Improving Health Care Outcomes & Supporting Providers in Value-Based Care

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Hello, everyone, and welcome to today's webinar, Improving Health Care Outcomes, and Supporting Providers and value based Care.

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Before we get started, I would like to go over a few items, so you know how to participate in today's event.

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At the conclusion of today's event, you'll have an opportunity to complete a survey.

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I would now like to introduce our moderator for today, Kathryn Santoro.

0:59

Good afternoon. I'm Kathryn Santoro, Director of Programming at the National Institute for Health Care Management (NIHCM) Foundation. On behalf of NIHCM, thank you for joining us today for this important discussion.

1:11

We have witnessed the impact of the pandemic on providers this year.

1:16

A recent survey showed 8% of physicians permanently closed their offices in the last year, due to financial and mental strain, resulting in potential gaps in coverage for patients. Around 71% of physicians reported exhaustion and burnout in 2020.

1:35

This has fueled interest in accelerating the adoption of value based care. As of 2017, only 34% of health care dollars were the result of value based care payments.

1:46

This low rate of adoption exist despite evidence that tying payments to patient health outcomes and rewarding higher quality care leads to reduced costs.

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Today, we will hear from a prestigious panel of experts who are driving innovative initiatives and uncovering more effective ways to implement value based care.

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Our panel brings the perspectives of health plans, health systems, physician practice and academic research and education.

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Before we hear from them, I want to thank NIHCM's president and CEO, Nancy Chockely, and the NIHCM team who helped to convene today's event.

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You can find full biographies for our speakers along with today's agenda and copies of slides on our website. We also invite you to join the conversation today on Twitter using the hashtag value based care.

2:42

I am now pleased to introduce Dr. Amol Navathe. Dr. Navathe is an Assistant Professor of Health Policy and Medicine at the Perelman School of Medicine at the University of Pennsylvania. He has a Commissioner of the Medicare Payment Advisory Commission, or MedPac, a non partisan agency that advises the US. Congress on Medicare policy. He's a leading scholar on payment model design and evaluation.

3:09

And we're so honored to have him with us today. Amol?

3:20

Hello, everyone. Welcome to the session today.

3:23

First off, Kathryn and Nancy and the NIHCM Foundation, thank you so much for inviting me today.

3:30

Fantastic. So, what we're really going to be focusing on today is the role of physicians in accelerating value-based care and adoption, and most importantly, the implementation and how to succeed.

3:43

So, if we can go to the next slide, please. This has been an exciting time. Obviously, the pandemic has been a challenging time but if we reflect upon the past decade, some of the statistics that Kathryn noted, that we've had some adoption, but there's been an increasing acceleration in the adoption.

4:01

And one thing that's really important to understand is that physician groups, in many ways, are, in fact, leading the way in value based care.4:10So, what do I mean by that?

4:12

First, physicians have been driving. A lot of the adoption. This in groups, in particular, have been driving the adoption and participation in various programs. This is from public health plans and private health plans alike.

4:25

If we look at the map on the right side here, this shows us a map of the United States, where we're looking at the penetration of ACOs. This is specifically in the Medicare program across the United States.

4:38

Darker means more adoption, lighter means less adoption. What we can see is that by 2021, we have fairly widespread adoption. That's certainly geographic in some areas where it's a greater concentration.

4:52

But, nonetheless, this is a national view. If I showed you this from five years ago to three years ago to today, you would see a steady darkening of this slide, meaning that ACO adoption and participation is increasing in a continuous fashion.

5:10

Now, one thing that's really important to note is that, in many respects, physician groups have actually outperformed other types of entities such as hospitals in leading ACO participation and outcomes.

5:26

So, work by colleagues, such as Michael McWilliams and Michael Chernew and others, has shown us that the results within Medicare ACO Programs, for example, have been stronger.

5:36

This means higher results or better results on quality scores, more cost savings. Physician groups have actually been a linchpin of this progress.

5:47

Not just on ACO programs, it turns out, even if we look at bundled payment programs, physician participation has grown rapidly.

5:55

And, in fact, in today's current DPCI advanced projections, for many types of medical episodes or surgical episodes, it is, in fact, physician groups. They're driving more of the participation and other entities, like hospitals or post acute care facilities.

6:10

Once again, physician groups are driving the way. Now, this is obviously not happening in a vacuum. There are other policy dynamics at play. The Merit Incentive Payment System, or MIPS, has created multiple tracks that, I think, in a lot of ways, due in part to complexity.

6:28

And due in part to this uncertainty around the way that penalties may be implemented has served as an impetus to participate more in alternative payment models and value based payment models.

6:39

Why? Because it's a way to, to guarantee or step out of that uncertainty and create some certainty around the types of bonuses that one might gain.

6:49

Now, in parallel to the Medicare statistics and dynamics that I'm highlighting, commercial payers have also been driving tremendous amounts of transformation in terms of physician groups participating in value based care.

7:02

Just to mention a few Horizon, Blue Cross Blue Shield of New Jersey: New Jersey area; Hawaii Medical Services Association in Hawaii; Blue Cross Blue Shield of North Carolina is another group that, in fact, I've had the pleasure of working with. These are just a sampling of plans that have been partnering with physician groups.

7:23

Now, this partnership has existed for many years. What we're seeing is increased investment, over time, increased partnership together with physician groups to really propel forward innovative delivery models, delivery models that are ultimately centered around the patient, not centered around the physician group or the health plan in any way.

7:45

Next slide, please. So, what does this mean? What are the best practices?

7:53

We are now more than a decade into this. And my research group and others have been studying exactly what successful practices, successful physician groups, successful large networks, have been doing together in partnership, oftentimes, with health plans.

8:10

So, first, we see best practices around using techniques to support physicians with information infrastructure and incentives.

8:21

This has been wildly successful as a strategy. And there's a whole industry now of enabling types of companies that work together with physicians and health plans to make this become a reality.

8:32

What are the tactics that they take on? They take on several tactics, many of which have common themes.

8:39

First, they use rewards and targeted ways around short-term performance indicators, not relying just on the shared savings that may come 12 or 14, or 16 months after the performance here has started.

8:52

They provide estimates, tangible, specific estimates of incremental revenue. The practices would not receive if they didn't meet the targets.

9:02

It provide comparative data. This is critical. There's actually a ton of policy evidence. Now, that comparative data is a way to drive physicians and physician groups to change the way they practice, oftentimes, within the same ACO. So, comparing physician group A, versus physician group B, all of which, under the same umbrella, the same issue.

9:24

Encouraging, oftentimes, supporting directly through coaching interventions, or, otherwise, physician groups, to focus on key stream, key upstream, key performance indicators, or KPIs.

9:35

There's been an emphasis on prioritizing high risk patients, and others, specifically, to try to close gaps.

9:42

And, wherever possible, create automated workless or work plans, make this job easier, let's make the path of least resistance, the correct path for patients, Side-by-side to this.

9:55

We've seen investments in the culture, the culture of physician led care. And this has been fantastic. I think it's a really important develop development, think about not just achieving the triple aim but also the quadruple aim.

10:11

We put the physician well-being, the lack of physician burnout, as another centerpiece in our goals around value based care.

10:18

So here, transparency, co creation, getting buy in, engaging clinicians early in the process to do things like selecting appropriate measures, excluding ones that may not be that appropriate, and, defining salient Incentives.

10:34

These are, again, some of the important steps forward in engaging physicians early, but also defining a culture that is physician led or clinician led in some way.

10:44

Just a couple of others to quickly mention. Enabling development of workflows and other tools to support clinicians in improving their clinical practice patterns.

10:53

Engaging early to understand what are some of the potential unintended effects that might happen here?

10:59

What are ways in which we as an administrative leadership may not understand what's happening on the ground at the patient point of care level?

11:09

And these are all in support, again, creating a culture of change because guess what, change is hard. We have decades and decades of research to tell us that I think most of us would say we know that change is hard.

11:21

Next slide, please. This is obviously, again, not happening in a vacuum, particularly given the current times that we're living in with the Kobe pandemic.

11:32

That seemed in some sense. Like, it might be a beating. It then has created a bit of a resurgence recently.

11:38

But while we've had some drawbacks, obviously are some challenges that have been devastating under COVID.

11:45

There's also been some silver linings for health care. Some unlocking the potential.

11:52

I think one of the chief ones here is telehealth or digital health. This is a really interesting case example in some sense where the technology for digital health and telemedicine has existed for years and years and years, as Ezekiel Emanuel and I actually outlined in the New York Times op-ed.

12:09

And yet, what we found is when there was an impetus for change, a reason to overcome this inertia, the healthcare community and provider group at large, provider community at large, embrace telehealth and adopted it incredibly rapid.

12:26

This has unlocked a whole bunch of opportunities for how to care for patients in their home do infusions in the home that may be actually safer, even when you don't have a pandemic, then doing them in the hospital setting.

12:39

Increasing hospital at home care. There's a variety of new ways in which we can deliver care that will require the partnership of health plans and physicians.

12:49

And I think one of the interesting pieces here is, as health plans, health systems and physician groups work together to drive this forward.

12:58

There's, and increasing recognition that the majority of care and tons of innovation that we're seeing, is happening, driven outside in the outpatient setting.

13:08

Now, this may be an outpatient facility, an outpatient hospital, or in an ambulatory surgery center, But the point being that physicians are playing a central role in driving this change. Whether in the hospital, at, out of the hospital, or at the nexus where we're starting to see more and more advanced care.

13:26

The last thing I'll highlight here, is over the past several years, we've seen that the average risk, the severity of patients, who are managed outside the hospital, is getting higher and higher, patients are getting sicker and sicker, and the capability of hospitals to take care of sick patients is only ever increasing.

13:46

That also means that the margin of patient, the type of patient who ends up being cared by clinicians and organizations in the outpatient setting, is also increasing.

13:55

This is, again, where we need collaboration across multiple entities together, to drive the right type of innovation, and that it itself, has to be physician led, in part.

14:07

So, why don't I close here, and I look forward to a great panel.

14:16

Thank you so much, Amol. Now we've all engage in discussion with our panel of experts were joined by Allen Karp, the Executive Vice President of Health Care Management and Transformation at Horizon Blue Cross Blue Shield of New Jersey. Mr. Karp has responsibility for Horizon's healthcare value strategy, and clinical and network operations.

14:40

We're also joined by Dr. Matt Hanley, Interim Regional President and Chief Clinical Officer at SSM Health, where he's working towards transforming SSM Health to a value based care delivery system. And, finally, Dr. Miles Snowden, Chief Operating Officer at Navvis. Dr.Snowdon as responsible for clinical operations, as well as ongoing and in-market delivery of the company's population, health solutions.

