Quality Improvement – The Race to Value Podcast™

Today Ashley sat down and talked with Dr. Edwin Estavez.  Edwin is the founder of the Altacair Foundation.   He Previously, served as Market President of Value Based Care at Prominence Health, a leading health care company that provides high quality, cost-effective care to diverse populations. Edwin, has over 30 years of experience in health care and higher education administration, risk management, and business development, with a PhD in Administration and an MSW. He is passionate about organizational transformation. From health care delivery and outcomes through value-based care tactics, to patient engagement programs, and care coordination models.  Join as we chat about the mission of Altacair, how he ensures the foundation stays true to its mission and vision, and the collaboration between Altacair and The Leavitt School of Health on the Accelerator Conference.

Altacair Foundation:  About Us – Altacair Foundation

Accelerator 2024:  https://www.eventbrite.com/e/accelerator2024-advancing-value-for-health-equity-tickets-951490021267?aff=oddtdtcreator

The only way for the health care sector to sustainably contain costs and fulfill its mission is by putting the patient — and the delivery of outcomes that matter to patients — at the center of the industry’s efforts. We must align incentives around the continuous improvement of health outcomes in a cost-effective matter. This is what value-based health care is all about – better health outcomes to patients for the money spent. Contrary to traditional approaches to health system reform that emphasize cost containment, value-based health care shifts the focus to continuous improvement in the outcomes delivered to patients.

On the Race to Value this week, we are joined by two of the four authors from the new healthcare book, “The Patient Priority”. With this book, they wrote a practical step-by-step guide for clinicians, payers, policymakers, and other industry stakeholders to lead patient-centered, value-based health care innovation. It presents case studies from leading innovators and provides a roadmap for the comprehensive value-based transformation of national health systems. On the show this week is Stefan Larsson, MD, PhD — an independent advisor in health care and life sciences, and a senior advisor to Boston Consulting Group (BCG).  Joining him is Robert Howard, a former senior editor at Harvard Business Review and MIT Technology Review who collaborates with BCG on the topics of value-based care and health system transformation.

Episode Bookmarks:

01:30 Putting patients first is the only way for the health care sector to sustainably contain costs and fulfill its mission.

02:00 Introduction to Stefan Larsson, MD, PhD and Robert Howard and their new book, “The Patient Priority.”

03:00 Support Race to Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts.

04:30 The Triple Crisis:  There is a Crisis of Value, a Crisis of Evidence, and a Crisis of Purpose in American Healthcare!

05:30 How the vicious cycle of how a continued explosion of medical research knowledge drives higher costs due to anxiety and lack of guidance.

07:00 The crisis of outcomes (e.g. obesity, declining life expectancy) have persisted over a long period of time.

07:30 “The health care crisis will only get worse unless there is a fundamental shift in how we lead, define success, and agree on what good looks like.”

08:00 The criticality of shifting to an outcomes measurement model that values what matters to patients.

08:30 “Outcomes that matter to patients is the essence of the future of health care.”

09:00 Why the value-based care movement should focus more on the system than the individual provider organizations.

09:30 “The only way individual organizations can sustain value-based change is if we transform health systems as a whole – on a regional, national, and even international level.”

10:00 Health care is a complex adaptive system, and you don’t change it through rules-based policy.

11:00 “Measuring outcomes in accordance to what matters to patients should be the key metric to drive change in health care.”

12:30 This importance of clinical registries that collect comprehensive data on health outcomes in a population of patients with the same condition.

13:00 How a fragmented specialty-dominated healthcare system limits our ability to develop consensus standards for measuring outcomes that matter to patients.

15:00 “By measuring the outcomes that matter to patients, we take a holistic view of health care.  We can then integrate all the different professional capabilities in the most ultimate way.”

15:45 The important work of the International Consortium for Health Outcomes Measurement (ICHOM).

16:00 How Sweden is a driving force for the international adoption of patient-centered outcomes measures and clinical registries.

17:30 Why a health care comparison of Sweden to the United States is relevant. (Patient needs are the same!)

18:00 Stefan discusses how his partnership with Michael Porter led to the development of global standards for health outcomes measures through ICHOM.

18:45 A health system’s scientific approach for improving patient outcomes with acute myocardial infarction.

19:30 Outcomes measurement as a holistic approach to team-based, value-based care.

20:00 A decade of ICHOM’s work in leading a global movement for the adoption of standardized patient reported outcome measures.

21:30 “Patient registries are so much more than databases.  They are systems for continuous improvement and accelerate learning for professional communities.”

23:00 How the Cystic Fibrosis Foundation and Kaiser Permanente are excellent examples of how patient registries can be utilized in the U.S for continuous improvement.

24:00 The work that Blue Cross Blue Shield of Michigan is doing to propagate best practices in outcomes measurement.

26:00 Three leading exemplars that have a patient-focused approach to care delivery: Martini Kiinic (Germany), Oak Street Health, and Kaiser Permanente.

27:00 What can value-based care leaders learn from a prostate cancer clinic in Germany?

28:45 How incumbent healthcare organizations can utilize patient segmentation, accountability, and expert consensus in establishing outcome measurement goals.

29:30 Examples of how Cleveland Clinic and the Karolinska University Hospital (Sweden) completely reengineered healthcare delivery around specific patient groups.

30:00 “Defining success in outcomes measurement provides more autonomy to clinical care teams and allows them to organize around patients instead of specialties.”

30:30 Bridging fragmentation by coordinating care delivery along the provider chain.

31:00 How Martini Kiinic (Germany), Oak Street Health, and Kaiser Permanente are different but the same (e.g. focus on population segments, team-based care, data-driven).

33:45 A deeper exploration into patient-focused outcomes measurement and the team-based culture at Oak Street Health.

35:30 How Kaiser Permanente started a bus line to help unemployed patients access transportation so they can find employment.

