The Race to Value Podcast

ACOs are increasingly moving into two-sided risk options with MSSP BASIC E and ENHANCED. The Direct Contracting model (with both Professional and Global options) introduces new opportunities and flexibilities that are not included in other CMMI models or through the MSSP. Prospective participants must act now to evaluate their model options in preparation for the 2022 performance year, with both MSSP and DC application cycles quickly approaching. CMS will soon reopen the MSSP for the 2022 performance year, and the application period for DC’s second and final cohort is also expected to open around in Spring 2021, according to CMMI’s latest timeline.  Now is the time for organizations to evaluate options and make decisions.  To aid in that analysis and decision-making, the ACLC and Lumeris partnered together to develop an intelligence brief (coming soon) that is also the focus of this podcast episode. The brief is designed to help provider organizations who are ready to take on significant levels of downside risk to judiciously evaluate the available options, consider the general opportunities and risk associated with the models, compare the methodological differences between MSSP BASIC Level E and MSSP ENHANCED with DC Professional and DC Global, and assess organizational fit. We share detailed comparisons across 7 key areas:   Participant Eligibility  Beneficiary Attribution  Financial Benchmarking  Quality Performance  Payment Models  Financial Settlement   Additional Benefits  Our guest this week is Rick Goddard, Senior Director of Market Strategy at Lumeris. Rick is a subject matter expert on value-based payment models and primarily serves as an enterprise strategist. Prior to joining Lumeris, Rick served as the Director of Clinical Innovation at Advocate Physician Partners / Advocate Health Care where led the Clinical Innovation Team. His in-depth operational and consulting experience makes him the perfect guest to help organizations considering their next step on this race to value!  (Information coming from CMS is ongoing and any opinions are not necessarily those of Lumeris, the Accountable Care Learning Collaborative, or our research associate Leavitt Partners.) Access the transcript for this episode here. Glossary of Acronyms: MSSP – Medicare Shared Savings Program ACO – a contracted entity in the MSSP DC – Direct Contracting (new CMMI payment model) DCE – a contracted entity in the DC model APM – Alternative Payment Model MA – Medicare Advantage CMS – Centers for Medicare and Medicaid Services CMMI – Center for Medicare and Medicaid Innovation TIN – Tax ID# (ACO participants in the MSSP are contracted by TIN) NPI – National Provider ID # (DCE participants are contracted by the individual NPI)   Episode Bookmarks: 4:50 Rick Goddard explains his personal connection with mental health and how that informs his “Why” 6:00 Finding balance and lessons learned from training for the Ironman World Championship 7:00 “What excites me is that value is starting to get momentum in the environment, and that thaws out providers and forces them into the game.” 8:50 The accomplishments of the MSSP (growth, building a bridge to risk, and $2B in savings to date) 11:30 The early years of the Pioneer and MSSP ACO programs and what we learned as an industry 12:30 “The upside-only ACO opportunity didn’t have the teeth, nor did the program offer effective levers for us to succeed in managing the total cost of care.” 12:40 MSSP Challenges (e.g. beneficiary complaints and CCLF opt-outs, delays in data sharing, “black box” reconciliation) 14:00 “There weren’t enough managed care-like designs to assist MSSPs to progress in risk.” 14:40 CMS offering incentives for ACOs to accept risk (e.g. SNF 3-day rule, Telehealth waivers, an availability to work with a prospective attribution model) 15:00 “Up until the Next Generation ACO, there were not options to participate at the NPI level of network inclusion.” 15:40 Because there was no behavioral disincentive to go out of network or stay coordinated within your ACO care-network, ACOs continuously had to innovate to drive in-network value and provide loyalty/stickiness, to drive care coordination across their network.” 16:00 “With us reaching Direct Contracting at this point in time, as its latest innovation in the Medicare ACO, they’ve modeled Medicare Advantage-like levers–and it’s not a coincidence.” 17:30 What do ACOs need to know about the Direct Contracting model and how should ACOs proceed in the 2022 performance year with both the MSSP and Direct Contracting application cycles quickly approaching? 19:20 New entrants allowed in the DC program: (e.g. payer-based conveners, private equity-backed physician aggregators, high-needs organizations, MCOs, etc.) 20:00 DC Covered Entity requirement: DCEs put forth a minimum financial assurance (surety bond line of credit or escrow based) to cover downside losses 20:15 DCE Early-Term Withholds: CMMI looking to ensure providers proceed past the first performance year in Direct Contracting 20:40 DCE Beneficiary Attribution: “claims-based attribution still exist as the core driver for attribution in populations. However, more prominent is the use of voluntary alignment in Direct Contracting.” 21:00 DCEs can choose between prospective alignment (annual determination) and prospective plus alignment (quarterly inclusion period for newly voluntary aligned patients.) 21:30 DC Financial Methodology and Benchmarking Overview: (baseline periods, regional benchmarking) 22:40 “DC does favor the new entrants, because all of their benchmark is based off of regional because they’re all net-new voluntary aligned patients.” 22:55 DC Risk Adjustment Methodology: (CMS HCC prospective scoring, which is similar to how MA is evaluated) 23:10 “While there’s still a cap on risk adjustment expenditures annually, it’s going to be evaluated on an annual rolling basis with its coding intensity factor. Which, if you compare to MSSP across the entire agreement, that’s a substantial improvement.” 23:30 DC Global Discount Methodology: “There’s no discount in MSSP or professional Direct Contracting, but for the global model, it’s an escalating 2-5% over the contract period.” 24:10 DC Quality Performance: “Quality performance is tied to a 5% withhold compared to the benchmark to earn back that first dollar. Most of the measures are either claims-based or patient satisfaction–and since there’s no self-reported measures (that’s a positive thing for reporting), there are fewer measures overall.  Less measures means each individual measure is that much more important.” 25:05 DC Capitation and DCEs Payments to Downstream Providers: DC model allows for flexibility in payment design to downstream providers. 26:00 DC Beneficiary Engagement Incentives:  “Cost sharing is the biggest callout for beneficiary engagement incentives. The ability that you can essentially provide coinsurance coverage to increase access in your beneficiary population to encourage people to come to the doctor more, I think it’s incredibly effective against the cost given these beneficiary incentives will be charged against your– you have to manage to your own benchmark under budget.” 28:10 Rick discusses why voluntary alignment takes precedence over claims-based alignment. 30:40 “Those Geo DCEs that market well and align with strong preferred providers will have consumer engagement plus aligned incentives to drive comprehensive care throughout the DCEs continuum.” 31:00 Rick further explains how the CMS HCC Risk Adjustment model differs between the MSSP and DC models. 32:45 Rick explains the differences in capital requirements between MSSP and DC models. 34:30 The difference in capital requirements between Professional and Geo DCEs is a major hint by CMS is that they’re looking for large players (payer/provider combinations) players with lots of access points. 35:20 The pain inflicted on health systems by COVID-19 and how that will play into their decision to progress in risk with the new DC model. 41:00 How Direct Contracting can impact the ability of a health system to move to an asset-light business model. (“Thinking about the right assets to lower your cost per unit of service and making the right informed decisions on intervention investments is paramount.) 46:00 Rick discusses the benefits of DC over MSSP (i.e. improved cash flow, ability to be creative with beneficiary engagement incentives, tuning up for Medicare Advantage and delegated risk) 48:00 Rick discusses unknowns and potential contra-indications of DC (i.e. discount methodology within Global option, quality withhold, withdrawal penalties) 49:00 “Direct Contracting can be parlayed into multiple population types. So, a lot of the investments you make in the infrastructure can produce a halo effect that can be very powerful across your other populations.” 50:00 Rick on how DC can create mindshare with providers and provide a tune-up for MA by getting comfortable with capitation and downstream payment mechanisms, risk adjustment programs, and functioning under a STAR quality program. 55:20 Preparing a strategy for full-risk (investment in human capital, performance forecasting, analyzing claims data pre-contract, beneficiary engagement, marketing compliance, managing network leakage, building technology infrastructure, SCP sub-capitation, etc.) 59:00 Rick on the importance of competency-based workforce management to be successful in fully-delegated risk APMs.

