The Race to Value Podcast

Sixty years ago, May 1961, President John F. Kennedy challenged the American nation in a speech to Congress, asking them to commit to “landing a man on the Moon and returning him safely to the Earth.” Eight years later, that bold goal was realized – in July 1969 Apollo 11 landed and returned safely with a crew. President Kennedy’s moonshot goal is an important reminder of courageous leadership that sets an inspiring goal that pushes us to think and achieve boldly.  That is not unlike the 10-year vision of Ochsner Health to transform the health of Louisiana, taking it from 49th out of 50 in America’s Health Rankings to a ranking of 40 by 2030. As a native Louisianan, Dr. David Carmouche is committed to transforming the health outcomes of his state.  Dr. Carmouche serves as President of the Ochsner Health Network, the accountable care network of the massive Ochsner Health System. The health system is committed to a value-based strategy and its CIN has generated returns north of $100M in its value-based contract portfolio over the last few years.  In this episode, Dr. Carmouche shares meaningful lessons from his value journey covering such topics as physician leadership in the value movement, partnerships with employers, community resilience, precision medicine and social determinants of health, and Ochsner’s 40 by 30 vision to transform health in the state. Episode Bookmarks: 04:00 Dr. Carmouche’s leadership purview (and reflections from his glory days on the gridiron???) 07:20 Dr. Carmouche speaks to the national pursuit to value-based payment and looming Medicare insolvency 09:10 The experimentation phase of value-based care and the next-level commitment to pursue the most viable APMs 10:10 Subsidizing government contracts (Medicare, Medicaid) with commercial payers to spot margin and why that is no longer tenable 12:00 Dr. Carmouche discusses the financial results of Ochsner’s value-based contract portfolio 13:00 Board-level and CEO commitment to value as a strategy for population health and long-term economic success 13:25 Investment in care capabilities and realignment of incentives within large employed physician group as keys to success 14:10 The ‘muscle memory’ of owning a health plan and how that created orientation to risk at Ochsner 14:40 The importance of leadership in driving success in value-based payment with improved outcomes in patient communities 15:45 The three verticals of Ochsner Health’s business:  Care Delivery, Risk Operations and Insurance, and Digital Services 16:30 How Ochsner Health manages fee-for-service dependency in its legacy business model with its commitment to value 19:10 Building partnerships with insurance brokers and fully-insured employers to support appropriate steerage and drive cost savings 21:15 Creating economic alignment with self-funded employers and the challenges of creating meaning gainshare opportunities 22:50 Negotiating care management fees with self-funded employers as in interim step to full-risk 23:30 Dr. Carmouche discusses the network agreement they reached with Wal-Mart to provide high value care for employees across Louisiana. 26:45 “From Competition to Collaboration” – Dr. Carmouche’s contribution to a book that outlines the Health Ecosystem Leadership Model (HELM) 27:00 Dr. Carmouche reflects on the diverse experiences in his career that allowed him to learn about the different sectors of the healthcare ecosystem 28:15 “No one sector of the healthcare ecosystem can create significant value alone” 29:15 How an interaction with Dr. Paul Grundy inspired Dr. Carmouche to make the biggest impact possible in improving the health of Louisianans 31:00 Blending physician leadership with the business understanding of different sectors in the healthcare economy to drive value creation 34:00 How Ochsner worked to ameliorate the scourge of COVID-19 in New Orleans and lessons of community resilience from Hurricane Katrina 36:00 Rapid deployment of a virtual care model to deliver primary care and behavioral health services (going from 3,000 visits to 100,000 visits in one year) 36:40 Digital medicine program to provide full-service virtual remote monitoring and management of hypertension and diabetes 37:40 The disparate impact of COVID-19 on disadvantaged minority populations 38:20 Louisiana is next to last in health status of all 50 states and why it is so difficult to solve for social factors like poverty, education, and health literacy 39:40 The endless opportunities for population health and why Ochsner will have failed if Louisiana’s health rankings do not improve over time 39:50 Coordinating with state government, private investment, and communities through the 40 by 30 initiative 40:20 $100 million investment to address Louisiana’s most critical health needs 43:20 The physician culture of Ochsner Health that emphasizes teamwork 44:30 Dr. Carmouche discusses the moral injury that is happening to physicians because of administrative bureaucracy 45:30 Revising physician compensation so that it focuses less on RVU production and more on value-based care performance 46:30 Eliminating burdens in physician workflow through automation and point-of-care alerts 47:30 Growth in primary care that is attributable to compensation alignment and optimized care delivery model 49:30 Dr. Carmouche speaks to the connection between evidence-based care and precision medicine 50:20 Collecting social determinants data from health risk assessments to drive care processes and community-based interventions 51:30 Developing AI and machine learning algorithms to have more precision in predictive models 52:00 The application of population health-based genomics testing and genetics counseling to improve care outcomes 53:20 Leveraging digital medicine tools and wearables for chronic disease management 56:30 “Personalized care within a population health agenda is the way of the future.” 58:30 How moving to “asset-light” hospital models with fewer beds would have made us ill-prepared for pandemic response 59:30 “We can’t afford the fixed cost, asset-heavy healthcare delivery system that has been the hallmark of U.S. healthcare in the last 100 years.” 63:00 This vision of Warner Thomas, President and CEO of Ochsner Health 64:30 How improving health equity and transforming the workforce will deliver the promise of value in Louisiana 66:20 “We didn’t make it to the moon in ten years without someone putting a stake in the ground.”