37:30 Four examples of value-based change management:  Santeon, Erasmus MC (both in the Netherlands), Karolinska University Hospital, Intermountain Healthcare.

38:30 Visionary Leadership in value-based care transformation.

39:00 Martini-Klinik’s founder, Hartwig Huland, made the decision to focus narrowly on one field, prostate surgery, to lead the organization in VBC transformation.

41:30 An example of the transformational leadership of Marc Harrison (former Cleveland Clinic Abu Dhabi and Intermountain CEO).

42:30 Defining the strategy in value-based health care and navigating change management during system transformation.

43:00 Accepting responsibility beyond your own institution to improve the overall health system.

44:00 How Toby Cosgrove led both system-level and national health care transformation.

44:30 “Value-based health care can’t be done in isolation. It can only happen at scale when all stakeholders are aligned. Leaders must transform beyond the borders of their institution.”

46:00 Transformation VBHC can also happen from leadership in the middle of the organization.

50:00 The evolution of value-based payment innovation – from Medicare Advantage in the U.S. to experimentation with bundled payments in health systems around the world.

51:30 What does the transition from volume to value really mean?  (It won’t work unless it is holistic with payment focused on outcomes.)

53:45 The correlation between outcomes measurement reporting and payment models like Medicare Advantage capitation and episode of care bundles.

56:30 “In the U.S., value-based health care is all too often reduced to risk-based contracting.  Our view is that this is an oversimplification.”

57:30 “Medicare Advantage is a stimulus to value-based care innovation, but it still needs to become more connected to systematic outcomes measurement.”

58:30 The testing of payment models by CMMI shows mixed results.  The Innovation Center Strategy Refresh emphasizes an increased focus on outcomes measures.

61:00 Continued challenges in healthcare with data siloing and limited interoperability.

62:00 The need for data sharing to overcome health care complexity necessitates public-private investments in data security.

63:00 Additional investments in interoperability and health care informatics.

64:00 Artificial Intelligence and Machine Learning in patient outcomes for improved population health.

65:00 The ubiquitous use of outcomes measures through digital learning platforms will transform the health of the world.

66:00 CORAL:  Community in Oncology for Rapid Learning (an example of a leading AI-based digital learning platform at a global level).

67:00 The moonshot opportunity for value-based health care is not unlike John F. Kennedy’s 1962 decision to land a man on the moon b the end of the decade.

68:00 “The beauty of a patient-centric and outcomes-focused approach to health care is the alleviation of human suffering for all citizens across the world.”

69:00 The global approach to health care reform is not overly optimistic – it can be achieved.

71:00 COVID-19 has broken down pathways to international collaboration, yet there are countless examples of local innovation.

72:00 Imagining a world where heroic clinicians unite to form a better health care system.

Three perfect storms in recent years – the health storm produced by the COVID-19 pandemic; the economic storm that resulted from its disruptions; and the social storm that followed the murder of George Floyd which sparked fresh outrage at longstanding inequities – have sharpened and added important nuances of what health care really means. The goal of health care has always been to reduce suffering, but we must now prioritize transformation in leadership now more than ever. Building trust, eliminating inequities, and ensuring high reliability are of the highest magnitude of importance as we blaze a new path forward.

This week, on the Race to Value, we are joined by Thomas H. Lee, M.D., the author of the new book “Healthcare’s Path Forward” to discuss how the healthcare industry is being transformed by deeper knowledge of what suffering means for patients, their families, and healthcare providers themselves. Since healthcare is not working for anyone, Dr. Lee provides wisdom and insights of optimism for where true change can happen in creating new standards for excellence.

In addition to being a bestselling author and expert on healthcare transformation, Dr. Lee is the Chief Medical Officer of Press Ganey.  He brings more than three decades of experience in healthcare performance improvement as a practicing physician, leader in provider organizations, researcher, and health policy expert. He’s responsible for developing clinical and operational strategies to help providers across the nation measure and improve the patient experience, with an overarching goal of reducing the suffering of patients as they undergo care and improve the value of their care.

Episode Bookmarks:

01:30 Introduction to Thomas H. Lee. M.D. and his new book “Healthcare’s Path Forward”

03:00 Support Race to  Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts.

04:00 The six elements of organizational culture that lead to transformation – Excellence, Trust, Respect, Inclusion, Resilience, Reliability

05:00 John Nash (“A Beautiful Mind”) and Non-Cooperative Game Theory

06:00 Optimism for healthcare because how bad things really are!

07:00 Nash Equilibrium states are commonplace in healthcare – it creates inertia and stifles change.

08:30 “Equilibrium states break down when the pain of the status quo exceeds the fear of the unknown for multiple parties.”

09:00 “Healthcare is not working for anyone.  That is where real change can happen and what makes me optimistic.”

09:45 The destabilizing trends of supply chain disruption, social unrest, political divisiveness, consumerism, demographic shifts, workforce drain, and environmental disasters.

11:30 Responding to social justice, climate change, and the need to redesign healthcare – is it too much for us to tackle all at once?

12:00 “Changing the way healthcare is paid for – in absence of other reforms – is grossly inefficient.  There are many other things that have to happen.”

12:30 Michael Porter’s Value Chain and the importance of clarity and differentiation in the creation of value.

13:30 “Payment reform is just one activity of healthcare reform.  We also need trust in the workforce and with patients, an understanding of what safety means, and a response to consumerism.”

15:00 In times of turmoil, healthcare organizations need more than a performance culture; they need a learning culture.

16:30 The most important part of transformational leadership is division of responsibilities and areas of key focus to enact organizational change.

17:30 No one can do everything!  If leaders focus on only three things, they will be successful in strategy execution.