The American Dream is the hallowed ideology that any individual can advance his or her state of being through ambition and hard work. It defines the American psyche. Historian James Truslow Adams wrote, “The American Dream is that dream of a land in which life should be better and richer and fuller for everyone, with opportunity for each according to ability or achievement.” In today’s episode we explore a Dream Plan in health care – one that is based on consumerism accountability for health outcomes. Janis Powers is so intent on improving health care that she’s designed a completely new payment system. Her Dream Plan is to eliminate health insurance, enabling individuals to redirect their financial resources into personal accounts that fund their lifetime health care needs. Her ideas are outlined in her Amazon Bestselling book Health Care: Meet the American Dream. Powers founded the company Longitudinal Health Care to bring the ideas from her book to reality. Janis hosts her own podcast, The Powers Report, where you can learn more. She argues that the health care system needs a solution that must include affordability for consumers in addition to incentives that appropriately align behaviors, both for care provider as well as consumers Episode Bookmarks:  1:43 “The American Dream is that dream of a land in which life should be better and richer and fuller for everyone, with opportunity for each according to ability or achievement.” 2:34 Janis Powers’ mission to eliminate health insurance and her Amazon Bestselling book Health Care: Meet the American Dream 4:30 Do bundled payments really improve outcomes? 6:42 “It’s our job not just to critique what people do.  We must also come up with other solutions.” 7:13 Fixing Health Care by “starting from scratch” with a blue sky vision of decentralization and individualized consumerism 7:30 Why do we even need insurance since we have genetic information and predictive analytics? 7:55 “We don’t have health insurance…we have coverage. In designing it that way, we have created a one-size fits all system that creates tons of waste and administration.” 9:55 Disproportionate spending where the top 5% of most expensive patients spend 50% of the healthcare dollars, and the bottom 50% of the people spend 3% of the healthcare dollars! 10:45 The problems with government spending in healthcare (e.g. lack of consumerism, looming Medicare insolvency, rejection of single payer, low Medicaid reimbursement rates) 12:50 Rationing Care – Is this the only way to prevent Medicare insolvency? 13:10 Inappropriate treatment at the end-of-life and patient unwillingness to challenge doctors 14:05 “The goal of the government is to regulate – not manage — health care.” 14:30 Should Medicare patients be allowed to opt-out the federal program and get the capitated rate directly from the government? 15:15 Should the government make Annual Wellness Visits mandatory? 15:55 Does the ACA requiring coverage for preexisting conditions cause a moral hazard? 16:42 Should the Medicaid program be partially funded by states since it poses standardization challenges by creating a different health system in every state? 17:44 9% of the enrollees in Medicaid are elderly (i.e. dual eligible) yet they spend 21% of the dollars. 14% of the enrollees in Medicaid are disabled yet they spend 40% of the dollars. 18:20 Should we separate Medicaid funding for low income families from duals and disabled since patient segment needs are so different? 19:00 Should we revoke the non-profit status for hospitals or restructure the assessment of community benefit so the contribution of economic value can be fully realized? 21:30 Are B2C digital health companies more appropriate than B2B digital health companies (e.g Teledoc, Livongo) in enabling a consumer-driven revolution in healthcare? 26:45 Establishing an individual lifetime healthcare account that leverages genetic profiling and predictive analysis as a replacement payment strategy 31:14 How can we integrate pricing transparency reforms to facilitate a consumer-level understanding of how much they should save for healthcare during their lifetime? 34:45 Why is “spending transparency” is more important than pricing transparency in healthcare from a consumer-consumption perspective? 40:10 How will consumerization in health care work if we have a subset of the population that is relatively unhealthy which cannot and/or will not make the best decisions about their spending? 41:20 Should commoditized, low-dollar, high-value services like primary care be entirely covered by insurance or instead have costs borne by the consumer to ensure full engagement in health outcomes? 44:30 Unnecessary knee replacements as an example of overutilization 46:25 How can a consumerized health market ensure health equity and better serve those who are underserved, underrepresented and who are treated inequitably? 48:10 The role of government in fixing income inequality and education inequality to ensure public health 50:25 Ethical issues of genetic testing in a consumer-driven model when expensive genetic conditions are pre-diagnosed in under-funded populations 53:35 Leveraging innovation to improve health literacy in underserved populations as a strategy to promote equity in outcomes 56:00 The “social accountability problem” in the America and how it affects health care reform 57:20 The tragic normalization of obesity and the tracking of the Millennial generation as the most obese generation ever 1:00:00 “We should be doing things to help us be as healthy as we can be. That is our social accountability to one another.”

