The Race to Value Podcast

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

On February 24th, the Centers for Medicare & Medicaid Services (CMS) revealed the highly-anticipated fate of the Innovation Center’s (CMMI) Direct Contracting model options, announcing a redesign of the Global Professional Direct Contracting (GPDC) Model and the permanent cancellation of the Geographic Direct Contracting (“Geo”) Model. The revamped and rebranded GPDC model—now called Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH)— aims to better reflect the agency’s vision and Administration’s priorities for system transformation.  The new ACO REACH model has incorporated stakeholder feedback to alleviate the concerns of GPDC’s critics while maintaining the key features of the model and building on the momentum of the accountable care movement. ACO REACH also adds in exciting new components aimed at closing health equity gaps in keeping with the Innovation Center’s Ten Year Plan released late in 2021. This special podcast episode offers a short background on the model’s history and recent controversies leading up to the announcement, summarizes the major provisions of the new ACO REACH Model, outlining the key changes from the GPDC design, and considers potential implications for the Direct Contracting Entities (DCEs) currently participating in the GPDC model as well as the broader value movement. Joining this week we have two leading strategists in value-based care, Joe Satorius and Rick Goddard. They come to us from Lumeris – an accountable care delivery innovation company that enables health systems to deliver value-based care through advanced technology, risk-management, and outcome-based managed services. The ACLC and Lumeris have partnered to bring you the most in-depth information on the ACO REACH model. In addition to this episode, please download our free Intelligence Brief. Episode Bookmarks: 02:00 Background on the new ACO REACH payment model and its focus on health equity 03:00 Don’t forget to download the Intelligence Brief on ACO REACH released by the ACLC in conjunction with this podcast episode! 04:00 Background on Joe and Rick and their work at Lumeris 05:00 The complete redesign of the Global Professional Direct Contracting (GPDC) model 07:00 Rick and Joe provide perspective on the future of the Value-Based Care movement and the unsustainability of fee-for-service 08:30 CMMI’s Goal to have all Medicare beneficiaries in an accountable care relationship by 2030 11:00 Joe discusses CMS’ newly-refined eligibility criteria and why that matters when it comes to advancing health equity, promoting provider leadership and engagement, and enhancing beneficiary protections 12:00 The new ACO REACH requirement for 75% board representation from participating providers. 13:00 How ACO REACH incentivizes providers to address social disparities with underserved beneficiaries 15:00 The progression of capitation options in the ACO REACH model 16:30 Rick provides an extensive overview of the professional and global tracks of ACO REACH and the various capitation options that drive economics 20:00 The strategic implications of Total Care Capitation (TCC) and how network curation and design can support performance success and aligned behavioral economics 22:00 The Primary Care Capitation (PCC) + Advanced Payment Option (APO) 22:45 The importance of assessing risk appetite and value-based care readiness 25:00 Rick discusses the Health Equity Benchmark Adjustment – a new change to benchmarking methodology in the ACO REACH model 29:00 Providing greater and more equitable access to underserved communities, while leveraging telehealth and other value levers 32:00 Joe discusses risk adjustment methodology within ACO REACH and addresses concernsabout risk score gaming and over-coding 34:00 The 3% cap, the coding intensity factor, and demographic adjustments that serve as guardrails to inappropriate risk score increases 40:00 How should ACOs be preparing their population health reporting infrastructure to accommodate the additional requirement to collect health equity data? 41:30 The quality withhold that equates to a 10% bonus opportunity 45:00 Optional Beneficiary Enhancements and Incentives within the ACO REACH model and the importance of ACO participants to capitalize on them 46:45 Rick provides an overview of 3-day SNF waiver benefit, telehealth enhancements, post-discharge home visits, CM home visits, chronic disease management rewards program, etc. 53:00 ACO REACH application process and associated deadlines 55:30 ACO REACH implications on current DCEs in the Direct Contracting program 56:30 Governance Requirements for the new ACO REACH model 58:20 Joe provides parting thoughts on how organizations should be planning for the future and how ACO REACH plays into that strategy 60:00 The risk spectrum of ACO REACH from a capitation standpoint (primary care to global risk and total cost of care and advanced payment model options) 61:45 More information on Lumeris and how that help their partners navigate emerging value-based care requirements Please fill out the form below to receive a copy of the transcript for this episode

This week, we have as your guest the legendary Dr. Robert Pearl, a Stanford University professor, Forbes contributor, bestselling author and former CEO of The Permanente Medical Group.  Coming off of his bestselling book, “Uncaring: How the Culture of Medicine Kills Doctors and Patients” and a series of articles in Forbes about “Breaking the Rules of Healthcare”, Dr. Pearl describes the key economic and cultural forces that will reshape healthcare in the post-pandemic era. He highlights the flawed system design of our fragmented industry and how that has perpetuated economic status quo in the decades preceding the pandemic.  