Relentless Health Value

Robert Pearl, MD discusses the balance between art and science in medicine, the importance of evidence-based medicine and patient preferences, the shift in perspectives from individual accomplishments to team outcomes in medicine, and the challenges and cultural problems in healthcare.

Larry Bauer, healthcare industry innovator, discusses the societal perception of doctors as knights, knaves, or pawns. The podcast explores the implications of these classifications, the negative impact of a few doctors on the profession, and the importance of organizational decision making. It also addresses the contrasting perceptions of physicians as caring or solely motivated by money, the lack of coordination in healthcare, and the benefits of involving policymakers in physician practices.

Understanding Actuarial Risk Horizons in Healthcare with Keith Passwater and J.R. Clark To read the full article and show notes with links mentioned, click here. In this episode, Stacey Richter speaks with Keith Passwater and J.R. Clark, healthcare entrepreneurs and executives, about the importance of actuarial risk horizons in improving patient outcomes. They discuss how different risk horizons impact healthcare costs, benefit designs, and plan strategies. Keith and JR explain the key differences in risk management between short-term and long-term healthcare plans, such as individual exchanges and employer group insurance, and emphasize the significance of including the patient as a stakeholder in actuarial models. The episode highlights the complexities and challenges faced by actuaries in the healthcare system and the potential benefits of innovative, patient-focused actuarial practices. Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe. 02:39 Why is it a problem for actuaries to ignore the patient as stakeholders in benefit design plans? 04:37 What is a risk horizon for actuaries? 05:38 “What’s the time interval over which we hope to impact healthcare costs?” 07:25 What is a risky investment from an actuary’s point of view? 08:05 How do you keep premiums down when the time horizon is short in an actuary’s point of view? 10:31 How do actuaries assess risk horizons or health insurance, and why do they choose those risk horizons? 14:05 What options are on the table when the risk horizon is longer? 16:06 How does the length of risk horizon affect benefit design?

Lauren Vela, back on the pod, shares insights about benefit design employees may not explicitly ask for. Market research reveals employees don't read their benefits info, are unhappy, and value choice over managed care. Anticipating customer needs, like Steve Jobs, leads to true innovation. Other chapters discuss the lack of comprehensive primary care experiences, the benefits of integrated care, and the importance of employee engagement.

This summer short is about the dynamic between payers and providers. An opening point that Jacob Asher, MD, my guest in this healthcare podcast, makes in the interview that follows is that, for a payer, it’s super hard to competitively differentiate from both a cost and/or a quality perspective when you and all of your payer competition use the exact same PPO (preferred provider organization) networks. I mean, what? Are these same exact doctors gonna somehow do a better job with your members than with the rest of their patients? This is even more true if you think about this from a physician or a practice point of view. Will clinical teams in their clinical workflow figure out who your members are, first of all, which is a thing, and then switch up what they choose to do for your members that is special? Even theoretically, that sounds like an executional fandango, which is exacerbated in markets with lots of payers. I guess I am not shocked when I hear stories like Dr. Asher was talking about: Doctor sits down at desk after a long day and sees 27 “Dear Doctor” letters from all of the payers in his or her payer mix. “Hey, Doc. Let me tell you about our amazing new thing.” And Doc’s like, “Pajama time awaits.” And—boom!—the letters, unopened, right in the recycle bin. From a payer’s standpoint, back to square one, I guess. Now, I will chuck in the mix here—and this has nothing to do with the conversation with Dr. Asher that follows—but one thing I’ve spent my entire career doing is helping organizations set up programs to collaborate with other organizations. If I authentically solve an actual, authentic, prioritized problem, I usually can find many people who seem pretty pleased to work with me. Now, is this easy to do? No. It takes strategic thinking and executional competence and/or grit to see it through. You really have to understand and account for vested interests and all the weird perverse incentives. Personally, I gotta work with a whole team of others coming at this from all different directions to untie this Gordian knot. But anyone who really wants to or needs to reach across the aisle and engage with other stakeholders or customers, even in any sort of systemic way, it’s just not possible to phone it in. Anyway, I just want everyone to succeed in working together. It is impossible to have a longitudinal patient journey if everybody is all up in their own silos fragmenting care.   You can learn more by connecting with Dr. Asher on LinkedIn.   