EP360: How to Deliver Value-Based Care That Meets Value-Based Payment Objectives, With Jeb Dunkelberger

Before I get into the show today, let me just remind everybody about our mailing list, which you can sign up for on our Web site, relentlesshealthvalue.com. You might follow Relentless Health Value on LinkedIn or Twitter, which is a great option, for sure; but I wanted to point out that what you see there is abridged at some level. Meanwhile, if you subscribe to our mailing list directly (again, by going to our Web site, relentlesshealthvalue.com—it’s over on the right sidebar where you can sign up for the mailing list), if you subscribe that way, each week you’ll get an email with a full transcription of the whole introduction of the show with timed show notes. Also, we don’t send out literally anything else beyond what I just described on a weekly basis. Also, you can unsubscribe easily and anytime you want. You just hit the unsubscribe in the email. Also, we don’t share our list with anybody. We barely have time to look at it ourselves, so if you have any concerns there in that regard, please don’t. 

Last week’s show (EP359) was with Dan O’Neill, and he talked about the four gradations of value-based payments, from paying purely for volume on one end of the continuum to paying purely for value on the other. When you have a moment (not now, but when you can), go back and listen to that show, as it adds some color to what we talk about in this healthcare podcast. 

But in the meantime, one of the points that Dan O’Neill makes is that patients in this country won’t gain the benefits of value-based care unless commercial insurers pay for value, for reals. After all, value-based payments are payments that incentivize value-based care. Without value-based payments, how does anyone expect to get value-based care?

To belabor this point momentarily, a provider is not gonna switch up their FFS business model when insurers, especially commercial insurers, pay whatever for whatever with no reward going to providers who spend time and effort to create value and/or better outcomes for patients. I’m being super cynical here, I will grant you. But in this day and age of private equity and record profits by a consolidated healthcare industry, if I’m in charge of a provider organization just realistically here, Pramod John, PhD, says this really well in EP352. He’s talking about drug development in that episode, but same thing here is true for medical care. If you indiscriminately pay Ferrari prices for Hyundais, you’re gonna get a Hyundai for the price of a Ferrari.  

To add insult to injury—and this is just one important reason why providers aren’t really willing to invest in lifting outcomes—any value that they would manage to create is gonna be realized by the insurers. It’s gonna go right back into insurers’ pockets. Steve Schutzer, MD, talks about this in his episode (Encore! EP294) about the why and how to create a center of excellence. If, as a provider in a pure volume contract which is FFS, I work really hard to save downstream costs and complications for patients, some carrier is gonna bank the difference.  

It’s go time, all you self-insured employers out there. Pay for high quality. Make the carrot an orange-colored stick, as they say. Patients will benefit. Probably doctors and other clinicians, too, honestly: less moral injury and crappy workflows.

In this healthcare podcast, I am talking with Jeb Dunkelberger. Jeb Dunkelberger is the CEO of Sutter Health | Aetna, which is a payvider. Payviders, by Jeb’s definition, take on full risk. They have a full-risk insurance product, meaning they must switch up their business model and how they deliver care so that it works in a total capitation payment situation.

We go deep on payviders the last time Jeb was on the show (EP348). But in this relatively short conversation, I wanted to talk to Jeb about the operational imperatives of moving to value-based care, moving to a care model that is aligned with value-based payments—what needs to switch up in the day-to-day to ensure that patients don’t have care gaps that cause expensive trouble downstream, or patients at rising risk get taken care of promptly before something avoidable and/or acute (ie, expensive) happens.  

There are three main things that Jeb talks about:

1. Fixing up the clinical workflow
2. Having care navigators
3. Aligning physician comp to organizational goals

Let me dig into each one of them briefly.

