Primary Care Transformation – The Race to Value Podcast™

How can primary care physicians retain their independence in planning for future success in value-based care?  A medical practice must have access to capital to optimize physician workflow and improve patient experience; however, if it chooses the wrong partner, physicians will lose autonomy and compromise their own personal wellbeing.  Privia Health is a technology-driven, national physician enablement company that is on a mission to enable doctors and their teams to focus on keeping people healthy. Their goal is to transform healthcare by enabling physicians, and they want to build the largest primary care-centric ambulatory delivery system in the country. With a healthcare provider partner base of over 3,500 providers managing 3.9 million patients across eight states and the District of Columbia, they are well on their way. And their results in value-based care are superlative, as recently demonstrated by their most recent 2021 Performance Year in the Medicare Shared Savings Program yielding $99.9 million in savings.

Joining us in the Race to Value this week is Shawn Morris, the Chief Executive Officer of Privia Health. Shawn is a seasoned industry leader focused on building a platform that can transform the healthcare delivery experience for physicians and patients. He is driving initiatives to meet providers where they are on the transition to value, by building strategic partnerships with physicians, health plans, health systems, and employers to better align reimbursements to quality, affordability, patient satisfaction and provider wellbeing. In this podcast interview, you will hear from one of the leading voices in value transformation discussing such topics as risk-based contract progression, the importance of workflow optimization in supporting provider wellbeing, technology enablement based on the tenets of automation and consumer-centric innovation, effective governance and management of physician-led risk-bearing entities, bridging FFS to value through a multipayer contract portfolio, and the national movement to value-based care transformation.

Episode Bookmarks:

01:30 Register today for the “Population Health Equity: The North Star for Value” Virtual Event (December 1, 2022)

03:00 Privia Health — a technology-driven, national physician enablement company leading in value-based care transformation.

04:00 Introduction to Shawn Morris, Chief Executive Officer – Privia Health

06:30 Privia Health has expanded its healthcare provider partner base to over 3,500 providers managing 3.9 million patients across eight states and the District of Columbia.

08:30 “Our goal is to transform healthcare by enabling physicians. We want to build the largest primary care-centric ambulatory delivery system in the country.”

09:00 Shawn describes the value-based care contract portfolio held by Privia’s physician partners.

10:00 Average practice size of a Privia Health practice is 5 clinicians.

11:00 “If you are not focused on both patient experience and provider wellbeing, you cannot achieve success in value-based care.”

11:30 The importance of understanding medical risk to run a success physician practice.

13:00 The five key elements of the Privia Platform to optimize value-based care performance.

15:00 Shawn describes the opportunity for value transformation in a physician practice landscape that is unsophisticated in managing risk.

17:00 Building hubs of transformation within states, starting with Single TIN anchor groups that are enabled by a technology and MSO wraparound capabilities.

18:00 Creating enablement for physicians by embedding insights directly into a unified EMR workflow.

19:00 The challenges of an un-optimized EMR workflow when physicians are forced to click in and out of disparate information systems.

20:00 Enabling provider access through relationship-based care and a purpose-built platform (“digital front door”) built around the tenets of consumerism.

22:00 Workflow optimization to close care gaps, capture HCCs, and leverage specialty referrals within a high value network.

23:45 Post-visit, technology-enabled workflow optimization to ensure effective care management and improved outcomes.

24:30 Shawn provides an example of effective virtual care delivery.

25:30 Closing gaps through automated robotic processing that nudges patients and enhances data capture.

27:30 Consumer-centric innovations that can alleviate the administrative burdens of providers.

28:00 Search Engine Optimization can be used for service recovery and reputation management.

28:30 “Simplicity is the ultimate sophistication.” – Leonardo da Vinci

29:30 Privia’s ACOs (collectively known as the “Privia Quality Network”) achieved shared savings of $99.9 million in the MSSP, caring for more than 112, 000 Medicare beneficiaries in 2021.

32:00 Shawn provides his perspective of how value-based government programs (e.g. MSSP) are driving transformation through trial and error.

34:00 Most of Privia’s MSSP lives are in the Enhanced ACO track with the most financial risk.

34:30 Understanding provider maturity and value-based readiness across the continuum when calibrating an optimal risk profile in the MSSP.

35:30 Building the infrastructure for downside risk (e.g. escrow to insure the repayment on the downside, data science and analysis)

36:30 How Privia shares downside risk and financial upside with partner physicians (60/40 split with physicians receiving majority of payment on upside).

37:30 Building an effective governance model and pod structure that can manage risk-bearing entities and constituent physician practices.

39:30 Privia Health providers have high satisfaction with the platform (e.g. provider NPS of 54, 95% average provider retention over the past four years)

41:00 The CMS goal to have all Medicare beneficiaries in a value-based relationship by 2030 as evidence of continued risk progression in the industry.

42:00 Understanding provider needs, risk progression, and the importance of consumer-friendly doctor-focused technology.

43:00 “A value-based platform shouldn’t serve just Medicare Advantage or Commercial patients. Physicians need the autonomy to focus on whole-person care for everyone.”

43:30 The actuarial component of value-based care and how that leads to effective physician aggregation in risk-bearing entities at the state-level.

44:30 Privia Health customers are now the biggest source of new business referrals for the company.

45:00 How going public provided Privia with increased visibility and access to capital to support continued growth.

47:00 Privia Health is using FFS as a bridge to VBC success with practices realizing >90% practice collections predictability with a diversified revenue mix ($1.3B in total annual collections)

48:30 Shawn provides guidance on how to successfully navigate value transformation in fee-for-service given the slow progression of risk-based payment.

50:00 Most people don’t realize that Medicare Advantage is still pretty much all fee-for-service.

