The Race to Value Podcast

In the uncertainty of today’s healthcare industry, we must continue to persevere towards our true north.  The moral imperative to improve the quality of care for patients through better care coordination, including those are underserved, can only be achieved by the realities of the digital age. This transformation will require the medical profession to create a modernized Hippocratic Oath that extends to the broader health ecosystem. The proliferation of interoperable technology and digital health tools has the potential to catalyze value-based care delivery innovation and transparency. However, it must come along with an ethical commitment to guide data sharing, integration, and technical processes. True North will ultimately prevail in connecting value-based networks to those most in need; however, it will take continued progress in amplifying the demand signal for value-based care. On the Race to Value this week, you will hear from one of the top healthcare revolutionaries in our country.  We are honored to bring you, the one and only,Aneesh Chopra – the first chief technology officer of the United States who was appointed by President Obama and the Co-Founder and President of CareJourney. In this episode, you will be party to a powerful conversation on the promise of the digital age in healthcare.  You will learn about how health policy and innovation is ushering in a new era of data flow and interoperability, consumer-driven innovation, price transparency, and clinically-relevant analytics for the future of value-based care delivery transformation. Aneesh Chopra also explains why he feels so strongly why ACO REACH will help us reach True North. Episode Bookmarks: 01:30 Introduction to Aneesh Chopra –  – the first Chief Technology Officer of the United States and Co-Founder and President of CareJourney 04:00 The need for the medical profession to galvanize around the immense opportunity to transform care delivery by embracing the realities of digital age. 06:30 Why do we need a digital Hippocratic Oath to transform medicine? 08:00 The gap between patients being seen on a given day and the 98% of the patient panel that are not. 08:30 Designing database queries and algorithms to Identify patients in need of care. 09:30 Creating a compact between analytics communities and physicians to ensure patients are getting appropriate care. 10:45 The self-imposed barriers to technical and semantic interoperability that come from our current FFS model. 12:00 How the HITECH Act manifested in technology gaps, despite widespread EHR penetration. 14:00 “The delay in the demand signal for value-based care resulted in the de-prioritization in the market for interoperability.” 15:30 The regulatory goals of the 21st Century Cures Act to scale interoperability and eliminate information blocking. 16:45 Cures Act regulatory emphasis on population health is now reaching the market. 17:00 FHIR Interoperability Standards will ultimately deliver on the promise of population health through widespread data exchange and API-led connectivity. 18:00 Ensuring value-based care organizations a “plug and play” approach to unify electronic health records. 19:00 The promise of widespread data exchange in value-based care delivery and how it parallels with the consumer banking industry. 20:30 Similarities between Dodd-Frank Act (banking sector) and the Cures Act (healthcare sector) in regard to consumer data protections. 22:30 JPMorgan cutting off access to Mint because screen-scraping was far less secure than API connectivity. 25:00 If value-based care became the dominant delivery model, the industry wouldn’t need so much regulatory oversight. 26:00 The Cures Act is beginning to reverse FFS-driven market failures in order to create a much more rational economic model. 27:00 Referencing the opinion piece in STAT by Aneesh Chopra and Seema Verma about the new price transparency regulations in healthcare. 28:30 Economic research that shows how price transparency in healthcare doesn’t always lead to empowered consumerism. 29:30 Using fiduciaries in a VBC network to guide patients to the most appropriate clinical setting and provider. 30:00 How did hospitals, health plans, and employers respond to the federal requirement to disclose prices without any technical guidance? 33:00 “I believe in our vibrant technology economy to be helpful in converting raw transparency data into meaningful guidance for patients in VBC.” 33:30 The leadership of Todd Park and Farzad Mostashari in Health IT transformation and consumerism. 34:00 Coupling health information fiduciaries with population health best practices at scale could eliminate healthcare economic drag and improve care quality. 35:00 “A patient fiduciary equipped with price and quality information would improve patient matching to care resources and make a big difference in the system.” 36:00 How CareJourney is providing clinically-relevant analytics for value-based networks so they can succeed in care delivery transformation. 37:00 Affordable Care Act, Section 10332 provides the release of Medicare data for provider performance measurement 38:00 HHS initially blocked the release of Medicare performance data for fear that physician compensation would become public domain. 39:00 President Obama created the US CTO position and appointed Aneesh Chopra to create “a more open and transparent government”. 40:00 CMS created a program for researchers to access Medicare longitudinal data for provider performance measurement 41:00 CareJourney is creating a “Dartmouth Atlas-style” variation analysis for patients with certain disease conditions and monitoring their journey over time. 42:00 Looking at care variation in clinically relevant cohorts to identify where best practices exist in value-based care. 42:00 Applying well-defined, publicly accessible cost and outcomes measures to find the highest value doctors, facilities, and networks. 43:00 Using public data to determine which interventions have the highest level of return in population health outcomes. 44:00 The Biden administration aims to have all Medicare FFS beneficiaries in an accountable care relationship by 2030. 44:30 A recent CareJourney analysis showing that Medicare patients enrolled in value-based care arrangements were nearly two times more likely to get mammograms. 45:30 Many dual eligible patients in underserved communities are not able to access Medicare ACOs (their only choice for value-based care is Medicare Advantage) 47:00 The hope for the 2030 goal by CMS to reverse health inequities in underserved communities. 47:30 The historically paternalistic approach to value-based care led to an exclusion of the patient voice. 48:30 The lack of meaningful patient engagement in the Medicare open enrollment process. 49:00 The reason why Aneesh Chopra is excited about models like ACO REACH 50:00 Moving value-based care away from paternalistic, algorithmic models to true relationship-based care 50:30 “True North will prevail.  We have to find a way to connect value-based networks with those most in need. That day is coming, and it will happen first with ACO REACH.” 51:00 Health Equity as True North and the upcoming Institute virtual summit on Dec 1st. (Population Health Equity: The North Star for Value) 52:00 Referencing a recent article written by Aneesh Chopra and Rick Goddardoutlining the four programmatic Health Equity Components in ACO REACH. 54:00 How a ACO REACH Health Equity Plan will be a catalyst for change. (“looking inward for clinical priorities to demonstrate progress”) 55:30 Adjustments to benchmarking methodology for REACH ACO patients living in underserved areas. 56:30 Increased ACO recruitment of underserved beneficiaries through voluntary alignment because of changing financial incentives and accountability plans. 58:00 “Look to ACO REACH for a whole range of goodies, not the least of which is to get underserved populations into better coordinated care models.” 58:30 Aneesh discusses concerns by REACH ACOs that CMS may erroneously apply a retroactive trend adjustment to the benchmark during reconciliation. 62:30 What should the ACO REACH reference population be? 63:30 How can CMS constrain financial arbitrage opportunities while also providing predictability to benchmarking methodology? 64:30 Using responsible AI in healthcare (“Innovation can happen only at the speed of trust.”) 66:00 The spread of disinformation in a digitalized market-driven economy and why healthcare can’t follow the path of social media. 68:00 Aneesh provides perspective on the current development landscape of AI models to improve clinical care outcomes. 70:00 Parting thoughts on “precision health” and personalized care pathways by leveraging genomic sequencing, AI, and biometric data from wearables 72:00 Reflections on the leadership of Michael Leavitt and appreciation for the work of the Institute for Advancing Health Value.

