I have to admit that I am not sure I am a legacy in hospital medicine, and the term legacy throws me off a bit. I came to medical school after working at McKinsey & Co. consulting, and I chose pediatrics because of my love of working with children and families, as well as a vague notion that I wanted to work on “system” issues, and therefore, more generalist-type training seemed applicable.
I met Chris Landrigan, MD, MPH, and Vinny Chiang, MD, and learned what a hospitalist was, as an intern in 2002. We had a research elective and I was able to publish a couple of papers in Pediatrics on pediatric hospital medicine with Chris and Raj Srivastava, MD, MPH. In 2004, I went to my first Society of Hospital Medicine meeting and met Larry Wellikson, MD, MHM, and others. From there, I went to the Robert Wood Johnson Clinical Scholars Program, with Ron Keren, MD, MPH, and others, and along with faculty from the Cincinnati Children’s in hospital medicine.
In 2007, I applied for a White House Fellowship and told my wife that I didn’t think there was a chance that I would get it, so we should keep building our new home in Cincinnati. We were both surprised when I was selected. I served Michael Leavitt, the then-Secretary of the Department of Health & Human Services, as his White House fellow during the Bush administration, and then served as his chief medical officer. Exposure to health policy and leadership at that level was career shaping. Cincinnati Children’s was searching for a leader for the conversion of pediatric hospital medicine into a full division in 2009. So I returned to Cincinnati to take on leading pediatric hospital medicine, and a role leading quality measurement and improvement efforts for the entire health system. I loved the work and thought I would remain in that role, and our family would be in Cincinnati for a long time. Best laid plans …
In early 2011, Don Berwick, MD, who was then the administrator of the Centers for Medicare & Medicaid Services called and asked whether I “would come talk with him in D.C.” That talk quickly became a series of interviews, and he offered me the opportunity to be chief medical officer of CMS. He said “this platform is like no other to drive change.” He was right. I have been fortunate to have a few step-change opportunities in my life, and that was one.
On my first day at CMS, I looked around the table of senior executives reporting to me and realized they had more than 200 years of CMS experience. I was a bit scared. Together, we led the implementation of Hospital Value-Based Purchasing, the Compare websites, and numerous quality measurement and improvement programs. Partnership for Patients works on patient safety and was associated with preventing more than 3 million infections and adverse events, over 125,000 lives saved, and more than $26 billion in savings.
In early 2013, I was asked to lead the CMS Innovation Center (CMMI). The goal was to launch new payment and service delivery models to improve quality and lower costs. We launched Accountable Care Organizations, Bundled Payment programs, primary care medical homes, state-based innovation, and so much more. Medicare went from zero dollars in alternative payment models, where providers are accountable for quality and total cost of care, to more than 30% of Medicare payments, representing over $200 billion through agreements with more than 200,000 providers in these alternative payment models. It was the biggest shift in U.S. history in how CMS paid for care. Later, I became principal deputy administrator and acting administrator of CMS, leading an agency that spends over $1 trillion per year, or more than $2.5 billion per day and insures over 130 million Americans. We also improved from being bottom quintile in employee engagement and satisfaction across the federal government to No. 2.
I had assumed that, after working at CMS, I would return to a hospital/health system leadership role. But then, a recruiter called about the CEO role at Blue Cross Blue Shield of North Carolina. It is one of the largest not-for-profit health plans in the country and insures most of the people in North Carolina, many for most of their lives. I met a 75-year-old woman the other day that we have insured every day of her life. I am almost a year into the role and it is a mission-driven organization that drives positive change. I love it so far.
We are going to partner with providers, so that more than half of our payments will be in advanced alternative payment models. No payer in the United States has done that yet. This allows us to innovate and decrease friction in the system (e.g., turn off prior authorization) and be jointly accountable with providers for quality and total cost of care. We insure people through the ACA [Affordable Care Act], commercial, and Medicare markets, and are competing to serve Medicaid as well. We have invested more than $50 million to address social determinants of health across the state. We are making major investments in primary care, and mental and behavioral health. Our goal is to be a Model Blue – or a Model of Health Transformation for our state and nation – and achieve better health outcomes, lower costs, and best-in-class experience for all people we serve. I have learned that no physician leads a health plan of this size, and apparently, no practicing physician has ever led a health plan of this size.
What are some lessons learned over my career? I have had five criteria for all my career decisions: 1) family; 2) impact – better care and outcomes, lower costs, and exceptional experience for populations of patients; 3) people – mentors and colleagues; 4) learning; and 5) joy in work. If someone gives you a chance to lead people in your career as a physician, jump at the chance. We do a relatively poor job of providing this type of opportunity to those early in their careers in medicine, and learning how to manage people and money allows you to progress as a leader and manager.
Don’t listen to the people who say “you must do X before Y” or “you must take this path.” They are usually wrong. Take chances. I applied for many roles for which I was a long shot, and I didn’t always succeed. That’s life and learning. Hospital medicine is a great career. I worked in the hospital on a recent weekend and was able to help families through everything from palliative care decisions and new diagnoses, to recovering from illness. It is an honor to serve and help families in their time of need. Hospitalists have been – and should continue to be – primary drivers of the shift in our health system to value-based care.
As I look back on my career (and I hope I am only halfway done), I could not have predicted more than 90% of it. I was blessed with many opportunities, mentors, and teachers along the way. I try to pass this on by mentoring and teaching others. How did my career happen? I am not sure, but it has been a fun ride! And hopefully I have helped improve the health system some, along the way.
Dr. Conway is president and CEO of Blue Cross and Blue Shield of North Carolina. He is a hospitalist and former deputy administrator for innovation and quality at the Centers for Medicare and Medicaid Services.