50:30 Access is the key to value-based care success. RCM is the key to fee-for-service success.

50:45 The limitations of payers to administer capitation-based payment to medical groups (varying payer capabilities across states/regions)

51:30 The progression of risk in a medical practice – starting with upside-only models – to ultimately develop profitability in a more mature value-based care portfolio.

53:00 Shawn provides an example of building a RBE in Montana where there are currently no capitated MA risk contracts available.

53:45 Even in fully-capitated models, the bulk of provider payments (80-85%) are still paid out on a FFS basis to providers.

54:30 The importance of understanding benefit design in a commercial risk arrangement (e.g corridors, employer participation) to ensure success.

56:00 Only 32% of primary care physicians work in a private practice outside of corporatized care delivery business model.

57:00 “Privia does not employ providers. We want our community physician partners to be wildly successful by remaining independent.”

58:30 Shawn provides examples of successful independent physician models with their clients in Georgia, Texas, Florida, California, and Montana.

59:45 “The tenets of our model are Single Tax ID, movement to VBC in a disciplined way, diverse income streams, and a focus on patient experience and provider wellbeing.”

61:15 Recent strategic partnership with OhioHealth Health system to launch a medical group for independent providers throughout the state of Ohio.

61:45 Same-Store versus New-Market growth strategies driving the future of Privia Health.

65:45 Parting thoughts from Shawn Morris on how health systems should develop a physician alignment strategy for the future.

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.”

Fee-for-service healthcare has destroyed the physician-patient relationship by de-personalizing care delivery.  Patient encounters are looked at as transactions, instead of as opportunities to forge long-term healing relationships. Consequently, the healthcare system delivers inexorably bad cost and quality outcomes, and  primary care is marginalized in lieu of high cost specialists who perform procedures. This has created a perfect storm for physician burnout and moral injury, and we can only regain the humanity of health care by reinstating the primacy of the physician-patient relationship and empowering independent primary care physicians.

Dr. David Pak is an entrepreneurial Internal Medicine physician leader with over 25 years of direct patient care.  His medical practice (Pak Medical Group) is a leading example of a patient-centered, holistic, relationship-based, tech-enabled model that is transforming the lives of seniors. Dr. Pak is an entrepreneur with masterful skill at aggregating local market physicians to build value-based models of care.  He has formed an ACO and Medicare Advantage risk-bearing entity (Zenith Independent Physicians Network) that is moving primary care practices to fully-capitated risk. Dr. Pak is passionate about the personalization of primary care, technology enablement through remote patient monitoring, perpetuation of physician independence through value-based programs, and the creation of Human AI staffing support models that can transform care delivery and physician culture.  While he is an expert on value-based care and care delivery innovation, he is also a proponent of medicine revisiting its roots to a more simpler time where relationships were paramount.

This episode is a must-listen for entrepreneurial primary care physicians who seek independence through value-based care. By following Dr. Pak’s approach, they can reclaim their joy in medicine and propel their practices to business success in the race to value.

Episode Bookmarks:

01:30 Introduction to Dr. David Pak and his healthcare ventures (Pak Medical Group, Zenith IPN, and Eleos Staffing)

04:30 Dr. Pak’s early success as a physician entrepreneur that resulted in his practice to Humana

05:30 Dr. Pak speaks to his career as an entrepreneur in creating value-based, innovative care delivery models for seniors

07:00 “Fee-for-service is a broken model that rewards bad behavior that is not conducive to good outcomes.”

08:00 Holistic patient care only occur in a full-risk medical practice. Will this lead to mandated APMs?

10:00 The explosive growth and enrollment trajectory of Medicare Advantage.

11:00 Learning how to succeed in Medicare Advantage from more advanced models in Florida.

12:15 Identifying vulnerable populations in Medicare Advantage through appropriate risk adjustment coding.

13:00 Delivering customized care delivery care models for different segments of the MA population.

14:30 The need for primary care physician autonomy and independence to overcome current financial challenges.

15:30 Is a massive corporate takeover of primary care necessary for PCPs to succeed in capitated revenue models?

18:00 Comparing PMPM reimbursement to traditional FFS reimbursement and overcoming the physician “education gap” in risk

18:45 The importance of physician leadership and education in value-based care

20:00 It is possible for PCPs to get off the “hamster wheel” (and it doesn’t require a corporate takeover)

21:30 The need for independent physicians to take on a capital partner to support their value journey.

23:00 Dr. Pak explains the importance of physician education and a robust risk-based contract portfolio.

24:00 The aggregation of primary care physicians in local markets.

25:00 “The road to value-based care should be paved by physicians…especially primary care physicians.”

25:30 The difficulties in meeting ROI expectations from PE investors and why physician aggregation is crucial to success.

26:30 Avoidance of PCP commoditization and why hospital-led ACOs may not be an ideal long-term solution.

27:00 Finding “anchor physicians” in local markets as an aggregation strategy

27:45 How PE-led hospital acquisitions of primary care drives up prices and leads to poorer outcomes.

29:00 “M&A is easy; it is the integration that is a nightmare because investors may not understand the local market.”

30:00 The PE-led physician “land grab” in Texas and the challenges of physician integration due to lack of EHR interoperability.

32:00 Creating a data infrastructure in the independent PCP landscape within a local market.

33:30 Will AI robots replace healthcare providers?

34:30 The difficulties in automating personalized healthcare, and the opportunities for technology-enabled standardization.

35:30 Solving for physician burnout and moral injury is critical to avoid a mass workforce exodus.

37:30 A tearful patient testimonial for Dr. Pak’s medical practice

38:00 The biggest mistake made by physicians is thinking they are the “be all end all” of the medical practice.