The Institute for Advancing Health Value has recently released two new Intelligence Briefs highlighting two major impactful events in the movement to value-based care. 2021 MSSP Performance Results Analysis:  The Institute analyzes 2021 performance data, sharing high-level program performance and examining savings across participation tracks, by the provider type, size and location of ACOs, and their experience in the program, and reflects on the future of the MSSP in light of the recently proposed changes to the program and the beginning of CMS’s new capitated total cost of care model, ACO REACH. The ACO REACH Final Cohort:  The Institute analyzes the incoming final cohort of provisionally-accepted REACH ACOs within the context of the model’s history, analyzing the roster relative to GPDC’s current participants, and sharing expectations for the future.  (This Intelligence Brief was sponsored by Bamboo Health.) Check out this special bonus episode where Eric and Dan interview Kate de Lisle on her research analysis on these recent CMS announcements.  You may also download these Intelligence Briefs at  https://www.advancinghealthvalue.org/analysis-of-mssp-2021-and-aco-reach-2023/ Episode Bookmarks: 01:30 Download the new Institute intelligence briefs on the 2021 MSSP Performance Results and the ACO REACH Final Cohort 02:30 Background on Kate de Lisle, Senior Manager of Payment & Delivery Transformation at Leavitt Partners 04:00 Recently announced MSSP Results as an important bellwether for the success of the value movement 05:30 Total program savings of nearly $5.4 billion over the model’s lifetime 06:30 5th consecutive year of net savings – has the MSSP demonstrated proof of concept? 07:00 Was 2021 a good year for the MSSP since the net savings wasn’t quite as large as the year prior? 07:30 The average per beneficiary PMPM savings amount was $164 (double what it was in 2019) 08:00 81% of ACOs generated savings and 58% earned a Shared Savings bonus.  Quality scores were also high. 08:45 89% of ACOs taking downside risk generated savings (compared to 76% that saved in an upside-only track) 09:15 Risk-bearing ACOs generated $5.3M per ACO (compared to $2.9M for non-risk bearing) 09:45 ACOs led by physician groups realized the most savings. 10:00 Hospital-led ACOs realized a decline in savings. 10:30 Years of experience in the MSSP is no longer a straightforward predictive indicator of performance success. 14:00 Last month, CMS released the names of the 110 provisionally-accepted organizations selected to join the ACO REACH model starting in 2023 15:30 Only 47% of REACH applicants were provisionally accepted. 17:30 New cohort had similar profiles of selected groups accepting Global and Professional Risk. 18:00 New entrants are serving vulnerable and high-risk populations. 19:00 Groups moving from Next Gen ACO to ACO REACH 20:30 Far fewer payer-led ACOs in the new REACH cohort 21:30 What considerations did CMS take into account when selecting for participation in the new REACH program? 22:00 Sustained interest in ACO REACH from VBP enablement companies (e.g.Aledade, agilon health) 23:30 Provider-owned enablement companies participating REACH (e.g. Castell Health) 24:30 Upstart primary care companies accepted into ACO REACH (e.g. Oak Street Health, Iora Primary Care, ChenMed, Cano Health, Cityblock, ConcertoCare) 25:00 ChenMed  (a leading full-risk MA primary care practice in the country) is included in the new ACO REACH cohort. 25:30 OneMedical has also been accepted into the program. 26:30 The Institute for Advancing Health Value has a complimentary membership for provider organizations! 27:00 Will CMMI be sunsetting various APMs, including specialty care models like BPCI and CJR programs? 28:30 Kate speaks about the “weak signals” being broadcasted by CMMI around the future of the APM portfolio. 30:00 What impact will ACO REACH have on the CMS 2030 Goal?

Fee-for-service healthcare has destroyed the physician-patient relationship by de-personalizing care delivery.  Patient encounters are looked at as transactions, instead of as opportunities to forge long-term healing relationships. Consequently, the healthcare system delivers inexorably bad cost and quality outcomes, and  primary care is marginalized in lieu of high cost specialists who perform procedures. This has created a perfect storm for physician burnout and moral injury, and we can only regain the humanity of health care by reinstating the primacy of the physician-patient relationship and empowering independent primary care physicians. Dr. David Pak is an entrepreneurial Internal Medicine physician leader with over 25 years of direct patient care.  His medical practice (Pak Medical Group) is a leading example of a patient-centered, holistic, relationship-based, tech-enabled model that is transforming the lives of seniors. Dr. Pak is an entrepreneur with masterful skill at aggregating local market physicians to build value-based models of care.  He has formed an ACO and Medicare Advantage risk-bearing entity (Zenith Independent Physicians Network) that is moving primary care practices to fully-capitated risk. Dr. Pak is passionate about the personalization of primary care, technology enablement through remote patient monitoring, perpetuation of physician independence through value-based programs, and the creation of Human AI staffing support models that can transform care delivery and physician culture.  While he is an expert on value-based care and care delivery innovation, he is also a proponent of medicine revisiting its roots to a more simpler time where relationships were paramount. This episode is a must-listen for entrepreneurial primary care physicians who seek independence through value-based care. By following Dr. Pak’s approach, they can reclaim their joy in medicine and propel their practices to business success in the race to value. Episode Bookmarks: 01:30 Introduction to Dr. David Pak and his healthcare ventures (Pak Medical Group, Zenith IPN, and Eleos Staffing) 04:30 Dr. Pak’s early success as a physician entrepreneur that resulted in his practice to Humana 05:30 Dr. Pak speaks to his career as an entrepreneur in creating value-based, innovative care delivery models for seniors 07:00 “Fee-for-service is a broken model that rewards bad behavior that is not conducive to good outcomes.” 08:00 Holistic patient care only occur in a full-risk medical practice. Will this lead to mandated APMs? 10:00 The explosive growth and enrollment trajectory of Medicare Advantage. 11:00 Learning how to succeed in Medicare Advantage from more advanced models in Florida. 12:15 Identifying vulnerable populations in Medicare Advantage through appropriate risk adjustment coding. 13:00 Delivering customized care delivery care models for different segments of the MA population. 14:30 The need for primary care physician autonomy and independence to overcome current financial challenges. 15:30 Is a massive corporate takeover of primary care necessary for PCPs to succeed in capitated revenue models? 18:00 Comparing PMPM reimbursement to traditional FFS reimbursement and overcoming the physician “education gap” in risk 18:45 The importance of physician leadership and education in value-based care 20:00 It is possible for PCPs to get off the “hamster wheel” (and it doesn’t require a corporate takeover) 21:30 The need for independent physicians to take on a capital partner to support their value journey. 23:00 Dr. Pak explains the importance of physician education and a robust risk-based contract portfolio. 24:00 The aggregation of primary care physicians in local markets. 25:00 “The road to value-based care should be paved by physicians…especially primary care physicians.” 25:30 The difficulties in meeting ROI expectations from PE investors and why physician aggregation is crucial to success. 26:30 Avoidance of PCP commoditization and why hospital-led ACOs may not be an ideal long-term solution. 27:00 Finding “anchor physicians” in local markets as an aggregation strategy 27:45 How PE-led hospital acquisitions of primary care drives up prices and leads to poorer outcomes. 29:00 “M&A is easy; it is the integration that is a nightmare because investors may not understand the local market.” 30:00 The PE-led physician “land grab” in Texas and the challenges of physician integration due to lack of EHR interoperability. 32:00 Creating a data infrastructure in the independent PCP landscape within a local market. 33:30 Will AI robots replace healthcare providers? 34:30 The difficulties in automating personalized healthcare, and the opportunities for technology-enabled standardization. 35:30 Solving for physician burnout and moral injury is critical to avoid a mass workforce exodus. 37:30 A tearful patient testimonial for Dr. Pak’s medical practice 38:00 The biggest mistake made by physicians is thinking they are the “be all end all” of the medical practice. 39:00 “Healthcare is the only industry that doesn’t have a CRM program.  We are in a service industry, yet we don’t operate like one.” 40:00 The paramount importance of patient communication, patient access, and care coordination in building a support infrastructure in a medical practice. 41:30 Building a customer service-focused culture and the “Marcus Welby model” is not possible in a corporatized medical practice. 43:30 What is the difference in primary care access between an underserved American community and a third world country? 45:00 How Pak Medical Group leverages Remote Patient Monitoring in the delivery of patient-centered care (Institute members can download Case Study here) 47:30 How can Amazon and FedEx track packages across the country, but we can lose patients inside a hospital? 48:00 Fallacy #1: “You can’t teach an old dog new tricks” (seniors can adapt to technology!) 49:00 Fallacy #2: “Good health care can only be delivered in-person” (how wearables facilitate remote engagement) 50:45 Deploying mobile units and telehealth in building an asset-light care delivery model. 52:30 An overview of the Zenith Independent Physician Network, a risk-bearing entity of independent primary care physicians that Dr. Pak founded. 54:00 Dr. Pak describes how common it is for ACOs not to provide data reporting and financial transparency to partner physicians. 56:00 The 3 hallmarks of building a good Risk-Bearing Entity (i.e. infrastructure and contracts, financial transparency, performance report cards) 57:30 Creating physician leadership at the pod-level in various regions throughout the ACO’s geography 58:30 An overview of Eleos Staffing, a value-based care Human AI (staffing and automation) company that Dr. Pak founded. 61:30 Wrapping human capital around software, workflows, and processes to create automation. 63:30 Efficiencies in referral management, insurance verification, prior authorizations, scribing, and chart prep by using a virtual healthcare associate (Human AI) 65:00 How Human AI reduced physician burnout and improved ACO performance results. 67:30 Creating a care delivery environment for physicians to find job in their work through personalized relationships. 69:30 Moral injury occurs when physicians are forced to abandon their duty to care for patients in the best way possible. 70:30 Getting to the grassroots and fundamentals of medicine.

