Medicare Advantage – The Race to Value Podcast™

The future of care is not confined by walls; it thrives in the heart of homes, where compassion meets innovation, and healing becomes a daily experience. Home-based primary care with full-risk Medicare Advantage is a transformative model that not only brings health care to the doorstep of our seniors but also places the responsibility for their well-being squarely in the hands of dedicated providers, creating a proactive and patient-centered approach to aging with dignity and comprehensive care. By making primary care easier to access for our nation’s seniors, we can deliver personalized care that meets their needs; help them stay healthy and feel better; and live well with existing conditions so they can prepare for what’s ahead.

This week we are joined by two executive leaders from WellBe Senior Medical — the largest and fastest growing independent home-based medical group in the country. WellBe is a global risk medical group that provides longitudinal geriatric care to underserved, frail, complex, and homebound Medicare Advantage beneficiaries. In this episode, we feature Dr. Jeffrey Kang, Chief Executive Officer and Mike Stuart, Chief Growth Officer from WellBe Senior Medical.

Dr. Kang is a geriatrician with extensive experience in global risk and primary care for frail, elderly, and disabled populations.  Mike Stuart has extensive experience in fostering partnerships with health plans, health systems, and provider groups and leads commercial strategy and partnership development for WellBe Senior Medical.  In this interview you will learn about the home-based care continuum, primary care innovation, mission-driven leadership, Medicare Advantage risk, and the future of value-based primary care.

Episode Bookmarks:

01:30 An overview of WellBe Senior Medical – a global risk primary care group providing longitudinal geriatric care in the home.

02:30 Introduction to Dr. Jeffrey Kang, WellBe CEO (formerly served as ChenMed President, Walgreens SVP, Cigna CMO, and CMS CMO).

03:00 Introduction to Mike Stuart, WellBe Chief Growth Officer (formerly served in executive leadership roles at Somatus and Evolent).

05:00 An overview of the home care continuum (e.g. acute, post-acute, custodial, longitudinal primary care, DME, home infusion).

08:00 How WellBe is helping patients navigate and coordinate the fragmentation of home care point solutions.

10:30 A mission to help senior patients “lead healthier meaningful lives by delivering the most complete care”.

11:30 Opportunities to make care in the home more multidisciplinary, personalized, and SDOH-responsive.

12:00 Proactive vs. Reactive Care (leveraging analytics and unique provider skillsets for population health).

13:30 The clinical persona of the “frail elderly” and why WellBe focuses on this target population.

14:30 “Everything done in a primary care office can actually be done at home.”

15:30 “Home-based primary care is the best thing to do. You get better outcomes and better patient satisfaction.”

15:45 Is it possible to deliver high quality primary care (like ChenMed or Oak Street) in the home setting?

16:30 Referencing Marcus Welby, M.D. as an example of an empathetic approach to delivering care in the home (see Season 1 Trailer)

17:00 Care Fragmentation Challenges – NEJM found that the average Medicare patient sees a median of two PCPs and five specialist physicians per year.

18:00 “Quality of Life” is more important than “Quantity of Life” (why empathy and compassion matter most in caring for frail seniors).

19:30 Patients define a good doctor by bedside manner and respect given.

20:30 How the economics of full global risk enable complete care models for seniors.

20:30 Scalable home-based primary care is a new approach in value-based care.

23:00 WellBe’s results (e.g. >50% neighborhood engagement, patient satisfaction is at 95%, and MLR improvement >40% in 3yrs).

23:30 The importance of reaching a 4 Star Rating in a Medicare Advantage plan.

24:45 Key Measures of success:  Patient Engagement, HEDIS, Medical Costs and MLR

25:45 Bringing health plan leaders on a ride-along to see high quality care in action.

26:00 Negotiating global risk deals with MA plans that offer favorable economics for both parties.

27:00 The starting HEDIS Stars score of a typical WellBe patient is 2.3-2.5 (polychronic, frail, high-risk).

27:45 “When you are at full global risk, it is in your interest to do care innovation.”

28:00 Innovation #1 = Access (“Primary care in the home needs to be both convenient and responsive.”)

29:00 How WellBe developed a mobile paramedic program to enhance responsiveness to emergent acute care needs.

30:00 Mobile paramedic program reduced emergency room visits by 33%!

31:00 Dr. Kang’s recent article in Health Affairs responding to concerns from Berwick and Gilfillan about Risk Adjustment in MA.

31:30 The CMS-HCC V28 changes to the Risk Adjustment model that begin the phasing in next year.

33:00 The evidence for Medicare Advantage being overpaid relative to FFS?

33:45 Eliminating disease-based risk adjustment is the wrong policy (e.g. need for fair payment for complex populations, avoidance of cherry picking healthy populations).

35:30 The case for HCC under-coding in Traditional Medicare (due to lack of incentives in FFS).

36:45 “The bulk of the problem with HCC coding is under-diagnosis in fee-for-service Medicare – not over-coding in MA.”

38:00 Modern Healthcare Best Places to Work 2023 – WellBe Senior Medical

38:30 WellBe Senior Medical providers see 4-5 patients per day allowing them to build trusting relationships.

39:30 A recent study from Elation Health and the AAFP confirms that VBC can ameliorate the suffering of the physician workforce!

40:30 The culture of WellBe that empowers workforce collaboration with a “patients first” mentality.

42:00 Examples of how risk-based economics improve patient care.

43:00 Creating a foundation of values to underpin a culture of collaboration is crucial before accepting risk!

43:30 A clinically-led culture vs. a financially-led culture (“If you take good care of the patients, the financials will follow in a value-based model.”)

45:00 A financially-led organization will focus almost exclusively on risk adjustment (as opposed to delivering patient-centered care).

45:30 “Most of our MLR improvement is from medical cost reduction, not HCC coding.”

46:45 Wellbe Senior Medical is now in 7 states caring for 107,000 MA patients (20% of them which are dual eligibles).

48:00 Proving the scalability of a home-based primary care model.

48:45 Expansion into rural areas.

49:45 Future growth plans.

50:00 Advantage in Scalability: (“When launching new markets, we could actually be up and running in 90-days – we don’t have the problem of bricks and mortar.”)

51:00 Disadvantage in Productivity: (ChenMed and Oak Street providers can see 20 patients a day in the office, while we are only seeing 4-5.”)

52:30 The ethno-geriatric imperative (one-third of older Americans are projected to be from one of the minority populations by mid-century).

54:00 Dr. Kang discusses how the Chinese cultural significance of taking care of elders informs his leadership at WellBe.

54:45 Healthcare disparities are driven by inadequate access to care.

56:00 An example of how WellBe provides linguistically appropriate and culturally competent care in Chicago.

