Health Value Strategy – The Race to Value Podcast™: Recent Episodes
Institute for Advancing Health Value
The transformation of healthcare is a seemingly insurmountable challenge, yet overcoming any obstacle in the journey begins with the belief that it is possible to win! It’s not about the magnitude of the task; it is about the collective will to prioritize the wellbeing of every person we serve in our population. Perhaps when approached with the audacity to imagine a healthier and more equitable future for all, we’ll actually get there. And that is just what the Physicians of Southwest Washington (PSW) is realizing as they navigate a successful transition from volume to value.Our guest on the Race to Value this week is Melanie Matthews, the dynamic, creative, and innovative CEO of PSW. She leads a population health company that has been around for three decades. Melanie is not only leading their ACO and managing their progression in the adoption of full-risk Medicare Advantage delegation; she has become a nationally recognized voice for value-based health policy. In listening to this interview, you will hear from a leader that has a real personal capacity for leadership and a clear focus on excellence. If you want to hear from someone that is at the absolute forefront of risk-based contracting and innovation, who understands the issues at a granular level, this episode with Melanie is a must-listen!Episode Bookmarks:01:30 Introduction to Melanie Matthews and the Physicians of Southwest Washington (PSW)04:30 PSW has evolved over the last three decades from an IPA to a diverse business that includes a national leading ACO and risk-bearing entity for MA.06:00 “PSW is a story of independent physicians who, in a time of market consolidation, want to remain independent and focus on the patient relationship.”06:45 Achieving success in delegated risk and taking accountability for both quality and total cost of care.07:00 The impact of MACRA on the long-term value-based care strategy of PSW.08:30 Building an infrastructure and developing capabilities to move a value-based agenda.09:00 Developing a business model for agility in responding to new rules (“a kayak in a sea of cruise ships”) and engaging all types of physicians in the landscape.09:30 “The value-based movement is important as the fee-for-service chassis is not realistic, has poor quality and outcomes, and rising costs.”10:00 Taking risk with physician partners and providing them with MSO services, leveraging a technical infrastructure and population health platform.10:45 The glacial pace of scaling payment model transformation at CMS and CMMI’s bold goal for 2030.12:00 The increasing shift to home-based care delivery and the use of generative AI in reshaping care delivery.13:00 How the flawed economic design of the fee-for-service system creates industry inertia.14:00 Diverting to the known (i.e. fee-for-service care delivery) in times of stress is an unsustainable path forward.15:00 Convincing the Board room on the tenets of VBC when it hasn’t historically delivered on its promises.16:00 Trends in consumer cost-shifting and the challenges of private insurers cross-subsidizing provider losses from public payers.16:30 Unsustainable economics in employer-based healthcare and the looming insolvency of Medicare.17:00 What does the CMMI 2030 Goal mean for future of the value movement?18:30 An overview of the extensive services offered by PSW that empowers success in VBC.19:30 The explosive growth of strategic transactions of physician groups and how mass consolidation is impacting the landscape.21:00 Aligned incentives and access to a population health platform as keys to VBC success.22:00 PE investment impacts on competition in an independent physician ecosystem.23:00 Generational differences in the approach to the business of practicing medicine.23:30 “Organizations that are convened with independent physicians are able to show better costs of care.” (vs. employed or vertically integrated systems)24:45 Capital investment and consolidation as a forcing function for physicians to embrace total cost of care models.26:00 The explosive growth trajectory of Medicare Advantage and how PSW is capitalizing on innovation in full-risk MA delegation.28:30 Keys to Success in Full-Risk MA: 1) Incentive Alignment, 2) Empowering Data and Actionable Insights, 3) Standardized Workflows29:00 Developing a common set of quality and utilization goals across all payer contracts.30:00 Clinical connectivity, workflow optimization, and a data infrastructure for high- and rising-risk patient segmentation.30:30 Working with the array of incentive options in MA – from P4P, hybrid capitation, to full capitation options.31:00 How full capitation allows for an immediate recognition of the high utilizers in need of intervention.31:30 Prospective payment as a revenue stabilizer for independent practices.33:00 Using outcomes, quality, and clinical coordination data to align incentives in a physician network.33:45 PSW has a risk portfolio that covers 350,000 lives, of which 80,000 are Medicare beneficiaries in MSSP and ACO REACH programs.35:00 MSSP is vehicle for building risk maturity, while CMMI programs (e.g. ACO REACH) present the best opportunity for care delivery innovation.37:00 Consumer-centric innovation and benefit design flexibility in MA as a source of influencing CMMI payment model design.38:30 “ACO REACH is the first model that really contemplates the economic considerations of managing populations in underserved areas.”40:00 Strengths of ACO REACH (e.g. health equity benchmarking, care delivery innovation, incentives for SDOH interventions).40:30 What can CMMI do to improve the benchmarking methodology used in ACO REACH?42:00 Testing capitation and assessing health equity opportunities in ACO REACH.43:30 Executing on a playbook for Population Health improvement.45:00 Building a culture of team-based care in value transformation.47:00 Engaging patients through motivational interviewing.47:45 Ensuring access, capturing quality, and providing preventative screenings as the ABCs of comprehensive primary care.48:15 Developing shadow bundles within a total cost of care arrangement to align incentives with specialists.50:30 Melanie’s describes her experience as a leading advocate and health policy expert.51:30 The need for a unified voice to define what value-based care really is.52:00 A patient example of how social isolation caused extreme overutilization of the ED.53:45 “I feel like it’s important to shout from the rooftops on the importance of value-based care…”55:00 The Value in Healthcare Act as a policy striving to preserve Advanced APMs in the value movement.57:45 Parting thoughts from Melanie on the future of accountable care.
We have a broken healthcare system. Too often, individuals today experience care that is fragmented, duplicative, wasteful, and confusing. Through value-based care, we can improve the health care experience by coordinating care, creating care teams that communicate with one another, and supporting individuals in their care journey with services that address their medical and non-medical needs.Accountable for Health is a nonpartisan national advocacy and policy analysis organization accelerating the adoption of effective accountable care. Their members are advocating for value-based care on Capitol Hill so policymakers can understand how best to move American healthcare towards a model that achieves better outcomes, improved care experiences, increased access, and lower costs. Joining us on the podcast this week is Mara McDermott, the Chief Executive Officer for Accountable for Health. She is an accomplished healthcare executive with deep expertise in federal healthcare law and policy, including delivery system reform, physician payment and payment models.Take this opportunity to learn from a leading expert on accountable care as she translates the truth in building a bridge towards a more broad-based understanding of health value. And make sure to tune in to Mara’s special announcement about Health Care Value Week at the end of the interview so you don’t miss out on important educational events occurring January 29th thru February 2nd.Episode Bookmarks:01:30 The need for accountable care policies that create better health outcomes and patient experiences.02:00 Introduction to Accountable for Health (A4H) and its Founder/CEO Mara McDermott, JD, MPH03:00 Interview topics discussed (e.g. the meaning of VBC, MSSP vs. MA, MACRA 2.0, advanced APMs, integrated specialty care, Medicaid transformation, and the upcoming Health Care Value Week event).06:00 How A4H is translating thought leadership to action in the advocacy arena.06:30 Accountable care as the solution to fragmented, uncoordinated care.07:00 Political turnover in D.C. has made VBC a “new” health policy solution.07:30 Educating the Hill comes down to conveying enthusiasm for health care transformation.08:00 Accountable for Health Members are shaping the national conversation for payment and delivery system reform.09:00 The health policy controversy of the Global and Professional Direct Contracting model (the precursor to ACO REACH).11:30 If Direct Contracting was the natural evolution of a series of advanced ACO options, why was there such strong criticism?12:00 The need to overcome misunderstandings about what ACOs are trying to achieve.13:00 Providing education to dispel the myth that ACOs can actually limit services.14:00 How uninformed policy decisions could potentially create a catastrophic blow to the value movement.14:45 “Accountable care is integral to care delivery system reform.”15:45 Confusion with the term “value-based care” and why it will fail unless people understand the truest aims of the movement.17:00 The need for effective storytelling to advance care delivery transformation.18:00 Prioritizing care experience over cost reforms (delivery innovation will address costs!)20:00 The topline takeaways from CMS model evaluations and whether or not programs should be expanded.21:00 What do most people think when they hear the word “value”? (the need to reframe the conversation with more precise language)22:00 The MSSP and the Medicare Advantage programs as two distinct approaches to healthcare delivery and reimbursement.24:00 Mara provides a brief comparison between MSSP and MA (e.g. beneficiary assignment, risk adjustment, benchmarking).25:30 How strong relationships between MA plans and provider networks (underpinned by capitation) drive value.26:30 Understanding provider compensation in MA value-based payment and the synergies between managing MSSP and MA populations.27:00 Rethinking supplemental benefits in Traditional Medicare.28:00 An overview of the Medicare Access and CHIP Reauthorization Act (MACRA).30:30 The “cliff effect” of the Advanced APM Bonus reductions (and why that threatens the value movement).31:30 “We need strong incentives to continue this work in accountable care transformation. The Advanced APM Bonus has built important momentum.”32:30 The MIPS program maximum bonus is at 9% — in what world would the Advance APM incentive make sense at only 0.5%?33:00 Why are providers in the last year earning full bonuses in MIPS when 2-3% has been the historical average?33:30 An overview of The Value in Health Care Act of 2023 and consideration of a full-risk ACO option in the MSSP.35:45 The need for a long-term vision for MACRA (i.e. MACRA 2.0).38:45 The integration of specialists in accountable care models.39:30 Leveraging the physician fee schedule as a glide path for specialist adoption. Providing data to ACOs to better engage specialists.41:00 The responsibility of the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to advance specialty-specific APMs.41:45 The move to mandatory payment models to catalyze healthcare cost savings goals for CMMI.45:00 How are Medicare-value based efforts aligning with Medicaid transformation?47:00 Health Care Value Week is a week of action from January 29th to February 2nd, providing broad-based education on VBC.48:30 The Virtual Value-Based Payment Summit is open to everyone (free registration) and the speaker lineup is incredible!49:30 A4H’s Health Care Value Week Conference in D.C.on Feb. 1st to celebrate the progress of VBC in improving people’s lives!51:00 Learn more about A4H and sign up for their newsletter at accountableforhealth.org.
The World Health Organization has declared climate change as “the greatest threat to global health in the 21st century.” As our planet grapples with the accelerating impacts of climate change, it is crucial that we adopt a climate lens in the value transformation of our healthcare industry. The repercussions of climate change extend far beyond environmental shifts; they manifest in various health issues, including challenges with clean water access, increased allergens, respiratory diseases, heat induced illnesses, and the proliferation of infectious diseases. It’s essential to acknowledge that while climate change affects everyone, the burden falls disproportionately on historically marginalized populations, highlighting the interconnectedness of climate impacts and social determinants of health in underserved communities.
In our pursuit of delivering safe, effective, and efficient care amid the climate crisis, we as healthcare leaders also bear the responsibility to address the substantial greenhouse gas emissions generated by the sector. Accounting for nearly one fifth of the U.S. gross domestic product, the healthcare industry possesses considerable purchasing power that can be harnessed to steer the nation toward cleaner energy and a low carbon supply chain. Beyond mitigating environmental harm, embracing preventive models of care and enhancing care quality that lowers excess utilization naturally aligns with lower carbon footprints. Value-based care, therefore, can become a powerful catalyst in propelling us toward a net zero carbon future that will build a sustainable, resilient future for our planet.
This week we are interviewing Dr. Vivian Lee, a healthcare executive dedicated to the advancement of value-driven transformation in health and tackling climate change. Author of the acclaimed book,The Long Fix: Solving America’s Health Care Crisis with Strategies that Work for Everyone, she is an Executive Fellow at Harvard Business School and Sr Lecturer at Harvard Med School. Prior to her Executive Fellowship at Harvard, she was the founding President of Verily Health Platforms, an Alphabet company combining a data-driven, people-first approach to precision health. Dr. Lee is also a former health system CEO, medical school Dean and member of the National Academy of Medicine. She is regularly listed among Modern Healthcare’s Most Influential Clinical Executives as well as Modern Healthcare’s Most Influential People in Healthcare.
Episode Bookmarks:
01:30 The World Health Organization has declared climate change as “the greatest threat to global health in the 21st century.”
02:00 Climate change burden falls disproportionately on historically marginalized populations.
02:30 The responsibility to address the substantial greenhouse gas emissions generated by the healthcare sector.
03:00 Introduction to Vivian Lee, M.D.
04:30 One in four deaths can be attributed to preventable environmental causes…and climate change is exacerbating these risks.
06:00 Climate change resilience as a lens for value-based transformation.
06:45 The irrefutable scientific evidence about the unprecedented levels of carbon dioxide in our atmosphere.
07:00 What are health care leaders going to do about this? (The need to manage the crisis through an empowered workforce.)
08:30 Exposed vulnerabilities in our supply chain as a complication to address climate-related crises.
09:00 The healthcare industry is responsible for 8-10% of the overall carbon footprint of the country (more than twice the #2 country!)
10:00 How do we decarbonize healthcare in order to “do no harm”?
11:45 Pollution from health care–associated energy use results in an estimated 405,000 disability-adjusted life years annually (a burden comparable to that of preventable medical errors).
12:30 The strong business case for health care organizations to reduce their carbon footprint.
13:00 Tax credits offered by the Inflation Reduction Act to decarbonize hospitals.
14:30 “Renewable energy actually costs less than fossil fuel energy.”
14:45 The Inflation Reduction Act will cover about 30% of the capital needed to invest in a renewable energy system. (Add another 10% each for serving underserved regions and buying American made!)
15:00 ROI in the tens of millions for health systems going green! (“doing good and doing well”)
16:00 Non-productive energy use (e.g. ~60% of energy consumed by MRI and CTs occur when offices are closed on evenings and weekends!)
17:00 Putting high intensity imaging machines in idle mode would reduce the carbon footprint at a level equivalent to the NHS!
18:45 Kaiser Permanente became carbon neutral. (Referencing Kathy Gerwig article co-written with Dr. Lee – “Decarbonizing Healthcare“)
19:30 Boston Medical Center reduced carbon emissions by more than 90%.
20:00 Resources: Kathy Gerwig’s book, “Greening Health Care: How Hospitals Can Heal the Planet”, the AHRQ Climate Change Primer, and Health Care Without Harm, Medical Society Consortium on Climate & Health
22:00 “There are so many opportunities for aligning with the decarbonization effort that are completely synergistic with value-based care.”
22:45 “Primary care has a much lower carbon footprint than high intensity tertiary or quaternary care.”
23:20 How can we utilize telehealth and telenursing to reduce patient and clinician transportation needs?
24:30 Referencing the influence of Don Berwick in medical waste elimination. (see article “Eliminating Waste in U.S. Health Care“)
25:30 “Eliminating health care waste will do good for the planet, do good for the communities, and actually make ourselves financially healthier as well…all in the spirit of bringing more value to our health care system.“
26:45 The AMA is encouraging physicians to assist in educating patients and the public on sustainable practices and to serve as role models in providing environmental sustainability (see AMA Code of Medical Ethics Opinion on Climate Change)
28:00 Dr. Lee discusses the role of clinicians to advocate for eco-friendly practices in patient communities.
30:00 An example of how a pediatrician conducts climate change counseling (see Dr. Andrew Lewandowski’s study)
34:00 The tech-based application of AI, data, and analytics to combat climate change through value-based care delivery.
35:45 Using a health meter to advise patients on how best to deal with extreme heat and bad air advisories.
37:00 Lowering the health care carbon footprint through supply chain optimization.
39:00 The need for more engineering and technical innovation to support innovation in climate resilience.
39:30 The White House and HHS launched the Health Sector Climate Pledge to cut greenhouse gas emissions by 50% by 2030 and net zero by 2050.
40:00 “Solving the climate crisis is the greatest and most complex challenge that Homo sapiens have ever faced. The main solution, however, is so simple even a child can understand it. We have to stop our emissions of greenhouse gases. And we either do that or we don’t.” — Greta Thunberg
41:00 Parting thoughts from Dr. Lee on value-based care and climate change resilience. (“It doesn’t matter what political party or what socioeconomic class you are. We can’t escape this issue of climate change. We are all on this planet together.”)
In caring for our communities, a carefully designed Care Continuum Blueprint becomes the roadmap to enhanced population health outcomes—a testament to the profound impact of integrated care and strategic coordination. There has never been a more compelling time to adopt a system of care based on population health management. The COVID-19 pandemic revealed substantial health disparities and compels us to take action. The population is aging, and the Medicare insolvency crisis is looming. Now is the time to move away from fee-for-service care and toward an approach that prioritizes quality, outcomes, and affordability for all populations.
In this week’s episode, we interview Dr. Mark Angelo, a senior administrator of a large accountable care organization and a leader in population health and palliative medicine. He is the author of the new book Caring for Our Communities: A Blueprint for Better Outcomes in Population Health, that provides tactical guidance for developing effective population health programs and explores value-based care models. Dr. Angelo is an inspirational leader to the health value movement, providing a road map for creating an equitable, outcomes-focused system, using the right resources to nurture the health of our communities.
Dr. Mark Angelo currently serves as CEO and President for the Delaware Valley ACO (DVACO). In this role, he oversees clinical strategy and operations, including quality, population health pharmacy, clinical integration, care coordination, post-acute networks and practice transformation. In addition to serving patient communities as an executive with the ACO, he is a practicing palliative care doctor who continues to see patients. DVACO has participated in the MSSP since 2014 and also works with commercial and Medicare Advantage payers in an effort to grow and expand the mission of value-based care in the Greater Philadelphia area.
Episode Bookmarks:
01:30 Introduction to Delaware Valley ACO and Mark Angelo, MD, MHA, FACP.
04:30 Referencing Dr. Angelo’s new book Caring for Our Communities: A Blueprint for Better Outcomes in Population Health.
05:00 “Never doubt that a small group of thoughtful committed citizens can change the world; indeed, it is the only thing that ever has.” — Margaret Mead
06:00 Dr. Angelo provides his perspective on population health underpinned by his clinical practice of palliative care.
07:30 A care continuum strategy that ensures care continuity, collaborative planning, and case management for complex patients.
09:30 The post-acute care journey at DVACO that began in 2014.
10:30 The Skilled Nursing component of DVACO’s post-acute care strategy.
11:30 Using claims data and real-time readmission tracing to monitor performance of SNF partners.
12:30 Graduating from a post-acute care focus to an overall care continuum strategy.
13:45 Optimizing home health to prevent avoidable hospitalizations.
14:30 How to identify suboptimal hospice care (e.g. length of stay greater than 180 days).
16:30 Home-based therapy as part of the care continuum to reduce TCOC in a frail elderly population.
18:00 An optimal zone of therapy between 12 and 32 therapy units over the course of a year.
19:00 Medicare reimbursement differentials across the different settings in a post-acute care continuum.
20:30 Building a population health playbook in post-acute care begins with SNFs.
22:00 Assessing performance data in developing a small SNF network to guide steerage decisions.
23:30 Applying the SNF assessment strategy in the vetting of preferred providers in home health and hospice.
26:00 Are partnering PAC facilities communicating with you in a meaningful way?
26:45 “Discharge planning shouldn’t happen in the last 24 hours of discharge. It should be happening all along. This is an important factor when it comes to creating partnerships across the care continuum.”