Dr. Pearl describes a better future for our healthcare system once we move from fee-for-service to capitation. In this podcast he provides thought leadership and sets a bold direction for a better tomorrow, while sharing lessons learned from his leadership experience at Kaiser Permanente and how COVID-19 will serve as a strategic inflection point to bring scalability to value-based care. Episode Bookmarks: 01:45 Introduction to Robert Pearl, M.D. 03:50 COVID-19 as a strategic inflection point and how rules of industry (and society) are changing 05:40 System vs. Culture in medicine and the impossibility of separation 06:00 The consequences of cottage industry design and fee-for-service incentives in American healthcare 08:00 The trajectory of rising healthcare costs over the next decade and missed opportunities for social investment 09:45 How COVID-19 will change the rules of physician culture 11:00 A medical history lesson (ex: Ignaz Semmelweis and the pioneering of antiseptics) and how it relates to lack of progress in the modern-day 14:00 Why medical culture is holding back innovations that improve care outcomes (and how COVID-19 has exposed cultural flaws in the profession) 16:45 The positive aspects of physician culture and the heroism of physicians during COVID-19 19:30 The need to value primary care and prevention (over specialty care and intervention) and the impact on primary care on life expectancy 20:00 Why were Black patients 2-3X more likely to die from COVID-19 than White patients? 21:00 How physician culture tolerates low value care and the high frequency of personal bankruptcies of patients seeking care 23:00 How COVID-19 accelerated the adoption of virtual care (and why the culture of medicine continues to oppose it) 26:00 Why capitation is a better economic model to improve care outcomes 27:00 The impact of Private Equity on value-based care and digital transformation 29:00 How post-pandemic economic pressures will reshape care delivery and support VBC adoption (i.e. virtual systems of care, employer-led initiatives) 32:00 Dr. Pearl reflects on the Haven venture and future steps to be taken in healthcare by Amazon 33:00 The anger, denial, bargaining, and depression that will be experienced during the process of reshaping American healthcare 34:00 “Acceptance of change will be the opportunity to make American healthcare once again the best in the world.” 36:00 How digital transformation, AI and interoperability can eliminate friction in the healthcare value chain and create a new era of patient consumerism 39:00 The advancement of medical devices and wearables that will support advanced analytical capabilities in diagnostics 43:00 “The key step to reshaping healthcare will be moving from fee-for-service to capitation.” 50:00 Lessons from Kaiser Permanente’s success and why their full-risk model hasn’t shown scalability at a national level 52:30 How post-pandemic disruptions and virtual care models will bring scale to value-based care 53:30 Dr. Pearl explains how the government push towards value-based care actually began in 1932! (and how the AMA quashed the move to capitation)

Joining us on the podcast this week is Dr. Clive Fields, the Co-Founder and Chief Medical Officer for VillageMD. Dr. Fields is a leader of high influence in the value economy, having been named to Modern Healthcare’s lists of the 50 Most Influential Clinical Executives and the 100 Most Influential People in Healthcare.  His company, VillageMD, is a leading, national provider of value-based primary care services that partners with physicians to deliver high-quality clinical care and better patient outcomes, while reducing total cost of care. In the years since Dr. Fields co-founded the company, VillageMD has grown to 15 markets and is responsible for more than 1.6 million patients. In 2021, VillageMD received a $5.2 billion investment from Walgreens Boots Alliance, which is looking to expand its healthcare offerings with VillageMD as a partner. This significant multi-billion investment will accelerate the opening of at least 600 Village Medical at Walgreens primary care practices in more than 30 U.S. markets by 2025 and 1,000 by 2027, with more than half of those practices in medically underserved communities. The Race to Value is honored to have Dr. Fields share his perspective on the opportunity for consumer-centric care delivery in our country.  We discussed important issues such as health equity, digital transformation, integrated pharmacy, home-based care delivery, multipayer contracting, health policy, and employer healthcare costs. Don’t miss out on this important interview so you can learn what it takes to succeed for the future of value-based care! Episode Bookmarks: 01:40 Introduction to Dr. Clive Fields and VillageMD 05:00 The intersection between value-based care delivery and consumerism 07:00 “Value-based health care success requires affability, availability and ability.” 08:40 Using a team-based, proactive, risk-stratified approach to care to deliver the best outcomes 09:00 Are we using the term “value” incorrectly in the industry? 10:00 VillageMD’s recently announced partnership with Walgreens and how it will provide scalability 12:00 How outcomes-based reimbursement can improve health equity in underserved communities 13:00 The transformative impact of the value movement on primary care 16:00 The acceleration of virtual care and the role it plays in a consumer-centric care delivery 18:00 What will virtual care look like in the post-pandemic era? 18:45 How the economics of global capitation drives improved health outcomes 20:00 The role that pharmacy integration plays in value-based care 21:45 Dr. Fields discusses how pharmacists should be utilized in the ambulatory care setting 23:00 Lessons learned from pharmacy integration and how that informed VillageMD’s collaboration with Walgreens 24:20 How pharmacist intervention can improve both provider and consumer experience by switching to formulary-equivalent drugs 26:45 Referencing recent McKinsey & Company study that projects up to $265B in facility care shifting to the home setting by 2025 27:45 Village Medical at Home – a leading example of home-based care delivery 28:40 “The lack of home-based care is partly related to the hubris of physicians.” 29:30 Dr. Fields reflects on how office-based care contributes to a misinterpretation of social barriers 31:45 Care in the home as the safest and most comfortable option 34:00 How VillageMD has cares for all patient populations (not just particular high-risk segments) 36:20 “We built a model that actually expands doctors’ panels – not limiting them to a certain product or payer.” 