Primary Care Transformation – The Race to Value Podcast™: Recent Episodes
Institute for Advancing Health Value
A new era in value-based care is emerging where employers are no longer sleeping giants willing to tolerate a broken fee-for-service healthcare system. ‘Poor health’ costs employers $575B in lost productivity on top of the $880B they already spend in premium dollars annually. Employers (and their employees) continued to get fleeced by unsustainable double-digit premium increases every year, with hospitals using that excess spend in commercial insurance to their subsidize losses on the public pay side. The paradigm shift to value-based purchasing is underway in employer-based health insurance; however, it will not achieve the aims of population health unless a similar transformation occurs in workforce wellbeing. Joining us this week in the Race to Value is Dr. Richard Safeer, the Chief Medical Director of Employee Health and Well-being at Johns Hopkins Medicine, where he leads the Healthy at Hopkins employee health and well-being strategy. Dr. Safeer is a highly influential thought leader on building a culture of health and is the author of the groundbreaking new book, “A Cure for the Common Company: A Well-Being Prescription for a Hopper, Healthier, and More Resilient Workforce.” In this interview you will hear from one of the leading experts on employee health in our country about what it takes to cultivate a healthy workforce.Episode Bookmarks:01:30 Introduction to Richard Safeer, M.D. and “A Cure for the Common Company”04:45 Developing a holistic view where we look at individuals as both patients and employees.05:15 “Until we integrate a strategy that includes the workplace, we are not likely to optimize population health.”06:00 The economic and cultural imperatives for workforce well-being.06:30 A key factor in achieving health goals is the support of people you are closest to at home and at work.07:45 Connecting the spectrum of employee health from well-being to chronic disease.08:30 Why have attempts at corporate wellness failed so often in the past?09:30 “Our health and well-being are greatly influenced by the relationships we have in the workplace.”10:00 Most employers do not fully leverage the social sciences to optimize the support of their workforce.10:45 Innovative self-funded health insurance as a requisite component of a corporate wellness strategy.12:30 How a company benefits from a healthy workforce.13:45 Innovations to create access to high quality primary care and lifestyle medicine (e.g. Direct Primary Care and onsite clinics).17:00 Employers must fully leverage all resources (e.g. data from health insurers, EAPs, collaboration with local health systems).18:30 The 6 Building Blocks of a Wellbeing Culture.20:45 Making it easier for employees to make healthy choices.21:30 The influence of social climate in the workplace.22:30 The plight of healthcare workforce burnout and moral injury.23:45 We need supportive work environments to produce good health (not paternalism).25:00 “Employers who demonstrate genuine care and back it up with genuine resources to support health and well-being will be the ones to attract and retain talent.”25:30 Resiliency does not rest solely on the individual!26:00 Employees cannot maintain mental health if their work doesn’t align with education and skill set.27:00 Social connections to team and trust in management improves resiliency.29:00 70-80% of employees are willing to take a pay cut to get a job that better supports their mental health (see UKG study)30:00 Balancing the need for social connection with remote work.31:30 Referencing the new book, “Culture Shock: An Unstoppable Force is Changing How We Work and Live.”32:00 One-size fits all decisions about onsite work doesn’t make sense for all employees.33:30 Cisco Systems as an exemplar of a workplace culture for health and well-being.36:00 The role of technology in health is superseded in importance by the workplace, home, and community settings.37:00 How technology can be leveraged to foster community, communication, tracking, and data collection.38:00 The over-reliance of biometrics.39:00 Lifestyle Medicine as a foundation to a culture of wellness.40:00 How LM at Johns Hopkins has been successful in improving employee health.43:00 New Year’s Resolutions – advice from Dr. Safeer how to achieve success by using the workplace.45:30 Connect with Dr. Safeer and learn more about his thought leadership.
The future of care is not confined by walls; it thrives in the heart of homes, where compassion meets innovation, and healing becomes a daily experience. Home-based primary care with full-risk Medicare Advantage is a transformative model that not only brings health care to the doorstep of our seniors but also places the responsibility for their well-being squarely in the hands of dedicated providers, creating a proactive and patient-centered approach to aging with dignity and comprehensive care. By making primary care easier to access for our nation’s seniors, we can deliver personalized care that meets their needs; help them stay healthy and feel better; and live well with existing conditions so they can prepare for what’s ahead.
This week we are joined by two executive leaders from WellBe Senior Medical — the largest and fastest growing independent home-based medical group in the country. WellBe is a global risk medical group that provides longitudinal geriatric care to underserved, frail, complex, and homebound Medicare Advantage beneficiaries. In this episode, we feature Dr. Jeffrey Kang, Chief Executive Officer and Mike Stuart, Chief Growth Officer from WellBe Senior Medical.
Dr. Kang is a geriatrician with extensive experience in global risk and primary care for frail, elderly, and disabled populations. Mike Stuart has extensive experience in fostering partnerships with health plans, health systems, and provider groups and leads commercial strategy and partnership development for WellBe Senior Medical. In this interview you will learn about the home-based care continuum, primary care innovation, mission-driven leadership, Medicare Advantage risk, and the future of value-based primary care.
Episode Bookmarks:
01:30 An overview of WellBe Senior Medical – a global risk primary care group providing longitudinal geriatric care in the home.
02:30 Introduction to Dr. Jeffrey Kang, WellBe CEO (formerly served as ChenMed President, Walgreens SVP, Cigna CMO, and CMS CMO).
03:00 Introduction to Mike Stuart, WellBe Chief Growth Officer (formerly served in executive leadership roles at Somatus and Evolent).
05:00 An overview of the home care continuum (e.g. acute, post-acute, custodial, longitudinal primary care, DME, home infusion).
08:00 How WellBe is helping patients navigate and coordinate the fragmentation of home care point solutions.
10:30 A mission to help senior patients “lead healthier meaningful lives by delivering the most complete care”.
11:30 Opportunities to make care in the home more multidisciplinary, personalized, and SDOH-responsive.
12:00 Proactive vs. Reactive Care (leveraging analytics and unique provider skillsets for population health).
13:30 The clinical persona of the “frail elderly” and why WellBe focuses on this target population.
14:30 “Everything done in a primary care office can actually be done at home.”
15:30 “Home-based primary care is the best thing to do. You get better outcomes and better patient satisfaction.”
15:45 Is it possible to deliver high quality primary care (like ChenMed or Oak Street) in the home setting?
16:30 Referencing Marcus Welby, M.D. as an example of an empathetic approach to delivering care in the home (see Season 1 Trailer)
17:00 Care Fragmentation Challenges – NEJM found that the average Medicare patient sees a median of two PCPs and five specialist physicians per year.
18:00 “Quality of Life” is more important than “Quantity of Life” (why empathy and compassion matter most in caring for frail seniors).
19:30 Patients define a good doctor by bedside manner and respect given.
20:30 How the economics of full global risk enable complete care models for seniors.
20:30 Scalable home-based primary care is a new approach in value-based care.
23:00 WellBe’s results (e.g. >50% neighborhood engagement, patient satisfaction is at 95%, and MLR improvement >40% in 3yrs).
23:30 The importance of reaching a 4 Star Rating in a Medicare Advantage plan.
24:45 Key Measures of success: Patient Engagement, HEDIS, Medical Costs and MLR
25:45 Bringing health plan leaders on a ride-along to see high quality care in action.
26:00 Negotiating global risk deals with MA plans that offer favorable economics for both parties.
27:00 The starting HEDIS Stars score of a typical WellBe patient is 2.3-2.5 (polychronic, frail, high-risk).
27:45 “When you are at full global risk, it is in your interest to do care innovation.”
28:00 Innovation #1 = Access (“Primary care in the home needs to be both convenient and responsive.”)
29:00 How WellBe developed a mobile paramedic program to enhance responsiveness to emergent acute care needs.
30:00 Mobile paramedic program reduced emergency room visits by 33%!