57:00 The number of Americans aged 65 and older will more than doubling over the next 40 years — reaching 80 million in 2040.

58:00 Optimism for the value-based future of caring for seniors – does hope mostly reside only with Medicare Advantage and ACO REACH?

61:00 Multi-payer alignment in value-based care as an imperative to a hopeful future.

Connecting the health and wellbeing of patients of patients directly to the bottom line isn’t just good business; it is a visionary approach that shows how healthier outcomes can actually drive healthier profitability. Continued success in demonstrating the correlation between clinical and financial outcomes will be a catalyst for generating societal wellbeing that paves the way for others to adopt value-based care.  And in doing so, we create a more sustainable and effective healthcare ecosystem. In this Race to Value, the true race isn’t about speed; it is about the journey to improved outcomes. Strategic and transformational partnerships guided by an enabling vision to improve population health will ultimately create a healthcare system that we can be proud of.

In this episode, you will hear from Kyle Wailes, the Chief Executive Officer and Board Member of value-based care company, Wellvana.  Kyle Wailes is someone on a mission to demonstrate how fully-capitated models in primary care, empowered by the right partnerships to create enablement, will ultimately drive patient behavior change.  Under his leadership, Wellvana is an industry-leading example of a company that is connecting the healthy outcomes of patients directly to healthier profitability. With the tools, technologies, analytics, and resources for healthcare providers to successfully and seamlessly transition to value-based care, Wellvana is getting outstanding results and growing at an exponential rate for such a young company.  This is highlighted by the recent announcement of their partnership with AdventHealth to revolutionize primary care in the state of Florida.  Don’t miss this important interview to learn more about VBC enablement, high-touch primary care and clinical integration, the power of storytelling, patient behavior change, lifestyle medicine, and the current state of private equity investment in healthcare!

Episode Bookmarks:

01:30 Connecting healthy outcomes of patients to healthier profitability.  (A High-Touch Approach for High Performers)

02:00 Introduction to Kyle Wailes, Chief Executive Officer and Board Member at Wellvana.

04:00 Big Announcement — AdventHealth partners with Wellvana to transition its Florida primary care network to VBC

05:00 Wellvana is the first value-based care enablement organization in the country to partner with a multi-state/national health system.

06:00 Kyle provides more details on how Wellvana’s recently announced partnership will impact the delivery of healthcare in Florida.

06:30 “Building clinically integrated primary care networks across the country requires flexibility.”

07:00 Expanding primary care impact through interdisciplinary roles (e.g. case management, care coordination, pharmacy integration, social work, coding)

07:45 Health systems across the country are extremely distressed with expenses growing 2X as fast as Medicare payments.

09:30 “The pandemic has been an accelerant overall to drive the adoption of value-based care.”

09:45 The opportunity to reposition primary care in the health system setting, taking it from loss leader to profit center, as a strategic cornerstone for transformation.

10:00 A health system focused only on fee-for-service can lose up to $200-300K per employed PCP.

10:30 “Clinically integrated primary care networks can drive better clinical outcomes, but they can also drive profit and growth as well.”

11:00 Flexibility in growing a PCP network through either an employed or affiliated model.

11:30 Kyle’s personal journey as a professional athlete, student of neuroscience, and value-based healthcare executive.

12:30 “The Story of the Chinese Farmer” – a parable that illustrates the idea that events that initially seem bad or good can lead to unexpected outcomes.

14:00 Kyle provides perspective on the highs and lows of life and how that translates to theculture at Wellvana.

15:00 Lessons learned from playing competitive sports (discipline, hard work, and preparation in winning…while also overcoming losses).

16:00 Wellvana has raised $140 million in capital since 2021 and is now in 22 states, reaching more than 100K lives through multiple payers, Medicare Advantage and ACO REACH.

17:30 Building large high-touch primary care networks at scale requires behavior change.

18:15 Aligning a high-quality specialty network with tech-enabled primary care to achieve appropriate procedural utilization and lower costs.

19:00 Merging High-Touch with High-Tech (“Technology as a standalone solution doesn’t work well in healthcare today. You have to wrap services around it to drive behavior change.”)

19:45 Building Capabilities to Improve Care for High-Risk Patients (“The ability to transition into fully-capitated risk is impossible for a doctor to do on their own.”)

20:30 The connection between improved patient outcomes and higher profitability — a patient success story showing how high-touch care management reduced avoidable ED utilization.

22:00 The power of effective storytelling in value-based care transformation.

24:00 Kyle discusses how Wellvana utilizes storytelling to revitalize care teams and provider partners in creating positive change.

26:00 The Challenging Politics of Value-Based Care (differing ideologies, debates about government involvement, conflicting interests and lobbyists, uncertainty about implementation, economic concerns, partisan politics).

27:30 Kyle shares insights from his involvement in advocating for value-based care on Capitol Hill.

28:30 The evidence that fully-capitated models work despite low market penetration in Medicare (e.g. MA <10% full-risk, ACO REACH).

29:00 How Wellvana educates legislators on the importance of frontloading savings payouts and provider aggregation in networks to drive success in fully-capitated risk.

30:00 Advocacy in patient communities is just as important as political advocacy.

31:00 How Wellvana engages and educates patients on the purpose of value-based care and care planning.

32:00 “To win long-term in this industry, you’re going to have manage medical spend more effectively. We do this by engaging patients in way that can drive behavior change.”

33:30 Wellvana co-founder, Charlie Martin:  “Building a Sustainable Economic Model for Lifestyle Medicine”

34:45 Kyle discusses the importance of Lifestyle Medicine in creating a holistic, patient-centered wellness model.

35:45 Wellvana is conducting a clinical trial study on LM with the goal of applying broader findings that drive behavior change at scale.

37:30 Are investors placing more bets on value-based care enablement?

38:30     The runway for value-based care companies in the current investment landscape and why PCPs relationships are so critical to success.

39:30 Digital health and AI solutions will support primary care value transformation.

40:00 Nashville as the epicenter of healthcare investment.

41:00 ACO REACH as an inflection point for adoption of fully-capitated risk in the primary care setting?

42:00 How fully-capitated models will strengthen the connection between improved SDOH interventions and Health Equity outcomes.

43:45 Kyle discusses the future of Wellvana in terms of continued growth and sustained high performance.

46:00 “Success in value-based care is not about the speed; it is about overall outcomes and finding the right partners to take risk.”