Many roads will bring us to health value, but some roads will get us there faster than others. As we reimagine our nation’s healthcare system, we must build alternative avenues to value beyond the conventional fee-for-service approaches to transformation. In building a superhighway that fully unleashes the power of independent and accountable physician groups, we will produce faster and better results. Joining us this week on the Race to Value is Susan Dentzer, the President and Chief Executive Officer of America’s Physician Groups (APG), the organization of more than 335 physician practices that provide patient-centered, coordinated, and integrated care for patients while being accountable for cost and quality.  APG members provide care to nearly 90 million patients nationwide and are leading this nation’s superhighway in the race to value. In this podcast episode, we discuss advanced primary care transformation, restructuring of payment models to reach scalability and impact, health policy reforms, PCP employment trends, the M&A landscape in provider consolidation, Medicare Advantage, and the power of tech-enabled asset-light care delivery. Episode Bookmarks: 01:30 Introduction to Susan Dentzer, President and Chief Executive Officer of America’s Physician Groups (APG) 04:30 More than 60% of health care payments in 2020 included some form of quality and value component 05:30 Despite traction, moving to value at a glacial pace (reference recent surveys fromMGMA and HCP-LAN) 06:30 Susan discusses the entrenchment of FFS and how difficult it is to change the payment edifice in U.S. healthcare 09:00 Overcoming the extraordinary backlash and resistance to realigning payment incentives in American healthcare 12:00 How APG is approaching the national transition to value 13:30 The need for advanced primary care in helping CMS achieving its 2030 goal to drive accountable care 14:45 The systematic undervaluing of primary care and overemphasis on hospitalizations 16:00 How the payment structure was hijacked by proceduralists and specialty care 16:30 Clinton era health policy reforms that attempted to restructure Medicare payments to primary care 17:30 Where would we have been if we tackled primary care reimbursement and workforce challenges in the 1990’s? 18:30 Limited progress in voluntary innovation models to advance primary care effectiveness (e.g. PCMH, team-based care) 19:30 How the NHS in England created state-of-the-art primary care through 24/7 access 20:45 The private sector stepping up to modernize care delivery access and infrastructure where public policy failed 21:30 Investment in primary and secondary prevention to address chronic disease 22:00 Transitioning from a cottage industry to a well-funded, risk-based primary care strategy to improve population health 24:00 PCP employment by hospitals often not an driver of value-based care due to referral maximization objectives 24:30 Independent PCPs will need to find investment partners to advance risk-based transformation 24:45 Susan discusses the success of Central Ohio Primary Care’s partnership with agilon health 29:00 Medicare Trust Fund solvency will be depleted by 2026, but APM adoption could help avoid this fate. 30:30 “Many roads can bring you to value, but some roads will get you there faster than others.” 31:00 MACRA legislation created MIPS and APMs using the current fee-for-service chassis 31:45 The importance of the 5% bonus/incentive payments to QPP participants that are a part of Advanced APM models 32:30 Hospitals pocketing APM incentive payments for employed providers will not accelerate path to value. 32:45 Results comparison between physician-led and hospital-led ACOs 34:00 Susan explains why America’s physicians are the superhighway to Value Transformation 36:00 Capitation within the ACO REACH model as a continuation of full-risk success in Medicare Advantage 38:00 “Alternative avenues to value – beyond the conventional FFS approaches to transformation — will produce faster and better results.” 39:00 The ACO REACH Coalition 40:00 How instituting primary care capitation to the MSSP will improve patient care outcomes 42:45 “We’re not going to get there through the current crop of ACOs. You need capitation in the MSSP, as well as the new ACO REACH model.” 43:30 Extending the CMS 2030 Goal to Medicare Advantage by driving MA patients to accountable care relationships 44:30 Plan turnover in Medicare Advantage does not support accountable care. 45:30 “Accountable care means very strong relationships at the primary care-level.” 48:00 Susan discusses potential reforms that will motivate MA plans to push budget-based prospective payment downstream to the physician group level. 50:00 Referencing recent JAMA article by Ezekiel Emmanuel that concludes MA produces better spending results than MSSP 51:30 “Medicare Advantage has been at the vanguard to the transition to value, but it can do even better.” 53:00 Recent M&A Activity in value-based care (e.g. CVS Health and Signify Health, Amazon and One Medical, Walgreens partnership with VillageMD) 54:30 “The future is already here – it’s just not very evenly distributed.” – William Gibson 55:30 Susan explains how Walmart is shaking up healthcare 57:45 How Iora Health will be an asset to Amazon as it leverages its investment in One Medical and why Amazon Care is closing. 59:00 Physician perspectives on the impact Amazon will make in healthcare transformation. 60:30 Referencing Susan’s book “Health Care Without Walls: A Roadmap for Reinventing U.S. Health Care” on digital transformation 61:30 Susan speaks about the progression to tech-enabled, asset-light care delivery 63:00 Distributed care and “Hospital at Home” models 64:30 Applying the Airbnb model to capitalize on unused capacity in patient homes to deliver care

One of the silver linings of the pandemic has, in fact, been, the expansion of telehealth services and virtual care delivery. The pandemic has also accelerated the healthcare industry’s transition from fee-for-service to value-based care. The continued growth of telehealth is fueled by providing incentives for care delivery in the lowest cost settings, identifying and interacting with highest-risk individuals before disease onset, managing care teams with more efficient workflows, and taking advantage of digital remote technologies. Virtual care is an easy and cost-effective path to achieve value-based care, thereby improving health outcomes and patient satisfaction across a broader population of patients. Our guest this week, is Dr. Carrie Nelson, the Chief Medical Officer for Amwell, a leading digital care and telemedicine company.  Dr. Nelson is a seasoned physician leader committed to healthcare transformation. She has demonstrated success in innovation and change management, physician engagement, solution development and deployment, value-based care, managing and coaching other leaders and delivering results.  Before joining Amwell as Chief Medical Officer and President of their Amwell Medical Group, she served as the Senior Vice President and CMO for Population Health and Health Outcomes at Advocate Aurora Health.  She also served as the Chief Clinical Officer for Advocate Physician Partners, a benchmark organization known internationally for delivering value-based care in collaboration with about 5000 employed and independent physician practices. With more than 28 years’ experience as a Family Medicine provider, Dr. Nelson is an innovative physician leader with a proven track in quality improvement, patient safety and population health. Bookmarks: 01:30     The silver lining of the pandemic is the expansion of telehealth services/virtual care delivery and the acceleration to value-based care. 02:15     Introduction to Dr. Carrie Nelson, the Chief Medical Officer for Amwell, a leading digital care and telemedicine company. 05:00     Dr. Nelson’s recent career transition from Population Health leadership at Advocate Aurora Health to a national leadership role in digital transformation and virtual care enablement. 06:00     A career in driving healthcare transformation in population health, quality, and patient safety. 06:30     The influence of “Crossing the Quality Chasm” and “To Err is Human” on awakening a healthcare transformation. 07:00     The pace of change across the country is still insufficient due to over-dependence on fee-for-service. 08:00     The consequences of poor disease control during the pandemic as a result of ineffective healthcare delivery. 08:30     The multifactorial limitations in the capacity for healthcare systems to change (e.g. culture, failure to adapt to technology) 09:00     Strong technology partnerships needed to prevent health systems from regressing back to their pre-pandemic care delivery model. 09:30     Workforce burnout in healthcare prevents sufficient time to think about system transformation. 10:30     Telehealth improves patient health, reduces overall costs of care, and improves health equity in medically underserved communities. 