As we prepare for a new era in our government with President-Elect Biden’s administration and a Democratic-controlled Congress, we must be steadfast in our commitment to value-based care. Can soon-to-be President Biden capitalize on this historical moment of unrest to unite our country with a value-based care policy agenda? Is COVID-19 truly a silver-lining moment for the value movement? How will providers, payers, policy-makers, public health, and patients leverage increased regulatory flexibilities, technological innovations, and major cultural shifts to fast-track strategic priorities that support the triple aim? Our guest this week is Andrew Croshaw, Chief Executive Officer of Leavitt Partners. Andrew’s insights inspire and inform. Supported by leading-edge health care value economy research and intelligence from Leavitt Partners, this episode will provide you with the best policy analysis out there on this “Race to Value.” For additional information on the topics discussed in this episode, make sure to download the latest ACLC Intelligence Brief, The Future of Value-Based Care: 2021 and Beyond. Episode Bookmarks: 1:40 A nation’s sadness due to recent events that have unfolded in Washington, D.C., and hope for a peaceful transfer of power in our democratic republic 2:40 Value-Based Care in the new era of government with President Biden’s administration and a Democratic-controlled Congress 3:13 How the value movement will allow us to improve population health and remain competitive in a global marketplace 3:40 The moral and economic imperative to make value-based care work 4:34 Referencing the newly-released ACLC Intelligence Brief entitled, “The Future of Value-Based Care: 2021 and Beyond” 6:20 Andrew’s personal reflection on the recent violence at our nation’s Capitol and the need for human connection and civility 7:10 How lack of accountability and the divisiveness of social and mainstream media creates incivility and violence 8:40 Hope for a moment for renewal and a better tomorrow 8:53 How the recent Georgia runoff election, giving control of the Senate to Democrats, will enable additional pathways for President Biden’s health policy agenda 9:12 Progress independent of any bipartisanship with elements of the health policy agenda that will still require bipartisan support 10:00 Passage of legislation in the Senate with a budget maneuver called “reconciliation” that can allow legislators to pass certain bills with a bare majority of votes (not the typical 60 votes required) 10:27 “I am encouraged for a sense of bipartisanship based on us learning how precious and fragile we now realize stability in our country really is.” 11:50 COVID-19 emphasizing the need for significant payment and delivery transformation, showcasing the advantages of prospective, non-FFS-based alternative payment models 12:20 Leavitt Partners’ monitoring of public and private sector value-based contracts showing that “Value-based contracts continued in 2020 despite the pandemic.” 13:15 Increase private sector focus on value-based payment (e.g. bundles, specialty ACO models, traditional ACO contracts) 13:27 Medicare Advantage, as a segment of value-based care, showing significant growth and newly-emerging plans are working well for beneficiaries and sponsor 14:12 Large employer advocacy of value-based care and how their voice will continue to grow louder 14:52 Startups forming meaningful partnerships with employers in the value space and how that will be disruptive over time 16:05 The promise of high-touch, full-risk primary care organizations (like ChenMed) as an important driver of value transformation and an influencer of health policy reform 17:20 “One of the benefits of 2020 was that it did highlight the benefit of taking risk to primary care providers. (I am a little afraid, also, of what that signaled to payers.)” 17:30 Historical reluctance of payers delegating risk and how that paid off for them in a big way with record profits in 2020 18:58 “The asset-light orientation of high-touch primary care, coupled with a full-risk business model, will continue lead transformation in value-based care.” 22:20 Continued suppression of hospital volumes due to COVID-19, growth in infection rates, and new variants of the virus will continue to pose financial stress on health systems 23:20 Health systems getting out of value-based contracts should continue to be expected.  Successful transition to value-based care will ultimately come down to who has the right perspective on timing. 23:30 “Transitioning too early will be just as poor of a decision as not transitioning to value at all.” 23:55 The electrification of vehicles and those that will continue to make internal combustion engines as a parallel to the health industry’s transition to VBC 24:45 The 3-5 year impact of the post-COVID economy have on the move to value and the exhaustion of the Medicare Trust Fund 25:41 Consumer embrace of virtual care will embolden both providers and policymakers as a component of value-based care 27:10 The Biden Administration’s definition of “value” will include components of social justice, health equity, and consumer transparency 30:33 The “dangerous and dynamic” nature of the Post-Acute Care business model due to disruption by stakeholders upstream (hospitals) and downstream (home care, primary care) 33:15 Carving in hospice care in MA plans will enable them to be leveraged more effectively in value-based models 35:30 Potential, but limited, opportunity to capitalize on COVID-19 vaccine innovation within the pharmaceutical industry 38:20 How the trend toward “payvider” models that involve deep, formal collaboration between a payer and a provider organization will impact value-based care 41:55 The uncertainty of whether or not continued underfunding of the public health sector will continue 42:50 Renewed focus on public health in the prevention and management of chronic disease 43:41 Failure to capitalize on the raised awareness of the broken public health system during the H1N1 pandemic and how COVID should be different 46:20 Challenges with nascent and emerging innovations (e.g. solar cells, electric cars) as a metaphor for how we should interpret the performance results of the MSSP and CMMI’s APM portfolio 47:30 Policymakers demand of more mandatory value-based payment models 49:30 “This isn’t just a health care journey.  Reforming the medical industrial complex is critical to the future of our country’s economic success in a global marketplace.” 51:30 If President Biden is re-elected in 2024, those two terms will define the transition to VBC because of trends that were accelerated due to COVID-19. 52:15 The leadership of WGU and the Accountable Care Learning Collaborative as an enabler of higher education focus and peer learning in value-based care.