18:30 3 Functions of Governing Boards and Executives: Articulate the Core Values, Develop Strategy, Understand the Value Chain

18:45 “An organization is the lengthened shadow of its leaders.” – Ralph Waldo Emerson

20:30 3 Functions of Managers: Create Social Capital, Bring High Reliability Principles to Life, Eliminate Waste of all Types

21:30     “Social capital is more important than financial capital in the times in which we live.”

22:00 Applying High Reliability to all the dimensions (including patient experience) and refusing to tolerate failure in matters of trust.

23:45 “Culture of No Waste” – includes both time and resources

24:30 3 Functions of Frontline Caregivers: Create a Culture of Respect, Be Full Participants on Great Teams, View Job as Shaping the Memories of Patients and Families

25:30 The healthcare workforce often feels that they are part of a organization that does not respect them.

26:30 “Treating people with respect should be treated in the same way that the industry tackled hand hygiene to improve patient safety.”

27:45 Referencing the TED Talk from Daniel Kahneman: “The Riddle of Experience vs. Memory”

29:00 Frontline caregivers are like Steven Spielberg, i.e. they are the producers and directors of the patient memories.

32:00 “We live in a time where trust is under attack in society.  You can’t take trust for granted in healthcare.”

33:00 Trust goes beyond the clinician encounter – it encompasses the whole episode of care, including the web presence of the provider before the visit.

35:30 The importance of 5-Star Ratings online in building trust.

36:30 “Patients are unnerved from friction, chaos, and any indication that they may not be safe. The pandemic has really heightened their fears.”

38:00 Dr. Lee discusses how Press Ganey has begun surveying patients on their perceptions of patient safety.

39:45 High-reliability and the Anna Karenina Principle (“Happy families are all alike; every unhappy family is unhappy in their own way.”)

41:45 In 2021, the Press Ganey Employee Engagement Indicator declined in every single job category!

43:00 Dr. Lee discusses how building trust with workers coincides with the actions taken to build trust with patients.

44:30 Personal Pride:  Pride in the organization, Pride in what you do for the organization, Pride in what your team does.

45:30 Personal Alignment: Aligning with the cultural beliefs of employees and the need for inclusion. (Lack of DEI creates a 4X greater risk of employee turnover.)

46:00 Personal Resilience: Activation (employee motivation) and Decompression (ability of employees to forget about work when at home).

47:30 Activation is increasing in healthcare, but decompression continues to go down!

50:00 Dr. Lee explains how the pandemic and social unrest has created a deeper understanding of human suffering and how systems create harm.

50:30 Understanding Patient Safety beyond Physical Harm by also considering Emotional Harm (e.g. not feeling safe or financial distress due to healthcare)

51:30 The nuance of perception in Patient Safety (an example of how patients didn’t feel safe when a change when a hospital starting using odorless disinfectant).

53:00 Lack of respect as a safety issue.

53:00 The murder of George Floyd prompting an examination of the impact of inequality throughout society.

54:00 Diversity, Equity, and Inclusion in healthcare as a form of social capital and the pursuit of zero inequity.

55:00 The importance of DEI in health equity is now understood at a deeper level by healthcare leaders following the murder of George Floyd.

56:00 “Zero Inequity should be our goal just like Zero Harm is our patient safety goal.”

56:45 The data from safety net hospitals showing continued challenges in assessing pain with African American patients.

58:00 How organizational mistreatment of patients creates mistreatment of workers (and why lack of patient-centeredness is main reason for employee turnover).

61:00 Dr. Lee touts the virtues of healthcare and why it is such a great industry to work in.

62:00 New Skills for the Era Ahead:  Strategy (Porter’s Value Chain), Social Capital (Teamwork, Leadership), Growth Mindset (read Grit: The Power of Passion and Perseverance!)

64:00 The potential to do great work in medicine and making a difference in the lives of others.

64:30 “This is the best time to be going into healthcare. You can really make a difference in a noble field.”

65:00 How to reach out to Dr. Lee and learn more about his work in healthcare transformation.

This week on the Race to Value you will hear from Dr. Neil Wagle, the Chief Medical Officer at Devoted Health. This is a company we have been wanting to profile on the podcast for quite some time! Devoted Health is a healthcare company that designs Medicare Advantage plans for seniors; however, they are so much more than just a MA plan. Devoted Health has built a different model of care that starts with knowing their members on a personal level and earning their trust. By focusing on each member as a person and not as a chart, they are able to provide the best quality care for older Americans through an all-in-one healthcare solution combining the MA plan, access to high quality local providers alongside virtual and in-home care, and full-service guides—with world-class proprietary technology powering it all. This company is a leading innovator in value-based care.

Dr. Neil Wagle knows a thing or two about transforming healthcare. He is an internal-medicine physician by training, spent six years at Partners Healthcare (now Mass General Brigham) leading the health system’s efforts to improve the quality of care for patients. In 2017, he joined Devoted Health, a $12.7 billion health-insurance startup. As its chief medical officer, he’s spearheading the development of a model of care aimed at improving the health of older Americans by getting them the right care at the right time while saving costs for the US healthcare system.

In this episode, we discuss clinician burnout and moral injury, post-pandemic recalibration of the healthcare system, virtual care delivery, the benefits of a fully-integrated technology platform, health equity transformation, creating a virtual “Blue Zone”, patient-reported outcome measures, activation of chronically ill patients, and the importance of company culture in delivering relationship-based care.

Episode Bookmarks:

01:30 Introduction to Dr. Neil Wagle, the Chief Medical Officer at Devoted Health.

03:45 Dr. Wagle provides his background as a “synthesizer between medical-scientific world and the business world.”

04:15 Inspiration and mentorship from Dr. Tom Lee and being a part of Mass General Brigham’s first value-based contract.

04:45 “We’ll probably lose $70m in the first year, but we’re moving to value-based care because it is the right thing for patients.”