1. Fixing up the clinical workflow. There’s basically five aspects to that:

• Ensuring that the right data is in the clinical workflow. Let’s talk about this data for just one sec and we’ll find actually one more reason that payers and purchasers need to get kinda engaged in this making sure members get care thing. Because data—data that payers have that is needed at the point of care. Like claims data. Please provide it to providers and actually insist that it gets used by clinicians making clinical decisions at the point of care.
• Ensuring that there are pick lists of drugs, with generic drugs first
• Making sure it’s easy to get to pended orders that close care gaps right within the clinical workflow
• Empowering medical assistants and holding them responsible to create value for members
• Building referral management into the clinical workflow in pursuit of a nonfragmented patient journey

2. Having care navigators. I just want to remind everyone: This is even more important if the EHR doesn’t support referral navigation. Also, Liliana Petrova talks about this extensively, the need for care navigators, in EP357. She’s talking about it relative to telehealth, and she makes a really important point: If you want to ensure that the right patients are getting telehealth and also taking advantage of it to streamline their longitudinal care and make it less fragmented, you have to have navigators involved in scheduling. Otherwise, how’s a patient supposed to know whether to go in person or telehealth or even that telehealth is available? 

3. Aligning physician comp to organizational goals. We definitely get into this in some detail.

We cover these three top-line operational must-haves in this episode, and you’ll hear about them right from a CEO who is doing them right now. Besides this conversation, another resource I would highly recommend checking out is a recent article in Nature entitled “Deploying Digital Health Tools Within Large, Complex Health Systems.” While this article is about digital health tools (obviously by its title), 80% of the article is pertinent to deploying pretty much anything in a big provider organization, including an upgrade to value-based care delivery—and/or probably digital health tools are pretty requisite in any attempt to effectively remodel the clinical workflow in this way in 2022, so there’s that, too.  

For additional Relentless Health Value episodes on this topic of how to build an operational model that fulfills value-based care objectives, I’d listen to the show with Shawn Rhodes on the essentials for clinical integration (EP354)—also the show with Lisa Trumble (EP349) on what that clinical integration looks like from a care perspective. I am also going to refer you to the episode next week (EP361) with Carly Eckert, MD, MPH. So, check that out for sure. We talk about care gaps. 

Jeb Dunkelberger, MSc, MHCI, currently serves as CEO of Sutter Health | Aetna (SH|A), a commercial insurance plan serving Northern California. The health plan aims to combine the value of retail, provider, and payer via its partnerships with CVS, Sutter Health, and Aetna. Prior to SH|A, Jeb led growth for two bay-area healthcare start-ups: Cricket Health and Notable Health. Jeb has also held executive roles at Highmark, McKesson, and EY. Jeb holds healthcare-related degrees from Virginia Tech, The London School of Economics, Cornell University, and University of Pennsylvania.

08:36 What must a provider organization consider operationally when incorporating value-based care and value-based payments? 09:44 How can you use perverse incentives to encourage people to do the right thing? 12:25 How should clinical workflows operate to incorporate value-based care? 14:10 “How do you align patients?” 15:52 How should the EHR operate to maximize value-based workflow? 16:52 Why is taking action on claims data and clinical data together important? 20:26 “Have they actually solved the last mile of integrations?” 21:15 “Changing the behavior of a provider is an absolute art and science.” 22:57 “We have to do more.” 27:09 “That administrative headache … doesn’t just end with the insurer.”

@Jeb_Dunk discusses #valuebased #clinicalworkflows in this week’s #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs

What must a provider organization consider operationally when incorporating value-based care and value-based payments? @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week’s #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs

How can you use perverse incentives to encourage people to do the right thing? @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week’s #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs

How should clinical workflows operate to incorporate value-based care? @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week’s #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs

“How do you align patients?” @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week’s #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs

How should the EHR operate to maximize value-based workflow? @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week’s #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs

Why is taking action on claims data and clinical data together important? @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week’s #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs

“Have they actually solved the last mile of integrations?” @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week’s #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs

“Changing the behavior of a provider is an absolute art and science.” @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week’s #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs

“We have to do more.” @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week’s #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs

“That administrative headache … doesn’t just end with the insurer.” @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week’s #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs

Recent past interviews:

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Dan O’Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb