Former nurse guides Carilion

Nancy Howell Agee remains focused on patient care

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Print this page by Robert Powell

Nancy Howell Agee began her health-care career as a nurse at what is now Carilion Clinic in Roanoke, and essentially she has never worked anywhere else. On July 1, she became president and CEO of Carilion, a health-care organization that is the region’s leading employer.

“I think having a nursing background gives me insight into what I think of as a very precious moment when a caregiver is caring for a patient,” she says. “Every decision that I make [concerns] how do I create an environment for patient care?  That’s what’s most important.”

Agee succeeds Dr. Edward Murphy, a physician who had guided Carilion through dramatic changes since 2001. During his tenure, Carilion began a 13-year transition from a hospital network to a patient-focused clinic employing physicians in a wide variety of specialties, a move that angered a number of independent doctors. In a joint venture with Virginia Tech, Carilion also founded a medical school and research institute, which enrolled its first 42 students last fall. In addition, Carilion announced in March it is collaborating with the insurance company Aetna in developing health-care plans.

As chief operating officer during the past 10 years, Agee has played a leading role in the organization’s transformation.  She now directs a nonprofit organization that, in addition to the medical school, includes eight hospitals, the Jefferson College of Health Sciences and 12,300 employees, including about 600 physicians.

The Roanoke native was the first member of her working-class family to graduate from high school, much less college. She volunteered as a hospital “candy striper” while growing up. Agee attended the Roanoke Memorial School of Nursing before earning a bachelor’s degree from the University of Virginia and a master’s from Emory University.

Before becoming chief operating officer, Agee served in a variety of management roles at Carilion during the past 20 years, including vice president of medical education and senior vice president.

She takes over the reins of a health-care system still recovering from the effects of the 2007-09 recession. Last summer, Carilion reported an operating loss in 2009 of $56.5 million on revenue of $1.26 billion.

As it moved to a clinic model and created a medical school, Carilion was building a clinic, hiring physicians and implementing an extensive electronic health records system “at a time the economy decided it might not be cooperative,” Agee says.  Financial markets were in turmoil, unemployment rose, and charity care provided to patients jumped 31 percent.

Carilion is budgeted to have a $18 million operating loss in 2011 and expects to break even in 2012.
Agee is married to Judge G. Steven Agee, a Roanoke native and former Virginia Supreme Court justice who now sits on the Richmond-based Fourth Circuit Court of Appeals. Their son, Zach, is in graduate school in Washington, D.C.

Nancy Agee is active in a number of local organizations, including the Community Foundation of the Roanoke Valley, and has served two terms on the Radford University Board of Visitors.

She and her husband have remained in the Roanoke area despite the fact that most of his work in recent years has been in Richmond. “We made a very conscious decision to be here because we love it here,” she says. “The health care that we provide in this region is important to me professionally but also personally.” 
Virginia Business talked with Agee at her office at Carilion Roanoke Memorial Hospital.

Virginia Business:  You began your career in health care as a nurse. Will that make a difference in how you run Carilion?

Agee:  I think having a nursing background gives me insight into what I think of as a very precious moment when a caregiver is caring for a patient. I haven’t done that kind of clinical care in a long time, but I never forget it.  Every decision that I make [concerns] how do I create an environment for patient care?  That’s what’s most important. I have been here a long time. I know a lot of the people. I know what their hopes and dreams are. I know why they are here, what they care about and I do think that makes a difference.

VB: Is it a daunting task to follow somebody like Dr. Murphy in this role?

Agee: I think it’s a daunting task, regardless.  You know Ed was here for a decade. He’s a visionary. For me he’s been a wonderful mentor. He’s a good teacher. He’s a very patient person — a lot of people don’t know that about him —  and he dreams big dreams.  His footprint will be different than mine ...  We’ve an interesting history that is different than a lot of places. We’ve had a lot of longevity in the leadership and people who seemingly look around corners and figure out where things were going be and then position us to get there. 

VB: How would you run Carilion differently than Dr. Murphy?

Agee: I’m not sure differently is the right word. I am, I think, what Carilion needs right now. What this region needs right now is more of an implementer to help understand all of the disparate parts of where we’re going with health-care reform, pulling all those pieces together and living our values every day, being very rooted in why we do what we do and how we’re going about that. That’s not different than Ed, but it’s a distinction.

VB: Do you expect Carilion to become a destination health center like the Mayo Clinic or the Cleveland Clinic?

Agee:  I think health care is in such a state of evolution, and I think even the Mayo and the Cleveland clinics would say their goal of being a so-called destination clinic has changed.  I’m more concerned that we provide high-quality care for individuals and work towards improving the health of the population in western Virginia than any sort of superstar service that’s intended as a destination clinic.

VB: How do the new medical school and the research institute fit in with the overall goal of the clinic?

Agee:  The clinic itself is sort of a tricycle. So the biggest wheel is patient care.  It’s supported by education and informed by research, the two smaller wheels … We’ve had a longstanding tradition of education … But we felt to strengthen our graduate medical education, develop more fellowships, really further and facilitate care in the region, we needed a medical school.  And to some extent, at the same time Virginia Tech was looking at its goal of being a top 30 research institution in the country and began to feel like it needed a medical school.  So together we developed a medical school. 

That’s gone quite well and is an important piece of who we are, and we are continuing to develop our relationship with Virginia Tech.  The research institute is part and parcel with the medical school, but it is wholly owned by Virginia Tech.  I see our real focus on what we call translational research — clinical trials … I think what we need in health care is to more rapidly provide appropriate therapies for patients across the country and across the globe. 