05:45 A chance coffee meeting with Ed Park led to the “ridiculously challenging” quest to build a system that could radically transform healthcare!

07:00 Provider burnout and moral injury is one of the major crises in healthcare (along with rising costs and inadequate care for aging Americans).

08:45 Dr. Wagle on how the pandemic has exacerbated moral injury and why we need to return to the altruistic underpinnings of medicine.

09:30 “The ability for physicians to connect with others has been decimated by overbooked 15-minute visits.”

09:45 How documentation requirements in fee-for-service medicine robs providers of “pajama time” with their families.

10:00 The Great Resignation in healthcare is being driven by the perpetuation of the fee-for-service business model.

10:30 Resolving the three crises of healthcare (i.e. Provider burnout, aging population, and rising healthcare costs) through care delivery transformation.

11:00 The good news in VBC: providers want to practice medicine in this way and patients actually have better outcomes with lower costs!

11:45 “You have to be able to monetize fewer hospitalizations. If you can’t, the value-based model of care won’t work financially.”

12:30 The emotional fuel of seeing better patient outcomes in VBC drives continual value-based care transformation.

13:00 The new wave of healthcare consumerism from the pandemic is causing a much-needed recalibration of care delivery.

14:00 “COVID exposed cracks in our fee-for-service model…”

15:45 “Value-based care is actually the ideal home for virtual care services because you don’t have to worry about over-utilization.”

16:00 Dr. Wagle describes how Devoted Health dramatically improves the health and wellbeing of Americans through person-centered care.

16:30 The “all-in-one healthcare” offering of Devoted Health as a virtual in-home medical group and MA plan, enabled by full-service guides and integrated technology.

17:30 Medicare Advantage patients receive this “all-in-one” care for free as part of their enrollment in the health plan.

17:45 Scaling a virtual care model further enhanced Devoted Health’s mission to treat members like family.

19:15 Overcoming the challenges of loss aversion in the perception of patients when adopting a virtual-first care delivery model.

20:00 The benefits of a virtual-first mentality when it comes to organizational scalability and culture.

21:30 Devoted Health has developed an end-to-end data and technology system that choreographs care delivery in a single, vertically integrated, tech-enabled model.

22:00 Dr. Wagle on the well-deserved skepticism of technology as a panacea…but how that is balanced with the practical vision of Ed and Todd Park.

22:45 Building a full-stack technology platform from the ground up was necessary (market-based solutions are based on FFS medicine and are incredibly fragmented).

23:00 Full-stack tech platform at Devoted does everything! (e.g. sales, enrollment, pharmacy, medical claims, prior authorizations, customer service, full EHR)

23:30 “Having a full-stack technology platform with all information in a single place allows us to deliver on the promise of complete, coordinated, and customized care.”

24:00 How human-centered technology design drives targeted population health interventions and personalized care delivery.

27:00 Human connection (relationship-based care) can be fostered with a full-stack technology platform because people don’t have to remember minute details.

28:00 Enabling tech-enabled rapid cycle innovation to deliver improved population health outcomes.

29:00 The challenges of defining “value-based care” and how health equity is changing how we understand value.

30:30 The historical debate about the adjustment of outcome measures to account for demographic factors.

31:00 “The world has moved to a different place where we have put a spotlight on health equity itself, rather than burying it in adjustment methodologies.”

31:45 How “Community Guides” at Devoted Health correlate the overcoming of SDOH with the Maslow Hierarchy of Needs to help members achieve full potential.

32:30 An example of how helping a member successfully enroll for public benefits can give them an extra $ 325/mo.

33:00 The development of a Health Equity Dashboard to measure their impact in closing equity gaps.

34:00 The product goal of Devoted Health is to be the world’s first virtual “blue zone” where people enjoy much longer, healthier lives than average.

35:00 “Longevity is not the ultimate goal. The first task of a health system is to make sure we treat people like family so they are happy and fulfilled.”

36:30 Dr. Wagle on what it really means to create a virtual Blue Zone at Devoted Health.

37:45 Creating the “Devoted Social Club” to help members overcome loneliness and social isolation through human connectedness and resilience tools.

39:30 Dr. Wagle on why the people and the culture is the foundation of Devoted Health.

41:30 “As we go out and look for new team members we look for experience, clinical acumen, and love in your heart.”

43:00 Caring for the clinician workforce so they can cultivate the love in their heart for the caring of others – it is a self-perpetuating phenomenon.

45:00 Keeping the mission as a “prime directive” by closing your eyes and imagining someone you love…than take action.

46:45 How Community Guides cultivate trusting relationships with members and help people overcome their mistrust of the healthcare system.

47:30 Spending time with members as an enabler of trust and empathy (e.g. a 90-minute phone call).

49:00 Trusting relationships are why Devoted Health has such a high net promoter score of 79 (higher than Apple, Netflix, and Amazon).

50:30 Starting with “Patient Priorities Care” in member engagement first…and then moving to data-enabled, rapid-cycle deployment of interventions.

51:30 Dr. Wagle discusses the importance of Patient-Reported Outcome Measures in value-based care.

54:00 6 in 10 adults have a chronic disease, and it is the leading driver of the nation’s $3.8T healthcare spend.

54:30 Dr. Wagle provides examples of how Devoted Health is making an impact in medication adherence and Hgb A1c reduction.

56:00 85% of diabetic members have their blood sugar under control, with an average A1c reduction of 2.3 within 100 days.

56:30 77% of hypertensive members now have their blood pressure under control, with an average reduction in systolic BP of 15.2 within 40 days.

57:00 Reduction of acute events related to Congestive Heart Failure by 50%.

57:45 Dr. Wagle shares an a research example of “learned helplessness” in dogs and how that behavioral pattern relates to most chronically ill patients managing their disease.

60:00 “We must relate clinical outcomes back to patient priorities. Those cycles are what capture momentum.”