The difference between average people and achieving people is their perception of and response to failure.  “Failing Forward” was a concept defined by John C. Maxwell several years ago, and that axiomatic truth could not be more readily apparent than in value-based care.  Transforming healthcare to lower costs and improve patient outcomes is tough work. PERIOD.  It requires many years of experimentation and “trial and error” innovation. The suffering index in the value movement can be immense, but the returns – in both financial success and personal/professional fulfillment – make it a purposeful endeavor. Dr. Jesse James, the Chief Medical Officer for CHESS Health Solutions, is a leader in the value movement who believes in Failing Forward as a key to success in value-based care.  In his role, he oversees quality and clinical services for a population health management company that supports more than 3,000 providers and 150,000 patients. Dr. James joins us this week to show us that as leaders in value, “We must be willing to fail forward. “It’s our scar tissue that makes us stronger.”  Tune in this week to learn from one of the best!  In this episode, Dr. James provides leadership and business insights that are profoundly helpful for physicians, executives, and entrepreneurs looking to win this Race to Value. Episode Bookmarks: 04:20 Dr. James’ “defining moment” when he found his calling to practice medicine 06:00 The decision to begin a medical career at the bedside and then working at the system-level to transform healthcare 07:30 Dr. James’ early work in clinical quality and the influence and mentorship of Dr. Cary Sennett (“The Godfather of Quality Measurement”) 08:45 The permission to fail bestowed by a mentor has been a constant reminder to “Be Humble” in the practice of medical leadership 11:00 The legendary basketball coach John Wooden on how “Failure is not fatal, but failure to change might be.” 12:25 “As a leader, you have be willing to fail forward. It’s our scar tissue that makes us stronger.” 12:45 The story of how CHESS was borne out of an innovative medical practice that embraced value before the payment environment would support it 14:30 Lessons learned from hardships in the Value Journey (transitioning from FFS to P4P to Gainshare to Full Downside Risk) 15:30 “You have to remove the stigma around failure. These are opportunities to learn and grow.” 15:40 The story of Sir William Osler and how the ideal physician should be equally to call out failures as much as successes 16:50 The influence of the Institute of Medicine report “To Err is Human” on the culture of safety in the practice of medicine 17:00 The need for a new culture change in medicine to learn from mistakes and failed experiments to advance population health and VBC 19:00 Medicare payment model innovation and how CHESS isgetting as close to premium dollar as possible by taking downside risk with MA and commercial insurers 20:00 CMS experimentation with global capitation and why providers should be thinking about the Direct Contracting model 23:30 The use of “innovation cells” to effectively disseminate learnings within partner organizations 25:00 Addressing transportation as a social determinant of health in rural areas 26:00 Partnering with Wake Forest Baptist Health to deploy a “hospital at home” model 27:15 Creating wrap-around services in the technology and clinical domains to meet with needs of clients with varying degrees of maturity 29:30 Dr. James describes the value-based care landscape in North Carolina and the impact of the Atrium Health–Wake Forest Baptist Health merger 33:10 Developing a leading Medical Management program with service hubs in Care Management, Pharmacy, Quality, and Risk Adjustment 33:40 Data Analytics and Predictive Modeling and how CHESS partnered with Wake Forest to develop a frailty index 34:35 Implementing a high utilizer conference to review high cost patients and develop a multidisciplinary approach to intervene 34:45 The impact of social issues on health and how CHESS is developing a hub for Social Work to meet patient needs 35:30 “In Value, you can increase your savings by having a willingness to meet the patient where they are through community-based interventions.” 36:40 Pharmacy Integration in clinics to address med assistance, adherence assistance, and improvement of quality 38:20 Dr. James provides a general overview of CHESS’ approach to Risk Adjustment and explains how improved RAF scores can drive success in value 41:40 Dr. James reflects on his tenure with the ONC and how the pandemic has exposed continued vulnerabilities in aggregating data to assess public health outcomes 43:00 The importance of APIs to move data and provide better information to improve care 44:00 Developing smarter predictive models for better tailored interventions 46:00 Dr. James discusses his views on health equity and responsibility of physicians to deliver culturally competent care 47:15 Appreciating the diversity of patients (e.g. race and ethnicity, health literacy, education level, income level) to serve them well 47:40 How Value-Based Care creates an economic incentive for physicians to have an appreciation for the diversity of patients 48:50 Ensuring that AI and predictive models are devoid of racial bias and are inclusive of all populations 49:40 Dr. James discusses how his mother grew up in an era of racial segregation 51:00 The growth of CHESS, how the culture is responding to the needs of the future, and the importance of “failing forward”

Former President of South Africa, Nelson Mandela, made an important observation when he said, “There can be no keener revelation of a society’s soul than the way in which it treats its children.” Our children are wholly dependent upon us, their parents, teachers, and society for their education, their safety and their health. It is with this mindset that we proclaim, high-value pediatric care is critical for winning the race to value. Our guests this week are Ginger Hines, Executive Director, Seattle Children’s Care Network and Dr. Sheryl Morelli, Medical Director for Seattle Children’s Care Network, and Clinical Professor of Pediatrics, University of Washington School of Medicine. Seattle Children’s Care Network (SCCN) is a pediatric clinically integrated network comprised of Seattle Children’s Hospital, 600 specialists in Children’s University Medical Group, and 20 primary care pediatric practices comprising more than 200 providers and 6 specialty clinics. Member practices in the CIN support the health of 50,000 pediatric lives in value-based contracts. Episode Bookmarks: 03:20 Background on Seattle Children’s Care Network (SCCN) and Seattle Children’s Hospital 04:45 Pediatric value-based care being driven by employers and how SCCN formed direct-to-employer contracts 05:30 The movement to value-based care in Washington State’s Medicaid program 06:00 How SCCN engages with physicians to build trusting relationships and a shared vision 09:00 The long-term societal benefits to investing in children’s health 10:30 Children with high BMIs that become adults with diabetes, CHF, and depression 12:00 Parents missing work to take care of unhealthy children and how employers investing in children’s health care lead to productive employees 12:40 Leveraging data and analytics in the CIN and how vaccinations and well child visits are key to disease prevention 15:00 How pediatric value-based care is different than adult value-based care 15:30 Data integration within SCCN and how the HIT infrastructure is foundation to success in population health 17:20 The validation of data accuracy as a critical success factor to building trust and supporting evidence-based quality improvement 19:30 Operational efficiencies within the CIN as a more effective way to provide actionable insights to providers 21:00 Developing consistent pediatric