We are on an enlightening journey to transform American healthcare in the race to value. Medicare Advantage increasingly stands out as a superior vehicle for value transformation due to its ability to catalyze care delivery innovation through full-risk capitation. By promoting coordinated care and integration among healthcare providers, MA plans foster a patient-centric approach that improves overall care quality and health equity. Additionally, these plans prioritize preventive care and wellness initiatives and enable early identification and management of chronic disease, ultimately reducing healthcare costs. By incentivizing providers to prioritize outcomes over volume, Medicare Advantage is our path forward to a uniquely American healthcare system that we can be proud of.

Joining us this week on the podcast is Don Crane, former CEO of America’s Physicians Groups. In this episode, he shares his valuable insights and expertise on Medicare Advantage and how it will shape our future in healthcare transformation. Join us as we explore the challenges and opportunities that lie ahead for Medicare Advantage and discuss the potential impact on the healthcare landscape!

Episode Bookmarks:

01:30 Introduction to Don Crane (Former President and CEO of APG) and the potential for Medicare Advantage to transform American healthcare.

03:30 Support Race to Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts.

04:00 Don Crane joins the Race to Value again as returning guest. (Check out his prior episode on Primary Care Transformation!)

05:00 The explosive growth of MA and the evidence showing that MA plans deliver better economic and clinical outcomes.

06:30 How a capitation in Medicare Advantage enables population health outcomes through effective SDOH interventions.

08:00 The criticisms of Medicare Advantage from notable thought leaders Richard Gilfillan and Don Berwick.

09:30 Protection of the Medicare Trust Fund is the common point of agreement between MA proponents and opponents.

10:00 Don addresses the criticisms of risk adjustment gaming and the program’s overall spend.

10:45 Is it necessarily a bad thing if MA costs more than Traditional Medicare if it provides better care outcomes and supplemental benefits?

11:30 “Spending more on Medicare Advantage makes all the sense in the world to me if it provides better outcomes and value for seniors.”

12:00 The perspective from seniors enrolled in Medicare Advantage on the appropriateness of spending for supplemental benefits.

12:30 “The astronomical growth of Medicare Advantage should be celebrated.”

13:00 The V28 HCC changes to the Risk Adjustment model for payment year 2024 will decrease the number of codes by more than 2,000 from the HCC model.

14:00 The adverse impacts of risk adjustment coding changes will increase administrative complexity and hurt seniors by reducing MA funding to the tune of $10B.

15:45 The need to evaluate both Traditional Medicare and MA to determine the best path forward.

16:30 Risk adjustment is grounded on the premise of fairness to both the payer and provider and should prevent both over- and under-payment.

17:30 “Risk adjustment is such an important ingredient in capitated payment models and provides a business case for addressing inequities in underserved communities.”

18:30 Concerns about the elimination of risk adjustment and how that will adversely affect sicker patent populations through “cherry picking” during MA enrollment.

19:30 Don compares the bad actors in MA who perform upcoding to the overpayments and overutilization that occurs in Traditional Medicare.

20:00 Is the potential for upcoding exaggerated by detractors of Medicare Advantage?

20:30 Eliminated risk adjustment in Medicare Advantage is an example of throwing out the baby with the bathwater.

21:00 How Star Ratings work in Medicare Advantage to unlock bonuses and rebates when improving care quality.

23:00 Don discusses the importance of performance quality measurement and why Stars Rating program is so effective.

25:00 Overall MA spending is 2-5% higher than Traditional Medicare –does that additional investment spawn care delivery innovation and improved patient outcomes?

26:30 Sachin Jain’s Op-Ed discussing how MA plans perform better on several key quality measures, with annual beneficiary costs that are about 40% lower than traditional Medicare.

28:00 The flawed thinking in comparing overall spending between Traditional Medicare and MA programs and why MA is the better vehicle for value-based care.

29:00 The positive impact that the provision of MA Supplemental benefits has on social determinants of health.

30:00 The new science of studying the ROI of SDOH investments to improve overall population health.

31:00 The silver lining of the MA debate in creating the opportunity to save American healthcare.

32:30 We are moving in the direction of 70-80% MA enrollment over the next decade, whereby making it an attractive vehicle for healthcare reform.

34:00 The blunt force instrument of Medicare fee schedule cuts and the need for a different tool in the health policy toolbox.

35:30 The double whammy of Medicare FFS spending cuts and the V28 Coding policy changes on the value movement.

37:00 Transitioning Risk Adjustment from Version 24 to Version 28 – how code eliminations impact Medicare Advantage?

38:45 MA Risk Adjustment coding changes will ultimately inure to the detriment of seniors, especially those in underserved populations.

40:00 The glacial pace of value transformation coupled with depletion of the Medicare Trust Fund is causing further FFS cuts to the Medicare Fee Schedule.

41:00 The need for the entire nation to rally behind value-based care to bring scale to the movement! (reimbursement cuts are not the long-term answer)

43:00 The “Meaningful Use” program as a perfect example of how “carrots and sticks” can scale the value movement.

45:00 The critical intersection between private equity capital investment and Medicare Advantage.

47:00 The advantages and disadvantages of capitalization and profit incentives from PE and VC investment communities.

50:00 The unshakable presence of health plans in the value-based care ecosystem.

51:00 Advocating for a mandate for health plans to offer capitation and why “Medicare For All” is not a realistic option.

52:00 Getting over the knee jerk hatred of health plans and instead turn them into a vehicle for value transformation.

55:00 A vision for the future of Medicare Advantage and as a moonshot opportunity to create a healthcare system we can be proud of.

56:45 The universal consensus that value-based care models are the way to go (and why we fail to adopt them at scale!)

58:00 Acceleration of capitation is our only hope.

59:00 Can Medicare Advantage transformation catalyze the attainment of the Quintuple Aim?

63:00 The problem of physician burnout and how it can be ameliorated by a value-based payment model.

64:00 The need for AI and scribing support to eliminate the burdens of EHR workflow.

64:30 How advanced Primary care models are more effectively in addressing societal challenges with chronic disease.

68:00 Parting thoughts of optimism for a brighter future in value-based care.

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!

When you hear about value-based care, do you get tired of hearing about concepts without tangible best practices?  Do you ever wish you could just acquire insights from a leader who navigated a successful value journey?  If you want to learn from one of the best in the “value game”, look no further than Dr. Bill Wulf, the CEO of Central Ohio Primary Care (COPC). Dr. Wulf is a respected leader in the value movement and leads the largest physician-owned primary care group in the United States.  During his leadership tenure, COPC has grown to over 480 physicians and 83 locations in central Ohio. The growth of the practice has empowered a successful value journey, with COPC caring for 75,000 senior patients in full-risk arrangements with Medicare Advantage and ACO REACH in partnership with Agilon Health (and the current move to full-risk in commercial plans with employers in partnership with Vera Whole Health).

Dr. Wulf describes a value journey that has been over two decades in the making.  It started with a merger in the late 90’s to create a fully-integrated primary care practice platform. And then in 2010, a Patient-Centered Medical Home (PCMH) transformation led to unprecedented success in full-risk Medicare Advantage.  COPC has built upon their MA success to now partner with large employers in full-risk programs, and they are also one of the new participants in the ACO REACH program. In this interview, Dr. Wulf goes into great depth on the care delivery innovations that were made possible by prospective payment and capital investment. He discusses hospitalist and ER care coordination programs, home-based care delivery, after-hours primary care access, telehealth, onsite clinics at employer locations, and the importance of data-driven insights from a unified EHR. You will also hear about how COPC has benefited from successful partnerships to build an even more effective infrastructure for population health outcomes. Most importantly, you will hear how COPC playing the “value game” helps their independent physicians take better care of patients!

Episode Bookmarks:

03:30 The origin story of Central Ohio Primary Care (COPC) – the nation’s largest independent primary care practice that is leading in VBC

05:30 Dr. Wulf describes how a practice merger in the late 90’s led a successful hospitalist program, contracting strategy, and ancillary services model

07:00 Post-merger growth of practice because of better contracting rates and ancillary services revenue

07:30 “Our growth in the last 10 years has been a result of us playing the “value game” in helping physicians take better care of patients.”

08:00 This year COPC is integrating 3 practices (30 physicians) at a time when there aren’t as many independent PCPs available.

09:00 COPC’s commitment to physician independence, where physicians have the freedom to care for their patients without interference.

09:30 Beginning the value journey through the decision to transform into a Patient Centered Medical Home (PCMH)

11:00 How physician independence leads to freedom to make data-driven referrals that improve population health outcomes.

12:00 A unified Electronic Health Record (EHR) led to the identification of the “best” doctors in the practice.

13:00 “The best physicians in the practice were not the busiest ones…but these physicians (pre-value journey) were making the least income.”

13:45 “Our best physicians were creating value for the payer, employer, and the government, but they were not recognized for value in a FFS world.”

14:30 Dr. Wulf describes how Level 3 PCMH recognition led to value creation (“a stepping stone”)

16:00 PMPM payments from commercial and MA plans led to programs that improved outcomes with high-risk patients.

16:30 COPC’s Hospitalist Program (100 physicians) and ER Care Coordination Program

17:00 Nursing care coordination that leads to effective post-discharge planning and transitions of care from the hospital.

17:30 Home visits to patients from nurses and social workers that prevent a hospital readmission.

18:30 COPC’s VBP Portfolio Progression that shifted from FFS to shared savings arrangements and then risk-based, prospective payments.

20:00 COPC has 75,000 senior patients in a full-risk arrangement through Medicare Advantage and ACO REACH.

20:45 Deciding to focus on Medicare Advantage early on (instead of becoming a MSSP ACO) by leveraging PCMH relationships in local market

21:30 The recognition that partnership was needed to advance practice to full-risk Medicare Advantage

22:30 Dr. Wulf explains how COPC chose Agilon Health as a partner to support its value journey in MA.

23:30 Commercial prepayments now also carry a risk component.

24:00 20-50% of COPC’s physician compensation is tied to value in some way.

24:45 Strategic partnership with advanced primary care provider Vera Whole Healthwhich recently merged with healthcare data company Castlight Health

26:00 Dr. Wulf explains COPC’s disruption-focused strategy in the large dysfunctional, self-insured employer healthcare space.

27:15 “Company CEOs don’t buy health; they buy insurance.  By partnering with an employer to impact TCOC spend, our practice can change the dynamic.”

28:00 Providing employers with onsite health clinics, health coaching, behavioral health services, and after-hours access to care.

29:00 Agilon Health has grown to over 250k Medicare Advantage members and over 90k attributed Direct Contracting beneficiaries (referencing Steve Sell podcast)

31:00 Dr. Wulf explains how partnership with Agilon’s technology, process standardization, and capital investment drives scale in global risk capitation models in Medicare Advantage.

32:30 “The challenge with CMMI value-based programs is that they are not long enough to recognize full value.”

32:45 Leveraging risk stratification to drive care delivery innovation for chronically ill, high need seniors.

33:45 Contracting expertise and passion are key ingredients to COPC’s partnership with agilon health.

34:45 Lower Hospital Admissions: 156 Admits per 1,000 (average Medicare ADK rate is 300+)

35:50 Lower Hospital Readmissions: 10-11% (average Medicare readmit rate is 18-19%)

35:00 “Because we are investing in the outcomes, we can provide a level of care that few can.”

36:00 COPC’s participation in the Comprehensive Primary Care Plus (CPC+) Advanced APM in the traditional Medicare program.

37:45 CPC+ prepayments (just like earlier experience with MA) led to investment in programs that led to better patient outcomes.

38:00 Dr. Wulf describes how the ER Care Coordination program allowed practice to send 400 patients home (instead of getting admitted).

39:00 Only 1 in 7 patients surveyed had attempted to call their PCP before going to ERà this led to nurses answering phones after hours!

40:00 Fall Risk Prevention and Smoking Cessation programs started with CPC+ funds.

41:00 COPC is now in the full-risk ACO REACH program in partnership with Agilon.

42:00 Starting with the ACO REACH program, CMS plans to be embed health equity into all payment models, with more focus on improving health outcomes in underserved populations.

43:30 COVID-19 brought health inequities to the forefront, and (finally) the new ACO REACH program has the potential to address it.

45:00 >40% of COPC clinics are located in underserved areas

45:15 “CMMI is taking us in the right direction to address health inequities through ACO REACH.”

46:00 COPC has been successful in expanding its integrated care network through skilled nursing, end of life, and 24/7 care to continue the population health journey.

47:30 How clinical integration can improve patient experience, eliminate care fragmentation, enhance information sharing, and ultimately improve patient outcomes.

48:45 Partnership with Leading Reach to digitize referrals and improve specialty referral management.

49:00 “We need to integrate specialists into value. Healthcare waste leads to unnecessary patient suffering.”

50:00 Dr. Wulf provides an example of how COPC used data to profile specialists by quality performance.

50:30 Partnerships to improve care in MSK and Oncology care.

51:00 COPC rapidly created and implemented a telemedicine program — within 1 week — during the pandemic.

53:30 The failure of HealthSpot and how COPC learned that patients are amenable to telehealth.

55:00 In primary care, telehealth is best utilized in a follow-up visit for a medication change.

56:00 “Telehealth, outside of a patient relationship and a longitudinal health record, is a low-level of care.”

57:30 Telehealth will continue to grow.  COPC is expecting 10-15% utilization in the long-term.

59:30 Dr. Wulf provides his parting thoughts on the movement to value-based care.