11:00     The plunge of telemedicine usage since the peak of the pandemic. 12:00     “During the pandemic, we largely moved brick and mortar care to online.  If that is all we ever achieve, we will have fallen far short of the potential for a technologically-enabled model.” 12:30     Shawn Griffin (President and CEO of URAC) and his analogy of COVID-19 telehealth deployment to only “watching the dancing baby online” when launching the Internet. 13:00     Dr. Nelson discusses Amazon Care’s recent departure from telehealth and itsrecent acquisition of OneMedical. 13:30     Wider uses cases for telehealth and recent trends in claims activity. 14:30     Inserting new tools into the virtual visit creates healthcare transformation that improves quality and lowers costs. 15:00     “The office visit is a dinosaur. It is an insufficient touch-base in managing a chronic condition.  We need more digitized touchpoints to help support health behavior change.” 15:30     Optimism for the future of digital care delivery due to opportunities for automation and customization. 16:30     Delivering a concierge-like experience to patients, a Virtual Primary Care solution can facilitate an even stronger relationship with a PCP and  dramatically improve care management. 17:45     The challenges of rural communities in accessing health care and the shortage of providers in both rural and urban areas. 19:00     Dr. Nelson shares a patient story of how virtual care delivery improved the health of a chronically ill patient. 21:00     Distinguishing between a technical problem and a complex adaptive problem in the primary care setting. 21:45     “Patient noncompliance is an indictment of how the healthcare system is not setup to deal with a complex adaptive problem. We seem to offer only technical solutions in the form of a treatment plan.” 22:45     The purity of the value-based care model in improving health outcomes and how to approach deployment of limited care intervention resources. 23:30     Value-based care reduces the logistical challenges of virtual primary care, whereby improving adherence to a customized care plan. 24:00     The healthcare system spends $32 billion annually on avoidable emergency room visits that could be treated by primary care physicians. 24:45     Emergency department visits for people with at least one chronic condition contribute to nearly 60 percent of all annual visits (over 4 million ED visits each year that are potentially preventable). 25:30     Dr. Nelson discusses how virtual primary care and urgent care models are effective ways to lower unnecessary emergency visits. 26:45     Helping patients navigate the healthcare system through emergency department follow-up programs and virtual primary care. 28:00     How Advocate Aurora utilized virtual engagement to manage patients safely at home when there were capacity constraints during the pandemic. 29:00     Results with the Spectrum Health automated ED follow-up visit program in lowering inpatient admissions and unnecessary costs. 30:15     2 out of 3 Medicare beneficiaries have 2 or more chronic conditions, and 1 in 3 patients living with 4 or more chronic conditions! 30:45     Chronic diseases are the leading cause of death and disability in the United States, accounting for seven in 10 deaths. 32:00     The opportunity costs in our society due to the high spending on ineffective care models for managing chronic disease. 33:00     Dr. Nelson explains the function of care management, how it is not reimbursement in FFS, and the variability in patient outcomes between different programs. 34:00     Taking advantage of what we know about patient behavior change to impact clinical outcomes. 35:00     The importance of the human relationship between patients and their care teams and how technology interventions can further enhance patient activation. 36:30     Dr. Nelson provides an overview of Remote Patient Monitoring (RPM) and its two forms (remote physiologic monitoring, remote person monitoring) 38:00     Telemedicine can do a lot to alleviate the relative misdistribution of providers and bring healthcare to rural areas of the country and areas that are less resourced. 39:00     14 million homes in urban settings and 4 million homes in rural communities lack broadband access (and 75% of them are people of color). 40:00     50 million adults experience mental illness (and 56% are not getting adequate treatment) 40:15     How Amwell is partnering with healthcare providers to ensure access to virtual care in underserved and rural communities. 41:30     “The emergency room is the worst place in the world for people with mental health issues – it actually exacerbates their condition.” 42:30     Telemedicine enablement in the behavioral health setting and how it empowers the workforce. 44:30     Between 2000 and 2019, the portion of beneficiaries seeing five or more physicians annually increased from 18 to 30%, and the mean annual number of specialist visits increased by 20%. 46:00     The shortage and poor distribution of specialists and how telehealth presents and opportunity to make specialty care more responsive to patient care needs. 48:00     Specialist access challenges for Medicaid patients and the lack of PCP/SCP coordination in the traditional “brick and mortar” care model. 49:00     Referencing the Penn State hybrid cardiac rehab program 50:45     The passage of H.R. 4040 (the Advancing Telehealth Beyond COVID-19 Act) to extend vital telehealth flexibilities enacted during the COVID-19 pandemic 51:30     “You can’t put the genie back in the bottle.  Telehealth is here to stay.” 52:00     The need for sound policy and the importance of leadership in hardwiring education in telehealth to drive clinical transformation. 52:00     Prior experiences where physicians have been burned by technology advancement and why we can’t repeat history in scaling tele-driven models of care. 53:30     Patients overwhelmingly want to preserve telemedicine in the healthcare industry. 55:00     As care becomes more virtualized and procedures shift more and more into the ambulatory setting, the “hospital of the future” will be asset-light. 56:00     Health systems often see telehealth as a major competitor—82% of health systems surveyed reported that telehealth companies like Teladoc or Amwell are competitors. 57:00     Dr. Nelson describes the opportunity for traditional healthcare systems and health plans to partner with virtual care enablers to improve care delivery. 57:45     Referencing the work of Barbara Starfield and how virtual care delivery can realize the potential of advanced primary care. 59:00     Supporting health systems with workflow adoption of telehealth and urgent care solutions. 60:00     Referencing the electronic intensive care (eICU) model at Advocate Aurora as an example of asset-light care delivery that improves sepsis management 62:00     Hospital-at-home care models as a future trend. 63:30     Telehealth can minimize hospital-acquired infections by keeping people out of the facility. 65:00     Dr. Nelson provides her parting thoughts on how value-based care will serve as a catalyst to drive digital transformation for the future of healthcare delivery in our country.

The Gambrell-Fowler family pose for a portrait. From left are Keith Gambrell, Gary Fowler, Cheryl Fowler, Troy Fowler, and Paris Fowler.                   Oprah Winfrey began her crusade to change the healthcare system when COVID-19 elevated our national awareness of health inequities in our country – a result of exacerbated health outcomes triggered by coronavirus infection across racial lines and the longstanding preexisting disparities that were already there. She launched The Color of Care education  campaign to prepare current and future doctors, nurses and medical professionals to play an active role in combating systemic racism in the delivery of healthcare, as well as provide others with the necessary tools to advocate for and empower patients who experience these inequities. The Color of Care movement for more equitable healthcare in America began when Oprah Winfrey was inspired to take action following the death of Gary Fowler. In this episode, we discuss the tragic and unnecessary death of Gary Fowler inflicted by a grossly negligent and racist healthcare system.  Multiple hospitals have the blood of Mr. Fowler on their hands; however, this is a story of hope in that his death started a national campaign for health equity. Oprah says the following about the death of Mr. Gary Fowler: “I read a story that haunted me…the story of the Fowler family. When Mr. Fowler became ill, three different hospitals turned him away. He went home, sat in his recliner, and died. I wondered how many different Gary Fowlers there are out there. What if I told you the biggest indicator of how long you are going to live is your zip code? What if access to lifesaving care for somebody that you love depended on the color of their skin? The COVID pandemic exposed a tragic divide in our healthcare system. We now need to stand up, and we need to do something about it. We need to change an entire system. This is something you start now! Together we can make it better.” The story of Gary Fowler’s death is the focal point of the recent documentary, The Color of Care that premiered on the Smithsonian Channel earlier this summer. From executive producer, Oprah Winfrey, this new documentary chronicles how people of color suffer from systemically substandard healthcare in the United States and how COVID-19 exposed the tragic consequences of this inequity.  