Jacob Asher, MD, completed a residency in otolaryngology–head and neck surgery at the University of California, San Francisco, after receiving degrees from Brown University and the Boston University School of Medicine. Dr. Asher then practiced as an ENT (ear, nose, and throat) surgeon with Kaiser Permanente in Northern California and also served on the board of directors of The Permanente Medical Group, where he focused on physician compensation reform, member satisfaction initiatives, and retirement benefits. After transitioning to full-time health plan management, Dr. Asher served as a California commercial market medical director between 2008 and 2022 for Anthem Blue Cross, Cigna, and UnitedHealthcare. In those roles, he supported membership growth and retention in both fully insured and self-funded product lines and promoted value-based reimbursement, including capitation. He has led utilization management teams, collaborated with internal and external population healthcare advocates, and worked to develop clinical initiatives that sought to achieve the Triple Aim. In his role as the clinical face of the health plan to the local market, he worked with network colleagues on accountable care organization partnerships and hospital and physician contract renewals with integrated pay for performance, supported Obamacare exchange participation, engaged in quality improvement collaboratives, and supported regulatory compliance efforts. Currently, Dr. Asher is serving as a mentor for the Stanford Master in Medical Informatics program while exploring innovative solutions to healthcare delivery.   03:38 Why providers contracted with multiple health plans don’t have a financial incentive to do something unique with one payer over another. 04:01 Why it doesn’t make sense for providers to offer unique pathways for different payer organizations. 05:23 Why, broadly speaking, standards of care between payer policies aren’t really differentiators in clinical practice. 06:47 Why financial incentives might not be aligned to make providers want to standardize their care. 09:16 What improvement has there been in plans making providers more aware of the benefits they offer? 11:47 Why won’t providers off-load their pop health?   You can learn more by connecting with Dr. Asher on LinkedIn.   @JacobAsher18 discusses #payers and #providers on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest’s name for their latest RHV episode! Eric Gallagher (Summer Shorts 4), Dan Serrano, Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg  

Here’s a quote from Rolling Stone magazine: “A supergroup is a very fragile thing. Rock bands are always about balancing huge egos, but when those egos are oversized from the get-go it can lead to huge problems. That’s why supergroups like Blind Faith often fail to go beyond a single album, and why long-lasting ones like CSNY had drama that never seemed to end.” Hmmm … that’s apropos because, turns out, super ACOs (accountable care organizations) may have some similar issues. A super ACO means multiple ACOs or CINs (clinically integrated networks) which are each comprised of multiple practices or provider organizations, and it’s all under different ownership. Said another way, there are multiple levels of competitors—frenemies, if you will—trying to work together or not work together as the case may be. There’s a lot of infrastructure complexity and process complexity and, frankly, inefficiency. There’s trust issues. There’s the problem that rule #1 of change management is to create “quick wins” so that everyone can smell potential success and realize it’s possible, so momentum happens. But if doing anything is hyper-complicated, then it’s really tough to have a quick win. Today in this summer short, this is what I am chatting about with Eric Gallagher. We talk about how Ochsner evolved from a super ACO or super CIN into its current form. This summer short is a 13-minute clip that went a little far afield from the main topic of episode 405, which was the full episode with Eric Gallagher, and therefore, I cut it. But as I always do when I cut an actually pretty great section from a show for reasons of time, I have been on the edge of my seat to share it with you. This show is actually a very nice follow-on to the one with Dan Serrano (EP410) from last week. As Eric describes Ochsner’s history and its path forward, it is a case study of some of the recommendations that Dan mentioned. This summer short also really echoes some of the themes in episode 409, which was the one with Larry Bauer, and also one upcoming with Jodilyn Owen. What will work in one local market, don’t count on it working elsewhere—or not work as well at a minimum. Healthcare is local. This is a lesson many investors and entrepreneurs looking for rapid scaling prototypes have learned the hard way, and listening to Eric, it’s really easy to catch the why for that. If this topic intrigues you, also listen to the show with Dr. Amy Scanlan (EP402). Also episode 349 with Lisa Trumble. And lastly, I would recommend the show with David Carmouche, MD (EP343). Dr. Carmouche was talking about Ochsner’s work improving patient outcomes with a Medicare Advantage plan. One final note/point to ponder: scale. To really get value-based contracts, you need it. You need it to afford the infrastructure, and you need it to demand a seat at the table. But yeah with that … everything in moderation, I guess, because any scale that starts to approach monopoly proportions seems to invite bad behavior. You have to get big enough to matter in the market but not so big that your big footprint squashes market dynamics, because it seems like many succumb to the siren song at that point of putting profits over patients.   