15:09

I invite all of our panelists to turn on their cameras and microphones and to get us started. Allen, can you describe the initiatives at your organization related to value based care and supporting physicians?

15:25

Yes, thank you. Thank you, Kathryn, and thank you for having me here with such a great group of panelists.

15:33

So, just a little bit of background on us. We have approximately 60% of our members and value based programs, and all lines of business.

15:42

We have patient centered medical home programs with over 4000 primary care physicians, Strategic Alliance partnerships with six of the largest health systems in New Jersey, and they're clinically integrated network of physicians.

15:55

We have bundle the radius of about a thousand specialists, so we have several initiatives that we use to support positions.

16:02

The first is an incentive system focused on quality metrics and cost of care targets, data integration, and sharing of plan, administrative data, and combining that with provider clinical data to a private HIE that we built called Health Sphere, And we also provide analytics support and insights to physicians on medical cost opportunities, variations of care, and quality measures.

16:32

We've also created a value based playbook for the physicians, which they, back to, what you heard from Amol.

16:43

They worked with us to build this playbook, so this was a lot of physician input. Hospital input, which is important, get buy in.

16:52

We created a quality committee, which is made up of clinicians from the physician groups and health systems that we support, along with our clinicians.

17:01

And that's really important, again, to get their feedback and help us make any course corrections that we need throughout the relationships. And the last thing is a governance structure, which I think is really important to oversee these arrangements.

17:18

We have governance structures for each of our large groups and health systems where we meet on a regular basis.

17:25

share information, identify areas where we can improve from a cost and quality perspective in a patient service perspective.

17:35

And that's really important because it creates the partnership necessary to be able to drive towards triple aim.

17:46

So I'll stop there.

17:49

Thanks. Matt, how about SSM Health?

17:54

Yeah, thanks Kathryn. Delighted to be here. A little high level overview of SSM Health or just about us, we are a $9 billion faith based health system across four different states here in the mid-west.

18:05

And we, In addition to a broad based care delivery, we also have a health plans for the, formerly what's known as the dean health Plan covers, under about 500,000 lives, across a system with predominant being in Wisconsin, and also, own a pharmacy benefits manager, Navitus which helps with the management and delivery of medication through health plans across 50 different states. So, fairly diversified portfolio.

18:41

And, then, I would say, within Wisconsin, there's, there's a uniqueness there in the sense that, with the predominance of our Health plan lives up there, we have a significant amount of our, our IT and Revenue or premium, rather than a fully capitated for the work that we do, which is a unique situation. So, in terms of how we have, as an organization positioned ourselves, I would say.

19:05

The first thing is, several years ago, we, as a leadership group, took the position from the top of our organization that we're going to be a value based care organization, aligned with our mission, think it's easier to say, it's just better care. But, it's also, I think, consistent with wanting to create a sustainable solution for our nation, in terms of a, of a care delivery platform. I think we all have this sense that we're running off the cliff. We have done a number of things to visitor shelves. And also, I think, position or clinicians to help lead that charge.

19:44

So certainly, we have engaged in a partnership with Navvis has been critical in helping us, I would say, catalyze, and help build infrastructure, and muscle and competency as it relates to doing the things related to value based care. Because I think when you engage your clinicians, they ask you two different questions.

20:04

What do I do?

20:06

And how do I lead? And so there is, and I'll, I'm not going not going to repeat what Alan said, but we've done a lot of very, a lot of the similar things around governance, around data, about putting in specific infrastructure. I think as it relates to, specifically, the care delivery piece, itself, you know, we've been very deliberate about going in and designing workflows, as it relates to, specifically talking about population and taking care of the populations.

20:38

I think we've been very deliberate about starting to change the culture with the clinicians. So, in other words, how do I actually do this work? It's very different from, from how we were trained as clinicians coming out.

20:50

It's a very different care delivery platform.

20:53

And I think the third thing I would that I would, I would emphasize is being very crystal clear about the problem we're solving for.

21:02

Which, to me, is defining value, and then specifically telling and clinicians what value means, and then how we're going to measure that.

21:12

And then the last thing I think Allen also mentioned was incentives I.

21:16

Honestly, think that incentives are absolutely critical, and lack of incentives can only sort of gets you so far as it relates to engaging the clinicians. And so we have been we have been very purposeful in redesigning our compensation programs specifically around primary care, but we're also looking into the specialty space as well.

21:40

Thank you. And Dr. Snowden and Matt just alluded to your role, but why don't you give us a little bit more context and talk about how you're working with these organizations and others across the country.

21:53

And you're on mute.

22:04

All right. I was so careful not to interrupt anyone. I did I interrupted myself. Thanks, Kathryn. And I appreciate the chance to be here. And I so much respect.

22:14

What each of these others have been accomplishing Amol in his bringing rigor and observation and measurement to population.

22:25

We very much need, Allan, too, advancing the ball in regard to help payers actually deliver enabling capabilities to their network physicians, which is so important.

22:35

And then Matt advancing a massive health system into a whole new way of thinking about serving their community and their ministries.

22:43

It's such a neat combination of participants in the market.

22:47

Navvis is, if you think about what Amol opened this session with, is an organic development out of the secular changes, that he describes so well.

23:00

And that is the under the representation in the understanding that the physicians are an essential ingredient to being successful in managing cohorts or populations of individuals.