28:00 DVACO (in partnership with Main Line Health) developed a palliative care program that reduced hospitalizations by 50%!
28:45 “If you are an ACO and you are not focusing on your seriously illness population, you are missing a big opportunity.”
29:30 Developing an analytics methodology to identify patients with serious illness.
31:00 Guidance from Dr. Diane Meier, a nationally-recognized geriatrician and palliative care expert.
31:30 Improving lives of patients while decreasing costs at end-of-life through a home-based palliative care program.
34:00 Population health data that confirms the superiority of home-based palliative care (e.g. decreased hospitalizations and ED visits, increased hospice utilization).
37:30 Dr. Angelo provides leadership insights on how best to engage providers in population health approaches to care.
38:45 An example of supporting providers in VBC (a dedicated call center that connects resources to patients most in need).
41:00 SDOH and behavioral health resources for patients (e.g. addressing food insecurity to improve population health).
42:00 Another example in supporting providers in VBC (a successful aging program).
43:00 In-home wellness assessments for patient (e.g. medication reconciliation, dietician and care coordinator consults).
44:45 “We help our providers to better care for patients at the point of care. That is a great way to get providers to want to be part of your ACO.”
46:00 Health equity as a societal flashpoint and the challenges of inequality in the Greater Philadelphia area.
47:30 How DVACO provides a health equity lens in the design and implementation of all population health programs.
48:45 The need to compare QM results between population segments (e.g. an overall mammogram completion rate of 88%).
49:30 How the pandemic highlighted health inequities and reframed opportunities for improving population health.
50:00 “In an Accountable Care Organization, you’re responsible for managing the care of your community, not the care of a fraction of your community.”
52:00 The impact of social isolation on frail and elderly populations.
52:45 People experiencing social isolation have a higher risk of heart disease, stroke, depression, and anxiety.
53:45 Surgeon General Dr. Vivek Murthy’s call to action to address “the epidemic of loneliness” as a public health crisis.
54:00 The correlation between excess utilization of healthcare services and social isolation.
55:00 Building bridges with Community Benefit Organizations to address social isolation.
57:00 The emerging “payvider” trend and how Humana became a valued partner in Delaware Valley ACO.
58:45 The benefits of a strong payer relationship within an ACO.
60:00 “Payvider relationships say to the market that we are laser-focused on the success in value-based programs.”
61:00 The Infinite Game: “Infinite-minded leaders don’t ask their people to fixate on finite goals; they ask their people to help them figure out a way to advance toward a more infinite vision of the future that benefits everyone.”
63:00 Parting thoughts on balancing fee-for-service with the “infinite game” of value-based care.
Many factors impact our health beyond genetics and aging. Collectively, these are called social determinants of health and include factors such as education, housing, income, occupation, hunger, language, literacy, where we live, and access to affordable healthcare services. However, there is a gap in the current list of social determinants of health, and that is the influence of “information” or an “information ecosystem” on patients’ behavior, engagement, and health outcomes. It is critical to consider “information” as another social determinant of health since it can be used to drive positive patient health outcomes. How we deliver it, where we deliver it, and who delivers it is crucial to value-based health care transformation and patient-centeredness.
So, how do we harness this idea that information can change health outcomes? To answer this question, we have invited Debbie Welle-Powell back to the Race to Value! As a 30-year healthcare executive veteran, value-based care thought leader, and educator, she is committed to the empowerment of change management principles to drive population health at the intersection of patient engagement and information sharing. In this episode, we discuss what is needed to empower the patient and clinician, technology-enablement and value-based payment to fine tune the delivery system, and the information ecosystem needed to drive healthy outcomes.
As a companion to this podcast, make sure to read Debbie’s new article on this topic. It is available for download on the Race to Value webpage for this episode!
Information as a Social Determinant of HealthEpisode Bookmarks:
01:30 Introduction to Debbie Welle-Powell, a healthcare executive veteran whose work focuses on delivering affordable and accessible high quality care.
02:45 Reference previous R2V episode – “Climbing the Mountain: Reaching New Heights for a Transformative Future”)
03:00 Read the companion article to this interview on the Race to Value episode website!
03:45 Debbie provides a brief update on her professional work in value-based care (and her mountain climbing adventures!)
05:30 The influence of “information” or an “information ecosystem” on patients’ behavior, engagement, and health outcomes.
06:30 Should we consider information as another Social Determinant of Health (like transportation, education, housing, and food security)?
07:30 “Information only really matters if it helps patients change behaviors. The delivery of information is crucial to empowering health outcomes.”
08:30 “The American healthcare system is not as patient-centric as it claims to be because of a failure to provide empowering information.”
09:00 The roles of clinicians and patients to improve health literacy.
10:00 Patient noncompliance – Ex: 20-30% do not pick up prescriptions, 30-40% do not follow-through on referrals.
10:45 The challenges of interpreting and addressing SDOH challenges to avoid unnecessary utilization.
12:00 The importance of the patient-provider relationship. (Eric shares insights from his healthcare trip to Cuba.)
14:30 Technology enablement and health system evolution to better address patient information needs.
15:00 Improving patient engagement through the online user journey (i.e. the digital front door).
15:45 Debbie shares a personal example from her cancer journey where the care team failed to provide adequate information.
17:00 Half of patients seeking receive misleading information when independently searching online sources.
17:30 The opportunity for clinicians to provide trusted and reliable online educational resources.
18:00 The hyper-saturation of online content (e.g. 500 hours of content uploaded to YouTube per minute!)
18:30 How the value-based care movement provides incentives for improving patient engagement.
19:30 The use of Generative AI in the clinical setting to help patients better navigate their care journey.
20:45 Merging the science of medicine with the art of information – how to best engage patients during a formidable time of distress.
22:30 Realigning healthcare investments into patient engagement information systems, AI-based tools, and team-based care delivery.
23:30 The need for change management tools at the system-level to improve patient engagement.
24:00 Transforming clinical practice using the Prosci ADKAR change management model.
25:45 Creating a patient advisory council to guide health systems in the optimal curation of patient information.
26:30 Addressing chronic disease through online resources, team-based care delivery innovation, and value-based payment.
27:00 The importance of neuroplasticity (rewiring of the brain’s neural pathways) to reinforce new habit formation.
28:00 Mountain climbing as a metaphor for behavior change in chronically ill populations (i.e. dealing with pain, incremental progress).
28:45 The overwhelming challenges of addressing SDOH in underserved communities.
30:00 Differing perspectives on the role of the individual in health accountability.
31:00 Merging system-level patient-centered engagement with individual-level accountability.
32:00 Deploying information tools to empower health and improve SDOH screenings.
32:45 Rethinking medicine to live better longer (referencing new book, “Outlive: The Science and Art of Longevity” by Dr. Peter Attia).
34:00 “Poor health literacy is a public health problem.” (9 in 10 adults exhibit poor health literacy when under extreme stress.)
34:30 Population health resources should be written at a 5th grade level to ensure they are readable, actionable, and trustworthy.
35:00 Improving Health Literacy Could Prevent Nearly 1 Million Hospital Visits and Save Over $25 Billion Per Year. (see UnitedHealth study)
35:30 The importance of primary care in empowering patient education.
36:30 A recent court ruling threatens access to critical preventative care for more than 150 million people! (see USofCare Preventive Services Resource Hub)
38:00 The importance of Patient Advisory Councils in care delivery design (e.g. telehealth, AWV campaigns, patient portal design, refill strategies)
38:45 CBO Partnerships as an opportunity to “learn, course correct, and transform.”
39:00 The flawed structure and lack of funding for a Public Health system that improves health equity and fosters patient trust.
41:00 The intergenerational impact of health information in improving health, supporting families, building social cohesion, and ensuring economic competitiveness.
42:00 What is the role of government in creating a healthy, well-educated population? How can CMS improve beneficiary engagement?
42:30 Prioritizing multipayer alignment, administrative simplification, and health equity accountability to promote value-based care.
43:30 The 21st Century Cures Act is a health policy focused on information sharing and care coordination.
44:00 Creating accountability in underserved communities through workforce competency and alignment of payments.
45:00 “You can’t talk about quality unless you talk about equity.”
46:45 ADKAR is an acronym for the five outcomes of successful change management: “Awareness, Desire, Knowledge, Ability, and Reinforcement”.
47:00 Debbie discusses the systemwide application of ADKAR as a powerful tool for change management at an individual level.
48:00 How did the ADKAR change management model improve care delivery at Essentia Health?
49:45 Applying change management principles to achieve patient-centricity.
50:45 The promise of precision medicine (at the individual level) as a compliment to community health (at the group level).
52:30 Developing a roadmap to make wellness and prevention a priority (versus sick care and chronic disease management).
53:30 Parting thoughts from Debbie on actions that can be taken today to improve patient communications.
In the Race to Value, we must recognize that quality of life is the ultimate currency of healthcare, and this aim is all the more important in senior living facilities. Transforming health outcomes for skilled nursing and senior living populations is not just a goal; it’s a commitment to providing the care and dignity our elders deserve. This week, we profile a leader in the value movement who leads a company on a mission “to improve the health, happiness, and dignity of senior living residents”. We are joined by Mark Price, CEO of Curana Health – a leader who lives by the mantra that “extreme passion” is the single most important ingredient to reform the American healthcare system.
Curana Health is a provider of value-based primary care services exclusively for the senior living industry, including in nursing homes, assisted/independent living facilities, CCRC/life plan communities and affordable senior housing communities. Curana Health serves more than 1,100 senior living community partners across 30 states and participates in the MSSP ACO, ACO Reach and Medicare Advantage programs with CMS. Backed by more than $300M in venture capital funding, the organization is poised to disrupt care delivery in senior living on a meaningful scale through innovative care models and applied analytics.
In this episode, you will learn about how to transform health outcomes for skilled nursing and senior living populations through extreme passion. We cover such topics as how to leverage APMs such as MSSP and ACO REACH in the senior living setting, the performance results of Curana Health across their value-based portfolio, technology innovation, palliative care, the state of the nursing home industry, and future trends in the shift to home-based care delivery.
Episode Bookmarks:
01:30 Introduction to Mark Price, CEO of Curana Health.
03:45 An estimated 27M more people are aging into the 75+ cohort through 2050, resulting in rising age and higher health acuity levels of residents moving into senior living.
05:00 Curana Health has achieved a 39% reduction in 30-day hospital readmissions and a 37% reduction in total hospital admissions among Medicare Advantage I-SNP members.
06:00 “There are many subsectors in the industry where value-based care can succeed. The important thing is ensuring that your people have an extreme amount of passion for making it work.”
07:00 Founding story of Curana Health based on how we would want our loved ones to be cared for at the end of life.
08:45 The majority of Americans will spend some time in senior living or skilled nursing in the final years of their life.
10:00 Elite Patient Care ACO performed in the top 1% of ACOs in its first year of operation, achieving PBPY savings amount of $2,235—the highest PBPY for any first-year MSSP ACO since 2012.
11:30 Curana Health also has one of the top performing ACO REACH and risk-based MA I-SNP programs in the country.
11:45 “Our core business is not a payment model. It is a clinical model that produces health outcomes which, in turn, enables affordability as well.”
13:00 Developing a population health playbook for the senior living space.
14:00 Success in developing a level of clinical integration within a senior living facility that is now owned by the company.
15:00 MA Institutional Special Needs Plans (I-SNPs) are designed to meet the needs of people living in long-term care settings such as long-term care nursing, skilled nursing facilities, and inpatient psychiatric facilities.
16:45 Facilities are taking an ownership position of MA plans for senior living and skilled nursing residents.
17:00 Mark provides perspective on I-SNPs and how the Curana Health clinical model is achieving results to improve clinical outcomes.
18:30 Performing well by recognizing the commonality between MSSP, ACO REACH, and Medicare Advantage.
20:00 How CMS and CMMI is incorporating innovation to value-based payment models (e.g.SNF 3-Day Rule Waiver).
22:00 Building a technology enablement ecosystem within a high-touch, integrated care model for senior living communities.
23:00 Value-based care technology adoption starts with the input from the clinical care teams.
24:00 Seeking technology enablement for both common and specialized challenges.
26:00 Developing technology partnerships with intentionality. Augmenting those partnerships with internally-developed customized analytical and educational solutions.
28:45 A survey by Leavitt Partners and NAACOs shows that only a 10% of ACOs selected palliative care as a top priority for improving efficiency and lowering costs.
30:00 Mark provides perspective on the importance of palliative care and advanced care planning in their senior-focused care model.
33:00 Many nursing home providers operate on thin margins and have been squeezed tighter as they’ve struggled with occupancy.
34:00 Chapter 11 bankruptcies among nursing homes and senior living operators continue to increase and show no signs of abating going into next year.
35:30 The impact of the pandemic on the senior living industry.
36:30 The workforce challenges faced by nursing homes.
37:00 Financial impact of rising variable interest rates on nursing homes attempting to service their facility debt.
38:00 CMS-imposed staffing mandates on Skilled Nursing Facilities.
38:45 The impact of aging baby boomers on distressed SNFs and senior living facilities.
40:45 Collegiality and information sharing is important to advance value-based care transformation across the country.
41:30 Skilled Nursing and Senior Living communities traditionally ignored value-based care (and how they are now waking up!)
43:30 Success in the future requires us to think differently than we did in the past.
44:30 Up to $265 billion worth of care currently delivered in traditional facilities for Medicare FFS and MA beneficiaries could shift to the home by 2025.
46:45 Post-acute skilled care will increasingly move to the home in the future.
48:00 The significant demand for senior resident models in the future.
49:30 Mark discusses why technology won’t disrupt the senior living space like it will other sectors in care delivery.
52:00 CMS’s goal of having every Medicare beneficiary in an ACO or ACO-like model by 2030.
53:00 Americans aged 65 and older will more than double over the next 40 years — reaching 80 million in 2040.
53:45 Parting thoughts of optimism on the imperative for value-based care transformation in the country.
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.
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In the universe of value-based care transformation, there has been one disease that represents a metaphorical black hole, where the gravitational pull of fee-for-service is so strong that nothing can escape. These patients experience the fullest depths of pain and despair, and this chasm is so deep and wide that there is only darkness. You may have guessed it, but we are talking about chronic kidney disease, a condition that impacts 37 million people in the U.S. The suffering of those inflicted with CKD is so immense, yet the Medicare reimbursement system is designed to fail this patient population. In fee-for-service medicine, we wait until patients succumb to end-stage kidney disease, where they crash and burn and need costly dialysis to stay alive for a little while longer. Because of this flawed reimbursement model, Medicare pays over $125 billion for people with all stages of renal disease, which is around 20% of all Medicare spending! Unless we go upstream and start engaging patients prior to kidney failure, success in value-based kidney care will be limited. We must “give life” to this patient population in the Race to Value!
The giving of life and that is what DaVita Kidney Care is doing. In fact, the name DaVita is an adaptation of the Italian phrase for giving life. In value-based care, DaVita works with healthcare payers and providers to develop and implement care delivery models that focus on improving outcomes and reducing costs for CKD patients. And I am excited to share with our listeners, that our guest this week is Dr. Adam Weinstein, the Chief Medical Information Officer for DaVita. Dr. Weinstein works across numerous lanes helping bridge the intersection of IT, clinical nephrology, and healthcare policy. He is focused on delivering IT tools that take advantage of DaVita’s clinical data and help nephrologist and DaVita teammates deliver the best care possible. A kidney doctor from Maryland, Dr. Weinstein is passionate about slowing the progression of chronic kidney disease in patients. This was such an outstanding conversation with one of the true innovators in technology and clinical care!
Episode Bookmarks:
01:30 The importance of crossing the chasm of chronic kidney disease, a condition that impacts 37 million people in the U.S.
02:30 Introduction to Dr. Adam Weinstein, the Chief Medical Information Officer for DaVita Kidney Care.
03:30 Support Race to Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts.
05:30 Dr. Weinstein shares how his lived experiences and positive mindset have shaped his work as a nephrologist, healthcare executive, and technology innovator.
06:45 Treating kidney disease costs Medicare $130B – although CKD patients are 1% of the population, they account for over 7% of all Medicare spending!
08:30 An overview of the DaVita Integrated Kidney Care (IKC) program and how it produces solid results through data enablement and relationship building.
10:30 Integrated Kidney Care accomplished through people working in collaboration, predictive modeling, and population health management.
11:30 Facility versus At-Home Dialysis and the empowerment of patients through education and health literacy.
12:30 An overview of DaVita’s participation in value-based care payment models focused on CKD and ESKD.
14:30 Dr. Weinstein on how to bring scale to value-based payment innovation in kidney care.
16:00 The need for specialist and care team coordination that goes well beyond the office visit.
17:00 Kidney Care First (KCF) and Comprehensive Kidney Care Contracting (CKCC) Models and how they provide financial and philosophical alignment for integrated care.
18:00 The challenges of including broader specialties and building an advanced data infrastructure in value-based kidney care.
19:00 The “clinical nebulous” that requires a longer runway for value-based payment model innovation to deliver improved patient outcomes.
22:00 The Relative Value Scale Update Committee (RUC) and how it provides recommendations for setting payment amounts for different physician services.
23:30 The challenges of valuing the technical aspects of physician services that reward procedural intensity versus cognitive services that require critical thinking.
24:00 The tension that a Relative Value Unit system provides in a healthcare system evolving to value-based care.
27:00 Black Americans are 3.5X more likely than White Americans to experience kidney failure. (Black Americans are also less likely to do home dialysis or get a kidney transplant.)
28:00 “Value-based care arrangements are one step toward solving health inequities.”
29:00 The need for a culturally sensitive and contextual understanding of health determinants to address disparities in care.
32:30 “The single most important trust building issue in healthcare is the assurance that we have a caring workforce.”
33:00 How DaVita ensures that its facilities are equipped with motivated, engaged, and culturally competent care teams.
34:30 Addressing clinician burnout through the provision of robust talent pipelines.
36:00 The need to focus on early CKD detection so interventions can happen earlier to slow the progression of disease.
37:00 How lab tests to screen kidney function are not always the best diagnostic indicator for early detection of CKD.
38:30 The role of nephrologists in assuring an effective care regimen.
39:00 The use of Artificial Intelligence to help predict the progression of CKD to ESKD or the likelihood of a hospitalization.
41:00 How risk models that predict future likelihood of dialysis can drive crucial conversations with patients.
42:00 The need for clinical experts to interpret AI predictions in a way that can drive meaningful patient interventions.
43:00 Innovation Results at DaVita (e.g. survival rates for dialysis patients, cost improvement in dialysis, increase in home dialysis, lower hospitalizations).
44:30 Dr. Weinstein discusses DaVita’s innovative approach to data and how it informs an enhanced understanding of value-based care as a clinician.
46:30 The development of a CKD-specific EHR system to drive value-based care at a practice level.
47:30 How data integration and HIEs can bring about improved care delivery with independent providers on disparate EHR systems.
47:45 “Chronically ill patients are similar to projects that need their own personalized Gantt Chart to drive care delivery with enhanced outcomes.”
48:45 The importance of patient- and population-level data at the point-of-care, alongside performance benchmarking tools.
51:00 A brief update on Mozarc Medical – the new venture between DaVita and Medtronic established to develop new kidney care technologies and at-home treatments.
52:45 DaVita Venture Group (DVG) invests in companies that are aligned with DaVita’s mission of improving the quality of life for patients with kidney disease.