39:00 “Healthcare is the only industry that doesn’t have a CRM program.  We are in a service industry, yet we don’t operate like one.”

40:00 The paramount importance of patient communication, patient access, and care coordination in building a support infrastructure in a medical practice.

41:30 Building a customer service-focused culture and the “Marcus Welby model” is not possible in a corporatized medical practice.

43:30 What is the difference in primary care access between an underserved American community and a third world country?

45:00 How Pak Medical Group leverages Remote Patient Monitoring in the delivery of patient-centered care (Institute members can download Case Study here)

47:30 How can Amazon and FedEx track packages across the country, but we can lose patients inside a hospital?

48:00 Fallacy #1: “You can’t teach an old dog new tricks” (seniors can adapt to technology!)

49:00 Fallacy #2: “Good health care can only be delivered in-person” (how wearables facilitate remote engagement)

50:45 Deploying mobile units and telehealth in building an asset-light care delivery model.

52:30 An overview of the Zenith Independent Physician Network, a risk-bearing entity of independent primary care physicians that Dr. Pak founded.

54:00 Dr. Pak describes how common it is for ACOs not to provide data reporting and financial transparency to partner physicians.

56:00 The 3 hallmarks of building a good Risk-Bearing Entity (i.e. infrastructure and contracts, financial transparency, performance report cards)

57:30 Creating physician leadership at the pod-level in various regions throughout the ACO’s geography

58:30 An overview of Eleos Staffing, a value-based care Human AI (staffing and automation) company that Dr. Pak founded.

61:30 Wrapping human capital around software, workflows, and processes to create automation.

63:30 Efficiencies in referral management, insurance verification, prior authorizations, scribing, and chart prep by using a virtual healthcare associate (Human AI)

65:00 How Human AI reduced physician burnout and improved ACO performance results.

67:30 Creating a care delivery environment for physicians to find job in their work through personalized relationships.

69:30 Moral injury occurs when physicians are forced to abandon their duty to care for patients in the best way possible.

70:30 Getting to the grassroots and fundamentals of medicine.

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

One of the silver linings of the pandemic has, in fact, been, the expansion of telehealth services and virtual care delivery. The pandemic has also accelerated the healthcare industry’s transition from fee-for-service to value-based care. The continued growth of telehealth is fueled by providing incentives for care delivery in the lowest cost settings, identifying and interacting with highest-risk individuals before disease onset, managing care teams with more efficient workflows, and taking advantage of digital remote technologies. Virtual care is an easy and cost-effective path to achieve value-based care, thereby improving health outcomes and patient satisfaction across a broader population of patients.

Our guest this week, is Dr. Carrie Nelson, the Chief Medical Officer for Amwell, a leading digital care and telemedicine company.  Dr. Nelson is a seasoned physician leader committed to healthcare transformation. She has demonstrated success in innovation and change management, physician engagement, solution development and deployment, value-based care, managing and coaching other leaders and delivering results.  Before joining Amwell as Chief Medical Officer and President of their Amwell Medical Group, she served as the Senior Vice President and CMO for Population Health and Health Outcomes at Advocate Aurora Health.  She also served as the Chief Clinical Officer for Advocate Physician Partners, a benchmark organization known internationally for delivering value-based care in collaboration with about 5000 employed and independent physician practices. With more than 28 years’ experience as a Family Medicine provider, Dr. Nelson is an innovative physician leader with a proven track in quality improvement, patient safety and population health.

Bookmarks:

01:30     The silver lining of the pandemic is the expansion of telehealth services/virtual care delivery and the acceleration to value-based care.

02:15     Introduction to Dr. Carrie Nelson, the Chief Medical Officer for Amwell, a leading digital care and telemedicine company.

05:00     Dr. Nelson’s recent career transition from Population Health leadership at Advocate Aurora Health to a national leadership role in digital transformation and virtual care enablement.

06:00     A career in driving healthcare transformation in population health, quality, and patient safety.

06:30     The influence of “Crossing the Quality Chasm” and “To Err is Human” on awakening a healthcare transformation.

07:00     The pace of change across the country is still insufficient due to over-dependence on fee-for-service.

08:00     The consequences of poor disease control during the pandemic as a result of ineffective healthcare delivery.

08:30     The multifactorial limitations in the capacity for healthcare systems to change (e.g. culture, failure to adapt to technology)

09:00     Strong technology partnerships needed to prevent health systems from regressing back to their pre-pandemic care delivery model.

09:30     Workforce burnout in healthcare prevents sufficient time to think about system transformation.

10:30     Telehealth improves patient health, reduces overall costs of care, and improves health equity in medically underserved communities.

11:00     The plunge of telemedicine usage since the peak of the pandemic.

12:00     “During the pandemic, we largely moved brick and mortar care to online.  If that is all we ever achieve, we will have fallen far short of the potential for a technologically-enabled model.”

12:30     Shawn Griffin (President and CEO of URAC) and his analogy of COVID-19 telehealth deployment to only “watching the dancing baby online” when launching the Internet.

13:00     Dr. Nelson discusses Amazon Care’s recent departure from telehealth and itsrecent acquisition of OneMedical.

13:30     Wider uses cases for telehealth and recent trends in claims activity.

14:30     Inserting new tools into the virtual visit creates healthcare transformation that improves quality and lowers costs.

15:00     “The office visit is a dinosaur. It is an insufficient touch-base in managing a chronic condition.  We need more digitized touchpoints to help support health behavior change.”

15:30     Optimism for the future of digital care delivery due to opportunities for automation and customization.

16:30     Delivering a concierge-like experience to patients, a Virtual Primary Care solution can facilitate an even stronger relationship with a PCP and  dramatically improve care management.