60:30 “If we just focused on waste, we could transform healthcare.”

Many roads will bring us to health value, but some roads will get us there faster than others. As we reimagine our nation’s healthcare system, we must build alternative avenues to value beyond the conventional fee-for-service approaches to transformation. In building a superhighway that fully unleashes the power of independent and accountable physician groups, we will produce faster and better results.

Joining us this week on the Race to Value is Susan Dentzer, the President and Chief Executive Officer of America’s Physician Groups (APG), the organization of more than 335 physician practices that provide patient-centered, coordinated, and integrated care for patients while being accountable for cost and quality.  APG members provide care to nearly 90 million patients nationwide and are leading this nation’s superhighway in the race to value.

In this podcast episode, we discuss advanced primary care transformation, restructuring of payment models to reach scalability and impact, health policy reforms, PCP employment trends, the M&A landscape in provider consolidation, Medicare Advantage, and the power of tech-enabled asset-light care delivery.

Episode Bookmarks:

01:30 Introduction to Susan Dentzer, President and Chief Executive Officer of America’s Physician Groups (APG)

04:30 More than 60% of health care payments in 2020 included some form of quality and value component

05:30 Despite traction, moving to value at a glacial pace (reference recent surveys fromMGMA and HCP-LAN)

06:30 Susan discusses the entrenchment of FFS and how difficult it is to change the payment edifice in U.S. healthcare

09:00 Overcoming the extraordinary backlash and resistance to realigning payment incentives in American healthcare

12:00 How APG is approaching the national transition to value

13:30 The need for advanced primary care in helping CMS achieving its 2030 goal to drive accountable care

14:45 The systematic undervaluing of primary care and overemphasis on hospitalizations

16:00 How the payment structure was hijacked by proceduralists and specialty care

16:30 Clinton era health policy reforms that attempted to restructure Medicare payments to primary care

17:30 Where would we have been if we tackled primary care reimbursement and workforce challenges in the 1990’s?

18:30 Limited progress in voluntary innovation models to advance primary care effectiveness (e.g. PCMH, team-based care)

19:30 How the NHS in England created state-of-the-art primary care through 24/7 access

20:45 The private sector stepping up to modernize care delivery access and infrastructure where public policy failed

21:30 Investment in primary and secondary prevention to address chronic disease

22:00 Transitioning from a cottage industry to a well-funded, risk-based primary care strategy to improve population health

24:00 PCP employment by hospitals often not an driver of value-based care due to referral maximization objectives

24:30 Independent PCPs will need to find investment partners to advance risk-based transformation

24:45 Susan discusses the success of Central Ohio Primary Care’s partnership with agilon health

29:00 Medicare Trust Fund solvency will be depleted by 2026, but APM adoption could help avoid this fate.

30:30 “Many roads can bring you to value, but some roads will get you there faster than others.”

31:00 MACRA legislation created MIPS and APMs using the current fee-for-service chassis

31:45 The importance of the 5% bonus/incentive payments to QPP participants that are a part of Advanced APM models

32:30 Hospitals pocketing APM incentive payments for employed providers will not accelerate path to value.

32:45 Results comparison between physician-led and hospital-led ACOs

34:00 Susan explains why America’s physicians are the superhighway to Value Transformation

36:00 Capitation within the ACO REACH model as a continuation of full-risk success in Medicare Advantage

38:00 “Alternative avenues to value – beyond the conventional FFS approaches to transformation — will produce faster and better results.”

39:00 The ACO REACH Coalition

40:00 How instituting primary care capitation to the MSSP will improve patient care outcomes

42:45 “We’re not going to get there through the current crop of ACOs. You need capitation in the MSSP, as well as the new ACO REACH model.”

43:30 Extending the CMS 2030 Goal to Medicare Advantage by driving MA patients to accountable care relationships

44:30 Plan turnover in Medicare Advantage does not support accountable care.

45:30 “Accountable care means very strong relationships at the primary care-level.”

48:00 Susan discusses potential reforms that will motivate MA plans to push budget-based prospective payment downstream to the physician group level.

50:00 Referencing recent JAMA article by Ezekiel Emmanuel that concludes MA produces better spending results than MSSP

51:30 “Medicare Advantage has been at the vanguard to the transition to value, but it can do even better.”

53:00 Recent M&A Activity in value-based care (e.g. CVS Health and Signify Health, Amazon and One Medical, Walgreens partnership with VillageMD)

54:30 “The future is already here – it’s just not very evenly distributed.” – William Gibson

55:30 Susan explains how Walmart is shaking up healthcare

57:45 How Iora Health will be an asset to Amazon as it leverages its investment in One Medical and why Amazon Care is closing.

59:00 Physician perspectives on the impact Amazon will make in healthcare transformation.

60:30 Referencing Susan’s book “Health Care Without Walls: A Roadmap for Reinventing U.S. Health Care” on digital transformation

61:30 Susan speaks about the progression to tech-enabled, asset-light care delivery

63:00 Distributed care and “Hospital at Home” models

64:30 Applying the Airbnb model to capitalize on unused capacity in patient homes to deliver care

Primary Care in the United States is flawed, especially for our most complex patients in the Medicare program.  We have built this incredibly expensive primary care model around a fee-for-service system that is incredibly fragmented and uncoordinated.  There is now a need for a new model – one that yields a much better experience for patients and physicians.  We now stand at the threshold a great dawning. An era is ending, and we are at the core of creation in reimagining a more idealized, value-based model for primary care – one that untaps a massive reservoir of healing capacity. This vision for “A New Primary Care Model” will transform community health for our most clinically complex and vulnerable populations.  And it all starts with payment model innovation which, in turn, spawns care delivery innovation. Although we are in early days of full-risk Medicare Advantage and global capitation models in Medicare, there are leading indicators that show promise for the future of health. What exactly does a reimagined primary care model look like and how can it scale?  Look no further than agilon health – a company that partners with independent primary care practices that are leaders in their markets and helps them transition to value-based care success in the Medicare program.

On the Race to Value this week, we are joined by Steve Sell, the Chief Executive Officer and a member of the board at agilon health.  Steve leads agilon health as an experienced, mission-based CEO known for transforming organizations through partnerships, product innovations and talented, collaborative teams. With over 25 years of experience in value-based care in the health plan environment, Steve Sell is building a new model of primary care for the future. Under Steve’s leadership and guidance, agilon health is transforming health care delivery through a technology enabled, full risk value-based care model that places the primary-care physician as the quarterback of patient care. And they are doing this at scale, in geographies that have operated in a fee-for-service environment. If you are want to know more about how we can transform primary care at scale, this week’s podcast episode is a must-listen!