54:30 Impacting the kidney space at scale through capital investment in innovation.
56:30 Achieving success in value-based kidney care through people, process, and tools.
58:00 Aligning clinicians for the future of value-based care.
Dr. Stephen Klasko is a transformative leader and advocate for a revolution in our systems of health care and higher education. He has been a university president, a dean, a CEO, and an obstetrician, and now pursues his vision for the creative reconstruction of American healthcare by bridging traditional academic centers with entrepreneurs and innovators. His passion is using technology to eliminate health disparities and offers everyone the promise of health assurance. Dr. Klasko is also a lifelong DJ who believes that the message in the music can give us the courage to tackle a broken, fragmented, unfriendly, expensive, and inequitable healthcare system.
In this episode, Dr. Klasko merges with his alter ego “Stevie K the DJ” to discuss his new book, “Feeling Alright: How the Message in the Music can Save Healthcare” published by ACHE. Feelin’ Alright leverages the emotional power of song lyrics to inspire healthcare executives to envision and build a more accessible, high-quality, and equitable healthcare system. Using music as a metaphor, Dr. Klasko encourages us to examine what is problematic in the existing healthcare model and to take tangible steps toward a more consumer-centered healthcare experience.
Infused with the passion inherent in music, this interview motivate healthcare leaders to take the lead in building a better healthcare system!
Episode Bookmarks:
01:20 DJ Eric “The Dream” Weaver introduces Dr. Stephen Klasko (aka Stevie K the DJ)!
03:30 Support Race to Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts.
04:30 Using the power of music to inspire a more optimistic world.
05:30 Dr. Klasko discusses his prior career as a DJ and how getting fired started him on the path to medicine.
06:30 Using music at Jefferson to inspire his others to find hope in overcoming the pandemic, financial tsunami, and systemic racism.
07:00 “Choice of Colors” by Curtis Mayfield and the Impressions (healing during the George Floyd protests)
07:45 “Courage to Change” by Sia become a theme song for frontline workers and their heroic response to the COVID-19 pandemic.
10:00 Health care delivery during the pandemic was a war and how music helped to see a brighter day.
10:45 “We have to stop saying we are the best healthcare system in the world.”
11:00 “Medicine’s Dilemmas: Infinite Needs Versus Finite Resources” and the “Iron Triangle” of Healthcare
11:30 The performance of stocks as evidence for flawed thinking around healthcare disruption.
12:30 Kaiser Permanente and Geisinger come together to launch Risant Health and expand access to value-based care.
13:00 Payer-Provider Alignment in Medicare Advantage
13:45 Cityblock Health leveraging capital investment to build a Community Health Worker model for population health.
14:30 Taking population health, social determinants, predictive analytics, and health equity to the mainstream of healthcare.
14:45 “Keep the Customer Satisfied” by Simon & Garfunkel as inspiration for health assurance to rebuild trust and equity in a broken system.
17:00 In healthcare, do we really view the people as the customer?
18:00 The healthcare system is setup to enrich the people in control.
18:30 “The concept behind health assurance is that costly sick care will give away to affordable, personalized, and preemptive care, partly through genomic sensors and AI-based digital therapies.”
19:00 The future of Jefferson as a health system without a location.
20:00 Livongo and Jefferson Health — a strong, sustainable partnership between technology and providers to remake medicine.
21:00 Poor consumer segmentation in American healthcare (viewing patients monolithically).
22:45 Radical change needed! (collaboration, concentration on health disparities, creativity, and portfolio diversification)
24:00 Dr. Klasko’s prediction for the future market landscape of health systems and hospitals.
25:00 “Mr. Roboto” by Styx bemoans the plight of ‘modern man’ oppressed by technology and is a cautionary tale for the use of tech-enabled healthcare.
27:30 The interface between technology and humans (“When offline meets online, what happens to the human in the middle?”)
27:45 Elon Musk and Generative AI
28:00 The importance of recognizing change in society when selecting and training medical students.
29:00 How do we create humans that are more human than robots, instead of more robotic than robots?
29:45 Retraining doctors and faculty who “joined a cult” when entering medicine.
30:00 The lies to providers that technology would make their life easier.
31:30 Building a relational bridge between healthcare leaders and generative AI.
32:00 Failure of IBM Watson vs. Success of Aidoc (why it is important to augment – not replace human intelligence).
33:00 “I am Changing” by Jennifer Hudson from the movie Dreamgirls – a theme song for American healthcare delivery in the 2020s.
35:30 “Hospital CEOs need to think like Target and Walmart trying to compete with Amazon.”
37:45 Why hospital billboard ads and commercials make no sense!
38:30 The new marketing in healthcare is all about consumerism (helping patient navigate, offering convenience, inspiring loyalty).
39:45 “We need to demonstrate value by giving consumers a single point of contact to create a seamless experience across the continuum.”
40:00 The Amazon acquisition of OneMedical is emblematic of a failed primary care model that lacks consumerism.
41:00 The inevitable failure of Chief Marketing and Growth Officers that are aging white men.
41:45 Examples of innovation: Strongline (staff safety) and Guild (upskilling the workforce)
43:00 Dr. Austin Chang and his incredible work as a Chief Medical Social Media Officer at Jefferson.
44:00 Overcoming the “poor me” mentality (embracing payer-provider alignment, lower costs, consumerism,Jand portfolio diversification).
44:30 “For the Love of Money” by The O’Jays speaks to the destructive impact that a singular focus on money and profit can have on individuals and society at large.
44:30 The Maryland All-Payer Model – mandated global budgets for hospitals achieved great success.
46:30 Dr. Klasko discusses the concept of a single payer by state model.
47:45 Fear and greed caused by the flow of money into politics.
48:30 Direct patient marketing of expensive, specialty drugs.
49:00 Spending 4X more for obstetrical care than other countries (with far worse outcomes).
50:00 The dilemma of expecting a system to change when salaries depend on it not changing.
51:00 Our healthcare system does absolutely great! (for plaintiff’s lawyers, specialists, pharma and insurance industries, EMR companies, PBMs, and patients with unlimited resources who have the best insurance)
52:00 The unconscionable deaths of people during the pandemic who died at home when telehealth companies made record profits.
53:00 The need for companies to fail.
54:00 “Born This Way” by Lady Gaga as an anthem for self-acceptance and celebrating diversity.
55:30 Dr. Klasko on how zip code and living conditions mean more to life expectancy than one’s genetic code.
56:30 Dr. David Nash and his landmark population health research on Social Determinants of Health.
57:00 “In a practical world, a health system CEO is incentivized to keep their population as healthy as possible.”
57:30 The radical shifts that took place at Jefferson Health to improve health equity.
60:00 Solving for food deserts through bar coding and drone delivery.
61:00 The challenge of focusing on SDOH interventions when fee-for-service revenue declines.
62:00 “The Myth of Trust” by Billy Bragg as a somber reminder that people have lost trust in institutions.
63:00 Lack of trust in the healthcare system (citing the failure of GPS technology to improve health)
64:30 Distrust with genomics testing and the privacy of data.
65:30 Patients being able to monetize their own data when participating in clinical studies.
66:30 Nurses who feel that CEOs do not care about them.
67:00 Reinstating healthcare as a public good with servant leadership at the helm.
68:00 “Don’t Stop Believin’” by Journey
69:00 The future of 3D printing, RPM, and digital medicine in serving humankind alongside compassionate providers
70:00 Dr. Klasko describes a future scenario in 2033 where technology could prevent a global pandemic.
73:00 Optimism for the future of health assurance with currently available technologies.
74:00 “Will it Go Round in Circles” by Billy Preston as reminder that we do not want to reform healthcare 360 degrees!
In rural communities, the transformation towards value-based care is an ongoing journey rather than a fixed destination. Rural healthcare faces unique challenges such as geographic barriers, limited resources, and reduced access to specialized care. The value journey in these communities involves adapting care models to meet the specific needs of rural populations. It requires innovative solutions to overcome barriers which can bridge the distance between patients and healthcare providers. It represents a fundamental shift in healthcare delivery, focusing on improving patient outcomes, enhancing the patient experience, and controlling costs. Ultimately, this journey involves continuous adaptation, collaboration, and innovation that is fostered by a mission-driven culture to improve community health and wellbeing.
One of this nation’s leading examples of value-based rural health transformation is the Bassett Healthcare Network, and we are joined this week Leonard Lindenmuth, their Vice President of Strategy and Population Health. Since 2014, he has been leading value-based care transformation throughout Central New York. In this episode you will learn about what it takes to lead a successful value journey through a cultural evolution that increasingly seeks innovation to improve rural health outcomes. We discuss such topics as risk progression, the use of commercial ACOs as a learning laboratory in value-based care, population health playbook success that focuses on pharmacy optimization and interdisciplinary team-based care, deploying remote patient monitoring to rural populations, how workforce burnout is related to fee-for-service payment, and the importance of SDOH innovation to better serve vulnerable patients in underserved communities.
Episode Bookmarks
01:30 Introduction to Leonard Lindenmuth, DHA – Vice President, Strategy & Population Health, Bassett Healthcare Network
02:00 Bassett Accountable Care Partners, LLC – BHN’s Accountable Care Organization founded in 2014
03:00 Support Race to Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts.
05:30 How a data-enabled value-based care journey changed the culture of the health system.
05:45 “The value journey helped us understand much more about ourselves so we can better care for our rural communities. It has evolved our culture.”
06:00 A calculated progression to downside risk as a rural healthcare provider.
09:00 An increase in Medicare Advantage penetration in the marketplace and how that is impacting value-based care strategy.
10:00 Developing a co-branded regional MA product and the intention to take aggregated risk with a national MA plan.
12:00 Leveraging brand equity of the health system to develop a MA plan in the future.
12:30 Approaching MA risk-readiness of providers through coding education.
13:00 “MA Risk is clearly on the horizon.”
14:45 Leonard describes BHN’s commercial value-based playbook strategy that includes focus on pharmacy spend.
15:30 The Ambulatory Intensive Pharmacotherapeutics (AIP) program to reduce pharmacy costs through lower medication-related adverse events, avoidable hospital admissions and ED visits.
16:00 How the AIP program reduced BHN’s commercial spend on pharmacy through comprehensive medication management.
16:30 1% of the population drives 55% of specialty drug costs.
17:00 Risk progression in a two-sided risk arrangement with Excellus Health Plan (a local Blue Cross affiliate).
18:00 What being in a Commercial ACO has taught BHN about value-based care transformation.
18:30 How a rural health system balances the “two canoes” – volume vs. value.
19:00 “We have to get to a point where value drives the equation, but it is not an overnight transformation.”
19:30 How a healthcare organization performs better – both financially and clinically – under a fully-capitated environment.
21:30 An alarming divergence of health outcomes and life expectancy between urban and rural populations.
22:00 The challenges of improving population health in rural communities that are highly agricultural and farm-based.
23:00 Leveraging remote patient monitoring and other digital devices to better serve rural populations in upstate New York.
24:00 Bridging the digital divide in rural communities where access to broadband access is limited.
24:45 The Bassett Research Institute conducts research to understand and improve the health and well-being of rural populations.
25:00 Leonard describes the rural community of Cooperstown, New York and how their patient population is challenged by SDOH (lack of transportation, housing instability, food insecurity).
26:00 Medicaid expansion in New York fostered partnership and innovation with Community Benefit Organizations (ex: partnership with a local food bank).
28:00 Creating an anchor institution in a community where the health system is an enabler of improvement in social determinants of health.
29:00 Moving the needle on value by moving closer to the premium dollar and building infrastructural capability to manage delegated premiums from payers.
30:00 The maldistribution of premium dollars that disproportionately benefits insurers through excess profits (at the expense of health system investment to improve patient outcomes).
31:30 The imperative to adopt a payment system that supports lower costs and improved population health outcomes.
32:00 The importance of knowing trends in medical claims costs and utilization.
33:00 Being conscious of what you are getting into when it comes to assumption of risk-based payment.
33:45 Lessons learned from building a vertically integrated system and how that informed perspective on opportunities in a risk-based world.
34:45 Referencing prior podcast — Ep 141 – Cultivation of Physician Wellbeing in the Value Journey, with Dr. Dike Drummond, Dr. Moshe Cohn, Dr. Amadeo Cabral
35:00 How capitation can alleviate workforce burnout and moral injury.
36:00 The unsustainable pharmaceutical cost trajectory, with Americans spending an average of over $1,500 per person on prescription drugs, paying much more than comparable nations.
37:00 Leonard discusses the challenges of pharmacy spend and how Comprehensive Medication Management (CMM) has become an important area of focus in their population health playbook.
39:30 Understanding disease-specific use cases for pharmacy optimization and the340B Drug Pricing Program.
40:30 “Increased pharmacy spend is only acceptable if it crowds out medical spending on the inpatient side.”
41:30 The role of pharmacists in interdisciplinary team-based care and how they can meaningfully collaborate with physicians.
43:30 Value-added pharmacy programs that create a win-win-win for patients, providers, and payers.
45:00 The ticking timebomb of the healthcare workforce!
46:30 Alarming rates of nursing turnover resulting in higher costs due to increased reliance on agency nursing.
48:00 “At any given shift, we are down anywhere from 6-16 nurses. We have the demand to fill our beds, but we can’t get them in because of the nursing shortage.”
49:00 How nursing burnout is ultimately related to the dependence on a fee-for-service payment model.
50:45 New York is one of a number of states that is attempting to address the social needs of Medicaid enrollees through Section 1115 waivers with SDOH-related provisions.
53:00 Economic development zones and SDOH networks in New York supported by Section 1115 demonstration projects.
55:00 Examples of innovative SDOH programs (ex: giving patients free air conditioners to prevent acute exacerbations of chronic asthma).
56:30 Tackling disparities in care through VBC will drive community health outcomes (more so than philanthropic support of CBOs).
58:00 Parting comments on the challenges of health equity transformation.
Medication adherence remains an important yet vexing issue in American health care. According to the World Health Organization, medication adherence can have a more direct impact on patient outcomes than a specific treatment itself. Still, it is estimated that a staggering 50% of Americans don’t take their chronic long-term therapy medications as prescribed. Statistics show that each year, poor adherence contributes to more than $500 billion in avoidable health care costs, around 125,000 potentially preventable deaths, and up to 25% of hospitalizations in the United States. This issue of medication adherence is so important, yet so vexing to solve for because it is so multi-faceted and entrenched into the business economics of healthcare. In this Race to Value, we must find a better way to ensure affordability and promote adherence to medication therapies. This is a life or death situation – both from an economic and a clinical perspective. If we don’t find solutions to improve medication adherence as part of value-based care, patients will die. And eventually, the weight of the entire healthcare system will collapse upon itself due to the unsustainable costs that are incurred due to avoidable healthcare utilization that medication adherence would have prevented!
Our guest this week is Jason Rose, a leading expert on the trillion dollar impact of the medication adherence issues in our country and what can be done to address them. Since 2018, Jason Rose has been spearheading value-based care as CEO of AdhereHealth. The innovative technology company is focused on transforming healthcare by leveraging intelligent data analytics, promoting medication adherence and working with patients to resolve social determinants of health. Customers are managed care companies and employers looking to improve quality of care and reduce costs for their patients and employees, respectively. After one year in his role, AdhereHealth experienced its fastest-ever year of growth and has grown from about 100 employees to nearly 1,000 employees over the past three years. This is a leader in the value-based care movement that you should be listening to, as medication adherence is one of the most critical challenges to overcome in the transformation of our industry.
Episode Bookmarks:
01:30 According to the World Health Organization, medication adherence can have a more direct impact on patient outcomes than a specific treatment itself.
01:45 50% of Americans don’t take their chronic long-term therapy medications as prescribed.
02:00 Poor adherence contributes to more than $500 billion in avoidable health care costs, causes 125,000 potentially preventable deaths, and up to 25% of hospitalizations.
03:00 Introduction to Jason Rose, a leading expert on medication adherence and CEO ofAdhereHealth.
04:00 Support Race to Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts.
06:30 If unabated, medication non-adherence will soon be a trillion-dollar problem with no end in sight.
07:00 Jason discusses the financial impact of non-adherence and the criticality of addressing this issue in healthcare.
08:00 “Medication non-adherence should be one of the top issues in all of healthcare, given the size of the actual problem.”
08:30 How value-based care programs can improve adherence outcomes in both senior and commercial populations.
10:00 A series of factors, rather than a single one, determine patients’ ability to follow treatment recommendations correctly.
11:00 Jason discusses the impact of social determinants of health (SDOH) on medication adherence.
12:00 How SDOH symbolize the “Maslow Hierarchy of Needs for Health Care” (e.g. safe drinking water, transportation, health literacy).
13:00 A critical decision point – paying for the food of a beloved pet instead of purchasing lifesaving medication!
14:00 Referencing Jason’s recent AJMC article: “Medication Adherence is a Force Multiplier for Medicare Advantage Profitability, Enrollment, and Star Ratings”
15:00 70% of MA prescription drug plans earned a rating of 4.0 Stars or higher in the 2022 Star Ratings compared with 49% for 2023.
16:00 Medication-related measures make up 52 percent of the overall Stars Ratings weighting, and adherence measures for cardiovascular, hypertension, and diabetes are all triple-weighted.
16:30 The exacerbation of chronic diseases during the COVID-19 pandemic and implications on value-based adherence programs.
18:30 Jason explains the reason for the year-over-year MA Star Ratings adjustment due to lower health plan investment and more competitive ratings.
19:30 How Hemoglobin A1c quality measures for diabetics relates to medication adherence.
20:30 33% of Star Ratings relate to patient experience, and these CAHPS measures will suffer if plans to perform well in medication adherence measures.
21:00 “It is quite obvious and logical that medication adherence outcomes is exactly what CMS is focusing on with quality measurement.”
21:45 How CMS will be “tripling down” on medication adherence outcomes related to MA Star Ratings.
22:30 The importance of achieving the 4 Stars (or above) to unlock needed health plan profit margin to compete in the open MA marketplace. (“Darwinism in Healthcare”)
24:30 More than a quarter of 30-day hospital readmissions are directly tied to medication adherence reconciliation issues.
25:00 AdhereHealth Survey: 62% of discharged patients would have had at least one drug therapy problem that would have gone unaddressed without telepharmacy outreach.
26:00 Jason discusses why CMS will soon be retiring Medication Reconciliation Post Discharge (MRP) measures for higher-weighted Transitions of Care (TRC) measures.
26:30 How TRC measures will emphasize PCP admissions and post-discharge notifications along with increased emphasis on medication reconciliation.
28:00 25-40% of medication issues related to lack of reconciliation (referencing a personal story of a patient that almost died because of taking two different statins).
29:00 The need for automated clinical workflows to drive provider notifications and data-analytics to identify drug therapy problems.
30:30 For every 100 prescriptions written, just 50 to 70 are ever picked up at the pharmacy. Once a patient leaves the pharmacy, a mere 25% of the medications are taken as directed at home. And then just a fraction—15% to 20%—are refilled.
31:00 A typical Medicare beneficiary saw a median of 7 physicians per year, highlighting the need for more coordinated, multifaceted strategies in medication management.
32:00 Home care is expected to increase nearly 4-fold by 2025, comprising up to $265 billion in care services (a quarter of the total cost of care for Medicare fee-for-service and MA members).
33:00 Lack of clinical integration and interoperability contributes to poor medication reconciliation in the healthcare industry.