17:45     The challenges of rural communities in accessing health care and the shortage of providers in both rural and urban areas.

19:00     Dr. Nelson shares a patient story of how virtual care delivery improved the health of a chronically ill patient.

21:00     Distinguishing between a technical problem and a complex adaptive problem in the primary care setting.

21:45     “Patient noncompliance is an indictment of how the healthcare system is not setup to deal with a complex adaptive problem. We seem to offer only technical solutions in the form of a treatment plan.”

22:45     The purity of the value-based care model in improving health outcomes and how to approach deployment of limited care intervention resources.

23:30     Value-based care reduces the logistical challenges of virtual primary care, whereby improving adherence to a customized care plan.

24:00     The healthcare system spends $32 billion annually on avoidable emergency room visits that could be treated by primary care physicians.

24:45     Emergency department visits for people with at least one chronic condition contribute to nearly 60 percent of all annual visits (over 4 million ED visits each year that are potentially preventable).

25:30     Dr. Nelson discusses how virtual primary care and urgent care models are effective ways to lower unnecessary emergency visits.

26:45     Helping patients navigate the healthcare system through emergency department follow-up programs and virtual primary care.

28:00     How Advocate Aurora utilized virtual engagement to manage patients safely at home when there were capacity constraints during the pandemic.

29:00     Results with the Spectrum Health automated ED follow-up visit program in lowering inpatient admissions and unnecessary costs.

30:15     2 out of 3 Medicare beneficiaries have 2 or more chronic conditions, and 1 in 3 patients living with 4 or more chronic conditions!

30:45     Chronic diseases are the leading cause of death and disability in the United States, accounting for seven in 10 deaths.

32:00     The opportunity costs in our society due to the high spending on ineffective care models for managing chronic disease.

33:00     Dr. Nelson explains the function of care management, how it is not reimbursement in FFS, and the variability in patient outcomes between different programs.

34:00     Taking advantage of what we know about patient behavior change to impact clinical outcomes.

35:00     The importance of the human relationship between patients and their care teams and how technology interventions can further enhance patient activation.

36:30     Dr. Nelson provides an overview of Remote Patient Monitoring (RPM) and its two forms (remote physiologic monitoring, remote person monitoring)

38:00     Telemedicine can do a lot to alleviate the relative misdistribution of providers and bring healthcare to rural areas of the country and areas that are less resourced.

39:00     14 million homes in urban settings and 4 million homes in rural communities lack broadband access (and 75% of them are people of color).

40:00     50 million adults experience mental illness (and 56% are not getting adequate treatment)

40:15     How Amwell is partnering with healthcare providers to ensure access to virtual care in underserved and rural communities.

41:30     “The emergency room is the worst place in the world for people with mental health issues – it actually exacerbates their condition.”

42:30     Telemedicine enablement in the behavioral health setting and how it empowers the workforce.

44:30     Between 2000 and 2019, the portion of beneficiaries seeing five or more physicians annually increased from 18 to 30%, and the mean annual number of specialist visits increased by 20%.

46:00     The shortage and poor distribution of specialists and how telehealth presents and opportunity to make specialty care more responsive to patient care needs.

48:00     Specialist access challenges for Medicaid patients and the lack of PCP/SCP coordination in the traditional “brick and mortar” care model.

49:00     Referencing the Penn State hybrid cardiac rehab program

50:45     The passage of H.R. 4040 (the Advancing Telehealth Beyond COVID-19 Act) to extend vital telehealth flexibilities enacted during the COVID-19 pandemic

51:30     “You can’t put the genie back in the bottle.  Telehealth is here to stay.”

52:00     The need for sound policy and the importance of leadership in hardwiring education in telehealth to drive clinical transformation.

52:00     Prior experiences where physicians have been burned by technology advancement and why we can’t repeat history in scaling tele-driven models of care.

53:30     Patients overwhelmingly want to preserve telemedicine in the healthcare industry.

55:00     As care becomes more virtualized and procedures shift more and more into the ambulatory setting, the “hospital of the future” will be asset-light.

56:00     Health systems often see telehealth as a major competitor—82% of health systems surveyed reported that telehealth companies like Teladoc or Amwell are competitors.

57:00     Dr. Nelson describes the opportunity for traditional healthcare systems and health plans to partner with virtual care enablers to improve care delivery.

57:45     Referencing the work of Barbara Starfield and how virtual care delivery can realize the potential of advanced primary care.

59:00     Supporting health systems with workflow adoption of telehealth and urgent care solutions.

60:00     Referencing the electronic intensive care (eICU) model at Advocate Aurora as an example of asset-light care delivery that improves sepsis management

62:00     Hospital-at-home care models as a future trend.

63:30     Telehealth can minimize hospital-acquired infections by keeping people out of the facility.

65:00     Dr. Nelson provides her parting thoughts on how value-based care will serve as a catalyst to drive digital transformation for the future of healthcare delivery in our country.

For anyone following healthcare transformation in our country, you have undoubtedly heard about ChenMed – a family-owned, primary-care physician run organization that serves a challenging patient population under a full-risk global primary care reimbursement model. This is a high touch primary care company that has become the gold standard for how healthcare should be delivered in our country. In a prior episode of Race to Value, “Changing the World through a Full-Risk Value-Based Care Model”, Dr. Gordon Chen discussed how ChenMed is delivering transformative primary care – at scale – with superior health outcomes. It was one of our best podcast episodes ever, and we invited him back to talk about the Chen family calling to care for the underserved. This week’s episode is focused on his new book (co-written with his brother Dr. Christopher Chen) entitled, “The Calling: A Memoir of Family, Faith, and the Future of Healthcare” – an inspiration for living a purpose-driven life in the attainment of value-based care. The ChenMed success story of providing care to the most vulnerable among us is really a story about an American journey of a family guided by Faith and Love. The Calling tells the inspirational story of the Chen family, which over two generations not only completed the American Dream, but also transformed American medicine. This is a story about the life experiences that shaped two generations of innovative leaders in healthcare that made ChenMed the beacon for value-based care in our nation.

