Primary Care Transformation – The Race to Value Podcast™

ChenMed was created with a mission to provide care in such a way that it could alleviate suffering for those seniors in the poorest of communities, recognizing that full-risk primary care can truly be transformative in providing superior health outcomes. This strong sense of purpose is what guides the physicians at ChenMed and serves as a moral compass in caring for patients. It is born out of an idea that ChenMed is a ministry that allows those in the organization to glorify God by spreading more love and promoting better health to those they serve.

ChenMed is a family-owned, primary-care physician run organization that serves a challenging population: 75% have five or more chronic diseases, 70% are racial minorities, the average age of patients is 73 years old, 95% of patients within 300% of the Federal Poverty Level. But the success speaks volumes: patients use hospital emergency rooms at a rate 34% below the national average,  have 50% fewer admissions than the average primary care practice, and have close to 30% lower cost. ChenMed’s scalable and successful approach has already reached 60 practices, and it is no wonder that they are poised to grow 4 times larger over the next 3 years.

Dr. Gordon Chen, CMO, along with his brother Christopher Chen, CEO, and other great leaders throughout the organization are proving that full-risk primary care is a solid and necessary foundation for winning the race to value!

Episode Bookmarks:

4:45 ChenMed named to Fortune Magazine’s “2020 Change the World List” for measurable social impact, business results, innovation, and corporate integration

5:30 Dr. Chen discusses the spiritual underpinnings of his family-run organization and the Chen family’s suffering during his father’s cancer misdiagnosis

10:13 The ChenMed ministry in glorifying God, spreading love, and promoting health in underserved communities that are suffering

11:20 A scalable approach that has resulted in 50% fewer hospitals admissions, a 75% reduction in ED visits, and 28% lower per-member costs

13:35 “The traditional, fee-for-service primary care model handcuffs PCPs to see more and more patient volume without being able to optimize outcomes.”

14:14 A Medicare Advantage full-risk business model allows ChenMed to see shrink the PCP panel size so they can focus on cultivating trusting relationships with deeper connectedness

15:50 How a full-risk model enables Primary Care Physician empowerment

16:55 The shift from a reactive approach (e.g. ER and preventable hospitalizations) to a more proactive, preventative model that supports health value

17:45 Having “Stockholm Syndrome” for a broken fee-for-service model that has held PCPs captive from practicing medicine in the way they thought they would when dreaming of becoming a doctor

18:05 COVID-19 as a tipping point for full-risk primary care models, struggling primary care, and PCP moral injury

20:40 Consistency of revenue within a capitated model

21:16 “Fee-for-service primary care is going to end. It is too challenging to make it work, and PCPs don’t like a purely transactional model that doesn’t value relationships.”

22:45 Dr. Chen discusses the fulfilling purpose of full-risk primary care and how it makes a deep impact in communities

24:55 Supporting high-risk patients through high touch telephonic “love calls” and telehealth

26:11 How ChenMed adjusted its care delivery model during the COVID pandemic (“flipping to 90% virtual in less than a week”)

29:05 Realizing the need for the ChenMed model is far greater than could have ever been imagined during a period of pandemic uncertainty and civil unrest

29:50 Finding the right balance between in-person and virtual visits during the COVID pandemic

30:34 “Telehealth is here to stay.”

31:05 Increased Net Promoter Scores when serving patients during the pandemic

31:30 Health inequities, racial disparities in care, and the plight of racial injustice in our society

33:30 Closing gaps in life expectancy within African American and Hispanic communities

35:30 Dr. Chen discusses his personal experience living homeless and without financial means to live comfortably

36:45 Populations with high chronic disease burden is the greatest opportunity to succeed in a full-risk model

37:25 “Full-risk primary care that spreads love and promotes health can create a beautiful, virtuous cycle where savings (earnings) can be reinvested into even more needy communities.”

38:15 ChenMed’s expansion from 76 centers in 2020 to 100+ centers in 2021 made possible by reinvesting earnings

39:00 Christopher Chen’s (Gordon’s brother) harrowing ordeal as a patient with a COVID-19 infection

40:45 “Every day is a precious gift from God.” (Dr. Chen discusses how both his father’s past suffering and his brother’s COVID-19 infection served as a call to action to make every day count.)

41:30 Dr. Chen’s reignited commitment to accelerate the scalability of ChenMed’s model following Christopher’s COVID diagnosis

43:25 Research showing that high-touch preventive care delivered by ChenMed can effectively prevent and manage cardiovascular disease

47:04 Since most EHRs are designed for fee-for-service, ChenMed decided to build its own.

48:21 How ChenMed’s homegrown EHR system provides enhances outcomes by integrating data

50:00 How ChenMed approaches physician and executive leadership development and interdisciplinary care team workforce development

52:50 “For ChenMed to be able to scale across America, we’ll need to train and empower leaders to transform care in communities.”

