A recent Saturday night at the Moses Cone Memorial Hospital Emergency Department felt different. It didn't reflect the madhouse triage atmosphere of past years, when a standing-room-only crowd of patients might wait hours to be seen.
"We were worried about what it might be like on a Saturday," said Claire Hampton, who brought her young son in with an asthma-related breathing problem a little after 9 p.m. "But they got us right through. It's really gotten a lot better. We've noticed that."
One factor driving that change: Cone Health's , including locations near the main hospital on Greensboro's N. Church Street and Elmsley Court, as well as in Winston-Salem, Burlington, and Asheboro.
Those locations have helped keep less serious cases 鈥� small accidents, non-lethal allergic reactions 鈥� out of the main E.R., which can both lower patient costs and free up capacity for treating life-threatening emergencies.
Cone is doing what other systems across the state have, planting its brand's flag in smaller locations in the Piedmont to reach more patients.
In the past decade, large hospital systems across North Carolina like Duke, UNC Health, and Atrium have been growing and building urgent care facilities, freestanding emergency departments, and clinics outside their traditional service areas. That's made them more powerful and better able to drive harder bargains with insurance companies.
UNC Health has acquired a handful of troubled rural hospitals, their finances buoyed by the more profitable businesses at the flagship in Chapel Hill and Rex Hospital in Raleigh. Atrium 鈥� which is restricted from purchasing distant hospitals within North Carolina by its status as a county hospital authority 鈥� has instead "partnered" with Wake Forest Baptist while also acquiring hospitals in Georgia and South Carolina. Now merged with , Atrium has become one of the 10 largest health systems in the country, providing care at .
Unlike those other systems, Cone hasn't focused as aggressively on growth. In part, that's because it's hemmed in geographically by giants like Atrium to the west and Duke and UNC Health to the east.
Cone's modest growth pattern could change with this month's finalization by Risant Health, a new nonprofit health care provider that California-based Kaiser Permanente formed in a deal announced over the summer.
Risant and Cone are already touting the potential benefits in Guilford County. After the initial , Risant said it was as much as $1.7 billion into helping Cone update its facilities and support system growth.
Cone is the second system in the country to sign on with Risant, which finalized the acquisition of Pennsylvania's Geisinger Health in April. Risant's leaders claim that their goal is "expanding and accelerating the adoption of value-based care" 鈥� which, if successful, would be nothing short of a transformation for U.S. health care.
Right now, people in Greensboro wonder what it will mean for them.
'Our focus is community'
Cone Health ranks well in quality scores from the federal Centers for Medicare and Medicaid Services, particularly the Moses H. Cone Memorial Hospital on North Elm St. in Greensboro.
The hospital really shines in the evaluation of its 鈥� i.e., it does a good job and much of the time, does it for less money.
Cone has put a particular emphasis on the quality of the care it delivers through its physician practice, Triad HealthCare Network.
Cone has four hospitals 鈥� the Greensboro flagship, Wesley Long on the west side of town, Alamance Regional Hospital in Burlington, and Reidsville's Annie Penn Hospital 鈥� as well as a psychiatric facility and dozens of specialty clinics and urgent care centers across the Triad.
But the system is surrounded. In recent years, it seemed all but assured that it could get gobbled up or out-competed. There's new pressure from players such as Atrium, which moved to in a well-heeled west Greensborolocation. ( to state officials, saying it would "bring higher health care costs, add no medical services not already available close by and would not serve people living in areas needing more health care options." Cone lost that fight.)
Not that the system hasn't considered growth. In 2020, Cone with Virginia-based Sentara Health, announcing a deal that would have given the system more heft. In the end, Cone gave back the engagement ring, citing differences in organizational culture, the loss of local control, and the way Sentara would have had the upper hand.
"Since the Sentara deal, we've had many offers from many folks that we did not seriously entertain," said Cone CEO Mary Jo Cagle. "Or we would talk to them for a short period of time and just say, 'No, that just doesn't make sense for us.'"
Edward Cone, the fourth generation of his family to serve on the system's board, said alignment of philosophy was essential to the Risant acquisition.
"From the birth of Cone in 1911 until now, we've had a mission," Cone said. "'Cone Hospital shall be an institution for the alleviation of human suffering' 鈥� period. 鈥� We always have to have a real presence in Greensboro and we have to treat people whether they pay or not."
He compared Kaiser Permanente's operation in California to an iPhone 鈥� every part designed, manufactured, and owned by its creator.
"You go national, you actually don't design and own every part," Cone said. "And that's a challenge."
Risant's culture and history had to be compatible for the marriage to work. He and other board members felt it was, he said.
From volume to value-based
What likely drew Risant's to Cone is the system's aggressive approach to transforming its payment model to something known as "value-based care."
Even as costs have spiraled for the past 20 years, the world of health care has been trying to move away from the old way that hospitals and providers get paid.
For generations, much of health care was essentially a local, mom-and-pop industry: Hospitals were locally run. Individual practitioners had their offices, patients saw a generalist who, if they needed it, referred them to another doctor for specialty care. Coordination was often patchy; maybe the generalist and the specialist talked about the patient's issues, maybe they didn't. That created glitches with coordination of care, duplication of tests and services, and ever-growing expenses. Everyone鈥攄octors, labs, technicians鈥攚as paid each time they did anything, with little or no thought to coordination.
This "fee-for-service" model incentivized a lot of activity, even as there was often no one overseeing how it all fit together. Fee-for-service payment creates economic incentives for a doctor to do more, even when the "more" is unlikely to yield much beyond additional remuneration for the providers.
Does the patient end up healthier? Maybe.
"We already know exactly what we got from the fee-for-service world," said former Triad Healthcare Network executive director Steve Noerr during . "It'll deliver expensive, inefficient care, fragmented, low quality, and it's a sick care system."
With the passage of the Affordable Care Act in 2009, large government payers like Medicare were empowered to push to get providers paid for offering better quality care, not just for doing more. The hope was that pivoting to quality would save money in the long run because there's less waste and more focus on outcomes.
As Mandy Cohen, the former head of the N.C. Department of Health and Human Services , the goal was to buy health, rather than buying health care.
A Cone Health Urgent Care location in Wendover. That sounds good in theory but has been challenging in practice. Actually achieving value in care has been something of a holy grail for the past 15 years.
For starters, defining "value" and "quality" is complicated. Trying to change the economic incentives to perform more services has been difficult, because it requires doctors and health systems to modify their behavior.
Doctors have to have deeper conversations with patients, explaining that instead of just pills, perhaps they need to go to physical therapy or change the way they eat. And then they need to help them accomplish those goals. Hospitals have to be more conscientious about the factors outside their control鈥攖hings like transportation, housing, or whether their patients have access to fresh fruits and vegetables鈥攁nd help patients address them.
Cone has been at the forefront in making this pivot.
Change is hard, and risky
For health systems, the culture transformation means getting away from the emphasis on having heads in beds and instead focusing on prevention and outreach 鈥� services like providing to make their appointments.
Health systems need to set up the technology to analyze the data coming in, something that costs money but is often not reimbursable. They need to hire care coordinators to reach patients, especially those who are high-need and high-risk.
The end goal: Better managing care for the most expensive patients can help bring down costs across a system, while at the same time helping patients become healthier.
But all that costs money, especially up front.
Cone has been pursuing value-based care for a decade. The system established one of the first "accountable care organizations" in the country. Spurred on by financial incentives offered by the federal government that started in 2012, Cone , Triad HealthCare Network, that engaged in intensive care coordination for close to 28,000 older adults on Medicare.
In those first few years, the costs can often outweigh the benefits. That's why few health systems really dug in, initially.
And by most measures, Cone has led the way. It saved a few million dollars in its first year or two and federal payers rewarded it for that work, all while keeping patient ratings and outcomes positive. But the costs remained high. Some years it lost money, and along the way, federal regulators tweaked the way Medicare reimbursed systems like Cone.
The community has taken notice.
"They've continued to honor their commitment to health equity," said Greensboro Mayor Nancy Vaughan. "They continue to invest in the city 鈥� They have a strong track record of really prioritizing care."
That identity has been vital in Greensboro's Black community, said Councilwoman Sharon Hightower鈥攁nd it seems set to continue under Risant.
Cone's relationship with the Black community has evolved from the days of , a landmark 1963 civil rights case in which Black doctors and patients sued the system for discrimination. The case was heard by the U.S. Fourth Circuit Court of Appeals. The hospital appealed to the U.S. Supreme Court but was denied.
Today, a historical marker with details of the case stands in front of the Moses H. Cone Memorial Hospital. In 2016, Cone Health for the "separate but equal" stance that made the suit necessary. The system also pledged $250,000 over 10 years to a scholarship benefiting students pursuing careers in health care in honor of the plaintiffs.
Hightower represents District 1, in heavily Black East Greensboro. Over the course of her lifetime, she said, Cone went from being an adversary where discrimination was an issue to in expanding health care.
"Cone has really opened up the door to realizing the health disparity that exists between East Greensboro and West Greensboro," said Hightower. "They've made a commitment to reducing that gap by having a greater commitment to East Greensboro. I would hope they continue that commitment, whoever they partner with."
Hightower said she has heard some concerns in the community that becoming part of a much larger network may dilute the relationship.
"Sometimes becoming too big means that you can't narrow your focus the way you should because you're trying to help as many hands in the pot as you can," Hightower said. "So that's the only thing we worry about. Kaiser Permanente has been in California for years. They have a strong presence out there. So coming in here, I just want them to understand who we are and what we're trying to achieve."
"(Cone is) making significant inroads in East Greensboro and they have more planned," she said. The Risant money will surely help.
She noted Cone's promise to have a significant presence in the where the city has advertised a Public Health and Cooperative Extension that will offer health classes and connect residents with the county's food security resources.
In recent years, Cone's physician practice, Triad HealthCare Network, has saved between 1 and 4 percent of costs for patients compared to federal benchmarks, all while racking up quality scores above 95 percent.
And though the percentage of money saved may seem small, the value runs into the millions, something that鈥攊f replicated across the country鈥攃ould begin to arrest the medical cost inflation that plagues the U.S. health care system.
The federal Centers for Medicare and Medicaid Services recently announced that accountable care organizations around the country, like Triad Healthcare Network, saved more than $2.1 billion for Medicare last year, even as the practices received a total of $3.1 billion in performance bonuses. The agency has set a goal that all patients in the traditional Medicare program鈥攁bout half of the total 67.7 million across the country鈥攚ill receive their care through such practices, where the focus is on value even as quality of care is closely monitored.
More recently, Cone has extended this philosophy beyond its traditional Medicare population. Triad Healthcare Network, which started with fewer than 30,000 patients, to about 185,000 people throughout the Triad. In addition, the system has worked with almost 1,300 doctors from outside the Cone system, training them in the philosophy of providing higher quality, higher value care, saving money along the way.
"We began to work with the insurance companies and take risk for their Medicare Advantage providers," said Cone CEO Mary Jo Cagle, referring to the private insurance-run plans that cover .
The success of Cone's accountable care organization is emblematic of the qualities that make it something of a unicorn in the hospital world. It has big ambitions that don't center around acquisition and market dominance. Instead, Cone has forged a track record and found success by emphasizing quality over quantity.
Building on Kaiser
That record is what helped attract Risant, which had previously partnered with Pennsylvania's Geisinger Health.
The company's mission, it said in a release, "is to expand and accelerate the adoption of value-based care in diverse, multipayer, multiprovider, community-based health system environments and improve the health of millions of people in communities across the country."
If that's the case, Risant's acquisition of Cone will likely look very different from what happened in western North Carolina, where health system giant HCA purchased the Asheville-based Mission system in 2019. Since that purchase, locals have complained about the , the system's , dozens of providers federal regulators have , and multiple entities .
The players in Greensboro are very different from HCA.
Kaiser Permanente, Risant's parent company, has been engaged in some form of value-based care for decades. The health system in the West Coast shipyards that employed legions of "Rosie the Riveters" during World War II. Eager to retain workers at a fiercely competitive time, Henry J. Kaiser's shipbuilding company offered them health benefits, including a hospital in Oakland, that became the model for employer-based insurance.
Kaiser created an "integrated" system that's unique in the U.S.: it provides the insurance, runs the hospitals and clinics, and employs the doctors, nurses, and other providers. All of this gives them an incentive to coordinate to deliver the best care.
Kaiser also had one of the first electronic health records, pioneering the use of "Big Data" in health care and using the records of hundreds of thousands of patients to suss out the efficacy of interventions and medications. As the original health maintenance organization, or HMO, Kaiser has long boasted patient outcomes.
All this integration also allowed Kaiser to be leaner and more efficient than its competitors.
The desire to bring that to other regions is why Risant first acquired Pennsylvania's Geisinger Health in 2023, which also had a reputation for strong care coordination and savings.
Cone is its second acquisition, and the plan is that with other like-minded partners across the country, Risant could eventually compete against other large, multistate providers.
Not everyone believes American health care is ready for value-based care. Mark Pauly, a health economist at the Wharton School of Business at the University of Pennsylvania, argued that at present, value-based care is "a dud."
"The evidence that it produces changes, much less that the changes are beneficial, is pretty weak," he said. But if it's ever going to work, he said, Kaiser is the horse to bet on. "At least they have been able to set up a system where physicians seem to behave differently than they do in ordinary practice, and particularly in hospitalizing less and still producing at least pretty good health outcomes."
Risant would want to seek out partnerships with providers who have a culture of doing just the right amount of intervention. Cone, with more than 15 years of experience, is the best bet in North Carolina.
It's also a good time for Cone. Pascaris noted that it is coming into the partnership from a position of strength, with a solid agency rating and balance sheet, plus a network of 1,400 providers.
Nonetheless, it's hard to know how Risant's expansion is going to go, he said, because it just hasn't been underway long enough. The Geisinger deal closed in May, and the Cone deal just closed on December 1. The last quarter was rocky for Kaiser, which , even as the system has been overall profitable this year. Nonetheless, Kaiser announced it was reducing administrative expenses and trimming discretionary spending.
Doing well by doing goodFor all of the talk about transforming health care, local hospitals still need to make money, which has been difficult even for the biggest players. and 鈥攚hich got into providing care with big splashy announcements鈥攔ecently abandoned their efforts.
Cone, Geisinger, and Risant are all not-for-profit health systems, with different motivations than profit-maximizing, traditional corporations. They still have to survive.
Cone understands the culture and landscape in North Carolina. Together with Risant's heft and money, the system could use the local knowledge鈥攁nd trust built up over decades鈥攖o scale up provision of value-based care to larger pools of patients, enough to keep its balance sheet in the black.
One place to find lots of new patients is in the industrial resurgence occurring in the Piedmont, where Toyota is bringing thousands of jobs to a battery plant in Liberty, Wolfspeed at a new plant in Siler City, and Boom Supersonic is growing in Greensboro, among others.
All of these large employers will need to provide health benefits. For companies that run their own insurance plans, the value proposition that Cone and Risant could make is they would offer better鈥攁nd cheaper鈥攃are.
Cone seems to be making strategic moves in the area around Guilford County to do just that.
In October, Cone Health 51,000-square-foot multispecialty clinic in Asheboro that includes a cancer center. The system is also planning , where a new Nestl茅 plant is slated to open.
Greensboro mayor Vaughan said she sees Cone's reputation as a valuable tool in attracting major employers.
"That's good for Greensboro and it's good for Cone," she said.
Greensboro's Chamber of Commerce agrees.
"The Risant Health acquisition of Cone Health does nothing but elevate Greensboro's profile as a city that offers robust business opportunities and a nationally recognized healthcare network that prospective companies can trust," said Marvin J. Price, executive vice president of economic development with the chamber. "It's a powerful asset in showcasing our city's ability to support growth and success."
Still, everyone agrees that attracting businesses or enhancing the bottom line are secondary to the actual care patients experience at Cone's facilities.
"If that changes, it's not a success," said Hightower, the city council member.
Fortunately, she said, she can speak to that personally.
Hightower's daughter, Sharonda, gave birth at Cone's flagship hospital last year, which can be a harrowing experience given the significantly worse for Black women compared to white women.
"She had a very good experience," Hightower said. "The doctor was wonderful."
More recently, Hightower's daughter found herself back at Cone when her baby was hospitalized for four days with a bad case of hand, foot, and mouth disease.
"That can be scary," Hightower said. "But they knew they were in great hands. So that definitely hasn't changed."
This first appeared on and is republished here under a Creative Commons license.
