Several health providers are seen as positioned for success in health reform. While some claim that they have been operating as accountable care organizations, those that truly are positioned for success have been preparing for ACOs for a long time. They've done this not to comply with a law that didn't yet exist, but to do the right thing. One of those institutions is the Greenville (S.C.) Hospital System, an integrated health system comprising a tertiary academic medical center, 11 specialty hospitals, more than 120 practice sites (including the University Medical Group), skilled nursing care and extensive subacute facilities.

Greenville's journey toward physician engagement began approximately 10 years ago with a small group of employed physicians, including Angelo Sinopoli, M.D., now the CMO. That group gradually gained a stronger foothold in various administrative roles, supported by a willing administrative team and willing physicians. Over time, the system made key physician administrative appointments, including that of Jerry Youkey, M.D., from Geisinger Health System, as vice president of medical affairs.

In 2006, Greenville selected a new CEO—Michael Riordan, former CEO at the University of Chicago Hospitals. That appointment formalized the board's commitment to a more academic vision and to a leader who could execute the structure required to engage physicians and integrate clinical services.

Leading by Example

Under Riordan's leadership, Greenville enhanced physician engagement and integrated clinical services according to its vision of accountable care and community commitment. It made several organizational changes to cement a new, physician-led clinical structure:

  • It launched an initiative to recruit affiliated physicians into employment. The employed physician group has grown in the last five years from 220 to almost 600 today, allowing for tighter clinical integration and physician engagement.
  • It rewrote bylaws and created a structure in which chairmen and vice chairmen align physicians with quality initiatives; the chairmen drive Joint Commission compliance, while the vice chairmen work with multidisciplinary quality improvement teams.
  • It restructured board committees to accommodate more physicians who address quality and academics.
  • It established an operations council to drive care delivery at Greenville and to improve quality performance. The council is a multidisciplinary team of department chairs and support staff who review each clinical area, assess plans for improving performance, then implement those changes.
  • It expanded the president's council to include the chief medical officer and the chief academic officer. As the critical decision-making body, the council now is better able to reinforce the importance of physician leadership to all organizational constituents.

Leadership Pyramid

Greenville has transformed itself from a hospital with affiliated practices to an integrated, quasi-clinic model health system that incorporates teaching and academic medicine. The system's objectives, illustrated in Fig. 1, form the basis for its evolution into an ACO. This degree of organizational change necessitated a firm hand from Greenville leaders as well as board support, because tension emerged between those supporting the new model and those holding on to the past. Physician leaders and employed physicians gave their support at a critical time and helped build momentum.

Short-Term Results and Long-Term Planning

Structural leadership changes have yielded significant benefits. Greenville now represents best practice in its market area, and its financial performance has improved. Fifteen months ago, prior to establishing the operations council, the finance department and the University Medical Group still were separated into distinct silos. With guidance from the operations council, Greenville integrated those silos and reported good financial performance for 2010, despite the recession and its impact on patients, employers and providers.

About two years ago, Greenville began planning for what it believed health care would look like in 2020. A clinically integrated team helped develop the 2020 plan. The outcome included five goals that have refocused Greenville's strategic plan:

  • Become a total health organization.
  • Transform core organization structures and processes into a highly integrated delivery system.
  • Become an accountable care organization.
  • Improve care delivery and workforce development through innovation in academics.
  • Ensure a sustainable financial model that supports the Greenville vision and mission.

Greenville continues to move toward a clinic model, although it is not a closed model. Many institutions will not have the time and financial resources to move toward a closed model or fully employed model in time for Patient Protection and Affordable Care Act milestones.

A Note of Caution

Donald Berwick, M.D., administrator of the Centers for Medicare & Medicaid Services, recently stated that "cloaking the status quo is not authentic" during a keynote address at the National Committee for Quality Assurance's policy conference in Washington D.C. (Read "Some Claim ACO Status without Truly Changing," by Sandra Yin, in the Dec. 4, 2010, issue of FierceHealthcare. The statement was part of a discussion on how several institutions are suddenly finding that they always have been an ACO.

Berwick's point is that success in health reform is greater than meeting a set of requirements. It will need to be demonstrated in many ways across the clinical enterprise. Institutions focused on achieving a set of criteria are at risk for missing the greater opportunity of broad clinical care coordination.

That point is not lost on Greenville. Delivering care in a way that improves patients' health requires a paradigm shift in leadership, organizational structure and care delivery. Greenville's commitment to clinical integration and physician leadership is an example of the change required for success as an ACO.

Although Greenville's physician integration efforts are pervasive, they are not a guarantee of future performance. Better results will require constant work and dedication to a common set of strategic goals that are reinforced in the daily work of the institution.

Looking Ahead

Greenville continues to pursue its strategic objectives amid many challenges and much change. A next step for Greenville is realigning the rewards system so that quality and effective care delivery are supported with the right incentives. Funding will pose a significant challenge for Greenville and other institutions in the coming years, including potential reductions in Medicaid reimbursement at the state level. Many other challenges lie ahead as well, such as uncertainty in PPACA regulations, and even whether some aspects of the legislation will be underfunded or modified by the new Congress.

Despite the uncertainty, Greenville is in a position to succeed with a strong leadership team, including its physician managers. This guidance is critical to providing a clinically integrated academic health system for Greenville's community and for the state in which it operates.

Christine Stead is a principal and Tom Enders is the managing director of CSC, headquartered in Falls Church, Va.