53:41 The “humble healer” approach to physician peer-to-peer learning

55:30 ChenMed’s hyper-accelerated your growth strategy by looking to quadruple over 3 years!

56:38 The moral imperative to grow ChenMed to serve as many needy communities as possible

59:55 “If we can have physicians, health care leaders, and team members share in the mission, vision, and passion for what we are doing at ChenMed, we believe we can change the world.”

1:01:00 “If we can accelerate this move to value-based care, and empower more people to go into primary care, then we are on the right track.  That is what America needs.”

The concept of “accountable care in the safety net” was introduced in a Dartmouth Study published by the Commonwealth Fund back in 2013.  In that study, there were 4 critical success factors outlined for a coalition-based Medicaid ACO: 1) aligned leadership through a shared vision, 2) strong governance, 3) a unified strategy for using data, and 4) a sophisticated care coordination infrastructure.  MHN ACO has exhibited excellence in all four of those areas.

Since 2009, Medical Home Network has served as a beacon for healthcare transformation and collaboration. Established as a formal provider collaborative working to improve healthcare delivery and access for individuals most in need, today MHN leverages a suite of innovative technologies, healthcare expertise, and a passion for improving the provider and patient experience to create practice-based programming that integrates Chicago’s delivery system, transforms on the ground delivery and achieves real results.

Cheryl Lulias launched and serves as CEO of the 1st Medicaid ACO in Illinois. The MHN ACO is provider owned and governed by leaders from 12 health care organizations, representing nine federally qualified health centers and three hospital systems. In an ever-changing healthcare landscape, MHN ACO has established itself as a beacon high value, high impact integrated delivery system in the safety net ensuring patients receive better care where and when they need it.

Bookmarks:

4:01 “History of Accountable Care in the Safety Net”  (Reference to Commonwealth study on FQHC coalitions forming ACOs)

5:38 Cheryl shares the history of Medical Home Network and its journey in health value

7:42 Creating a standardized, whole-person model of care centered within a digitally connected, clinically integrated delivery system

8:35 Cheryl discusses MHN ACO’s results ($50 million in savings, 24% reduction in inpatient hospital days, 25% reduction in readmissions, 8% reduction in ED visits)

9:51 FQHC resiliency during the COVID-19 pandemic crisis and scaling up of telehealth and virtual care

13:46 Adjusting MHN’s AI-powered risk stratification model to identify community members at high-risk for hospitalizations from a COVID infection

16:15 The devastating impact of COVID and the scourge of violent crime, drug overdoses, and suicides impacting Cook County

17:40 Establishing ADT connectivity and real-time alerting with 30 hospitals through MHN Connect Health Information Network

18:21 Data liquidity, supercharged AI predictive models, and the creation of a 360o patient view by integrating data from claims, pharmacy, and health risk assessments

21:04 How prediction of “rising risk” informs MHN’s whole approach to care management

26:10 Cheryl explains MHN’s collaborative care program that utilizes a decentralized, team-based approach where interdisciplinary care teams are embedded at the practice level

28:26 Cheryl shares a patient success story

31:17 Cheryl counters the skepticism of artificial intelligence by sharing the results of her collaboration with Closed Loop AI

35:22 MHN’s commitment to advance health equity and reduce disparities of care through the Racial Equity Rapid Response Team

36:41 The impact of systemic racism and threat it poses on the health of our communities

43:03 Holistic integration of primary care and behavioral health at Medical Home Network

45:43 Cheryl’s strategy in forming a Board that decoupled ownership and governance and created a balance of power between the health centers and the hospitals

49:37 MHN’s commitment to workforce development for care coordinators and community outreach workers

51:23 The challenges associated with provider and care team burnout in developing the workforce

53:48 MHN’s launch of a MoreCare, a Medicare Advantage Special Needs Plan in partnership with Cook County Health

57:09 Cheryl describes the future of medicine and what we need to do to fix a broken healthcare system

Today’s episode follows Austin Regional Clinic (ARC), a large multi-specialty medical group that serves over 500,000 patients in Austin, Texas. Founded in 1980 as an HMO, ARC is coming full-circle on their journey in value-based care as they now serve more than half of their population in value-based contracts.

Tyler Willson, VP of Population Health and Clinical Quality talks with us about the tipping point for value, ARC’s strategy during and post-COVID, as well as partnerships with payers. We also explore Austin’s unique market where corporate giants like Apple, Tesla, Amazon, and IBM are turning the area into a hub for innovation, which offers a unique opportunity for ARC. Find out what will happen with Medicare Advantage plans in the market, how analytics and automation are enhancing care, and how an important partner is making it all possible for ARC to be a leader in the race to value.

