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Walgreens: Purveyor or Provider?

Walgreens-store

An intriguing question emerged from last week’s merger announcement from Walgreens Boots Alliance and Rite Aid.  Led by CEO Stefano Pessina and his largely European executive team, will Walgreens be purveyor focused on retail sales or provider engaged with a transforming U.S. health care system?

The signals are mixed.  A tea-leaf reading of last week’s investor call suggests Walgreens is destined to be a purveyor, focused on selling products and services.  Today, however, Walgreens announced a big technology move that points to a provider future, closely integrated with payers and providers.

Purveyor or provider?  Read on.

Tobacco:  To Sell or not to Sell

“Are you considering eliminating tobacco,” Barclays Capital analyst Meredith Adler asked Walgreens president Alex Gourley during the investor call as the company fielded questions about earnings and the merger.

Gourley had just praised RiteAid for its new, sales-increasing wellness format, saying it was an opportunity for Walgreens, which also is seeing success with its new health, wellness and beauty positioning.

“It seems pretty clear,” said Adler, explaining her question, “that providers and payers feel uncomfortable working with a retail pharmacy that still sells tobacco.”  In the background was the 2014 tobacco sales halt of CVS Health, which boasts 49 clinical affiliations, including Cleveland Clinic.

Gourley’s answer:  No.

Walgreens would instead continue investing in smoking cessation.  Anyway, he noted, only about three percent of all tobacco sales occur in a drugstore.  He did not pivot to emphasize how Walgreens is working with providers and payers, notwithstanding tobacco sales.

A tea-leaf saying “purveyor”? Perhaps.

Outposts in Seattle

Gourley could easily have drawn the analyst’s attention to a Walgreens announcement just two months previously.  In August, Walgreens and Seattle-based Providence Health & Services launched a new “strategic clinical collaboration.”

Providence will own and operate clinics in 25 Washington and Oregon Walgreens stores under its Providence and Swedish brand names.  The first three will open in early 2016, with the remainder following in two years.

Rite Aid made a similar move in the Seattle market in May when it announced a joint venture between its RediClinic subsidiary and MultiCare Health System.   The joint venture will operate clinics in 11 stores staffed by board certified MultiCare Nurse Practitioners in collaboration with MultiCare affiliated physicians.

Seattle, home to only three CVS stores, will provide a sheltered environment for Walgreens and Rite Aid to test the strategy of developing “deeper and more strategic relationships” with health systems.  In particular, Providence is quite a catch, having directly contracted with Boeing to provide health care for the aircraft maker’s employees.

The EpicCare Connection

However, the nation’s 1,000 CVS MinuteClinics dwarf both Walgreens 400 Healthcare Clinics and Rite Aid’s small number of in-store RediClinics.  Surpassing 25 million patient visits since the opening of its first clinic, CVS says it is opening three new MinuteClinics a week.   Aiming for 1,500 clinics by 2017, CVS is acquiring all of Target’s 1,660 pharmacies and 80 clinics.

CVS is converting all of its MinuteClinics to the market leading EpicCare electronic medical records (EMR) system.  Used broadly across health care, Epic also has strong interoperability with other EMR systems.   This will provide seamless data exchange with most American hospitals.

“EpicCare will help us work more closely with physician practices as part of the medical home team, facilitate co-management of patients, and advance our mission to make health care more accessible, convenient and affordable for Americans,” said MinuteClinic chief medical officer Nancy Gagliano, M.D.

Dr. Patrick Carroll agrees.  Today, the chief medical officer for Walgreens Healthcare Clinics announced the clinics would begin moving to EpicCare early next year.  “As our clinics play an increasingly important role in health care, supporting the health care system, provider practices and patients’ medical homes, care coordination can be critical,” he echoed.

So, a provider future for Walgreens?  It certainly looks like it.  “This will benefit our patients, clinic providers and partners, and serves as an instrumental part of our strategic growth plan [emphasis added],” explained Carroll.

Confusing Signals

However, as recently as May, Walgreens quietly shuttered 35 clinics, a move two former employees described to Crains Chicago Business as signaling “uncertainty whether Walgreens really wants to spend more on primary care and in particular upgrading the clinics’ electronic medical record systems.”   Today’s announcement erases some of that uncertainty, at least with respect to the EMR system.