VB: One of the things we are seeing with major health systems around Virginia is some of them moving into parts of the state outside their traditional territory.  Is that something that Carilion has any interest in doing?

Agee:  I think that over the next couple of years we’re going to be highly focused on finishing our task.  That is, we’re committed to health care in western Virginia.  We’ve done a lot of investments differently than other places, and they all have their own business models. We want to focus on accountable care: accessible, affordable, coordinated care in a deeply caring environment.  We have a variety of pieces: We have the infrastructure for the clinic, we have the medical school, we have electronic health records enterprise-wide, and we have our own Medicare Advantage plans. We need to spend some time making these parts work together. 

We aren’t really looking out to go after other hospitals. In fact, I would say that, from our perspective, care in the future is going to be much more in the outpatient and primary-care practices than in a hospital. So if you ask me what I see 10 years from now, I think hospitals will be much smaller … We need to do all we can to develop the kinds of resources necessary for patients to be cared for where they need to be cared for.  I think that a better place for that is outside the hospital. 

VB: Would you foresee a time when there would be fewer hospitals in the Carilion system?

Agee:  Maybe not fewer hospitals, but fewer patients in hospital beds.  Let me give you a few examples that we are already doing.  [Patients complaining of chest pains previously came to the hospital emergency room.]  Now they are in a chest pain center. They may be in the chest pain center for hours to a day or two, but they are not admitted to the hospital [if their condition doesn’t warrant it.] 

We are certifying all of our primary-care practices as medical homes and providing nursing resources there to care for patients with chronic illnesses and [offering] hours of operations that are longer than your traditional office hours.

So if you or I get sick, we don’t come to the emergency room, we go to our primary care office. That’s sort of a cultural evolution. People don’t want to bother their primary-care physician. They would rather come to the emergency department, but a better place for care would be in the physician’s office.  Those are the things that we are doing to try to provide that kind of fabric of care to help keep patients in a more appropriate and less costly level of care.

VB: That brings us to your collaborations with Aetna. Could you tell me a little bit about that? 

Agee:  We’ll have an Aetna contract for all of our employees, and we’ll be working with Aetna on ways that we can help our own employees be healthy.  The second piece is that we’ll be working with Aetna with our Medicare Advantage program.  Initially they’ll be providing more infrastructure support for that, but we are hopeful that that will grow.  Thirdly, we’ll be providing our own health plans, selling our own health plans, co-branding or working with Aetna to provide other services. Aetna has taken a real leadership role in the country, positioning itself to share information and work with physicians and health-care providers in developing an accountable-care organization. We are learning from each other right now what that might look like. 

VB: Let’s go back to health-care reform.  What’s your assessment of where it stands? 

Agee: In our country, we have this great honor and privilege in health care to take care of patients, but I’m uncertain that we have done as good a job as we could to collectively improve outcomes.  I think it’s apparent that our health-care outcomes for chronic illness are not as good as we would like as an industry.  Worse, we had millions of people in this country who didn’t have insurance and had limited access to care.  We know that that is problematic. 

I think that the work [being done] trying to figure this out is very complicated, and so I think the [federal] Affordable Care Act is the right step.  It is pretty complicated. At the same time, health care in our country is pretty complicated, and the pace of change can be tough.

Interestingly what I think has been missing in this whole health-care reform talk is a social network. Without that, I just don’t see how we’re going to accomplish what we need to do.

In our country, if you’re an 84-year-old, you live alone.  It is very likely that your 50- and 60-year-old children live in Nebraska or California. I’m doing fine as an 84-year-old widow living in my home until I fall and break my hip.  I come into the hospital, and then what?  I can’t really go back home because there’s nobody there.  So I go indefinitely into a costly setting, maybe a nursing home. Maybe I get good rehab, but it’s costly and then I go home.  I am socially isolated.  Do you have a way to get good nutrition?  Do I have transportation?  Have I gotten my medication? 

This isn’t really about income per se, and of course that’s a really interesting issue for us here in my rural part of the state.  I think that phenomenon is happening all over, and we’ve lost sight of that.  Without that social environment, without safe schools, without good nutrition, without transportation, without getting medications, having safe places for people to walk, we just can’t do all that through health-care reform.  We’re not going to be successful.

That seems completely absent in any of our conversations. So when you ask is health-care reform going the right place?  Where is it going to be heading?  I don’t know the answer to that. What’s important is that we need to assure patients who entrust their care with us, that we’re going to do the best job possible for them, and that they are in a safe and caring environment. 

We need to get paid differently, and when a percentage, in our case a large percentage, of your patients don’t pay for care, that’s a burden on all those patients who have commercial insurance who do pay for care, and it’s a hidden tax.  If you’re getting paid only for, what you might call, an endless stream [of services], if you’re only getting paid for doing something instead of caring for populations of patients with chronic illnesses, then I don’t think we’re going be successful improving care in general or bending the cost curve.

VB: Is there anything that we haven’t covered that you wanted to talk about?

Agee:  We’re a big employer in the region, and what’s real important to me is that our employees — our physicians, our clinicians — are building a career, and feeling like they have a place that’s brings them joy and meaning ... 

I do have a perspective of [working as] a nurse seeing the administrators, and wondering what the heck they did all day.  I wake up every morning knowing I’m simply overhead, and I’ve got to prove my worthiness to these people here because they’re the ones doing the work.  I don’t hesitate to tell my management team we are servant leaders.  We are here to serve the people who do the real work.

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