31:00 Dr. Kang’s recent article in Health Affairs responding to concerns from Berwick and Gilfillan about Risk Adjustment in MA.
31:30 The CMS-HCC V28 changes to the Risk Adjustment model that begin the phasing in next year.
33:00 The evidence for Medicare Advantage being overpaid relative to FFS?
33:45 Eliminating disease-based risk adjustment is the wrong policy (e.g. need for fair payment for complex populations, avoidance of cherry picking healthy populations).
35:30 The case for HCC under-coding in Traditional Medicare (due to lack of incentives in FFS).
36:45 “The bulk of the problem with HCC coding is under-diagnosis in fee-for-service Medicare – not over-coding in MA.”
38:00 Modern Healthcare Best Places to Work 2023 – WellBe Senior Medical
38:30 WellBe Senior Medical providers see 4-5 patients per day allowing them to build trusting relationships.
39:30 A recent study from Elation Health and the AAFP confirms that VBC can ameliorate the suffering of the physician workforce!
40:30 The culture of WellBe that empowers workforce collaboration with a “patients first” mentality.
42:00 Examples of how risk-based economics improve patient care.
43:00 Creating a foundation of values to underpin a culture of collaboration is crucial before accepting risk!
43:30 A clinically-led culture vs. a financially-led culture (“If you take good care of the patients, the financials will follow in a value-based model.”)
45:00 A financially-led organization will focus almost exclusively on risk adjustment (as opposed to delivering patient-centered care).
45:30 “Most of our MLR improvement is from medical cost reduction, not HCC coding.”
46:45 Wellbe Senior Medical is now in 7 states caring for 107,000 MA patients (20% of them which are dual eligibles).
48:00 Proving the scalability of a home-based primary care model.
48:45 Expansion into rural areas.
49:45 Future growth plans.
50:00 Advantage in Scalability: (“When launching new markets, we could actually be up and running in 90-days – we don’t have the problem of bricks and mortar.”)
51:00 Disadvantage in Productivity: (ChenMed and Oak Street providers can see 20 patients a day in the office, while we are only seeing 4-5.”)
52:30 The ethno-geriatric imperative (one-third of older Americans are projected to be from one of the minority populations by mid-century).
54:00 Dr. Kang discusses how the Chinese cultural significance of taking care of elders informs his leadership at WellBe.
54:45 Healthcare disparities are driven by inadequate access to care.
56:00 An example of how WellBe provides linguistically appropriate and culturally competent care in Chicago.
57:00 The number of Americans aged 65 and older will more than doubling over the next 40 years — reaching 80 million in 2040.
58:00 Optimism for the value-based future of caring for seniors – does hope mostly reside only with Medicare Advantage and ACO REACH?
61:00 Multi-payer alignment in value-based care as an imperative to a hopeful future.
Connecting the health and wellbeing of patients of patients directly to the bottom line isn’t just good business; it is a visionary approach that shows how healthier outcomes can actually drive healthier profitability. Continued success in demonstrating the correlation between clinical and financial outcomes will be a catalyst for generating societal wellbeing that paves the way for others to adopt value-based care. And in doing so, we create a more sustainable and effective healthcare ecosystem. In this Race to Value, the true race isn’t about speed; it is about the journey to improved outcomes. Strategic and transformational partnerships guided by an enabling vision to improve population health will ultimately create a healthcare system that we can be proud of.
In this episode, you will hear from Kyle Wailes, the Chief Executive Officer and Board Member of value-based care company, Wellvana. Kyle Wailes is someone on a mission to demonstrate how fully-capitated models in primary care, empowered by the right partnerships to create enablement, will ultimately drive patient behavior change. Under his leadership, Wellvana is an industry-leading example of a company that is connecting the healthy outcomes of patients directly to healthier profitability. With the tools, technologies, analytics, and resources for healthcare providers to successfully and seamlessly transition to value-based care, Wellvana is getting outstanding results and growing at an exponential rate for such a young company. This is highlighted by the recent announcement of their partnership with AdventHealth to revolutionize primary care in the state of Florida. Don’t miss this important interview to learn more about VBC enablement, high-touch primary care and clinical integration, the power of storytelling, patient behavior change, lifestyle medicine, and the current state of private equity investment in healthcare!
Episode Bookmarks:
01:30 Connecting healthy outcomes of patients to healthier profitability. (A High-Touch Approach for High Performers)
02:00 Introduction to Kyle Wailes, Chief Executive Officer and Board Member at Wellvana.
04:00 Big Announcement — AdventHealth partners with Wellvana to transition its Florida primary care network to VBC
05:00 Wellvana is the first value-based care enablement organization in the country to partner with a multi-state/national health system.
06:00 Kyle provides more details on how Wellvana’s recently announced partnership will impact the delivery of healthcare in Florida.
06:30 “Building clinically integrated primary care networks across the country requires flexibility.”
07:00 Expanding primary care impact through interdisciplinary roles (e.g. case management, care coordination, pharmacy integration, social work, coding)
07:45 Health systems across the country are extremely distressed with expenses growing 2X as fast as Medicare payments.
09:30 “The pandemic has been an accelerant overall to drive the adoption of value-based care.”
09:45 The opportunity to reposition primary care in the health system setting, taking it from loss leader to profit center, as a strategic cornerstone for transformation.
10:00 A health system focused only on fee-for-service can lose up to $200-300K per employed PCP.
10:30 “Clinically integrated primary care networks can drive better clinical outcomes, but they can also drive profit and growth as well.”
11:00 Flexibility in growing a PCP network through either an employed or affiliated model.
11:30 Kyle’s personal journey as a professional athlete, student of neuroscience, and value-based healthcare executive.
12:30 “The Story of the Chinese Farmer” – a parable that illustrates the idea that events that initially seem bad or good can lead to unexpected outcomes.
14:00 Kyle provides perspective on the highs and lows of life and how that translates to theculture at Wellvana.
15:00 Lessons learned from playing competitive sports (discipline, hard work, and preparation in winning…while also overcoming losses).
16:00 Wellvana has raised $140 million in capital since 2021 and is now in 22 states, reaching more than 100K lives through multiple payers, Medicare Advantage and ACO REACH.
17:30 Building large high-touch primary care networks at scale requires behavior change.
18:15 Aligning a high-quality specialty network with tech-enabled primary care to achieve appropriate procedural utilization and lower costs.
19:00 Merging High-Touch with High-Tech (“Technology as a standalone solution doesn’t work well in healthcare today. You have to wrap services around it to drive behavior change.”)
19:45 Building Capabilities to Improve Care for High-Risk Patients (“The ability to transition into fully-capitated risk is impossible for a doctor to do on their own.”)
20:30 The connection between improved patient outcomes and higher profitability — a patient success story showing how high-touch care management reduced avoidable ED utilization.
22:00 The power of effective storytelling in value-based care transformation.
24:00 Kyle discusses how Wellvana utilizes storytelling to revitalize care teams and provider partners in creating positive change.
26:00 The Challenging Politics of Value-Based Care (differing ideologies, debates about government involvement, conflicting interests and lobbyists, uncertainty about implementation, economic concerns, partisan politics).
27:30 Kyle shares insights from his involvement in advocating for value-based care on Capitol Hill.
28:30 The evidence that fully-capitated models work despite low market penetration in Medicare (e.g. MA <10% full-risk, ACO REACH).
29:00 How Wellvana educates legislators on the importance of frontloading savings payouts and provider aggregation in networks to drive success in fully-capitated risk.
30:00 Advocacy in patient communities is just as important as political advocacy.
31:00 How Wellvana engages and educates patients on the purpose of value-based care and care planning.
32:00 “To win long-term in this industry, you’re going to have manage medical spend more effectively. We do this by engaging patients in way that can drive behavior change.”
33:30 Wellvana co-founder, Charlie Martin: “Building a Sustainable Economic Model for Lifestyle Medicine”
34:45 Kyle discusses the importance of Lifestyle Medicine in creating a holistic, patient-centered wellness model.