In Seattle, Walgreens will provide in-store space, overseeing any needed build out.  Providence will be using its own Epic system.  “Patients will experience a seamless patient experience through our existing electronic health record system, providing direct connectivity to the clinics and billing systems, which will ensure better continuity of patient care and collaboration among providers,” said Providence senior vice president of physician services Mike Waters.   Now, Walgreens will be able to connect directly.

Convincing Collaborations

In Seattle, a provider land lord; in Tampa, still a provider.  There, Walgreens partners with a multi-specialty practice, assuming risk in an accountable care organization (ACO), Diagnostic Clinic Walgreens Well Network.  Serving 7,500 patients, the ACO saved $1.5 million or 2% in costs.  However, Walgreens has exited ACO partnerships with Baylor Scott & White in the Dallas-Fort Worth area and New Jersey’s Advocare.  The company continues a clinical affiliation with Baylor Scott & White.

Meanwhile, Walgreens has launched additional collaborations with CHE Trinity Health, a 30-hospital, Michigan-based system, Arizona Priority Care, a unit of California’s Heritage Provider Network, and Mercy Health – Cincinnati.  Leading Trinity Health is former Medicare official Dr. Richard Gilfillan, chair of the Health Care Transformation Task Force; Mercy Health is part of the nation’s largest not for profit health system, Ascension Health; and Arizona Priority Care specializes in accountable care.

In Baltimore, Walgreens has a long-standing relationship with Johns Hopkins Medicine (JHM).  The company provides grants for population health research overseen by a joint committee.  Two years ago, it opened a store, including a Healthcare Clinic, adjacent to the JHM campus.  In this case, Walgreens’ board certified nurse practitioners staff the clinic, although they and company pharmacists can work with JHM faculty.

Rite Aid’s Health Alliance program should dovetail nicely with Walgreens provider collaboration initiatives.  The program brings together physicians, pharmacists and special care coaches to provide care and support to individuals with chronic and poly-chronic health conditions, helping them achieve health improvement goals established by their physicians.

Eight provider organizations currently are participating in Health Alliance, which leverages Rite Aid’s population health subsidiary, HealthDialog.  Another 11 reportedly are be interested.  On average, patients participating in the Rite Aid Health Alliance are 36% more adherent to their medications; they have lost an average of 7.7 pounds; they have a 39% reduction in blood pressure; and they have lowered their blood sugar by 36%, reports Drug Store News.

Big Bet on Consumer Technology

Rite Aid is also bringing Cleveland Clinic physicians into some of its Ohio stores via telehealth start up HealthSpot.  Installed in the stores is a kiosk, enclosed for privacy, which includes a video connection with a physician and the capability to take and transmit vital signs to the physician.

Opting for mobile, Walgreens is using the Pager platform, designed by an early Uber architect, to connect customers with physicians.  It also is relying on the MDLive platform for telemedicine, and working with WebMD on a wellness app, and with PatientsLikeMe enabling people to share medication experiences with each other.

Walgreens has been a leader in using technology to engage its customers.  Its app is the third most downloaded retail app in the U.S. and the number one brick and mortar pharmacy app, reports mobihealthnews.  Fourteen million people visit a Walgreens app or website each week and Walgreens fills more than one mobile prescription every second.

Walgreens’ Epic Catch-Up

However, until the EpicCare announcement today, Walgreens lagged in using technology to engage providers.  Its electronic record system could not easily communicate with other systems, forcing stores to use secure fax and email to communicate with physicians and other providers.   That raised serious questions about the future of its provider collaborations and role as a provider.

Now, EpicCare means Walgreens can be more than a purveyor.  It can also be a provider, fully integrated into the new health care.

As Insurers Merge, What’s Next for Healthcare? Watch Gretzky!

Gretzky

Remember that quote from hockey great Wayne Gretzky, “I skate to where the puck is going to be, not where it has been.”  To see where healthcare is going, watch Gretzky.  Watch the successful organizations that always seem to be in the right place at the right time. Watch Ascension Health.

The nation’s largest not-for-profit health system, Ascension popped up in a recent New York Times story on health insurer consolidation.  It had become an insurer, too, when it acquired Michigan-based U.S. Health and Life Insurance in February.