ChenMed was created with a mission to provide care in such a way that it could alleviate suffering for those seniors in the poorest of communities, recognizing that full-risk primary care can truly be transformative in providing superior health outcomes. This strong sense of purpose is what guides the physicians at ChenMed and serves as a moral compass in caring for patients. It is born out of an idea that ChenMed is a ministry that allows those in the organization to glorify God by spreading more love and promoting better health to those they serve. ChenMed is a family-owned, primary-care physician run organization that serves a challenging population: 75% have five or more chronic diseases, 70% are racial minorities, the average age of patients is 73 years old, 95% of patients within 300% of the Federal Poverty Level. But the success speaks volumes: patients use hospital emergency rooms at a rate 34% below the national average,  have 50% fewer admissions than the average primary care practice, and have close to 30% lower cost. ChenMed’s scalable and successful approach has already reached 60 practices, and it is no wonder that they are poised to grow 4 times larger over the next 3 years. Dr. Gordon Chen, CMO, along with his brother Christopher Chen, CEO, and other great leaders throughout the organization are proving that full-risk primary care is a solid and necessary foundation for winning the race to value! Episode Bookmarks: 4:45 ChenMed named to Fortune Magazine’s “2020 Change the World List” for measurable social impact, business results, innovation, and corporate integration 5:30 Dr. Chen discusses the spiritual underpinnings of his family-run organization and the Chen family’s suffering during his father’s cancer misdiagnosis 10:13 The ChenMed ministry in glorifying God, spreading love, and promoting health in underserved communities that are suffering 11:20 A scalable approach that has resulted in 50% fewer hospitals admissions, a 75% reduction in ED visits, and 28% lower per-member costs 13:35 “The traditional, fee-for-service primary care model handcuffs PCPs to see more and more patient volume without being able to optimize outcomes.” 14:14 A Medicare Advantage full-risk business model allows ChenMed to see shrink the PCP panel size so they can focus on cultivating trusting relationships with deeper connectedness 15:50 How a full-risk model enables Primary Care Physician empowerment 16:55 The shift from a reactive approach (e.g. ER and preventable hospitalizations) to a more proactive, preventative model that supports health value 17:45 Having “Stockholm Syndrome” for a broken fee-for-service model that has held PCPs captive from practicing medicine in the way they thought they would when dreaming of becoming a doctor 18:05 COVID-19 as a tipping point for full-risk primary care models, struggling primary care, and PCP moral injury 20:40 Consistency of revenue within a capitated model 21:16 “Fee-for-service primary care is going to end. It is too challenging to make it work, and PCPs don’t like a purely transactional model that doesn’t value relationships.” 22:45 Dr. Chen discusses the fulfilling purpose of full-risk primary care and how it makes a deep impact in communities 24:55 Supporting high-risk patients through high touch telephonic “love calls” and telehealth 26:11 How ChenMed adjusted its care delivery model during the COVID pandemic (“flipping to 90% virtual in less than a week”) 29:05 Realizing the need for the ChenMed model is far greater than could have ever been imagined during a period of pandemic uncertainty and civil unrest 29:50 Finding the right balance between in-person and virtual visits during the COVID pandemic 30:34 “Telehealth is here to stay.” 31:05 Increased Net Promoter Scores when serving patients during the pandemic 31:30 Health inequities, racial disparities in care, and the plight of racial injustice in our society 33:30 Closing gaps in life expectancy within African American and Hispanic communities 35:30 Dr. Chen discusses his personal experience living homeless and without financial means to live comfortably 36:45 Populations with high chronic disease burden is the greatest opportunity to succeed in a full-risk model 37:25 “Full-risk primary care that spreads love and promotes health can create a beautiful, virtuous cycle where savings (earnings) can be reinvested into even more needy communities.” 38:15 ChenMed’s expansion from 76 centers in 2020 to 100+ centers in 2021 made possible by reinvesting earnings 39:00 Christopher Chen’s (Gordon’s brother) harrowing ordeal as a patient with a COVID-19 infection 40:45 “Every day is a precious gift from God.” (Dr. Chen discusses how both his father’s past suffering and his brother’s COVID-19 infection served as a call to action to make every day count.) 41:30 Dr. Chen’s reignited commitment to accelerate the scalability of ChenMed’s model following Christopher’s COVID diagnosis 43:25 Research showing that high-touch preventive care delivered by ChenMed can effectively prevent and manage cardiovascular disease 47:04 Since most EHRs are designed for fee-for-service, ChenMed decided to build its own. 48:21 How ChenMed’s homegrown EHR system provides enhances outcomes by integrating data 50:00 How ChenMed approaches physician and executive leadership development and interdisciplinary care team workforce development 52:50 “For ChenMed to be able to scale across America, we’ll need to train and empower leaders to transform care in communities.” 53:41 The “humble healer” approach to physician peer-to-peer learning 55:30 ChenMed’s hyper-accelerated your growth strategy by looking to quadruple over 3 years! 56:38 The moral imperative to grow ChenMed to serve as many needy communities as possible 59:55 “If we can have physicians, health care leaders, and team members share in the mission, vision, and passion for what we are doing at ChenMed, we believe we can change the world.” 1:01:00 “If we can accelerate this move to value-based care, and empower more people to go into primary care, then we are on the right track.  That is what America needs.”

In this episode, we interview Ken Terry, author of one of the best-researched books we’ve ever seen! The new book, Physician-Led Healthcare Reform: A New Approach to Medicare For All, explores why we must, and how we can, get doctors to change how they practice. Most employed physicians and independent physicians alike feel powerless. Hospital-employed doctors feel like cogs in a machine, and community doctors are increasingly threatened by forces beyond their control. The biggest problems of physicians–both employed and independent–are a loss of professional autonomy, overwhelming administrative requirements, and the conflict between business and patient care imperatives. This book, directed to physicians, healthcare administrators, health policy experts, politicians, and consumers, explains why the U.S. healthcare delivery system must be restructured to lower costs–and how to do it. Physician-led healthcare reform will give them back a large measure of control and pride in their work. Ken Terry has been writing about health care for more than 25 years. He was a senior editor at Medical Economics, has contributed to numerous publications, including Medscape Medical News, Information Week, and FierceHealthIT, and has received several journalism awards, including the Neal Award from American Business Media. He’s also authored the book RX for Health Care Reform. You can read more of Ken’s work, including articles and blogs at his website: https://physicianledreform.com. Episode Bookmarks: 3:33 The progression of value-based care over the last decade (e.g. hospital