Bookmarks:

4:01 Reaching the financial tipping point in health value

5:24 Austin Regional Clinic’s value-based care journey

8:28 Tyler describes ARC’s current population health infrastructure

9:08 The shift of payment environment towards full- and delegated-risk models

10:25 Sourcing capital and investments to build infrastructure

10:45 JV with Agilon Health (a PE-backed company that supports ARC in taking fully delegated, capitated risk in Medicare Advantage)

11:35 Evaluating the landscape to determine strategic planning horizon, scope, and scale for VBC portfolio

12:00 How the increased level of involuntary risk will necessitate strategic investments in enhanced care models

12:35 Lessons from COVID-19 in determining the “true” risk in ARC’s revenue portfolio

13:40 Shared Savings are critical lifelines in the COVID era

14:40 Austin, TX as an emerging national innovation hub

16:04 “so much of an organization’s capacity for innovation comes from what it believes”

17:00 Competition for workforce talent in Austin

17:30 How to design and implement patient satisfaction surveys to collect meaningful data

18:53 Austin as an “innovate or die” type market

19:35 An outline of poor public health measures in the state of Texas

21:04 ARC’s commitment to patient access as a bedrock principle

24:05 ARC’s holding true to its value proposition during the pandemic crisis

25:11 Ensuring patient access to telehealth

26:00 Creating a patient-centered care medical home by focusing on patient access

27:10 An overview of ARC’s quality measure performance

29:00 ARC’s focus on automation, predictive analytics, and extensive outreach to ensure successful closure of care gaps

33:45 The use of ML and NLP in algorithms to drive automation in burden of illness documentation

36:22 Predictive analytics as the “unicorn of our industry”

38:00 Development of a Medicare Advantage strategy in partnership with Agilon

41:30 Incubating the types of infrastructure to test innovation viability for managing full-risk MA

42:31 The importance of an investment partner in ARC’s expansion of its full-risk MA portfolio

43:00 Market growth of Medicare Advantage being driven by consumer price sensitivity

45:00 Capturing accurate documentation in the burden of illness to the highest level of specificity

46:30 Advocating for CMS to include audio-only visits as a means to document and revalidate HCC codes

49:30 An overview of ARC’s participation in Medicare ACO program with Ascension Seton

50:58 Evaluation of the Direct Contracting ACO model

53:50 Employer-physician collaboration to deliver quality care

Primary care is especially compromised in the ongoing pandemic crisis. PCPs are uniquely vulnerable to the deleterious economic effects of COVID-19, since most of their revenue still comes from in-person visits which have plummeted since March amid widespread stay-at-home orders and fears about in-office virus transmission. The pain has been particularly acute for PCPs who are not backed financially by health systems, private equity or other entities. Roughly half of U.S. doctors still own their own practices, and those independents were already operating on razor-thin margins after years of reimbursement cuts, unfavorable payment structures, and expensive EHR and tech implementations. Add a pandemic to the mix, and it’s a recipe for disaster.

We are pleased to welcome Dr. Jed Constantz as our guest this week. As a primary care finance and delivery reform strategy consultant, he has worked with payers, employers, and providers, all the way from independent primary care physicians to large health systems. Over his 30 plus years in healthcare, he has developed tools and resources for primary care providers and employers seeking to reduce costs, drive greater efficiency and quality outcomes, and thereby create a “featured-and-favored” network in their regions and community. This process includes a deep focus on the selection of the right community of primary care physicians and specialists, a thorough audit of existing patient and population data, commitment to accountable care standards, and improved compensation for the physician. Jed comes with wisdom and critical counsel for sustaining PCPs as the foundation of our health care system.

Bookmarks:

5:50 The lack of a payment strategy for primary care prevents trusting relationships.

6:50 COVID-19 has provided a deeper understanding of why primary care needs to be purchased differently.

8:00 Payment reform will allow primary care to live up to the expectations of true patient-centered care and population health.

10:30 Primary Care must retain the agency to care for patients when underlying financial arrangements and equity positions change.

11:30 Terms and conditions of primary care business arrangements must allow physicians to continue to have a high level of accountability to the patient.

14:30 Primary care physicians must pursue business models that allow them to practice independent clinical decision-making.

16:00 The VillageMD and Walgreens partnership is a perfect example of a corporate model that retains primary care independence.

16:45 Blue Cross North Carolina as an example of how to calculate the future value of primary care so money in health care can be spent more intelligently.

21:55 Innovation must be focused on meeting the needs of the patients, and F2F encounters are not as important as we once thought.

22:40 Dr. Constantz explains how the FFS economic model makes it impossible to spend quality time with patients.

23:17 The innovation of telemedicine is a great example of how primary care was able to make a pivot towards improved population health during COVID-19.

24:00 The Primary Care Innovators Network (PCIN) and its contribution to innovating care delivery through payment reform.

