five percent, then we likely reimburse the state again or reduce our rates based on a reduced volume. And the whole incentive here is not to focus on growing volume and fighting with each other to bring in market share, as much as it is to focus on keeping people healthy and only admitting those that truly need admission.

John:   So does that mean throughout the state—I mean, my sense is that from patient management perspective, that Life Bridge is really leading in this area—but does that mean throughout the state that other hospitals and other health systems have an incentive to execute some of the population health or some of the community measures that you were talking about?

Neil:   Oh, absolutely. In fact, if you take a look at hospitals throughout the state of Maryland, most are involved in some level of population health management. And it also requires that we work together because it is such a small and dense state that it would be difficult for any one organization to be totally independent of some community services that are being offered.

John:   Sure, sure. That makes sense.

So what you’re really talking about (and this is going back to a previous point) is really, truly patient centered care, like the example with the woman that that needed a cardiac procedure, and really changing to understand the needs of that patient at a new level.

And when you talk about some of the community initiatives, I’m wondering how much education does the community require? In other words—teaching people that instead of coming to the emergency room that you’re going to send an ambulance out and take care of a minor issue. How does a community learn to respond to a health system in the kind of work that you’re doing?

Neil:  I think it’s a little bit surprising initially, but I think what we’re finding is that the insurers are in the state of Maryland also recognizing the impact it has on them, the positive impact. Because if we continue to reduce total cost of care, they can keep their fees at a relatively reasonable level. So they have put into place incentives for patients to use an urgent care centers opposed to an emergency department if it’s truly not an emergency, per se.

They also put into place measures that encourage the use of ambulatory sites or ambulatory surgery for certain procedures that historically have been done in an outpatient setting in a hospital. Because the hospital setting, by nature of its overhead, tends to be more expensive than a free standing facility out in the community.

So I think the over the past decade or so the residents have become pretty comfortable with the approach we’ve been taking, though we’re always trying to push the edge of the envelope a little bit, such as the use of the paramedics out in the community.

I think, generally speaking, once people experience it, they kind of like it. It allows us to engage with patients more. I think there’s a stronger sense of connection with the health facility, and it improves communication not only between the patient and the hospital, but also between the patient and their insurance company, the patient and their primary care physician.

I think we’re all also heavily involved in ACOs, and we’re finding that our ACO’s allowing us to create a stronger partnership with our physicians towards a common goal of improving quality and reducing costs as well. And we’re fortunate just as an organization for the past three years, we’ve had a successful ACO running where we have saved the federal government money through reduction in total cost of care of our Medicare population that we’re serving. Plus, we’ve improved quality fairly significantly. And it’s all really been done through the good work in partnership with our medical staff.

John:  I was going to ask you about the ACO. I’m fascinated by this model, and I guess we’re… What–six years, seven years? Something like that.. running into various ACO experiments. How has the ACO—if at all… The kinds of initiatives that you’re executing in the Medicare ACO–does that spill over into the rest of the system? Or is it just, you know, the physicians are following standards of care that you’ve that you’re doing elsewhere?

Neil:  No, it really is falling over to the rest of the system, in part because it’s difficult to treat one group of patients or one insured group one way and everyone else another way. So what it’s allowed us to do is really apply the same approach that we’re using Medicare patients really to the whole population. It becomes a, I think, a way of life for many of our physicians.

Now, we are constantly tweaking it. We’re looking at new ways to further engage the patients to make sure that physicians and every caregiver’s practicing the top of their license. Part of the way we’re doing that is through the use of technology. We’ve implemented something called Health Loop, which provides information to patients post-discharge. So there can be a fairly good communication and follow-up in the ability for patients to ask questions electronically to their caregivers and get fairly immediate responses.

We’ve also done something kind of unique by put putting in a call system called Life Link, which connects with our EMR (in our case Cerna). It allows a group of nurses quite honestly, from out of the country.

We have a call center in the Philippines, and we have a call center now in Israel that reviews medical records at night, follows up on anything that needs to be performed on a patient, and contacts the physician in the way they want to be contacted the following morning to follow up on any patient issues. We’re also now using it to follow up with patients directly to get an understanding of how their experience was, but also to get a sense of whether or not they have questions about something that may have occurred the prior day and be able to either answer the questions directly—because these are clinicians who are answering the telephone—or providing them with a contact number or getting back to them with the information that they have questions about. So I think a lot of what we’re doing is trying to create a stickiness with patient, but also improved patient engagement. And compliance, quite honestly,

John:   You know, this is highly unusual… *laughs* You have a health system that is running a call center overseas to be able to stay on top of the patient and their journey. Where did you get the idea for that? Or how did that come about it?

Neil:    You know, we’ve got a pretty creative team. We now have a Director of Innovation. We have an innovation center… But quite honestly, it’s been our team sitting around a conference table, brainstorming about new and different approaches. Saying, jeez, why can’t we? Instead of coming up with reasons why we can’t or shouldn’t because we’re not of sufficient size or scale or financial ability, we try. And in most cases we succeed. I think part of what sets us apart as an organization is we have such a complete continuum of care. And we have a complete continuum of care in part because we said we need to own the patient experience from beginning to end.