The Color of Care documentary traces the origins of racial health disparities to practices that began during slavery in the U.S. and continue today. Using moving testimony from those who lost loved ones to COVID-19 and frontline medical workers in overwhelmed hospitals, it interweaves expert interviews and powerful data to expose the devastating toll of embedded racism in our healthcare system. The Color of Care is produced by Harpo Productions with executive producers Oprah Winfrey, Terry Wood, and Catherine Cyr. The film is directed by OSCAR®-nominated and Emmy® award-winning director Yance Ford and produced by Kate Bolger and Yance Ford. After listening to this podcast, I urge you to watch the Color of Care to understand how the system was built, why it doesn’t work for everyone, and how together we can make it better! This episode is sponsored by the American College of Lifestyle Medicine. How to get involved and learn more! Join the movement: https://www.thecolorofcare.org/ The Color of Care Documentary Trailer:  https://www.youtube.com/watch?v=AwgNH2XsbKU Special PSA from Oprah Winfrey:  https://www.youtube.com/watch?v=lD5Bpr5Qdco&t=30s Register to attend the Health Equity Virtual Summit hosted by the Institute for Advancing Health Value. We are screening The Color of Care on 11/30 and hosting a Health Equity Summit on 12/1! https://www.advancinghealthvalue.org/population-health-equity-the-north-star-for-value/ Click here to download the new Institute/ACLM Intelligence Brief on Lifestyle Medicine and Health Equity At the Smithsonian Museum for a screening of “The Color of Care” are (from left) Dr. Hetty Cunningham, associate professor of Pediatrics at Columbia University; Yance Ford, the Oscar-nominated, Emmy-winning filmmaker and director of the film; Dr. Ala Stanford, founder of the Black Doctors COVID-19 Consortium; and Keith Gambrell, who’s featured in the film during which he talks about his father who died from COVID-19 after being denied care. David Fowler, 76, died of coronavirus on April 6, 2020. His son, Gary Fowlier passed away only hours later.                       Episode Bookmarks: 01:30 The tragic and unnecessary death of Gary Fowler inflicted by a grossly negligent and racist healthcare system. 01:45 How the death of Gary Fowler inspired Oprah Winfrey to start the The Color of Care movement for more equitable healthcare in America. 02:30 “We now need to stand up, and we need to do something about it. We need to change an entire system. This is something you start now! Together we can make it better.” – (Oprah Winfrey Special PSA) 03:30 How do the murders of George Floyd, Breonna Taylor, and Ahmaud Arbery impact societal awakening for social justice and health equity? 04:00 The Color of Care documentary that traces the origins of racial health disparities to practices that began during slavery in the U.S. and continue today (watch trailer here) 05:00 Join the Color of Care movement as a Medical or Nursing Student, Medical Professional, or aDoctor or Nurse 05:30 Learn more about this week’s sponsor, The America College of Lifestyle Medicine and download the new Institute/ACLM Intelligence Brief on Lifestyle Medicine and Health Equity 06:30 Introduction to Keith Gambrell, the son of Gary Fowler 07:00 “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.”  — Martin Luther King, Jr. 07:30 Keith Gambrell tells the story of the death of his father, illustrating how systemic racism and anti-blackness are a public health crisis. 09:45 The hospital sends Gary Fowler home despite him being acutely ill from COVID-19. 10:00 “The doctors wrote him off and didn’t listen to him. The health system didn’t give him a fighting chance and failed my father. They sent him home to die.” 10:15 Keith’s grandfather passed away from COVID-19 just hours before the passing of his father. 11:30 “He shouldn’t have had to go to three different hospitals to seek treatment…and he didn’t even get treated after all of that.” 12:00 “Every hospital sent us a billed after my father died…for services they didn’t even render when they refused to treat him.” 12:30 The body of Gary Fowler resided in the home for over 10 hours after death from COVID-19. 13:00 Keith’s mother comes down with COVID-19 within a few hours after the death of her husband. 13:30 A patient with food poisoning from bad sushi was admitted to the hospital at the same time Keith’s mother was denied admission. 14:30 Keith is forced to take his mom to a second hospital (after his father dies from COVID-19 upon being denied treatment by three hospitals!) 15:45 Keith’s mother is sent home from the hospital after only two days. (She ends up developing pneumonia and blood clots post-discharge.) 17:00 “My dad would be here today if he wasn’t written off by the healthcare system.” 17:15 “Health equity is an issue that needs to be discussed in America. Why aren’t we receiving health care? We are equal human beings just like everyone else.” 18:30 “Our lives begin to end the day we become silent about things that matter.” – Martin Luther King, Jr. 19:30 Keith discusses his experience working with Oprah Winfrey and The Color of Care documentary. 20:30 Keith’s job now is to use his voice to advocate for health equity so we can eliminate racial disparities in our country. 21:00 Referencing Keith’s Op-Ed on the deaths of Floyd, Arbery, and Taylor and how there are 22:20 Keith discusses the parallels between the death of his father and racially-motivated killings. 23:30 “No one cares about us. The entire system needs to be overhauled.” 24:30 How COVID-19 raised awareness of health inequities in African American communities that have persisted for centuries. 26:00 “Doctors should listen more to patients. They should learn how to take into consideration what patients are telling them.” 27:30 Keith advocates for the need for medical schools to provide training in culturally competent care for minority populations. 28:00 Eric explains how value-based care is about health equity and relationship-based care. 29:00 Gary Fowler was never tested for COVID-19 – despite providers knowing that he had been exposed by close contact to his father who had tested positive, and was hospitalized! 30:30 Keith discusses the role that churches can play as a cornerstone for activism, resources, and community building to improve the health for communities of color. 31:30 Daniel explains the importance of culturally competent care in the provision of health equity. 33:00 “All people, regardless of color, should be treated equally when going to the hospital.  My dad was begging for his life and sent home with a piece of paper.” 34:00 The medical establishment has a long history of mistreating Black Americans — from gruesome experiments on enslaved people to forced sterilizations and the infamous Tuskegee syphilis study. 35:30 Keith provides perspective on what it will take for Black people to begin trusting the healthcare system. 37:00 The resilience of black communities in Detroit 38:00 “My family had to learn how to take something so negative and make it positive. Our pain can change the world.  It is time for a change in the healthcare system.” 38:45 Keith wears the ashes of his father and grandfather around his neck inside gold teddy bear pendants to remember their legacy. 39:00 Don’t be afraid to speak out. Watch The Color of Care documentary and get involved! 40:00 Keith shares personal stories about who his father and grandfather were and how their lives impacted him. 42:30 Parting thoughts from Keith on the need to change healthcare for the better. 43:00 The Color of Care education campaign is working to prepare current and future doctors, nurses, and medical professionals to play an active role in combating systemic racism in healthcare. 44:00 The Institute for Advancing Health Value is screening The Color of Care on 11/30 and hosting a Virtual Health Equity Summit on 12/1! Keith Gambrell of Detroit is seen in a window in the front of his house while on quarantine with COVID-19 symptoms in April 2020. Gambrell has had his life ravaged after losing his grandfather and stepfather to COVID-19 along with his mother being admitted to Henry Ford on a ventilator. Gary Fowler at his happiest – a man who care his family and lived his life in love for them.                       Oprah Winfrey was inspired by the death of Gary Fowler to develop the Color of Care documentary in hopes of exposing rampant racial inequities in our healthcare system.