37:45 Managing risk across different populations with segregation by SDOH and risk determination (not payer status) 39:30 Referencing Dr. Fields’ most recent Op-Ed in Modern Healthcare addressing the criticisms of the Direct Contracting model 40:30 Dr. Fields provides commentary on the hyper-politicized debate related to public-private partnerships in the Medicare program 43:00 How a program like Direct Contracting can improve care for patients in underserved communities 46:00 Dr. Fields on how employers our now reaching an inflection point in addressing unsustainable healthcare costs 47:30 Brokers, payers, and providers working together to collaborate with large, self-funded employers 48:00 The co-location of primary care clinics with employer groups 50:00 The total addressable market for VillageMD is projected to grow 7% annually through 2025 to $1.4 trillion 50:30 Why Dr. Fields feels “overly bullish” about the state of the value-based care movement (outcomes-based reimbursement) 52:30 How VillageMD is positioning itself for the future of outcomes-based reimbursement with a model that can replicate at scale 54:45 VillageMD will have at least 50% of primary care locations in underserved communities 56:45 Parting comments from Dr. Fields and how to find out more about VillageMD

Patient Engagement is of paramount importance in value-based care.  Healthcare organizations are increasingly turning to solutions that promise more targeted patient outreach, more coordinated care management, and more potential for patient self-support in between care episodes. These solutions fall under a broad umbrella that can be described as patient relationship management, or PRM – and despite its name, it’s much more than a rebranding of customer relationship management for healthcare. True PRM is not just a “CRM for healthcare.” It focuses on patients’ needs outside of the healthcare facility setting –in between care episodes — as they live their everyday lives. It is more than improving engagement at the hospital bedside, more than making phone calls after hospital discharge, and more than launching a “portal of portals” to provide a unified engagement experience. A comprehensive PRM strategy can support value-based payment models by bridging the gap between the care setting and the patient’s home. In this episode, we interview Dr. Anil Jain (Chief Innovation Officer for Innovaccer) and Alex Lennox-Miller (Senior Analyst with Chilmark Research) to discuss how C-Suite executives should plan their future journey in PRM and digital transformation.  Patient Relationship Management is key to unlocking the digital front door in the Race to Value! Episode Bookmarks: 01:45 Does patient engagement have more of an impact in value-based care than SDOH?  What is Patient Relationship Management (PRM)? 04:45 The current state of dysfunctional patient engagement 05:30 How can a unified data platform create a more effective omnichannel approach to engaging patients? 06:30 Siloes of data and lack of consumer-orientation creating a less than ideal care journey for patients and families 07:15 PRM is not just for value-based care.  Billable events in FFS are also an opportunity for providers. 08:00 More engaged patients have better clinical and cost outcomes, with providers seeing improved quality measure performance. 08:40 The positive impact of a PRM platform on providers, nurses, and staff (i.e. lower burnout, higher satisfaction) 09:45 “The use of actionable clinical information within a robust PRM solution can help interdisciplinary care team members practice to the top of their license.” 11:00 Understanding the “full context of a patient”  (looking beyond the single patient record) 12:15 The use of clinical data in PRM (and how that differs from traditional CRM systems used in business) 12:45 Developing a patient engagement strategy for Congestive Heart Failure (based on clinical data and risk stratification) 13:45 “Clinical data can help create stratifications around risk.  However, that data needs to also be coupled with non-clinical data to determine how best to motivate and engage patients.” 16:00 Only 15% of hospital patients and 30% of medical practice patients access their health records electronically! 17:00 Will the 21st Century Cures Act create a more vibrant ecosystem of information exchange brought about by native APIs? 18:30 The limitations of legacy patient portals due to lack of robust data consumption and integration 19:45 How COVID-19 has reshaped patient engagement through experiments in virtual care 20:45 “A platform with rich APIs is critical to building a comprehensive Patient Relationship Management strategy.” 22:00 Patient recognition during COVID-19 that care delivery is grossly deficient in managing effective consumer relationships 25:30 Effective Patient Engagement versus Ineffective Patient Inundation (the need to integrate communications within provider organizations) 28:30 The potential for PRMs to revitalize patient engagement and provide more consumer-centric care based on optimal data integration. 31:00 Using non-clinical factors to develop open APIs, systems, and algorithms to match patients to resources in the community 34:00 PRM can provide value-based cost savings in the millions of dollars (i.e. 50% decrease in 30-day readmissions, two-thirds decrease in ED utilization, 10% increase in care compliance) 35:30 “True patient engagement has a profound impact on the measures that organizations are tracking.” 37:00 Communication-focused improvements for the consumer have better ROI than clinical improvements that optimize provider workflow. 38:40 Impacts of PRM on patient education, care plan adherence, and health literacy 43:00 Potential benefits of PRM in preventing disease progression with low- or medium-risk patients 44:30 The modularity of mature PRM platforms that can integrate condition-specific, behavioral science tools 47:00 The importance of a holistic PRM approach on longitudinal chronic care and the challenges of specialty care fragmentation 51:45 Overcoming system fragmentation through a governance process for PRM that includes both primary care and specialists 53:45 Technology must enable the right solutions and be a part of an overall, comprehensive strategy (technology is not the solution in and of itself!) 56:30 Parting thoughts on how C-Suite executives should plan their future journey in PRM and digital transformation