quality metrics and standardizing care within the CIN 24:00 Benchmarking quality performance at both the regional and national level 25:00 Recognizing the opportunity in pediatric value-based care and how you have to look for cost savings and improvements in different areas 27:30 Establishing a secure intranet to provide resources and reports to providers in the CIN 29:30 Focusing on the full panel of patients in the presentation of data and how that leads to success in population health 30:00 Transitioning to telemedicine during the pandemic and how that will impact pediatric care delivery in the future 34:00 Financial results from value-based contracts by focusing on ED utilization, asthma management, well visit completion rates, transitions of care, and quality measures 36:00 Capitalizing on quality improvement projects to decrease exacerbations within asthmatic pediatric population 42:00 Expanding value-based contracts with payers, employers, and Medicaid to prepare for full capitation 44:00 Mental health of children nationally is more important than grades in school (mental health-related pediatric emergency department visits on the rise) 45:00 Integrating behavioral health within primary care and addressing social determinants of health through innovative partnerships 49:30 Food insecurity with children as a national problem (14 million children living with food insecurity, almost 6 times as many as in all of 2018) 50:00 How SCCN is looking to build a scalable, community-based approach to addressing SDOH and food insecurity 52:00 Health policy solutions for value-based care all too often treat kids as an afterthought and how SCCN approaches advocacy on behalf of children 57:00 “There can be no keener revelation of a society’s soul than the way in which it treats its children.” – Nelson Mandela 58:00 “If we helped all of our kids live the healthiest lives possible, what would the long-term value impacts be?”

The all-too-common visualization of balancing between the two canoes of fee-for-service (FFS) and value-based care (VBC) is an appropriate illustration of the pressure that providers feel, but maintaining balance is clearly focused on staying upright, on survival. The challenge is that the FFS canoe has a motor, and the paddle for the VBC canoe is not enough to change direction – clearly the tools used to optimize reimbursement in the two worlds are oftentimes diametrically opposed. The mission behind VBC (lower cost, better outcomes, better care) has not been sufficient for many to overcome the momentum of the status quo, the requirement for margin that is the focus of FFS. This week’s episode features two leaders in the race to value who have vital insights focused on achieving margin in risk, giving provider leaders more clarity to make the best decisions for their organizations in positioning for the future. François de Brantes serves as Senior Vice President of Commercial Business Development at Signify Health. He leads customer development of the Medicare Advantage, Self-Insured Employer, and Commercial Payer markets. He has spent close to two decades working to transform the U.S. healthcare system by improving incentives for providers and consumers in order to encourage value-based decisions.  He is the foremost expert on designing and implementing episodes of care programs for employers, providers and health plans. Joe Fifer is president and CEO of the Healthcare Financial Management Association. HFMA’s mission is to lead the financial management of health care. With more than 50,000 members, HFMA is the nation’s leading membership organization of healthcare finance executives and leaders. Prior to assuming this position in 2012, Joe spent 11 years as vice president of hospital finance at Spectrum Health in Grand Rapids, Mich. He also spent time with McLaren Health Care Corporation, Ingham Regional Medical Center and Ernst & Young.   Episode Bookmarks: 02:00 Introduction to our Mission-Oriented Expert on Value-Based Care, François de Brantes (SVP, Signify Health) 02:20 Introduction to our Margin-Focused Healthcare Finance Executive, Joe Fifer (President & CEO, HFMA) 03:40 Healthcare organizations must position themselves for value-based payment without going bankrupt in the process! 05:00 The recently released report entitled, “The Future of Value-Based Payment: A Road Map to 2030” 07:00 François provides his perspective on the current state of value-based care and the current track record of CMS and CMMI payment models 11:30 Joe explains how excessive healthcare spending has forced the U.S. under-invested in infrastructure 13:00 Moving from payment model experimentation to a more focused set a models with the right incentives to move the industry forward 14:30 Performance Results of the Bundled Payments for Care Improvement (BPCI) initiative 16:00 How François and Joe initially met 10+ years ago while working on a bundled payment program 17:45 François explains how making better decisions in post-acute care when managing an episode of care can generate margin at the patient-level 21:00 Joe on why CFOs are leery of value-based payment because of the variation and uncertainty of the financial model, and how to create an attitudinal change 23:30 CMMI needs to develop a core set of APMs that show evidence in helping the delivery system make the right decisions around resource allocation to optimize their organizational structures. 25:00 Is there an organizational tipping point for value-based care based on the percentage of their revenue portfolio at risk? 26:00 François explains the “CFO’s Dilemma” (i.e. shifting a portion of FFS revenue to risk with increased associated margin per patient that can offset the decrease in the overall margin from the loss of incremental hospitalization revenue in FFS) 27:40 The “CFO’s Dilemma” is all about reaching a tipping point in risk-based payment that can shift how margin exists in your system and how you can allocate that on a fixed asset base.” 29:00 Joe on how to reach economies of scale by convincing payers to offer the same types of incentives in their risk contracts 30:30 François on the “free rider effect” when payers in FFS contracts vicariously benefit from the risk-based contracts of other payers 32:00 Joe on the need for employers to boldly address the need for employee plan benefit plan redesign 35:00 Joe on the power of market forces impacting employer approaches to health benefits 36:00 Rosen Hotels is a leading example of how a business can succeed in taking control of their healthcare spend 37:40 François discusses how reference-based pricing and the shift of costs to employees affects the differential fee schedule comparison between public pay and commercial insurance 39:15 Joe explains how health systems calculate actual yield on a payer-specific basis 41:00 Joe comments on the importance of attitude in the C-Suite and the importance of behavioral economics in value-based care 42:30 François discusses the inherently flawed design of many APMs and how that causes underperformance in many risk-bearing organizations 44:00 Joe raises concerns for the lack of transparency in risk-based payment models and how there is a ‘black box’ in understanding how incentives are calculated or how the risk is determined 47:40 Joe shares his passionate position on Hospital Price Transparency and provides his perspective on the new CMS transparency rule that just went into effect 50:30 François discusses specifics with the new CMS rule and outlines the current challenges in creating true pricing transparency to consumers 55:00 Joe comments on the absurdity of both payers and hospitals refusing to provide cost and price transparency 60:00 Joe and François spend the last 10 minutes of the interview debating Medicare Advantage For All as a possible policy option for the future of public financing of healthcare!