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Episode Bookmarks:

01:30 Introduction to ChenMed and Dr. Gordon Chen (referencing prior episode of Race to Value, “Changing the World through a Full-Risk Value-Based Care Model”)

02:30 “The Calling: A Memoir of Family, Faith, and the Future of Healthcare” – an inspiration for living a purpose-driven life in the attainment of value-based care.

04:30 Inspiration from John C. Maxwell and “The 5 Levels of Leadership”

06:45 Positional leadership is the current state of the majority of physicians in healthcare currently.

07:15 Leadership is influence – how Drs. Chris and Gordon Chen adapted their leadership to influence broad growth in others to achieve service excellence.

08:45 How Value-Based Care magnifies physician leadership

10:00 The Chens find meaning in their value-based care mission through their connection to Family and Faith

11:00 “There is no line separating our Family, our Faith, and our work at ChenMed.  It all blends together in a beautiful synergy.”

12:30 “Healthcare needs to be transformed, and you must start with those in greatest need.”

13:30 How the Chen Family transcended suffering during their journey to America, experiences with poverty and homelessness, and a false cancer scare

15:45 Finding the beauty in suffering through a faith-based perspective

17:00 “Struggle produces perseverance, perseverance leads to mature character, and mature character offers hope.”

18:00 The ancient wisdom of the Chinese saying —“One to grow, one to maintain, one to lose.”

20:00 Dr. Chen on the importance of living up to one’s God-given potential.

21:00 The Chris and Gordon Chen relationship —“Iron sharpens iron, and one man sharpens another.”

22:00 The business model for ChenMed as a high-touch, relationship-based, tech-enabled primary care practice.

23:00 The early work of Dr. James Chen as an early pioneer of value-based care.

25:00 How the early struggles and suffering of Dr. James Chen shaped the ChenMed focus on serving our most vulnerable.

27:00 What is the core essence of the ChenMed model and how does relationship-based care improve care outcomes?

28:00 An excerpt from a letter written by a ChenMed physician who had recently left the fee-for-service matrix

30:00 A Physician Culture that is “A.L.L. in”—Aligned with mission, vision, and values and has Learning agility and Learning humility.

30:30 How the open learning mindset of medical students changes once they enter into practice.

31:00 Hiring prospective physicians that are open to learning and have a drive to fix healthcare.

32:00 Creating a mission-driven physician culture based on learning agility and learning humility.

33:45 How experiential learning supports rapid growth and scale at ChenMed.

35:00 What can medical schools do differently to help students lead with more empathy and influence?

36:45 The Chen Family 7-part Mission Statement and how that is manifested in the ChenMed Mission to “honor seniors with affordable VIP care that delivers better health.”

38:30 “The ChenMed model only works if you have the right people, with the right culture and values.”

39:45 The impact of company culture on patient outcomes.

40:30 The need for more purpose-driven opportunities in America.

41:30 Building ChenMed as a “city on a hill” for healthcare and how their impact can change the world.

43:45 The industry of healthcare is moving in the wrong direction, but primary care is the main beacon of light shining in the darkness.

45:30 How the prioritization of a mission-focus will ultimately lead to margin.

46:00 Optimism for the future of healthcare.

47:00 “The goal of our book, “The Calling” is to inspire others to change the world…and we can.”

48:30 Dr. Gordon Chen provides his thoughts on the future of Medicare Advantage and how MA provides an opportunity for PCP leadership.

49:45 Dr. Chen’s perspective on the new ACO REACH payment model.

51:30 Parting thoughts from Dr. Chen and his new book “The Calling: A Memoir of Family, Faith, and the Future of Healthcare”

The need to strengthen and empower primary care, like the drive towards health equity, is one of the great causes célèbre of American healthcare. As David Blumenthal and Lovisa Gustafsson recently wrote in the Harvard Business Review:

“America’s health care system seems, paradoxically, both endlessly innovative and profoundly dysfunctional. On the one hand, we hear almost daily about flashy new ventures like, most recently, Amazon’s recent purchase of One Medical, a large provider of primary care, that promise transformative improvements in health care efficiency, quality, and service.

On the other hand, the day-to-day performance of the U.S. health care system is an international embarrassment. The United States spends twice as much as any other high-income country on health services while its maternal mortality, infant mortality, preventable mortality, overdose deaths, levels of chronic illness, levels of obesity, and deaths from Covid-19 put it at the bottom of the pack in the developed world. The American public is awash in personal medical debt, and even the best-connected struggle to find a primary care physician.”

In this week’s episode of the Race to Value, we are going to highlight the plight of primary care in the US and share real-time updates of what is actually happening in the marketplace. This important dialogue will help us understand how to improve the role, standing, supply and compensation of primary care practitioners in the US.  Joining us the week is Don Crane, Former President and CEO of America’s Physicians Groups. Don recently served as the Co-Chair of the National Primary Care Transformation Summit that occurred on July 25-29th, and we will be discussing with him the key insights from this important meeting. This was an event that the Institute for Advancing Health Value proudly sponsored, along with other key groups such as the Commonwealth Fund, Heritage Provider Network, Upstream, PCORI, Equality Health, Signify Health, and other important organizations leading in the value movement.  This event was made possible by our mutual friend Peter Grant, and Don served as a co-chair along with other healthcare luminaries Francois de Brantes, Dr. Clive Fields, Anne Greiner, Shawn Martin, and Elizabeth Mitchell.