Allison Brennan is the Senior Vice President of Government Affairs for the National Association of ACOs (NAACOS) in Washington, D.C. where she helps develop and advocate for policies to benefit ACOs. In this special bonus episode, she provides an extensive update on health policy and directly addresses the critics of the Global and Professional Direct Contracting (GPDC) Model.  This episode was recorded and released on February 16, 2022 in order to address the alarming concerns related to the potential cancellation of the Direct Contracting program. Check out this episode for the latest health policy updates and to learn more about this controversial GPDC issue in the value-based care movement! Episode Bookmarks: 01:30 Introduction to Allison Brennan, NAACOS Senior Vice President of Government Affairs 03:00 Controversary and panic around the rumored cancellation of the Global and Professional Direct Contracting model (or GPDC) model! 05:30 The history of the ACO program as the premier payment model in the shift to value-based care 07:00 The recent trend of flat or declining growth of ACOs 08:00 Allison provides her perspective on the value movement as it relates to the growth of ACOs and other APMs 09:30 Recent changes in ACO policy and the importance of not defining “risk” as the same as “value” 11:00 The integration of health equity in all CMMI payment models and the need for upfront funding 13:00 Allison discusses the need to support providers (e.g. data, tools, education) in order to address SDOH and equity requirements of APMs 17:00 Prior success with the ACO Investment Model (AIM) and other provider investment programs to support APM adoption 18:30 Benchmarking methodology and the importance of focusing on inequities 20:00 An outline of value-based care legislative priorities contained within the “Value In Health Care Act of 2021” 22:30 Incentives for MSSP ACOs adoption and the extension of the 5% Advanced APM bonus as a top priority for NAACOS 29:00 Allison reflects on her work with the current Administration and the continued leadership needed 32:00 Allison explains the challenge with the “Rural Glitch” and the importance of fixing the MSSP Benchmarking Methodology 37:00 An overview of the Global and Professional Direct Contracting (GPDC) model 39:00 Allison explains NAACOS’ support of the Direct Contracting model and the differences between the three DC options (Global, Professional, and Geographic) 42:00 Recent criticisms of GPDC and the need for the model to be more “provider focused” 43:00 Approaches to capitation models and benchmarking for DCEs 45:30 The deeply partisan arguments against the Direct Contracting program and rumors of its pending cancellation (e.g. Physicians for a National Health Program, Senator Warren) 49:30 Allison provides a real-time, in-depth perspective on the recent GPDC controversy 54:00 “Cancelling the program would shatter the confidence of the provider community in the shift to value” and why outright cancellation of GPDC is unlikely 57:00 Parting thoughts from Allison on the state of the value movement (Is health policy heading in the right direction and moving fast enough in this Race to Value?)

This week we are honored to have as our guest, the legendary John W. Bluford III. Mr. Bluford is a nationally known healthcare innovator who has been recognized by Modern Healthcare and Becker’s Hospital Review as one of the Most Influential People in Healthcare. Mr. Bluford is the Founder and President of the Bluford Healthcare Leadership Institute (BHLI) – a nonprofit organization focused on value-based care leadership to eliminate health care disparities. BHLI provides an intense professional development program designed to expose undergraduate scholars with exceptional leadership potential to today’s challenging healthcare landscape, cultivating them for future leadership roles where they will serve to eliminate disparities in healthcare.  This Institute was created by John Bluford as a way to advance health equity in today’s healthcare system by sponsoring, mentoring, and coaching underrepresented talent for healthcare leadership and creating opportunities for the emerging leaders to improve health outcomes for minority and vulnerable populations. In this episode, you are going to learn from John Bluford how “Culturally Competent Leadership to Eliminate Disparities in Healthcare.”  Mr. Bluford currently serves on the Board of Trustees for Western Governors University – the leading online university in the country with a College of Health Professions that is deeply involved in the provision of workforce readiness to deliver on the promise of high value, high quality care that delivers equitable outcomes for all. https://www.blufordinstitute.org Episode Bookmarks: 01:45 Introduction to the legendary John W. Bluford III, MBA, FACHE 03:10 The Bluford Healthcare Leadership Institute (BHLI) program’s commitment to culturally competent leadership 07:45 Lessons learned from a 6-week experience at Harvard University that informed a new way of thinking about healthcare 09:00 The rewarding experiences as a mentor while serving as a preceptor for graduate students 10:00 Mr. Bluford never mentored minority students in 12 years as a preceptor because there weren’t any at the time! 11:00 A vision to create a more diverse pipeline of healthcare administration students 12:00 “Our mission is to create leaders of the future that will eliminate health care disparities among minority and vulnerable patient populations over the next two generations.” 13:00 The impact of BHLI alumni leaders who have completed the program 16:00 The observance of Black History Month and the cultural zeitgeist for civil rights and social justice has been awakened in the collective consciousness of all ethnicities 17:30 Why institutional racism will take generations to fix because it is so deeply embedded in our country’s history 18:40 “The accomplishments of Black Americans should be celebrated routinely just like everyone else.  Black history is American history and should be treated as such.” 20:45 How the CMS Innovation Center is integrating health equity into the design and reengineering value-based payment models 22:15 The elevation of national consciousness regarding the existence of health disparities 22:45 “We can’t fix the problem without realizing that there is a problem.  Health care disparities do, in fact, exist.” 23:00 The need for strong, pervasive leadership in healthcare, society, and government to overcome the systematic perpetuation of racism 24:20 The role of hospitals in addressing health equity and population health in the communities they serve 26:45 Mr. Bluford discusses the importance of culturally competent leadership, reflecting on lessons learned from his hospital administration career 28:00 Understanding the culture of communities and how socioeconomic determinants of health impact care outcomes 29:50 Love, hope, and compassion needed in population health leadership 30:30 Case management of patients with chronic disease is more effective when you understand SDOH barriers 31:40 “You really don’t know a patient until you go to that patient’s home.” 33:30 Understanding employees is just as important as understanding patients (ex: ensuring financial literacy for employees) 35:45 The capital intensity of SDOH investments and the responsibility of the health system (versus the role of government or CBOs) 36:40 “Tearing down those walls will be painfully slow. But we will never get to the destination if we don’t start the journey.” 38:00 The emergence of partnerships between hospitals and community benefit organizations 39:20 “Common good” is a more appropriate term than “public good” because the private sector has a responsibility to address health equity 40:15 Referencing Governor Leavitt and his questioning of who will take the lead in addressing health equity 42:00 Mr. Bluford casts a vision for how the elimination of health disparities to create community health, economic prosperity, and intergenerational wealth 44:00 How public policy and education shapes the direction of society 45:00 Great healthcare leaders who unite people (ex: Nicholas Tejeda, Patricia Maryland, Lloyd Dean, Kevin Lofton, Kathleen Sebelius, and Mike Leavitt) 45:30 Overcoming the pandemic is important because “there will not be economic health until there is public health” 47:30 How the WGU College of Health Professions provides scalable educational programs that provide pathways to establishing competency in population health and health equity 48:30 How Higher Education can better serve underserved learner populations to build a more qualified, culturally-competent healthcare workforce 50:00 The importance of early childhood education to build individual accomplishment and community prosperity 51:30 An example of education empowerment of employees that made an economic impact 53:30 The inaccessibility of higher education due to extremely high tuition costs 55:00 The need to hardwire conformance to social justice and health equity within the health administration profession 56:30 Diversity, Equity, and Inclusion (DEI) leaders in healthcare organizations need to be in the C-Suite 61:00 The role of technology in transforming our fragmented, expensive, and inequitable healthcare system and “bridging the digital divide” within underserved communities 62:30 The caution of health information technology in that it should not replace human relationships in the health care setting

Our guest this week is Micky Tripathi, the National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services, where he leads the formulation of the federal health IT strategy and coordinates federal health IT policies, standards, programs, and investments.  As the Office of the National Coordinator (ONC) chief, Micky Tripathi is advancing healthcare interoperability to support value-based payment and improved health equity.  Before taking the helm of the ONC a year ago, Micky served as chief alliance officer for Arcadia, a population health management and healthcare intelligence platform company. Our conversation with Micky covers the ONCs efforts in COVID-19 response in support of public health, aligning with federal partners, improving health equity through purposeful and intelligent HIT design, improving EHR and interoperability, TEFCA standards adoption, information blocking, FHIR APIs, and the development of a robust apps ecosystem to improve population health. This episode is sponsored by Arcadia, the only healthcare data and software company dedicated to healthcare organizations achieving financial success in value-based care, and recognized as Best in KLAS in Value-Based Care Managed Services three years in a row. Episode Bookmarks: 01:50 Introduction to Micky Tripathi – the National Coordinator for health information technology with the ONC 02:20 This week’s sponsor:  Arcadia – Recognized as Best in KLAS in Value-Based Care Managed Services 4 years in a row 04:15 Visit arcadia.io/theschema to explore how we can use data to improve the current and future state of healthcare 05:00 There are 40 times more bytes in the digital universe than there are stars in the observable universe!  07:20 Micky provides perspective on how to begin getting more visibility into data and analytics in order to transition from volume to value 08:10 How the data explosion and exponential growth of computing power requires data liquidity and fluidity 09:00 The increasing competition for data science expertise – how does healthcare compete with tech companies and financial industries? 