23:12

And we can't, cannot free the physician of participation in that we can't work around them. We have to lift them up, enable them, and let them lead.

23:20

And everyone on this session today is working in some way or that.

23:26

So, that is developed to be able to provide asset, essentially, an operating partner role, primarily focused on serving physicians, but at the sponsorship of any of the major stakeholders in the industry.

23:41

So, we have almost an even share right now of sponsorship and partnership and client relationships with payers, health systems, and physician groups.

23:52

Yeah, Regardless of which of the three partnerships' sponsors, our work, our primary focus is on lifting up, enabling, and preparing physicians to lead complicated systems of care into different reimbursement models. So we we do this at the behest of each of the different stakeholders but focus primarily on the physician as the key to success and value based care.

24:19

We do that with three principles in mind.

24:24

The first is win-win.

24:26

We primarily want to have an exclusive relationship that's highly durable, that allows each of us, both ourselves and our partner to invest deeply in, was capital, both human and financial, to advance a very complicated process or very long term.

24:43

We don't try to distribute a zero point solution and wish the very best.

24:48

Secondly, we believe its standing starts as a principle, and that is, we want to take what's already deployed and use it to its best and highest purpose.

25:01

So, no, rip and replace, represent and understand that, which has already been invested in make the best of it.

25:08

And then last, all in, we fundamentally believe that it is impossible for recession's physician practices and systems of care delivery to treat differently, contracted patients differently.

25:22

And so all contracts, all payers, Medicare Advantage, Medicare fee for service, commercial, ACOs, all all members of the community being served, are treated to the same process and procedures. So, win-win for all, standing start. Start with what you got and make the best of it, and last, all in all contracts, and that's those are the principles we start with on these sorts of partnerships. Thanks, Kathryn.

25:50

Thank you. Going back to Matt, could you talk about some of the challenges that you face as you move to increase levels of risk, and, also, how COVID-19 either accelerated or complicated the transition?26:04Yeah, absolutely.

26:05

Well, I mean, COVID has I think, been the centerpiece for conversation for the last 18 months. Um, and I think it's been both a gift, and also, you know, an opportunity for us, all, I think, you know, just practically speaking. I mean, COVID has, has taken up a lot of bandwidth, so any any, you know, um, dedicated focus on this transition to value based care, has been somewhat consumed by the shift of attention and energy, in terms of how we how, and what we need to respond to kind of it.

26:40

And so we're sort of in this yo-yo period where we're hoping this, this pandemic moves on, so we can all focus on the work at hand. It's created distraction with finances.

26:51

So depending on, you know, the type of organization you're at, your habits are, there, have been the ultimate hedge, or it's been the ultimate stressor. I think SSM, we're in the middle ground because we have diversified set of assets.

27:04

And then the third is just the fatigue, know, I don't like the word burnout, but the fatigue has been just intense. So it has been hard and challenging in that aspect.

27:16

But it is also, I think, allowed for, honestly, as I said, a burning platform.

27:22

It's allowed us to really crystallize and be singular and in our commitment towards knowing that at the other side, that the value based care is, is the right strategy.

27:33

For us, it has also allowed us to, to I think many, many people have experienced the, I would call it a lateral leadership, and the collaboration between clinicians that didn't didn't exist in the ways they do today. So one year, singularly focused on solving a problem that is, frankly, singularly clinical. It is a wonderful way to to convene your clinicians, which we have done, and we've been able to sustain and keep some of the operational models we've had in place. That has led to collaborations. It's led to relationships, and it's led to new processes and workflows. That will vastly benefits benefits this benefit us in the future.

28:15

And then the last thing I'd say is also provided us an opportunity to continue to, to integrate the clinical voice into the operations of the organization.

28:26

Which is, I think, absolutely incredibly important for moving towards value based care or value based care delivery, especially at risk.

28:36

So I think, you know, those things have been a gift and I think coming out of, I wouldn't say coming out of COVID, but still being in COVID, I would also say that is also crystallize the markets demand or focus on total cost of care.

28:50

And so I think that that, to me, that voice is as loud as it's ever been.

28:55

Because of the broad stressor, that COVID has put on our economy, and that just affirms that the work we're doing.

29:05

Great. Thank you, Matt. Allen, I know you're joining us by phone, what are you seeing in New Jersey?

29:12

Well, so, first, I agree with everything Matt said, I thought he laid it out well.

29:19

What we've learned, and we have about 350,000 of our members under risk today, we're expecting to be around a million by 2024.

29:30

1 of the first things we, we learned is, we have to get the leadership from providers, whether it's physician leadership or health system leadership, in our case, comfortable with moving, first from fee for service to value based reimbursement and risk.

29:46

So, our approach was to start with what we call a pathway to risk, which which moves the providers shared savings initially to get away from completely fee for service reimbursement, and then get them comfortable with the new model.

30:04

And part of it is getting them to understand the financial opportunities under the new model, but, more importantly, the impact that it has on patients, if or if we're working together.

30:15

The other thing we're able to do is to limit the downside risk for the first year, or are our partners by offering re-insurance and other ways to limit their risk and, as the years go by expand the risk profile on the downside with us.

30:35

And, but last thing is it helps the physicians in that we are delegating more of our services down to the physician and clinical level where they belong.