For anyone following healthcare transformation in our country, you have undoubtedly heard about ChenMed – a family-owned, primary-care physician run organization that serves a challenging patient population under a full-risk global primary care reimbursement model. This is a high touch primary care company that has become the gold standard for how healthcare should be delivered in our country. In a prior episode of Race to Value, “Changing the World through a Full-Risk Value-Based Care Model”, Dr. Gordon Chen discussed how ChenMed is delivering transformative primary care – at scale – with superior health outcomes. It was one of our best podcast episodes ever, and we invited him back to talk about the Chen family calling to care for the underserved. This week’s episode is focused on his new book (co-written with his brother Dr. Christopher Chen) entitled, “The Calling: A Memoir of Family, Faith, and the Future of Healthcare” – an inspiration for living a purpose-driven life in the attainment of value-based care. The ChenMed success story of providing care to the most vulnerable among us is really a story about an American journey of a family guided by Faith and Love. The Calling tells the inspirational story of the Chen family, which over two generations not only completed the American Dream, but also transformed American medicine. This is a story about the life experiences that shaped two generations of innovative leaders in healthcare that made ChenMed the beacon for value-based care in our nation. Enter the book giveaway by signing up for our newsletter HERE.   Episode Bookmarks: 01:30 Introduction to ChenMed and Dr. Gordon Chen (referencing prior episode of Race to Value, “Changing the World through a Full-Risk Value-Based Care Model”) 02:30 “The Calling: A Memoir of Family, Faith, and the Future of Healthcare” – an inspiration for living a purpose-driven life in the attainment of value-based care. 04:30 Inspiration from John C. Maxwell and “The 5 Levels of Leadership” 06:45 Positional leadership is the current state of the majority of physicians in healthcare currently. 07:15 Leadership is influence – how Drs. Chris and Gordon Chen adapted their leadership to influence broad growth in others to achieve service excellence. 08:45 How Value-Based Care magnifies physician leadership 10:00 The Chens find meaning in their value-based care mission through their connection to Family and Faith 11:00 “There is no line separating our Family, our Faith, and our work at ChenMed.  It all blends together in a beautiful synergy.” 12:30 “Healthcare needs to be transformed, and you must start with those in greatest need.” 13:30 How the Chen Family transcended suffering during their journey to America, experiences with poverty and homelessness, and a false cancer scare 15:45 Finding the beauty in suffering through a faith-based perspective 17:00 “Struggle produces perseverance, perseverance leads to mature character, and mature character offers hope.” 18:00 The ancient wisdom of the Chinese saying —“One to grow, one to maintain, one to lose.” 20:00 Dr. Chen on the importance of living up to one’s God-given potential. 21:00 The Chris and Gordon Chen relationship —“Iron sharpens iron, and one man sharpens another.” 22:00 The business model for ChenMed as a high-touch, relationship-based, tech-enabled primary care practice. 23:00 The early work of Dr. James Chen as an early pioneer of value-based care. 25:00 How the early struggles and suffering of Dr. James Chen shaped the ChenMed focus on serving our most vulnerable. 27:00 What is the core essence of the ChenMed model and how does relationship-based care improve care outcomes? 28:00 An excerpt from a letter written by a ChenMed physician who had recently left the fee-for-service matrix 30:00 A Physician Culture that is “A.L.L. in”—Aligned with mission, vision, and values and has Learning agility and Learning humility. 30:30 How the open learning mindset of medical students changes once they enter into practice. 31:00 Hiring prospective physicians that are open to learning and have a drive to fix healthcare. 32:00 Creating a mission-driven physician culture based on learning agility and learning humility. 33:45 How experiential learning supports rapid growth and scale at ChenMed. 35:00 What can medical schools do differently to help students lead with more empathy and influence? 36:45 The Chen Family 7-part Mission Statement and how that is manifested in the ChenMed Mission to “honor seniors with affordable VIP care that delivers better health.” 38:30 “The ChenMed model only works if you have the right people, with the right culture and values.” 39:45 The impact of company culture on patient outcomes. 40:30 The need for more purpose-driven opportunities in America. 41:30 Building ChenMed as a “city on a hill” for healthcare and how their impact can change the world. 43:45 The industry of healthcare is moving in the wrong direction, but primary care is the main beacon of light shining in the darkness. 45:30 How the prioritization of a mission-focus will ultimately lead to margin. 46:00 Optimism for the future of healthcare. 47:00 “The goal of our book, “The Calling” is to inspire others to change the world…and we can.” 48:30 Dr. Gordon Chen provides his thoughts on the future of Medicare Advantage and how MA provides an opportunity for PCP leadership. 49:45 Dr. Chen’s perspective on the new ACO REACH payment model. 51:30 Parting thoughts from Dr. Chen and his new book “The Calling: A Memoir of Family, Faith, and the Future of Healthcare”

If you are looking for the most egregious profiteering and fleecing of American consumers of healthcare, there is no better example than that of the giant industry of middlemen called pharmacy benefit managers – PBMs for short – that are systematically gouging American businesses.  Most people are familiar with the few bad actors in the pharmaceutical industry.  For example, we think of the infamous “pharma bro” Martin Shkrelli that jacked up the price of his company’s drugs – and then smirked his way through subsequent court proceedings.  However, the inner workings of the drug pricing game fostered by the non-transparent PBM industry is actually a far worse scenario that it is million times bigger – and more expensive – than the games of the pharma bad actors.  PBMs who collectively manage pharmacy benefits for 266 million Americans, routinely fleece American businesses using clever shell games that are the absolute antithesis of Value-Based Care. But there is good news…there is an upstart PBM – Capital Rx – that provides a more transparent, sustainable, consumer-centric, and ethical model in the administration of pharmacy benefits. Joining us this week is A.J. Loiacono, the CEO and co-founder of Capital Rx.  A.J.’s company is the fastest-growing healthcare company in the country, serving more than one million lives across its customer base of payor entities, employers, unions, health systems, and municipalities. It grew by 400% in 2020 and doubled in size in 2021.  Capital Rx are the “good guys” in the PBM industry – they offer a pharmacy benefits spending platform that links providers, patients, pharmacies and plans to bring cost-effective care to employers and their workforce. On average, Capital Rx saves its clients 27% on drug costs, mainly by refusing to use the industry standard model for drug costs: average wholesale price. As a result, Capital Rx has achieved a 96 NPS score, compared to the industry average of 14 in healthcare. A.J. is a visionary leader in the health value movement and was recently named an Entrepreneur Of The Year® 2022 New York Award finalist by Ernst & Young. Under A.J.’s leadership, Capital Rx is modernizing our healthcare infrastructure to reduce costs and deliver superior care, and they have the highest satisfaction scores in the industry. In this episode, A.J. provides you with an unfiltered perspective on our need to reimaging pharmacy benefits in our country. Episode Bookmarks: 01:30 Pharmacy Benefit Managers (PBMs) – the traditional PBM model is an egregious example of healthcare profiteering and consumer fleecing 02:00 The drug pricing game and non-transparent PBM industry has a far worse negative impact on society than “bad acting” in Big Pharma 02:30 Introduction to A.J. Loiacono and Capital Rx (the “good guys” in the PBM industry) 04:30 Prescription drugs are the fastest growing healthcare expenditure and consistently outpace other health spending. 05:30 Some employers devoting >30% of their health plans’ total cost of care on pharma! 06:00 Half of patients with chronic conditions take their medications as prescribed due to high drug costs. 07:45 The slow compounding effect of incremental drug price increases year over year 08:00 The higher base of drug prices in the US (compared to other nations) and how R&D is recouped by fleecing American consumers 08:30 The opaque and inefficient PBM industry as another reason for escalating prescription drug costs 09:00 Consultant and broker compensation models are misaligned with goals of cost containment. 09:30 The three largest PBMs (CVS Caremark, Express Scripts, and OptumRx) manage 80% of all prescriptions and provide no transparency. 10:00 PBMs are making sick profits from rebates and “the billing spread” 11:00 A.J. provides a comprehensive explanation of what a PBM really does and why they are more than just middlemen 13:30 “PBMs are a problem because of the non-transparent pricing model they use – not because of the invaluable services that they provide.” 14:00 “There has been a lack of regulatory oversight in the PBM industry for 25 years. That is why pharmacy benefits have exploded in cost.” 15:00 “The inelastic demand curve, price inflation, and high margin specialty drugs have created a PBM market that values consolidation over innovation.” 16:30 PBM oligopolies control 80-90% of the market and have no incentives to improve (main focus is maximization of economics) 17:30 The transparent, fixed-price model at Capital Rx and how that differs from a spread pricing model that serves to only maximize PBM margin 19:30 “The PBM game of complexity and opacity creates an optic that payers are saving money when they really aren’t.” 21:30 The current FTC probe (focused on how PBM vertical integration and lack of transparency affects access and pricing) and rebate disclosure requirements 22:30 “You shouldn’t be able to mark up a prescription if you are an administrator of benefits. It should be illegal because of the conflict of interest.” 24:00 The CAA Prescription Drug Benefit Reporting Requirement for group health plans and health insurers to submit information related to prescription drug costs 25:15 Specialty drugs are projected to be a whopping 40-50% of prescription drug costs but only 2% of the transactions. 26:00 Hospitals are marking up infused specialty drugs for cancer up to 2-6X the acquisition cost! 26:30 A.J. provides the context why specialty drugs are so expensive in the United States. 28:00 The massive conflict of interest that occurs in traditional PBMs providing Prior Authorizations 29:15 Typical PBMs have >90% approval rate (Capital Rx has a ~64% approval rate and has the highest NPS in the industry!) 30:00 “Patients want prompt attention, information, communication, and reasonable timeframes.” 30:30 Drug pricing based on NADAC benchmark (versus AWP) and how Capital Rx is disrupting the PBM market 31:45 NADAC-based pricing reduces prescription drug with deflation rate >50% 32:30 Manufacturer-derived revenue for PBMs on specialty drugs in the form of rebates 33:00 Why don’t we have negative cost trend if generic drugs deflate 10-15% each year and branded specialty drugs net prices are going down? (Hint: PBM Opacity) 34:30 PBMs can’t change to a transparent business model because of earnings expectations of a publicly-traded company. 