VBP program, BPCI, the mandatory bundled payment program CCJR, CPC, MSSP) 6:20 Consolidation of the healthcare system and employment of doctors driving up costs 7:33 ACOs led by health systems are not as successful as physician-led ACOs in the MSSP 7:58 The first wave of managed care did little to move provider organizations towards taking financial risk (with the exception of Kaiser Permanente and a few others) 9:18 The push towards value-based purchasing in the Obama Administration (e.g. P4P, bundled payments) did not go far enough to change industry appetite towards risk 10:00 Advancement of medical technologies have been driving up healthcare costs (not lowering them) 10:42 “The evidence shows that where you have more primary care physicians, where you coordinate care, and where you pay to keep people healthy, you get better outcomes at lower cost.” – Dr. David Nash 11:31 Research by Barbara Starfield showing that a higher ratio of PCPs to the population is associated with a lower mortality rate from all causes, heart disease and cancer 11:50 States where a higher percentage of physicians who were PCPs have higher quality of care and lower cost per beneficiary 13:00 The impact of medical school debt burden on the supply of primary care physicians and the relegation of PCPs to lower tier status in the medical community 13:51 How Advanced Practice Providers are filling the void to meet unmet primary care needs 14:32 Retail clinics and urgent care centers competing with PCPs 14:53 “The best way to reduce costs and improve outcomes in healthcare is to have larger groups of primary care doctors taking financial risk and competing on quality of care in local areas.” 15:20 Changes that would need to occur before we implement Medicare-For-All health reform (i.e. hospital payment parity, corporate practice of medicine restrictions) 16:10 Proposing federal requirements of hospitals divesting of their medical practices 16:35 Medicare-For-All option that would pay PCPs Medicare rates unless they join a larger primary care group and take financial risk for a larger upside opportunity 17:22 Primary care groups choosing high-value specialists to contract within their network 17:51 Placing primary care in charge of the healthcare system to build medical neighborhoods 18:21 How primary care-led medical neighborhoods differ from patient-centered medical homes 19:05 Referencing the IOM report, Crossing the Quality Chasm, and how it raised awareness of poorly designed care processes that lead to unnecessary duplication of services 19:50 Referencing the famous New Yorker article published in 2009 by Atul Gawande about the overutilization of healthcare in McAllen, Texas 21:15 Clinical practice guidelines and the Choosing Wisely recommendations as tools to eliminate waste 22:16 Doctors are barraged by differing, non-standardized quality measures in a multipayer insurance system 22:35 EHRs that are built to support FFS billing instead of clinical practice guidelines 23:00 Implementation success of clinical practice guidelines in Minnesota supported by the Institute for Clinical Systems Integration (ICSI) 24:00 Choosing Wisely has not achieved its potential due to intervention by specialty societies and non-conforming physician culture 25:20 How UPMC reduced hysterectomies by utilizing minimally invasive surgical procedures instead 26:00 Why large physician groups are more effective in implementing value-based care in comparison to large health systems 27:00 The challenges of hospital consolidation and ineffective payment models like Hospital Readmissions Program 27:40 “We will know when things have gone in the correct direction when hospitals are trying to help people stay well rather than keeping beds filled. But that’s habit, and it’s hard to change.” – Dr. Don Berwick 28:20 Realigning incentives for hospitals by putting primary care in charge of the system 28:40 “Hospitals have to go back to regarding them as sites of care, not as managers of care. A primary care-led system will work to keep patients out of hospitals.” 29:00 The role of hospitalists in reducing utilization of hospital resources 30:25 Examples of outstanding Bright Spots (e.g. Rio Grande Valley Health Alliance, Kaiser Permanente, Intermountain Healthcare, Geisinger Clinic, Prevea Health, Heritage Physician Network, Austin Regional Clinic, Aledade, Oak Street, One Medical, and Iora Health) 32:22 Sophisticated use of Health Information Technology is the common variable across all successful Risk-Bearing Entities 33:10 Early experiments in HIT innovation 33:25 Interoperability is mostly at the document-level (still no interoperability at the discrete data-level) 34:12 Current limitations of EHR systems in care management 34:18 Difficulty in getting claims data from some payers 34:41 “Without claims data, you are flying blind.” Dr. Anas Daghestani, Austin Regional Clinic 35:20 Managing patients with chronic conditions through telemedicine, virtual visits, and remote monitoring 37:00 Closed-loop referrals between the specialist and the PCP 37:48 Relationships with Community Benefit Organizations 38:20 Patient Centered Medical Homes (PCMHs) contributing to the value-based care movement 39:50 Imposing Health Taxes at the highest rate to patients who do not choose a primary care physician in a lower cost setting 41:00 “Economically, focusing on highest-risk patients is probably going to give the highest return in the short run. But the underlying reason they’re at such high risk is driven by social determinants. For example, the homeless are among the highest utilizers of healthcare. But the core problem is the fact that they’re homeless.” – Dr. David Nash 41:20 SDOH success with health plans (e.g. Kaiser Permanente and CVS Aetna, UnitedHealthcare, Geisinger Health Plan) 41:45 Payment models focused on SDOH (e.g. CMMI’s Accountable Health Communities Models, MA plans offering SDOH services, states overhauling Medicaid programs) 42:40 Should responsibility for SDOH be turned over to the healthcare system or should we do more to fund societal programs that exist outside of the traditional healthcare ecosystem? 46:20 Overcoming blowback from hospitals and health systems when implementing a physician-led reform model 47:20 How Medicare-For-All will force hospitals to adapt to lower reimbursement and require full divestiture of physician practices 49:40 Is Medicare Advantage-For-All a possible health reform policy option? 52:14 Bernie Sanders’ estimate that single payer system can save 10% in administrative cost savings