Episode Bookmarks:

01:30 Introduction to Steve Sell and agilon health

04:00 agilon’s growth to over 250k Medicare Advantage members and over 90k attributed Direct Contracting beneficiaries

06:30 “Primary Care in this country is really flawed. It’s been built around a FFS system that is incredibly fragmented and uncoordinated.”

07:00 The vision for “A New Primary Care Model” to transform community health that is empowered by payment model and care delivery innovation

08:00 Steve discusses the rapid growth of agilon health since its founding in 2016 (1% of all PCPs in the country, 23 communities in 12 states) and how PCP trust is built over time

09:00 Partnering with physicians to support scale and alignment in markets that have been historically dominated by FFS

09:45 “We believe that full-risk, value-based care is the best way to organize an entire community. PCPs can then move to the top of the overall delivery of care.”

10:15 The Speed of Transformation — agilon’s intensive 12-month implementation period

10:45 Win/Win/Win (Patients, Doctors, Communities) – transformed health outcomes, satisfied primary care providers, high industry-leading Net Promoter Scores

12:00 The consumer-centric innovation opportunity in fully-delegated, capitated Medicare Advantage plans

13:30 How changing demographics and an aging population fuels Medicare Advantage Growth

14:00 The economic challenges of a shifting payer mix in primary care, i.e. less concentration of commercial business when a population ages

14:45 “The reform of payment models are the key to starts the process of transformation in primary care practices.”

15:00 The early days of full-risk MA and global capitation models in Medicare as an indicator for future success

16:00 Recent study showing the association of full-risk value-based care and improved acute care utilization outcomes (e.g. 5-8% reduction in hospitalizations, 11-13% in ER visits per 1000)

18:00 Steve discusses agilon’s medical margin experience in impacting client success and primary care reinvestment

18:45 “This year, as a result of driving positive improvements in medical margin, agilon will reinvest over $100M into primary care in our communities.”

19:30 Creating a “flywheel effect” by capitalizing on the waste in the healthcare delivery system

20:00 Reestablishing a primary care visit cadence (i.e. frequency and regularity of visits) for the most complex patients

20:30 PCP visit within 48 hours of being discharged can reduce hospital readmission rates by >20%

21:00 The importance of medication adherence in high-touch, chronic care management

22:00 Amazon’s acquisition of One Medical for $3.9B — how will this impact the value-based, primary care landscape?

24:00 “There is need for a new primary care model – one that yields a much better experience for patients and physicians than what we’ve seen historically.”

25:00 Universal recognition of the broken nature of primary care as a driver of capital investment

26:00 Steve differentiates agilon’s primary care model with what we may see from Amazon Care/One Medical model

27:30 “The Amazon decision on One Medical is the latest indicator that a number of competitors have identified primary care as a place to invest.”

29:00 The scarcity of primary care physicians (only 200K nationwide): “We must treat them well.  Competition is a good thing.”

30:00 PCP Shortage: only 20% of young doctors are going into primary care, and the percentage of PCPs in the physician workforce has fallen to 32%

31:45 The need to slow the attrition rate of primary care doctors leaving the profession (and how value-based primary care can make this happen!)

34:00 “My dream is that we are going to look like the rest of the world, where adult primary care becomes one of the top 5 medical specialties in the next 5-10 years.”

34:30 Steve discusses the significance of primary care physician compensation models in realigning incentives to “do the right things”

36:30 “The elegance and simplicity of our compensation model is that it aligns with better outcomes for patients, and that allows our physicians to win.”

38:00 The agilon vision “to transform the future of health care in 100+ communities across the country by empowering patient-physician relationships.”

40:00 Driving success through scalability and how that enables agilon’s mission and vision

41:00 How a scalable partnership model and VBC support platform integrates with local health care markets to achieve success

45:00 Steve discusses the impact of the COVID-19 on the value movement and how it will reshape the primary care landscape

46:00 How telehealth innovation and amplified access further strengthened patient-provider relationships during the pandemic (with net promoter scores actually increasing!)

47:30 Partnering with practices to address staffing shortages in clinical care teams

48:30 “The macro effects of COVID-19 have pushed us more towards value.”

49:30 Eric provides brief overview of the new ACO REACH model

51:00 Steve discusses the important opportunity of ACO REACH with agilon’s physician partners

53:00 The scale and concentration benefits of ACO REACH as a tipping point for risk-based value transformation

54:00 Perspectives on how ACO REACH will impact health equity outcomes for agilon’s communities

56:00 Steve describes how agilon’s partner practices are taking upstream actions to address social determinants of health

58:30 Steve discusses agilon’s recent IPO and why a publicly traded primary care company should have a long-term focus on positively impacting health care

63:30 Learn more about agilon health through online resources (website, Twitter, LinkedIn, Instagram) and by talking to their existing partners

George Halvorson is a retired American healthcare executive who served as CEO of six health plans over the last 30 years.  From 2002-2013, he was the CEO of Kaiser Permanente and was listed several times on Modern Healthcare‘s “Most Influential People in Healthcare”. During his tenure at Kaiser Permanente, he led the nation’s largest nonprofit health plan and hospital system, which is also a leader in the adoption of technology to advance community health outcomes and reduce health inequities.  Under Halvorson’s leadership, Kaiser Permanente’s investment in electronic medical records and physician support systems resulted in diminished infection rates and scalable population health outcomes within partnering communities.

Since his retirement from Kaiser, George Halvorson has devoted his time to promoting the benefits of early childhood education and to addressing social difference and tensions through his own Institute. George Halvorson is currently the Chair and CEO of the Institute for InterGroup Understanding, a nonprofit organization that works on issues of racism, prejudice, discrimination and intergroup stress and conflict by facilitating a collective understanding of what children need to achieve safe and productive lives. George is someone who leads with a passion to help create intergroup Peace for our nation so that we may intellectually overcome our more negative and damaging instinctive behaviors.

In this episode, you will learn the truth about the Medicare Advantage program from one of the leading intellectuals in healthcare.  We also discuss Health IT transformation and the power of organizational culture to reshape care delivery. In the last 20 minutes of the interview, George Halvorson also discusses his mission to improve the culture of our world by helping others overcome negative and instinctive behaviors that lead to intergroup conflict.  This is a powerful discussion about the impact of tribalism in our world and how we have a collective and ethical obligation to help each child from every ethnic, economic, cultural, and racial group in America to overcome the hardwiring of societal conditioning that leads to “us versus them” intergroup conflict. “We need to steer ourselves away from the easy abyss of anger through tribalism, into a higher level of interaction. This is a just-in-time learning opportunity.”