36:00 Vertical and horizontal consolidation of pharmacies and how there are 3X as many pharmacies as there are Starbucks and McDonalds combined! 37:30 “We have the right number of pharmacies in this country but not the right number in the right locations.” 38:00 The challenges of accessing medications in rural communities 39:00 Consolidation of retail pharmacies are inconsequential when compared to consolidation of mail and specialty facilities of Big 3 PBMs. 40:30 Capital Rx is the only PBM with a fully transparent pricing structure with no pricing variability between customers and patients. 41:45 Very few pharmacies publicly report their NADAC data. 43:00 The inconsistent pricing seen when the federal government when buys drugs, as seen by pricing variation of 150% between various public program. 43:30 Unencumbered pricing occurs when PBMs don’t make money on fulfillment, and they can’t manipulate prices. 45:00 A.J. provides insights on the Prescription Drug and Health Care Spending Transparency Rule of the No Surprises Act. 46:30 What does the federal government plan to do with data reported to create a more equitable drug system? 48:30 A.J. explains how innovative PBMs like Capital Rx can get closer to the premium dollar by becoming risk-bearing entities that take on full PMPM risk. 51:45 Innovation gets shut down when incumbent PBMs refuse to bid to self-insured employers in a way that aligns financial risk. 52:45 Capital Rx saves an average of 27% on drug costs and has an industry-leading net promoter score of 92 (far outpaces the healthcare industry average of 15). 53:15 Financial alignment and customer-centric efficiency is why Capital Rx has such a high NPS. 55:00 1st Call Resolution at Capital Rx call center is 90%. 55:45 The technology stack at Capital Rx (JUDITM) that unifies all PBM operations on to a single platform 56:45 What is A.J. most proud of accomplishing at Capital Rx? 58:15 The move to precision medicine (e.g. individualized drug formularies) in the future of pharmacy benefits 60:00 America and New Zealand are the only countries that allow direct-to-consumer advertising of pharmaceuticals. 61:00 A.J. critiques the advertising tactics of pharma manufacturers. 63:00 Parting thoughts from A.J. on the role of an aligned PBM model in value-based care

Creating a value-based healthcare ecosystem with the highest quality outcomes at a reasonable cost for employers and their healthcare consumers requires collaboration. In the state of Connecticut, a grassroots community has formed with the mission to create a value-based healthcare ecosystem.  The Moving to Value Alliance is a multi-stakeholder community composed of individuals, practices, and organizations deeply rooted in Connecticut’s healthcare environment.  They believe that collaboration is the key to solving complex problems and are leading the way to transform healthcare delivery in their state. Joining us this week are two leaders involved in this important movement to employer-based healthcare transformation in Connecticut. With more than 35 years in the health care sector, Jeff Hogan is a consultant to payers and large provider groups for product development and launch and a resource to employers desirous of implementing strategies to manage their health spend. Lisa Trumble is the President and CEO of the Southern New England Healthcare Organization (SoNE HEALTH), a clinically integrated network comprised of six hospitals and 1,700 physicians, which is a for-profit entity owned jointly by Trinity Health Of New England and its employed and independent physicians.  In this episode, we talk about healthcare transformation in the state of Connecticut, vertical and horizontal consolidation in the industry, the dysfunctional health benefits market, the need for employer alliances, leading innovators in the marketplace, value-based insurance design, prescription drug costs, healthcare consumerism, and bundled payment innovation. The time to move to value is now!  We can create a transformed healthcare ecosystem through industry collaboration.  Thank you, Lisa and Jeff, for showing us the way. Episode Bookmarks: 01:30 “Collaboration is the key to solving complex problems.” 01:45 The Moving to Value Alliance – a multi-stakeholder grassroots community creating a value-based healthcare ecosystem for employers in Connecticut 02:00 Introduction to Jeffrey Hogan and Lisa Trumble 03:45 Eric reflects on his recent experience attending the MTVA 2022 Symposium 05:00 The leadership of Dr. Stephen Shutzer and other leaders 06:00 Referencing Michael Leavitt’s book, “Finding Allies, Building Alliances” where he talks about the power of collaboration networks 06:20 “Connecticut is known for being ground zero for most of the BUCA health plans and has also been the land of frozen molasses in value-based care.” 07:00 “Healthcare is opaque and balkanized, and COVID has inspired the opportunity to think about things differently.” 07:30 Transparency, Collaboration, Innovation, Consumer Expectations, and the “Great Resignation” 08:30 Lisa shares her background in value-based care transformation in Massachusetts and how that differs from Connecticut 09:30 “We must break away from the traditional structures of fee-for-service, and pursue clinical integration, innovation, alliances, and partnerships.” 10:00 A new wave of horizontal and vertical consolidation between hospitals and physician practices 12:00 The inevitability of consolidation after the pandemic and how consolidations have not resulted in cost and quality improvements. 12:30 The lack of value-based transformation strategy in health systems and why that is short-sighted 13:00 “The pandemic opened up the doors to innovation in a way that none of us anticipated in every sector of healthcare.” 13:40 Concerns about vertical integration of providers in consolidated payer-led structures 14:20 Lisa shares background on SoNE HEALTH (Southern New England Healthcare Organization) and how they partner with physicians. 15:20 Jeff describes how he has never seen so much change in healthcare in such a short period of time. 16:00 The movement to health equity as a result of consumer pressures, innovation, and market trends. 17:00 The hybridization of health systems, balancing in-person care with digital therapeutics, virtual care, home-based care, and other tech-enabled innovations. 17:30 Recent announcement from Mass General Hospital that they are doubling down on hospital at home care investments. 18:30 State of Connecticut employees have moved to value-based care models. 19:00 Variation in cost and quality data across hospitals across the US (referencing RAND study) and how consolidation leads to higher costs/lower quality 20:00 Commercial insurance costs have gone up 4X the rate of other benchmark goods and services! 21:00 Lisa describes the fallacy of the “free market” in employer-purchased healthcare and how it contributes to high costs and health disparities. 22:00 “If we truly believe in health equity, we need to look at our insurance market with employers.” 23:00 Direct-to-employer solutions in healthcare where providers and employers can drive value-based transformation. 24:00 Pay increases to employees occur when healthcare costs are lowered. 24:30 Jeff discusses the challenges with employer brokers and advisors due to their compensation model that favors more expensive healthcare. 26:30 Public disclosure of compensation with benefits brokers and risk-sharing arrangements between them and employers. 27:00 Health Rosetta as an example of a transparent Benefits Advisor Program (see Race to Value episode with Dave Chase) 27:15 “The employer needs a truth source and agent that is on their side when purchasing benefits. That role has yet to be revealed in the marketplace.” 28:00 Coupling direct-to-employer contracting with benefits transparency 29:00 $1 billion in employer spend on healthcare in Connecticut 29:30 “Connecticut is dead last in primary care investment in the country.” (referencing PCC study) 31:00 “Legislators don’t understand the relationship between cost and quality in the provider supply chain.” 31:45 Bright Spots for Value in the State of Connecticut (e.g. SoNE, Optum) 32:30 Collaboration with Advanced Primary Care companies (e.g. Vera Whole Health) 33:00 Lisa provides her observations on the private equity landscape in Advanced Primary Care. 34:30 Virtual care can improve health equity as an extension of primary care. 35:00 How Lisa’s health system is partnering with advanced primary care groups in the marketplace. 35:45 The challenges of implementing virtual care capabilities in a health system. 36:30 Local partnerships in the marketplace are needed for long-term sustainability. 38:00 How are self-insured and fully insured employers coming together to build a Value Based Insurance Design (V-BID) consortium to address benefit design? 39:00 The leadership of Dr. Mark Fendrick in V-BID 40:00 Difficulties of employers and payers understanding value-based insurance design 41:00 Some Connecticut employer-sponsored health plans have annual premiums >$40,000 per family! 42:00 V-BID failed because there was not any “skin in the game.” 43:00 Variations in quality measurements for diabetes create variations in patient outcomes. 44:00 V-BID can only work with normalized quality measurement. 45:00 Lisa expresses her frustration with providers getting blamed for not moving to VBP when other system reforms are ignored. 46:00 For many employers, prescription drug spending can be as high as 30% or more! 47:00 Jeff discusses how Pharmacy has the highest trend factor of any other medical cost category 48:00 >50% of specialty pharmacy is on the medical side and doesn’t go through PBMs 48:30 Referencing the transparent PBM model of Capital Rx that uses deflationary fixed-pricing based on NADAC 49:30 CAA reporting requirements of PBMs will accelerate the business case for transparent PBMs 50:00 Site of service challenges in managing specialty pharmacy costs 51:00 How complexities of pharmacy reimbursement and variations in drug efficacy prevent real understanding of how to reform it 53:00 The rearchitecting of healthcare will need to be based on consumerism and digital transformation 54:30 How do you measure digital transformation? 55:30 Hospitals are seeing declines in patient volumes and why care needs to patient homes and communities. 57:00 The value of innovation and how it will drive care delivery transformation 58:00 Cancer is either #1 or #2 cost category for employers and ~73% of those diagnosed never get a second opinion! 59:00 Democratizing patient access to clinical care trials for treatment of cancer 60:00 The general distrust in government will necessitate that health transformation be driven at the local level. 61:00 Self-insured bundled payment programs being modeled after the CMS Bundled Payment for Care Improvement (BPCI) program 62:30 Lisa provides a comprehensive overview of Bundled Payment innovation for employers 64:30 Chronic care bundles do not have the same effect as surgical procedure bundles 65:45 Jeff on how employers choosing the right bundle can prevent them from hitting their stoploss corridor 67:00 Signify Health is getting out of Medicare and Commercial bundles. Carrum Health and Accarent Health are now leading in the employer bundled payment space. 68:20 Wildflower Health is managing maternity bundles 69:00 Lisa explains difficulties in administering bundled payments between providers and payers. 71:00 Parting thoughts (Lisa) – collaboration and community is the only way towards value and equity 72:00 Parting thoughts (Jeff) – the percent of GDP spent on healthcare will rob the future of our grandchildren if we do not align incentives and democratize access to primary care.