This month is National Military Appreciation Month and with this week’s episode we take  opportunity to offer our solemn regard and deep gratitude to the brave men, women, and their families who have served our nation with selflessness, gallantry, and sacrifice in upholding our foremost ideals of liberty. We are grateful for their nobility, for their duty, and for their sacrifice and that they “loved country more than self” so that we may live in a nation that is free. We are grateful that our liberty and our pursuits of virtue, equity, and happiness continue to be protected by those who now serve. As we express our gratitude for all of those who have served and now serve to preserve our country, our security, and our liberty, we have invited a veterans advocate unlike any other. Our guest this week is The Honorable David Shulkin, M.D., former U.S. Secretary of Veterans Affairs, and one of the most courageous leaders in the value movement that we have had on our podcast! As Secretary, Dr. Shulkin represented the 21 million American veterans and was responsible for the nation’s largest integrated health care system with over 1,200 sites of care, serving over 9 million Veterans. VA is also the nation’s largest provider of graduate medical education and major contributor of medical research and provides veterans with disability payments, education through the GI bill, home loans, and runs a national cemetery system. Episode Bookmarks: 01:45 A Special Message from Race to Value regarding Military Appreciation Month 03:15 Brief Background on The Honorable David Shulkin, M.D., the former U.S. Secretary of Veterans Affairs 05:10 Examples showing that the VA System is an exemplar of innovation 06:30 Dr. Shulkin on how the VA is a leader in behavioral health integration, use of non-traditional therapies, and addressing social determinants of health 07:45 How the VA is entirely unconflicted with fee-for-service reimbursement and why we should learn from it as we build a more value-based delivery system in the private sector 08:45 The national scandal that rocked the VA and how Dr. Shulkin was called to serve by President Obama to address the crisis 11:30 As the newly appointed Undersecretary, Dr. Shulkin describes how he addressed access issues for urgent care in the VA system, while also improving delivery of same-day services and publishing wait times for all to see 16:00 Speaking out against the Trump Administration during his time as a cabinet member (e.g. Charlottesville violence, Agent Orange benefits, privatization of the VA system) 17:45 “It Shouldn’t Be This Hard to Serve Your Country”: the dual meaning of Dr. Shulkin’s book title 19:30 Accepting the consequences of staying true to your principles which means even losing your job 23:10 Dr. Shulkin reflects on the government’s response to COVID-19 and how it felt to be on the sideline due to his firing by President Trump 24:30 Self-inflicted and avoidable failures in bio-surveillance, testing, and communication strategies and how we can overcome them in the Biden Administration 27:45 Dr. Shulkin explains the Whole Health Model of Care at the VA that includes self-care, peer counseling, and team-based interdisciplinary care 29:20 Results of the Whole Health Model, e.g. decreased opioid use, lower utilization, better patient outcomes 30:30 Dr. Shulkin’s awakening to the effectiveness of non-traditional therapies when he visited the VA Winter Sports Clinic with 400 veterans who were paralyzed or had spinal cord injuries, lost limbs and prostheses 33:30 Veteran Suicide as the top priority for the VA health system and how technology and behavioral health integration can improve care delivery 37:15 Dr. Shulkin speaks about the need for private citizens to enter into public service and how we can restore trust in our government. 40:00 Dr. Shulkin provides parting thoughts of gratitude for our military and their families in helping us keep our democracy strong and robust.