61:30 Dr. Wagle discusses company growth and expansion and how Devoted Health is entering eight new states in 2023.

62:15 How will Devoted Health consistently replicate and scale as it enters into new markets at a national level?

64:00 Parting thoughts of appreciation from Dr. Wagle and how gratitude makes dreams come true in value-based care!

64:45 “Value-based care is more than possible…it is coming.  The arc of history is bending towards progress, and I am grateful to be a part of that journey.”

Paying it forward begins in the heart. Leaders who use their gifts in the service to others are those who understand that value given is value added.

By every measure of success, Dr. Shawn Griffin has become one of the most impactful physician executives in value-based care transformation. And his story is all about how he recognized his unique gifts and built amazing teams to improve population health outcomes. Additionally, his sharing of best practices and key learnings with others across the country – through peer learning and mentorship – has amplified impact in improving the lives of others. The host of this podcast, Eric Weaver, was one of the people impacted by the mentorship of Dr. Shawn Griffin. His mentorship inspired Eric to make a difference as an evangelist for a better way of delivering care in this country.

In this episode, you will gain access to an in-depth conversation with Dr. Shawn Griffin, the President and CEO of URAC. You will be inspired by his servant leadership in the pursuit of value-based medicine, and you will learn of his career path from rural physician to one of the leading physician executives in the country. We discuss the important of team-based care delivery and primary care transformation.  We also cover such important topics as healthcare accreditation, quality improvement, rural health care, pharmacy integration, technology innovation, and genomics-based care.

The truest measure of a leader is whether they are generous, have a big heart, and pay it forward. Dr. Shawn Griffin is the quintessence of this type of servant leadership in the race to value!

Episode Bookmarks:

01:30 Introduction to Dr. Shawn Griffin, the President and CEO at URAC

04:00 Eric shares a personal extension of gratitude to Dr. Griffin for the mentorship he provided years ago.

06:45 Dr. Griffin describes his journey in value-based care, beginning in the early days of practicing rural family medicine.

08:00 The United States is an outlier in that Primary Care is not at the center of medical care delivery.

08:45 A decision to impact more lives by taking on leadership roles in system design and care delivery transformation.

09:30 How love for family and others manifested into a commitment to patient care quality.

10:30 Building an effective Population Health Team at Memorial Hermann ACO during his leadership tenure.

11:00 The importance of effective storytelling and celebrating wins to drive value transformation.

12:00 “One has to decide in life if they are going to use their gifts to help themselves or help others.” (how VBC leadership is Dr. Griffin’s way of paying it forward)

12:45 The impact of constantly changing health policy on ACO success (and how frustration led Dr. Griffin to make a difference at a federal level).

13:30 How mentorship and teaching in value-based medicine can transform care delivery on a national scale.

17:00 Dr. Griffin explains the importance of accreditation programs and how URAC was founded to set standards in healthcare.

19:00 Specialty Pharmacy Services Accreditation as an example of standard setting to drive quality improvement.

20:00 Telehealth Accreditation and how “Telemedicine is more than just a good camera. It is good quality medical care using technology to do it.”

21:00 “Raising the bar and advancing the quality mission as things change is what accreditation should be doing.” (Reference video on revamping telehealth accreditation)

22:00 Why an accredited program (e.g. URAC Gold Star) provides a basis for a patient to validate their trust in the care provided.

23:00 Dr. Griffin discusses how URAC accreditation is driving care delivery redesign across the world (e.g. Egypt and Saudi Arabia).

25:00 The challenges of defining health care quality.

26:30 “Measuring quality is an ongoing unsolved problem in health care.”

27:30 The power of a trusting patient-provider relationship in care quality and how patient definitions differ.

28:30 The limitations of HEDIS measures.

29:30 Quality measurement data capture at the point-of-care is a major contributor to provider burnout (“checking the boxes”)

32:00 “Most of us have better information available on picking a hotel in Paris than we do selecting a high quality primary care provider.”

34:00 Realigning incentives to get more medical students to practice family medicine in rural communities.

35:00 The role of the federal government to ensure adequate access to primary care in rural areas.

36:00 The crushing economic pressures on rural hospitals.

36:30 “We talk about food deserts in cities. We have provider deserts in the country.”

37:30 “If we are concerned about providing electric charging options for someone’s Tesla crossing the country, perhaps a bigger concern is whether you can receive healthcare in rural parts of the country.”

40:00 Dr. Griffin on opportunity for pharmacy integration and team-based care.

41:00 “One of the good things about medicine in the last 40 years is the recognition that a ‘captain of the ship’ model is not sustainable for doctors or patients. Team-based care is the way to go.”

42:30 The role that URAC is playing in Pharmacy Accreditation and Rare Disease Certification.

45:30 Dr. Griffin on the importance of data liquidity and information sharing in value transformation.

47:00 How concerns about HIPAA compliance (a “HIPAA-chondriac”) can contribute to the problem of data siloing.

47:30 “More data is not always better for physicians. Technology will not always make health care better. A relationship will do more for a person’s health.”

49:00 Balancing Population Health Management with Targeted, Individualized Interventions (examples such as Kaiser Permanente, Intermountain, UPMC).

52:30 Dr. Griffin discusses how the pandemic shifted consumer demand for telemedicine and what we should expect for telehealth delivery in the future.

54:00 Behavioral health telemedicine visits are effective. Pre-surgical screening for heart transplants does not work with telemedicine.

55:00 The “Telemedicine Tug-of-War” going on nationally and why we must always consider the most appropriate application of technology.

56:00 Convenience doesn’t trump quality.

57:00 Telemedicine, Remote Patient Monitoring, Wearables, ML/AI – these will not suddenly make healthcare the “Garden of Eden” overnight.

58:30 Parting thoughts on genomics-driven care and individualized-care planning in a population health model.