Episode Bookmarks:

01:20 George Halvorson’s legacy as a healthcare executive and former CEO of Kaiser Permanente

02:20 The Institute for InterGroup Understanding, a nonprofit organization that works on issues of racism, prejudice, discrimination and intergroup stress and conflict

03:10 George’s extensive experience in international healthcare reform and his authorship of several books related to healthcare reform and intergroup peace

04:20 “The fragmented nature of care delivery and siloing of data creates an expensive plethora of uncoordinated, unlinked, economically segregated, operationally limited microsystems, each performing in ways that too often create suboptimal performance”

06:30 “We are on the cusp of the golden age of healthcare delivery, and it’s going to be made golden by information, data, and systems.”

07:15 Innovation at Kaiser Permanente led to a 40% reduction in congestive heart failure crisis events

08:15 Leveraging biometric data and predictive algorithms for disease detection and prevention

09:45 George Halvorson as a national leader in mitigating health disparities and his 2013 book, “Ending Racial, Ethnic and Cultural Disparities in American Health Care”

11:15 Medicare Advantage has become a successful social services program for millions of people (and our most important vehicle to reduce health inequities)

12:15 How Kaiser Permanente reduced prostate cancer death rates for Hispanic Americans

13:30 “I believe that we should deliver better care to every single American, and we have done a pretty miserable job for many subsets of our population.”

14:30 Linkage of uterine infection during pregnancy and childhood asthma (and how this disproportionately affects African Americans)

15:20 Dual-eligibility in Medicare Advantage and Medicaid is leading to better care outcomes and higher satisfaction scores

17:00 How fee-for-service Medicare failed COVID patients

18:00 Health plan competitive bidding, benefit design, and economics of MA leads to better care and lower costs (“a clearly superior model”)

20:00 Misinformation about health plan profitability (MA plans make 4% profit; whereas, all other American businesses make 10-20% profits)

21:00 Debate with MedPAC regarding benefit enhancements that improve patient outcomes for low-income members

22:15 Richard Gilfillan and Don Berwick’s two-part series of articles in Health Affairsexpressing their grave concerns related to Medicare Advantage (Part 1 and Part 2)

23:30 Response to Gilfillan and Berwick’s concerns related to health plan profitability and PE investment in companies driving MA care delivery innovation

26:50 Response to MA critics concerns of upcoding and how current coding limitations in the program prevent abuses in the MA program (“You can’t upcode into a system that doesn’t exist”)

29:00 Reinvestment of profit surpluses to provide better benefits for members and how MA 5-Star plans are “the best care plans anywhere in the world”

31:00 George Halvorson discusses the financial and cost savings differential between traditional fee-for-service Medicare and Medicare Advantage

32:30 MA beneficiary enrollment in urgent need counties and why spending concerns in that part of the program may be misrepresented

36:00 The importance of organizational culture in value transformation (“When the student is ready, the teacher appears.”)

37:15 “Organizational culture needs to be centered around the patient, built around transparency and data sharing, and focused on continuous improvement.”

38:45 The success story of care process redesign at Kaiser Permanente that led to reduction in death rates due to sepsis (reduced from 30% to 3%)

41:00 What culture in health care delivery do we want in our country?

42:00 George’s mission to improve the culture of our world by helping others overcome negative and instinctive behaviors that lead to intergroup conflict

43:00 “We are all creatures of instincts. Every one of us is instinctively tribal, instinctively hierarchical, instinctively territorial, instinctively emotional.”

43:40 The slippery slope of tribalism that leads to “us versus them” behaviors without values and ethical standards

45:00 The Truth Agenda – how the Institute is working on making public and political discourse honest and respectful

45:40 Epigenetic neurogenesis in children and why intergroup conflict is so harmful in early childhood brain development, i.e. hardwiring tribalism

47:30 The case for universal and affordable healthcare and how tribalism in American undermines true progress in healthcare transformation

48:20 “When people realize that an instinctive behavior is not an underlying value for the universe, you get a lot more flexibility, both in your own emotions and in your own interaction.”

49:00 George Halvorson’s books on intergroup activity that are available for free online

49:40 The Cusp of Chaos:  how tribalism leads to genocide, mass killings, intertribal bloodshed, rapes, mutilation, ethnic cleansing, and other genocidal behaviors

50:45 How tribalism relates to the current Ukrainian conflict

51:30 How George Floyd and the Me Too movement was a powerful learning experience for America

53:00 “We need to steer ourselves away from the easy abyss of anger through tribalism, into a higher level of interaction. This is a just-in-time learning opportunity.”

54:00 Predicting future and understanding history by interpreting the pattern of intergroup interaction (how George predicted the Russian atrocities in Ukraine 5 years ago)

56:00 The danger of alpha instincts —  the January 6th insurrection and lifelong conquests of political leaders to stay in power at all costs

57:30 “We’ve got a relatively short time in this country to steer us back to a good and safe place.”

58:00 Websites of interest:  Three Key Years and the Institute for InterGroup Understanding

How does a 3-physician practice sell for over $100 million dollars? The answer is simpler than it seems – full-risk contracting is better for providers and patients. Aligned incentives promote better outcomes for patients, and better reimbursement for those providing the care. It comes down to this – full risk unlocks the door to a true relationship with the patient, a relationship that provides more information than sophisticated AI models, risk coding and predictive analytics. And Medicare Advantage plans are the most accessible vehicle to achieve full capitation.

We are pleased to welcome back Dr. Tom Davis as our guest. Dr. Davis is an expert in value-based care, a family physician, angel investor, founder of 6 companies, consultant, and speaker. In this episode, he articulates how Medicare Advantage is a critical strength in the race to value. You can find more from Dr. Davis at his website: https://www.tomdavisconsulting.com/

Episode Bookmarks:

01:40 Introduction to Dr. Tom Davis

03:30 Dr. Davis started a small primary care practice that took full-risk Medicare Advantage (MA) and sold it for $132M!

06:30 Dr. Davis explains the “spectrum of value-based care” in MA and how he took the first full-risk contract in his market.

09:00 Analyzing cost drivers in patient population and how that prompted investment to capitalize on a site-of-service arbitrage

11:00 Implementing internal systems to optimize on physician workflow efficiencies in value-based care

12:00 Dr. Davis describes how it felt the first time he saw that he earned $1M+ in income as a primary care physician.

14:00 Dr. Davis explains “the offer we couldn’t refuse” when his full-risk MA practice was acquired.

14:40 “Value-based care under a full-risk Medicare Advantage model allowed me to be the family physician that I had always wanted to be.”

15:30 The enrollment growth trajectory in Medicare Advantage and the continued potential for rewarding economics for PCPs

17:15 “Devolving the financial consequences of the clinical decision down to the POS unleashes the most valuable asset in healthcare–the clinicians themselves.”

18:40 How to take full advantage of Medicare Advantage – Dr. Davis explains how to take full financial responsibility in a risk contract!

20:00 Full financial risk is only up to the attachment point of the stop-loss insurance.

21:00 The pool of capital in private insurance markets and the delegation of risk to both providers and the private liability market.

22:00 “Fee-for-service medicine sucks your will to live as a clinician.”

23:30 The economics of the MA Stars system and how it aligns with improved patient outcomes

24:45 Proxy Value vs. True Value in measurement

25:15 Full-risk contracts as the only true way to unlock value.

26:15 Moving from 3 to 5 Stars in Medicare Advantage equates to an 18% increase in practice revenue.

27:00 Deriving true value in MA contracts as the most sustainable and optimal ROI opportunity

28:30 The advantages and disadvantages of physician-led risk-bearing entities

29:45 “You will never learn to swim if you only stay in an ACO.”

31:00 Working with smaller MA plans because they are more likely to collaborate with physicians.

31:45 The rise of Direct Contracting Entities (DCEs) leaves no excuse for physicians to not up their risk profile.

33:00 The value of the patient relationship in driving business performance (versus short-term revenue generation to goose the bottom line in FFS)

34:40 Referencing the father of the modern container ship system in how we unlocked true value.

36:00 “Everything, everything, everything in your organization wraps around the value between the patient and the clinician.”

37:00 Dr. Davis shares a personal story of how a patient relationship supported colorectal cancer screening compliance.

38:00 How patient relationships trump sophisticated AI models and predictive analytics

39:00 The moral, ethical, and a functional advantages of value-based care over the industrialized business model

42:00 The importance of the Annual Wellness Visit (AWV) as a key component to the MA patient relationship

44:30 Using the AWV as a reflection of the amount of engagement that a clinician has with their panel

45:30 Balancing short-term P&L “gun to your head” pressure with long-term R&D success in value-based care

47:00 “Value-based care is here to stay. The government has no interest in shouldering this burden anymore.”

48:20 Capturing SDOH data with Health Risk Assessments (referencing podcast interview with Cheryl Lulias)

49:30 Identifying the rising risk as early as possible to mitigate preventable costs

50:30 A PCP can fight the counter influences of the food industry, but you can still have meaningful interventions.

51:30 Care management as an opportunity for engagement (but never as good as a F2F visit with the physician)

54:00 Dr. Davis shares everything you need to know about Risk Adjustment Coding!

59:20 “Your job as a leader, is to stand there like superman, let those non-clinical tasks ping off your chest like bullets, and protect your clinicians to let them generate the value that only they can generate, and they generate so well.”

61:15 Dr. Davis on healthcare waste and how the easiest way to avoid it is by controlling inpatient admissions through the emergency room

63:00 Cultivation of trusting patient relationships will cause patients to call their PCP before going to the ER!

64:30 Disruption of the primary care landscape through private-equity backed practices (and how you compete with them!)

Dr. Kevin Spencer, Medical Director, Texas at Agilon Health, is passionate about improving the health care delivery system. He believes that by enabling physician-led organizations with technology, proven processes, and human capital under global risk capitation models, we can transform care for patients and physicians alike. With a deep understanding of the local market, combined with extensive health care experience, Kevin Spencer, MD  oversees the strategy, operations, and growth for the Connected Senior Care Advantage program, the unique Agilon Health risk-bearing entity (RBE) partnership model in the Austin, Texas market.  As the former Managing Partner and CEO of Premier Family Physicians, the Austin-based physician network that joined Austin Regional Clinic in the Agilon Health RBE joint venture, Dr. Spencer takes his leadership and understanding of how to effectively partner with primary care physicians to build sustainable success in global risk capitation models in Medicare Advantage.

In this episode, Dr. Kevin Spencer shares important insights about the business of Medicare Advantage and how full-risk payment in primary care can lower costs and improve clinical outcomes within a senior population.  This interview is not to be missed for anyone wanting to understand how to build value-based care success over time in a physician-led environment that embraces full-risk capitation within a market that is still heavily entrenched in fee-for-service.  Dr. Spencer demonstrates a superior understanding of population health with a business acumen of Medicare Advantage that makes for a thought-provoking conversation on how MA may be the future of payment model reform.  Given the success of global risk capitated models in the senior space, could Medicare Advantage-For-All be a viable health policy in the years to come?

Episode bookmarks:

4:38 Lessons learned in the early years of physician-led Accountable Care

9:08  “Health care is better delivered in a value environment. I believe that putting the premium dollar in the hands of the physicians that are taking care of patients will empower them to do the right thing, for the right reason, at the right cost.”

10:40 Choosing the right capital partner to form a Risk Bearing Entity

11:40 Agilon Health’s approach to physician partnership

12:50 Dr. Spencer referencing the excellent work done by other disrupters in the senior space (e.g. Oak Street, ChenMed, Iora)

18:00 “Medicare Advantage risk will only work if we deliver a much superior product to our seniors in America. The care they have been receiving up to now, in many cases, has been fragmented, disjointed, and not always aligned with their belief systems.”

18:55 Dr. Spencer discusses Connected Senior Care Advantage, the outward facing brand of his physician-led JV with Agilon Health

20:00 Medical management program investments (transitions of care, care management, home visits, and pharmacy programs)

21:00 Building patient trust so physicians can effectively quarterback care and how the pandemic has affected the patient-physician relationship

23:00 Medicare Advantage risk and its impact on physician burnout and physician/patient Net Promoter Scores

24:40 Marrying Risk Adjustment to Quality and the appropriate documentation needed to fuel the Population Health engine

25:20 Prospective chart reviews to improve coding documentation of disease burden

24:37 Annual Wellness Visits to improve coding documentation, screening effectiveness (mental health, fall risk), and care gap closure

28:00 The Economic Model of the Stars Rating in Medicare Advantage

30:00 Why the higher Stars-Rated MA plans actually cost less

31:20 Implementing a Playbook for Quality Improvement aimed at QM performance and improving patient experience/clinical outcomes

35:20 Capital Investment in Primary Care and how PCPs can maintain autonomy through interdependence with the right partners

38:25 Physician-led governance to prevent the corporate practice of medicine

40:50 How the pandemic paved the way for value-based care and primary care capitation

42:40 The launch of telehealth at Premier Family Physicians during the early stages of the pandemic

45:00 How Agilon Health is launching six different DCEs in the Direct Contracting (DC) model’s first cohort

48:26 Implementing a patient-centered Benefit Design as part of the DCE

49:11 Collaborating with other organizations to develop the DCE

50:30 Medicare Advantage–For–All approach as a potential health reform solution