Nurses have been rightly recognized as heroes during the pandemic – on top of their consistently tireless effort, providing sustained caring and empathy over long hours, nurses stepped up to do more, to meet their patients’ needs despite risk to themselves. For example, they innovated to find solutions that would allow families to stay connected despite the barriers of quarantine. Building on a tradition that has been evident since they first began, nurses have always innovated solutions to improve patient care and outcomes. Their humble service and willing advocacy for each of their patients have made them heroes. This week is Nurses Week, and in honor of nurses everywhere, we are proud to welcome Bonnie Clipper, DNP, MA, MBA, CENP, FACHE as our guest. Bonnie is an expert in the nursing innovation space and was the first Vice President of Innovation for the American Nurses Association and created the innovation framework that is inspiring 4 million registered nurses to transform health through nurse-led innovation. She has published the Amazon international best-seller The Nurse’s Guide to Innovation, The Innovation Roadmap: A Guide for Nurse Leaders, and has published on the impact of AI and robots on nursing practice, as well as authored The Nurse Managers Guide to an Intergenerational Workforce. Bonnie’s insights into nursing are important and clearly articulate that, where a race to value is concerned, nurses are the ones innovating and delivering the solutions that will get us to the finish line! Episode Bookmarks: 05:45 Nurses are more with patients and families than any other discipline 06:30 Nurses are in the best position to transform how care is delivered and how we view health 07:10 The scope of the nursing profession and how their problem-solving can drive cost-effective solutions 09:10 Where do nurses fit in this big picture? 10:00 Nurses in leadership and the 10th anniversary of the IOM’s landmark report, “The Future of Nursing: Leading Change, Advancing Health” 12:50 Interdisciplinary training of the current generation of nurses 13:40 Training nurses about the business of healthcare 14:30 The need for upgraded competencies in nursing (e.g. climate science, gun violence, AI and big data) 15:10 Virtual Reality as a crucial component of the future of nursing education 16:00 The pandemic as a catalyst for health equity, telehealth, and virtual care and how that will impact nursing education 17:45 The nursing workforce shortage and the trend of nurses leaving the bedside 19:00 Staffing ratios in nursing and how nursing can be amplified by Artificial Intelligence 21:30 The trend away from acute inpatient care and how nurses will provide care more home-based care in the future 22:10 “Nursing services should be paid for in relation to the value it brings in the care paradigm. It should not be built in the room rate like a commodity.” 23:00 Restructuring nurse compensation and how this will incentivize performance and promote retention 23:50 The agency-based nursing model and how nurses are finding this model more rewarding 25:00 Innovation in nursing and how that can be leveraged for human-centered design 27:30 Creating a culture of innovation for nursing to flourish and for patient outcomes to improve 28:30 Examples of nurse innovation on the frontlines during COVID-19 29:45 How younger nurses may lead the way in innovation and the “entreprenurse” 30:30 Teaching human-centered design in medical and nursing schools 31:00 The empathy and compassion of nurses and how the broken system can create moral injury 32:00 Eric reflects on a prior podcast interview with a patient and how it taught him the importance of culturally competent care 34:00 How to deliver culturally competent care with DEI coupled with artificial intelligence to reduce implicit bias 35:45 The accounting of the nurse labor structure as a challenge to provide patient-centered care 38:00 Differing expectations in care between older and younger patients (the need for both “high tech” and “high touch” care) 41:30 Burnout and moral injury in the nursing profession during COVID-19 43:00 Bonnie defines moral injury and the importance of Trauma Informed Leadership 45:00 Traditional ways to become more resilient will not be enough to overcome the traumas of nursing during COVID-19 46:00 How chaplain services are being utilized by staff more than patients 50:00 Bonnie talks about Wambi, a company that provides gamified engagement technology to increase workforce engagement, reduce clinician burnout, and drive higher patient satisfaction 54:00 Correlating data from the Wambi platform with HCAHPS scores 55:00 Building a culture of gratitude and how powerful that is in improving staff engagement and patient outcomes 58:00 The importance of having women in leadership and in Board positions 59:00 The duty to mentor young, aspiring leaders 1:01 The Power of Gratitude and reflections for National Nurses Week 1:03 “Just be thankful” and the science that shows how gratitude rewires your brain plasticity

This week’s episode is the second part of our conversation with Dr. Robert Pearl. In his book, Uncaring: How the Culture of Medicine Kills Doctors & Patients, Dr. Pearl asserts that doctors are taught how to cure people, but they don’t always know how to care for them. There are many contributing factors, ranging from how doctors are trained, to increasing workloads and lack of resources, a widening disconnect between patients’ and doctors’ values and expectations, and increased risk and death due to the pandemic, all of which are intertwined with systemic and cultural issues. These are people who, with the highest ideals of caring for people, have entered a system rife with misaligned incentives that undermine and contradict their own hopes and expectations, and a culture that shapes them into being unable to care in the way they originally intended. The book examines the elements of physician culture that need to be corrected, the ones that should be preserved, and how to accomplish both. Dr. Robert Pearl is the former CEO of The Permanente Medical Group (1999-2017), the nation’s largest medical group, and former president of The Mid-Atlantic Permanente Medical Group (2009-2017). In these roles, he led 10,000 physicians, 38,000 staff, and was responsible for the nationally recognized medical care of 5 million Kaiser Permanente members on the west and east coasts. He is the author of Washington Post bestseller “Mistreated: Why We think We’re Getting Good Healthcare—And Why We’re Usually Wrong,” and “Uncaring: How the Culture of Medicine Kills Doctors & Patients” which is scheduled to be published in spring 2021 (all proceeds from the book go to Doctors Without Borders). Dr. Pearl also hosts the popular podcasts Fixing Healthcare and Coronavirus: The Truth. Episode Bookmarks: 00:30 The cultural hierarchy in medicine 01:00 Research on effects of concentrated primary and specialty care on life expectancy 03:00 Dr. Pearl explains how primary care was once on top of the cultural hierarchy before technology advancements 04:00 The need for Primary care to adjust to the current world (The Acceptance stage of the Kübler-Ross grief cycle) 05:30 Leading innovation in Primary Care and the success of ChenMed as a primary care model that can lower cost and improve outcomes 06:30 How the current fee-for-service model creates ineffective primary care delivery to ensure population health (e.g. lack of access and availability) 08:00 The use of telemedicine in the primary care setting to improve patient outcomes 09:15 The need for interdisciplinary, technology-enabled primary care teams and the integration of specialty services 10:00 How Kaiser Permanente leveraged telemedicine and other digital tools for clinical integration 11:30 PCP/SCP collaboration to determine evidence-based practices in a consistent, technologically-enabled, efficient way 12:00 Redefining primary care to elevate its value. 