34:00 Fee-for-service incentives do not align with improving medication adherence outcomes.
35:00 The need for health plans to reconcile drug utilization data with a targeted list of patients for which medication adherence outcomes could improve.
36:00 “Seventy-percent of medication adherence problems are related to patients not taking the drug they were prescribed. It’s not even low adherence; it is no adherence.”
36:30 How a value-based care environment provides an incentives platform for collaboration and co-development of tools to address non-adherence.
38:00 Public-private partnerships (like Medicare Advantage) as the best opportunity to drive value-based care.
38:30 The lack of chronic care management and focus on medication adherence in the home health environment.
40:00 How the lack of care management analytics for home health providers causes them to “fly blind” in their clinical workflows for medication-related issues.
41:00 The opportunity for medication adherence analytics and real-time data to improve clinical outcomes for home-based patients!
42:30 Collaborative care models that include a clinical pharmacist have been shown to alleviate some of the demand for physician-provided care and facilitate access to primary care services.
44:00 Jason discusses the need for more integrative models of care that utilize a team-based, multidisciplinary approach.
44:30 How Walgreens and CVS are freeing up the dispensing time of pharmacists so they can spend more time counseling patients.
45:30 The opportunity for ACOs to enable pharmacy-led interventions with targeted high risk patients.
46:30 Polypharmacy (the use of 5 or more prescription medications) is present in nearly 20% of the U.S. population and 40% of the population over 65 years or age.
47:00 Nearly 20% of seniors take 10 drugs or more, which can lead to a higher risk for adverse reactions and drug interactions!
48:30 How AdhereHealth is accessing reference databases to drive real-time analytics that identify potential over-prescribing of drugs.
51:00 The importance of capturing patient-reported data in a medication management program.
52:00 Over 75% of all ambulatory communications are over facsimile (fax machines) – not EHRs!
54:00 The moral imperative of ensuring that diabetics can afford life-saving insulin.
54:45 Price gouging by the pharmaceutical industry – a vial of insulin now costs about $300 — roughly 30,000% more than the original cost of the patent!
55:00 Eli Lilly’s recent announcement that it will slash its high list prices for some of its insulins and will immediately offer programs to limit out-of-pocket costs to $35 per month.
56:00 Jason explains why the Eli Lilly change was not voluntary and is more related to regulation by the Inflation Reduction Act.
57:00 According to IQVIA Institute for Human Data Science’s 2020 report, prescription abandonment rates are less than 5% when the prescription carries no out-of-pocket cost; it rises to 45% when the cost is over $125 and to 60% when the cost is more than $500.
58:00 Optimism for the future in the lowering of prescription drug prices.
59:00 Real-time benefit checking of formularies at the point-of-care.
60:00 The future of medication adherence to be addressed in value-based care through partnerships and collaboration.
61:00 Medical cost inflation as a continued challenge for those taking risk.
62:00 How AdhereHealth is bringing patient-centered solutions to the marketplace to guide clinical outcomes and improve patient relationship management.
Patients who are high utilizers, also known as multi-visit patients (MVPs) or frequent flyers, whether found in the ED, inpatient units or other departments, drive up readmission rates and tie up resources. Often, clinicians and administrators hold out little hope that they can end the multi-visit cycles of these patients. Yet, by looking at a patient’s multiple visits as a symptom of a deeper problem, and then identifying and rectifying that underlying problem, clinicians can end a patient’s cycle of care utilization.
On this podcast, a leading expert in high-utilizer care discusses her MVP Method which has been used by rural hospitals, community hospitals, safety net hospitals, and academic medical centers across the country. Dr. Amy Boutwell, President of Collaborative Healthcare Strategies, is a nationally recognized thought leader in the field of reducing readmissions and improving care for highest risk and multi-visit patients. She is the developer of the STAAR, ASPIRE, ASPIRE+ and MVP methods to reduce avoidable acute-care utilization and deliver whole-person care across settings and over time.
The general principles and actions of the MVP Method can revolutionize care, break the cycle of utilization and change the life of your patients. The Institute for Advancing Health Value has released an Intelligence Brief and Case Study to accompany this special podcast episode.
- Download the Open Access Intelligence Brief: “Building An Effective Care Pathway for Multi-Visit Patients: The MVP Method” (Available to Everyone!)
Building An Effective Care Pathway for Multi-Visit Patients: The MVP Method
- Download the Members-Only Case Study Brief: “Transforming Care MVPs at a Safety-Net Health System” (Available to Institute Members – Join the Institute for free if you work for a Provider Organization!)
Episode Bookmarks:
01:30 High utilizers, also known as multi-visit patients (MVPs) or frequent flyers, whether found in the ED, inpatient units or other departments, drive up readmission rates and tie up resources.
02:00 Can high utilization by MVPs be impacted by addressing symptoms of a deeper problem?
02:30 Introduction to Dr. Amy Boutwell and the MVP Method to improve care for High Utilizers.
03:15 Support Race to Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts.
04:45 Referencing the Dr. Atul Gawande article called “The Hot Spotters” which showed how a health system experienced a 40% reduction in super-utilizer reduction.
07:00 The risk of conflating the terms of “high risk,” “high utilizer,” “high cost,” and “complex”.
07:45 Busting the myth that multi-visit patients are un-impactable.
08:30 “We must walk away from the dogma that it is not worth serving high utilizers. The industry must reengineer its thinking around that to advance health equity.”
09:00 Dr. Boutwell references the work of the Camden Coalition and how “Hot Spotters” did not confirm the myth of un-impactability.
10:30 The Hospital Readmissions Reduction Program (HRRP) aims to minimize the number of avoidable hospital readmissions by incentivizing hospitals to improve post-discharge planning.
11:30 Dr. Boutwell discusses the challenges of HRPP as a health policy and why hospitals have still yet to evolve in care delivery transformation.
12:30 Readmissions programs often are treated as a pilot instead of as a strategy for transformation.
13:30 Dr. Boutwell’s work in partnering with health systems to develop a population health playbook to lower hospital readmissions.
14:30 The challenge of focusing on just one chronic condition in a readmission reduction strategy (e.g. heart failure).
15:45 “Multi-visit patients account for over half of all readmissions at every single hospital in the United States.”
16:45 “We have to go beyond payer-specific or disease-specific paradigms to find higher leverage population segments to impact.”
18:00 The MVP Method was designed for scale and is used by rural hospitals, community hospitals, safety net hospitals, and academic medical centers across the country.
19:00 Dr. Boutwell provides a thorough explanation of the MVP Method and how it supports hospitals in achieving delivery system redesign.
22:30 Multi-visit patients are typically determined to be ~7% of all patients, yet account for 20% of hospital admissions, 50% of readmissions, and 10% of ED visits.
24:30 Physicians identify the cause of a symptom to accurately diagnose a patient. (This is the same paradigm one should apply to a MVP with a symptom of recurrent overutilization!)
26:00 The root cause approach is at the core of the MVP Method.
26:45 Harris Health article (“A New Way to Support Frequent Emergency Department Visitors”) about how they achieved a 15% reduction in ED visits across all MVPs (with Ben Taub reducing theirs by 77%!).
28:00 The success that Harris Health has had in implementing your MVP Method for addressing frequent ED utilizers. (Join the Institute and download the members-only Harris Health Case Study!)
35:00 New York State Medicaid is the largest sponsor of the MVP program so far and is focusing on hospital and community partnerships in care delivery redesign as part of its DSRIP strategy.
37:00 A personal story about a multi-visit patient dealing with housing instability.
38:45 Human-centered pathways and systems are a crucial determinant of success with the MVP Method.
39:00 How the New York State Medicaid system built equity value-based population health through cross-continuum team-based care on the frontlines.
42:00 The need for accountable teams to ensure definitive and timely linkages to MVP root cause solutions.
43:00 A personal story about successful care team engagement with a complex multi-visit patient.
48:00 ASPIRE Framework to Reduce Hospital Readmissions
50:00 The importance of understanding patient data before implementing a readmissions reduction strategy.
51:00 How analyzing data led to health systems learning for the first time that alcohol abuse was the main cause of hospital readmissions.
53:00 A great example of how a hospital developed a collaborative team-based interdisciplinary approach to readmissions reduction.
55:00 Nationally, 56% (or roughly 67 million ED visits) are potentially avoidable. The average cost of an ED visit is $580 more than the cost of a comparable office visit.
57:00 The importance of advanced primary care access and the need to address the fear and uncertainty that patients experience regarding their condition.
60:00 Emergency rooms do not adequately address fear and uncertainty (an opportunity for person-centeredness).
62:00 How the state of Maryland dramatically decreased overutilization once financial incentives were realigned (from worst place to above the national average!)
65:00 “Value-based is the way we must practice medicine with regard to whole-person care.”
65:30 Parting thoughts from Dr. Boutwell on the importance of value-based care in the practice of medicine.
Three perfect storms in recent years – the health storm produced by the COVID-19 pandemic; the economic storm that resulted from its disruptions; and the social storm that followed the murder of George Floyd which sparked fresh outrage at longstanding inequities – have sharpened and added important nuances of what health care really means. The goal of health care has always been to reduce suffering, but we must now prioritize transformation in leadership now more than ever. Building trust, eliminating inequities, and ensuring high reliability are of the highest magnitude of importance as we blaze a new path forward.
This week, on the Race to Value, we are joined by Thomas H. Lee, M.D., the author of the new book “Healthcare’s Path Forward” to discuss how the healthcare industry is being transformed by deeper knowledge of what suffering means for patients, their families, and healthcare providers themselves. Since healthcare is not working for anyone, Dr. Lee provides wisdom and insights of optimism for where true change can happen in creating new standards for excellence.
In addition to being a bestselling author and expert on healthcare transformation, Dr. Lee is the Chief Medical Officer of Press Ganey. He brings more than three decades of experience in healthcare performance improvement as a practicing physician, leader in provider organizations, researcher, and health policy expert. He’s responsible for developing clinical and operational strategies to help providers across the nation measure and improve the patient experience, with an overarching goal of reducing the suffering of patients as they undergo care and improve the value of their care.
Episode Bookmarks:
01:30 Introduction to Thomas H. Lee. M.D. and his new book “Healthcare’s Path Forward”
03:00 Support Race to Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts.
04:00 The six elements of organizational culture that lead to transformation – Excellence, Trust, Respect, Inclusion, Resilience, Reliability
05:00 John Nash (“A Beautiful Mind”) and Non-Cooperative Game Theory
06:00 Optimism for healthcare because how bad things really are!
07:00 Nash Equilibrium states are commonplace in healthcare – it creates inertia and stifles change.
08:30 “Equilibrium states break down when the pain of the status quo exceeds the fear of the unknown for multiple parties.”
09:00 “Healthcare is not working for anyone. That is where real change can happen and what makes me optimistic.”
09:45 The destabilizing trends of supply chain disruption, social unrest, political divisiveness, consumerism, demographic shifts, workforce drain, and environmental disasters.
11:30 Responding to social justice, climate change, and the need to redesign healthcare – is it too much for us to tackle all at once?
12:00 “Changing the way healthcare is paid for – in absence of other reforms – is grossly inefficient. There are many other things that have to happen.”
12:30 Michael Porter’s Value Chain and the importance of clarity and differentiation in the creation of value.
13:30 “Payment reform is just one activity of healthcare reform. We also need trust in the workforce and with patients, an understanding of what safety means, and a response to consumerism.”
15:00 In times of turmoil, healthcare organizations need more than a performance culture; they need a learning culture.
16:30 The most important part of transformational leadership is division of responsibilities and areas of key focus to enact organizational change.
17:30 No one can do everything! If leaders focus on only three things, they will be successful in strategy execution.
18:30 3 Functions of Governing Boards and Executives: Articulate the Core Values, Develop Strategy, Understand the Value Chain
18:45 “An organization is the lengthened shadow of its leaders.” – Ralph Waldo Emerson
20:30 3 Functions of Managers: Create Social Capital, Bring High Reliability Principles to Life, Eliminate Waste of all Types
21:30 “Social capital is more important than financial capital in the times in which we live.”
22:00 Applying High Reliability to all the dimensions (including patient experience) and refusing to tolerate failure in matters of trust.
23:45 “Culture of No Waste” – includes both time and resources
24:30 3 Functions of Frontline Caregivers: Create a Culture of Respect, Be Full Participants on Great Teams, View Job as Shaping the Memories of Patients and Families
25:30 The healthcare workforce often feels that they are part of a organization that does not respect them.
26:30 “Treating people with respect should be treated in the same way that the industry tackled hand hygiene to improve patient safety.”
27:45 Referencing the TED Talk from Daniel Kahneman: “The Riddle of Experience vs. Memory”
29:00 Frontline caregivers are like Steven Spielberg, i.e. they are the producers and directors of the patient memories.
32:00 “We live in a time where trust is under attack in society. You can’t take trust for granted in healthcare.”
33:00 Trust goes beyond the clinician encounter – it encompasses the whole episode of care, including the web presence of the provider before the visit.
35:30 The importance of 5-Star Ratings online in building trust.
36:30 “Patients are unnerved from friction, chaos, and any indication that they may not be safe. The pandemic has really heightened their fears.”
38:00 Dr. Lee discusses how Press Ganey has begun surveying patients on their perceptions of patient safety.
39:45 High-reliability and the Anna Karenina Principle (“Happy families are all alike; every unhappy family is unhappy in their own way.”)
41:45 In 2021, the Press Ganey Employee Engagement Indicator declined in every single job category!
43:00 Dr. Lee discusses how building trust with workers coincides with the actions taken to build trust with patients.
44:30 Personal Pride: Pride in the organization, Pride in what you do for the organization, Pride in what your team does.
45:30 Personal Alignment: Aligning with the cultural beliefs of employees and the need for inclusion. (Lack of DEI creates a 4X greater risk of employee turnover.)
46:00 Personal Resilience: Activation (employee motivation) and Decompression (ability of employees to forget about work when at home).
47:30 Activation is increasing in healthcare, but decompression continues to go down!
50:00 Dr. Lee explains how the pandemic and social unrest has created a deeper understanding of human suffering and how systems create harm.
50:30 Understanding Patient Safety beyond Physical Harm by also considering Emotional Harm (e.g. not feeling safe or financial distress due to healthcare)
51:30 The nuance of perception in Patient Safety (an example of how patients didn’t feel safe when a change when a hospital starting using odorless disinfectant).
53:00 Lack of respect as a safety issue.
53:00 The murder of George Floyd prompting an examination of the impact of inequality throughout society.
54:00 Diversity, Equity, and Inclusion in healthcare as a form of social capital and the pursuit of zero inequity.
55:00 The importance of DEI in health equity is now understood at a deeper level by healthcare leaders following the murder of George Floyd.
56:00 “Zero Inequity should be our goal just like Zero Harm is our patient safety goal.”
56:45 The data from safety net hospitals showing continued challenges in assessing pain with African American patients.
58:00 How organizational mistreatment of patients creates mistreatment of workers (and why lack of patient-centeredness is main reason for employee turnover).
61:00 Dr. Lee touts the virtues of healthcare and why it is such a great industry to work in.
62:00 New Skills for the Era Ahead: Strategy (Porter’s Value Chain), Social Capital (Teamwork, Leadership), Growth Mindset (read Grit: The Power of Passion and Perseverance!)
64:00 The potential to do great work in medicine and making a difference in the lives of others.
64:30 “This is the best time to be going into healthcare. You can really make a difference in a noble field.”
65:00 How to reach out to Dr. Lee and learn more about his work in healthcare transformation.
As the healthcare industry moves towards achieving CMS’s goal of having every Medicare beneficiary in an ACO or ACO-like model by 2030, we must focus on patients in institutional settings. For long-term care patients, better care and better health means ensuring patients receive advanced care planning and regular wellness visits. And it also requires providers and facilities to work together in preventing avoidable hospitalizations and unnecessary SNF and hospice utilization. Unfortunately, the needs of geriatric patients in an institutional setting are often overlooked as compared to other populations in the vast environment that falls within the influence of value-based care. LTC ACO — the first ACO in the country focused specifically on the special needs of Medicare beneficiaries residing in long-term care facilities — is changing that narrative. The mission of LTC ACO is to dramatically improve the quality and cost of healthcare delivered to these Medicare beneficiaries, rewarding participating providers for achieving these outcomes. Using this approach, it is their vision to revolutionize the way healthcare is provided to Medicare beneficiaries residing in long-term care facilities.
Joining us this week in the Race to Value is Jason Feuerman, the President and Chief Executive Officer of LTC ACO. In addition to leading one of the only ACOs that is dedicated exclusively to management of long-term care facility residents, Jason supports managed care and strategic value-based initiatives for Genesis HealthCare, the biggest post-acute care operator in the country. In this episode, you will learn about LTC ACO implemented a program in the traditional Medicare population that mirrors Institutional Special Needs Plans (I-SNPs). He discusses how the ACO engages and incentivizes providers and facilities and has operationalized a data infrastructure to drive care interventions. They have woken up an entire ecosystem with their approach to value-based care and have generated well over $40M in Shared Savings throughout their lifespan. By focusing on improving care outcomes and engaging providers, they have become the industry-leading exemplar for improving patient outcomes in long-term care!
Episode Bookmarks:
01:30 Introduction to Jason Feuerman and LTC ACO, the first ACO focused specifically on the special needs of Medicare Beneficiaries residing in long-term care facilities.
03:00 LTC ACO was launched by Genesis Healthcare, the biggest post-acute care operator in the country, with significant experience in MA risk and bundled payment models.
06:00 Lessons Learned from MA: How Institutional Special Needs Plans (I-SNPs) provided an operational thesis for LTC ACO in the Medicare Shared Savings Program.
07:00 By improving quality and driving down unnecessary costs, LTC ACO returns the Shared Savings earned to LTC facilities and the physicians who support them.
08:00 “Waking up the ecosystem” by providing outcomes data to long-term care providers.
10:00 Achieving capital efficiency in a model where there is no downside risk.
12:00 How capital requirements for delegated Medicare Advantage differ from the MSSP model.
13:00 Less than 15% of residents in long-term care facilities are in a MA plan. (Limited business opportunities in Medicare Advantage)
15:30 Applying the same tenets of I-SNPs to a Medicare ACO (e.g. aligning providers and providing rewards with surpluses)
16:00 “Waking up an Ecosystem”: Most LTC providers do not know what happens to their patients once they leave the long-term care institutional setting.
17:00 How data can be used to inform long-term care providers how their patients are doing across the continuum.
18:30 The use of AI for population-based predictive analytics to identify potential health risk (see recent Press Release regarding ClosedLoop AI partnership)
19:00 “Long-term care providers gravitate towards population health data and how they can contribute to bending the cost curve.”
21:00 Alzheimer’s dementia is the only top-10 cause of death that cannot be prevented, cured or slowed. We spend $200B on Alzheimer’s and Dementia care (more than Cardiology and cancer care combined!)
22:00 Jason discusses the potential implications of Alzheimer’s/Dementia in value-based care.
25:30 The impact of hospitalization on a LTC patient can include more time in bed, which can result in increased blood clots, pressure ulcers, muscle atrophy and loss of function.
26:30 Using data from EHRs and pharmacy utilization (Medicare Part D) to predict the risk of hospitalization.
28:00 “Our goal is to reduce hospitalizations and the need for skilled care using predictive analytics.”