You can learn more at Ochsner Health Network.   Eric Gallagher, chief executive officer for Ochsner Health Network (OHN), is responsible for directing network and population health strategy and operations, including oversight of performance management operations, population health and care management programs, value-based analytics, OHN network development and administration, strategic program management, and marketing and communications. Prior to joining Ochsner in 2016, Eric held leadership positions in healthcare strategy and execution—including roles at Accenture, Tulane University Health System, and Vanderbilt University and Medical Center. A New Orleans native, Eric earned a bachelor’s degree in human and organizational development from Vanderbilt University and an MBA from Tulane University.   04:23 How Ochsner Health went from a super ACO to their current value-based care model. 06:09 What signs did Ochsner Health see that helped them recognize that the clinically integrated networks they were building wouldn’t help them achieve the outcomes goals they were aiming for? 07:42 Why Ochsner Health’s story is a classic example of change management. 08:41 What tough decision did Ochsner Health have to make that’s ultimately led to much higher success rates? 10:46 “Really … it’s about changing the economic model.” 11:03 Why was CMS a driver of change? 13:00 What’s the more sustainable business model in Ochsner Health’s market? 15:09 How has Ochsner Health been ahead of the game in the healthcare market?   You can learn more at Ochsner Health Network.   Eric Gallagher of @OchsnerHealth discusses #valuebasedcare and #superACOs on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest’s name for their latest RHV episode! Dan Serrano, Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela  

In this healthcare podcast, I am talking with Dan Serrano; and we’re talking about payer/provider collaboration—blocking and tackling, I’m gonna say—from primarily a financial and revenue point of view. I’d classify this as, say, a 201-level discussion (ie, not entry level, but it’s also not super deep in the weeds). We mainly cover the ins and outs of why a provider organization should probably be looking to get paid to better take care of patients with chronic disease and drive better patient outcomes at lower downstream costs and, to some degree, also why payers should be helping provider organizations in their local communities to do so by providing some help and shelter on the journey from here to a capitated payment. The focus today is really, I’d have to say, on the messy middle, where a provider organization does not have capitated contracts nor access to any premium dollars, which, by all accounts, is the holy grail here. The premium is where it’s at, and provider organizations might want to be aiming to get a piece of that action. The why for this “get the premium dollar” prime directive is pretty self-evident when you look at the big bucks rolling around in the coffers of those who are collecting said premium dollars. So, this “get the premium” endgame is, for sure, a big piece of the why—why, if I am a provider organization, I might want to take the time and energy and spend the money to embark on a path that might lead me to be able to get compensated for the stuff that patients really want and need to do better, which includes all of the things that I spoke about with Eric Gallagher in episode 405. Also, Vivek Garg, MD, MBA, in episode 407 and Amy Scanlan, MD, in episode 402. Spoiler alert: It’s not easy. Now, I asked Dan Serrano, as aforementioned my guest today, to offer up his advice here in the context of CKD (chronic kidney disease) patients. Why did I ask Dan to use the CKD case study, as a touchstone? Well, first of all, talking about this topic in totally theoretical terms is not ideal. We need an actual example for a lot of this to kind of make sense, combined with the first step for most outcomes improvement programs, which is to study your data and pick a patient population to focus on where the data suggests that you can have a big impact. And speaking of impact, did you know that an underlying reason why heart failure patients get hospitalized and rehospitalized is because of underlying CKD? So, impact in the short term and longer term, which I’ll get to in a sec. Another reason is—and I’m quoting John Rodis, MD, MBA, here, who is the independent medical director of QC-Health®—Dr. Rodis said the other day, “I sure as heck hope I don’t get CKD, because if I do, chances are I’m not going to be diagnosed. And even if I am diagnosed, I won’t be treated properly.” So, there’s that. And I can see why he’s saying that. Two out of five patients with ESRD (end-stage renal disease) don’t even know they have kidney disease at all. And the number of patients with progressing CKD on any kind of evidence-based treatment plan is stunningly low. But also, here’s another reason I asked Dan Serrano to talk about CKD patient populations specifically as his example: I and Dr. Rodis and the team at QC-Health are not the only ones