Bonus episode – The Race to Value Podcast™: Recent Episodes
Institute for Advancing Health Value
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.
A large wooden ship encased in glass sits prominently in the lobby of Humana’s Louisville headquarters. Its placement seems out of the ordinary, until you understand its symbolic purpose. The ship symbolizes the collaboration necessary from all of those focused on member/patient well-being. We must all row together to make progress and help those we serve live their healthiest lives. Physicians. Nurses. Health coaches. Pharmacists. Health plans. And many others. Collaboration and teamwork are critical to now and in the future of value-based care.
The annual Humana Value-based Care Report spotlights the progress value-based care physicians make in achieving better outcomes for their patients with Humana individual Medicare Advantage. It details four key areas—prevention, outcomes and utilization, patient-physician experience and costs and payments.
Humana shares these results annually to highlight how the company supports physicians in helping their patients achieve their best health. In this special episode, we are joined by Kate Goodrich, MD, MHS, the Chief Medical Officer for Humana. Dr. Goodrich discusses the annual Humana VBC report and strengthens the care for value-based care as the future of healthcare!
Episode Bookmarks:
01:30 Download the ninth annual Humana Value-Based Care Report
02:15 Introduction to Kate Goodrich, MD, MHS, is Chief Medical Officer for Humana
04:00 How a large wooden ship in the lobby of Humana’s Louisville headquarters symbolizes collaboration in Value-Based Care.
04:45 Collaboration within the care team. (“Financial incentives matter in optimizing the care of patients.”)
07:00 Collaboration within communities. (“It takes a village to take care of patients and their social determinants of health.”)
09:00 Collaboration at the national level across entities and within the federal government.
11:00 The Institute for Advancing Health Value as a leading example of national collaboration in VBC transformation.
13:30 Humana has over 74,000 primary care physicians in value-based relationships, caring for over 3 million Humana MA members.
14:30 How value-based Humana Medicare Advantage achieved better outcomes than FFS (e.g. hospitalizations, ED utilization, diabetic control).
16:15 “Control of blood sugar is a critical leading indicator of value-based care success.”
17:00 Avoiding low value care services that provide little or no clinical benefit (e.g. MRIs and CTs for routine low back pain).
18:00 Humana MA members receive 9.2% fewer low value services than those that are enrolled in fee-for-service.
19:00 Dr. Goodrich on the importance of VBC in addressing the healthcare cost problem in our country.
19:45 50% of Humana value-based programs earned shared savings (compared to original Medicare at 20.1%).
20:00 Humana value-based care physicians earn almost three times as much of Medicare’s fee schedule.
21:00 “If you’re a primary care physician, frankly, you will make more money in value-based care arrangements.”
22:30 Humana MA members average $500 in annual additional health plan benefits (e.g. home care, prescription delivery, healthy food cards) when associated with a value-based physician.
23:30 How screening for social barriers aligns with the provision of additional health plan benefits that improve care outcomes.
25:00 Examples of preventive care and CCM programs that close care gaps and increase Stars Ratings.
26:00 “Our outreach campaigns have closed more than 350,000 gaps in care per year. That’s paved the way for 10% of members who were previously non-compliant with the screening to identify a particular condition and then have the opportunity to seek more focused care.”
27:00 The success Humana is having in improving medication adherence in value-based arrangements.
28:00 “Non-adherence to medications is traditionally seen as a patient non-compliance issue. And I would argue that that it is rarely true that patients “don’t want to take their medications.”
31:00 Humana’s senior-focused primary care model as a holistic approach to healthcare that empowers patients.
33:00 Examples of Humana’s primary care model include CenterWell, Conviva, and alliance partnerships with Cano Health, Oak Street Health, and ChenMed.
35:00 Clinical Integration within senior-focused primary care teams (e.g. behavioral therapy, social work, pharmacy, nutritional counseling)
37:00 The positive correlation between value-based financial incentives and improved utilization outcomes.
37:30 Ambulatory-sensitive chronic conditions (e.g. CHF, COPD, asthma) that can be better managed in primary care setting.
39:00 Compared to traditional Medicare beneficiaries, Humana MA members had lower rates of hospital stays, emergency department visits, and 30 day readmissions (Referencing research article: “Comparison of Health Care Utilization by Medicare Advantage and Traditional Medicare Beneficiaries with Complex Care Needs”)
41:00 Dr. Goodrich discusses how Star Ratings are reflective of member experience (90.6% of Humana members are in contracts rated four star or above, and 66% are in contracts rated 4.5 stars or higher.)
43:00 How value-based care arrangements can address the plight of physician and nurse burnout.
45:00 Dr. Goodrich discusses Humana’s strategy to reinvest value-based savings in future innovation.