24:42 The Triple Aim as a foundation for patient activation to improve health outcomes (Dr. Constantz cites the research of Judith Hibbard.)

25:08 Payment reform in primary care gives you the opportunity to imagine a different relationship between the primary care team and the patient.

26:50 The disruption of the employer-sponsored health insurance marketplace

27:52 Rosen Hotels as an example of what employers can do to take charge of healthcare costs and funnel savings back into the community.

31:15 Dr. Constantz shares his perspective on how self-funded employers are planning their health benefits strategy for 2021.

33:54 Partnership between The National Alliance of Healthcare Purchaser Coalitions (National Alliance) and the American Academy of Family Physicians (AAFP).

35:21 Collaboration between employers and community-based primary care to rebuild healthcare

37:53 Practice-level technologies are a core element of an advanced primary care model practice

39:00 AthenaHealth and Navina collaboration as an example of a technology enablement that drives clinical decision-making

40:20 The coupling of payment reform and a strong practice-level technologies program allows the care team to be redeployed more effectively

41:41 More effective ICD-10 documentation and capture is an opportunity to improve care in the “New World” of primary care

43:05 Dr. Constantz addresses the various factions of the primary care community that are still resistant to change

46:30 Not all primary care is created equal – focus on the most exceptional segment of advanced primary care first as a source of inspiration for the laggards.

48:57 The repositioning of the primary care industry to make it the predominant force of reshaping the future healthcare

50:00 Dr. Constantz questions the notion of a national primary care shortage and proposes that we instead consider more effective deployment of existing resources

50:51 Care team innovation will address the “shortage” of primary care by allowing for more effective execution of care plans (references the work of Dr. Peter Anderson)

53:20 Dr. Constantz posits that we should zero in on the sincere interest in succeeding in the care of an individual (instead of defaulting to financial risk arrangements)

56:20 The PCMH laid the foundation for primary care transformation but didn’t meet expectations because the money didn’t follow

58:30 True patient-centered care can improve outcomes and lower costs and is an important part of the ongoing evolution of primary care

59:45 The important of the ACLC in creating a catalog of resources for primary care and disseminating that knowledge to the entire industry

60:00 “The ACLC is the kind of organization that strengthens the ability to design a best-in-class primary care capability that is ultimately able to deliver the goods.”

Physician groups are becoming the dominant type of new entrant into the ACO space and have been most successful in achieving savings to date.  Many in our industry think that physician-led ACOs are at a disadvantage in comparison to hospital-led ACOs because they lack the capital and the administrative firepower to spin up a population health infrastructure. RGV ACO, one of the leading Accountable Care Organizations in the country, has proven that physician leadership is actually the key ingredient to success in health value.

Located in the southernmost tip of Texas along the US-Mexico border in the Rio Grande Valley, RGV ACO has achieved its success with some of the most insurmountable odds imaginable.  In the Rio Grande Valley, more than a third of families live in poverty. Nearly half of the residents have no health insurance, and obesity, diabetes, and heart disease are widespread. This region, made infamous by Dr. Atul Gawande over a decade ago in the New Yorker article “The Cost Conundrum” was once the most expensive healthcare market in the country.  In response to the problems of its local community, RGV ACO was formed and took the charge to lead a revolution in health value.  Their success story shows that something truly magical can happen when physician leadership, innovation, and aligned incentives converge in a way to solve important problems in our health care system.

In this podcast episode, we are speaking with Edwin Estevez, the Chief Executive Officer of RGV ACO.  Edwin is a remarkable leader in our health care industry and will share his journey in health value.  Anyone interested in how leadership can transform the care outcomes in a community should listen to the story of RGV ACO.  We are in a race to make health value work in our country, and RGV ACO is a true success story of how to beat the odds and transform the lives of many.

06:45  Creating a competency-based framework for value-based care

10:00  The Success of Physician-Led ACOs

13:00  When “something magical happens in value-based care”

15:20  Community engagement with high-risk populations

18:10  Tapping into the altruism inherent in the practice of medicine

19:30  Creating “interdependence” for independent physicians

22:14  Capital requirements for startup ACOs

25:15  Creative thinking and capital support from payers

28:17  Incentivizing for physician leadership and process transformation

32:40  Overcoming the “The Cost Conundrum” by refusing to fail

35:00  Engaging the community in a culturally appropriate way

36:00  Home Health Partnerships

38:42  Addressing Racial Disparities in Care and Health Equity

43:00  Developing a Patient-Centered Diabetes Care Playbook

48:55  Partnering with local grocery stores to improve population health

54:00  Edwin shares his passion for health care and education

58:00  Workforce Development for independent practices within an ACO

1:02    Next-level risk contracts and multi-payer strategies

1:07    Direct Contracting must be “physician-led” to be successful