29:00 How primary care physicians can become the “true quarterbacks of care” by empowering them with data.
29:30 How LTC ACO is approaching pharmacy utilization to better care for their patients.
32:00 LTC ACO has achieved well over $40M in Shared Savings during its lifespan.
34:00 Jason provides an industry-leading example of how to align providers and facilities in the ACO’s value-based care strategy.
35:30 Most ACOs incentivize SNFs by just providing them with them the promise of referrals.
36:30 LTC ACO recently distributed $1.5M to providers and facilities from its most recent Shared Savings event.
37:00 Balancing both cost and quality initiatives of the CMS program to achieve Shared Savings.
37:30 The “feel good” aspect of independent providers working with the ACO beyond bonuses earned (e.g. lowering unnecessary SNF and hospice utilization to improve care).
38:30 “Our goal is to get as much money into the hands of providers as possible. This is not about holding back dollars so the ACO can make money.”
41:30 Jason describes the impact of COVID-19 on LTC ACO and the overall long-term care segment of the industry.
43:00 How social isolation with the pandemic created a high increase for inpatient rehabilitation needs.
44:00 The trauma of the pandemic on the healthcare workforce that comprises the LTC ACO network.
44:45 How hospitals learned a lesson to “care in place” during the pandemic (instead of referring patients to a long-term care facility).
47:00 The number of Americans aged 65 and older will more than double over the next 40 years — reaching 80 million in 2040.
47:30 Did CMS contemplate the institutional population when developing its goal to have all patients in an accountable care relationship by 2030?
49:00 Jason describes the importance of the value-based movement in improving care for the geriatric population.
50:00 ACO REACH focuses on communities (not institutions!)
51:00 “Most people not being addressed in value-based care are in institutional settings.”
52:00 How CMS will continue to move the needle on VBC, in partnership with private industry innovation, will benefit the entire geriatric population.
53:00 LTC ACO, with six years of experience as an ACO, is driving industry-leading results in improving care outcomes!
Are you ready to climb the mountain and reach new heights for a transformative future?
In the “race to value”, the mountain climber must not be intimidated by the steep terrain of a broken healthcare system. Instead we must look within ourselves, while also finding inspiration from others, to keep climbing! The ultimate summit of value transformation is what drives us, but the climb itself is what matters. If you are looking for inspiration in your value journey, look no further than our guest this week, Debbie Welle-Powell. Debbie is a healthcare thought leader, educator, national speaker, and content expert in delivery systems, clinical models of care, population health, and digital care. She is also an avid mountain climber, having attempted three of the Seven Summits while also reaching the summit of all 58 of Colorado’s 14,000 peaks. She has also climbed Mt. Rainer in in Washington and Grand Teton in Wyoming and, she has climbed peaks in Bolivia, Mexico, France, Argentina, and Mt. McKinley in Alaska. In this podcast, you will learn how taking the path least travelled is when you learn the most about yourself and why value transformation is a most noble journey to undertake in healthcare.
As the former Chief Population Health Officer at Essentia Health – an integrated delivery system with 14 hospitals, and 1,500 provider health system spanning the states of Minnesota, North Dakota, and Wisconsin – Debbie Welle-Powell designed, built, and operationalized Essentia’s $2.5 billion dollar transition from a primarily fee-for-service model of care to one that focused on value. She oversaw risk-based contracting with payers and care delivery transformation, resulting in forty-five percent of the system’s fee-for-service revenue tied to financial and clinical performance which produced record earnings on shared savings. Debbie’s exceptional experience and background in multi-state, large integrated delivery systems, coupled with industry involvement and insights into emerging opportunities, trends, and challenges, have been valuable to health systems and purchasers seeking to grow, diversity, and promote expertise in the development and implementation of data-driven strategies and solutions in population health and value-based care.
Episode Bookmarks:
01:30 Introduction to Debbie Welle-Powell, a nationally-recognized leader in value-based care transformation.
03:30 Support Race to Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts.
04:00 The grim statistics of American healthcare and the moral and economic imperative to reform it!
05:00 Recent article from Don Berwick about the excess profiteering and greed in healthcare: “Salve Lucrum: The Existential Threat of Greed in US Health Care”
06:30 Debbie discusses the current state of the healthcare industry and how she spent her career moving healthcare delivery to full-risk and globally capitated payments.
07:30 A leadership commitment to test models of care that address the moral imperative for improved outcomes.
08:30 Reflections on Dr. Berwick’s article and the need to expand the conversation by focusing on solutions.
11:00 The Innovation Center Strategy Refresh is a stake in the ground for 100% of Medicare beneficiaries to be in an accountable care relationship.
12:00 The need for innovation in specialty care and new risk models that improve health equity.
13:00 “Medicare is a laboratory for change.” (e.g. alignment of quality measures, multi-payer approaches to improvement, expansion of access in rural areas)
13:45 Two-thirds of those in Medicare Shared Savings contracts are now taking risk.
14:00 Balancing the need to move fast while not being too aggressive (“people are exhausted!”)
15:00 In the last year, hospitals have seen their operating costs increase upwards of 10%, and their bottom lines are now hemorrhaging to the tune of billions of dollars.
16:00 Pay inequity with nonprofit hospital CEOs making on average 8X the rate of hospital workers without advanced degrees (while the highest paid receiving 60X the hourly pay of general workers).
17:30 How do we better align hospitals and health systems with VBC? How should they be rethinking their approach to investment in delivery assets and organizational culture?
18:00 “Value-based care and the ACO movement has significant opportunities to create more affordability and better outcomes for our patients.”
18:15 The need for a federal framework that provides a groundswell of support to move in the direction of value.
18:30 Leveraging the CMMI Strategic Framework to move 150 million Americans into value-based payment models.
19:30 Debbie describes how she led her health system towards the acceptance of downside risk in 2015. (Learn more about Essentia’s Population Health Strategy)
20:30 When Debbie left Essentia Health, 42% of health system revenue was flowing through value-based contracts (upside and downside).
21:30 The importance of leadership, organizational culture, and data in a health system’s value journey.
22:30 Referencing Debbie’s recent article on “The Future of Integrated Virtual Care.”
23:30 Essentia Health’s integrated virtual care generated higher patient satisfaction scores, eliminated many SDOH barriers, prevented ED visits, and saved approximately $2.5M in healthcare costs.
24:00 Debbie discusses the Essentia Health integrated virtual care journey and how they navigated the challenges of COVID-19.
26:00 How remote patient monitoring and a Personal Health Record (Epic MyChart) lowered healthcare costs and utilization for specific chronic conditions.
27:00 Implementing a Hospital-at-Home program – lessons learned in testing a different model of care.
28:00 What is the permanent nature of virtual care in the post-pandemic era?
29:00 The need for Telehealth ROI and the demands of younger patients for virtual care.
31:00 Unlike in a fee-for-service model, payer contract negotiations in value do not always have to be a zero-sum game.
32:30 Debbie explains how to cultivate meaningful payer-provider partnerships to improve population health outcomes and reduce health disparities.
34:00 Strategies for engaging payers to get “must have” value-based contract terms and meaningful data to deliver on care model transformation.
37:00 “The willingness to solve problems in partnership with payers is the true test of the commitment to deliver better care for communities.”
38:45 The importance of data, governance, and strategy to guide the fluidity of ever-evolving payer-provider relationships.
41:00 Debbie elaborates on her success in planning targeted SDOH interventions to eliminate health disparities using the ADKAR® Model for change.
42:00 Recognizing the health divide between North and South Minnesota and how Essentia Health addressed gaps in care and health inequities.
43:30 Conducting health risk assessment screenings on all patients and how that data drove community-based interventions.
44:30 Using community benefit funding within the health system to support CBOs taking care of patients’ social needs (e.g. food, transportation, housing).
47:00 In 2023, 10.9 million beneficiaries are being cared for in MSSP ACOs, while 2.1 million are being cared for by REACH ACOs.
48:30 Debbie provides her leadership perspective on CMS payment model innovation.
49:30 Improving alignment and consistency between MSSP, REACH, MA, and Medicaid payment models.
50:30 “If you are not in risk, take the first step in an upside-only value-based arrangement. The benefit is knowing your performance against your peer groups.”
51:00 The inevitability of mandated bundled payments.
52:00 The lack of payer alignment in the commercial market creates a challenge for them to lead in value transformation.
52:45 Expect to see significant growth in the value movement by 2025.
54:00 How important is it that we teach emerging healthcare leaders about value-based care? Do we need a new kind of leader to disrupt legacy thinking in healthcare?
56:00 “Be involved and willing to take risks. That is what it is going to take to challenge the status quo and push our stakeholders to be better.”
57:30 As an avid mountain climber, Debbie has attempted three of the Seven Summits and climbed all 58 of Colorado’s 14,000 peaks, as well as Mt. Rainer in in Washington and Grand Teton in Wyoming. Additionally, she has climbed peaks in Bolivia, Mexico, France, Argentina, and Mt. McKinley in Alaska.
58:00 Parting thoughts of inspiration on what it means to reach the summit and how mountain climbing relates to the value journey.
58:45 “When you take the path least travelled, that is when you learn the most about yourself. People deserve this race to value.”
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.)
The healthcare industry is facing immense financial pressure. Staffing shortages, skyrocketing labor costs, continuing supply chain disruptions, inflation, rising interest rates, and volatile markets are pressuring both revenue and expenses for provider organizations. These economic challenges, however, are an opportunity to catalyze value-based care. The promise of value in health can lift up communities through improved clinical outcomes, reduced disparities, financial rewards associated with population health, and emerging opportunities for upskilling the workforce. Now is the time to prioritize value-based care as a key strategic priority for long-term success and sustainability. There are few other health systems in the country that have demonstrated more of a longstanding commitment to transformation than Ochsner Health through its population health enterprise.
A leader in innovative healthcare delivery, Ochsner Health Network (OHN) is the accountable care network of the massive Ochsner Health system – the largest nonprofit, academic healthcare system in Louisiana (and one of the largest health systems in the Southeastern region of the US). Ochsner has 47 hospitals and more than 370 health and urgent care centers across Louisiana, Mississippi, Alabama, and the Gulf South. Ochsner Health Network – the value-based care arm of the health system –has 277 affiliated physician practices with nearly 3,500+ physicians spanning 625 locations. They are responsible for managing 406,000 lives across six risk-based, accountable care contracts in their value-based care portfolio. Through its collaborative efforts, OHN is making a difference for the nearly 1 million patients throughout Gulf South communities each year.
In this week’s episode of the Race to Value, we are engaging two incredible leaders from Ochsner Health Network (OHN). As Chief Executive Officer for OHN, Eric Gallagher is responsible for directing network and population health strategy and operations, including oversight of value-based performance management operations, population health services and care management programs, post-acute and home care strategies, value-based analytics, and OHN network development and administration. Joining him is Dr. Sidney “Beau” Raymond, the Chief Medical Officer for OHN who is board-certified by the American Board of Internal Medicine and has been on staff at Ochsner since 2016 and practicing medicine since 2000. These two leaders discuss what it takes to transform a health system in the “race to value” and how to ultimately improve the health for an entire state in the process!
Episode Bookmarks:
01:30 Ochsner Health Network (OHN) is the value-based care arm of the Ochsner Health system – the largest nonprofit, academic healthcare system in Louisiana.
02:30 Through its collaborative efforts with patients, communities and employers, OHN is caring for nearly 1 million patients in Gulf South communities.
04:00 Introduction to Eric Gallagher (CEO, OHN) and Dr. Sidney “Beau”Raymond (Chief Medical Officer, OHN)
05:00 Support Race to Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts!
06:00 A recent Kaufman Hall report on the mounting pressures facing providers (e.g. staffing shortages, labor costs, supply chain disruptions, inflation, rising interest rates, volatile markets).
07:30 Eric Gallagher discusses the critical challenges of staffing shortages and the skyrocketing cost of labor.
08:30 “Staffing shortages and rising costs of labor is a critical challenge. It serves as a catalyzing environment for value-based care.”
09:30 Investments in value-based infrastructure has forged collaborative relationships within the entire system.
11:00 Dr. Raymond on how post-pandemic workforce pressures have impacted primary care access and care delivery innovation.
13:00 The number of Americans ages 65 and older is expected to more than double over the next 40 years.
14:00 Approximately 10,000 Americans are aging into Medicare each day.
15:00 The Ochsner value journey in caring for seniors — from global capitation risk in Medicare Advantage to the Ochsner Accountable Care Network (OACN) ACO.
15:30 OCN/OACN have saved CMS over $100 million in the last 5 years! (recent press release on OACN Shared Savings Results)
16:30 Ochsner Health Plan – the only Medicare Advantage plan sponsored by and fully integrated with Ochsner Health.
17:30 Oschsner 65 Plus – a new initiative consisting of freestanding, PCP value-focused clinics delivering high touch, team-based primary care for seniors.
20:00 In the last three years, OACN MSSP ACO has doubled in size to 63,000 attributed beneficiaries.
21:30 How Ochsner has improved quality results performance in the ACO and is scaling it through continued growth.
23:00 The importance of value-focused leadership in building infrastructure and culture to drive performance outcomes.
23:45 “You can’t undervalue the importance of having the talent, leadership-buy-in, and investment to drive value-based outcomes.”
26:00 How senior-level engagement and alignment creates an environment for care delivery innovation.
27:45 The elevation of value-based care to one of four pillars of success for Ochsner Health.
28:00 Hardwiring VBC success into the compensation model for both system executives and physicians in the Ochsner Health enterprise.
28:30 How primary care engagement has led to next-level partnerships with specialists in the network.
30:00 How compensation plans and bonus incentives have driven provider engagement in value-based performance.
33:00 Ochsner’s partnership with Walmart to provide integrated, coordinated, high value care for employees across Louisiana.
34:30 The importance of employer-provider partnerships in improving the health and wellness of a workforce.
35:30 Sharing of financial-risk with self-funded employer-sponsored health plans.
37:00 Negotiating PMPM prospective payment with employers for a care management team model that improves clinical outcomes.
40:00 How Ochsner has been very intentional in building a population health data infrastructure to support its partner physicians.
41:00 Using claims groupers and population-based analytics to evaluate the totality of care spend for specific patient populations.
41:45 Collaborating with partner hospitals and community physicians to democratize population health data analytics at the point-of-care.
43:00 “HIT infrastructure capability and democratization of data at the point-of-care are the dual challenges in reaching greater depths of analytical precision.”
43:45 Ochsner’s patient population: 14-percent have diabetes and 40-percent have hypertension.
44:00 Improving outcomes for patients through enrollment in the Ochsner Digital Medicine program.
46:30 The use of algorithms for personalized care interventions to better engage chronically ill patients.
47:00 Overcoming physician concerns that the use of digital medicine is competitive to in-person E&M encounters.
47:30 The digital medicine program has improved outcomes (e.g. screenings, care gap closures, patient engagement) without diminishing office-based RVUs.
48:30 Piloting digital medicine for Medicaid populations and how that has increased care access and engagement.
50:00 Digital Health as a core component of Ochsner Health’s strategy (along with value-based payment).
51:00 The role of innovationOchsner (iO) as an important think tank and lab for digital health innovation.
52:00 Piloting the Ochsner Connected Stability Fall Prevention digital health program for MA members who are the highest risk of falls.
56:30 How the Ochsner population health enterprise delivers integrated behavioral health in the primary care setting.
58:00 Virtual behavioral health integration as the next big opportunity for care delivery innovation.
59:00 The Office of Professional Well-Being at Ochsner that has been established to improve the well-being of the workforce.
60:00 The growing concern of burnout and moral injury with physicians, APPs, and other clinicians.
61:30 A conscious effort to minimize inbox messaging for providers as a way to eliminate administrative burdens that contribute to provider burnout.
62:30 Integration of pharmacists in primary care setting to help manage prescription refills.
63:30 Team-based care (e.g. social workers, nurses, care coordinators, dieticians, patient engagement specialists) as an opportunity to improve overall workforce outcomes.
66:30 Partnering with Higher Education for interprofessional upskilling opportunities (e.g. Delgado Community College partnership in training nurses and CHWs).
69:00 The Healthy State by 2030 initiative as a catalyst to improve health equity in marginalized and underserved communities in Louisiana.
71:00 Community partnerships that recognize the impact of education as an opportunity equalizer.
74:00 Parting comments on the importance of health equity as a societal priority that is a shared responsibility in communities.
The message from state and federal regulators, healthcare leaders, and our society-at-large is being heard loud and clear: Health equity is a moral imperative.
A cultural zeitgeist for health equity has been awakened in the collective consciousness of all ethnicities in the context of COVID-19 health disparities and the ongoing fight for civil rights and social justice. The economic imperative for equity is also too big to ignore, given that inequities in the US health system cost approximately $320 billion today and could eclipse $1 trillion in annual spending by 2040 if left unaddressed. The future of equitable health is important to the future of our country, and we must address this moral imperative with business solutions.
Joining us this week in the Race to Value is Jay Bhatt, D.O., MPH, MPA – a leading physician executive, internist, geriatrician, and public health innovator. Dr. Bhatt is the Executive Director of the Deloitte Center for Health Solutions (DCHS) and the Deloitte Health Equity Institute (DHEI), Dr. Bhatt directs the research, insights, and eminence agenda across the life sciences and health care industry while driving high-impact collaborations to advance health equity. He is a prominent thought leader around the issues of health equity, health care transformation, public health, and innovation.
Do you want to learn more about how we can create a catalytic engine for equitable health? Tune in to this podcast to learn from one of the nation’s leading minds on how to advance health equity through business solutions. In this episode, we discuss collaboration with life sciences and health care industry to advance health equity, digital transformation, ACO REACH, and climate-related strategies.
Episode Bookmarks:
01:30 Introduction to Jay Bhatt, D.O., MPH, MPA – a leading physician executive, internist, geriatrician, and public health innovator.
03:00 Subscribe to the Race to Value weekly newsletter and leave us a review and rating on Apple podcasts!
04:30 The three root causes of health equity: 1) socioeconomic, gender, racism and other biases, 2) disparate circumstances in the drivers of health, and 3) inadequately designed healthcare systems.
06:15 Creating a catalytic engine for the future of equitable health and why the Deloitte Center for Health Solutions and The Deloitte Health Equity Institute (DHEI) are so critical to the health of this country.
06:30 “There is a workforce imperative, a market imperative, and a moral imperative for health equity. We must address the moral imperative through business solutions.”
07:00 Deloitte Report: “Inequities in the US health system cost approximately $320 billion today and could eclipse $1 trillion in annual spending by 2040 if left unaddressed.”
07:30 Collaboration with life sciences and health care industry to advance health equity, digital transformation, and climate-related strategies.
08:30 Engaging key decision makers and global leaders in health equity through Deloitte’s involvement in the World Economic Forum.
09:00 Activating Boards and C-Suite leaders in health equity and implementing place-based change through community outreach and population health interventions.
09:40 Health equity innovation through an accelerator that supports minority-led non-profit organizations and social entrepreneurs.
10:00 Addressing access to maternity care deserts that contribute to inequities throughcollaboration with the March of Dimes.
10:45 A recent research report conducted by the Deloitte’s Health Equity Institute and other partners entitled, “Collection of Race and Ethnicity Data for Use by Health Plans to Advance Health Equity.”
11:45 “Continuing to analyze the delivery of care and examine patient outcomes across demographics, including race and ethnicity but also sexual orientation, gender identities, and language is critical to administering more equitable and inclusive care, and building trust with communities across America.”
12:45 “Building and sustaining trust is critical to improve the availability of high quality race and ethnicity data to advance the journey of health equity.”
13:30 The importance of proximity and lived experience, community partnerships, transparency, and assurance of patient privacy in the collection of race and ethnicity data.
14:30 Federal agencies are advancing more inclusive standards for self-reported, voluntary identification of race and ethnicity data.
14:45 “Health Equity by Design” through interoperability standards developed by the Office of the National Coordinator (ONC).
15:30 “Transparency, trust, and partnership can improve the collection and use of race and ethnicity data. If we want better results, we have to create better systems.”
16:30 Medical Home Network (MHN) – a FQHC that is one of the nation’s foremost clinically integrated and digitally connected delivery networks to improve the health of Medicaid beneficiaries in safety net communities in the Greater Chicago area.
17:45 Chicago is a city facing immense challenge in health equity. In the last decade, life expectancy has fallen for everyone except for non-Hispanic white Chicagoans.
18:30 ACO REACH explicitly identifies Equity – not just Value – as a central goal. Have other payment models perpetuated racism and structural inequities?
19:30 REACH ACOs now being required to develop a Health Equity Plan.
20:00 Dr. Bhatt speaks to the MHN FQHC model and how it contributes to improved community health outcomes.
21:00 Health Risk Assessments (HRAs) that drive the advanced application of AI and predictive analytics for targeting population health interventions in underserved communities.
21:45 Individuals with unstable housing have a life expectancy that is 27-years less than others with a stable housing situation.
22:30 “Industry collaboration is an ecosystem. The alliances we make support trust, collaboration in alternative care sites, and reduce friction to care access.”
23:00 The importance of the “Digital Front Door” and Virtual Care Delivery Transformation in value-based care.
24:00 How SCAN Health Plan educed disparities in medication adherence for cholesterol medications by 35%.
26:30 The ACO REACH payment model and a data-driven strategy will be key to designing a more equitable model for care delivery.
27:30 Translating key learnings in equity improvement through rapid cycle evaluation and improvement in action.
28:00 An example of a SDOH intervention to find improved housing for someone dealing with allergen exposure.
29:00 Seizing the moment for industry to galvanize around the advancement of health equity.
30:00 The seminal IOM Report, Unequal Treatment, that determined Black and Hispanic Americans typically receive lower quality of care—across a range of diseases—when compared to white Americans.
31:00 Referencing the recent actuarial analysis from Deloitte entitled, “Breaking the Cost Curve”
32:00 Dr. Bhatt explains why our country can no longer afford to endure systemic health inequities.
32:30 COVID-19 awakened a national consciousness for health equity.
33:00 How nonprofits, CBOs, governments, and the private sector can collaborate to overcome the challenges of the past, heal the present, and build a more resilient healthcare system for the future.
33:30 Gender equity and how placed-based change can help to identify, understand, and address social issues.
34:00 Diversity, Equity, and Inclusion (DEI) in the workforce as a key lens and driver of health equity.
34:45 Creating an ecosystem for equity through community partnerships and collaboration.
37:30 How digital tools (e.g. SMS texting, virtual care, remote patient monitoring, VR) can empower healthcare consumerism.
38:45 Creating digital literacy and improved access to broadband connectivity in underserved communities.
40:30 Designing clinical workflows and implementing training programs to avoid provider burden.
41:00 The impact of life sciences and research & development to improve diversity in clinical trials and address issues with pricing and affordability.
41:30 Referencing the 2022 Deloitte Global Life Sciences Outlook focused on health equity innovation in the life sciences sector.
42:00 Dr. Bhatt speaks about the need to improve diversity in clinical trials.
43:30 Establishing relationships with community leaders in black colleges and minority-serving institutions.
45:00 Dr. Bhatt discusses the future of Public Health and how it will overcome extreme challenges such as a decades-long backlog of funding needs and a global pandemic.
48:00 The complex relationship between climate change and health equity (climate change is now the “greatest threat” to global public health)
49:30 Dr. Bhatt on how climate change exacerbates health inequities and increases the total cost of care.
51:00 “Climate change stands out as a key force multiplier that amplifies the effects of health inequities in an exponential, non-linear way.”
53:00 Parting thoughts from Dr. Bhatt on rebuilding trust between minoritized communities and the health care sector.
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.
Nearly 75% of Americans are overweight, including 42% who have obesity. The pandemic has heightened the problem, since many of us find comfort in food, and delivery services like Door Dash and Uber Eats make it easier than ever to consume calories while barely getting off the couch to answer the door. This obesity epidemic has huge implications on value-based care due to the impact it has on chronic morbidity, increased mortality, and unrelenting demands on the utilization of limited healthcare resources. Chronic conditions associated with obesity include, but are not limited to, type-2 diabetes, hypertension, hypercholesterolemia, and heart disease. These diseases have a destructive effect on the US healthcare system, and leaders in value-based care must start thinking about lifestyle medicine and evidence-based nutrition interventions. While there are many apps and tools for consumers or patients to use to lose weight on their own, programs that incorporate medically-assisted weight management and obesity care yield the best outcomes.
Rather than weight loss as a sidebar suggestion once a disease state is diagnosed, weight loss can be a potent catalyst for disease prevention within value-based care. Dr. Jamy Ard is the Co-Director of the Weight Management Center at Atrium Health Wake Forest Baptist. Joining him this week in the Race to Value is Rich Steinle, CEO of Carium – a technology company that partners with clinicians to offer a complete, virtual care platform ensuring every person – regardless of location, demographic or disease state – has access to quality, personalized care, education, and tools to support health and wellness goals. In this episode, we discuss the importance of partnerships between healthcare providers and technology companies to empower clinicians, patients, and their caregivers. Do you want to learn more about how real-time, aggregated health data and analytics can guide clinical decision-making in obesity? Well, this is an interview that you will not want to miss. Within a platform-enabled, virtual care ecosystem, weight management care teams can achieve positive outcomes that deliver on the promise of value-based care!
Episode Bookmarks:
01:30 An introduction to the concept of Virtual Weight Loss Management in Value-Based Care
02:00 Background on Dr. Jamy Ard (Atrium Health Wake Forest Baptist) and Rich Steinle(Carium)
03:30 Subscribe to our newsletter and leave us a Review and Rating on Apple Podcasts!
04:00 Chronic conditions associated with obesity include type-2 diabetes, hypertension, hypercholesterolemia, and heart disease.
04:45 Direct medical costs attributed to obesity account for $147 billion. Lost productivity due to obesity cost $303 billion. Adding chronic diseases make obesity a $1 Trillion problem!
06:00 Dr. Ard speaks to the economic challenges of obesity – “Obesity is a multifocal chronic relapsing disorder. It is a disease epidemic that can be addressed through patient engagement.”
07:00 The limitations of medical education in training doctors on nutrition and how to effectively treat and manage patient obesity.
08:30 Dr. Ard discusses the Weight Management Center at Atrium Health Wake Forest Baptist and the challenges with patient engagement in an obesogenic environment.
09:00 The impact of the COVID-19 pandemic on societal obesity and how technology empowers an effective patient engagement strategy.
10:00 Rich discusses the diametrically opposed reality that treating obesity is typically conducted as a prescription upon the onset of chronic disease (instead of as a prevention).
11:30 How technology can extend team-based care to provide a conduit for meaning patient engagement and treatment interventions.
12:00 Technology can be leveraged to address community health and equity, especially for patients living in food deserts.
13:00 How can a trusting business partnership between a care delivery organization and a technology company embolden relationship-based care for value transformation?
14:30 Dr. Ard on how technology can identify care gaps and then inform the agile development of intervention solutions.
15:00 “Technology doesn’t replace providers. It instead enables the provider to do more than what they can do alone.”
15:30 “A data-assisted approach to obesity care (e.g. patient-reported outcomes, physiologic monitoring) can enable personalized medicine.”
17:00 Rich outlines the tenets of relationship-based care – a common vision, trust, and innovation.
19:45 Demonstrating results with innovation can create expanded scale and reach in clinical efficacy.
21:00 How can research into the science of behavior change improve our understanding of how to influence health-related behaviors, such as diet, exercise, and medication adherence.
22:30 Lifestyle medicine as the starting point for any treatment strategy.
23:30 Uncontrollable variables in an obesogenic environment (i.e. Social Determinants of Health) determine the development of a personalized treatment strategy.
25:00 Having a trusted resource provided real-time feedback and guidance can guide better lifestyle choices.
26:30 Tailored feedback provides the opportunity for more sustainable changes (versus self-monitoring)
26:45 How automation of a “one-to-many” engagement strategy can be reinforced with individualized feedback.
27:30 The saturation of DIY health applications and how it differences from a patient-centered care model that emphasizes trusting relationships.
28:30 The real-time continuous learning of engagement algorithms used in weight management programs.
29:30 Incorporating biometric data from wearables to care management programs capturing self-reported data.
31:30 Rich on how the founders of Carium had a vision for data-enabled predictive analytics in healthcare (based on prior experience with telecommunications industry).
33:00 Creating data visualizations and actionable insights to drive value-based care outcomes.
35:00 In the conventional treatment of obesity, we often rely on a “one-size-fits-all” approach despite significant pathophysiological heterogeneity among people with obesity.
36:45 Dr. Ard provides perspective on the opportunity for precision medicine and individualized care planning in the personalized treatment of obesity.
38:00 The heterogeneity of treatment response for obesity allows for much faster realization of patient outcomes (i.e. a short-term ROI opportunity for medical cost savings)
39:30 Precision medicine and individualized care planning allows for a more effective utilization of healthcare workforce.
40:30 Rich discusses how virtual care delivery and remote patient monitoring can provide the enablement to help clinicians “deliver care at the point of life.”
41:30 White labeling or co-branding of technology supports the curation of a trusted engagement platform.
42:30 An example of how the technology relationship between Carium and Dr. Ard helped improve data capture and integrity.
43:30 The importance of shared goals between providers and technology companies.
45:00 Healthcare needs a renaissance of human experience design in technology solutions.
46:30 Moving medicine from an episodic, fee-for-service paradigm will require patient-centered technology design.
50:00 Approximately 13-percent of US households report food insecurity, meaning that they lack consistent, dependable access to enough food for active, healthy living.
51:45 Dr. Ard on how tech-enabled VBC can support the elimination of health disparities related to obesity with low-income and minoritized populations.
56:00 Rich describes how the proliferation of obesity-specific patient engagement can extend to other areas of medicine (e.g. fetal maternal health, oncology).
56:45 Technological scarcity is a social determinant of health and we must “bridge the digital divide” if it exists.
57:30 Does income fragility mean that people do not have access to smart phones and broadband access?
60:00 Are we in the beginning of a 4th Industrial Revolution where scalable disruption of our current care delivery model will occur through digital transformation?
60:45 Why hasn’t the Internet transformed healthcare like it has all other industries?
62:00 Rich discusses what the future look like in the next few years with emerging advancements in AI, internet of things, 5G, wearables, and gamification of consumer health apps.
63:00 Dr. Ard on how providers will eventually prescribe technology applications to their patients and provide automated meal planning based on context and geolocation.
This week on the Race to Value you will hear from Dr. Neil Wagle, the Chief Medical Officer at Devoted Health. This is a company we have been wanting to profile on the podcast for quite some time! Devoted Health is a healthcare company that designs Medicare Advantage plans for seniors; however, they are so much more than just a MA plan. Devoted Health has built a different model of care that starts with knowing their members on a personal level and earning their trust. By focusing on each member as a person and not as a chart, they are able to provide the best quality care for older Americans through an all-in-one healthcare solution combining the MA plan, access to high quality local providers alongside virtual and in-home care, and full-service guides—with world-class proprietary technology powering it all. This company is a leading innovator in value-based care.
Dr. Neil Wagle knows a thing or two about transforming healthcare. He is an internal-medicine physician by training, spent six years at Partners Healthcare (now Mass General Brigham) leading the health system’s efforts to improve the quality of care for patients. In 2017, he joined Devoted Health, a $12.7 billion health-insurance startup. As its chief medical officer, he’s spearheading the development of a model of care aimed at improving the health of older Americans by getting them the right care at the right time while saving costs for the US healthcare system.
In this episode, we discuss clinician burnout and moral injury, post-pandemic recalibration of the healthcare system, virtual care delivery, the benefits of a fully-integrated technology platform, health equity transformation, creating a virtual “Blue Zone”, patient-reported outcome measures, activation of chronically ill patients, and the importance of company culture in delivering relationship-based care.
Episode Bookmarks:
01:30 Introduction to Dr. Neil Wagle, the Chief Medical Officer at Devoted Health.
03:45 Dr. Wagle provides his background as a “synthesizer between medical-scientific world and the business world.”
04:15 Inspiration and mentorship from Dr. Tom Lee and being a part of Mass General Brigham’s first value-based contract.
04:45 “We’ll probably lose $70m in the first year, but we’re moving to value-based care because it is the right thing for patients.”
05:45 A chance coffee meeting with Ed Park led to the “ridiculously challenging” quest to build a system that could radically transform healthcare!
07:00 Provider burnout and moral injury is one of the major crises in healthcare (along with rising costs and inadequate care for aging Americans).
08:45 Dr. Wagle on how the pandemic has exacerbated moral injury and why we need to return to the altruistic underpinnings of medicine.
09:30 “The ability for physicians to connect with others has been decimated by overbooked 15-minute visits.”
09:45 How documentation requirements in fee-for-service medicine robs providers of “pajama time” with their families.
10:00 The Great Resignation in healthcare is being driven by the perpetuation of the fee-for-service business model.
10:30 Resolving the three crises of healthcare (i.e. Provider burnout, aging population, and rising healthcare costs) through care delivery transformation.
11:00 The good news in VBC: providers want to practice medicine in this way and patients actually have better outcomes with lower costs!
11:45 “You have to be able to monetize fewer hospitalizations. If you can’t, the value-based model of care won’t work financially.”
12:30 The emotional fuel of seeing better patient outcomes in VBC drives continual value-based care transformation.
13:00 The new wave of healthcare consumerism from the pandemic is causing a much-needed recalibration of care delivery.
14:00 “COVID exposed cracks in our fee-for-service model…”
15:45 “Value-based care is actually the ideal home for virtual care services because you don’t have to worry about over-utilization.”
16:00 Dr. Wagle describes how Devoted Health dramatically improves the health and wellbeing of Americans through person-centered care.
16:30 The “all-in-one healthcare” offering of Devoted Health as a virtual in-home medical group and MA plan, enabled by full-service guides and integrated technology.
17:30 Medicare Advantage patients receive this “all-in-one” care for free as part of their enrollment in the health plan.
17:45 Scaling a virtual care model further enhanced Devoted Health’s mission to treat members like family.
19:15 Overcoming the challenges of loss aversion in the perception of patients when adopting a virtual-first care delivery model.
20:00 The benefits of a virtual-first mentality when it comes to organizational scalability and culture.
21:30 Devoted Health has developed an end-to-end data and technology system that choreographs care delivery in a single, vertically integrated, tech-enabled model.
22:00 Dr. Wagle on the well-deserved skepticism of technology as a panacea…but how that is balanced with the practical vision of Ed and Todd Park.
22:45 Building a full-stack technology platform from the ground up was necessary (market-based solutions are based on FFS medicine and are incredibly fragmented).
23:00 Full-stack tech platform at Devoted does everything! (e.g. sales, enrollment, pharmacy, medical claims, prior authorizations, customer service, full EHR)
23:30 “Having a full-stack technology platform with all information in a single place allows us to deliver on the promise of complete, coordinated, and customized care.”
24:00 How human-centered technology design drives targeted population health interventions and personalized care delivery.
27:00 Human connection (relationship-based care) can be fostered with a full-stack technology platform because people don’t have to remember minute details.
28:00 Enabling tech-enabled rapid cycle innovation to deliver improved population health outcomes.
29:00 The challenges of defining “value-based care” and how health equity is changing how we understand value.
30:30 The historical debate about the adjustment of outcome measures to account for demographic factors.
31:00 “The world has moved to a different place where we have put a spotlight on health equity itself, rather than burying it in adjustment methodologies.”
31:45 How “Community Guides” at Devoted Health correlate the overcoming of SDOH with the Maslow Hierarchy of Needs to help members achieve full potential.
32:30 An example of how helping a member successfully enroll for public benefits can give them an extra $ 325/mo.
33:00 The development of a Health Equity Dashboard to measure their impact in closing equity gaps.
34:00 The product goal of Devoted Health is to be the world’s first virtual “blue zone” where people enjoy much longer, healthier lives than average.
35:00 “Longevity is not the ultimate goal. The first task of a health system is to make sure we treat people like family so they are happy and fulfilled.”
36:30 Dr. Wagle on what it really means to create a virtual Blue Zone at Devoted Health.
37:45 Creating the “Devoted Social Club” to help members overcome loneliness and social isolation through human connectedness and resilience tools.
39:30 Dr. Wagle on why the people and the culture is the foundation of Devoted Health.
41:30 “As we go out and look for new team members we look for experience, clinical acumen, and love in your heart.”
43:00 Caring for the clinician workforce so they can cultivate the love in their heart for the caring of others – it is a self-perpetuating phenomenon.
45:00 Keeping the mission as a “prime directive” by closing your eyes and imagining someone you love…than take action.
46:45 How Community Guides cultivate trusting relationships with members and help people overcome their mistrust of the healthcare system.
47:30 Spending time with members as an enabler of trust and empathy (e.g. a 90-minute phone call).
49:00 Trusting relationships are why Devoted Health has such a high net promoter score of 79 (higher than Apple, Netflix, and Amazon).
50:30 Starting with “Patient Priorities Care” in member engagement first…and then moving to data-enabled, rapid-cycle deployment of interventions.
51:30 Dr. Wagle discusses the importance of Patient-Reported Outcome Measures in value-based care.
54:00 6 in 10 adults have a chronic disease, and it is the leading driver of the nation’s $3.8T healthcare spend.
54:30 Dr. Wagle provides examples of how Devoted Health is making an impact in medication adherence and Hgb A1c reduction.
56:00 85% of diabetic members have their blood sugar under control, with an average A1c reduction of 2.3 within 100 days.
56:30 77% of hypertensive members now have their blood pressure under control, with an average reduction in systolic BP of 15.2 within 40 days.
57:00 Reduction of acute events related to Congestive Heart Failure by 50%.
57:45 Dr. Wagle shares an a research example of “learned helplessness” in dogs and how that behavioral pattern relates to most chronically ill patients managing their disease.
60:00 “We must relate clinical outcomes back to patient priorities. Those cycles are what capture momentum.”
61:30 Dr. Wagle discusses company growth and expansion and how Devoted Health is entering eight new states in 2023.
62:15 How will Devoted Health consistently replicate and scale as it enters into new markets at a national level?
64:00 Parting thoughts of appreciation from Dr. Wagle and how gratitude makes dreams come true in value-based care!
64:45 “Value-based care is more than possible…it is coming. The arc of history is bending towards progress, and I am grateful to be a part of that journey.”
Paying it forward begins in the heart. Leaders who use their gifts in the service to others are those who understand that value given is value added.