Ascension Health as Insurer

Ascension plans to continue the small insurer’s focus on serving small, self-insured employers, according to a filing with Michigan regulators.  Although 20 states have licensed the insurer, Ascension plans to concentrate on Michigan, where the health system’s footprint is biggest, as well as in Illinois, Indiana and Wisconsin.

Longer range, the system has the much more ambitious vision of coupling its new insurance asset with a newly formed Ascension Care Management subsidiary to provide employers with population health services. Ascension then can take provider direct contracting with employers to a new level.

Generally, organizations like the Mayo Clinic and the Cleveland Clinic have contracted with national employers for single-price orthopedic and cardiac surgeries.  Ascension, on the other hand, is ready to provide capitated care arrangements directly to employers for all their employees, not just surgical patients. Modern Healthcare reports that risk based contracts, including capitated arrangements with payers, already cover about 1.9 million Ascension patients.

Being a Healthcare Gretzky

To be a Gretzky, a healthcare provider must be able to assume risk. However, not every provider capable of assuming risk will be as good as Gretzky.  There is more to being a Gretzky, including focused scale, powerful information technology and clinical leadership.

Focused Scale

Surely, Ascension’s size is its most striking characteristic.  However, size alone does not make Ascension a Gretzky.  Instead, Ascension brings a distinguishing focus to its size, one that recognizes healthcare in the U.S. as a confederation of 50 state markets plus the District of Columbia.

For example, in Michigan, Ascension has allied with CHE Trinity Health Michigan to form Together Health Network for joint managed care contracting and, potentially, offering narrow network coverage products on the state’s public insurance exchange.

The network, which does not involve an asset merger, covers nearly all of the state, with 75% of the population no more than 20 minutes from a participating hospital or physician practice. Reinforcing that coverage, Ascension has also agreed to acquire Crittenton Hospital Medical Center in Southeast Michigan.

On the other hand, Ascension has scaled back in Arizona, where it has entered into a joint venture with Tenet and Dignity Health, resulting in Tenet operating Ascension’s Carondelet Health Network.  Ascension had not been a major presence in the market.

Ascension is also configuring horizontally for the nation’s diverse healthcare payment models.  In a recent article, CEO Tony Tersigni observed that Medicare resembles Canada, our under-65 model is closer to France, Germany or Japan, veterans, military and Native American healthcare is a lot like the British National Health Service and, for the uninsured, rural India or Cambodia provide the best comparison.

Consistent with this mental map, Ascension last year announced establishment of Ascension Health Senior Care, now the nation’s second largest not-for-profit long-term care provider in the nation.  Consisting of 34 facilities serving more than 5,500 patients, the unit shares best practices and establishes consistent standards.

Once again, like Gretzky, Ascension has positioned itself well. At this week’s White House Conference on Aging, the Obama Administration announced a proposed rule updating, for the first time in nearly 25 years, the quality and safety requirements for nursing homes and skilled nursing facilities.

Powerful Information Technology

Ascension is not waiting for national data to achieve “drastically reduced hospital readmissions.”  Instead, in almost real time, it spots patterns in 30-day readmissions using admission, discharge and transfer (ADT) data across the care continuum. The immediacy enables Ascension to evaluate and adjust interventions on a local level.

“We are highly engaged with supporting the technology that would enable rapid identification and management of those conditions, so we are working very hand-in-glove with our clinical leaders,” Ascension Information Services (AIS) vice president Mary Paul recently explained to HealthITAnalytics.

The system has identified three key risk factors for readmissions – medication management, access to primary care and socio-economic factors.  ““We can predict fairly well which patient is likely to get in trouble from their clinical situation, but their social determinants are just as important,” Chief Quality and Nursing Officer Ann Hendrich told the publication.

Meanwhile, 2,500 AIS employees are also working to standardize and consolidate across 1,900 sites of care in 23 states, according to CIO Mark Barner.  They are shrinking more than 4,000 software applications to a much smaller number and consolidating 37 disparate interface engines into one.  Ascension is using the Athenahealth ambulatory electronic health record application and cloud based applications for ambulatory physician practice management.