49:30 The future growth of Humana’s portfolio.
50:30 Continued investment in closing health equity gaps.
51:00 The importance of the annual Humana Value-Based Care Report – showing progress and sharing data of value-based success!
Disclaimer: The information provided in this podcast is purely for educational purposes and should not be interpreted as a recommendation for a specific treatment plan, medicinal plant, or course of action for medical treatment. None of the statements or ethnobotanical information in this episode have been evaluated by the Food and Drug Administration (FDA). The purpose of the information conveyed in this podcast is simply to explore the ancient healing practices of indigenous cultures. Please consult a professional if you are considering the use of plant-based medicines.
In many ways people have become disconnected, dislocated, and dislodged from their place in the world as a result of trauma. Trauma due to physical, emotional, and sexual abuse, neglect, household dysfunction, or just everyday unmanaged stress as an important social determinant of health. These traumas can actually change the chemical makeup of the brain and increase the risk for developing certain physical ailments, including digestive problems, diabetes, chronic pain, and heart disease. Unfortunately, the American healthcare system is not effective in addressing the root causes of the chronic issues we face at a psycho-emotional level. Western culture is now looking for alternative ways to stem the epidemic of anxiety, depression, and stress we see in the modern world. Is there an opportunity in health transformation to seek alternative and ancient sources of healing medicine that finds coherence between the mind and heart and the body and the spirit?
This week we are offering our listeners with a Bonus episode to discuss the healing potential of ayahuasca. Our guest is Kevin Johnson (also known by the Q’ero people of Peru as Puma Blanco). He is a shamanic healer who has become a popular public speaker, giving presentations on consciousness, shamanism, plant medicines and psychedelics. He’s been featured in several magazines and periodicals, and has appeared on many popular podcasts including; “Tangentially Speaking” with Christopher Ryan, “The Duncan Trussell Family Hour”, “The Warrior Poet” with Aubrey Marcus, “Not Just Paleo” with Evan Brand, “Fat Burning Man” with Abel James, and “The Truth Junkie Podcast” with Kevin Bates…just to name a few. This won’t be your typical Race to Value episode. Not only are we exploring the congruency between ayahuasca and healing and the parallels between shamanism and Western medicine, but we will also be learning about the Q’ero people of Peru who have a special relationship with the planet and an approach to energy balancing that maybe we could all learn from.
If you have an open mind and an open heart, you will find this conversation to be quite enlightening and informative as people around the world are retracing the ancient pathways of shamanism, the oldest spiritual practice of healing on the planet. So let’s now hear from Kevin Johnson, who is joining us for this special bonus episode of the Race to Value!
Episode Bookmarks:
01:30 Trauma as an overlooked social determinant of health that leads to chronic disease.
02:30 Introduction to Kevin (Puma Blanco) Johnson – a shamanic healer and popular public speaker on the topics of consciousness, shamanism, plant medicines, and psychedelics.
03:00 The healing potential of ayahuasca, parallels between shamanism and Western medicine, and the Q’ero people of Peru.
05:45 Referencing prior episode with Dr. Charles Nemeroff, the Co-Director for the Center for Psychedelic Research & Therapy.
06:00 Inspiration from Hippocrates: “The greatest medicine of all is teaching people how not to need it.” “Foolish the doctor who despises the knowledge acquired by the ancients.”
06:30 Ayahuasca is a very ancient medicine, with archaeological evidence for the consumption of ayahuasca going back at least a thousand years.
07:30 An overview of ayahuasca as a plant medicine and how it can provide healing, alleviate suffering, and enhance spirituality.
09:45 Is cultural appropriation of ayahuasca in the West necessarily a bad thing according to indigenous healers?
11:00 Celebrities like Prince Harry and Aaron Rodgers are touting the benefits of ayahuasca.
11:45 Dr. Rick Strassman was the first person in the U.S. to undertake human research with DMT (the psychoactive component of ayahuasca) and called it “The Spirit Molecule.”
12:45 Research shows that most ritualistic ayahuasca users have a shared experience with something that is deeply spiritual and mystical in nature.
13:30 “There is an intelligence behind the medicine that is directing the experience.”
14:00 “A hygienic process for psychology” — the universe has an energetic impact on human beings (positive and negative), and ayahuasca can help people purge negative energies.
15:30 Is there a potential physical healing component to ayahuasca?
16:45 The psychological healing of a ceremonial ayahuasca experience.
17:45 The “mother” can provide clarity, insight, discernment, and wisdom.
18:30 The ancient culture of the Q’ero – a Quechua-speaking community that live in one of the most remote places in the Peruvian Andes.
19:30 The Q’ero have kept their ancient teachings, secret codes and Andean cosmovision intact and alive for centuries.