The need to strengthen and empower primary care, like the drive towards health equity, is one of the great causes célèbre of American healthcare. As David Blumenthal and Lovisa Gustafsson recently wrote in the Harvard Business Review: “America’s health care system seems, paradoxically, both endlessly innovative and profoundly dysfunctional. On the one hand, we hear almost daily about flashy new ventures like, most recently, Amazon’s recent purchase of One Medical, a large provider of primary care, that promise transformative improvements in health care efficiency, quality, and service. On the other hand, the day-to-day performance of the U.S. health care system is an international embarrassment. The United States spends twice as much as any other high-income country on health services while its maternal mortality, infant mortality, preventable mortality, overdose deaths, levels of chronic illness, levels of obesity, and deaths from Covid-19 put it at the bottom of the pack in the developed world. The American public is awash in personal medical debt, and even the best-connected struggle to find a primary care physician.” In this week’s episode of the Race to Value, we are going to highlight the plight of primary care in the US and share real-time updates of what is actually happening in the marketplace. This important dialogue will help us understand how to improve the role, standing, supply and compensation of primary care practitioners in the US.  Joining us the week is Don Crane, Former President and CEO of America’s Physicians Groups. Don recently served as the Co-Chair of the National Primary Care Transformation Summit that occurred on July 25-29th, and we will be discussing with him the key insights from this important meeting. This was an event that the Institute for Advancing Health Value proudly sponsored, along with other key groups such as the Commonwealth Fund, Heritage Provider Network, Upstream, PCORI, Equality Health, Signify Health, and other important organizations leading in the value movement.  This event was made possible by our mutual friend Peter Grant, and Don served as a co-chair along with other healthcare luminaries Francois de Brantes, Dr. Clive Fields, Anne Greiner, Shawn Martin, and Elizabeth Mitchell.   Episode Bookmarks: 01:30 The need to strengthen and empower primary care, like the drive towards health equity, is one of the great causes célèbre of American healthcare. 02:00 “The American public is awash in personal medical debt, and even the best-connected struggle to find a primary care physician.”  (Amazon’s Foray into Primary Care Won’t be Easy) 03:00 Introduction to Don Crane, Former President and CEO of America’s Physicians Groups and the recent National Primary Care Transformation Summit 04:00 The PCT Summit had over 4,800 registrants, with 33 mini-summits, 26 plenary sessions and 150 faculty that were a veritable Who’s Who in American Healthcare! 05:00 “Staying the same is the first step to getting worse.  We must change the way we do Primary Care, and the crazy ideas of today will be the genesis of breakthroughs tomorrow.”  – Dr. Richard Merkin 05:30 Primary care is that no longer in the backwaters of medicine; it is now being seen as the backbone of the value movement. 06:30 Types of Primary Care: Suboptimal, Fragmented PPO Model vs. Optimal, Integrated HMO/Capitated Model 07:00 Reflections from Dr. Christopher Chen on the need for Primary Care Transformation 08:00 Primary Care Demand-Side: 96% of Medicare spend relates to individuals with multiple chronic diseases. 09:00 The need for coordination processes in primary care to improving quality and moderating costs. 09:30 Care Variation and Waste: 35% of healthcare is related to unnecessary, avoidable care that is wasteful. 10:00 The Improvement of Health as the Ultimate Goal: Better, Personal, Whole-Person Care to Prevent and Predict Disease to Reduce System Demand 11:00 Primary Care Bright Spots:  SCAN’s Healthcare in Action, ChenMed, Oak Street, Iora, Privia, and agilon, CVS Aetna, VillageMD and Walgreens, Everside Health, Crossover, ConcertoCare, Geisinger at Home, etc. 12:30 Since capitation has been around so long, why has it taken so long to achieve high scale, consumer-centric, primary care innovation? 13:30 “The world has woken up and learned that Primary Care is the tool to eliminate waste. And when you eliminate waste, every dollar saved goes straight to the bottom line as profit.” 14:30 “Primary care capital investment is a social good when it funds the proliferation of a value-based system.” 16:00 Amazon Acquisition of One Medical:  “Amazon is the lurking megalodon, its 11-foot jaws and 7-inch teeth the largest in history. With the acquisition of One Medical, Amazon is no longer circling … but attacking.” (Prime Health) 18:30 “Our wounded healthcare system is an embarrassment to the rest of the world and is bankrupting the United States of America.” 19:30 Don shares insights from the PCT Summit session he moderated with Susan Dentzer and Francois DeBrantes about the Amazon acquisition of One Medical. 20:00 Does Amazon know precisely what steps it will take in the OneMedical/Iora deal? 20:30 Addressing lack of primary care access and absence of convenience with a digital front door 22:00 Leveraging full-risk global primary care reimbursement in long-term transformation 23:30 Liz Fowler (CMMI Director): “While there might be fewer payment models, they will move towards total cost of care approaches that will require a focus on advanced primary care and ACOs.” 25:00 Don provides perspective on the goal of CMMI to have every Medicare beneficiary in an accountable care relationship by 2030. 26:00 “Let’s bring value to Medicare Advantage. Only 14-15% of MA is truly capitated to physician groups downstream. True prospective, population-based payment in MA is really a rarity.” 28:00 “Traditional Medicare is critically screwed up since it is so predominantly based on fee-for-service. ACO REACH is the gold standard of what we want.” 29:45 Are we moving too slow in the transformation of American healthcare? 30:30 PCPs are underpaid and underappreciated a very long time because of money, and this has been a huge mistake in our system. 31:30 PCPs can’t effectuate long-term changes in patient health status that amounts to savings at the system-level, with short-term capitation contracts. 32:30 Don shares his perspective on the underpayment of primary care and why fixing this is the lever to transform the American healthcare system. 33:45 “The best primary care groups in the country (e.g. Kaiser Permanente, WellMed, ChenMed) are not getting 1/3rd of what specialists are earning.” 34:45 Don speaks about the need for multi-payer alignment to reach a critical mass of primary care capitation in the marketplace. 37:00 Estimated PE deal values for healthcare services doubled from 2016 to 2021, going up to $77.5B. Within primary care specifically, in the last ten years, total deals have increased from $15M to $15B! 37:45 One in five physician transactions involved primary care practices—a signal that investors are banking on profits to be made in the shift to value-based care models. 39:00 Balancing PE investor exit expectations and the creation of the right incentives – with needed marketplace regulations — to create socially good primary care investments. 41:30 The employer-sponsored health insurance marketplace covers 157 million Americans and is dysfunctional and ineffective in producing value in health. 42:15 Dr. Ezekiel Emmanuel advocating for the government to work with self-funded employers and insurance carriers to bring about universal change. 43:00 “Self-insured employers of Americans are really grabbing the reins and helping drive the transformation that is necessary.” 44:00 Employers blaming ASOs and fully-insured health plans for not controlling the costs of healthcare. 45:30 The challenges of moving geographically dispersed employees into an evolved primary care model. 46:00 The cultural hierarchy in medicine where PCPs are at the very bottom of the caste system – how does this contribute to PCP burnout? 47:30 “Fee-for-service models are much worse for physician burnout than prospectively paid, population-based models.” 49:00 The work of Barbara Starfield showing that primary care helps prevent illness and death, where increased supply is associated with better population health and more equitable outcomes. 50:30 The business case for increased funding of primary care and the need to address Social Determinants of Health (comparisons to European investments in social services) 52:30 Marrying medical care with social care – the solution to a more effective and equitable healthcare system!