By every measure of success, Dr. Shawn Griffin has become one of the most impactful physician executives in value-based care transformation. And his story is all about how he recognized his unique gifts and built amazing teams to improve population health outcomes. Additionally, his sharing of best practices and key learnings with others across the country – through peer learning and mentorship – has amplified impact in improving the lives of others. The host of this podcast, Eric Weaver, was one of the people impacted by the mentorship of Dr. Shawn Griffin. His mentorship inspired Eric to make a difference as an evangelist for a better way of delivering care in this country.
In this episode, you will gain access to an in-depth conversation with Dr. Shawn Griffin, the President and CEO of URAC. You will be inspired by his servant leadership in the pursuit of value-based medicine, and you will learn of his career path from rural physician to one of the leading physician executives in the country. We discuss the important of team-based care delivery and primary care transformation. We also cover such important topics as healthcare accreditation, quality improvement, rural health care, pharmacy integration, technology innovation, and genomics-based care.
The truest measure of a leader is whether they are generous, have a big heart, and pay it forward. Dr. Shawn Griffin is the quintessence of this type of servant leadership in the race to value!
Episode Bookmarks:
01:30 Introduction to Dr. Shawn Griffin, the President and CEO at URAC
04:00 Eric shares a personal extension of gratitude to Dr. Griffin for the mentorship he provided years ago.
06:45 Dr. Griffin describes his journey in value-based care, beginning in the early days of practicing rural family medicine.
08:00 The United States is an outlier in that Primary Care is not at the center of medical care delivery.
08:45 A decision to impact more lives by taking on leadership roles in system design and care delivery transformation.
09:30 How love for family and others manifested into a commitment to patient care quality.
10:30 Building an effective Population Health Team at Memorial Hermann ACO during his leadership tenure.
11:00 The importance of effective storytelling and celebrating wins to drive value transformation.
12:00 “One has to decide in life if they are going to use their gifts to help themselves or help others.” (how VBC leadership is Dr. Griffin’s way of paying it forward)
12:45 The impact of constantly changing health policy on ACO success (and how frustration led Dr. Griffin to make a difference at a federal level).
13:30 How mentorship and teaching in value-based medicine can transform care delivery on a national scale.
17:00 Dr. Griffin explains the importance of accreditation programs and how URAC was founded to set standards in healthcare.
19:00 Specialty Pharmacy Services Accreditation as an example of standard setting to drive quality improvement.
20:00 Telehealth Accreditation and how “Telemedicine is more than just a good camera. It is good quality medical care using technology to do it.”
21:00 “Raising the bar and advancing the quality mission as things change is what accreditation should be doing.” (Reference video on revamping telehealth accreditation)
22:00 Why an accredited program (e.g. URAC Gold Star) provides a basis for a patient to validate their trust in the care provided.
23:00 Dr. Griffin discusses how URAC accreditation is driving care delivery redesign across the world (e.g. Egypt and Saudi Arabia).
25:00 The challenges of defining health care quality.
26:30 “Measuring quality is an ongoing unsolved problem in health care.”
27:30 The power of a trusting patient-provider relationship in care quality and how patient definitions differ.
28:30 The limitations of HEDIS measures.
29:30 Quality measurement data capture at the point-of-care is a major contributor to provider burnout (“checking the boxes”)
32:00 “Most of us have better information available on picking a hotel in Paris than we do selecting a high quality primary care provider.”
34:00 Realigning incentives to get more medical students to practice family medicine in rural communities.
35:00 The role of the federal government to ensure adequate access to primary care in rural areas.
36:00 The crushing economic pressures on rural hospitals.
36:30 “We talk about food deserts in cities. We have provider deserts in the country.”
37:30 “If we are concerned about providing electric charging options for someone’s Tesla crossing the country, perhaps a bigger concern is whether you can receive healthcare in rural parts of the country.”
40:00 Dr. Griffin on opportunity for pharmacy integration and team-based care.
41:00 “One of the good things about medicine in the last 40 years is the recognition that a ‘captain of the ship’ model is not sustainable for doctors or patients. Team-based care is the way to go.”
42:30 The role that URAC is playing in Pharmacy Accreditation and Rare Disease Certification.
45:30 Dr. Griffin on the importance of data liquidity and information sharing in value transformation.
47:00 How concerns about HIPAA compliance (a “HIPAA-chondriac”) can contribute to the problem of data siloing.
47:30 “More data is not always better for physicians. Technology will not always make health care better. A relationship will do more for a person’s health.”
49:00 Balancing Population Health Management with Targeted, Individualized Interventions (examples such as Kaiser Permanente, Intermountain, UPMC).
52:30 Dr. Griffin discusses how the pandemic shifted consumer demand for telemedicine and what we should expect for telehealth delivery in the future.
54:00 Behavioral health telemedicine visits are effective. Pre-surgical screening for heart transplants does not work with telemedicine.
55:00 The “Telemedicine Tug-of-War” going on nationally and why we must always consider the most appropriate application of technology.
56:00 Convenience doesn’t trump quality.
57:00 Telemedicine, Remote Patient Monitoring, Wearables, ML/AI – these will not suddenly make healthcare the “Garden of Eden” overnight.
58:30 Parting thoughts on genomics-driven care and individualized-care planning in a population health model.
59:00 A patient’s Walmart receipts are more valuable to a physician than genomic data.
60:00 Screening genomics for hereditary diseases are scaling as costs come down, but we still cannot discount the impact of lifestyle choices on health.
63:00 How to find out more about URAC and the importance of peer learning and sharing of best practices.
Did you know that musculoskeletal care is one of the biggest challenges facing the value transformation of healthcare? Musculoskeletal healthcare spending is rising at an unsustainable rate – having doubled in the last decade! Many of these procedures (such as knee replacements and spinal fusions) contribute to overspending on care that is not even needed, as it has been estimated that only 50% of MSK procedures are evidence-based. The rising costs ofmusculoskeletal care is now a top cost driver for employers and health plans. Yet despite rising costs, MSK outcomes for members haven’t gotten better over the last ten years. Studies have shown that, despite a dramatic increase in health care expenditures for patients with back and neck problems over the last decade, there has not been a corresponding improvement in patient clinical outcomes. In short, spending more money has not correlated with better outcomes. We are in dire need of a value-based revolution in the provision of musculoskeletal care. The current system is clearly broken. Studies have demonstrated that common approaches to MSK care (surgery, imaging, injections, opioids) do not effectively resolve back and joint pain. And the challenges of escalating costs associated with such low value are too big to ignore.
There is a better way, and this week on the Race to Value, we interview two of the leading innovators in orthopedic value-based care! In this special episode, we will begin with an interview with Dr. Kevin Bozic, the chair of surgery and perioperative care at the Dell Medical School at The University of Texas at Austin. He is an internationally recognized leader in orthopedic surgery and value-based health care payment and delivery models and currently serves on the Board of Directors for the American Academy of Orthopaedic Surgeons – a clear signal from the AAOS that the specialty is moving into the value-based care arena. Our second interview on the podcast is with Dr. Kian Raiszadeh, the CEO and Co-Founder of Livara and SpineZone, an orthopedic surgeon who has created an innovative orthopedic care management system for payors, providers, and health systems to unify the patient experience and transition to orthopedic value-based care.
Episode Bookmarks:
01:30 Musculoskeletal healthcare spending is rising at an unsustainable rate – having doubled in the last decade!
01:45 It has been estimated that only 50% of MSK procedures are evidence-based.
02:00 Increased MSK spending in healthcare not associated with a corresponding improvement in patient clinical outcomes.
03:00 Introduction to Kevin Bozic, M.D., MBA and Kian Raiszadeh, M.D.
03:45 Upcoming conference in value-based orthopedics – OVBC on January 26th-28th
05:00 At the Musculoskeletal Institute at UT Health Austin, Dr. Bozic has created a MSK Integrated Practice Unit.
06:30 Dr. Bozic provides an overview of the Musculoskeletal Institute and how it functions as an Integrated Practice Unit.
07:30 “The vast majority of patients with musculoskeletal conditions do not require or benefit from surgery.”
08:00 The role of the primary care in treating MSK disease within a “musculoskeletal medical home”.
08:45 Comorbid conditions with chronic MSK disease (e.g. anxiety, depression, obesity) are rarely treated in a non-integrated model.
09:45 Holistic integration of primary care-based orthopedic physicians, APPs, physical therapists, dieticians, and social workers.
12:30 Dr. Bozic discusses the potential for condition-based bundled payments in the treatment of MSK disease.
13:45 The role of bundled payment care pathways in lowering overall costs with better clinical outcomes.
14:00 How reduction of inpatient post-acute care can result in lower episode spend with “no detrimental impact on patient outcomes.”
15:00 The big value opportunity — addressing the continuum of care across the spectrum of disease (not just focusing on the surgery).
16:00 Redesigning MSK delivery for optimizing outcomes associated with pain, functional status, and quality of life.
16:30 “Value is all about improving health outcomes in ways that over time reduce the cost of health care. Health is inherently less expensive than disease.”
17:00 The Value Institute for Health and Care and its work in improving health outcomes. (Reference podcast with Elizabeth Teisberg).
19:00 Dr. Bozic discusses the important of patient-reported outcomes (PROs) and how they are used in his musculoskeletal IPU.
20:45 How PROs provide an understanding of a patient’s baseline for pain, functional status, quality of life, and mental health.
23:30 Dr. Bozic provides his parting thoughts on physician leadership in the progression of VBC and the role that AAOS will play in this movement.
26:45 Dr. Raiszadeh and his founding of SpineZone and Livara to reverse the trend of overutilization in orthopedic care through integrated care delivery.
29:30 Dr. Raiszadeh provides perspective on the lack of value-based care from his years of practicing as an orthopedic surgeon.
31:00 “We can create a radically new patient experience in orthopedics allows patients to heal without surgical intervention.”
33:30 Dr. Raiszadeh describes the concept of Orthopedic Whole Health and how it evaluates patients comprehensively from the top-down.
35:30 The impact of obesity, anxiety, and depression on hormonal physiology that affects how patient sense musculoskeletal pain.
36:30 “MSK pain is like the canary in the coalmine. It is giving us an indication of something that is deeper, and that is what Orthopedic Whole Health addresses.”
37:30 The life altering perspective of orthopedic whole health and how this model can be built to scale.
38:00 Transitioning orthopedic care from a biomedical to a biopsychosocial model.
39:00 In the 1990’s, doctors began to view pain as a fifth vital sign, and they over-prescribed opioids (without focusing on safer and more holistic interventions).
40:00 Dr. Raiszadeh discusses the Bio Psychosocial Model of Pain Management in value-based care.
41:30 60-70% of orthopedic patients experience some degree of anxiety, depression, or shame and anger associated with childhood trauma.
42:30 How 1:1 and group sessions, expressive writing, and meditation can be used in MSK treatment.
43:30 Opioid dependency and risks of addiction in orthopedic care.
45:00 “How you feel is the overall foundation of health. It changes our entire chemical environment.”
46:00 The rise of consumerism in orthopedic care and how SpineZone’s consumer-centric model boasts an industry-leading net promoter score of 94.
47:30 Dr. Raiszadeh provides his insights about orthopedic consumerism and how to change a patient’s mindset for MSK treatment.
49:30 How orthopedic consumerism and bio psychosocial care aligns with employer expectations for risk-based payment.
50:30 Creating a MSK model that is non-transactional and opens one up to all aspects of life.
51:45 The launch of Livara – an orthopedic care management system to transition to value-based care at scale.
53:00 Using cost and clinical outcomes data to build a scalable platform that applies to all of orthopedics.
54:30 Leveraging data-driven algorithms to drive diagnosis and value-based care interventions.
57:00 Parting thoughts on the movement to value-based orthopedic care.
For all of you leaders out there on a value-based care journey, it is not lost on any of you that health value has become synonymous with health equity. We are at an inflection point in our society in the recognition that everyone needs a fair and just opportunity to attain their highest level of health. Achieving this will require ongoing societal efforts to address injustice, overcoming socioeconomic barriers to health, and eliminating preventable health disparities. But we cannot do that as a healthcare industry without the proliferation and scale of payment models that align incentives so we can realize true change for the better. On the Race to Value this week, you will hear from one of the foremost leaders on the national scene who is shaping the landscape for accountable care delivery that can advances health equity.
Dr. Dora Hughes is someone who has taken this charge to lead in service to the underserved so that we may realize the dream of a more equitable and healthy society. She is the chief medical officer at the CMS Innovation Center at the Centers for Medicare & Medicaid Services (otherwise known as CMMI). She leads the Center’s work on health equity, provides clinical leadership and input on models, serves as the Innovation Center’s primary liaison with medical and clinical stakeholders, and provides leadership to the Innovation Center’s clinician community. In addition, Dr. Hughes is part of the CMS Innovation Center’s Senior Leadership Team, helping to provide enterprise-level leadership and strategic direction to the Center. In this interview, we discuss the elevated national consciousness to advance health equity, how ACOs and other risk bearing entities can succeed with a health equity strategy, and the work being done by the Innovation Center to redesign alternative payment models for equity. We spend considerable time discussing ACO REACH and value-based Medicaid transformation as well. This is certainly a conversation you should listen to as you plan for success in your Race to Value!
Episode Bookmarks:
01:30 Health Value has become synonymous with Health Equity — everyone needs a fair and just opportunity to attain their highest level of health.
02:30 Introduction to Dora Hughes, M.D., M.P.H., the chief medical officer at the CMS Innovation Center (CMMI)
04:30 If you control for all variables that may contribute to health disparities, African Americans still get the worst quality of healthcare of any demographic in the country.
05:30 The first pillar of CMS’ Strategy Plan is Health Equity
06:30 Cara James, Ph.D., president and CEO of Grantmakers in Health: “I’m someone who’s working on equity before it became cool to work on equity.”
07:00 Referencing the seminal findings of the Heckler Report in the 1980s that investigated racial and ethnic disparities in the United States.
08:00 Momentum has been building towards addressing health inequities, despite the historical lack of national prioritization.
08:30 “It really took the pandemic and police brutality to blast the issues of health inequities into the national consciousness.”
09:00 Disparities go beyond COVID (e.g. black disparities in maternal health, colorectal cancer, kidney disease)
09:45 “Executive pay is now being tied to reduction in disparities. You wouldn’t have heard that 10 years ago or even perhaps five years ago.”
10:00 Referencing CCSQ Deputy Jean Moody-Williams: “For those of us engaged in health equity, this is our moment, but it is only a moment.”
10:30 Actions Needed: collecting and analyzing demographic and health data, knowing patients individually and at the population level, identifying disparities, implementing evidence-based interventions.
11:45 “It takes vibrancy, resiliency, and an indomitable spirit to tackle disparities and scale progress at a national level.”
13:00 CMMI’s work to address Social Determinants of Health (SDOH), e.g. ACOs, Accountable Health Communities (AHC) Model
14:30 80% of what contributes to health reflects non-medical or social determinants of health (e.g. healthy eating, stable housing, educational economic opportunity, jobs)
15:00 “To maximize our patients health, we as providers have to think about our role both inside and outside the health system.”
15:45 The revolutionary nature of the AHC model in fostering healthcare and community partnerships to plan SDOH interventions.
16:30 Results from the AHC Model showing a 9% reduction in emergency department use among participants.
17:00 “Our understanding of healthcare has evolved. We are not going to be able to achieve our health goals without addressing health related social needs.”
17:30 The flaw of Medicare FFS that does not allow providers to code for SDOH interventions.
18:00 The flexibility of MA benefit design and capitated payments in advanced Medicare APMs supports hiring of social workers and CHWs.
18:45 Dr. Hughes responds to criticism from providers that SDOH interventions are “out of my lane” when it comes to health care delivery.
19:30 The need for health policies to address food deserts, lack of affordable housing, weak transportation infrastructure, etc. at the community level.
20:00 Dr. Hughes describes how CMS and other agencies are working to support culturally-competent and linguistically-appropriate care.
20:45 Resources: “A Physician’s Practical Guide to Implementing Culturally Competent Care” (CMS), “Think Cultural Health” (OMH), and “Multicultural Health Care” (NCQA)
22:00 Is implicit bias within current payment models contributing to health inequities?
24:00 Referencing Dr. Hughes’ and Melissa Majerol’s recent blog in Health Affairs: “CMS Innovation Center Tackles Implicit Bias”
25:00 How the estimated glomerular filtration rate (eGFR) leads to erroneous results and findings of kidney disease in African Americans.
26:00 Another example of how a heart disease risk calculator may incorporate racial bias into diagnosis of disease.
27:30 Identifying potential sources of bias before the launch of new payment models.
29:30 The longstanding history of bipartisan support for the movement to VBC and accountable care.
30:00 The 2021 performance year marks the fifth consecutive year that the MSSP has generated net positive savings to CMS. (See recent Race to Value podcast and Institute Brief)
31:30 Dr. Hughes responds to concerns about the reduced growth and participation in the Medicare ACO program and how this challenge is addressed in the CMMI Strategy Refresh.
33:00 Addressing health equity and ACO growth through external partnerships like the Health Care Payment Learning & Action Network (LAN) and provider site visits.
35:00 Developing a CMS-wide vision for Accountable Care expansion (Referencing recent NEJM Article on “Expanding Accountable Care’s Reach among Medicare Beneficiaries”)
35:45 The ACO program is a chassis for testing innovation center models in achieving 2030 accountable care goals.
36:00 CMS has proposed scaling successful features of the ACO Investment Model (AIM)and will leverage ACO REACH more broadly in years to come.
37:30 The ACO REACH program unlike other APMs to date, has made health equity a bedrock of payment model design.
39:30 Dr. Hughes on healthcare complexity, PCP and specialist fragmentation, and the challenges of reforming the system to better care for underserved communities.
41:00 MSSP ACOs and ACO REACH models are helping providers coordinate care and improve health outcomes for Medicare beneficiaries.
42:30 How the ACO REACH model provides flexibility to healthcare providers in how they deliver and they coordinate care (e.g. telehealth, diabetes preventive care, dental care, pharmacy integration)
44:30 “ACO REACH is forging new ways to address the health inequities underserved communities experience.”
44:45 Health Equity Action Planning and Health Equity Benchmark Adjustments under ACO REACH.
46:00 Dr. Hughes addresses concerns expressed by critics of the ACO REACH model.
50:30 Dr. Hughes provides perspective on CMS’s newly refined eligibility criteria and design characteristics for ACO REACH and why it matters to advance health equity.
55:45 Dr. Hughes discusses the work that CMS is doing to advance accountable care to Medicaid beneficiaries and how they are engaging with safety-net providers.
62:00 Parting thoughts from Dr. Hughes on how CMMI is engaging beneficiaries and caregivers in conceptualizing, designing, and testing payment models.
Are you ready for the risk-based tsunami on the horizon? If you are a frequent listener to this show, you understand just how seismic this shift to value-based care really is and why we need the right culture, people, processes — fueled by capital – to spawn care delivery innovation. It is in reimagining care delivery that we can truly deliver on the aims of improved outcomes, lower cost, better patient experience, and equity for all populations. Joining us in this Race to Value this week are two outstanding leaders in the value movement, Drs. Brian Silverstein and Yates Lennon. We discuss how organizations should be preparing for the risk-based tsunami on the horizon through care delivery innovation.
Dr. Brian Silverstein is the Chief Population Health Officer for Innovaccer, a leading healthcare technology company committed to helping healthcare care as one. He is an expert in value-based care delivery and health system transformation with vast experience in helping providers improve population health initiatives. And joining him in this interview is Dr. Yates Lennon, the President of CHESS Health Solutions – a population health MSO empowering physicians and health systems to make the transition to value-based care. Dr. Lennon has extensive experience in quality, practice transformation, and physician engagement and has been instrumental in teaching health systems and providers across the country how to transform patient care and shift to value-based payment. If you are looking to understand the state and science of value-based care, look no further than this conversation with two of the leading minds in industry transformation!
Episode Bookmarks:
01:30 The seismic shift towards value-based care and the risk-based tsunami on the horizon.
02:00 Introduction to Dr. Brian Silverstein and Dr. Yates Lennon
04:30 Progressing in the value journey by understanding the landscape
05:45 Dr. Lennon provides an overview of the value ecosystem with varying adoption of risk in provider organizations.
07:00 “The days of sitting on the sideline are running out. It is time to get started with value-based care if you haven’t already.”
08:00 The State and Science of Digital Maturity at U.S. Healthcare Providers (a recent report from Frost & Sullivan, commissioned by Innovaccer)
09:30 Dr. Silverstein on the legitimacy of the value movement with perspective on how digital infrastructure impacts the pacing of adoption.
10:45 The differentiation of the technology stack utilized by providers accepting full risk-based payment.
12:00 Traversing the value landscape with emerging changes in payment model design focused on the reduction of health disparities.
13:30 Dr. Lennon on how VBP and population health technology tools are perfectly suited to address problems in health disparities.
14:00 Codifying the health equity design of the ACO REACH payment model into operational programs.
14:30 Ensuring access to care in a medical home – an example from Atrium Health Wake Forest Baptist
15:30 “Access is important in value-based care when attempting to address health equity.”
16:00 Focusing on the quality and performance improvement measures that can improve equity.
16:30 Clinical workflow optimization and the use of Community Health Workers to conduct patient outreach.
17:00 Leveraging community resources to address Social Determinants of Health (SDOH).
17:30 findhelp (formerly Aunt Bertha) and Unite Us as examples of technology platforms that can improve SDOH interventions and community partnerships.
18:15 Lifestyle coaching to improve health outcomes with dual eligible populations.
19:00 Dr. Silverstein explains how traditional healthcare will not able to improve population health outcomes in a silo.
20:00 The correlation between a patient’s zip code and their overall health and wellbeing.
20:30 Dr. Lennon provides perspective on how the creativity of value-based care will improve models for patient engagement and care delivery.
21:30 Organizations that are in a “payment straddle” trying to figure out where the fee-for-service curve and the value curves can intersect.
22:30 Capitalizing on both FFS and VBC through Annual Wellness Visits (AWVs), Advanced Care Planning (ACP), Chronic Care Management (CCM), and Transitional Care Management (TCM).
24:45 “I can’t emphasize enough how important providing patient access is for primary care physicians in value-based care.”
25:30 The importance of coding and documentation in risk stratification and compliance.
26:00 Making quality “second nature” by leveraging teams to close care gaps.
26:45 The challenges of finding a competent workforce and retaining physician independence to ensure care delivery innovation.
28:30 The plight of primary care and the struggle to retain independence.
29:00 Referencing recent article from Dr. Mai Pham on how a hybrid payment model will be a lifeline for primary care physicians.
30:00 Dr. Silverstein discusses the inherent complexity of value transformation and the importance of local market dynamics and the art of timing.
32:00 Dr. Lennon on the climate for value-based payment in the North Carolina market and PCP considerations to reach a critical mass in value.
33:00 Should independent PCPs consideration a physician aggregation model to pool lives and access capital?
34:00 Managing contract availability with available cash flow and the timing of investment decisions.
34:45 The difficulties of ensuring holistic patient care delivery while simultaneously maximizing fee-for-service revenue.
37:00 Dr. Lennon discusses the insufficiency of Risk Adjustment in truly understanding the needs of vulnerable populations.
38:00 Educating providers on risk adjustment coding on the connection between good patient care and financial accountability.
39:30 Optimizing an EHR workflow for risk adjustment data capture and clinical data visualizations at the point-of-care.
40:45 Dr. Silverstein on the importance of accurate risk adjustment coding to appropriately plan population health interventions.
42:00 Dr. Lennon discusses the need to importance of coding accuracy to eliminate compliance scrutiny.
42:30 The shift in changing the mindset of FQHCs to focus on diagnosis code specificity.
43:00 How point-of-care tools embedded in the EHR can improve risk adjustment data capture.
43:45 “EMRs and digitization in patient care is just the beginning – not the end state.” (referencing the use of transaction engines from other industries)
44:30 Focusing more on patient care than the sophistication of tech stacks will ensure long-term success.
45:30 Are mandated risk-based payment models the right thing to do in ensuring value-based care adoption?
47:00 Dr. Silverstein on the “multi-level complex Chess” of payment model innovation and provider adoption.
48:30 Dr. Lennon speaks against the mandating of APMs in the current healthcare delivery environment.
49:00 The beauty of the natural progression of value-based care innovation at the physician-level.
50:30 Dr. Lennon reflects on the inability of fee-for-service to create sustainable population health models.
52:30 Drs. Lennon and Silverstein speak about controversies associated with Medicare Advantage upcoding and potential abuses in value-related plans.
55:30 Why don’t we shift the industry coverage of Medicare Advantage to the benefits and opportunities of the program?
57:30 The burdensome regulations that hinder those providers who are not the bad actors. (ex: the SNF 3-Day rule, home-based infusions)
60:00 Referencing recent report from Morning Consult, commissioned by Innovaccer onThe State and Science of Value-Based Care.
61:45 Parting thoughts from Drs. Lennon and Silverstein on the moral imperative of value transformation.
The Health Care Payment Learning & Action Network (HCP LAN or LAN) is an active group of public and private health care leaders dedicated to providing thought leadership, strategic direction, and ongoing support to accelerate our care system’s adoption of alternative payment models (APMs). The LAN mobilizes payers, providers, purchasers, patients, product manufacturers, policymakers, and others in a shared mission to lower care costs, improve patient experiences and outcomes, reduce the barriers to APM participation, and promote shared accountability.
Last month the LAN held their 2022 Summit, and this year’s event featured appearances by CMS and CMS Innovation Center leadership, the release of the 2022 APM Measurement Effort results, a discussion on the HEAT’s Social Risk Adjustment Guidance for APMs, and the announcement of the LAN’s 2030 APM Adoption Goals for Medicare, Medicaid, and commercial plans. Joining us this week in the Race to Value are LAN Executive Forum Co-Chairs, Dr. Judy Zerzan-Thul and Dr. Mark McClellan. They discuss the overall goal of the LAN and the LAN Summit is to collaborate and act on strategies that will accelerate the transition to innovative, patient-centered payment models by focusing on equity, access to high-quality and affordable care, engagement of patients, and reduced provider burden.
HCP-LAN Fall 2022 Summit: Summary
Visit the Institute for Advancing Health Value’s website.
- Download their recently released Intelligence Brief summarizing the 2022 LAN Summit.
Visit the LAN’s website:
- Learn more about 2020 & 2021 APM Measurement Efforts
- Consult the HEAT’s APM Design Guidance – Advancing Health Equity Through APMs
Episode Bookmarks:
01:30 The purpose of the Health Care Payment Learning & Action Network (HCP LAN)
03:00 Introduction to Dr. Mark McClellan and Dr. Judy Zerzan-Thul
05:45 Dr. Mark McClellan speaks to the impact of the pandemic on value-based health reforms
06:45 “Payment flexibilities are one of the unsung heroes in the pandemic when it comes to value transformation.”
07:15 How capitation enabled some to navigate the pandemic favorably, while others struggled with FFS revenue disruption, team-based care, and telehealth deployment.
08:45 CMS payment flexibilities will soon go away so prepare for continued focus on patient-longitudinal well-being and outcomes tracking.
09:45 The especially challenging times of high inflation and workforce resilience and how value transformation is a strategy for sustainability.
12:00 Dr. Zerzan-Thul speaks about the Accountable Care Commitment Curve and how that can guide organizations to advancements in Health Equity.
13:30 The LAN’s Health Equity Advisory Team (HEAT) and its recommendations for developing a Health Equity action plan.
14:30 Measuring equity outcomes through an enhanced data infrastructure and community partnerships.
15:45 Dr. McClellan speaks to how Social Risk Adjustment (SRA) can advance health equity through APMs (starting with ACO REACH)
17:30 The challenges of implicit biases in individual measures of social risk.
18:15 “Risk factors like food insecurity and transportation will eventually get more built in to our approach to health care.”
19:00 The additional considerations of community engagement, peer transformation, and other payment incentives to advance health equity.
20:30 The recent release of the APM Measurement Effort (survey data compiled the HCP LAN).
21:30 Dr. McClellan discusses the current status of 2022 APM adoption (see interactive graphic showing that nearly 20% of payments flowing through Category 3B-4 models.)
24:30 Dr. Zerzan-Thul comments on trajectory of APM adoption and current status of Medicaid transformation in population-based payment.
27:00 Dr. McClellan discusses the Accountable Care Commitment Curve more at length.
29:00 “You can’t get to a critical mass of value transformation in the U.S. healthcare system without multistakeholder alignment.”
30:00 Dr. Zerzan-Thul speaks to what state agencies like the Washington State Health Care Authority can do to move healthcare organizations along the Commitment Curve.
31:00 Examples of legislative tools in Washington State that are advancing value-based payment and collaboration.
33:00 Data and transparency – how do we measure progress in health equity and value transformation?
34:30 Dr. Zerzan-Thul speaks about the work LAN is doing with State Transformation Collaboratives (STCs) (see Summit video on State Transformation)
35:00 Primary care transformation and multi-payer alignment as the starting points to transform healthcare at the state-level.
36:00 The impact of the economic downturn and Medicaid transformation in states moving to value.
37:00 Dr. McClellan on the importance of state leaders (e.g. policymakers, employers) to reform healthcare.
38:30 The STC pilot states (Arkansas, Colorado, California, North Carolina) are working closely with CMS in reaching their value-based care goals.
39:30 Key directional alignment between CMS and states will reshape health policy at the federal level.
41:45 Dr. Zerzan-Thul discusses the importance of FQHCs as “safety net” providers and how they can transition to APMs.
42:45 Oregon, Colorado, and Washington are leading states in FQHC adoption of APMs.
43:30 Dr. McClellan on how Medicaid payment shifts in Washington State are bringing more affordable and accountable care to patients.
46:00 Dr. McClellan discusses the strategic importance of multi-payer alignment in the national movement to value-based care.
49:00 Reducing care variation and supporting more efficient processes in delivering care across disparate populations.
50:00 Dr. Zerzan-Thul on how multi-payer alignment of quality measures can lead state-level value transformation efforts.
51:00 “We are asking payers to align on paying primary care at a Level 4 level, and we have commitments from payers to do that.”
52:00 Data aggregation and exchange at the state-level.
52:30 Certifying advanced primary care at a centralized level as a means to direct payment transformation.
53:15 Engaging health plans in various states to adopt and scale APMs in the transition away from FFS.
55:00 How the LAN, in partnership with states, are engaging purchasers in the commercial market.
56:30 Dr. McClellan on how to get patients to understand “accountable care” or “value-based care” by delivering on our goals.
58:00 “Value-based care is not a privatization plot of Traditional Medicare.”
59:00 Paying for “health” can help with the reduction of chronic diseases.
59:30 The political pressures of disrupting the status quo in healthcare.
60:00 The importance of effective storytelling in value-based care success as a way to inform legislators.
61:30 Dr. Zerzan-Thul on how the U.S. is 4% of the world’s population but spends half of the $8T global spend on healthcare services.
62:30 How do we measure whether people are getting person-centered care? (We need patient-reported outcomes in addition to CAHPs.)
65:00 Dr. McClellan on the imbalances of healthcare worker supply and demand.
63:30 Capital investments in value-based care are going towards digital transformation and upskilling of the workforce.
65:30 “The biggest challenge in the movement to value-based care is the workforce.”
67:30 Dr. Zerzan-Thul speaks about the challenging demands of managing the workforce pipeline for behavioral health professionals.
68:00 The importance of team-based care (everyone) in guiding us to the health care that we want.
69:20 APMs and the work of the LAN is key to building a better workforce and improving health care!
Equitable and accessible care must ensure appropriate and optimal use of medications since nearly 70 percent of clinician visits involve drug therapies. However, each year there are an estimated 275,000 deaths and $528.4 billion wasted in the US due to suboptimal medication use through inaccurate prescribing, medication errors, adverse drug reactions, skipped doses, or treatment failures.
Given that most therapeutic options for the treatment of illness involve pharmaceutical interventions, we must find a way to maximize medication benefits and mitigate harm. That promise for a more patient-centered approach to optimize medication use can be found through Comprehensive Medication Management (CMM). The GTMRx Institute defines CMM as: “The standard of care that ensures each patient’s medications (whether they are prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended.”
Joining us this week on Race to Value are three amazing thought leaders who recently wrote a Health Affairs article on how CMM should be integrated within value-based care delivery:
- Katie Capps, is co-founder, executive director and board member of the Washington-based Get the Medications Right Institute (GTMRx) and founder and president of Health2 Resources, a national health care project management and consulting firm practicing in the Washington area for nearly 23 years. At GTMRx, Capps collaborates with fellow board members to develop and execute the Institute’s strategy, bringing together critical stakeholders to focus on appropriate use of medications and gene therapies.
- Michael Barr, MD, MBA, MACP, FRCP – Dr. Michael Barr is a mission-driven physician executive with 35+ years of clinical and leadership experience is founder and president of MEDIS, a health care consulting company which provides customized, client-driven services and support for health care organizations and the dedicated professionals who deliver care to people. In addition, he is the executive physician advisor at GTMRx.
- M. Shawn McFarland, Pharm.D., FCCP, BCACP — Dr. McFarland is the National Program Manager VA Clinical Pharmacy at Veterans Health Administration in Washington D.C. In the past, Dr. McFarland was responsible for the direction of clinical pharmacy services within the Tennessee Valley Health Care System.
In this episode, we discuss the role of CMM in value-based care, the importance of interprofessional collaboration, CMM implementation strategies, CMM use cases, HIT infrastructure requirements, pharmacoequity, and value-based payment reforms needed for CMM adoption growth and sustainability.
Episode Bookmarks:
01:30 Nearly 70 percent of clinician visits involve drug therapies; however, there are an estimated 275,000 deaths and $528.4 billion wasted due to suboptimal medication use.
04:00 Introduction to Dr. Michael Barr, M. Shawn McFarland, Pharm D., and Katie Capps (and their recent Health Article on CMM and VBC)
07:00 Katie defines Comprehensive Medication Management (CMM).
07:45 Dr. Barr further explains that CMM helps provide “better care for people” and the work GTMRx Institute is doing to bring much-needed attention to it.
09:00 Katie outlines the multitude of problems in care delivery associated with the inappropriate use of medications (e.g. polypharmacy issues, adverse events, high costs)
10:00 The important role of a clinical pharmacist working in close collaboration with physicians.
10:30 Shawn discusses the success of CMM in the Veterans Affairs system.
13:45 Shawn describes the confusion about the role of the pharmacist and how CMM can expand the profession.
15:00 The role of the pharmacist in interprofessional, team-based care and how CMM relates to winning teams in football.
16:45 “When we integrate a pharmacist on a care team to provide CMM, we provide the utmost benefit to patients and can win together by improving outcomes.”
17:30 CMM services have an estimated 12:1 return on investment when used for patients with chronic conditions. (Referencing Fairview Case Study)
18:45 Dr. Barr describes his prior experiences with team-based care with a clinical pharmacist.
20:00 Katie describes how a winning strategy for interprofessional, team-based care is to appropriately define roles.
21:45 USC School of Pharmacy study that shows 87% of patients receiving CMM reached their blood pressure targets within 45-days.
22:45 “Adding a clinical pharmacist to the interprofessional team makes sense from a clinical and economic perspective – and it is a more humane way to manage medication needs.”
25:30 Shawn outlines the three components of successful CMM implementation.
25:45 #1 Success Strategy: “Philosophy of Practice”
26:30 #2 Success Strategy: “Fidelity to the Practice Management components CMM”
28:00 CMM Practice Management Assessment Tool
28:40 #3 Success Strategy: “Well-Defined Patient Care Process”
30:30 Katie references the multitude of free CMM resources that are available through GTMRx (GTMRx Resource Page on Value-Based Care)
31:20 The confusion between CMM and MTM
32:00 Dr. Barr discusses the importance of trust in interprofessional, team-based care delivery and the need to make CMM broadly available.
33:00 Katie describes how trust brings about success in performance measurement and accountability.
35:00 Shawn provides an example of how the VA incorporates patient experience into the delivery of CMM services.
37:00 How the VA enhanced patient access – creating an additional 3 weeks of provider availability – by implementing CMM.
38:30 “CMM occurs over the journey of healthcare – not just in the 30-minute patient appointment.”
40:30 The extensive studies that show how pharmacist integration improves clinical outcomes.
41:00 How CMM decreases provider burnout and improves patient satisfaction.
42:45 Dr. Barr explains how clinical pharmacist integration can impact on CAHPs scores, HEDIS measure performance, and overall Medicare Advantage Stars Ratings.
44:15 Katie references the GTMRx Library of CMM Use Cases and further explains how Fairview Health received 12:1 ROI on CMM and lowered overall healthcare costs by 31.5%
46:00 The HealthPartners CMM Use Case showing 3.5 ROI with $1,268 PMPM healthcare cost reduction.
49:00 The Four Formative Pillars: Top Health IT Capabilities that will Improve Comprehensive Medication Management
49:30 Dr. Barr speaks to how CMM success is at the mercy of a sophisticated data infrastructure.
52:20 How important is Artificial Intelligence in CMM?
53:00 Katie on the importance of liberating actionable data at the point-of-care.
54:00 Identifying all drug therapy problems (not just those related to one medical condition).
54:45 Creating a care plan, that includes medication management, in collaboration with patients.
55:30 Shawn provides an example of how the VA creates automated dashboards for recommending patients to CMM.
58:00 Recent JACCP issue on pharmacoequity and how equitable medication use is paramount to eliminating health disparities.
59:00 Dr. Barr discusses the intersection of health equity and Comprehensive Medication Management.
60:30 The origin of the term “pharmacoequity” by Dr. Utibe Essien as a policy prescription for reducing health disparities.
61:00 Shawn discusses the integration of health equity within the VA system.
65:00 Katie on why a common definition for CMM is important for value-based payment policy reforms.
66:00 Shawn provides an in-depth explanation comparing CMM vs. MTM (Patient-focused process vs. medication-focused activity)
68:20 The Medicare Modernization Act was an early attempt to promote CMM, but it fell short.
69:00 Katie on why value-based payment needs to evolve to a point where care teams are directly reimbursed for CMM services.
70:20 “Value-based payment models are optimal for the provision and sustainability of CMM.”
72:00 Measuring the value of CMM with attributable patient outcomes measures and clinical information provided at the point-of-care.
72:30 Integrating pharmacogenomics into the CMM process to improve clinical decisionmaking.
74:00 Will the new vision for Medicare to advance accountable care and health equity by 2030 catalyze policy changes to support patient-centered CMM programs?
75:30 Focusing only on drug costs does not support access and appropriateness in medication use.
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