20:00 The destructive nature of Western Culture that leads to domestication and conditioning that is incongruent with living as a spiritual being in Nature.
21:00 A pilgrimage to the Q’ero Nation in the Peruvian Andes and the ancient wisdom ofDon Gino Chaka-Runa.
22:00 How the Q’ero people experience happiness by living in close connection with the earth and their community.
22:45 The Mystical World of the Q’ero as “Masters of the Living Energy”
23:00 “The game is energy, and you play it through acquisition, maintenance, and investment.”
23:45 Living in reverence and harmony to the spirit of nature (Pachamama) and managing a system of living energy.
24:45 How Western culture creates physical, psychological, emotional, and spiritual sickness due to living incongruently with the natural world.
27:30 The ancient Q’ero healing principles and approach to energetics (the balance of “Sami and Hucha” – light refined energy vs. heavy dense energy).
30:00 The domestication of Western culture that leads to an atrophy of the energy system (“Poq’po”), resulting in trauma and sickness.
32:00 “We must always be in Ayni – living in sacred reciprocity.”
33:00 The Q’ero as “wisdom keepers” and their prophecy to restore ancient wisdom for the healing of the world.
33:45 The Ancient Prophecy of the Eagle and Condor and why the Q’ero moved to South America to preserve their wisdom.
36:30 A planetary realignment that shifted Earth into a new epoch and signaled the restoration of wisdom to people in the West (the people of the Eagle).
37:30 How the release of condors in California is emblematic of the fulfillment of a prophecy!
38:30 “Thoughts, words, and actions are energy. We need to control of the ways we are using our energy so that it benefits us, the people around us, and the world as a whole.”
39:45 The energetic concept of sympathetic resonance (like energy attracts like energy).
41:00 Changing the energy we address the world with to determine the outcomes of the situations in our lives.
42:00 How shamans engage with plant medicines on an energetic level to curate vibrational energies in ceremony that facilitate healing.
45:00 Are their similarities between Q’ero energy practices and other cultural practices of shamanism, mindfulness, yoga, meditation, etc.?
47:00 The optimism of ancient wisdom spreading in the West to provide more holistic healing.
48:30 Plant medicines are not a panacea. Ayahuasca is for everyone, but not everyone should drink ayahuasca or take other psychedelics.
49:30 Other ways to alter consciousness for profound transformation (e.g. floatation therapy, yoga, meditation)
50:30 A warning about bad acting shamans that can weaponize ayahuasca.
51:30 How ayahuasca tourism in South America has created a dangerous environment for healing with plant medicine.
52:30 The importance of music in ayahuasca ceremonies. Medicine songs known as Icaros can create waves of frequency to move blocked energies and repel negative energies.
53:30 “There is a lot of potential with plant medicines and psychedelics, but we must approach with wisdom and discernment. We must always keep safety in mind.”
54:00 Find out more about Kevin (Puma Blanco) and his work in the ancient practices of shamanism through Vida Brilliante.
55:00 Kevin (Puma Blanco) closes the podcast by singing an Ayahuasca Icarosthat calls the spirit of a tree.
Did you know that an estimated 80 million Americans currently lack access to dental care? As oral health is essential to the overall health and well-being of an individual, the high volume of those without access can have potentially devastating health consequences such as an increased risk of developing cardiovascular disease, respiratory disease, diabetes, and adverse pregnancy outcomes. Oral health can also influence eating habits and sleep patterns, which in turn can adversely impact both physical and mental health. And tragically, research shows that poor oral health is more common among individuals with lower income and educational attainment. And in value-based care, the growing number of emergency department visits for conditions related to poor oral health clearly shows the relationship between oral health and physical health. (There are approximately 1.8 million hospital ED visits annually for non-traumatic dental conditions which cost $3.4 billion to treat!)
We need to establish a more integrated, accessible, and equitable oral health landscape in our country. In this special episode, you will hear from a leader in the field of oral health who is working to reduce disparities in access to and quality of care. Kaz Rafia is the Chief Health Equity Officer for the CareQuest Institute for Oral Health — a leading national nonprofit focused on creating a more accessible, equitable, and integrated oral health system. At CareQuest, he leads strategic initiatives to advance access to integrated oral health care for ethnically and socially diverse communities. He is someone definitely leading us in this Race to Value!
If you like what you hear, you can also access a companion blog to this episode entitled, “Why Oral Health is Critical in a Value-Based System” brought to you by the Institute for Advancing Health Value and the CareQuest Institute for Oral Health!
Episode Bookmarks:
01:30 An estimated 80 million Americans currently lack access to dental care.
01:45 Lack of dental care can lead to devastating health consequences and an increased risk of developing chronic disease.