59:00 A patient’s Walmart receipts are more valuable to a physician than genomic data.

60:00 Screening genomics for hereditary diseases are scaling as costs come down, but we still cannot discount the impact of lifestyle choices on health.

63:00 How to find out more about URAC and the importance of peer learning and sharing of best practices.

In this episode, we are going to discuss the impact of diagnostic errors on health equity. For patients of color, the unequal medical care and quality of the diagnosis received isn’t due to just location, education, or income. It’s also at times due to healthcare professionals’ cognitive biases, along with decades of clinical studies that examined only white, male bodies, and a lack of understanding about the social determinants of biological illnesses.

The causes of poor quality diagnosis for people of color is multifactorial and is not just related to explicit or implicit racial bias, however — lack of trust, missing data, and reduced data at the point-of-care are just a few of the other contributing factors. Although health inequities within communities of color have persisted for hundreds of years, many are just now waking up to the problem.  There is now an elevated sense of awareness of health inequities in our country due to the exacerbated health outcomes triggered by COVID-19 and preexisting disparities that have been magnified under the microscope of the pandemic.

If one studies history, you can easily find preexisting health inequities that took form long before COVID. It is widely accepted that the first kidnapped Africans to reach European colonies in the Americas for the purposes of slavery did so in 1619 – meaning Black health was ignored from or country’s beginning with health disparities persisting through the next 400+ years. The very foundation of the transatlantic slave trade is false medical theories of black inferiority and physical differences between blacks and whites.

To better how the patient safety movement aligns with health equity, healthcare professionals should listen to Dr. Ronald Wyatt.  Dr. Wyatt is one of the most renowned patient safety experts and health equity champions in this country.  He is Vice-President and Patient Safety Officer at MCIC Vermont, a risk-retention group, where he leads multiple patient safety initiatives for several leading academic health systems. He is an internationally known equity, safety and quality improvement/implementation expert. Dr. Wyatt was the first co-chair of the Institute for Healthcare Improvement (IHI) Equity Advisory Group and is faculty for the IHI Pursuing Equity Initiative. After serving as the Medical Director for the US Defense Health Agency/Military Health System Patient Safety Analysis Center, he became the first medical director of The Joint Commission (TJC) Office or Quality and Patient Safety and the first patient safety officer for The Joint Commission. While at TJC, Dr. Wyatt led the team that wrote the Patient Safety Systems Chapter, contributed to Sentinel Event Alerts and created the Quick Safety publication. He served as technical advisor on the RCA2 document that has been widely adopted as a guide to completing a root cause analysis.

Dr. Wyatt is a member of the ACGME Clinical Learning Environment Review committee, as well as faculty on the ACGME Disparity Collaborative. He also serves on several boards including the IHI Certified Professional in Patient Safety, the Society to Prevent Diagnostic Error and the Consumers Advocating for Patient Safety. Currently, he is faculty/advisor/coach on multiple health equity collaboratives including BCBS Massachusetts/IHI, ACGME BCBS Illinois Equity Matters, KC Learning Action Network and the Providence health system equity collaboratives. Dr. Wyatt has written and published many articles, blog pieces and chapters on patient safety, health equity/disparity and process improvement.

Episode Bookmarks:

01:30 Introduction to Dr. Ron Wyatt

04:30 The human cost of diagnostic error (patient deaths due to a diagnostic error are estimated at 40,000-80,000 per year!)

06:00 “To make the right diagnosis in a timely manner is a core quality component.”

06:30 Dr. Wyatt discusses how correct diagnoses are the link between patient safety and healthcare quality.

07:15 The patient safety goal in diagnostic accuracy is “Zero Preventable” harm, injury, and death.

08:00 Prioritizing a culture that values open lines of communication, teamwork, and patient engagement.

08:30 The authority gradient in medicine that makes individuals less likely to speak up or report a diagnostic error.

09:30 Poor leadership is the common denominator of healthcare organizations with high rates a sentinel events.

10:00 Dr. Wyatt discusses his patient safety work with The Joint Commission that identified root causes of sentinel events.

11:30 LEADERSHIP: The leadership behaviors required in hospitals and health systems to support high performance in Patient Safety.

12:30 The need for leaders to hold physicians accountable and apply systems thinking (going after the “unknown unknowns”)

13:30 CULTURE OF SAFETY: The institution of a Reporting Culture to mitigate risks of patient harm.

14:30 Establishing a system of transparency in a culture that creates a “psychologically safe environment.”

15:30 Implementing strong corrective actions is the responsibility of good healthcare leaders.

16:30 CONTINUOUS PROCESS IMPROVEMENT: using tools and methods to create a closed loop system to make the system safer.

17:15 “Leadership, a culture of safety, and continuous process improvement must all be strategically aligned, operationally robust, and tactically impactful.”

18:30 Health inequities have resulted from healthcare professionals’ cognitive biases and other issues of institutional racism leading to poor trust.

19:15 The origins of health disparities beginning with the transatlantic slave trade.

20:30 Defining health inequity – health outcomes that are avoidable, systematic and unjust.

21:30 Contributors to inequities — Institutional racism, stereotype bias, implicit bias, workforce capacity, resource allocation, ineffective DEI strategies

21:45 “The canary in the coalmine for health inequity existed long before COVID.”

22:30 Dr. Wyatt provides a comprehensive explanation of the history behind  slavery and how the resultant devaluing of black lives led to health inequity.

23:45 Social drivers of health as the manifestation of racism.

24:45 Food insecurity explains why Mondays are the most attended school day of the week.

25:30 Mortality rates of minority populations during COVID-19 pandemic should not have been a shock to anyone studying public health data.

25:45 Implicit and explicit bias and “trust decay” due to lack of empathy by the health system.

26:20 Dr. Wyatt describes why current DEI efforts are insufficient.