10:20 The self-imposed industry barrier of cleaning and wrangling data and the need for authorized aggregation of health data 11:20 Rethinking what access to data means in light of the information blocking rules within the 21st Century Cures Act 12:15 Micky references his tenure with Arcadia and how the information sharing landscape is changing population health management 12:40 Making both structured and unstructured data available and how/why unstructured data is valuable 14:30 The implications of SDOH on health equity and the concept of “health equity by design” where SDOH can be a core feature of Health IT 16:50 Micky explains how the ONC is influencing “health equity by design” through the trajectory of Health IT 18:00 Accessing data to identify outcomes disparities in communities and the heterogeneity of data collection (e.g. OMB and CDC classifications) 20:00 Deploying data-driven, upstream interventions for social determinants of health (e.g. UT Dell Med Community-Driven Initiatives) 21:40 Streamlining consistency and focus in the collection of race, ethnicity, and language data to lower friction in healthcare 23:00 How lack of “health equity by design” contributed to the development of modern-day EHR systems 25:00 How an event notification algorithm design flaw caused failure in providing appropriate population health interventions 27:20 “Value based care is critically important and it is a key driver of interoperability. We need to move from basic information exchange to apps that will use the whole portfolio of interoperability capabilities.” 28:00 FHIR-based CDS Hooks – an HL7 specification for clinical decision support 29:20 “The business case for Value-based Care is a key driver of interoperability in the marketplace.” 31:45 Information blocking is due to lack of economic incentives (not intentions) 33:00 Micky explains how TEFCA will drive network interoperability and how ONC implementation will support value-based care 36:45 The availability of FHIR APIs by all EHR systems due to technical requirements of the 21st Century Cures Act 37:45 Creating a vibrant app ecosystem through FHIR APIs 38:30 FHIR Bulk Data Access 41:30 How the ONC’s interoperability vision and the 2020-2025 Federal Health IT Strategic Plan will set policy prioritization and government agency alignment 46:45 Micky discusses the ONC’s “Health Interoperability Outcomes 2030” idea crowdsourcing initiative helped prioritize a set of interoperability outcomes 52:00 Micky discusses the importance of having a trusted exchange network and nationwide interoperability governance using the example of cellular network connectivity 54:00 How can TEFCA help open doors of opportunity for the market to further drive interoperability? 55:30 “Payer participation in information exchange with providers should be a two-way street.” 59:00 Micky provides an overview of the 21st Century Cures Act, how it impacts information sharing regulations, and how it compliments HIPAA 63:00 An update on the current status of the 21st Century Cures Act implementation 64:00 How the ONC processes complaints for Information Blocking in conjunction with the OIG 65:00 The fines and penalties for EHR vendors in breach of Information Blocking Rule 70:00 Micky explains how we should get EHR vendors to make open APIs available (“The aggregation of demand gets the supply-side to move.”) 73:00 The role of patients in advocating for more information sharing 75:00 The opportunity for patient engagement in healthcare through apps (comparison to TikTok) 77:00 Closing sponsor message from Arcadia

This week on our show we have Dr. Terry Knapp – Founder, Director, and Chief Medical Officer of CareSpan Holdings, Inc.  Dr. Knapp has a storied 50-year record of achievement in health care and business. His company CareSpan provides a comprehensive, integrated digital healthcare “Clinic-in-the-Cloud” solution by creating unfettered access to care for the underserved, with an emphasis on the care of chronic illness. Dr. Knapp has devoted his life to working with native peoples throughout the world and deeply understands the health problems and impediments to better healthcare that afflict Native Americans.  In this episode, he is here to share his views in order to raise awareness for the plight of indigenous peoples in our country who are receiving sub-standard care. There are some deeply emotional moments in this episode, as he discusses the failures of healthcare delivery as promised by the U.S. government more than 100 years ago. He describes American Indians that are dying a slow and agonizing death.  Their land – a reservation – is a concentration camp where they are treated as third-class “citizens” by receiving medical care that is killing them. He talks about the bureaucracy of the Indian Health Service, the failure of the IHS to provide enough good doctors, the lack of choices by patients, and the lack of respect for Native American ways by a health system that ignores their culture. He discusses the denial of access to modern medical care and posits that the Indian Health system actually makes them sicker by exacerbating psychological trauma and socioeconomic challenges associated with their physical imprisonment (as seen by rates of substance abuse and mental illness). The inhumane treatment that Dr. Knapp has observed firsthand has made him speak out about what he sees as a slow-moving but progressive bureaucratic genocide of our Indigenous peoples. The Native American phrase Mitakuye Oyasin means “all my relations”.  This is said at the end of every prayer in the Lakota Nation, and it reminds us at all times to honor all of our relations – past, present, and future. This transcends our human relatives and includes our relation to all of creation – the water, the plants, the animals, and the Creator. Indigenous people think intergenerationally as well, by honoring those in the past, present, and future. In thinking of value-based care, how can we consider all of our relations – which includes Native Americans who have suffered irreparable harms from a deeply flawed healthcare system? Episode Bookmarks: 02:00 Introduction and Background to Dr. Terry Knapp 03:50 Dr. Knapp is speaking out after seeing firsthand the inhumane treatment of our Indigenous peoples by the healthcare system 05:20 The Native American phrase Mitakuye Oyasin (“all my relations”) as a reminder that value-based care must consider all of our relations – including Native Americans who have suffered irreparable harm 07:10 Dr. Knapp discusses his medical training and life’s work to make a social impact as a surgeon, inventor, and entrepreneur 13:00 Insights as a cancer patient led him to develop a “clinic in a cloud” integrated digital care company (CareSpan Health) that leverages technology to enable health equity 14:45 The catastrophically high rate of COVID-19 cases and deaths in the Native American population (and similarities to the 1918 flu pandemic) 15:15 Tribal healthcare facilities are underfunded (in 2017, US healthcare expenditures were $9,207 per capita but only $3,332 per capita for Indian Health Services) 15:50 Unethical medical practices of the past (e.g. Native American women undergoing forced sterilizations in the 1960s and 1970s) 16:20 Dr. Knapp’s early experiences in treating the Yurok and Hupa tribes in California as a medical resident 18:00 Treatment of disadvantaged people in Mexico, Peru, Ecuador, Columbia, Chile, and other parts of Central America 18:30 How a friendship with Gene Thin Elk taught him the importance of native healing and how to live in harmony in nature through ceremony 20:50 Lessons learned from the Lakota Sioux nation about how community support can help warriors heal from PTSD 21:20 An invitation to speak the 18 tribal Chairmen to share views on modern medicine and virtual technology 21:50 The horrific stories shared by John Yellow Bird Steele about the suicide of 7 young women in one week, the death of a young boy, and other suicides and drug overdoses on reservations 24:00 Insufficient access to care to Native Americans due to lack of providers willing to live under reservation circumstances 25:00 The shock of seeing such alarming grievances expressed by tribal Chairmen when meeting with a federal official representing HIS 27:00 Dr. Knapp explains how the 638 Self Determination provision for healthcare prevents the IHS from sharing resources (e.g. Internet signal) with a tribal system clinic on the same site! 28:00 “There is something amiss when it comes to the bureaucracy that will not allow the sharing of simple, potentially lifesaving resources between an IHS facility and a tribal clinic.” 28:50 The insufficient, outdated, and essentially unusable RPMS Electronic Health Record system used by the IHS that needs either significant improvements or a complete overhaul 29:30 “The RPMS Electronic Health Record used by the IHS kills people. It was first developed in the late ’70s and hasn’t had a complete overhaul since 1982.” 30:30 Bringing telehealth to the reservations is virtually impossible since it cannot interoperate with RPMS 31:00 “The lack of interoperability of RPMS actively denies health equity to the Native Americans.” 31:40 The Native Americans call their IHS ID Number their “Auschwitz number” 32:00 Dr. Knapp discusses how the United States of America will not allow Native Americans to be self-determinant and has robbed them of their identity. 33:40 Treaties signed with the US government guaranteed that healthcare be paid for in perpetuity, but the care is poor with no choices to receive care in the private sector. 35:00 The failure in our country of the healthcare system to provide optimal outcomes for chronic disease (and how chronic disease is so much worse on the reservation) 36:00 Dr. Knapp discusses Social Determinants of Health,  Whole-Person Care, and Blue Zones 37:30 Realigning economic incentives with care delivery that leverages digital health approaches to primary care 38:00 Why we need to focus on outcomes instead of value (since value is so hard to define) 39:30 The importance of relationship-based, tech-enabled, coordinated, whole-person, holistic care and how that could benefit indigenous peoples 41:00 Dr. Knapp provides a personal definition of health equity and what it means on a population health basis, i.e. how the overall health of a society adds benefits and opportunities for all 43:00 The sad truth of declining life expectancy in the United States, yet we spend more on healthcare than any other country in the world 44:00 How technology can enable value-based care if it is properly integrated to drive a systems engineering process (P4 Medicine) 45:00 Development of a digital ecosystem that monitors data, delivers comprehensive care, engages patients, provides continuity of services, and utilizes predictive and outcomes-based analytics 49:00 Honoring Native American traditions and heritage through the provision of culturally-competent care 51:00 Keeping an open mind to indigenous Native American Healing traditions and why Western Medicine should partner with native healers 52:00 “The only way to create a sustainable healthcare paradigm is to pay for outcomes-based care in a risk-adjusted, capitated fashion…” 54:00 How the flawed fee-for-service model limits access to primary care and raises per capita costs 56:00 Dr. Knapp discusses how technology can be used to create health equity in our country 57:30 The failure to address the drug predators who prey on American Indians to create a massive public health crisis 58:20 “Drugs like Fentanyl, Methamphetamine, and Heroin are weapons of mass destruction.” 59:30 The public health crisis of obesity in our country 60:00 Delivering the same level of care to Native Americans while also respecting their culture is a “great life’s work” 61:20 Dr. Knapp provides parting thoughts on the inhumanity of the bureaucratic state and how COVID-19 has “opened a window” for change