30:53

So they can make those decisions, enlists some of the burden, that they typically PO and the additional stressors associated with, things like, you know, calling for authorizations and some of the other administrative administrative challenges they have with payers. So, that's been big.

31:12

Um, then, again, the patient care model allows the physicians to spend more time with patients, allows us, as a payer to focus on things we do well, data analytics, and, you know, some of the other things we can bring to the table.

31:30

Thank you. Amol, what are you seeing from an industry perspective and your research?

31:38

Yeah, I think I would echo a lot of the themes that Matt and Allen mentioned, You know, there's obviously a lot of moving parts at play in the shift from a volume based system to a value based system and what we've seen. So, for example, through work that we've done with the Blue Cross Blue Shield Plan, Hawaii, in instituting a primary care payment system, a new primary care payments system that was heavily based on population based payments for PCP computation.

32:06

There's, there's a variety of kind of baseline capability that you start with. Some practices, in fact, are really high functioning practices. They're just really high functioning for fee for service. Right? Because that's the system that they're optimizing.

32:20

Others are exposed to multiple different types of payment mechanisms and so they found a way to straddle that.

32:27

So, shifting those systems oftentimes, there have been, you know, years or maybe even decades of investments that have gone into that optimization, so I think we have to be realistic about what that means in terms of a change.

32:41

Over time we have to catalyze the right type of investment.

32:45

We have to make what I would consider longer term commitments, and I think, you know, the the group that's on this panel, of course, has a lot of experience doing that.

32:53

But unless you have a 5, 7, plus year horizon, it's often very hard as a physician group or a health system to find those dollars to say, look, we can invest this in the correct way. And COVID obviously has complicated a lot of pieces around the finances.

33:10

I mean, it has created a lot of uncertainty which, you know, I agree with Matt's point that this has been an accelerant in some way.

33:16

And thinking about, you know, getting to fixed type of global budget models, total cost of care models, capitation based models.

33:25

These are all ways to mitigate that type of uncertainty, but we've also seen the pendulum start to spring back, so, for example, early in the pandemic, we saw Elective Surgeries, some of which were definitely necessary, some of which probably were low value. We've seen that research in the past several months. A lot of that elective care has come back.

33:45

The Telehealth pendulum obviously it swung really far in the early, early part of 2020 to the summer of 2020.

33:53

We've started to see that pendulum swing back, I would say in our local market here in Philadelphia, for example, know, now only about 10 to 15% of what it used to be at its peak. Not saying that peak was perfect, but just as indicated, that pendulum swing.

34:08

So I think it's incumbent upon us as healthcare leaders as clinicians on the ground say look, we're going to embrace the good things that happened again as Matt highlighted of the pandemic to try to preserve those things because those are actually good for our patients. All of course working on the parts that are more challenging.

34:31

So Dr. Snowden, how do you create this value based care culture especially thinking maybe pre pandemic post pandemic too with everything that's happening and what are some of the key strategies for aligning payers and physicians?

34:48

Sure. Thanks, Kathryn.

34:49

So, my observation is that I consistently see two things that are in short supply that I consider to be the fuel for transitioning to value based reimbursement. What is capital want to scale?

35:05

And that's, I think, is why it's so critical that our commercial payers, such as Allen at Horizon and others that were mentioned earlier and many others that they participate in, and they foster are the sorts of transitions and also large health systems like Matt foster this sort of transition to provide capital.

35:27

And I'll get to scale just a moment, but to stay with the capital for a minute.

35:30

I think the ability to leverage existing payer contracts and forgone upside opportunity in those value based contracts that are already executed and sitting on the shelf, provides some of the capital necessary to make this transition, which is why actually, my observation on COVID was there was no pause in the interest to move into value based reimbursement. I saw, no one, any less interested, recognizing and respecting a force of severity.

36:00

And then make this effect that there was still high interest in being able to advance the financial ball in regard to gaining some opportunity on the foregone, gain share opportunities. Our own analysis is that about 70% of ACO's leave dollars on the table.

36:17

So, if you just improve your performance, you leverage those dollars that you were forgoing. And then you re-invest those into your program to create more capital and move forward and investing in technology.

36:27

New people doing new processes, more people during new processes, new analytics, new data.

36:34

Then you have the ability to self fund to some degree. Your transition.

36:40

Scale is the second item I mentioned as a fuel for value based reimbursement pivots.

36:47

What I mean by scale is the reason smaller physician groups are not very successful in this exchange, in this change, is they are trying to continue that fee for service reimbursement model. Because they don't have a capital process, they're not allocating capital each year to the next year's needs.

37:05

And so they have to maintain the fee for service cash flow to fund what is actually a long tail on a reimbursement model for value based reimbursement and the two don't jive.

37:16

You can't have a cash based business that is, that needs to invest in a long tail reimbursement on a different, different model.

37:24

So, out there requires getting to scale quickly, meaning bringing more of your patients into value based reimbursement models as quickly as possible.

37:36

So, concerted efforts to move as many of your patients prudently to value based reimbursement models moving up the risk continuum gradually.And finding a capital partner or a source of capital through foregone, gain sharing and existing contracts.

37:51

Those are the two things that I feel like are first steps in this process. And for these reasons, really no reduction in interest of his past year to year and a half.

38:07

Allen, how are you creating this value based culture among physicians that you're working with, the Horizon?

38:28

Allen, are you still with us? You might be muted.

38:31

I was I'm sorry. Thank you, Kathryn. Sorry about that.

