‘Health care could be so much better’

Before Dr. John Chessare took over as president and CEO of Greater Baltimore Medical Center nine years ago, the hospital’s board asked him whether GBMC could remain independent at a time when other hospitals across the state and the country were consolidating.

Chessare told them that it could, but it would require the hospital to commit to a transformation of how it cared for people, including an increased focus on treating people before they ever came to the hospital.

“My basic premise is the average man on the street in Baltimore has no idea, has no idea that health care could be so much better if we could just redesign care to get closer to what the patient actually needs,” Chessare said. “There’s no doubt (we) do a great job in the hospital, but we are not doing what we need to do in the management of chronic disease.”

In an interview with The Daily Record, Chessare spoke about GBMC’s approach to redesigning care, the Affordable Care Act and other issues affecting hospitals.

The following has been edited for length and clarity.

The Daily Record: You are not the first person who has said these sorts of things about transforming care to us. What should policymakers be doing to bring this transformation about?

Chessare: We have to get the other players more involved and one big group of players that need to get more involved are primary care docs. … We have had nurse care managers to help the primary care doc get the patient what they need and keep them healthy. We have had weight loss programs in the offices. Three years ago we added masters-prepared behavioralists, addiction specialists and psychiatrists. And now the Maryland Primary Care Program is incentivizing other doctors to do this, and paying organizations like GBMC have … to help these other doctors do it.

I personally don’t see the depth of transformation that we need, and so I think policymakers should keep pushing and incentivizing people like me to transform some more. A huge need is advanced primary care in the inner city. Advanced primary care, in the current reimbursement world, is a money loser on the primary care itself. You cannot bill enough because primary care is not well reimbursed. You can’t bill enough to cover the cost of the nurse care managers, the behavioralists. …

We got a call from the Helping Up Mission. They were desperate. They had a group that was providing primary care for their 500 men three days a week. Never on the evening and never on the weekend. In the days that somebody was there, Helping Up Mission was OK, but for the whole rest of the week if anybody had a real need, they had to ship them to an emergency department and wait, wait sometimes hours, and then get a very large bill.

Most of their men are Medicaid eligible and they are served by Medicaid HMOs and they were upset because they are paying big bills for things like sore throat, cough, headache.

They were looking for somebody to come in, and we thought that this was a perfect opportunity for us. We said, we will take care of your 500 men and we’ll do it seven days a week. We will be accountable for them with their care, but our stipulation is you have to let us open the office to the neighborhood. We believe that a reason … why the U.S. is spending so much on health care is bad design of the management of people with chronic disease, and the inner city is filled with people with chronic disease.

Are the health insurers partners in advanced primary care?

I think most of the payers get it. But it’s not a one-way conversation where they just say it and people do it. It’s more like a dance. And there wasn’t, they had no dancing partner before. If you are running a four-person business of primary care, it’s really hard for you to even have the time to think about how might we do this differently.

Now, I think with the Maryland Primary Care Model, you are going to see that more payers are going to try to change contracting agreements. Why? Because there will be more providers ready to do the negotiation dance with them and we will probably make more progress.

You mentioned that you came into this looking to keep the hospital independent. Are you secure in that position?

Oh, we are extremely secure. … At GBMC we are very agile. We get a few people in a room and we can make a decision and transform a lot faster. GBMC’s balance sheet is very strong. We could pay off all of our debt four-and-a-half times.

We got that way by being good stewards, because we didn’t build a new hospital. We haven’t done any construction on a significant new building on our campus since a physician office building was built in the 90s. … Why? Because we didn’t think the community needed that. We’ve spent all of our money on what the community really needs.

You seem to think that some of the major hospital renovation projects are simply unwarranted?

I think there’s no doubt about it that hospitals need to stay on top of technology that is really adding value to patients. And obviously, physical plants only last so long. I think the two major things that Baltimore’s health care systems need are advanced primary care and mental health capacity. …

I think everything else needs to go on a one-by-one basis. We certainly don’t need any more operating rooms, and we are getting more … because there is still profit to be made in moving or doing surgery in non-regulated space. Without public policy to say, “Let’s make sure we have the right number of operating rooms,” we are going to get the number of operating rooms that can stimulate profit for investors.

Right now you have the Affordable Care Act in the middle of a political conversation. Some people want to tear it up, others want to move to a single-payer system. How would that affect hospitals?

The sad part of the conversation about the Affordable Care Act is no one ever discusses the entire Affordable Care Act. What they discuss is the market for individual policies. …This was a monumental piece of legislation, but they are only talking about this little sliver of the act. …

But what people don’t realize is, the rest of the legislation is about changes to the delivery system. Under the Affordable Care Act, the U.S. hospitals have drastically reduced the amount of harm that is done in U.S. hospitals. … So I will go on the record as saying undoing the Affordable Care Act would be one of the stupidest things ever.

Back in March when the UMMS had their board situation come out, what went through your mind in relation to your own board and your own hospital? What did you do?

We probably did what everybody did, which was we took a deep breath and we said we need to go and reflect on everything that we are doing. We had been following our rules. … We did not have rules prohibiting board members from doing business with the corporation, but we do have rules requiring competitive bidding.

I guess every not-for-profit has to continually ask the question, what is reasonable? You don’t want to send something out to bid that is going to cost you $200. That won’t work. What is the line beyond which you should competitively bid? We are competitively bidding all construction projects over $50,000. You can’t get much done for under $50,000 anymore.

Dr. John Chessare

Age: 67

Education:

University of Rome

Medical degree, 1979

Pediatric Residency, University of Massachusetts Medical Center

University of Michigan School of Public Health

Master of public health, medical care organization

Career highlights:

President and CEO, GBMC HealthCare, 2010-present

Interim president, Caritas Christi Health Care System, 2006-2008

President, Caritas Norwood Hospital, Sept. 2005 – Oct. 2008

Boston Medical Center/Boston University School of Medicine, 1998-2005

Albany Medical Center/Albany Medical College, 1994-1998;

Medical College of Ohio from 1983-1994.

Correction: A previous version of this story incorrectly left out a word in Chessare’s answer about the reimbursement of primary care. He said, “You cannot bill enough because primary care is not well reimbursed.”