Dr. Kevin Spencer, Medical Director, Texas at Agilon Health, is passionate about improving the health care delivery system. He believes that by enabling physician-led organizations with technology, proven processes, and human capital under global risk capitation models, we can transform care for patients and physicians alike. With a deep understanding of the local market, combined with extensive health care experience, Kevin Spencer, MD  oversees the strategy, operations, and growth for the Connected Senior Care Advantage program, the unique Agilon Health risk-bearing entity (RBE) partnership model in the Austin, Texas market.  As the former Managing Partner and CEO of Premier Family Physicians, the Austin-based physician network that joined Austin Regional Clinic in the Agilon Health RBE joint venture, Dr. Spencer takes his leadership and understanding of how to effectively partner with primary care physicians to build sustainable success in global risk capitation models in Medicare Advantage. In this episode, Dr. Kevin Spencer shares important insights about the business of Medicare Advantage and how full-risk payment in primary care can lower costs and improve clinical outcomes within a senior population.  This interview is not to be missed for anyone wanting to understand how to build value-based care success over time in a physician-led environment that embraces full-risk capitation within a market that is still heavily entrenched in fee-for-service.  Dr. Spencer demonstrates a superior understanding of population health with a business acumen of Medicare Advantage that makes for a thought-provoking conversation on how MA may be the future of payment model reform.  Given the success of global risk capitated models in the senior space, could Medicare Advantage-For-All be a viable health policy in the years to come? Episode bookmarks: 4:38 Lessons learned in the early years of physician-led Accountable Care 9:08  “Health care is better delivered in a value environment. I believe that putting the premium dollar in the hands of the physicians that are taking care of patients will empower them to do the right thing, for the right reason, at the right cost.” 10:40 Choosing the right capital partner to form a Risk Bearing Entity 11:40 Agilon Health’s approach to physician partnership 12:50 Dr. Spencer referencing the excellent work done by other disrupters in the senior space (e.g. Oak Street, ChenMed, Iora) 18:00 “Medicare Advantage risk will only work if we deliver a much superior product to our seniors in America. The care they have been receiving up to now, in many cases, has been fragmented, disjointed, and not always aligned with their belief systems.” 18:55 Dr. Spencer discusses Connected Senior Care Advantage, the outward facing brand of his physician-led JV with Agilon Health 20:00 Medical management program investments (transitions of care, care management, home visits, and pharmacy programs) 21:00 Building patient trust so physicians can effectively quarterback care and how the pandemic has affected the patient-physician relationship 23:00 Medicare Advantage risk and its impact on physician burnout and physician/patient Net Promoter Scores 24:40 Marrying Risk Adjustment to Quality and the appropriate documentation needed to fuel the Population Health engine 25:20 Prospective chart reviews to improve coding documentation of disease burden 24:37 Annual Wellness Visits to improve coding documentation, screening effectiveness (mental health, fall risk), and care gap closure 28:00 The Economic Model of the Stars Rating in Medicare Advantage 30:00 Why the higher Stars-Rated MA plans actually cost less 31:20 Implementing a Playbook for Quality Improvement aimed at QM performance and improving patient experience/clinical outcomes 35:20 Capital Investment in Primary Care and how PCPs can maintain autonomy through interdependence with the right partners 38:25 Physician-led governance to prevent the corporate practice of medicine 40:50 How the pandemic paved the way for value-based care and primary care capitation 42:40 The launch of telehealth at Premier Family Physicians during the early stages of the pandemic 45:00 How Agilon Health is launching six different DCEs in the Direct Contracting (DC) model’s first cohort 48:26 Implementing a patient-centered Benefit Design as part of the DCE 49:11 Collaborating with other organizations to develop the DCE 50:30 Medicare Advantage–For–All approach as a potential health reform solution

Our nation has lost more than 300,000 people from COVID-19.  It is the latest sign of a generational tragedy – one still unfolding in every corner of the country.  As we head into the Christmas holiday, refusal to acknowledge the severity of the pandemic by acting irresponsibly will result in countless more deaths from the virus. Our nation is at stake, and this week’s Race to Value guest, Dr. Brent Staton wants to share a personal message of love and hope for a brighter tomorrow.  His featured podcast episode (recorded with Dr. Ty Webb) on how the Cumberland Center for Healthcare Innovation is “Building Economic Strength in Rural Communities” was released earlier this week.  After recording that episode, he contracted COVID-19.  We invited him back for a Bonus episode to share a message of God’s love in serving others by taking the pandemic seriously during this upcoming holiday season.  Dr. Staton recorded this episode while hooked up to oxygen battling this terrible disease. This pandemic is real.  If Dr. Staton’s message saves just one life, his service to his community, and the world as a whole, will have been realized. Episode Bookmarks: 0:00   Update on the COVID crisis and Dr. Staton’s personal battle with the illness 1:30 “As an American nation, we need to re-focus on unity and protecting one another” 2:30 Complications with COVID-19, Influenza B, and underlying asthma 2:50 Due to a flu vaccine shortage, Dr. Staton gave his own personal dose to a patient (and then ended up contracting the flu) 3:10 How Dr. Staton contracted COVID-19 from a patient during a 15-second interaction 4:30 Serving Others:  Practicing medicine with a servant’s heart and Dr. Staton’s plea for his community to wear a mask as the ultimate gesture of servanthood and love for others 4:45 Health Inequities:  Dr. Staton has access to care during COVID that all Americans should have. 6:20 Dr. Staton is in his late 40’s and was in excellent health prior to his COVID infection. 7:30 Post-COVID complications after recovery 7:50 Misinformation on COVID from the media and the Internet.  “We can’t continue down a pathway of mistrust.” 9:15 Dr. Staton provides perspective on the unnecessary deaths he has seen due to COVID 9:50 Pandemic deniers, and the culture of fear and misunderstanding in our nation 11:00 The worst case scenario if people don’t begin taking the pandemic serious during the Christmas holidays 12:00 Appropriate mask wearing protocol 13:00 What a COVID infection really feels like (“a torture chamber”) 14:10 The truth about mask wearing and vaccine efficacy 15:10 “The disrespect for other human life” by those who refuse to wear masks 15:30 Trusting Dr. Fauci and public health officials, an update on the vaccine research, and misunderstanding of herd immunity 17:10 Using the God-given gift of a human brain and loving others as we get through the pandemic 18:20 Spiritual reflection on death and how we can preserve life by re-focusing on a pandemic plan, mask wearing, and social distancing 19:50 The end of the pandemic will take another year to reach and what Dr. Staton is seeing in the data from other countries 21:50 Treatment with monoclonal antibodies 23:20 The ultimate goal of CCHI is to serve patients in our community 24:00 World War II as a lesson for the unity needed in our nation to defeat COVID-19 27:10 Getting back to the basics (“wash your hands, social distance, love your neighbor, wear your mask, and take care of yourself appropriately”)