38:35

First of all, I agree with everything I just heard from Miles.

38:41

But, for us, it, it, it starts with, again, the buy in from the leadership, position leadership, and leadership, from the top to begin to build that culture.

38:51

Um, and we know, again, we do that by getting them involved in the understanding of the models and understanding the opportunities.

39:02

Um, understanding the difference in a value based culture than in a fee for service culture.

39:10

We use data and analytics to show them data and get them to understand where, where opportunities are, as I said earlier.39:20We take a lot of time on aligned incentives to make sure we address, right, both, both from cost and quality perspective, and then we work very closely with them, too, make sure that we are cultivating that culture where the view is on managing populations as opposed to just seeing patients in the office.

39:45

And that really, really has been a big win for us, because, you know, most physicians have their way that they want to spend time with, with their patients.

39:57

And then last but not least, a governance structure, That is that niche continually that continues to reinforce certain behaviors.

40:07

That's really important when it comes to the new culture that we're trying to build, So those are some things we've done, in addition to what you heard from miles.

40:19

Thanks, Matt, What is your experience with us as SSM Health?

40:23

Yeah, so, first of all, I really appreciate the previous comments and the one on capital. And scale it, I think, is absolutely salient. You, know, I think, for us, you, know, as I said before, I think it's, you know, first and foremost, as being very crystal clear about the problem we're solving, You know. And being crystal clear what the clinicians and what what your specific definition of value is, and I'll say, you know, I think the problem we're solving, and not to be trait is total cost of care.

40:55

And I know, you may say, because I'm a clinician, it's a little bit of a heretic statement, but I do believe that until, you know, decisions are made on cost these days, qualities, assume, and experiences desired.

41:08

And I also believe that if we pursue total cost to care, the right way will deliver the right quality outcomes and will deliver the right experience and access for patients. So, I think it's being crystal clear about that.

41:21

And then, I think the, you know, for us, the three ways that we're engaging them, the clinicians are one through an innovative care model. Redesign.

41:31

And, I think, you know, we all can do supply chain. We can all do FTEs, we can all do cost, cost management structure, we can all do scale as well.

41:39

But at the end of the day, I think we're still left with care model, know, redesign. We have to, fundamentally, as I think I'm all refer to, is take care of patients. They're fundamentally different in a way that does drive down that total cost.

41:54

So can we do infusions at home instead of a provider based boing and so and so? Or can we take care of more patients at home instead of the hospital?

42:04

And that's the crux of why I think what we're doing, we have to be able to turn to our patients and say, hey, this is a better value product this year than it was last year.

42:14

The second is the culture, and the communication with the clinician.

42:19

So, I mean, we've talked about that, but again, the clinicians are asking the question, what do I do, they want to understand the competencies in expertise, how did, how do I redesigned care. I wasn't taught that in med school or residency.

42:32

What does a care management structure look like? And how does that integrate into my practice?

42:37

What does it mean to be at risk for payments?

42:41

And then, how do I lead?

42:42

How do I lead my, my colleagues and my, my teammates in this direction when I was taught to lead them in another direction?

42:51

And then the last thing, we've started again and again, but I do believe the incentive pieces is so very important.

42:58

And so when we look at, you know, clinicians who are fundamentally incentives for at risk payments, have different behavioral, just different behaviors as it relates to care delivery, than if you're incentive fee for service.

43:12

And, and I just think that's, you know, normal human behavior, right?

43:17

And I think we have to sort of pay attention to that, So, for us, being very innovative, but also very aggressive to a whiner incentive compensation structures with the clinicians.

43:29

And then I would also add that, in addition to the clinicians, we have to, we have to incent the rest of the system as well, so with an entire ecosystem, how your hospital presidents, for example, get incented is important.

43:44

So, thank you.

43:46

Thank you. Would you like to add anything based on your experience working with payers on health systems?

43:54

Sure. I mean. So I definitely agree with the preceding comments. And I would say, wow, what mean, How great would it be to have a leader, like Matt driving, change, that, every health system and physician practice across the country, Right? Who's totally embrace the value based paradigm and thinking about getting all the different nuts and bolts and peace to drive that. So, I think that's A reflection one, obviously, that match a dynamic leader, but also that it can be done, right. It, is. Absolutely can be done.

44:21

And I think there's a couple of additional things to highlight here, Right? So, first off, we have to recognize that physicians are different than other skilled workers, if you will, you know, in, across other industries.

44:33

Because we give physicians a lot of our townhall, I, myself, am a practicing physician at the point of care, right, I'm the expert, because I'm the one who's working with this patient.

44:43

I know that family, I know their values, We have to find a way to influence physicians while still giving them the autonomy to spread their wings, and really own the patient.

44:53

If we take that autonomy away, it's not going to work, right, It's just totally not going to work, And I highlight this, in fact, in Harvard Business Review, article for anybody's interested in heavy share. I think it's just a fundamentally different in the healthcare industry with physicians in particular.

45:09

Then other, you know, sort of analogs, if you will and I think that means a couple of things. one, you know we have to get early buy in, we have to engage them in the process.

45:19

And this ultimately has to be done starting with the physician in some sense, right?

45:24

This is kind of a bottoms up approach, We have to start with a rank and file, practicing physician and generate culture change at that level and drive it upwards Razak, rather than thinking about it as a totally top-down approach.

45:38

And I think incentives, for example, really do matter.