Episode Bookmarks:

01:30 The need to strengthen and empower primary care, like the drive towards health equity, is one of the great causes célèbre of American healthcare.

02:00 “The American public is awash in personal medical debt, and even the best-connected struggle to find a primary care physician.”  (Amazon’s Foray into Primary Care Won’t be Easy)

03:00 Introduction to Don Crane, Former President and CEO of America’s Physicians Groups and the recent National Primary Care Transformation Summit

04:00 The PCT Summit had over 4,800 registrants, with 33 mini-summits, 26 plenary sessions and 150 faculty that were a veritable Who’s Who in American Healthcare!

05:00 “Staying the same is the first step to getting worse.  We must change the way we do Primary Care, and the crazy ideas of today will be the genesis of breakthroughs tomorrow.”  – Dr. Richard Merkin

05:30 Primary care is that no longer in the backwaters of medicine; it is now being seen as the backbone of the value movement.

06:30 Types of Primary Care: Suboptimal, Fragmented PPO Model vs. Optimal, Integrated HMO/Capitated Model

07:00 Reflections from Dr. Christopher Chen on the need for Primary Care Transformation

08:00 Primary Care Demand-Side: 96% of Medicare spend relates to individuals with multiple chronic diseases.

09:00 The need for coordination processes in primary care to improving quality and moderating costs.

09:30 Care Variation and Waste: 35% of healthcare is related to unnecessary, avoidable care that is wasteful.

10:00 The Improvement of Health as the Ultimate Goal: Better, Personal, Whole-Person Care to Prevent and Predict Disease to Reduce System Demand

11:00 Primary Care Bright Spots:  SCAN’s Healthcare in Action, ChenMed, Oak Street, Iora, Privia, and agilon, CVS Aetna, VillageMD and Walgreens, Everside Health, Crossover, ConcertoCare, Geisinger at Home, etc.

12:30 Since capitation has been around so long, why has it taken so long to achieve high scale, consumer-centric, primary care innovation?

13:30 “The world has woken up and learned that Primary Care is the tool to eliminate waste. And when you eliminate waste, every dollar saved goes straight to the bottom line as profit.”

14:30 “Primary care capital investment is a social good when it funds the proliferation of a value-based system.”

16:00 Amazon Acquisition of One Medical:  “Amazon is the lurking megalodon, its 11-foot jaws and 7-inch teeth the largest in history. With the acquisition of One Medical, Amazon is no longer circling … but attacking.” (Prime Health)

18:30 “Our wounded healthcare system is an embarrassment to the rest of the world and is bankrupting the United States of America.”

19:30 Don shares insights from the PCT Summit session he moderated with Susan Dentzer and Francois DeBrantes about the Amazon acquisition of One Medical.

20:00 Does Amazon know precisely what steps it will take in the OneMedical/Iora deal?

20:30 Addressing lack of primary care access and absence of convenience with a digital front door

22:00 Leveraging full-risk global primary care reimbursement in long-term transformation

23:30 Liz Fowler (CMMI Director): “While there might be fewer payment models, they will move towards total cost of care approaches that will require a focus on advanced primary care and ACOs.”

25:00 Don provides perspective on the goal of CMMI to have every Medicare beneficiary in an accountable care relationship by 2030.

26:00 “Let’s bring value to Medicare Advantage. Only 14-15% of MA is truly capitated to physician groups downstream. True prospective, population-based payment in MA is really a rarity.”

28:00 “Traditional Medicare is critically screwed up since it is so predominantly based on fee-for-service. ACO REACH is the gold standard of what we want.”

29:45 Are we moving too slow in the transformation of American healthcare?

30:30 PCPs are underpaid and underappreciated a very long time because of money, and this has been a huge mistake in our system.

31:30 PCPs can’t effectuate long-term changes in patient health status that amounts to savings at the system-level, with short-term capitation contracts.

32:30 Don shares his perspective on the underpayment of primary care and why fixing this is the lever to transform the American healthcare system.

33:45 “The best primary care groups in the country (e.g. Kaiser Permanente, WellMed, ChenMed) are not getting 1/3rd of what specialists are earning.”

34:45 Don speaks about the need for multi-payer alignment to reach a critical mass of primary care capitation in the marketplace.

37:00 Estimated PE deal values for healthcare services doubled from 2016 to 2021, going up to $77.5B. Within primary care specifically, in the last ten years, total deals have increased from $15M to $15B!

37:45 One in five physician transactions involved primary care practices—a signal that investors are banking on profits to be made in the shift to value-based care models.

39:00 Balancing PE investor exit expectations and the creation of the right incentives – with needed marketplace regulations — to create socially good primary care investments.

41:30 The employer-sponsored health insurance marketplace covers 157 million Americans and is dysfunctional and ineffective in producing value in health.

42:15 Dr. Ezekiel Emmanuel advocating for the government to work with self-funded employers and insurance carriers to bring about universal change.

43:00 “Self-insured employers of Americans are really grabbing the reins and helping drive the transformation that is necessary.”

44:00 Employers blaming ASOs and fully-insured health plans for not controlling the costs of healthcare.

45:30 The challenges of moving geographically dispersed employees into an evolved primary care model.

46:00 The cultural hierarchy in medicine where PCPs are at the very bottom of the caste system – how does this contribute to PCP burnout?

47:30 “Fee-for-service models are much worse for physician burnout than prospectively paid, population-based models.”

49:00 The work of Barbara Starfield showing that primary care helps prevent illness and death, where increased supply is associated with better population health and more equitable outcomes.