A guiding principle of Cumberland Center for Healthcare Innovation, CCHI, is that communities and the state benefit from healthier families, and it’s not just about cost savings or longer lives. Better health means a more productive workforce and greater opportunity for economic development. CCHI is focused on a structured approach to build economic strength in the community. And their approach is working – since being established in 2012, CCHI has saved CMS over $43 million and achieved a 98.48% quality score! In PY 2019 CCHI was one of the top performing ACOs in the nation, without any adjustment for benchmark. In this episode, Dr. Brent Staton, CEO, and Dr. Ty Webb, CMO, share important insights into the challenges and successes of rural primary care. With a very lean team, they work with providers across more than 80% of Tennessee to provide personalized care at the practice-level. They truly fulfill their mission to demonstrate the value of rural independent primary care physicians in communities throughout Tennessee. Their model gives value-minded professionals nationwide an effective example for succeeding in the race to value. Episode Bookmarks: 04:48 “Rural healthcare is personal” – having a deep personal awareness of each patient’s needs, values and preferences 06:58 Dr. Webb speaks about the challenge of getting physicians to practice medicine in rural areas 08:11 Dr. Staton on how the roots of family and growing up on a farm led him to a career in rural medicine 09:30 Dr. Staton on how hauling hay and stripping tobacco instilled the Rural American values of hard work in his life 10:50 The health and socioeconomic challenges in rural Tennessee and the opioid epidemic 12:22 “The depth of the challenges in rural health care is as deep as the sea.” (Staton) 12:40 The impact of the opioid epidemic, poverty, SDOH, and lack of health care resources in rural communities 14:05 High-touch approach to primary care and how ideas and best practices spread across various counties in the ACO 16:30 The mission of the ACO and how improving health will build economic strength in the community 17:20 “We saw that if we had healthier students, we could improve education.  We saw that if we had a healthier workforce, we could improve productivity and attract new businesses and job opportunities to our communities.” (Staton) 18:30 “Rural communities grow and develop over time, in much the same way as a field or a meadow in the study of natural history and biology. The same pattern of strength, complexity, and diversity is there.” (Webb) 19:05 Education and Health care are important foundations for rural communities to grow, develop, and progress.” (Webb) 19:30 Hospital closures in rural communities 20:11 The economic contribution of physician practices and hospitals to rural communities 20:45 “Hanging on by a thread really isn’t enough – whether it is your health or your economic solvency as a family or company.” (Webb) 21:10 Practice stabilization through communication of best practices, standardized care delivery, and revenue stabilization 24:02 Dr. Staton on how a large physician-led ACO can collaborate with hospitals 25:17 “Acuity of care for a hospital is more important that ‘heads in beds’. Our goal is not to prevent a necessary hospitalization or preventing emergency care when it is needed. Our goal is to make sure that patients get appropriate care and early interventions that they need and deserve.  (Staton) 29:00 The resiliency of CCHI’s primary care practices during COVID-19 31:12 Telehealth implementation and the benefits of telemedicine in rural communities 35:50 The lack of access to broadband internet access in rural communities and the need for additional infrastructure 37:37 CCHI’s COVID Task Force to prevent the spread of the virus 41:20 CCHI’s Shared Savings Success: $43 million in the Medicare ACO program (positive in corridor every year of ACO existence) 48:52 CCHI’s focus on Quality Reporting Performance and how the ACO had improved its quality scores over the years 49:51 CCHI’s expansion of its multipayer contract portfolio and how it learned to analyze data to identify cost containment opportunities 53:30 “We’re not in it for the dollars.  My grandfather always told me – whether it is pumping gas, washing windows, or hauling hay – if you do the right thing, the money will come.” (Staton) 54:44 Applying high touch primary care across the entire contract portfolio (not just risk-based contracts) 57:38 The relationship between quality and cost 58:00 The correlation between happier doctors and better patient outcomes (The Quadruple Aim) 1:00:00 Approaching the presentation of data and analytics to physicians with the art of simplicity 1:04 Decentralizing care coordination by activating practice-level staff to support ACO needs 1:11 Trust and teamwork in leading a Rural ACO (“Trust goes to the core of what we do.”)

Join us in this episode as we speak with Dr. Mark McClellan, former CMS Administrator and former FDA Commissioner during SARS – his understanding of the COVID-19 pandemic and options for our national response is nearly unmatched. His unique insights into our health care system provide clarity around the new administration’s position on value-based care as well as offer understanding regarding what the presidential transition will mean for COVID-19 response efforts, including vaccine distribution. Further, we highlight Dr. McClellans’s recent work on the Resiliency Framework with HCP LAN which presents a vision to create a health care system that is responsive and resilient to events like the current public health emergency and achieves better patient experience, outcomes, equity, quality, appropriateness, affordability and accessibility at a reduced total cost of care. We have learned through the pandemic that we must upgrade our health care system – this is not the time to go back to health care the way it was before. Dr. McClellan’s work and insights are paramount for professionals in this race to value. Episode Bookmarks 02:37 Dr. McClellan shares his thoughts about the ACLC and the role it plays to advance VBC in our country 03:35 Will the next two years will either be a period of gridlock or a time of historic legislative productivity? 04:14 Economic response and COVID-19 Recovery Plan are the two big legislative issues for the upcoming year 04:24 Evenly-divided Presidential election and the “reverse coattail” effect 04:36 Best case for the Democrats is a 50/50 Senate with moderate Democrats being “thoughtful” about big progressive agenda items 04:55 Bipartisan legislation is most likely outcome (most big legislation items – other than COVID recovery – are not going to happen) 05:14 Other key priorities: climate change, racial issues 05:25 Longshots: Lowering the eligibility age of Medicare or a big coverage expansion (unless Supreme Court ruling somehow takes action on ACA) 06:00 ACA guaranteed issue and community rating provisions 06:23 Potential bipartisan interest: transparency and surprise billing, drug pricing, and value-based care 06:45 “Value-Based Care approaches are a bipartisan issue, but it may not continue quite in the same way.” 07:11 How the Biden Administration approach to VBC may be different 08:15 Health Care Payment Learning & Action Network trying to align public and private efforts on reform 09:15 “We can now see the light at the end of the tunnel.  Vaccines are moving into more advanced development and availability” 09:26 “What we learned throughout the pandemic is that we really need to upgrade our health care system. This is why the work of the ACLC is particularly relevant now.” 10:00 Disruptions in our health care system due to massive reductions in revenue associated with shelter-in-place provisions. 11:30 “The farther away you were from fee-for-service, the more robust and resilient your care response was to the pandemic.” 