who have figured out that CKD patients are notoriously expensive and way underdiagnosed. You know who else has figured this out? Payers. Also, private equity. In fact, I was in a meeting with a payer recently, and they stated they had to get CKD patients into point solutions. This payer—and I’ve heard of others, too—none of these entities are waiting around. And I guess, fair enough, if you look at some of the population health data, that I’m sure these payers and others are looking at. But if you work for a payer and you’re listening right now, what I would say, “Okay, with the point solutions, one that you have carefully vetted, of course, because we have patients suffering right now and dollars being frittered away right now.” But I also would submit that those point solutions will perform a whole lot better if we are all gunning for synergies. PCPs (primary care physicians) and traditional FFS (fee-for-service) models in this country need your help. The payment models and admin burden are decimating. Payers certainly are a group with some culpability here. (Sorry to be saying the quiet part out loud.) Instead of forgoing them, please help PCPs. Am I saying be altruistic? Actually, no. Listen to episode 409 with Larry Bauer or episode 391 with Scott Conard, MD, or an upcoming show with Jodilyn Owen and what you will hear is the amazing ability for clinicians rooted in the community to actually drive change in their local markets. In fact, I’d hypothesize that these community-rooted organizations probably have a better track record for actually moving the needle on patient outcomes than any snazzy tech that I have seen, although I am sure that there are one or two very effective snazzy techs out there—the exception proves the rule and all that. Bottom line: As I do so often, I am advocating for payers and provider organizations within communities to collaborate, regardless of whether there’s a third party also in the mix. I am reporting all of this in the spirit of being helpful but also with some degree of urgency for any care delivery organization because, I mean, really, forget about the holy grail of trying to capture a percentage of the premium if the money is already going elsewhere to too many point solutions who are already capturing a portion of the premium. IRL, this is what’s already going on out there. But where there’s a challenge, there is also opportunity. As I have said pretty repeatedly for the past four minutes, because the bar is so low and because CKD patient outcomes are bad news, in general, from a lot of angles, CKD is actually a great place for providers to work hard to improve care and quality. From a financial standpoint, I think there’s also a great business case for payers to help provider organizations do so. Doing better than the local standard of care is not hard, sadly. And what that means is that there’s so much money that’s possible to save due to the expense of this condition. And if you’re a payer, even a payer with a third-party CKD solution, if you can help local PCPs and others level up their care, then either you don’t have to pay for the third-party point solution for patients who can be managed successfully locally and/or there’s a more frictionless path for those patients to be identified and get into the point solutions that are available to them. Let’s all keep in mind that patients at rising risk are falling through a lot of cracks. You can have the best point solution in the world, but if patients aren’t making it there, then, yeah, no outcomes will improve. No costs will be reduced. Everything I just went through are also all of the reasons why we picked CKD as our focus for a national Groundswell Movement™ that the benefit corp I am co-president of is kicking off to improve CKD patient outcomes. If you are also thinking about improving CKD patient outcomes, for sure, hit me up. On to a few thank yous. Thank you so much to Carl Hansen, MD, a direct primary care physician, for a really generous tip in our tip jar. Also, thanks so much to Keith Passwater, who is CEO of Havarti Risk Services and Pasco Advisers, for a really nice donation to the cause over here. It was such an honor and a pleasure to moderate a panel at the Society of Actuaries’ latest meeting at Keith’s invitation also. Additionally, may I extend thanks to Dffdgg, RKC2023, and Healthy economist for super nice iTunes reviews. The shout-outs are amazing, especially when public like this. Also much appreciated how you have shared Relentless Health Value with your colleagues. Back on track, let’s hear from Dan Serrano, who is a consultant with COPE Health Solutions, where he works to help clients figure out the best way to make investments that drive better outcomes in a more cost-efficient way.   You can learn more at the COPE Health Solutions Web site or by emailing Dan at dserrano@copehealthsolutions.com.   