Our wellness facility was a initially joint venture with NutraSweet, which was a subsidiary of Monsanto at the time, but it’s now our own. We’ve partnered to create a homecare company, a medical transport company. We kept saying, “Why are we spending thousand two thousand dollars to transport a patient across the street from the hospital to a nursing home? Why don’t we own the transport company?” So we created a transport company.

We’re discharging patients to a visiting nurses association. We say, “Why don’t we own the homecare company?” And little by little, we began to expand our continuum of care when we recognize that jeez, we do have the skill set to do this and where we don’t, we could create unique partnerships in the community. And it’s allowed us to create bonds organizations which were historically competitors. And I think people realize that in many cases, we’re a theater to many of these organizations and they benefit by partnering with us.

John:   So Neil, as you as you look to the future of your organization, tell me a little bit about your plans… About where you see Life Bridge headed in the coming years.

Neil:   I think we anticipate expanding further in the ambulatory settings. We’re going farther and farther out from our historic base, but doing it in concentric circles where it makes some sense.

At the same time, we’re always looking to expand our continuum. We’ve acquired our first assisted living facility. We’re looking at a second assisted living facility because we’re being questioned about that. We’re looking at the development of a nurse’s aide company which allows patients who don’t want an R.N. in the home or don’t need an R.N. in the home to have paramedical personnel in the home to help out mom or dad, or whoever might just need some assistance in the house.

We are considering adding another hospital or to the organization—again where it makes sense. But I’m not sure where ultimately we’re going to end up. We’re spending a lot of time and money right now on technology and the use of technology to better engage patients and better engage our physicians. So I think we’ll see a lot more growth in… I don’t want to say telemedicine… but sort of the use of technology to engage patients in a variety of levels.

One of the things we’ve done recently with nine other hospitals, we created an organization called the Advanced Health Collaborative. These are all small systems or individual hospitals that are working with us in a nonprofit organization to achieve some of the benefits of a merged entity, a much larger more entity without the encumbrances of necessarily merging.

So we’ve got groups looking at how we can work together to improve or become more cost effective in laboratory medicine. What capabilities do we have across the system? How can we leverage each other’s capabilities? Do we set up an independent reference lab that we all own?

We’re looking at a common pharmacy formulary. What can we do there to bring price of medications down? Employee benefits—should we have our own TPA? What could we be doing together in terms of buying benefits?

We’re looking at a solution for behavioral health across these ten hospitals because we’re all struggling with a growing demand for behavioral health technology.

We have our IT folks working together to see if it makes sense to do predictive analytics or big data repository together as opposed to independently.

And we’ve just recently become clinically integrated, which allows us a lot more capability working with our medical staff to possibly even create an area network that would allow us to sell either directly to employers or offer an area network to the payers.

So I see going beyond the four walls of the hospital. The hospitals tend to be fairly expensive cost centers, and where care is moving is into the outpatient setting, and we need to be there as well.

John:   So a lot going on.

Neil:   There is a lot.

John:  I’m gonna ask you sort of an unusual question in closing.

We’ve been tracking, here [at Darwin Research], the effects of the Affordable Care Act really since its inception and it’s implementation and have been monitoring the growth in ACOs. Then we had a change in administration. And as you’re as you’re aware, changes in how things were being implemented from CMS and from other government agencies. And I’m just wondering with all the change that you’ve seen in insurance markets–it’s been a little bit chaotic and healthcare space. If you had a piece of advice for CMS or Health and Human Services as to what they could do better, what would you, if you had a mouth mouthpiece to tell them? What would you say?

Neil:   Oh my God. Make it easier for the patients to gain information about the services that they offer for which the patients have been covered, number one.

I think the paperwork on the part of the health system that they need to perform in order to meet all sorts of regulations needs to improve. I think the number of quality metrics that are being monitored is becoming a little bit crazy, and I think of the amount of time and money and people power we’re spending on the administrative aspects of healthcare… It kind of gets me sick, because we could be using those funds better for care of the populations we serve or the populations that aren’t even getting served.

John:   I think in all those measures—and I’m not here to defend the government—I think in all measures that what you’re asking for, they’re making intents.

Neil:   Oh, they are.

John:   They’re making intents to do all those things.

Neil:    Yeah. No, I agree. I do think they are. I just think it’s a difficult task. Because it’s grown involved over decades and to move it is monumental and it’s going to go well beyond my career, probably, to get it where it needs to be.

John:   Sure. Well, Neil, I want to thank you so much for your time today. As I said at the onset, I think that you’re running a fascinating system and you’ve got a lot of neat things going on. And I think that Life Bridge is a model that some of the other CEOs out there should take a look at it, and I think that there’s some lessons that can be learned.

Neil:   Thank you. I’m flattered, I know we’re not doing everything we should be doing, but we’re moving, I think, in the right direction. Hopefully time will prove that. And I look forward to further conversations. Thank you for the opportunity to speak with you today.

John:   And thank you again. Take care.

Neil:    You too.