Clinical Leadership

Ascension Health has been at the forefront of the patient safety movement for more than 20 years.  In connection with a 2002 commitment to 100% access to safe, effective care, Ascension adopted a goal of clinically excellent care with no preventable injuries or deaths by July 2008.  The Joint Commission Journal on Quality and Patient Safety published a series of articles charting the system’s journey toward clinical transformation.

Ascension continues its leadership through its Hospital Engagement Network (HEN).  Selected by and with funding from CMS, Ascension’s HEN is developing advances in ten areas, including sepsis, hospital acquired infections, patient safety culture, home healthcare models, hospital acquired kidney failure, and safe patient handling.  Ascension will share the advances with hospitals throughout the nation.

The Ascension HEN has already identified, documented, refined and shared best practices in ten additional areas, including urinary tract infections, adverse drug events, pressure ulcers, fall injuries and central line associated blood stream infections. For example, Ascension developed a protocol for reducing catheter induced urinary tract infections, which account for 30% of hospital-acquired infections, by limiting catheter use.

In another example, Ascension has dramatically reduced induced or C-section deliveries before 36 weeks, which often result in higher complications for babies and mothers.  In February 2012, Ascension’s early-elective delivery rate was about 3.5%, already substantially lower than the national average of 10% to 15%.  Now, it is even lower, at 0.6% after shared data with physicians and stepped up patient education efforts.  (For additional advances in obstetrical care, see three Ascension-authored articles in the January 2014 edition of Health Affairs.)

Last month, Ascension told the White House Forum on Antibiotic Stewardship that it wants to “set the pace for the nation in antimicrobial stewardship.” It has pledged to establish facility-based antimicrobial stewardship programs in all Ascension hospitals that will include both a pharmacist and a physician with antimicrobial expertise.  The system also said it would reduce the use of three broad-spectrum or niche antimicrobials by at least 10% reduction during the first 12-18 months.

What’s Next for Ascension?

One of the best ways to project where a Gretzky organization will be next is to watch the Gretzky’s within it.  In Ascension’s case, that would include Chief Quality and Nursing Officer Ann Hendrich, who joined Ascension in 2003, after leading the development of an innovative coronary care unit at Methodist Hospital in Indianapolis.

That she would be a Gretzky to watch at Ascension was clear from an observation she made in her application to be a Robert Wood Johnson Executive Nurse Fellow in 1998.  Hendrich wrote, “The opportunity to take shell space and not replicate the present and familiar but integrate environmental design, technology and a new care delivery model is imperative.”

In her dozen years at Ascension, Hendrich has played a key role in cementing Ascension’s clinical leadership.  Given the system’s accomplishments, especially in clinical quality and patient safety, Ascension merits the recognition usually afforded the great healthcare brand names like Mayo, Cleveland Clinic, MD Anderson and Kaiser.

Establishing a strong national brand is “what’s next” for Ascension.  The need and the opportunity are clear and, to track how Ascension intends to build its brand, look to the recent arrival of another Ascension Gretzky, Nick Ragone.  A lawyer and author, Ragone most recently led the Washington office of Ketchum, a global public relations agency.

As Ascension’s chief communications officer, he will “enhance the strategic identity of Ascension,” according to the 2014 announcement of his arrival. His initial focus has been internal, engaging 153,000 employees, as it should be for any brand-building exercise.  Ragone is supporting an enterprise-wide “One Ascension” initiative, which is integrating and establishing best practices throughout the once highly decentralized system.

Meanwhile, Ragone is preparing to take his branding initiative on the road:  He is looking for a brand strategy director to “lead work around the definition and development of the Ascension brand, both internally and externally.  The Director will be responsible for developing the value of the Ascension brand and driving strategies to build brand equity for Ascension, its Subsidiaries and Health Ministries.”

Epilogue as Prologue

Earlier this month, Modern Healthcare editor Merrill Goozner interviewed Ascension CEO Anthony Tersigni.  He asked Tersigni about Aetna buying Humana and Anthem pursuing Cigna.  Tersigni shrugged off the big deals, saying, “Ascension is preparing to take on risk itself for self-insured employers as the system strives to manage population health while encountering an increasing number of patients in high-deductible plans.”

Spoken like a true healthcare Gretzky.