12:20 “Primary care shouldn’t just be the gatekeeper for referrals; they should be the facilitators of higher quality care by collaborating with specialists.” 12:40 Inefficient, low-value referrals from primary care for consultations that could be prevented with better integration 14:00 Onsite primary care clinics for Apple employees that are improving collaboration with specialists 14:30 Consumerism and Patient Experience — patients feel disrespected by long wait times, short visits, and poor communication. 17:00 “Culture, to some extent, allows you to avoid the harm you inflict and take privilege in what you desire.  Some of that exists within the physician world.” 17:20 Physicians that refuse to value patients’ time as much as their own as seen by long wait times, limited access and availability, and limited consumer-driven technology 18:20 The culture of customer-focused technology and service, exemplified by Amazon, has changed patient expectations 18:50 Patients value empathy, listening, and being available – not a provider’s medical training, publications, degrees, etc. 19:55 “The culture of the consumer will end up winning in healthcare. If the traditional medical system doesn’t offer it, someone else will.” 20:10 Amazon as a force of disruption in healthcare. Anyone who doubts the ability of Amazon to take over healthcare is in denial. 21:30 Dr. Pearl’s Fixing Healthcare podcast episode with a patient diagnosed with advanced breast cancer 23:00 Loss of purpose and mission in medicine as a positive force for physician culture change 23:45 The story of a physician treating an Ebola patient in the most miserable of circumstances but feeling immense happiness due to a connection with purpose 24:50 Physician’s returning from medical missionary trips deeply inspired and fulfilled 25:40 Providing care that is equitable and magnanimous with a deep sense of gratitude helps the physician heal as much as the patient 26:45 The invisible component of physician culture: the gap between what physicians know and what they actually do (e.g. handwashing) 27:15 In-hospital deaths in 1850’s Vienna, Austria blamed on miasmas by physicians, and how Semmelweis’ research on hospital cleanliness was rejected by his colleagues 31:40 The leading cause of death in U.S. hospitals is a hospital-acquired infection, and how 1 in 5 doctors today still fail to wash their hands 33:00 Killing patients with a hospital-caused infection as a source of inspiration for the book’s title “Uncaring” 34:00 The irrefutable public health data shows that U.S. medicine threatens the health of the African American community more than police brutality 34:40 Denial of institutional racism in medicine by physicians and how poor outcomes are instead attributed to external factors or biological falsehoods 36:10 Two-thirds of white physicians have implicit bias against African American patients 37:45 Recognition of the problem of unintentional, implicit bias (physicians are simply not aware that their actions are biased) 40:10 Dr. Pearl’s article on the use of Artificial Intelligence as a means to address racism 41:00 The limitations of using medical claims data for AI models 44:30 Using unbiased AI models and clinical decision support alerts to inform physicians of possibility of biased decisions 47:40 In Buddhism, a bodhisattva refers to anyone who is able to reach nirvana but delays doing so out of compassion in order to save suffering beings. This sacred role, which requires great personal sacrifice, mirrors the virtues of medical practice. 48:00 As healers, doctors have traditionally put the needs of others ahead their own. In the twenty-first century, however, physicians are focused on their own suffering. 50:00 The Five Cs of Cultural Change as an approach to help evolve complex organizations and help people move forward. 50:30 Confront (understanding and confronting reality) 52:11 Commit (making change happen) 53:50 Connect (physicians connecting together in ideation) 55:00 Collaboration (how physicians work together for the greater good) 55:35 Contribution (sense of purpose in the practice of medicine) 57:16 Parting thoughts from Dr. Pearl on the death of his father and why he wrote “Mistreated” and “Uncaring”

In a year of great need, during the pandemic, Americans saw and celebrated an army of physician heroes. In doing so, they overlooked an uncomfortable reality. Doctors are humans who share a culture that produces both remarkable successes and abysmal failures. As in Robert Louis Stevenson’s gothic novella The Strange Case of Dr. Jekyll and Mr. Hyde, it is possible that one person — or this case, one culture — can be both a virtuous force and a destructive influence. Until now, the negative aspects of physician culture have remained largely invisible. But like a virus, it affects people even if they can’t see it. Physician culture wields tremendous influence over the lives of patients, doctors, and the nation, regardless of whether people acknowledge (or are even aware of) its existence. This week, we have as your guest Dr. Robert Pearl.  He will be discussing his new book which tells the story of a profession that is both triumphant and dangerously flawed, filled with people who aspire to help others, yet who sometimes act coldly, callously, and indifferent. This book takes you inside the doctor’s world, revealing unique insights about their training, their daily practices, and the culture they share. It is a book about people striving for perfection and about the impossibility of achieving it. It sheds light on the norms, rules, and expectations of doctors, and shows how culture shapes their thoughts and beliefs. It deciphers their evolving language, symbols, and codes. It highlights what brings doctors together and what isolates them from their colleagues and patients. Finally, this book examines the elements of physician culture that need to be corrected, the ones that should be preserved, and how to accomplish both. If we are to win this Race to Value, we must fully understand and reform physician culture so it can be more caring. Episode Bookmarks: 2:00 “The Strange Case of Dr. Jekyll and Mr. Hyde” – Is it possible that one culture can be both a virtuous force and an equally destructive influence? 