Dan Serrano joined COPE Health Solutions in September 2022 as principal and senior vice president. He supports Analytics for Risk Contracting (ARC) finance build and cost models in terms of drive and delivery with Great Lakes Integrated Network (GLIN). He is a seasoned healthcare/finance professional with 20+ years’ experience and has held a number of roles across the industry and has primarily served as a senior finance leader with proven ability to drive strategy development and execution across multiple business lines for complex organizations in various stages of maturity. Prior to COPE Health Solutions, Dan served as senior vice president of finance at CareAbout, a private equity–backed start-up focused on driving performance for primary care physicians. He also was the vice president of value- and risk-based contracting at Mount Sinai Health System, where he worked to align contracting, operational performance, and network strategy for employed and voluntary physician groups. Prior to his role at Mount Sinai, Dan served as vice president of commercial products at Healthfirst, market chief financial officer at ChenMed, and Mid-Atlantic Region chief financial officer at Aetna, where he focused on driving strategic financial decisions by analyzing the value drivers for each of the stakeholders across the industry. Dan holds a bachelor’s degree in finance from the Peter J. Tobin College of Business at St. John’s University.   09:08 What is the importance of payer/provider partnerships in reducing costs with chronic condition care? 10:52 Josh Berlin, JD, of rule of three; look out for his episode in a few weeks. 11:19 What’s the endgame here with this payer/provider collaboration? 11:43 What advice does Dan have for providers who want to do better by patients with chronic conditions? 15:11 Who’s driving costs in the system? 15:50 Why is lowering the average cost of chronic condition care important? 17:03 Why is there a meaningful delta between well-controlled CKD patients and those who aren’t well managed or identified? 21:57 What does a realistic time horizon look like for addressing chronic condition care? 22:38 Why is it important to start in a shared savings place? 25:25 William Shrank, MD, of Andreessen Horowitz; look out for his episode in the fall. 26:35 Financially, what is the goal and how are we achieving a sustainable goal? 29:06 What is the balance between progress and risk here?   You can learn more at the COPE Health Solutions Web site or by emailing Dan at dserrano@copehealthsolutions.com.   Dan Serrano of @COPEHS discusses #chronicconditions and #payer #provider #collaboration on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest’s name for their latest RHV episode! Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249)  

In this healthcare podcast, we are talking about innovative primary care teams and, by way of Larry Bauer, my guest today, bringing you three inspiring case studies. Much can be inferred from these case studies, as much from how they are alike as how they are different. It is wildly important at the same time that it is wildly underappreciated how different local markets are. I love how Cody Coonradt put it on LinkedIn the other day. He wrote: “Healthcare is not a $4T market—it’s 500 some-odd interconnected markets ranging in size from $1-50B. [It is] not a singular problem … each market [is driven] by unique third party payer incentives with unique patient cohorts. … “Before you figure out the next great idea—seek to understand the underlying health economic, revenue cycle, service provider contracting, and cash conversion processes that undergird it all. [That] is how to truly disrupt healthcare.” Or, said another way, if you’re part of the community, if you are already caring for patients in that community because you’re a doctor or another clinician, you probably have the best shot at truly—and in meaningful ways—helping patients in that community. This whole statement is a really uncomfortable truth for many in private equity and anybody else who wants to find the easy button to fix healthcare with some big-ass, scalable, rapid-fire bulldozer approach. It’s also a very uncomfortable truth for any national payer looking for one model or one point solution to roll out in a broad stroke to every one of these 500 some-odd interconnected markets that Cody mentioned. One size does not fit all here, and leveling up patient outcomes and care is hard grueling work that requires local market knowledge, being rooted in the community with relationships to succeed. You gotta get a little closer to the ground. Policymakers, please take some notes here. And you, too, self-insured employers, payers. So many universal lessons are embedded in these three examples that Larry Bauer, my guest, shares today. But bottom line—and round of applause required—you go, all you doctors and nurses and other clinicians or mission-oriented teams who take it upon yourselves to find ways to address the problem of human suffering in your local area. Stay tuned for an upcoming show with Jodilyn Owen, where we dig into this whole dynamic hard. I’m talking about the dynamic where some barbarian at the gate (ie, some venture-funded start-up) has gotten money—in some cases, lots of money—while there are community-based organizations out there who are doing amazing work really helping patients in the community improving outcomes and cutting costs and struggling, scrambling for every penny they can manage to get their hands on. So, that’s in the future. Talking about today, though, we’re gonna cover the bright spots when you get a really creative and committed PCP (primary care) team who is part of their own community and who wants to do better by patients locally and got some money to attain that goal. Today, as I said earlier, I am talking with Larry Bauer, who has been working with innovative PCPs