35:45 Wellvana is conducting a clinical trial study on LM with the goal of applying broader findings that drive behavior change at scale.
37:30 Are investors placing more bets on value-based care enablement?
38:30 The runway for value-based care companies in the current investment landscape and why PCPs relationships are so critical to success.
39:30 Digital health and AI solutions will support primary care value transformation.
40:00 Nashville as the epicenter of healthcare investment.
41:00 ACO REACH as an inflection point for adoption of fully-capitated risk in the primary care setting?
42:00 How fully-capitated models will strengthen the connection between improved SDOH interventions and Health Equity outcomes.
43:45 Kyle discusses the future of Wellvana in terms of continued growth and sustained high performance.
46:00 “Success in value-based care is not about the speed; it is about overall outcomes and finding the right partners to take risk.”
Innovation and partnership are the twin engines that propel us into a new era of healthcare. The fusion of cutting-edge technology and clinical innovation, empowered by collaborative relationships, can revolutionize primary care. This cohesion of innovation and partnership makes primary care more accessible, effective, and patient-centered than ever before. There is no better example of primary care modernization than Central Ohio Primary Care (COPC), the largest physician-owned primary care group in the United States with over 480 physicians and 83 locations in central Ohio. Rooted in a long history of clinical excellence and a commitment to the highest ethical standards, COPC is building a new holistic model for primary care that gives physicians time to build relationships with their patients and one another. Through ACO REACH, full-risk delegated capitated Medicare Advantage Plans, and direct-to-employer value-based arrangements, they are able to engage their entire team in the innovation of their primary care model. Furthermore, through partnerships they are able to share risk and build a pathway to sustainability in the provision of value-based care for decades to come.
Joining us on the Race to Value this week is Donald Deep, M.D., the CEO of Central Ohio Primary Care. In this episode, we discuss the modernization of primary care that is underway at COPC – including technology-enabled care efficiency, 24/7 access, care management, and post-discharge follow-up. We explore the successes of their Extensive Care Center and Comprehensive Home and Palliative Care programs. There is also in-depth discussion on low value care, the importance of payer partnerships, direct-to-employer strategies for commercial populations, accessing capital partnerships in full-risk MA, and collaborative leadership for success in VBC.
This episode is sponsored by Agilon Health, a company that partners with independent primary care practices that are leaders in their markets and helps them transition to value-based care success in the Medicare program.
Episode bookmarks:
01:30 Introduction to Donald Deep, M.D., the CEO of Central Ohio Primary Care (the largest physician-owned primary care group in the U.S.)
02:45 Referencing prior episode featuring Dr. Bill Wulf (“The Value Game”: Achieving Success with Capitated Risk and Patient-Centered Primary Care)
03:00 This week’s episode is brought to you by Agilon Health
04:30 COPC has directing 2,200 employees across 90 locations covering six counties and has been on a value journey since 2010.
05:30 The modernization of primary care at COPC.
06:30 Patient care coordination that includes technology-enabled care efficiency, 24/7 access, care management, and post-discharge follow-up.
07:30 “We are responsible for the care of our patient population, even outside of the exam room.”
07:45 Empowering PCPs to spend more time with patients and engage patients and families in the care process.
08:00 Addressing prevention and SDOH requires a modernized primary care model.
08:45 Extensive Care Center (ECC): A Novel Approach to Reducing Emergency Department Visits and Observation Unit Utilization
10:00 The Extensive Care Center at COPC returns 95% of patients to the home (ER Avoidance) and prevents 2-3 hospital admissions each week.
11:00 Scaling the ECC model in co-location with Same Day Centers at COPC to provide immediate access for emergent primary care needs.
12:00 Addressing chronic disease in the extensive care center avoids unnecessary ER visits and hospitalizations.
13:30 Payer recognition of the ECC model, with high levels of patient satisfaction.
14:45 The Comprehensive Home and Palliative Care (CHPC) program at COPC provides primary and palliative care in the home setting.
15:30 Palliative care in ACOs have demonstrated reductions in 30-day readmissions, avoidable hospital admissions, and ED visits.
15:45 Advanced illness programs can consistently provide high patient and family satisfaction, reduce hospitalization by nearly 50%, and decrease costs in the last year of life by 20% to 25%.
16:30 The difference between palliative care and hospice.
17:30 Dr. Deep reflects on his experience as a hospitalist that repeatedly saw patients readmitted to the hospital due to poor symptom management.
18:00 “Palliative care is invaluable in primary care, and we must take it into the patient’s home. Poor symptom management leads to unnecessary ER visits and inpatient stays.”
20:00 The composition of the interdisciplinary team that provides comprehensive home and palliative care services.
21:30 Spending on low-value care range from $100 billion to $700 billion each year.
23:30 Identifying waste in the provision of primary care and defining clinical pathways that define value.
24:30 Patient advocacy for services provided outside of the practice in the promotion of high value care.
25:00 Demanding risk-adjusted outcomes for specialists seeing COPC patients. Providing RFPs to specialists to ensure accountability to expectations for high value care.
25:30 How PCP-led global capitation and compensation redesign incentivizes high value care.
27:00 Referencing a recent Morgan Health study that shows extreme variations in clinical quality for employer-sponsored health plans (e.g. statin medication adherence for CAD).
27:45 COPC’s partnership with JP Morgan Chase to provide onsite health clinics, health coaching, behavioral health services, and after-hours access to care.
28:30 Dr. Deep explains COPC’s advanced primary care model that is provided on a direct-to-employer basis.
29:30 Direct-to-employer care that is convenient, longitudinal, preventative, and consistent.
30:00 How partnering with Vera Whole Health expanded behavioral health services at COPC.
30:30 Providing an advanced primary care access point to large employers as a critical success strategy for VBC.
33:00 Dr. Deep discusses how the ECC model has allowed them to forge more collaborative partnerships with payers.
34:00 “Shifting of financial risk to prepayment (instead of Shared Savings) allows us to engage our entire team in the innovation of our care model.”
35:00 Assessing data to identify high-risk patients. Developing win-win payer-provider partnerships.
36:30 The history of COPC’s partnership with Agilon Health.
37:30 The COPC-Agilon partnership with COPE Health Solutions that led to the development of a primary care Advanced Practice Provider (APP) Fellowship Program.
39:00 The exciting potential of a new value-based care fellowship for APPs.
40:00 “The old way of delivering care where a physician does everything is not sustainable. Team-based care will ensure that we are sustainable decades into the future.”
41:30 How the partnership with Agilon Health enabled value-based care transformation at COPC.
42:30 Finding a VBC enablement partner that truly believes in partnership (beyond just the provision of capital).
43:30 Parting thoughts from Dr. Deep on the importance of collaboration in value transformation.
45:00 “Leaders in healthcare must ensure that both their organization and the community they serve is strong. Doing that through trusted partnerships will make a lasting impact.”
Fourteen years ago, surgeon, writer, and public health researcher, Atul Gawande wrote his landmark article, The Cost Conundrum, about the healthcare challenges of the Rio Grande Valley (RGV) of South Texas. Gawande showcased the challenges that health systems confront when dealing with public and private insurers and the paradox between high-cost treatment options and low-quality outcomes. His careful assessment of McAllen, Texas, a small city on the border, found that it had the most expensive healthcare system in the nation. This “cost conundrum” in the Rio Grande Valley inspired President Obama to pass the Affordable Care Act and begin a national movement to value-based care. Now that ACOs have reached a critical mass in the Rio Grande Valley we must now ask ourselves “to what degree can value-based care accelerate health equity?”
Value-based care is the seed from which health equity transformation can bloom, nurturing a system that values every life, cultivates well-being, and harvests a future where health disparities are but a distant memory. Health equity transformation in underserved regions (like the RGV) is not just a matter of providing medical care; it’s a testament to our commitment to justice, compassion, and the recognition that the well-being of every individual, regardless of their circumstances, is a reflection of our shared humanity. Equity transformation is currently underway in the Rio Grande Valley, one of the most underserved regions in the entire United States. The RGV – a 50-mile stretch of towns that span the border of Texas and Mexico – is home to 1.4 million people (almost twice the population of El Paso), nearly 90% Hispanic, and has some of the poorest counties in the country. Issues like poverty and lack of access to healthcare burden the Valley. These factors are the leading cause of health problems like diabetes, obesity, and cervical cancer.
Our guest this week is Dr. Edwin Estevez, a nationally-recognized value-based care leader and champion for health equity in the RGV. His vision is to activate the local health ecosystem to expand access and promote inclusivity through the power of co-opetition. It involves competing organizations in the same market, working together on something that is mutually beneficial while simultaneously competing in other areas. Coopetition in healthcare is the catalyst for transformative change, where the pursuit of collective well-being transcends individual interests, and collaboration becomes the cornerstone of a healthier local ecosystem.
If you want to be a part of the health equity transformation in the Rio Grande Valley, register today for Accelerator2023 on October 17th! (Attendees can attend in-person in Mission, Texas or virtually). More information at www.equity-accelerator.org
Additional Resources:
WGU Aims to Transform Rio Grande Valley’s Healthcare
A Vision of Pioneering Co-opetition for Health Equity
Episode Bookmarks:
01:20 The landmark article, “The Cost Conundrum” about the healthcare cost crisis and how it inspired a national movement to value-based care.
01:45 Obama’s Favorite New Yorker Article led to the passage of the Affordable Care Act and the development of ACOs.
02:00 Edwin Estevez returns to the Race to Value! (Episode #1 with Edwin)
02:30 The underserved region of the Rio Grande Valley (RGV) as a focal point to create a replicable convening model of equity-based co-opetition.
04:30 Advancing health equity through a community-based ecosystem – Eric and Edwin discuss their upcoming collaboration in the RGV.
05:45 “Value-based care is a platform to shape policy, redirect programs, and understand services better through the lens of health equity.”
06:00 Edwin’s prior VBC success with RGV ACO, one of the earliest (and most successful) physician-led MSSP ACOs in the country.
06:30 Edwin discusses AltaCair, a new population health enablement company borne out of the desire to optimize efficiencies and maximize care management.
08:45 The RGV is a bilingual, border region is home to 1.4 million people (almost twice the population of El Paso), nearly 90% Hispanic, and has some of the poorest counties in the country.
09:00 According to the RGV Health Connect Organization, the region’s median household income is $46,016, compared to $71,347 median household income state-wide in Texas.
09:30 The RGV has 24.7% of families living below poverty level, nearly triple the percentage for the nation. The Rio Grande Regional Hospital states that an estimated 76,000 people in the region have diabetes.
10:00 Edwin provides his perspective on the economic development and demographic growth in the RGV (and how it has not contributed to a rising tide for underserved communities).
11:00 The opportunity for whole-person care and community collaboration to address social determinants of health.
11:45 Despite value-based interventions to reduce avoidable ED visits in the RGV, SDOH challenges still contribute to overutilization of healthcare services.
12:00 The opportunity for Community Benefit Organizations (CBOs) to create a “collective impact model.”
13:30 Dr. Gawande’s careful assessment of McAllen, Texas, a small city on the border, that found that it had the most expensive healthcare system in the nation.
14:00 According to the U.S. Census Bureau, 9.8% of people under the age of 65 do not have health insurance nationwide, but the percentages in the RGV are much higher at around 30%!
15:30 How a broken system of big business fee-for-service healthcare emphasizes profiteering at the expense of community health outcomes.
16:30 “The economics of value-based care galvanized our healthcare community in the RGV following the wake of Gawande’s The Cost Conundrum.”
17:00 The continued challenges of accessing primary care in the RGV (wait times may be up to 2 hours).
17:30 Various community ACOs (e.g. RGV ACO, RGV Health Alliance, South Texas Clinical Partners ACO) have triggered an elevation of consciousness to drive accountability.
18:30 “A mindfulness of engagement to see the whole-person” (focusing on prevention and AWVs)
18:45 RGV-based hospital systems are now focusing on value-based care (e.g. direct admissions)
19:30 Finding opportunities to disrupt the local ecosystem to improve equity (whole-person care responsiveness and focus on social influencers that drive health).
20:00 The critical shortage of PCPs, nurses, and other healthcare professionals and the opportunity to create equity in the access and attainment of education for underserved learners.
21:00 A recent survey of healthcare CEOs by ACHE shows the #1 challenge is workforce — eclipsing even financial challenges which held the top spot for 16 years in a row up until last year!
22:00 Edwin discusses the Higher Education landscape of the RGV (WGU Texas, UT RGV, STC) that are actively engaged to address staffing shortages and workforce development needs.
23:00 How the pandemic created a perfect storm to transform the educational landscape in the RGV for health professions.
23:30 The presence of educational institutions change the relationship of labor to community-based health challenges in a given region.
24:00 “Access to care is at the pinnacle of problems related to equity and opportunity for people of the Rio Grande Valley.”
24:30 “It is astronomically crazy that folks in our market can find it easier to access basis care in the ER than see a primary care physician!”
25:00 A renewed focus on the development of additional primary care access points in the RGV.
25:30 “We must think of access to primary care and labor shortages as a matter of equity. Collaboration can better coalesce around the opportunities to better meet these needs.”
26:30 A Vision of Pioneering Co-opetition for Health Equity — a partnership between theInstitute for Advancing Health Value at the Leavitt School of Health and AltaCair.
26:45 “Co-opetition is a transformation strategy that combines elements of both cooperation and competition. It involves competing organizations in the same market, working together on something that is mutually beneficial while simultaneously competing in other areas. Coopetition in healthcare is the catalyst for transformative change, where the pursuit of collective well-being transcends individual interests, and collaboration becomes the cornerstone of a healthier local ecosystem.”
27:30 Accelerator2023, will be held in Mission, Texas on October 17th, bringing together competing health system and ACO leaders, CBOs, Higher Education, entrepreneurs, civic and other community leaders.
28:00 Collaboration with Aneesh Chopra and Sister Norma Pimentel to advance value for health equity in the Rio Grande Valley.
29:30 “We want to advance equity through community-based focused conversations. Transformation in health equity in the RGV will result from co-opetition.”
31:00 Edwin discusses how a researched-backed convening event can foster impactful strategies that drive high-level tactical execution in the advancement of equity.
32:00 To what degree has health value accelerated health equity?
33:00 The activation of an ecosystem for better health.
34:00 Creating replicable models for health equity co-opetition across the country.
34:30 “Health equity transformation in underserved regions is not just a matter of providing medical care; it’s a testament to our commitment to justice, compassion, and the recognition that the well-being of every individual, regardless of their circumstances, is a reflection of our shared humanity.”
35:00 “It is impossible to continue on a trendline where your zip code is a better determinant of health than your genetic code.”
36:00 Activating entrepreneurship for social justice and health equity through community collaboration.
37:00 Parting thoughts from Edwin on our upcoming event to transform health equity in the Rio Grande Valley.
38:30 Register for in-person or virtual attendance to Accelerator2023!
The plasticity of primary care, in the new value-based era, embodies remarkable adaptability, innovation, and responsiveness to evolving community health needs. As our understanding of health and well-being expands, primary care stands as the first line of defense, ready to transform and customize its services to address the unique challenges faced by diverse populations. This flexibility allows primary care providers to pivot swiftly, whether it’s in responding to public health crises, addressing disparities in healthcare access, or integrating innovative technologies into daily practice. In embracing this plasticity, primary care not only becomes a cornerstone of community health but also a powerful catalyst for positive change, driving us closer to the goal of a healthier, more equitable society.
In this week’s episode of the Race to Value, we are joined by R. Shawn Martin, Executive Vice President and Chief Executive Officer for the American Academy of Family Physicians. The AAFP is the medical specialty organization representing 129,600 family physicians and medical students nationwide. Shawn Martin works with the AAFP Board of Directors on the mission, strategy and vision for the AAFP and provides representation to other organizations, including medical, public, and private sectors. He is nationally recognized for his thoughtful leadership on a range of healthcare and workforce issues. While his career portfolio has focused on numerous health care and public-policy issues, he is best known for his extensive work on the development and implementation of primary care delivery and payment models.
In this episode, we discuss such things as payment reforms in primary care, the industry impact of primary care consolidation, physician-led ACOs, the new Making Care Primary (MCP) payment model and the need for multipayer collaboration, health equity, rural healthcare transformation, physician workforce challenges, and the future implications of AI on the medical profession. With leadership from Shawn and his constituents throughout the primary care ecosystem, we are well-positioned for transformation in the race to value!
Episode bookmarks:
01:30 The plasticity of primary care and how it can evolve to meet community health needs in the new value era.
02:30 Introduction to R. Shawn Martin, the Executive Vice President and Chief Executive Officer for the American Academy of Family Physicians.
04:45 People who have access to advanced primary care tend to have better health, receive timelier diagnoses, and get more prompt treatment when it is needed.
05:30 The U.S. spends only 5-7% of its healthcare dollars on primary care — less than half of the 14% average in Western European countries.
06:00 AAFP Advocacy Priorities: Fighting for Family Medicine!
07:00 Shawn discusses the need for additional investment in primary care at a national level.
08:30 The misalignment of fee-for-service in the primary care setting.
09:00 “Appropriate investment in primary care, coupled with a prospective payment model, will transform both patient experience and care team performance.”
09:45 PCP Infrastructure Investments + Rapid Transition to Value-Based Care = Primary Care Transformation
10:45 Vertical integration of primary care can lead to higher prices and costs, including insurance premiums, without improving care quality or patient outcomes.
11:30 Site-of-service payment differentials create uneven playing field between independent practices and hospital-owned primary care.
12:00 Shawn’s congressional testimony to the Senate Finance Committee on the “Consolidation and Corporate Ownership in Health Care”
13:00 The Medicare program created siloed benefits between hospitals and physicians, and these design flaws created incongruencies in system economics and patient health outcomes.
14:30 The inability of independent physician practices to survive on the regulatory framework of the modern healthcare system.
15:30 Community-based primary care innovation empowered by partnerships.
16:30 The explosion of IPAs and clinically integrated networks and how these models are applied to population health management.
17:00 Data sharing and interoperability empowering chronic care management and transitional care pathways.
17:30 The trend of provider consolidation within “payvider” platforms offered by major payers (e.g. Optum, Centerwell).
17:45 Wall Street interest in primary care that led to additional capital infusion in the absence of public payer support.
18:30 “Private equity investment has created a necessary lifeline of capital for primary care to survive the onramp of value-based care.”
19:00 “It is difficult to focus on primary care transformation when you are seeing 30-35 patients a day, 6 days a week, for 48-49 weeks out of the year.”
19:30 How investments in primary care created the physician mindshare needed to transform their practices.
20:45 On average, physician-led ACOs produce almost 7 times the amount of Medicare savings per beneficiary than hospital-led ACOs.
22:45 Shawn discusses how the autonomy of physician-led ACOs leads to them having better Shared Savings results than their hospital counterparts.
23:00 “The empowerment of PCPs with the autonomy to be patient-centered at the point-of-care has shown what is possible with value-based care.”
24:00 “The challenging occupancy-dependent model of hospitals is not insurmountable if you create collaborative, community-based physician networks.”
24:45 Overcoming the toxicity of fee-for-service in primary care.
25:00 “Primary care is built upon the foundation of a trusting, longitudinal relationship between a patient, their caregivers, and the primary care team.”
25:45 Leveraging virtual care and telemedicine to enhance relationships in the primary care setting.
26:00 “The combination of primary care autonomy with risk-based payment models will help us overcome the toxicity of fee-for-service.”
26:30 The new state-based multi-payer model from CMMI, “Making Care Primary” (MCP), supporting primary care practices in the transition to prospective value-based payment.
27:00 Recent AAFP Press Release: “Primary Care-focused APM Checks AAFP Advocacy Boxes”
27:30 Shawn discusses how the multipayer MCP model construct (Medicare/Medicaid) will serve to eventually bring value to primary care at scale.
29:30 The rationale behind making MCP a 10-year transformation project (instead of a 3-4 year evaluation cycle).
30:00 The imperative for CMMI to transition providers to more sophisticated payment models with downside risk over time.
31:00 Referencing Shawn’s recent article: “How Moneyball can teach us to invest in primary care”
32:00 A recent AAFP member survey that indicated while 85% of surveyed physicians believe social needs are directly related to poor health, 80% are not confident in their ability to address their patients’ social needs.
33:00 Inspiration from Michael Lewis regarding the applicability of Moneyball in healthcare transformation.
34:00 “The single best investment to improve health equity in our system is primary care. It is a main street discipline of care in our communities that is not confined to a building.”
34:30 The plasticity of primary care to meet community health needs and why equity must start with empowered, community-based PCPs.
35:00 The AAFP formed the Center for Diversity and Health Equity to address social determinants of health with The EveryONE Project.
35:30 “You cannot even begin to change the trajectory of health inequities in our health system without primary care.”
36:00 Meeting the workforce goals having access to primary care in every community.
37:00 Mortality rates are 23% higher for people living in rural communities than those who live in urban communities.
38:00 “The movement to prospective, capitated payment models is nowhere more important than in rural communities.”
38:45 How trusting relationships and localized interventions drive patient engagement in rural communities.
39:00 Shawn shares the lessons learned from his father who was a primary care physician in a rural area.
40:00 The relationship between the physician workforce and critical access hospitals and the opportunity to reinvent the rural healthcare ecosystem.
41:30 Physicians have higher levels of satisfaction when practicing in a value-based environment.
42:30 U.S. health is threatened by a primary care workforce shortage, and the country will need up to 48,000 more primary care physicians by 2034.
43:00 Shawn shares his perspective on the physician workforce and the how the AAFP is working to ensure that we have an adequate physician workforce in the decades to come.
45:00 The “infatuation of specialization” that favors procedural intensity.
46:30 The multi-faceted roles of primary care are not fully understood in medical schools.
47:30 How specialty economics contribute to the shortage of primary care.
49:00 The transformative potential of AI in family medicine.
49:45 AAFP recently adopted a policy on the “Ethical Application of Artificial Intelligence in Family Medicine.”
50:30 The need for transparency in the development and implementation of AI in healthcare.
51:30 How AI can be used to reduce administrative burden in primary care practices (e.g. documentation, prior authorizations, utilization management, chart reviews)
52:00 Using AI to decompress the knowledge management of specialization in medicine in order to support more comprehensive primary care.
53:00 The future of AI-enabled, comprehensive primary care.
53:00 Empowering patients with AI through lifestyle-based knowledge transfer and improvement of health literacy.
55:45 Parting thoughts of optimism on the future of primary care and how the value movement will drive us to improved population health.
58:00 The presence of primary care increases life expectancy.
59:00 Stay connected with Shawn on social media and find out more about the work of the AAFP.
Democratizing access to value in healthcare through primary care enablement is the compass guiding us toward a future where health is a universal right, not a privilege, and where the promise of value-based care is accessible to all. It represents a fundamental shift in our approach to healthcare delivery. By prioritizing primary care and leveraging technology, we can extend the reach of healthcare services, making them more affordable and accessible to diverse populations. This approach emphasizes preventive care, early intervention, and patient education, reducing the burden on emergency rooms and hospital admissions. Ultimately, primary care enablement has the potential to transform the healthcare landscape, promoting healthier communities and improving the overall well-being of individuals while also making healthcare a more equitable and sustainable system for everyone.
Joining us this week on the Race to Value is Michael Kopko, the CEO of Pearl Health – a company that is on a mission to democratize access to value in healthcare. More than 800 primary care providers across the country partnered with Pearl to align payments with patient health and leverage emerging data and technology to achieve better outcomes more efficiently. And earlier this year, they closed on a $75M Series B funding round to bring even more capability to the health value economy, by empowering providers to transition to a more proactive care model, enabling them with a technology solution that surfaces urgent cases before they become emergent, and rewarding them for outcomes aligned with value. This is a company that you need to know about, and it is my pleasure to have Mike on the podcast this week to discuss the challenges facing our industry and how Pearl Health is accelerating the development of innovative solutions that place providers at the center of healthcare delivery and cost management.
Episode Bookmarks:
01:30 Introduction to Michael Kopko and Pearl Health — a company that is on a mission to democratize access to value in healthcare.
03:30 After more than a decade of value-based care efforts, the U.S. still pays about twice as much for healthcare than any other country, despite underperforming in quality and outcomes.
04:00 How do we reach a critical mass with ACOs and other APMs to save the Medicare Trust Fund from insolvency by catalyzing care delivery transformation?
05:45 There is reason for optimism for healthcare in the long-term, e.g. R&D in the health sector, the steady march to value since Michael Porter coined the term in 2006.
07:00 The increasing adoption of Medicare APMs and value-based Medicare Advantage (see HCP-LAN APM Measurement Effort).
07:30 “The underlying infrastructure and operating system for healthcare is positioned well for value.”
07:45 More work needs to be done, e.g. Medicare negotiations with pharma companies to lower drug costs, further realignment of incentives.
08:00 Medicare cost growth has abated. (See recent NYT article: “A Huge Threat to the U.S. Budget Has Receded. And No One is Sure Why.”)
08:30 The need to balance ACO Shared Savings performance over time with the democratization of data to improve population health outcomes.
09:00 “We are starting to get the highways and freeways established for data interoperability to be very proactive in creating health value.”
09:30 “Our healthcare system has so much money that with the right capability sets and incentives, we will solve any problem as long as we have the will to do so.”
10:00 Pearl has seen 10X year-over-year growth, expanding from 10 to 29 states, since its founding in November 2020.
11:00 Technology enablement requires the harmonization of the platform with the wisdom of experienced healthcare professionals.
12:30 Michael shares key learnings in his healthcare leadership journey and how that led to the founding of Pearl Health.
14:45 The realization that the missing piece of value transformation was the enablement of PCPs to visualize and understand how to better care for patients.
15:00 “VBC is no longer a gamble when the right physicians are plugged into the right enablement partners.”
15:45 The renaissance of primary care due to value-based care and business intelligence (and how that is addressing historically high levels of PCP burnout).
16:30 Predictive analytics in primary care (e.g. future diagnosis codes, ER admissions, missed medication moments).
17:30 Aggregation of data to power an Urgency Score, which prioritizes patients in need of outreach and creates holistic, longitudinal visibility.
18:30 The overburden of primary care (e.g. it would take 21.7 hours/day for a PCP to accomplish everything that he or she is expected to do to for patient care and maintaining a business.)
20:00 The assembly line of FFS compared to the “New World of Value” and how innovation can reduce administrivia and create cost effectiveness.
22:00 Using automation to streamline patient outreach efforts.
22:30 The delayed absorption of technology into healthcare as compared to other business sectors.
23:00 “The future of automation and AI in healthcare is just beginning, and that is a reason for optimism.”
23:30 Does the MIPS program really add to population health? (JAMA article: Time and Financial Costs for Physician Practices to Participate in the Medicare Merit-based Incentive Payment System)
23:45 How ACO REACH reduces the administrative burden of MIPS. (Reach for Simplicity: How ACO REACH Makes Quality Measurement Easy)
24:30 Since FFS favors procedural intensity over cognitive care, population health suffers. And the mental health of primary care physicians suffers too.
27:00 The crucible moment for PCPs to become elite practitioners in our healthcare system!
27:30 Getting “above the visit” by combining tools and technology to succeed in VBC.
28:00 A renewal of entrepreneurship and a willingness to change your business model.
28:30 An elite segment of the PCP landscape (5-10%) with business performance that surpasses FFS, along with impacts made in community health.
29:00 Solow Growth Model – the application of technology, labor, and capital to support long-run economic growth.
29:30 The enablement sector in value-based care is not feeling the pain of capital constraints.
30:00 “People are adopting and considering value-based models more rapidly than I’ve ever seen in a decade of working with and building networks in healthcare.”
31:00 The average PCP generally earns relatively little but influences ~$10M in downstream healthcare costs.
31:30 PCPs taking fully capitated risk must get specialists contracted into VBC arrangements and that requires overcoming friction due to oligopolistic market dynamics.
33:00 Recent Atul Gawande article in The New Yorker about the Costa Rica healthcare system (improved population health and longer life expectancy through primary care enablement).
33:30 The regression equation for healthcare – advanced primary care with optimal specialty management would address 60-80% of medical costs!
34:00 The changing business model for specialists due to advancements in VBC.
35:00 The tipping of the fulcrum – alignment of primary and specialty care is progressing due to data interoperability.
36:00 Democratization of access to value due to changes in enablement and economics.
37:00 Will advanced hospital systems have a role to play in the future of value?
38:00 Innovators and disrupters will be at the leading edge in VBC because they will be more nimble, agile, and unconflicted.
39:30 15% of the insurance premium dollar goes to administration and profit. (The shift of risk to providers will lower that admin cost to 4-5% or less!)
40:00 Upstarts can create real economic value. (Just look at how AWS disrupted intensive server requirements for businesses.)
40:30 VBC enablement can be as revolutionary as cloud-based computing!
41:00 Michael’s advice to entrepreneurs: “Focus on creating value in a thesis of change.”
41:30 Other opportunities for disruption, e.g. Drug delivery and development, AI and automation, data interoperability.
42:00 Creating an escape velocity through TAM (Total Addressable Market) and Team.
43:00 ACO REACH is a gamechanger for value because it presents an opportunity for PCPs to increase and stabilize revenue with prospective payment.
44:30 Keys to success in models like ACO REACH: reducing the cost of access and improving intelligence capabilities.
45:30 “ACO REACH is a cheaper, faster path to an alignment shift.”
46:30 “Healthcare doesn’t have a data problem. The real test now is what data matters and when does it matter. How do you synthesize and distill information at the POC in a salient way that is actionable.”
47:00 Developing an urgency score, promoting the patients that are most at-risk, and surfacing interventions through a suggestion engine.
48:45 The trend towards PCPs selling their practices to larger enterprises like hospitals and PE-backed physician aggregators.
49:30 The benefit of working within a larger primary care practice (more capabilities, risk protection, negotiation leverage).
50:00 Autonomy and independence of PCPs and how that can happen in a corporatized model.
51:00 Clinical integration – “Hospitals are a key ingredient in VBC when properly applied.”
52:00 Finding a business model that is aligned morally and ethically to what one wants to contribute to the world.
53:00 “The new practice of the future will be less capital intensive with these new value-based models becoming more proliferated.”
53:30 “Culture is what everyone says it is at that moment in time. It’s an evolving organism.” (A Values-Based Culture: Principles at Pearl)
54:00 Creating a company with a strong value compass.
55:00 Transparency and Interoperability.
56:00 Recognition that you get what you pay for. (FFS rewards chronic disease. We need to realign incentives to reward health.)
57:00 Technology, Automation, and Artificial Intelligence.
58:30 The value of health equity in value-based care transformation.
59:00 How ACO REACH finally put an emphasis on the importance of equity in the value movement.
59:30 “Start where the patient is, not where the business model begins.”
60:30 Multidisciplinary care to enhance the health of communities and how capital markets are the great unlock.
61:30 “The model of providing agency to the stakeholders generating high costs is a backwards model. We need a more proactive, sentient system.”
63:00 Parting thoughts on transforming a complex system.
The healthcare system in the United States is ailing and in need of a massive value-based transformation. While we are increasingly polarized in our politics, there is one issue on which most Americans agree: our health care system is broken. Despite spending more per capita on health care than any other country, Americans are in worse health, with lower life expectancies, higher hospital admissions, and at greater risk of suicide and maternal mortality compared to peer nations. This is largely because our health care model has been focused on “sick care” aimed at addressing acute or chronic conditions rather than preventive health maintenance. We have increasingly placed greater value on specialty care over primary care. If we are to right the course and seize this historic opportunity to deliver care that is patient-centered and financially accountable for outcomes, we must unleash the potential of massively powerful primary care!
This week on the Race to Value, you are going to learn about Southeast Primary Care Partners (SPCP) – an independent primary care MSO committed to upholding the independence, innovation and collaboration of Primary Care Physicians, with the ultimate goal of transforming healthcare and achieving true value-based care everywhere. Eric Lisle is the CEO, President and Co-Founder of Southeast Primary Care Partners. And joining him is Craig Worland, the Chief Development Officer for SPCP. These two industry leaders paving the way for a revitalization of primary care in the Southeast and are leading a value journey that we are excited to share with you on the podcast this week!
Episode Bookmarks:
01:30 Our ailing healthcare system and the need to unleash the potential of massively powerful primary care.
02:30 Introduction to Southeast Primary Care Partners (SPCP) and our guests Eric Lisleand Craig Worland.
03:00 Support Race to Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts.
05:30 Eric Lisle shares his “Personal Why” and how that informs his leadership in value transformation at SPCP.
06:30 “Our passion is bringing the love of medicine back to primary care physicians.”
07:30 Craig Worland describes personal challenges navigating the healthcare system and how that inspired him to create meaningful change.
08:45 “The fee-for-service economic system is not designed to streamline care delivery in a way that keeps the patient well.”
09:30 How pivoting to a new economic model creates enablement for primary care transformation.
12:00 Value transformation in primary care is often limited by regional dynamics in the payment landscape.
13:30 How primary care enablement improves patient care outcomes.
14:30 Primary care is the only specialty in medicine that increases life expectancy when community access is enhanced.
16:00 Only 32% of primary care physicians work in a private practice outside of corporatized care delivery business model.
17:00 How independent physician-enablement strategy at SPCP creates whole-person care and improves health equity in underserved communities.
19:30 “The culture, leadership, and long-term strategy of a primary care practice must be oriented towards robust Total Cost of Care revenue models.”
20:00 Can hospital-owned and PE-backed primary care groups effectively pursue a value transformation agenda?
23:00 Investing in FTEs to enhance the population health capabilities of a primary care MSO.
24:45 Creating EHR interoperability and data aggregation to empower population health insights.
25:30 How the SPCP MSO leverages capital to invest in a PCP-led, patient-centered care environment.
26:30 Forming effective payer-provider partnerships through spirited collaboration and demonstration of risk capability.
28:00 The SPCP MSO is differentiated through provider empowerment, payer agnosticism, and commitment to both rural and urban communities.
31:45 Creating a holistic patient view by combining data analytics from aggregated claims with an integrated electronic health records system.
33:30 Displaying actionable insights at the point-of-care to close care gaps.
36:00 Prospective payment models in primary care are a “gamechanger” because they allow for investment in critical infrastructure to drive value.
37:30 Is the CMS goal to move all Medicare patients in accountable care relationships by 2030 realistic?
38:00 ACO REACH is an encouraging sign of risk progression and prospective payment.
40:00 Health inequities in Georgia and Alabama (e.g. cardiovascular disease, diabetes, CKD, cancer, strokes, HIV/AIDS, maternal deaths).
41:00 “The beauty of prospective payment is that it allows providers to do what makes the most sense to improve the health of patients.”
42:30 Getting the economic right – how the dollars provided through prospective payment are agnostic to minority and underprivileged populations.
44:00 The true path to health equity is driven by economic incentives just as much as moral imperatives.
44:45 Hospital closures in rural areas are compounding health inequities. (How can VBC transform care outcomes in these areas?)
47:00 Eric Lisle discusses how SPCP will be able to replicate their MSO model at scale to succeed in new markets in the southeast.
49:30 Craig Worland on the importance of “leadership with empathy” in a successful primary care model.
51:30 The importance of the Institute for Advancing Health Value in supporting organizations like SPCP.
One of the most widely known and influential thinkers on management, Peter Drucker, once said, “The entrepreneur always searches for change, responds to it, and exploits it as an opportunity.” In this movement to value, it’s seems that the new players – innovators and disrupters with unbridled passion for entrepreneurialism – are going to be in the best position to be at the headwaters of a transformation in American healthcare. The financial incentives in the current model of healthcare are simply too entrenched to be overcome by most legacy incumbents worried about how value transformation will create demand destruction in their fee-for-service lines of business. We need a better way forward. Now is the time to throw away traditional economic principles to reshape healthcare in our country!
Our promise to build a uniquely new American healthcare system that is patient-centered and economically viable will be realized by innovators like the one you will hear on this week’s episode. We are joined this week by Thompson Aderinkomi, the Co-Founder and CEO of Nice Healthcare. Thompson has the mindset that if it’s broken, you fix it…we as industry leaders shouldn’t wait for someone else to figure out how we are going to win in this Race to Value! Thompson is a health economist and entrepreneur that you should be listening to. As the co-founder and CEO of Nice Healthcare, he has created a technology-enabled primary care clinic that delivers all care in the comfort of the patient’s home and contracts directly with small employers. Thompson built this company in response to the economic dysfunction and lack of cost accountability that he observed in our broken healthcare system. According to Thompson, it will be necessary for innovators to lead the way since the legacy model is too entrenched to reform itself. Listen to this incredible interview to find out why Thompson believes that value-based care (if done right) will ultimately lead to the bankruptcy of legacy companies!
Episode Bookmarks:
01:30 Introduction to Thompson Aderinkomi, the Co-Founder and CEO of Nice Healthcare.
02:30 Support Race to Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts!
03:30 In 2017, Thompson co-founded Nice Healthcare – an on-demand, in-home technology-enabled clinic that delivers comprehensive healthcare to employees of small and medium-sized businesses.
04:30 Thompson shares the horrific story of the poor healthcare his one-year old son received and how that shaped his entrepreneurial vision to start his company!
06:45 How the lack of consumer-centric innovation in healthcare harms the spirit and hurts patients financially.
08:00 Thompson’s privilege allowed him and his family to overcome their poor healthcare experience unscathed…how many people do not have that fortune? (The inspiration for Nice Healthcare)
09:00 Referencing the famous article, “It’s the Prices, Stupid,” by the late health economist Uwe Reinhardt where he argued that high prices explain most of why U.S. healthcare costs are so much higher than those in other advanced countries.
09:45 The problem with supplier-induced demand, where a physician (i.e. the “supplier”) also serves the economic role as a consumer by generating their own demand.
10:15 Nice Healthcare is fully capitated (no fee-for-serve whatsoever) which allows it to offer unlimited virtual care and home visits, along with lab tests, drugs, xrays, and EKGs conducted in the home.
10:45 “The problem with healthcare is the unit price.”
12:00 Thompson explains the pricing inelasticity demand in healthcare and why that creates flawed incentives for consumer price gouging.
13:00 Profit maximization by increasing market share is not necessarily the modus operandi in healthcare when you can get away by charging whatever you want.
14:45 “Unless you create a completely new business model in healthcare, you are not going to change the price.”
15:00 How Nice Healthcare has changed the pricing model through a disruptive business model.
17:00 Receiving delegated risk from payers in the form of capitation.
18:30 “Our technology and processes allows us to operate at a lower unit price point that we, in turn, pass on to the consumers of care.”
19:00 Referencing prior Race to Value episode with Dr. Farzad Mostashari
21:30 “The very notion that a legacy model for-profit entity would deliberately engage in activities (like value-based care) that lower their revenues or profit is ludicrous. Innovators and upstart companies must solve this problem.”
23:00 “If none of the incumbent healthcare players are going out of business, you don’t have value-based care. The ultimate result of true value-based care should be bankruptcy of legacy companies.”
24:30 A new innovator can be profitable and create value for shareholders and communities with much lower revenues than incumbents.
26:00 True innovators in healthcare do not grow fast because they are creating value.
26:45 Referencing “The Innovator’s Prescription’ by Clayton Christensen (the wasteful spending in healthcare that can be addressed by innovators)
28:30 “Simplicity doesn’t start with Technology. Technology only makes simplicity elegant.”
29:00 The simplicity of the Nice Healthcare care delivery model.
31:00 The surge of venture capital and private equity investment going into virtual care and high-touch primary care models and the move to asset-light hospitals.”
32:45 “Hospitals should not be for-profit and should not even be private organizations. They should serve as a utility offering a public good.”
34:30 Removing the profit motives from hospitals will make them a public utility (just like police and fire departments).
35:30 “Everyday primary care should be as easy to access as air. That is where free market principles, competition, and true innovation come into play.”
38:00 Employer-sponsored health plans have gone up 54% in the last decade. Are employers the “sleeping giants” that will awaken to force the change needed in our healthcare system?
39:30 Thompson explains how Medicare and commercial insurance plans are inextricably linked together. (Lower wages because increased healthcare costs creates less tax revenue to fund Medicare program.)
42:00 “Any solution we want for Medicare has to involve the commercial population.”
42:30 “The federal government needs to wake up to the fact that the healthcare industry is making it impossible to fund Medicare.”
43:30 “The most expensive and complex care should be provided by the government. The lowest risk pool has everyone in it.”
44:00 “Funding Medicare through income taxes harms employees. We have to be free from that paradigm so employers can affect change in healthcare with true innovation.”
45:30 How the high barriers to entry in the healthcare marketplace prevent new entrants from coming in to impact real change.
45:45 The need to create national provider licensure, loosen telehealth regulations, and lower the debt burden for students in medical schools.
47:45 The healthcare economic model must change to better serve society – healthcare should be a “right” instead of a privilege.
49:00 Will increased patient expectations become a formidable agent of change to hold the healthcare industry accountable for consumer-centric innovation?
50:00 Consumer demands will not lead change in healthcare because they lack agency and ultimately succumb to pricing inelasticity.
51:30 Thompson explains how Nice Healthcare provides patient-centered care by pulling up a random patient review on Google (and compares it to a random competitor clinic in Minnesota).
55:30 Nice Healthcare Results: 98% of patients rate care as better than their previous clinic, $453 net yearly savings per employee, and the company has a 93.2 Net Promoter Score.
56:30 Saying “no” to insurance and partnering with innovative, forward-thinking brokers led to product distribution at a low price point with minimal friction.
58:00 Combining virtual care with in-home visits to replicate the clinic experience.
62:00 Thompson provides a contrarian view of Population Health by stating that it has nothing to do with predictive modeling and algorithms (we should instead focus on changing our food industry, educational system, and policing to improve health.)
63:00 “The sole purpose of population health management is to improve patient experience and lower the cost of care to improve quality and outcomes. You don’t need data to do that. All you need is to provide access to primary care at a lower unit price.”
66:00 Thompson provides parting thoughts about what it takes to be a healthcare innovator (and provides criticism for those incumbents who are lying about the value they are creating.)
Physicians are looking for novel solutions to streamline and improve care delivery in our ever-changing industry. They already don’t have enough time to do all that they want, and they are always being asked to do more! They want more time with patients, but the fee-for-service machine demands they see more patients more quickly. It’s a system that demands more and more and offers less to accomplish it.
But there is potential for more success via risk-based reimbursement in value-based programs is on the horizon. Doctors in private practice or employed by systems are excited to know that there is a way they can provide the care they’ve always envisioned, to be that caring individual who spends time getting to know and serve the patient. When they discover the possibilities in VBC they oftentimes turn to seek a partner that can help them adapt, so that they can take advantage of the opportunity to really care for patients.
This week on the Race to Value we are interviewing Dr. Keith Fernandez to discuss physician enablement and how helping doctors helps patients. Dr. Keith Fernandez is the Chief Clinical Officer of Privia Health, and CEO at Privia Quality Network South Texas, located in Arlington, Virginia and Houston, Texas, respectively. Privia Health is a national physician practice management and population health technology company that partners with leading doctors to keep people healthy, better manage disease, and to reward providers for delivering high value care. Privia is dedicated to providing value based care to its patients, and an improved lifestyle to its physicians.
Episode Bookmarks:
01:30 Creating physician enablement is key to population health success.
03:30 Introduction to Dr. Keith Fernandez, Chief Clinical Officer at Privia Health
04:45 Subscribe to the Race to Value newsletter for weekly updates on new episodes!
06:30 Establishing governance to ensure a high degree of physician engagement.
07:45 Creating a National Clinical IT Advisory Council to provide feedback on Clinical Decision Support and AI.
08:30 The impact of clinical-decision support and data at the point-of-care.
09:30 Using data to understand specific populations covered under value-based arrangements.
11:00 Surfacing data in a team-based care environment drives quality patient care.
12:00 Using technology and remote scribing to ameliorate physician burnout.
13:45 Technology tools for billing and coding to alleviate provider documentation requirements.
14:30 Providing an “unencumbered interaction between the physician and a patient” brings joy to medicine.
15:30 Supporting competency in revenue cycle management to optimize fee-for-service.
16:30 Workflow optimization in an interdisciplinary care team to support higher efficiency and improved patient outcomes.
17:45 The pandemic left independent primary care practices operating on razor thin margins.
19:00 How does stabilizing PCP finances help care teams devote more time and energy and resources to patients?
20:00 Automated technology is helping practices in fee-for-service claims appeals to improve revenue capture.
21:30 Dr. Fernandez discusses how a natural disaster during his career provided key learnings in RCM optimization.
23:45 The importance of ancillary revenue streams to support value-based contracting success.
25:00 Using a clinical research program focused on population health.
27:00 Rebuilding practices for the future through the National Physician Advisory Council at Privia Health.
28:00 Effective use of Nurse Practitioners and Physician Assistants to reach full clinical effectiveness.
30:00 Conducting a complete analysis of each practice joining a value-based network.
32:00 Onboarding contracted doctors into the population health platform.
35:00 Engaging all doctors – both PCPs and specialists – as a key to physician enablement success in VBC.
36:00 “We’re trying to empower doctors, improve their life, and help drive great care for their patients.”
36:30 Developing a Physician Leadership Program and how that leads to physician-led ACO success.
38:00 The challenges of improving Social Determinants of Health in managed patient populations.
39:30 Aligning physician compensation to value-based care performance, especially with populations that are SDOH-challenged.
41:00 Home care and remote patient monitoring to improve outcomes in underserved populations.
42:30 The role of consumerism in value-based care and how care teams should prioritize patient preferences and values.
45:00 The benefits of practicing medicine in a group and how peer learning dynamics drive VBC performance outcomes.
48:00 Convening physicians and attentively listening to their concerns will ultimately lead to operational efficiency.
50:30 “If you improve patient outcomes and satisfaction, you reduce the cost. It is a matter of fact that better care reduces the cost of care.”
52:00 “If we want to transform healthcare, we need to save money. That means we need to win on these contracts.”
52:45 Behavioral Health integration, referral management, CDS, and clinical research partnerships are future strategies for Privia Health.
54:30 Finding local partnerships in communities to address SDOH.
57:00 Evolving physician leadership in healthcare transformation as the ultimate inspiration.
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