2:40 If we are to win this Race to Value, we must fully understand and reform physician culture so it can be more Caring. 3:00 Dr. Robert Pearl’s new book, “Uncaring : how physician culture kills doctors and patients.” 4:45 Physician culture tolerates low value care, inequitable outcomes, excessive profiteering, and perpetuation of institutional racism. 5:40 Despite the clear link between avoidable chronic disease and excessive COVID-19 deaths, physicians are not speaking out on this. 6:45 Dr. Robert Pearl defines what culture really is and how drives physicians to perform but also inflict harm 7:30 The “invisible” nature of physician culture 8:45 The heroism of physicians during COVID-19 10:00 Systemic issues and cultural issues go together – Why Mistreated and Uncaring are perfect companions in solving for healthcare. 10:45 Chronic diseases and the lack of accountability in physician culture 11:30 The focus on Prevention is not elevated in medicine, as illustrated by how we undervalue primary care 11:50 Research study showing that adding PCPs increases life expectancy in communities, while adding specialists does not have a comparable effect. 12:30 Primary care physicians are paid more in large multispecialty medical groups like Mayo Clinic, Kaiser Permanente, and Geisinger 12:50 Pre-Order information for “Uncaring” and all profits go to Doctors Without Borders/Médecins Sans Frontières (MSF) 14:00 How the “Art of Medicine” philosophy in physician culture prevents progress towards evidence-based medicine 15:30 Research showing that as much as one-third of physician services is low value care, offering little to no benefit for patients 16:30 The long lasting and pervasive effects of a physician culture that pre-dated scientific advancements 17:45 “It is not a question of how we maintain the esteem of the past, but how do we create the esteem of the future?” 18:15 The economic fallout of COVID-19 and how that will affect physician satisfaction 20:20 “What we have to understand as accountable physicians is that the care we provide is not affordable and it is not world leading.” 20:45 The entitlement of physicians feeling like they need a 5-10% FFS increase every year despite not delivering good outcomes in population health 20:55 The US is last among the 12 industrialized nations in life expectancy, childhood mortality, and maternal mortality.  Physicians don’t see it as their fault.  Instead they blame they systemic parts around them. 21:30 The role of technology in elevating the medical profession 22:00 The U.S. is last among the 12 industrialized nations in health care outcomes, and physicians don’t see it as their fault. 22:20 Healthcare costs in the post-coronavirus world will get lowered because people won’t have the resources to pay. 22:45 Rationing of care inflicts harm 23:00 Prospective payment is the only way to deliver care that is higher quality, more convenient, and at a lower cost. 23:40 The cultural evolution of the medical profession can give us hope. 24:55 Transformation will not be easy, but seeing physicians thrive in value-based care will enable change. 25:25 Roger Bannister breaking the 4-minute mile is similar to what we will see in physician culture transformation. 28:00 Confronting the truth about clinical outcomes and physician performance through transparent reporting 28:15 Dr. Pearl’s leadership at the Permanente Medical Group in creating a physician culture of transparency and “group excellence” 32:00 Kaiser Permanente went from “middle of the pack” to “number 1” with physician satisfaction that was 20% higher and total cost of care that was 20% lower 33:00 “The mindset of the 20th century is “Quality, Service, Cost:  Pick any Two.” We need a different mindset that we can achieve all three.” 36:25 Roughly 15 percent of physicians struggle with depression, and 20 percent report having had suicidal thoughts. 36:40 Physician burnout is affecting over half of the physicians in practice, and a recent Harvard report even called burnout “a public health crisis that urgently demands action.” 38:00 Physicians focus primarily on three causes of burnout (compensation, bureaucratic tasks, and technology) but ignore cultural issues within their profession 38:40 Pediatric physicians are paid less than adult medicine physicians, but they are actually more satisfied. 39:00 Urologists earn over half a million dollars annually, but they are extremely dissatisfied (more than twice than other surgical specialties). 41:00 Esteem in medicine is driven by doing the “coolest interventions” 42:20 Fewer prostatectomies in urology caused the rising burnout of the specialty because esteem was tied to that surgical procedure. 43:20 Moral Injury in the medical profession is real, but part of the reason is what physicians actually do to themselves. 44:30 The justification of surprise medical billing in the medical profession as a cause of physician moral injury. 45:40 Institutional racism in healthcare as a cause moral injury. 46:00 Dr. Pearl extensively outlines the racial inequities in our healthcare system and how physicians are not leading with the issue of health equity, racism, and unacceptable mortality. 48:00 Burnout with critical care and ID physicians and “Why Doctors Can’t Cope with Anguish of COVID-19 Casualties” 51:00 “PTSD in combat doesn’t happen in the battlefield but afterwards.  That is why I am really worried about what is going to happen to physicians in critical care and ID.” 52:00 Suicide rates in physicians projected to skyrocket once post-COVID PTSD sets in

It’s not a secret, the broken healthcare system is exquisitely tuned to react after patients get sick. For the most part, profits are made after we FAIL patients. And it hurts all of the caregivers who face the daily internal conflict of doing what is right for the patient or doing what is right for the business. But there are a few who are positioned differently. When the strategy and business are unconflicted they’re not worried about demand destruction and leakage but are instead focused on prevention and true care management. It all begins with prioritizing and properly aligning primary care. A group of 100 adult primary care physicians can influence $1 billion in healthcare spend. This is the source of potential power and change in a value-based world, where health will improve for patients and their providers while costs are decreased. Aledade is such a place – by allowing providers to remain independent and unfettered by the constraints of fee for service, Aledade is blazing the path toward true health value. Episode Bookmarks: 03:30 Comparison of Healthcare Spending ($6M per minute) to Niagara Falls (6M cubic feet per minute) 04:55 Aledade’s success in short lifespan of company (now at 800 practice partnerships with $360 million in healthcare cost savings) 06:05 The misalignment of incentives creating a perverse incentive for poor outcomes (e.g. profitability of treatments following a stroke) 06:45 Dr. Mostashari spending his career trying to find answers to the question, “How do we save the most lives?” 