45:42

I would care with, at this point that we have to make it about the patient, right?

45:46

Because most of us, who've gone into healthcare in any role, we're doing it from an intrinsic motivation that we really want to help our patients.

45:56

And so we can make that's the centerpiece of why we're engaging, such as the way that Matt said, right, We have to design, we have to redesign our system, because it's the right thing for patients.

46:07

We start there, and then follow on with the transparency principles, and the other pieces of alignment. I think we can build that culture and drive a lot more change.

46:17

We have a couple more minutes before we go into Q&A. So, wanted to ask each of you for executives who are looking to move their value based care initiatives from deployment to scalable enterprise class performance. What advice would you give?

46:37

Miles, do you want to start?

46:40

Sure, I'll start, but I am so, focused on what was just said by everyone that I have to have to just bring that if I might.

46:49

And I use that as my answer.

46:51

And my answer is that we need as an industry to recognize and provide for the fact that, as a model said, physicians are largely mission base.

47:04

They get their training not in white ivory, towers of research, but rather in municipal and county hospitals, VA centers, seeing patients who often are and a great deal of difficulty, And you don't forget that.

47:18

And you don't quit planning to serve that, and we need to respect the fact that physicians don't do population health.

47:29

They see patients have to see patients one at a time. Sequentially, There is no other way to deliver healthcare.

47:37

And so if we respect that fact, that medicine is delivered one at a time, and then surround that with that respect, and then build the infrastructure that allows the one-on-one patient care to be delivered, while potentially having the impact of that across the population that has been attributed to that physician.

47:55

Then we're making some headway there. So, we do that with respect for the art of medicine.

48:01

Sounds naive of me to say it, but I still believe it to be true, and with a value proposition, must be built and must be articulated well, that says, the positions.

48:11

This is why this transition will make your practice of medicine more sustainable, more enjoyable over your career, and more rewarding, rewarding in the broadest sense. How whatever way intrinsically you are rewarded that you will experience that to a higher level. And those are the sorts of things, that is the art of this transition.

48:32

I feel that we focus too much on technology, point solutions, and less about the culture of change, and how we build the value proposition for those most impacted by this other than patients. Thanks.

48:47

Thank you. Dr. Hanley?

48:51

You gave me a little more time than Miles to think up now. And it's a great question.

49:00

A couple of couple of thoughts, I think, you know, you gotta land on your definition of value, Does it not be complicated, but you have to fundamentally defined that?

49:08

I think it's important to think about the recognition that you have to engage the entire ecosystem.

49:15

So, I think up to this point, we have been, there have been a lot of individual players who've come into the market focused on maybe primary care. focused on a single payer focused on certain part of the care continuum. Maybe post acute, as they, as they looked again and value based care. And all those are great, but at the end of the day, it's the entire ecosystem of health care that has to be knitted together, so I think it's important to think about, to have that concept of mine. How are you changing care, crossing car tire continuum? We mentioned alignment of all the incentives.

49:50

Um, maybe the last thing is Good playing off, What what Miles said, is that this is, fundamentally, it's a clinical care delivery transformation.

50:01

I mean, like I said, there's going to be a lot of mechanics around payers, and finances, and scale and capital.

50:08

But the under underpinning of that is, we have to fundamentally change the way we're taking care patients.

50:16

And so, the integration of the clinical voice, the clinical leaders into the, the fabric of the operations of the, the organization is, is absolutely critical for them.

50:30

Allen are you still with us?

50:33

Yes, I am.

50:35

Um, I would say, if I was giving you advice, start, now, if you haven't started already, because it does take patients, it's a journey, not a sprint, it takes a while to get everybody aligned and positions aligned in what you're trying to accomplish.

50:51

I think, obviously, the definition of value, as much as important.

50:57

I would also say a strong business case for moving from fee for service to fee for value, what I mean by that, it's focused on total cost of care, why that's important.

51:08

Look at the delivery system re-evaluate, what processes are that that we're using today versus what we should be thinking about?

51:18

Again, data and strong analytic capability is important.

51:22

And then, the last point would be, measure what matters. I mean, you know, sometimes we try to boil the ocean.

51:29

I think, I think, focusing on the things that are important to actually change the culture and change the way care is delivered, and finance is really critical.

51:42

Amol?

51:44

I have four words.

51:46

Start small.

51:48

Think big.

51:49

And what I mean by that, start small, start in the micro away. Think about this.

51:54

Starting with an individual patient, an individual physician, as Matt and others have said, think about the individual metrics and the processes that we have to change, Right? Start small.

52:07

Think big, because you're trying to drive big transformation.

52:11

So, you're not going to have all the capabilities likely.52:14You're most likely going to need some capital.

52:17

You're most likely to need partners to make this journey possible.

52:21

So, I would say, start small, think big.

52:24

Great. Thank you. We have a few minutes left for Q&A. Our audience can continue to submit questions and not questions, box on your screen. I wanted to start with a question. We've heard a lot about the esteem of addressing the total cost of care. And could you, through your research or through your work, could you share some examples of how you, based care has improved health outcomes or reduce costs?

52:55

Sure, I mean, there's, there's a number of ways, right.

52:58

But, I think if we start with the understanding that our previous system was driving volume of care, right?

53:06

More services I provide, the better I feel like I'm doing. It's not even that somebody's necessarily doing this knowingly as providing low value care.