In a career focused on improving global health value through systems transformation, relationship-based primary care has been at the heart of Dr. Paul Grundy’s crusade.  Dr. Grundy is a data transformation advocate, active writer, social entrepreneur, speaker on global healthcare transformation, humanitarian, diplomat, and trusted healer.  He has traveled the world more than any other physician that has ever lived and seen how other country’s deliver health care.  Dr. Grundy is such a transformational force for social change that Nelson Mandela even called him a “good troublemaker” as someone who is always looking for innovative disruptions to benefit humankind.  We often reflect on those great leaders in American History who challenged us to be better…from JFK asking individuals to step up, and Ronald Reagan admonishing communists to join the free world, to Martin Luther King, Jr. who provided us with a powerful anthem for change with his work in advocating for civil rights.  In the healthcare history books Dr. Grundy will be known as a crusader with his own version of the “I have a Dream” vision for transformation! Our guest this week is Dr. Paul Grundy, commonly known in industry as “The Godfather of the Patient Centered Medical Home.” Although he didn’t invent the medical home model, he gave it a voice, definition, structure, and made it real. The model is focused on that which is most important – the cultivation of a trusting patient relationship. Whether you call it a milestone or the finish line, that trusting relationship is critical in the race to value. Episode Bookmarks: 02:00 Introduction to Dr. Paul Grundy – a humanitarian and healthcare legend in patient-centered care models and value transformation 04:30 Referencing Dan Pelino’s book, “Trusted Healers” that was written about Dr. Grundy’s worldwide crusade for better healthcare 05:00 Dr. Grundy’s international healthcare experiences as a humanitarian and diplomat that has traveled more air miles than any physician in history! 06:00 Dr. Grundy’s work with Nelson Mandela and how he become known as a “good troublemaker” looking for innovative disruptions to benefit humankind 07:00 How growing up in Africa informed Dr. Grundy of the importance of a traditional healer in creating relationships that drive better patient outcomes 07:30 “A relationship of trust must be the basis for an accountable health care delivery system that works.” 08:00 Reflections from observing health systems all over the world and how Denmark is the leading example of relationship-based primary care 08:45 Research showing that relationship-based primary care reduces both healthcare costs and mortality rates 09:10 Dr. Grundy speaks about his prior work at IBM and how IBM viewed the Patient-Centered Medical Home as foundational for “system integration” 09:30 The history of the Patient-Centered Medical Home and how shared data underpins the success of the model 10:15 Accountable Care begins at the intersection of trusted healing (relationships) and systems integration (coordinated data sharing) 11:00 Formative experiences growing up in the African bush and how that enabled Dr. Grundy to understand and apply deeply held tribal beliefs into his own life 13:00 Dr. Grundy discusses how Quakerism and The Eight Laws of Social Change has been his guiding light to seek social impact through global health reforms and value-based care 16:30 How early followers are just as important as revolutionary leaders in creating social change 17:00 “The current healthcare delivery system is a form of violence when an episode of care is what is valued – whether that episode of care is necessary or not. We need a cultural shift away from an episode of care to managing population health.” 18:00 The importance of accessing data at the point-of-care to improve population health outcomes 19:00 Eric engages Dr. Grundy on his leadership in the Patient-Centered Medical Home movement and how it is not unlike leading a social movement for civil rights 21:30 Dr. Grundy tells the story of how he received the ‘Godfather’ name by “changing the covenant” for primary care and data activation to achieve health value 25:00 Managing difficult diagnostic dilemmas and creating relationships of trust are the primary responsibilities for physicians 25:30 Specialized clinical programs (e.g. comprehensive medication management, behavioral health, education) are best delivered by interdisciplinary system in an integrated system 27:10 Building accountable care (like the Denmark health system) through integrated systems of care under the ownership of the physician 30:00 The impact that value-based care has on reducing physician burnout and why forcing physicians to be scribes is a terrible idea! 32:00 Teaching medical students that being a physician is “team sport” and redesigning for team-based care delivery 36:00 Referencing Dr. Grundy’s book entitled “Lost and Found: A Consumer’s Guide to Healthcare” 36:30 Dr. Grundy shares his views on healthcare consumerism and how patients can best navigate the obstacles that stand between them and high-quality, affordable healthcare 37:30 Access and availability is cornerstone of consumer-centric models and how Tom Lee, M.D. founded One Medical on this premise 38:00 Realignment of financial rewards with service through value-based payment and how low value care arises due to misaligned incentives 39:20 Community health centers as an consumer-centric model of care 41:30 “Data is going to do for a doctor’s mind what x-rays did for changing a doctor’s vision.” 42:20 Referencing The Flexner Report (a landmark report of medical education written 110 years ago) and how healthcare is the last industry running on the “master builder” model 43:20 The superiority of a data-based population health model to augment physician brainpower 44:30 How to modernize healthcare through pattern recognition empowered by Machine Learning/Artificial Intelligence models 46:00 “Data supports the relationship of trust with the healer. Having both working together is what enables you to make a difference in someone’s life.” 46:30 Dr. Grundy shares a story of how understanding data allowed for an effective intervention to address food insecurity 47:30 Dr. Grundy differentiates Machine Learning from Artificial Intelligence and the implications of Natural Language Processing (NLP) as a branch of AI 52:00 The concept of self-driving cars and how computers can understand patient communication better than doctors! 54:00 The Value-Based Care certificate program at Western Governors University 55:30 Dr. Grundy provides parting thoughts on the importance of workforce development in creating a cultural shift for healthcare transformation 57:00 More information on ACLC/Innovaccer, CareAsOne, and the Get the Medication Right (GTMRx) Institute