02:30 Introduction to Kaz Rafia and the CareQuest Institute for Oral Health
03:30 Companion blog to this episode: “Why Oral Health is Critical in a Value-Based System”
04:30 The link between oral health and community health.
06:30 Kaz speaks about the work that CareQuest is doing in building alliances to create a more accessible, equitable, and integrated oral health system.
07:00 “The inability of a person to receive oral health care is a clear threat to their overall health far beyond the mouth.”
07:30 Chronic periodontitis results in a higher risk of developing Alzheimer’s disease.
07:45 Oral care is a key intervention for reducing the risk of aspiration pneumonia.
08:00 The link between poor oral health and adverse birth outcomes.
08:30 CareQuest has developed MORE Care to integrate oral health capabilities into a person-centered primary care model.
09:30 Community Oral Health Transformation (COrHT) initiative and framework for safety net dental clinics to transform oral health care delivery.
11:00 Health disparities data showing that oral health varies across racial and socioeconomic lines.
12:00 Drivers for lack of access to dental care include geographic isolation, lack of transportation, and poverty.
13:00 How poor Medicaid reimbursement and “provider clustering” due to compensation economics contributes to oral health disparities.
14:00 Black adults are 68% more likely than white adults to have unmet dental care needs.
14:30 Dental coverage gaps contributing to oral health disparities in rural communities.
15:30 Alabama is now the only state currently lacking adult dental care benefits in Medicaid.
16:00 “The work done to evangelize value-based care models in dental care are reducing barriers to access nationally.”
17:30 World Health Organization recognition of dental care as a fundamental human right and their landmark global strategy on oral health.
18:30 Kaz discusses the importance of value-based care in oral health and how we define it.
19:00 Examples from Sweden and other countries on how to provide universal access to dental care.
19:45 The use of dental therapists to expand access to dental care and the recent legislative win for dental therapists to practice in Oregon.
22:00 The importance of clinical integration and how the “100 Million Mouths” campaign is integrating oral health into primary care.
23:30 Complications associated with lack of oral health, e.g. high blood pressure, diabetes, Alzheimer’s, poor pregnancy outcomes, behavioral health issues.
24:00 Research showing that medical-dental integration can enhance closure of medical care gaps.
24:30 Value-based opportunities to lower costs and improve clinical outcomes, e.g. checking Hemoglobin A1cs at dental appointments for diabetic patients.
25:30 Kaz discusses how the 100 Million Mouths campaign is integrating dental health into medical school curriculum.
26:45 There are 1.8 million hospital ED visits for non-traumatic dental conditions (NTDCs), which cost $3.4 billion to treat.
28:00 Kaz discusses the financial impact of non-traumatic dental conditions and how trends in ED utilization for NTDCs relate to social determinants of health.
29:00 Out-of-pocket expenditures are 40% of overall dental care spending and how this contributes to lack of optimal oral health outcomes.
30:30 “Accrued interest” that occurs when delays in front-end dental care treatment and prevention results in costly ED visits.
31:00 NTDC-related ED visits costs 3X what a regular dental visit would cost.
31:45 90% of NTDC-related visits are only given treatment for pain and then referred back to the dentist!
33:00 The mouth horror scene in Cast Away and how that relates to the millions of people facing access challenges to dental care!
33:30 6 million adults lost their dental insurance during the COVID-19 pandemic!
35:00 Kaz discusses the impact of the pandemic on dental care delivery and the potential for telehealth innovation in the long-term.
37:00 Teledentistry as a successful modality for triaging care needs to avoid unnecessary ED visits.
38:00 Investments to scale a value-based care infrastructure for oral health.
40:00 Kaz discusses the recent progress being made by CMS to include dental benefits coverage in the Medicare program.
42:00 “Oral health care is, in fact, health care.” – Kaz explains why preventive dental care coverage makes sense in value-based care transformation!
44:00 Anti-Racism in Dental Public Health: A Call to Action and the recent CareQuest collaboration to expand research in this area.
45:00 “Racism is a public health epidemic, and having difficult conversations is a key ingredient to change.”
46:30 “Being anti-racist is not a zero-sum game that takes away from anyone else. It is about the betterment of our society.”
49:00 Investing in Health Equity Innovation – how CareQuest Innovation Partners through a new initiative called SMILE Health will scale early-stage startups.
50:00 How do we effectively invest in health equity in a sustainable and meaningful way?
54:00 A recent CareQuest Institute survey revealed that more than half (51%) of oral health providers surveyed had never heard of APMs in dentistry.
55:30 Kaz on the importance of understanding the past to envision a more optimistic future for value-based care.
57:30 “The misnomer of dental insurance is that it seems more like a luxury than an absolute need and human right to ensure population health.”
59:00 nspiration from Michael Leavitt in the building of alliances to impact health inequities and low value care.
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