53:16

And, so, as we've shifted, we've seen all kinds of great results.

53:20

We've seen, for example, hospitalizations, or chronic conditions complications of diabetes, hypertension can hypertension congestive heart failure.

53:30

Actual hospitalizations have gone down, we've seen more efficient use of post acute care.

53:37

So when you're transitioning after your knee or hip replacement or some other type of procedure or medical condition, as you're transitioning outside of the hospital, we've seen better co-ordinated care, better touching base with patients, tracking of how they feel, how well are they walking, right, Do they feel like they're walking just as well as they did before they started this hospitalization?

53:59

And then they don't have to go and stay in a rehab facility, or a skilled nursing facility. Instead, they can get that delivered to them at home, in the comfort of their own home with their family around them.

54:09

So, we have seen very, very concrete benefits in terms of quality of care. In terms of reductions and low value, or utilization, that are all possible, because we're changing the paradigm from one of just do more, and more and more as a metric of success to one where we're thinking about what's right for the patient, and really, what's right for society at large.

54:38

Another question, Dr. Snowden, you alluded to population health, and the sort of the challenge that sense. What we see in the doctor's office stresses, what is happening and all the other ways that health is influenced. Could you talk about what you see as ways to connect community resources and address social determinants of health? And we had another specific question about the role of community health workers and the future of value based care. We've seen community health workers emerge a lot in the past year as care providers and connecting to, to vaccination and other resources.

55:18

Yeah. I think there are three drivers, primarily to success and value based care, care gaps, and closing those care gaps, which have a wealth of data to support the value in doing so, total cost of care, which Matt alluded to several times, and managing those who, who are intending to outspend the projected costs. And thirdly, And to your point to the point of this question, Kathryn: Our transitions of care.

55:46

And so, the Perhaps the most arguably, the most intractable area for population health are transitions.

55:55

Anytime a patient who is in a contract is going from one building to another building, whether it's home, or LTAC or Hospital. That's a huge opportunity, and that's where actually see the opportunity in regard to social determinants and community based workers.

56:11

And so, to the extent that we build our competency, and understanding what resources are available in a particular community, or a particular zip code, or a particular block of a city, and to the extent we're able to build new resources, in the same way, we can be more successful and fresh transitioning those patients, to the lowest intensity love venue for recovery.

56:38

And so, that's where I see the opportunity here for both community care workers And social determinants.

56:45

Permanence is expanding the opportunity set in regard to managing transitions of care, moving more people from inpatient to home, more people earlier from sniff the home, fewer people back to the ED. And so I think this is a great opportunity. Now, I don't wanna be pollyannish about this.

57:05

The available analytics data and insights that are available at scale to the physician group hospital system or payer to deliver this to a large population is scant today.

57:25

And so, this is where that's type smaller, physician, group and narrow couple of zip codes can actually outperform big, large state and national entities.

57:36

Because they do actually develop a proprietary knowledge of who can do what in a given community. So, this is where this very, as well, where we lack scale and technical insights today.

57:51

Kathryn, can I try to answer this question, because we've done a lot of work around this.

57:59

About three years ago, we created a division called Neighbors and Health.58:03And, and we've learned a lot.

58:05

We learned that the members that we had living in zip code areas with significant social issues are four times as expensive as the members who lived in that same age cohort, in, and say more rural areas.

58:24

The, the Community Health Worker model, we actually instituted several years ago in a partnership between our, our Strategic Alliance Health System partners, ourselves, and then the community itself, along with the Department of Health.

58:41

And as we, as we dug into this, we were able to better understand the impact your zip code had on a person's health versus the genetic code.

58:55

And it is significant, it's things like transportation, food deserts, housing, etcetera.

59:03

We had, we had members who were, who couldn't afford to pay their rent, so they were not taking their prescription drugs.

59:11

Members who had, we're taking care of children and elderly parents, didn't take care of themselves and had behavioral health issues.

59:19

So, when we dug down and we do have a lot of data on this, we're able to get to the block level.

59:26

Um, And what the role of the community health worker plays is they're there, there are people who actually live in that community.

59:33

When we train, we originally built the model off of the Impact model, and then we, we tailored it, we train them. And what they do is they're able to get us in the home.

59:44

So that our engagement rate was in the 45 to 50% rate range. Versus say a typical case management of game engagement rate of 12 to 13. We're on the phone now.

59:55

COVID changed that a little bit. But we are, we are huge believers in this model.

1:00:00

We currently, in ninety, zip codes, you started. And, or, throughout the state of New Jersey, we're in every county.

1:00:07

And we, you know, we have about 50,000 members engaged in this program, and we're, we're really excited about the impact that will have.

1:00:17

And it sits within the value based care paradigm, but we're very excited about the impact that we think this will have on member health status and total cost of care.

1:00:29

Thank you so much. We, we are at the top of the hour, and we're out of time, but I want to thank our excellent panel of speakers for being with us. Thank you for sharing your valuable work and perspectives. Thank you to our audience. We appreciate you joining us, and your feedback is important. We ask that you take a moment to complete a brief survey. We had a few questions about our recording. We are recording this. And we'll make that available next week.

1:00:59

And we also have some other resources, one says that shands healthcare, burnout, mental health, on our website. So thank you again so much for joining us today.

1:01:11

Thank you.

1:01:13

On behalf of NIHCM Foundation and our presenters, thank you for joining us today, and have a great rest of your day.