07:20 Adoption of electronic health records (“We succeeded in the battle, but we lost the war.”) 07:45 Provider workflow redesign and optimization (Regional Extension Centers) 08:25 “How can we create incentives so that private profit creates public good?” 09:30 “The Paradox of Primary Care Physician Leadership”  (the influence of primary care on downstream healthcare spend) 11:30 Consolidation of primary care by Optum and private equity firms 12:00 The resiliency of independent primary care practices 12:30 “Independent practices can do what they believe is in the patients’ best interest, without worrying that they’re obligation to the patient conflicts with their obligation to the corporation.” 13:00 Data shows remarkably little change in hospital employment of PCPs, thereby showing resilience in the primary care market 15:00 Movements are led by effective storytelling and these stories can revitalize communities of people 17:00 Primary care heroes during COVID-19, and how society neglected them by failures in supply chains, testing, and vaccines 18:40 Aledade’s support of primary care practices during the pandemic 20:00 “It is remarkable what happens when you do the right thing.” 22:00 Dr. Mostashari’s terror in seeing early ER utilization data in knowing that a pandemic was coming (before the media was covering it) 23:00 Implementation of telehealth, finding PPE, and securing loans for practices in early stages of pandemic 23:25 “The idea of practices going out of business during the pandemic highlights the insanity of fee-for-service payment for primary care.” 24:00 The lessons of COVID-19: 1) Healthcare can change, 2) Primary care doesn’t have to be an in-person visit, 3) Capitation in primary care is preferrable to fee-for-service 25:40 “Primary care is about the relationship between a practice and patient —  it’s not about the 99213 visit.” 27:30 Dr. Mostashari addresses recent delays by CMMI in new APMs and what we should expect in future health policy 28:30 Scaling the models that work is the job of good health policy.  (MSSP compared to CMMI programs) 29:00 The ACO Investment Model (AIM) program was successful and a model for future provider and patient incentive programs 30:30 CMMI delays should not be considered as a question to the direction of value-based models. 32:00 The progress of the ONC in standardizing health information 32:30 The sharing of Admission, discharge, transfer (ADT) notifications as a requirement for hospital participation in the Medicare program 33:00 The need for policy clarity to support improved interoperability and data sharing 35:30 Dr. Mostashari discusses the evidence for the benefits of Medicare Advantage plans 37:00 Could profits for Medicare Advantage plans be lower and still achieve same level of benefit in value-based care? 37:45 The focus should be moving practice panels to risk in order to ensure value-based care standardization 39:00 The murder of George Floyd as a reckoning for society (“We can no longer be bystanders.”) 40:00 Health equity as a company focus for Aledade and reduction of racial disparities in care for severe hypertension 40:30 Outcomes measures for racial disparities of care 41:00 Aledade’s work with majority minority practices 42:10 Aledade’s recent Series D raise and the future growth of the company 45:20 Servant leadership as a core component of company culture

Race to Value listeners — April is National Minority Health Month, and this year, the HHS Office of Minority Health is focusing on the disproportionate impact the COVID-19 pandemic is having on racial and ethnic minority communities.  This Bonus Episode is a compilation of viewpoints on health equity and racial disparities of care from some of our former guests in the past year.  We hope you take the time to listen intently to their message. Certainly over the last many year we have been exposed to the great inequities that have existed in our society for far too long.  We have one major obligation we have to each other…that is to tell the truth.  And the truth is, there are so many inequities in our society for minorities, including the manifestation of institutional racism within our nation’s health system. As leaders in value-based care, we have to be accountable to the endeavor that we are about. We endeavor to, in fact, ensure every patient receives the best treatment possible so they can live the life they are intended to live. That we endeavor to create the opportunity for health equity, and that is true regardless of race, ethnicity, gender, sexual orientation, or otherwise. We hope you find meaning in this Bonus episode and gain awareness for how important health equity and social justice is to win this Race to Value. Episode Bookmarks: 1:39 Daniel Chipping introduces National Minority Health Month and its’ focus on COVID-19 impact on minority communities 2:10 Dr. Eric Weaver delivers a special message on overcoming institutional racism in our nation’s healthcare system 3:29 Dr. Farzad Mostashari reflects on the murder of George Floyd and how it was a reckoning for social justice (and health equity) 6:33 Dr. Lerla Joseph discusses how she has devoted most of her life committed to health equity, how ACOs are a vehicle for change 12:30 David Smith provides a powerful social commentary on how pervasive systemic racism is in our society and his awakening as a white male 18:41 Christina Severin on the country’s reckoning, how her white privilege as conditioned her to be a racist, and how health centers can address inequities 23:10 Dr. Ernest Grant on the public health crisis of systemic racism, the disproportionate burden of disease related to SDOH, and how nurses can call for change 30:19 Dr. Stephen Klasko on how the zip code of communities ultimately determine health, and how the pandemic has raised awareness of inequities 31:46 Christina Severin on how the calling for racial justice, coupled with the pandemic, has created urgency to “bridge the digital divide” 33:36 Dr. Gordon Chen on the social injustice of different lifetime expectancy rates between white and minority communities 36:04 Shannon Brownlee on how Black Lives Matter has forced hospitals to focus on health equity 38:24 Dr. Mark Gwynne on how investment in data analytics can help ACOs identify opportunities in populations where there are disparate outcomes 39:11 Dr. Christopher Crow on how health equity in communities can be addressed through reforms in education, health, and business 40:27 Cheryl Lulias on building community-based coalitions to address health equity 42:10 Robert Sepucha on the disproportionate burden of kidney disease in minority populations 42:57 Dr. Edwin Estevez on the vulnerability of the Hispanic population on the Texas/Mexico border and how his ACO focuses on nutrition and health literacy 46:17 Mike Funk on how health plans can address disparities in minority communities 48:15 Dave Chase on the opportunity for social impact investment to creative cooperative structures in disadvantaged communities 48:53 Dr. Mark McClellan on health policy approaches to address health equity 49:30 Andrew Croshaw on how the Biden Administration will define value through health equity