27:15 The cultural revolution for civil rights and social justice following the murders of George Floyd, Breonna Taylor, Ahmaud Arbery, and others.

29:00 Dr. Wyatt discusses how over-policing is a public health issue and shares a personal story of how he was discriminated by police as a young man.

30:00 Slave patrols that led to a persistence of racism in law enforcement that carries on to the modern day.

30:20 Dr. Wyatt discusses “The New Jim Crow”, i.e. mass incarceration of African American males in the U.S.

32:00 “Weathering” in adulthood due to past childhood experiences of racism and over-policing that are carried over to the healthcare system.

32:30 Dr. Wyatt shares the story of police beating a patient inside of a hospital and how an African American physician was arrested for obstruction of justice.

33:15 The answer is not defunding the police, instead it is integrating them in the communities they serve.

34:30 The longstanding history of distrust with the healthcare system in African American communities (e.g. gruesome experiments on slaves, Tuskegee syphilis study)

35:40 “The historic erosion of trust in the healthcare system.”

36:30 The Philadelphia Negro – statistical differences in health between races is “a peculiar indifference” (1899)

37:00 Trust can be created by authentic displays of respect and compassion in the healthcare setting.

37:30 Dr. Wyatt describes how his son experienced distrust of the healthcare system based on a bad experience with a pediatrician.

39:00 The need for more African American physicians will increase trust in the healthcare system.

40:30 “Race is an independent risk factor for death, and the data bears that out.” – Dr. Don Berwick

41:00 Dr. Wyatt discusses the need for health equity transformation in our country at the training level.

41:30 Racist myths in the medical profession that have persisted since the 1800’s (e.g. race-based decisions in CHF, renal failure, transplant referrals, etc.)

43:30 Creating tele-equity to positively impact patient care and diagnostic accuracy.

44:15 14 million homes in urban settings and 4 million homes in rural communities lack broadband access (and 75% of them are people of color).

45:00 Dr. Wyatt describes his collaboration with the American Telemedicine Associationto create a framework for implementing telehealth to improve health equity.

47:20 Building structural competencies into the deployment of telemedicine (“closing the power gap”)

48:15 Aligning health literacy with digital literacy.

48:30 Payment reform of telemedicine services to make it more affordable.

49:30 Growing concerns that AI and machine learning algorithms reinforce existing biases.

51:00 Referencing the NEJM article “Hidden in Plain Sight – Reconsidering the Use of Race Correction in Clinical Algorithms”

51:45 Abolishing biased algorithms through community partnerships and the avoidance of “over the horizon” decisions in clinical treatment.

53:00 Understand the culture of a community before applying data to make algorithmic decisions in diagnosis (creating a social risk picture)

55:00 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.

56:00 Dr. Wyatt explains the 4 Domains of Value-Based Purchasing, i.e. clinical outcomes, community engagement, patient safety, efficiency and cost reduction.

56:30 Stratifying HCAHPS data by race, ethnicity, and language for health equity performance management.

58:00 CMS requirements for health equity strategic planning and leadership.

60:00 Allocating population health resources to highest need (not most wanted) once high-risk populations have been identified.

61:00 Developing an anti-racism action plan to reduce health disparities starting with The Joint Commission standards.

62:20 Dr. Wyatt provides a framework for developing a value-based care strategy for Health Equity.

64:00 Diagnostic error account for 17% of preventable errors in hospitalized patients.

64:45 The dearth of research in diagnostic error prevention despite the abundance of overwhelming data showing the severity.

66:00 Leaders confronting biases in diagnoses to overcome health inequities. (Those who won’t need to find another job!)

67:45 “With regard to health equity, a rising tide does not lift all boats.  We must put systems in place that adjust depending on those most in need.”

69:30 Be prepared not to get paid for poor outcomes in underserved populations.  Payment mandates for health equity are forthcoming.

70:00 Wisdom from the Dalai Lama on Compassionate Equality — having compassion for all sentient beings.

71:30 “The root of the word courage is Latin word for heart.  We must commit to “heart work.” Healthcare quality begins and ends love.”

73:00 Dr. Wyatt is optimistic for the future because of conversations like this podcast!

74:00 If you love people, you can change the world.

The Physician Organization of Michigan Accountable Care Organization (P.O.M. ACO) is a statewide ACO in the Medicare Shared Savings Program that has saved the Medicare Trust Fund more than $199 Million to-date. It is a physician-led partnership in operation since 2013 that supports more than 5,000 providers serving approximately 60,000 Medicare beneficiaries.  P.O.M. ACO aligned with the University of Michigan Health System, whose Faculty Group Practice participated in a Medicare demonstration project that paved the way for ACOs under federal health care reform years ago.  This is an outstanding Accountable Care Organization led by Dr. Tim Peterson and Kendall Cislo who are featured in this week’s episode of the Race to Value.

In this interview, you will learn how P.O.M. ACO has been successful by enabling localized solutions, in partnership with their provider network and beneficiary population, to improve care outcomes.  We discuss how the ACO engages their beneficiaries through committee and Board participation, how primary care providers and specialists work together to build “localized” population health programs, and how care management interventions can provide meaningful outcomes in both rural and urban settings.  This is an important interview for ACO leaders to listen to who are looking to establish improved relationships with both providers and patients to drive more effective care management interventions in caring for seniors and underserved populations.

Episode Bookmarks: 

02:00 Physician Organization of Michigan Accountable Care Organization (P.O.M. ACO) —  a statewide ACO that has saved more than $199 Million

02:40 Introduction to Dr. Tim Peterson (Population Health Executive for Michigan Medicine and ACO Executive and Chairman for P.O.M. ACO) and Kendall Cislo (Chief Operating Officer at P.O.M. ACO)

05:30 How ACO success has been determined by collaboration between a faculty academic practice and groups of independent physicians

10:00 Dr. Peterson discusses some of the unique public health and chronic disease challenges facing urban and rural Michiganders and how medical management programs of P.O.M. ACO meets patient needs

12:00 “Part of our ACO success has been the enablement of local solutions to address local problems.”

12:45 Recent study on patient perceptions of ACOs: Only 7 percent of 55- to 64-year-olds and 4 percent of those over 65 reported ever hearing about value-based care!

13:40 How beneficiary engagement and “the voice of the beneficiary” impact quality improvement and the Triple Aim

15:30 Why the economics of value-based payment shouldn’t matter to patients (focus on quality care and out-of-pocket burden most important)

17:30 Utilizing a beneficiary engagement advisory committee as a key strategy for performance success

21:40 “The goal of our ACO is not to build a centralized infrastructure – it is instead to build localized solutions with our network of providers.”

24:30 Engaging patients to raise awareness of high cost (low value) specialists in the area

25:40 Partnering with dialysis centers to more effectively engage patients with kidney disease

28:30 “The key message to remember in healthcare is that we do everything for the patient.  What would you do for a patient if it was your Mom.”

31:20 Engaging physicians to more effectively collaborate with them in population health and quality improvement strategies

34:30 Collaborative conversations to improve risk adjustment coding documentation to more adequately reflect burden of illness in the patient population

38:00 Building local market capabilities for pharmacy integration in rural primary care practices

40:30 Annual Wellness Visits as opportunities to address what is most important in a patient’s life and how that has transformed the ACO

44:30 The importance of clinical integration in improving care coordination and why specialist participation in an ACO is a performance advantage in improving patient outcomes

47:30 Primary care and specialist collaboration to improve utilization associated with inpatient hospitalizations and readmissions

50:30 Addressing health equity through localized problem-solving and practice-based population health interventions

51:30 “Clarity of data” to better understand beneficiary issues with social determinants of health

52:30 Using ACO beneficiary input to craft partner-based solutions to address social isolation and loneliness

54:00 Asking the inverse question of what services are being under-utilized and how “positive healthcare utilization” can be used as a lever to move away from overutilization of other services

56:00 Dr. Peterson (an Emergency Medicine physician and an ACO executive) explains how we should define “failures” associated with ED utilization

60:00 Parting thoughts from Kendall and Dr. Peterson on the future of the value-based care movement

Quality in health care has been a hot topic for over 20 years, ever since the landmark report, To Err is Human, which declared that up to 100,000 people die each year from preventable medical errors. Since that time, the industry has increased its efforts to incorporate quality principles from Lean, Six Sigma and other models, but only one organization has raised a quality standard for health care organizations and their workforce. The National Association of Healthcare Quality (NAHQ) is leading the quality revolution with its framework of essential qualities for the health care professional.

Join the conversation as we speak with Stephanie Mercado, CEO of NAHQ. Stephanie is a leader in healthcare association management, advancing healthcare professions, and workforce development. Since joining NAHQ in December 2013, NAHQ membership has increased by more than 70%. Stephanie has raised NAHQ’s prominence and value in the healthcare quality space, with the introduction of industry elevating initiatives such as the award-winning HQ Essential Competencies and the National Healthcare Quality Summit. In partnership with NAHQ’s Board of Directors, and an outstanding staff and volunteer team, Stephanie led the development of the profession’s first-ever Comprehensive Competency Framework, and the profession’s first-ever Workforce Study, offering critical insights to workforce development opportunities for healthcare quality and safety professionals.

In addition to her work with NAHQ, she currently serves on the Institute for Healthcare Improvement’s National Steering Committee for Patient Safety, the Association Forum Healthcare Collaborative Steering Committee, and is a board member of the Commission on Accreditation for Healthcare Management Education (CAHME), and more. In 2018, Stephanie was selected as a recipient of the Outstanding Nonprofit Leader Award from .orgCommunity. We are grateful for Stephanie’s leadership in the race to value!

Bookmarks:

6:00 Workforce Empowerment and Culture Alignment to support Quality Improvement6:55 Healthcare Quality Competencies needed to improve patient safety and health outcomes

8:45 The acceleration of Value-Based Care and the recognition of codependent relationships across the care continuum

9:45 A coordinated and competent workforce is a ‘must have’ to thrive in health value

10:15 Breaking down the barriers to coordinate care across the continuum

12:00  The NAHQ Healthcare Quality Competency Framework

12:55 The juxtaposition of Quality Training and Medical Training

14:00 Setting a standard to serve as a roadmap for the industry

14:40 Governor Leavitt providing thought leadership in the creation of national standards

15:00 NAHQ’s support of individual contributors

15:45 NAHQ’s partnerships with healthcare organizations to find opportunities for improvement

16:15 Healthcare leaders sometimes don’t know who is doing the work of quality in their organization

17:00 NAHQ’s partnerships with academic organizations to hardwire competencies into curriculum

18:05 WGU as a leading national example of hardwiring quality competencies into nursing education

22:35 Leveraging the synergies between health value and quality in partnership with the ACLC

25:30 The Quality competencies that are underperforming the lowest are ones that are underpinnings to Health Value

29:00 Data that shows a correlation between quality training and a higher level of work performance

32:20 Stephanie speaks about the administrative burden of quality measures and the need for standardization

33:10 Looking at other industries with similar challenges in alignment and harmonization of standards, e.g. the history of railroads

35:56 How healthcare can have its own “intercontinental connectedness” with outcome measures, systems, and competencies

38:46 How consumer focus on service reliability and customer service can align with clinical performance and process improvement

42:44 Priority #1 – focusing on individual contributors (training leads to higher performance)

43:30 Priority #2 – supporting corporations (you can’t “abracadabra” yourself of workforce competency gaps)

44:30 Priority #3 – academic partnerships (students need a common vocabulary, toolset, and competencies when entering the workforce)