11:56 Provider success stories in COVID: Advanced Integrated Care Systems (Intermountain, Geisinger) and Primary Care groups centered around capitation (Iora Health, Oak Street) 12:51 Hospital utilization returning back to pre-COVID levels 14:26 Advanced multidisciplinary primary care teams now including more virtual care and behavioral health integration 15:11 Shift to home dialysis for kidney disease and home drug infusion for cancer care 15:53 Social determinants of health enabled by capitation 16:26 Integrated approach to patient management for patients dealing with social isolation and depression consequences 16:45 Elimination of low-value care (the 30% of services that offer limited to no value in health outcomes) 17:05 NEJM Catalyst Article – Building a Better Health Care System Post-COVID-19: Steps for Reducing Low-Value and Wasteful Care 18:19 Payers providing financial relief to Primary Care and moving them to advanced physician-led ACOs (Blue Cross NC, Blue Cross Massachusetts, Blue Cross Minnesota, Blue Shield California) 19:20 Reforms in specialized payment reform models (BPCI, Maternity Care) 19:53 Private Equity investment in Alternative Payment Models (Aledade, Agilon, Optum) 20:33 Progress on Vaccines, Research, and Testing and “The Last Big Surge in the Pandemic” 20:50 Large employers taking more steps to VBC and Direct Contracting (Wal-Mart, Amazon) 21:30 Flexibility with telehealth and 3-Day Hospital stay rule 21:50 Supporting the longer-term predictable shifts due to VBC payment models 22:20 Using the Pandemic to address longstanding health equity concerns 23:05 “The Dark Winter” in the weeks ahead and how we get to a better health care system so we never have to do this again 25:55 Challenges in the Presidential transition and its effect on COVID recovery response planning 27:22 Paycheck Protection Program and other packages with economic implications 28:39 COVID PCR and POC antigen lab testing 31:05 The importance of reopening schools 31:46 FDA approval of monoclonal antibody treatment for COVID 33:30 Logistics to ensure equitable distribution of vaccines and distribution at scale 37:54 Efforts to make a longer-term sustainable investment in public health, contact tracing, and new diagnostic technologies as a result of the pandemic 43:33 How COVID-19 will create a more resilient American health system going forward 46:14 Health Care Payment Learning & Action Network Healthcare Resiliency Collaborative 49:22 The lame duck session focusing on health care resiliency and APMs to catalyze the VBC movement 50:30 If the pandemic showed us anything, it was that we really need value-based care”

Dr. Elizabeth Teisberg is a leading figure in the value-based health care strategy movement and is the executive director of the Value Institute for Health and Care as well as a Professor at the Dell Medical School at the University of Texas at Austin. With her deep background in strategy and innovation, and with special attention to the health care sector, she collaborates closely with Michael Porter, renowned authority on competitive strategy. Together they co-authored “Redefining Health Care: Creating Value-Based Competition on Results” (Harvard Business Review Press, 2006), which received the American College of Healthcare Executives’ 2007 James A. Hamilton book of the year award. Teisberg’s forthcoming book, “Capability, Comfort and Calm: Designing Health Care Services for Excellence and Empathy” is co-authored with Scott Wallace, who also recently joined the Dell Medical School faculty. While her definition of value in health care, “the measured improvement in a patient’s health outcomes for the cost of achieving that improvement,” has largely been adopted by the industry, the VBHC movement continues to move at a glacial pace in juxtaposition with the moral and economic imperative to make it happen. We struggle with how to operationalize it as we often conflate value-based health care with operational programs that focus on cost reduction, quality improvement, or patient satisfaction. Those efforts – while important – are not the same as value, which focuses primarily on improving patient health outcomes. We are not pursuing more treatment, we are pursuing more health and more caring. Value Institute For Health and Care Website Value Institute For Health and Care Annual Report 2020 Episode Bookmarks: 03:05 Dr. Eric Weaver shares with Dr. Teisberg how “Redefining Health Care” impacted his life and career 05:08 Revisiting Value-Based Health Care In the 15 years since Dr. Teisberg wrote Redefining Health Care (Current State of the VBHC movement) 07:07 Dr. Teisberg explains the difference between “healthcare” (one word) versus “health care” (two words) 07:59 Patients want to choose better health which doesn’t mean they always want more “healthcare” 08:41 The purpose of health care is to improve the health outcomes for the people we serve (instead of just measuring profits) 09:25 Dr. Teisberg shares her perspective on why the diffusion of innovation in value-based health care delivery takes so long 09:50 Strategy, Culture, and Measurement must be woven together for the transformation to occur (“braid of change”) 11:05 How the pandemic will accelerate the Value Based Health Care movement (COVID as an inflection point) 14:25 Improving health outcomes through clinically integrated care (Integrated Practice Units) 15:51 Identifying gaps to inform the development of human-centered solutions that can be delivered through IPUs 17:52 Dr. Teisberg shares an example of a new IPU at Dell Med (The Texas Center for Pediatric and Congenital Heart Disease) 20:00 Patient-Reported Outcomes as a core component of IPUs 21:50 “When we talk about value, we mean value for patients” (not to enable health plans) 22:48 Collaborating with Scott Wallace in working with patients to understand the outcomes that matter to them 23:33 Person-centered measurement through Capability, Comfort, Calm 27:05 “Health care is drowning in measures… And what needs to be reported externally is a relatively small set of important outcomes. Outcomes that matter to patients and families.” 31:43 The Musculoskeletal Institute at Dell Med and UT Health Austin as a success story in condition-based, bundled payment innovation 34:43 Alignment of the interdisciplinary team within condition-based, bundled payment models 35:30 “Payment change doesn’t need to precede change in care delivery”. 37:30 VBHC Lessons Learned from Other Countries (New Zealand Ministry of Health, King’s Health Partners, Santeon, and the Martini-Klinic) 39:48 How the Value Institute for Health and Care is approaching collaboration at an international level 41:26 An example from Victoria, Australia on how to restructure health care payments for vehicular accidents (full-cycle care with longitudinal consistency of payment over a patient’s life) 42:54 An example of a Dutch cooperative of teaching hospitals (Santeon) collaborating on research to improve health outcomes 43:24 An example of a specialist prostate cancer clinic in Germany (Martini Klinik) that excels in patient-centered outcomes measurement 44:45 An example of a dental clinic in Australia (Dental Health Services of Victoria) that ensures good dental health outcomes for underserved populations 45:12 An example of an inpatient psychiatric hospital that is focused on VBHC by redirecting goals based on patient outcomes 46:21 An example of an eye clinic in India (Aravind Eye Clinic) that is a national destination for extremely high-value care 47:07 “One of the tricks for developing high-value health care is to not reinvent wheels when the wheels are rolling well, but to look at other places.” 51:00 Experience group methodology at the Value Institute for Health and Care 52:20 An example of a breast cancer experience group identifying unarticulated needs related to cognitive impairment 53:30 An example of a diabetes experience group identifying unarticulated needs related to neuropathy and erectile dysfunction 55:00 How Dell Medical School is integrating Value Based Health Care into its curriculum for medical education 56:55 The Health Care Transformation Master’s Program that is designed to teach physicians and other health care leaders how to implement VBHC 60:00 The vision for the development of a new innovation district in Austin, TX to incubate VBHC ideas and solutions