50:30 The business case for increased funding of primary care and the need to address Social Determinants of Health (comparisons to European investments in social services)

52:30 Marrying medical care with social care – the solution to a more effective and equitable healthcare system!

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

Democratization of value can only happen through the replication of full-risk APM adoption in primary care.  As a country, we must accelerate primary care progression towards fully-capitated risk by thoughtful health policy and payment model redesign.  Change is underway — primary care is already moving to a capitated model of reimbursement, and ACO REACH is our first real test of realigning financial incentives to improve care of patients living with chronic conditions.  Furthermore, this inflection point in the value movement is finally bringing much needed emphasis to those living in underserved communities facing health inequities.  So how do we operationalize primary care transformation at scale?  Is it possible to replicate a ‘clinical flywheel’ that provides RN care coordination, home-based care, embedded pharmacists, and floating health concierges to close care gaps and addressing health inequities?

This week we are joined by two executives from UpStream, a billion-dollar, full-risk health services organization that embeds clinicians into participating doctors’ offices as an advanced, full-risk Medicare program for network physicians.  By focusing on patients living with chronic conditions, and physically embedding highly trained prescribing pharmacists and coordination nurses at each primary care physician office, UpStream partners with its client practices to create the right infrastructure and resources for the whole-person care experience. Their approach has been to fully invest in primary care delivery models accountable for Total Cost of Care, whereby reducing care fragmentation for chronically ill patients while also achieving the best clinical and financial outcomes.

Dr. Sanjay Doddamani (CEO and Co-Founder of Upstream) and Valinda Rutledge (Chief Corporate Affairs Officer of Upstream) are two of the biggest thought leaders in the value movement. In this episode, they talk about the transformation opportunity of massively powerful primary care, the impact of COVID-19 on the value movement, technology innovation, health equity, capital investment in primary care infrastructure, collaborative care models, and the new ACO REACH payment model. Together they are leading one of the most innovative companies out there supporting primary care physicians in the Race to Value!

Episode Bookmarks:

01:30 Upstream – the fastest-growing healthcare solution provider in the country

02:30 Introduction to Dr. Sanjay Doddamani and Valinda Rutledge

04:00 The transformation opportunity of massively powerful primary care within a value-based purchasing construct

05:00 Can we reach a “Win-Win-Win” for patients, primary care physicians, and patients?

06:00 Valinda on the impact of the pandemic on the value-based care movement and how it unleashed tech-enabled consumerism in primary care

08:00 Payment reforms and looming insolvency of Medicare and how it will impact the independent Primary Care landscape

09:00 The development of ACO REACH as a model for capitated primary care reimbursement

09:30 Sanjay speaks to the challenges of the post-pandemic environment and the ‘Great Resignation’ on physician networks

10:00 “Primary Care physicians influence 90% of all medical costs.”

11:00 PCP burnout and recent findings on how family medicine is one of the five most stressful specialties

13:00 “If you continue to practice in a fee-for-service environment, it is like being on a hamster wheel with no way to get off.”

13:30 Sanjay speaks about the need to reallocate investment dollars to build primary care infrastructure for the 21st century

15:00 Critical Success Factors: Pharmacy integration, home-based primary care, and advanced data science capabilities

16:00 Valinda speaks to the challenges of decreasing PCP panel size when there are access barriers in underserved communities

18:00 Population health infrastructure requirements as the table stakes needed to play the game of value-based care

19:00 How Upstream supports partner practices with the capital needed to move to fully-capitated risk

20:00 Valinda provides distinction between capital requirement needs in independent vs. health system-owned/employed PCP practices

21:30 An overview of the Upstream “Guaranteed Advanced Payments for Quality” (GAP-Q) advanced payments for quality performance

22:30 “As you shift off of the fee-for-service chassis, something needs to replace it.  And that to me is a floor incentive that is tied to quality.”

25:00 Sanjay’s previous work with Keystone ACO and Geisinger that built the health system’s first home-based care program

25:30 Recent McKinsey & Company study estimating that up to $265 billion worth of care in Medicare/MA (25 percent of the total cost of care) could shift to the home by 2025

26:00 Sanjay speaks about Upstream’s ‘clinical flywheel’ of home-based care and disease management for the chronically ill

29:00 The practice of forensic listening, behavioral psychology, and shared decision-making to engage patients in care management

31:00 Will collaborative care be more common than what we see now where pharmacists, physicians, and other clinicians address health disparities separately?

32:00 Valinda speaks about the importance of culture and interprofessional collegiality to build successful integrated team-based care models

33:00 Building partnerships with community benefit organizations to resolve health inequities in underserved communities

34:30 Sanjay provides clinical examples reaffirming the importance of workforce integration to build cohesive multidisciplinary team-based care models

37:30 Technology to implement specific individualized interventions to mitigate the risk of costly complications that have a significant impact on the quality of care

39:00 Sanjay speaks about the physician workflow challenges of the ‘measurement industrial complex’

40:30 Valinda counters the technology transformation imperative by emphasizing the need for deep interpersonal patient-provider relationships

43:00 Sanjay on the use of Artificial Intelligence and Machine Learning in value-based primary care in partnership with ClosedLoop.ai

44:30 How will the move toward value-based care with prospective payment models upend the way we’ve historically defined primary care delivery?

47:00 Sanjay questions the feasibility of the CMS goal for 100% of Medicare beneficiaries in accountable care models since physicians are getting left behind

47:30 “We must bring all physicians along in value by enabling them to participate in risk models, indemnifying their downside, creating upside opportunities, and reallocating dollars to primary care.”

48:00 Valinda outlines the 3 Barriers to Value-Based Care adoption (i.e. Benchmarking methodology, Risk Adjustment, lack of Value-Based Care awareness with beneficiaries)

51:30 “We need to change the language of value-based care.”

53:00 Sanjay on how the current Administration is redefining the value movement through payment model redesign to include equity as a centerpiece

54:30 Valinda addresses the need for multistakeholder input to develop health policies that drive equity transformation

57:30 Valinda provides an comprehensive overview of the new ACO REACH payment model

61:00 Sanjay provides parting thoughts on the future of Upstream and how it will replicate its’ primary care model across the country

Community-based health transformation can be unleashed by uniting traditional allopathic medicine with lifestyle medicine.  To achieve a vision for population health, we will never change things by fighting the existing reality – we must instead innovate to render that old model obsolete.  On a mission to flatten the curve of healthcare costs, James Maskell has spent the past decade innovating at the cross section of functional medicine and community. To that end, he created the Functional Forum, the world’s largest integrative medicine conference with record-setting participation online and growing physician communities around the world. His organization and bestselling book of the same name, Evolution of Medicine, prepares health professionals for this new era of personalized, participatory medicine. His new project, HealCommunity, follows his second book “The Community Cure“, makes it easy for clinics and health systems to deliver lifestyle focused care effectively and frictionlessly. He is a high-demand speaker and impresario, being featured on TEDMED, HuffPostLive and TEDx, as well as lecturing internationally.

In this episode, you will learn about the impact of social isolation on chronic disease, functional group medicine, the development of a community layer as a foundation to the population care pyramid, Empowerment Group models, Human Social Genomics and precision medicine, behavior health and psychedelic therapies, and the power of lifestyle-enabled value-based care. Tune in this week to hear from a leading population health economist on a mission to win the Race to Value!

Episode Bookmarks:

01:30 Introduction to James Maskell (Community Builder and Healthcare Entrepreneur)

02:00 Books (Evolution of Medicine and The Community Cure) and theHealCommunity project

02:30 “Community is the most powerful force to transform health.  And Medicine has been slow to adapt to this reality…”

04:30 R. Buckminster Fuller: “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.”

05:00 Blue Zone Regions and the Roseto Effect

06:00 Is Chronic Disease Reversible?

06:45 “The biggest driver of all-cause mortality is loneliness and social stress.”

08:00 “The combination of Lifestyle Medicine and Group Medicine are the potential foundation of the population care pyramid.”

08:30 How can insurance be restructured to rebuild the community layer?

09:30 Honoring our ancestry by resolving the isolation of modern living

09:45 The thesis by Raghuram Rahan that technology has ripped apart the fabric of traditional communities

12:00 Inspiration from Dr. Jeffrey Geller and his work with Empowerment Group Models, delivering care and providing social support to underserved populations

14:30 Innovation of medicine at the cross section community and health empowerment (the solution to loneliness)

16:15 Billing, reimbursement, and privacy challenges in implementing group visits

17:30 Value creation and the elegance of the empowerment group model

19:00 The social paradox: people’s willingness to share private information on Facebook rather than within a community health model

19:30 Development of skills and competencies for Group Medicine

21:00 The collective trauma of the pandemic has changed the way people engage together

22:30 Removing friction points in group medicine through virtual visits

23:30 The impact of human social genomics in precision medicine, disease prevention, and personalized care pathways

24:45 George Slavich, PhD and his work in Human Social Genomics

25:00 The cellular-level impact of stress and depression related to the loss of a social community

26:00 Is Group Medicine really the opposite of Precision Medicine?

27:30 The vision for Precision Public Health and the work of Dr. Christopher Mote

30:30 America’s Behavioral Health crisis and recent Mass Shootings

31:30 A comorbid behavioral health disorder makes a chronic disease cost 2-3 timesmore!

32:00 Emerging research in Psychedelic Medicine delivered in integrative mental health clinics (such as ketamine-assisted psychotherapy)

33:00 An economic perspective on the research related to Group Medicine and theBiopsychosocial Model

35:30 The promise of Psychedelic Therapy on PTSD and other major depressive disorders

36:45 Combining Psychedelic Therapy with Lifestyle Medicine delivered in groups

38:00 Functional Medicine and Knowledge Transfer (the doubling of medical knowledge every few months)

39:30 The hope for the future lies in the value-based care movement

40:00 Functional group medicine outperforms traditional hyper-individualized medicine in treating chronic disease (Cleveland Clinic Study)

42:00 Increased interest in functional medicine due to COVID-19

43:30 The competitive advantage and market economics of the community health model

46:00 Refocusing value-based payment reforms that emphasize clinical models for disease prevention and lifestyle medicine

47:45 Creating a “Lifestyle Medicine ACO” (e.g. Vytalize Health, self-funded employers)

49:30 The work of Dr. David Unwin in reversing Type 2 Diabetes and lowering healthcare costs

52:45 Leading advocates for Lifestyle Medicine (e.g. Dr. Dean Ornish, Dr. Mark Hyman, the ACLM, Mayor Eric Adams)

54:00 “Lifestyle Medicine is the future of Value-Based Care.”

55:00 How Governor DeSantis is focused on lifestyle medicine to address COVID-19

56:30 Lifestyle therapeutic interventions (e.g. plant-based eating, physical activity, restorative sleep, stress management, avoidance of risky substances, social connectivity)

58:45 What kinds of social determinants of health can effectively be addressed in the healthcare setting?

60:00 Digital transformation, Dr. Robert Pearl, and the benefits of telemedicine

61:00 Innovations in localized food growing and community-based group cooking

63:00 The threat of the Social Media Metaverse on mental health

67:45 More about James Maskell’s work in Value-Based Care and connecting with him on LinkedIn