and other docs for decades. All three of these case studies that Larry describes on the show today concern frail elderly adults, and this is on purpose (this using of the same patient population) for a couple of reasons. One of them is just to highlight that the same population in different geographies is not the same population and, therefore, the solution set is going to be different if we’re gonna reach out and care for them. The second reason for selecting three solutions that all pertain to frail elders is that this group is notoriously expensive and care is notoriously poor. Everybody has a story about how their frail elderly family member or friend died a bad death or did not “finish well,” as Larry Bauer puts it. It’s a patient population at the mercy of this industry and unable, a lot of times, to advocate for themselves. So, solutions here solve, in a way, for the worst-case scenario and might be a great starting point for anybody contemplating how to help other patient populations, too. The three innovations we discuss today are: 1. Dan Hoefer, MD, and Suzie Johnson in their Transition Program in San Diego helping those at the end of their lives to “finish well.” This is a capitated program. 2. Ken Coburn, MD, who, along with his team, created Health Quality Partners in Pennsylvania. This is a nurse navigator program, and it is paid for by a CMS grant. 3. Alan “Chip” Teel, MD, at Full Circle America with a program to wire up patient homes so that the clinical team could monitor what was going on in the home, intervene in case of emergencies, as well as organize community services. This program is paid for by the patient or the patient’s family, but, point of note, it is 10 times cheaper than a nursing home. I do ask Larry Bauer, by the way, how to best walk the line between right-sized care and not enough care (ie, the whole death panel counterargument to some of this stuff). I think Larry’s answer was elegant. You’re gonna need to listen to the show to hear it. My guest today is Larry Bauer, as I have mentioned four to six times already. He is a social worker by training who has been at this, as he says, for a very long time. He created a not-for-profit called Family Medicine Education Consortium (FMEC) over 30 years ago, and it became a platform for bringing together very talented and capable family physicians and some general internists. This gang has been really redefining and re-creating primary care … which is a great way to sum up the three programs that Larry Bauer will talk about today.   You can learn more at the Family Medicine Education Consortium Web site or by emailing Larry at laurence.bauer@gmail.com. Larry wrote a “Bright Spot” report; check it out here.   Laurence Mahoney Bauer, MSW, MEd, served as chief executive officer of the Family Medicine Education Consortium, Inc., from 1994 to October 2021. The FMEC is a not-for-profit corporation designed to promote collaboration among the academic family medicine and primary care communities in the northeast region of the United States. He has also served as director of network development for the Center for Innovation in Family and Community Health in Dayton, Ohio, from January 2006. He is an associate clinical professor in the Wright State University School of Medicine, Department of Family Medicine, in Dayton. Previously, he served at The Ohio State University School of Medicine, Department of Family Medicine, for 4 years as director of organization and faculty development. He served as director of faculty development and behavioral science in the Department of Family and Community Medicine at the Pennsylvania State University School of Medicine in Hershey, Pennsylvania, for 13 years. Presently, he is an active consultant committed to the creation of a primary care–driven system in the United States. He lives in Hershey. He enjoys pickleball, basketball, and gardening.   06:53 In a brief overview, what does end-of-life care in America look like? 10:38 What are the three innovative systems and physicians Larry Bauer has worked with? 14:27 What does it mean to be in a capitated system? 19:14 What does the Health Quality Partners system look like? 22:13 Andreas Mang from Blackstone; look out for his episode in September. 22:50 What is a number one reason for hospital readmissions? 23:26 The third example of innovative primary care. 27:04 Why is comprehensive care at the community level so important and successful for end-of-life care? 28:03 “The number one goal is not cost containment; that’s one of the outcomes.” 28:26 What is the core issue for these three types of innovative care? 31:02 What does good policy to encourage this type of innovation look like? 33:22 EP326 with Rishi Wadhera, MD, MPP. 34:14 Why is it important to trust physicians and be present and partnered with physicians?   You can learn more at the Family Medicine Education Consortium Web site or by emailing Larry at laurence.bauer@gmail.com. Larry wrote a “Bright Spot” report; check it out here.     Larry Bauer of @FMEC_ discusses #innovation in #primarycare on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest’s name for their latest RHV episode! Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher

I cut this clip out of episode 407 with Vivek Garg, MD, MBA, from Humana; and it’s actually a really nice follow-on from the show last week with Scott Conard, MD, where we talked about the blowback that happened with clinicians at a clinic. This clinic had put into effect a bunch of the comprehensive primary care kinds of things that Dr. Garg talks about in this summer short. But what happened in Dr. Conard’s case is a new practice manager tried to go back to the olden days, and, spoiler alert, it was a kerfuffle. All the docs and the rest of the clinicians staged what sounded like a “mutiny on the bounty” moment from the way Dr. Conard described it. So, this summer short you’re about to hear and the one from last week again share one key point: Doctors, advanced practice clinicians, medical assistants, pretty much everybody on the team really likes a well-executed, operationally excellent transformed primary care model. And it produces better patient care. I was reading Dr. Robert Pearl’s book Uncaring the other day, and he summed up the reason why, I think, these transformed primary care practices do better. He was quoting Atul Gawande, and here’s the quoted quote: “The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.” I interviewed Dr. Pearl, by the way, so stay tuned for that show coming up. In this summer short, Dr. Garg digs into one common objection to more comprehensively comprehensive primary care, and that is that by improving care, we decrease throughput and, therefore, access to primary care, especially in areas where there are not enough primary care doctors.   You can learn more at humana.com, centerwellprimarycare.com, and the Humana report.    Vivek Garg, MD, MBA, is a physician and executive dedicated to building the models and cultures of care we need for loved ones and healthcare professionals to thrive. He leads national clinical strategy and excellence, care model development and innovation, and the clinical teams for Humana’s Primary Care Organization, CenterWell and Conviva, as chief medical officer (CMO), where they serve approximately 250,000 seniors across the country as their community-based primary care home, with a physician-led team of practitioners, including advanced practice clinicians, nurses, social workers, pharmacists, and therapists. Dr. Garg is the former chief medical officer of CareMore and Aspire Health, innovative integrated healthcare delivery organizations with over 180,000 patients in over 30 states. He also previously led CareMore’s growth and product functions as chief product officer, including expansion into Medicaid primary care and home-based complex care. Earlier in his career, Dr. Garg joined Oscar Health during its first year of operations as medical director and led care management, utilization management, pharmacy, and quality, leading to Oscar’s initial NCQA accreditation. He was medical director at One Medical Group, focusing on primary care quality and virtual care, and worked at the Medicare Payment Advisory Commission, a Congressional advisory body on payment innovation in Medicare. Dr. Garg graduated summa cum laude from Yale University with a bachelor’s degree in biology and earned his MD from Harvard Medical School and MBA from Harvard Business School. He trained in internal medicine at Brigham and Women’s Hospital, received board certification, and resides in New Jersey.   02:31 Does advanced primary care reduce access to patients? 03:01 Are five-minute visits with patients really access? 04:17 Will advanced primary care provide outcomes that make certain PCP responsibilities unnecessary?   You can learn more at humana.com, centerwellprimarycare.com, and the Humana report.   @vgargMD discusses #advancedprimarycare on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest’s name for their latest RHV episode! Dr Scott Conard, Brennan Bilberry, Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher, Dr Suhas Gondi

Back at the beginning of this year, I was so sad when I had to edit out the clip that follows from the original and extremely popular episode 391 with Scott Conard, MD. In the literally probably three minutes that follows in this clip with Dr. Conard after I finish my ramblings here, Dr. Conard introduces the impact that changing the practice model in a PCP practice in Queens, New York, had on the staff and patients alike. Spoiler alert: No way no how were they going back to the old way of doing things. The “Before” here was a clinic where the waiting room was filled to overflowing out into the hall with patients waiting to be seen, and this included a mix of really sick people who really needed to be seen and also … others. And thus they had, among a whole host of other bad things going on, the whole issue of suboptimal ER (emergency room) visits and urgent care usage. Anyone who couldn’t wait just headed elsewhere. Also, as it is so many places, care was pretty transactional. A patient who wasn’t in clinic had an “out of sight, out of mind” relationship with their PCPs. There was no systemic way for the clinical teams to really think about the “in between spaces,” as Amy Scanlan, MD, put it (EP402)—the spaces in between office visits. But then as a result, of course, we wind up dealing with uncontrolled chronic conditions and the failure to prevent preventable disease. We wind up with urgent needs for care and acute situations that had, frankly, no business getting to that stage in the first place. So, Dr. Scott Conard and his team worked on practice transformation, including focusing on operational excellence. I say all that to say, here’s Dr. Scott Conard: DR. CONARD: We went and did one pilot clinic, which is, I think, the right way to do it. And then the practice manager was recruited by a competing group. They put another person in the clinic, another practice manager. And she immediately came in and thought that her job was to go back and put the old way of doing things in place, and within literally four or five days, they got together and sat down and said, “Look, we understand where you’re coming from, but we will never go back. We are not going back to that old system. We are going to do things in this new way because it makes our lives—and we work together—so much better. And we enjoy being together, and we’re seeing … we like not having 30 people waiting to get here at work. We like people getting … having a waiting room be close to empty as we just have one or two of the next people coming in. And we will never go back to that old system.” And, to her credit, she’s like, “Okay … cool. Let me understand this.” And she’s now one of the strongest leaders in that organization for this transformation. STACEY: So, the PCPs … it was like mutiny on the bounty. They were like, “No way no how are we going back.” DR. CONARD: Oh, it was the entire team: their receptionist, the telephone operator, the MAs. They have a patient navigator, which is another part of the equation we haven’t talked about that’s really important. And so, the whole team said no. Listen to the full episode 391 to learn more about Dr. Scott Conard and his team’s approach to practice transformation. But in the meantime, Peter Watson, MD, captured a few learnings from the original episode really nicely on LinkedIn. Dr. Watson has some other really great posts on the topics of value-based care and primary care. I would highly recommend following him on LinkedIn. Should you continue to be interested in this topic of transformational primary care, additional shows on transforming primary care—including bright spots and challenges—are the shows with Eric Gallagher (EP405) and, as aforementioned, the show with Dr. Amy Scanlan (EP402). Also check out the upcoming show with Larry Bauer, which will be approximately episode 409, should I get my act together. And Vivek Garg, MD, MBA (EP407), who, by the way, is coming up in next week’s summer short talking about the common rebuke of comprehensive primary care, which is that it diminishes patient access because PCP patient panel sizes tend to be smaller in comprehensive primary care models. Since the original show with Dr. Scott Conard aired, his new book Which Door? came out. I’m gonna say that this book is relevant. It’s written for employers but still relevant here because employers have a terrible track record for helping (ie, paying for healthcare) in a way that enables PCPs who want to do comprehensive primary care to actually do comprehensive primary care. When an employer lets the status quo prevail, employees get fragmented care provided by PCPs struggling under the weight of brutal administrative burden and often nasty and counterproductive incentives.   You can learn more by emailing Dr. Conard at scott@scottconard.com.    Scott Conard, MD, DABFP, FAAFM, is board certified in family and integrative medicine and has been seeing patients for more than 35 years. He was an associate clinical professor at the University of Texas Health Science Center at Dallas for 21 years. He has been the principal investigator in more than 60 clinical trials, written many articles, and published five books on health, well-being, leadership, and empowerment. Starting as a solo practitioner, he grew his medical practice to more than 510 clinicians over the next 20 years. In its final form, the practice was a value-based integrated delivery network that reduced the cost of care dramatically through prevention and proactive engagement. When this was acquired by a hospital system, he became the chief medical officer for a brokerage/consulting firm and an innovation lab for effective health risk–reducing interventions. Today, he is co-founder of Converging Health, LLC, a technology-empowered consulting and services company working with at-risk entities like self-insured corporations, medical groups and accountable care organizations taking financial risk, and insurance captives to improve well-being, reduce costs, and improve the members’ experience. Through Dr. Conard’s work with a variety of organizations and companies, he understands that every organization has a unique culture and needs. It is his ability to find opportunities and customize solutions that delivers success through improved health and lower costs for his clients.   02:15 Why a transformed PCP practice didn’t want to go back to the old way of doing things. 03:39 Dr. Peter Watson’s takeaways from Dr. Conrad’s EP391. 04:02 Can fee for service in the short term still benefit primary practice? 04:43 EP405 with Eric Gallagher; EP402 with Amy Scanlan, MD; upcoming episode with Larry Bauer; and EP407 with Vivek Garg, MD, MBA. 05:24 Scott Conard’s new book, Which Door?   You can learn more by emailing Dr. Conard at scott@scottconard.com.   @ScottConardMD discusses #PCP transformation on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest’s name for their latest RHV episode! Brennan Bilberry, Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid